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  • • Bacterial peritonitis is a suppurative response of the peritoneal lining to direct bacterial contamination

    • Clinical manifestations include:

    • -Fever and chills


      -Acute abdomen

      -Free air on plain films


  • • Primary bacterial peritonitis is caused mainly by hematogenous spread or transluminal invasion in patients with advanced liver disease and reduced ascitic fluid protein concentration

    • Surgical causes are classified as secondary bacterial peritonitis resulting from bacterial contamination originating from within the viscera

    • Secondary bacterial peritonitis most commonly follows disruption of a hollow viscus

    • Most common etiology in young patients is perforated appendicitis

    • Most common etiology in elderly patients is complicated diverticulitis or perforated peptic ulcer

Symptoms and Signs

  • • Fever and chills

    • Tachycardia

    • Oliguria

    • Severe abdominal pain with rebound tenderness, guarding, and rigidity ("acute abdomen")

    • Diminished bowel sounds

    • Physical signs of peritonitis may be subtle in the very young or old and in patients who are immunosuppressed

Laboratory Findings

  • • Leukocytosis

    • Abnormal liver profile or renal function test

    • Mild elevation in amylase

    • Elevated ESR and C-reactive protein

    • Bacteremia

Imaging Findings

  • Abdominal x-ray: Demonstrates free air and ileus pattern and may suggest the primary etiology

    Water soluble contrast study: Demonstrates the location of the perforated viscus

    Abdominal pelvic CT scan with IV and PO contrast: Best exam for characterizing source of bacterial peritonitis, although an operation should not be delayed to obtain this test in patients with an acute abdomen

  • • Primary bacterial peritonitis

    • Etiology of secondary bacterial peritonitis:

    • -Appendicitis

      -Perforated gastroduodenal ulcers


      -Gangrenous cholecystitis

      -Acute salpingitis

      -Nonvascular small bowel perforation

      -Large bowel perforation

      -Mesenteric ischemia

      -Acute necrotizing pancreatitis

      -Postoperative complications


    • Familial Mediterranean fever

Rule Out

  • • Primary bacterial peritonitis in patients with advanced liver disease (high operative mortality)

    • Nonoperative causes of peritonitis

    • -Pancreatitis


      -Acute salpingitis

  • • Thorough history and physical exam

    • CBC

    • Basic chemistries

    • Amylase and lipase

    • UA

    • Liver profile

    • Coagulation studies

    • Abdominal x-rays

When to Admit

  • • All patients with bacterial peritonitis should be admitted for appropriate surgical and medical management

When to Refer

  • • Primary bacterial peritonitis is ideally cared for nonoperatively by gastroenterologists

    • Secondary bacterial peritonitis should be managed by a general surgeon

  • • Resuscitation with IV fluids and electrolyte replacement

    • Operative control of the abdominal sepsis

    • Systemic antibiotics

    • Cardiorespiratory ICU support as indicated



  • • Operative goal is to correct the underlying cause of abdominal sepsis:

    • -Perforated viscus

      -Ruptured appendix

      -Infected necrotizing pancreatitis

      -Gangrenous cholecystitis

      -Abscess drainage



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