This document discusses peritonitis, which is inflammation of the peritoneum often caused by bacterial or fungal infections. It can be primary, secondary, or tertiary. Primary peritonitis occurs without an acute abdominal source, often in patients with ascites. Secondary peritonitis is more common and results from a preexisting acute abdominal condition like perforation or inflammation. Common causes, signs, diagnostic tests, treatment approaches, and complications are outlined. Management involves identifying and treating any infection through antibiotics and surgery as needed to control the infection, eliminate bacteria and toxins, and maintain organ function.

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