Peritonitis Diagnosis and Treatment

Clinical Findings

Abdominal pain and tenderness are common symptoms, occurring in 74-95% of patients, and are often accompanied by rebound tenderness and guarding 1, 2
Tachycardia is observed in 62.5% of patients 1, 2
Fever greater than 38.5°C is present in 38% of patients 3
Leukocytosis occurs in 40% of patients 1, 2
Decreased bowel sounds are a common finding 3
Rectal bleeding is observed in 15% of patients 1, 2
Isolated abdominal distension is seen in 6.6% of patients 1, 2
Ileus symptoms, such as vomiting and absence of defecation, may be present 4
Hemodynamic instability and shock can occur 2

Laboratory Findings

Leukocytosis with a left shift (band neutrophils >20%) is a common laboratory finding 3
Elevated C-reactive protein (CRP) levels are observed 1
Increased serum creatinine levels (more than 50% above baseline) are seen in some patients 3
Elevated serum lactate levels are a common finding 3
Ascitic fluid analysis showing a neutrophil count >250/mm³ is diagnostic for spontaneous bacterial peritonitis (SBP) 5
Low ascitic fluid glucose levels (<50 mg/dL) suggest secondary peritonitis 6

Imaging Findings

Free air on a plain abdominal radiograph is a sign of perforation 1
Ultrasonography may show free fluid in the abdomen 1, 4
Computed tomography (CT) scan may show:
- Free fluid and air in the abdomen 1
- Bowel wall thickening 7
- Pericolic fat inflammation 7
- Ascites 2

Peritonitis Types and Characteristics

Primary Peritonitis (Spontaneous Bacterial Peritonitis - SBP)

Typically occurs in patients with cirrhosis 8
Develops without gastrointestinal tract disruption 8
Ascitic fluid analysis showing a neutrophil count >250/mm³ is diagnostic 5
Usually, only one microorganism is isolated from the ascitic fluid culture 8

Secondary Peritonitis

Develops as a result of gastrointestinal tract perforation 8
Ascitic fluid culture usually shows multiple microorganisms 6
Ascitic fluid analysis may show high total protein levels, elevated lactate dehydrogenase (LDH), and low glucose levels (<50 mg/dL) 6

Peritonitis Complications

Renal failure is a potential complication 2
Hepatic encephalopathy may occur 2
Shock is a possible complication 2
Bacterial peritonitis can lead to sepsis and multi-organ failure 2

Treatment Approach

Appropriate antibiotic therapy is crucial, such as third-generation cephalosporins (e.g., cefotaxime 2 g, every 8 hours) for spontaneous bacterial peritonitis 6
Albumin infusion may be beneficial in reducing renal failure and mortality risk in patients with spontaneous bacterial peritonitis 6

Clinical Features and Management of Peritonitis

Diagnosis and Clinical Features

Abdominal rigidity, which strongly suggests the presence of peritonitis, is a key clinical feature 9
Hypotension and hypoperfusion signs, such as lactic acidosis, oliguria, and altered mental status, indicate ongoing sepsis 9
Diagnosis is primarily based on clinical assessment, especially in resource-limited settings 9
Ultrasound can be a valuable tool in resource-limited settings to identify free fluid in the abdomen 9

Management

Appropriate source control procedure is recommended for nearly all patients with intra-abdominal infection 10
Delay in diagnosis and treatment significantly increases mortality rates, especially in patients with diffuse peritonitis 9
Inadequate source control is associated with significantly elevated mortality rates 11

Peritonitis Diagnosis and Management

Clinical Features and Diagnostic Approach

When perforation occurs at a tumor site, peritoneal contamination is usually localized; when proximal to a tumor, it results in diffuse peritonitis and potentially septic shock 12
CT scan has the highest sensitivity and specificity for detecting peritonitis compared to ultrasound and plain X-ray 12
Plain abdominal X-ray may show free air in cases of perforation but has lower sensitivity 12
When perforation is suspected in a stable patient with positive findings on ultrasound or X-ray, a CT scan should be considered for better characterization 12

Peritonitis Diagnosis and Treatment

Introduction to Peritonitis

Peritonitis requires prompt diagnosis and treatment with antibiotics and source control procedures to reduce mortality and morbidity, as recommended by the World Journal of Emergency Surgery 13

Types of Peritonitis

Diffuse bacterial infection without loss of integrity of the gastrointestinal tract is characteristic of primary peritonitis, also known as spontaneous bacterial peritonitis, according to the World Journal of Emergency Surgery 13
Secondary peritonitis is the most common form of peritonitis, resulting from loss of integrity of the gastrointestinal tract, such as perforation, as stated by the World Journal of Emergency Surgery 13
Tertiary peritonitis is a recurrent infection of the peritoneal cavity following primary or secondary peritonitis, and may be associated with multidrug-resistant organisms, as noted by the World Journal of Emergency Surgery 13, 14

Treatment Approach

Source control is essential for secondary and tertiary peritonitis, and includes determining the cause of peritonitis, draining fluid collections, and controlling the origin of abdominal sepsis, as recommended by the World Journal of Emergency Surgery 13, 14
Surgical source control, such as resection or suture of perforated viscus, removal of infected organ, debridement of necrotic tissue, and repair of traumatic perforations, is a crucial step in the treatment of peritonitis, according to the World Journal of Emergency Surgery 14

Stoma Retraction and Peritonitis Risk

Mechanism of Peritonitis Development

A retracted stoma that maintains mucocutaneous continuity can cause local complications, such as skin irritation and leakage onto the skin, without peritoneal contamination, as noted by the American Gastroenterological Association 15

Clinical Presentation and Management

The American College of Surgeons recommends immediate surgical exploration for unstable patients or those with diffuse peritonitis, with source control through laparotomy or laparoscopy to assess contamination extent 16
In stable patients with limited contamination, primary repair may be possible, according to the World Journal of Emergency Surgery guidelines 17, 18
The Society of Surgical Oncology suggests that in unstable patients or diffuse peritonitis, damage control surgery principles apply, potentially requiring Hartmann's procedure or resection with diverting stoma 17, 18, 19

Special Considerations

The mortality from peritonitis secondary to bowel perforation or anastomotic complications ranges from 4-10% even with appropriate management, as reported by the World Journal of Emergency Surgery 19, 20
Patient outcomes depend heavily on time to diagnosis and intervention, adequacy of source control, and patient physiologic reserve, with the American Society of Colon and Rectal Surgeons emphasizing the importance of prompt intervention 21, 19, 20

Management of Peritonitis

Introduction to Peritonitis Management

Prompt surgical source control combined with broad-spectrum antibiotics started immediately is the cornerstone of peritonitis management, with delays in either intervention significantly increasing mortality 22, 23

Immediate Resuscitation and Diagnostic Workup

Obtain blood cultures and ascitic fluid analysis (if present) before initiating antibiotics 22

Antibiotic Therapy

Initiate narrow-spectrum empiric antibiotics immediately covering common bacteria, such as E. coli, Klebsiella, Streptococcus species, and anaerobes 22
Administer antibiotics within the first hour in critically ill patients to ensure timely coverage 22
Use broader-spectrum antibiotics with anti-ESBL and anti-Pseudomonal coverage due to higher risk of multidrug-resistant organisms in hospital-acquired peritonitis 22
Obtain intra-operative cultures in all hospital-acquired cases to guide de-escalation 22
Limit antibiotics to 3-5 days post-operatively in patients with adequate source control 22
No post-operative antibiotics are needed for uncomplicated appendicitis or cholecystitis with definitive source control 22
Investigate for ongoing infection if signs of peritonitis persist beyond 5-7 days of treatment 22

Surgical Source Control

Perform surgical source control immediately upon diagnosis of secondary peritonitis—delays beyond 24 hours significantly increase mortality 23
Operating room latency ≥60 hours is an independent predictor of need for relaparotomy and death 23
Source control includes resection or suture of perforated viscus, removal of infected organs, debridement of necrotic tissue, drainage of abscesses and fluid collections, and repair of traumatic perforations with primary anastomosis or diversion 22, 23
Consider damage control surgery in physiologically deranged patients with ongoing sepsis, preventing abdominal compartment syndrome 22
Open abdomen may be necessary for unstable patients with diffuse contamination 22

Non-Operative Management

The following patients may be managed non-operatively if hemodynamically stable and responding to antibiotics: perforated diverticulitis with abscess <4 cm diameter, peri-appendiceal phlegmon or small abscess, small perforated peptic ulcer with minimal contamination, and CT findings of pericolic air only without diffuse peritonitis or distant free air 23
Distant free air, hemodynamic instability, or diffuse peritonitis mandates immediate surgical intervention 23

Antifungal Coverage

Empirical antifungal therapy is recommended for hospital-acquired peritonitis due to high risk of Candida species 22

Common Pitfalls to Avoid

Do not continue antibiotics beyond 5 days without investigating for inadequate source control 22
Do not use narrow-spectrum antibiotics in hospital-acquired peritonitis—resistance patterns demand broader coverage 22
Adjust antibiotic dosing based on renal function and pharmacokinetic parameters in critically ill patients 22