Knowledge for all medical professionals including interns, general practitioners, residents

1. Peritonitis
Marc KAVAKURE, Intern medical student
Surgery rotation at CHUK 2019, UR
Supervisor Dr Elise RWAGAHIRIMA

2. Introduction
Inflammation or irritation of peritoneum often caused by bacteria infections
OR fungal infections`
Primary peritonitis
Secondary peritonitis
Tertiary peritonitis
Surgical emergency

3. Etiology
1) Primary peritonitis( SBP)
 Absent acute abdominal diseases ( intra-abdominal surgical treatable sources)
 In patients with an underlying diseases causing ascites (examples: decompensated cirrhosis,
ovarian cancer; nephrotic syndrome in children or ESRD), ~30 to 40% of ascites develop
SBP
 Usual monomicrobial infection(~90%):
a) Gram-negative: E.coli, klebsiella pneumonia, bacteroides
b) Gram-positive: streptococcus pneumonia
 Route: hematogenous, lymphogenous, or transmigration from intestinal wall

4. Etiology cont’d
2) Secondary peritonitis( more common):
a) Preexisting acute abdominal condition
• Hallow viscus perforation: peptic ulcer, diverticulum, volvulus, cholecystitis, typhoid fever
• Inflammation of intra-abdominal organs: appendicitis, diverticulitis, necrotizing pancreatitis,
female genital tract pathologies
• Post-operative complications: anastomosis insufficiency; unsterile puncture site or surgical
procedures
• Traumatic( iatrogenic) or external perforation,
• Peritoneal dialysis or
• Intra-abdominal abscess

5. Etiology cont’d
3) Mixed infections
• Aerobic: E.coli, klebsiella, enterobacter, streptococcus, enterococcus
• anaerobic: bacteroides, eubacteria, clostridia
4) Further causes;
• Peritonitis in immunosuppressed patients ( DM, chemotherapy, HIV,
lymphoma, congenital immunodeficiency disorders,
• Chemical peritonitis( irritants such as blood, bile or barium contrasts)

6. Pathophysiology
• Leakage of abdominal contents to abdominal cavity either due to inflammation, infection,
ischemia, trauma, or tumor perforation
• Bacterial proliferation occurs, then tissues edema, exudation of fluids in short time
• Fluids become turbid with increased amounts of proteins, white blood cells and cellular debris
• The immediate response is hypermobility, followed by paralytic ileus with an accumulation of air and
fluid in the bowel.
• Later on fluid becomes creamy and suppurative. It may spread to the whole peritoneum.

7. Clinical features
A) General symptoms
• Diffuse abdominal pain + guarding(rigidity) or rebound tenderness
• Nausea and vomiting leading to dehydration and oliguria
• Fever and chills; underlying bacterial infections( SBP)
• Possibly shoulder pain
• Ascites in SBP

8. History taking
• Dull aches severe to sharp pain especially in generalized peritonitis
• Recent abdominal surgery, previous episodes of peritonitis
• Drugs history ( immunosuppressive agents, PPIS, Antibiotic abuse, NSAIDs,
alcohol)
• Presence of diseases ( IBD, IBS, diverticulitis, PUD,….)
• Travel history

9. Physical examination
• Distended abdomen
• Distressed, knees drawn up when supine, avoid movement
• Abdominal tenderness and rigidity, rebound tenderness(+)
• Sparse peristaltic sounds, none in case of paralytic ileus
▲ Peritonitis: surgical emergency as it can cause sepsis with shock and organ
failure

10. Diagnostics
• Merely history and P/E
• Laboratory tests and peritoneal fluid analysis to confirm the diagnosis
• Imaging tests detect underlying diseases and excludes the differentials
Lab tests
• CBC significant for leukocytosis
• Peritoneal fluid analysis( diagnostic paracentesis):
A) Primary peritonitis(SBP): neutrophils> 250cells/mm3, positive bacterial culture
and/or gram stain, SAAG> 1.1

11. Diagnostics
• Lab cont’d
b) Secondary peritonitis
• Glucose < 50mg/dl
• Peritoneal fluid LDH > serum LDH
• PH< 7

12. Imaging
1) U/S may detect underlying diseases
• Pancreatitis, appendicitis or cholangitis
• Peritoneal fluid
2) Abdominal X-ray
• Air fluid levels (ileus)
• Free air secondary to organ perforation
3) CT scan of abdomen and pelvis

13. Differential diagnosis
• Any cause of acute abdomen complicated to peritonitis ( perforation )
• Gynecological cases complicated to peritonitis
• Colorectal ca superimposed with peritonitis
• Metabolic: DKA, acute intermittent porphyria
• TB peritonitis
• Further: hemolytic crises, lead poisoning

14. Management
Primary peritonitis; treatment indications includes
 Fever>37.8⁰c( 100⁰F),
 Neutrophils count(PMNs) in ascitic fluid>250cell/ mm3
 Altered mental status
Treatment includes
 General care (Fluids, analgesia, gastric decompression, vital support)
 Broad spectrum antibiotic( eg; cefotaxime, ceftriaxone, ..)

15. Management cont’d
Secondary peritonitis
Approach:( control infectious causes, eliminate bacteria and toxins, maintain organ
functions).
Interventional procedures
Antibiotic, fluid resuscitation, electrolytes and supportive care
Interventional procedures
 Surgery
 Extensive laparoscopic irrigation( lavage), debridement, drainage

16. Management cont’d
A) Interventional cont’d
 U/S or CT -guided percutaneous drainage of absesses
 Scheduled revision surgery( second look surgery) frequently necessary for extensive disease
B) General: hospital monitoring possibly ICU
C) Medical: broad spectrum antibiotics
 Ciprofloxacin or ceftriaxone+/- metronidazole
 In severe peritonitis: carbapenems eg: imipenem or meropenem
 Piperacillin +tazobactam
 Ampicillin + sulbactam +/- gentamycin
 Analgesics,thrombosis prophylaxis

17. Complications
• Paralytic adynamic ileus
• Sepsis
• Adhesions leading to mechanical ileus
• Enterocutaneous fistula
• Abdominal compartment syndrome

18. Take home message
• Peritonitis; inflammation of peritoneum often caused by bacteria
• Primary or SBP when there underlying ascites
• Secondary when there is preexisting acute abdominal diseases
• Clinics: severe abdominal pain, guarding, nausea and vomiting
• Surgical emergency
• Diagnostics: clinical presentation, imaging, and peritoneal fluid analysis
• TX; Medical vs surgical interventions
• Complications: Ileus, sepsis or abdominal compartment syndrom

19. References
• www.amboss.com
• www.uptodates.com
• www.medscape.com
• Baily and love’s short practice of surgery

20. Thank you!!!!!!!!!!!!!!!!!!

21. Addittional slides

22. Causes of Diffuse abdominal pain continued