Peritonitis

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Introduction

Peritonitis, or inflammation of the peritoneum, is a serious concern warranting careful evaluation

 

The Case of...

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Types of Peritonitis

 

Primary peritonitis

Primary peritonitis (spontaneous bacterial peritonitis, SBP) usually in people with ascites due to liver disease or nephrotic syndrome.

Bacteria can enter ascites fluid through bowel or the fallopian tubes. Portal bacteremia can increase due to impaired function of liver reticuloendothelial cells with cirrhosis.

The predominant pathogens include

 

Secondary Peritonitis

Secondary peritonitis can follow:

  • trauma
  • perforated duodenal ulcer
  • perforated appendix
  • bowel infarction
  • post-operative infection
  • peritoneal dialysis
  • reaction to starch or talc during operation
  • tuberculosis

Causative organisms can include:

  • gram-negative rods
  • streptococci
  • staphylocci
  • anearobes

Peritoneal dialysis is often caused by

  • Staphylococci, gram-negative rods, yeast

 

Tertiary Peritonitis

Tertiary peritonitis is a persistent abdominal infection leading to multiple organ failure, despite intensive surgical and antibiotic intervention. It represents severe immune and endocrine dysfunction, and has a mortality rate over 50%. Common pathogens, potentially a symptom rather than the cause, include:

 

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History and Physical Exam

  • history
  • physical exam

History

Peritonitis can result in:

  • diffuse abdominal pain
  • nausea and vomiting
  • diarrhea
  • paralytic ileus

Primary

Physical Exam

Patients are usually febrile and uncomfortable, preferring to lie quietly.

Other findings include:

  • diffuse tenderness
  • guarding
  • rebound tenderness
  • decreased bowel sounds
  • altered mental status

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Investigations

  • lab investigations
  • diagnostic imaging

Lab Investigations

Febrile patients with ascites should undergo paracentisis, with culture media innoculation at the bedside. Leukocyte count and gram stain can be helpful.

  • 100 PMNs for peritoneal dialysis

 

Mixed flora or anaerobes can follow bowel leakage.

Diagnostic Imaging

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Management

Antibiotic penetration of the peritoneum is excellent. Piperacillin-tazobactam or ampicillin-sulbactam should be considered emperically.

Prophylactic norfloxacin or TMP-SMX may be helpful in patients with cirrhosis and ascites.

 

Peritonitis resulting from peritoneal dialysis can be treated by IV or intraperitoneal antibiotics, administered by the dialysis catheter. Vancomycin plus a cephalosporin should be used. The catheter need not always be removed, but should be with yeast, Pseudomonas, or polymicrobial infections.

 

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Pathophysiology

 

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The Case of...

 

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Additional Resources

 

 

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Topic Development

created: DLP, Aug 09

authors: DLP, Aug 09

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