Peritonitis


PERITONITIS

Description:

Peritonitis: Inflammation of peritoneum.

Alternative Name: Acute abdomen, abdominal wall inflammation.

The peritoneum (or the visceral peritoneum) is a thin, two-layered membrane which covers the abdominal organs (like stomach, intestines or liver) and the abdominal walls (parietal peritoneum). When this membrane becomes inflamed it produces the disease called peritonitis.

Peritonitis is an inflammation of the membrane which lines the inside of the abdomen and all of the internal organs. This membrane is called the peritoneum. Peritonitis may be primary (meaning that it occurs spontaneously, and notas the result of some other medical problem) or secondary (meaning that it results from some other condition). It is most often due to infection by bacteria, but may also be due to some kind of a chemical irritant (such as spillage of acid from the stomach, bile from the gall bladder and biliary tract, or enzymes from the pancreas during the illness called pancreatitis). Peritonitis has even been seen in patients who develop a reaction to the cornstarch which is used to powder gloves worn during surgery. Peritonitis with no evidence of bacteria, chemical irritant, or foreign body has occurred in such diseases as systemic lupus erythematosus, porphyria, and familial Mediterranean fever. When the peritoneum gets contaminated by blood, the blood can both irritate the peritoneum and serve as a source of bacteria to cause an infection. Blood may leak into the abdomen due to a burst tubal pregnancy, an injury, or bleeding after surgery.

Primary peritonitis usually occurs in people who have an accumulation of fluid in their abdomens. Ascites is a common complication of severe cirrhosis of the liver (a disease in which the liver grows increasingly scarred and dysfunctional). The fluid that accumulates creates a good environment for the growth of bacteria.

Secondary peritonitis most commonly occurs when some other medical condition causes bacteria to spill into the abdominal cavity. Bacteria are normal residents of a healthy intestine, but they should have no way to escape and enter the abdomen, where they could cause an infection. Bacteria can infect the peritoneum due to conditions in which a hole (perforation) develops in the stomach (due to an ulcer eating its way through the stomach wall) or intestine (due to a large number of causes, including a ruptured appendix or a ruptured diverticulum). Bacteria can infect the peritoneum due to a severe case of pelvic inflammatory disease (a massive infection of the female organs, including the uterus and fallopian tubes). Bacteria can also escape into the abdominal cavity due to an injury which causes the intestine to burst, or an injury to an internal organ which bleeds into the abdominal cavity.

Peritonitis is generally rare but can be a common complication in people with pre-existing risk factors. Cirrhosis (scarring of the liver, usually due to alcohol abuse) is one of the leading risk factors for peritonitis as it can cause a build-up of fluid (ascites) inside the abdomen. Sometimes, the fluid can become infected.

It is estimated that between 10% and 30% of people with cirrhosis and ascites will experience at least one episode of peritonitis. See the Causes section, above, for more information about risk factors for peritonitis.

Peritonitis is a medical emergency that must be dealt with immediately. Treatment depends upon the cause, but generally involves surgery. An operation called a laparotomy is performed first. Through a surgical incision in the abdominal wall, the doctor examines the cavity, confirms the diagnosis, and corrects the problem by removing or repairing the source of the infection. If the appendix is at fault, for example, an appendectomy is performed to remove it.

Left untreated, peritonitis can lead to shock, and even death. Complications from this disorder develop rapidly and include fluid retention in the upper and lower intestines, a halt in the normal movement of food and waste through the digestive tract, and a loss of electrolytes (minerals such as sodium and calcium) from the bloodstream. In the end, lung, kidney, and liver failure can result, along with widespread clotting inside the body.

Symptoms:

Major symptoms of peritonitis are:

    Acute onset of severe, steady pain throughout the abdomen or localized in one area. Pain may persist for several hours and is worsened by movement or pressure on the abdomen.

  • Board-like rigidity of the abdomen, due to contraction of the muscles of the abdominal wall.

  • Swollen or bloated abdomen.

  • Chills and fever, with profuse perspiration.

  • Nausea and vomiting.

  • Weakness.

  • Pale, cold skin.

  • Shock.

Causes and Risk factors:

Primary spontaneous peritonitis: The most common cause of primary spontaneous peritonitis is liver disease, such as cirrhosis (scarring of the liver usually caused by alcohol abuse). Liver disease can lead to a build-up of fluid inside the abdomen which can become infected.

Peritoneal dialysis: People with kidney failure who are having a treatment known as peritoneal dialysis are at risk of primary spontaneous peritonitis. Dialysis is a medical treatment that replicates the main functions of the kidneys and is used to remove waste products from the body.Peritoneal dialysis involves implanting a small tube, known as a catheter, into the blood vessels of the peritoneum. Waste products are then removed through the catheter.

The major disadvantage of peritoneal dialysis is that the equipment can become contaminated by bacteria or fungi, leading to an infection of the peritoneum. As a precaution, people who are having peritoneal dialysis are often given antibiotics to help prevent infection.

Secondary peritonitis: Secondary peritonitis usually occurs when an injury or infection inside the abdominal cavity allows bacteria or fungi into the peritoneum.

Common causes of secondary peritonitis include:

    A ruptured (split) stomach ulcer.

  • A burst appendix.

  • Pancreatitis (inflammation of the pancreas).

  • Severe trauma to the abdomen, such as a knife or gunshot wound.

  • Digestive disorders, such as Crohn's disease or diverticulitis.

Blood poisoning (sepsis) is the most serious complication of peritonitis. In sepsis, an infection in the peritoneum spreads first into the blood and then to other organs.

Rather than helping get rid of sepsis, the immune system makes it worse. The immune system releases a high number of infection-fighting proteins (cytokines), but rather than fighting the infection, the cytokines damage the body's organs and affect the blood circulation.

If sepsis is allowed to progress, it can move into a more serious phase known as severe sepsis. Severe sepsis occurs when one or more organs are damaged by the infection, or there is significant loss of blood supply to tissues and organs (hypoperfusion).

The following factors may increase the risk for primary peritonitis:

    Liver disease (cirrhosis).

  • Fluid in the abdomen.

  • Weakened immune system.

  • Pelvic inflammatory disease.

Risk factors for secondary peritonitis include:

    Appendicitis (inflammation of the appendix).

  • Stomach ulcers.

  • Torn or twisted intestine.

  • Pancreatitis.

  • Inflammatory bowel disease, such as Crohn's disease or ulcerative colitis.

  • Injury caused by an operation.

  • Peritoneal dialysis.

  • Trauma.

Diagnosis:

The healthcare provider will take a person's medical history and perform a physical exam. A diagnosis of peritonitis is usually based on symptoms. Discovering the underlying reason for the peritonitis, however, may require some work. A blood sample will be drawn in order to determine the white blood cell count. Because white blood cells are produced by the body in an effort to combat foreign invaders, the white blood cell count will be elevated in the case of an infection. A long, thin needle can be used to take a sample of fluid from the abdomen in an effort to diagnose primary peritonitis. The types of immune cells present are usually characteristic in this form of peritonitis. X-ray films may be taken if there is some suspicion that a perforation exists. In the case of a perforation, air will have escaped into the abdomen and will be visible on the picture. When a cause for peritonitis cannot be found, an open exploratory operation on the abdomen (laparotomy) is considered to be a crucial diagnostic procedure, and at the same time provides the opportunity to begin treatment.

In cases of peritonitis in which the infection may be a result of other medical conditions (secondary peritonitis) or in which the infection arises from fluid buildup in your abdominal cavity (spontaneous peritonitis), your doctor may recommend the following tests to confirm a diagnosis:

    Peritoneal fluid analysis: Using a thin needle, your doctor may take a sample of the fluid in your peritoneum (paracentesis). If you have peritonitis, examination of this fluid may show an increased white blood cell count, which typically indicates an infection or inflammation. A culture of the fluid may also reveal the presence of bacteria.

  • Blood tests: A sample of your blood may be drawn and sent to a lab to check for a high white blood cell count. A blood culture also may be performed to determine if there are bacteria in your blood.

  • X-rays: Your doctor may want to use an X-ray to check for holes or other perforations in your gastrointestinal tract. In some cases, your doctor may use a computerized tomography (CT) scan instead of an X-ray.

The above tests may also be necessary if you're receiving peritoneal dialysis and a diagnosis of peritonitis is uncertain after a physical exam and examination of the dialysis fluid.

Treatment:

The cause must be identified and treated promptly.

Treatment typically involves fluid infusion to control shock, surgery to drain the peritoneal cavity and repair the cause, and antibiotics to deal with the infection. In cases associated with peritoneal dialysis, antibiotics may be infused through the dialysis catheter, but if the infection is severe, the catheter itself must often be removed.

Treatment typically involves surgery and antibiotics. In cases associated with peritoneal dialysis, antibiotics may be infused through the dialysis catheter, but if the infection is severe, the catheter itself must often be removed.

Course of illness:

  • The outcome is often good with treatment, but can be poor without treatment.

  • Sometimes the outcome is poor even with prompt and adequate treatment.

Peritonitis can be life-threatening and cause a number of different complications, depending on the type. Complications may include:

    Peritonitis stops the movement of bowel contents (peristalsis), which can block the bowel (paralytic ileus).

  • Septic shock - Fluid from the blood accumulates in the abdominal cavity and the loss of fluid from the circulation may also cause shock.

  • Abscess.

  • Intraperitoneal adhesions.

Medicine and medications:

Your doctor will likely prescribe an antibiotic medication to fight the infection and prevent it from spreading.

To relieve the pain caused by peritonitis, the patient may be given analgesics or opiate medication. The doctor may also prescribe vitamin or herbal therapy.

The following drugs and medications are in some way related to, or used in the treatment. This service should be used as a supplement to, and NOT a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners.

    Ceftin

  • Cleocin

  • Keflex

  • Metronidazole

  • Ceclor

  • Flagyl

  • Cipro

  • Bactrim

  • Duricef

  • Vantin

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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