Acute Peritonitis

Peritonitis is an inflammation of the peritoneum; it may be localized or diffuse in location, acute

or chronic in natural history, infectious or aseptic in pathogenesis. Acute peritonitis is most often
infectious and is usually related to a perforated viscus (and called secondary peritonitis). When
no intraabdominal source is identified, infectious peritonitis is called primary or spontaneous.
Acute peritonitis is associated with decreased intestinal motor activity, resulting in distention of
the intestinal lumen with gas and fluid. The accumulation of fluid in the bowel together with the
lack of oral intake leads to rapid intravascular volume depletion with effects on cardiac, renal,
and other systems.
Etiology
Infectious agents gain access to the peritoneal cavity through a perforated viscus, a penetrating
wound of the abdominal wall, or external introduction of a foreign object that is or becomes
infected (for example, a chronic peritoneal dialysis catheter). In the absence of immune
compromise, host defenses are capable of eradicating small contaminations. The conditions that
most commonly result in the introduction of bacteria into the peritoneum are ruptured appendix,
ruptured diverticulum, perforated peptic ulcer, incarcerated hernia, gangrenous gall bladder,
volvulus, bowel infarction, cancer, inflammatory bowel disease, or intestinal obstruction.
However, a wide range of mechanisms may play a role (Table 294-2). Bacterial peritonitis can
also occur in the apparent absence of an intraperitoneal source of bacteria (primary or
spontaneous bacterial peritonitis). This condition occurs in the setting of ascites and liver
cirrhosis in 90% of the cases, usually in patients with ascites with low protein concentration (<1
g/L) (Chap. 302). Bacterial peritonitis is discussed in detail in Chap. 121.

Table 294-2 Conditions Leading to Secondary Bacterial Peritonitis

Perforations of bowel
Trauma, blunt or penetrating
Inflammation
Appendicitis
Diverticulitis
Peptic ulcer disease
Inflammatory bowel disease

Iatrogenic
Endoscopic perforation
Anastomotic leaks
Catheter perforation
Vascular
Embolus
Ischemia
Obstructions
Adhesions
Strangulated hernias
Volvulus
Intussusception
Neoplasms
Ingested foreign body, toothpick, fish bone

Perforations or leaking of other organs

Pancreaspancreatitis
Gall bladdercholecystitis
Urinary bladdertrauma, rupture
Liverbile leak after biopsy
Fallopian tubessalpingitis
Bleeding into the peritoneal cavity

Disruption of integrity of peritoneal cavity

Trauma
Continuous ambulatory peritoneal dialysis (indwelling catheter)
Intraperitoneal chemotherapy
Perinephric abscess
Iatrogenicpostoperative, foreign body

Aseptic peritonitis may be due to peritoneal irritation by abnormal presence of physiologic fluids
(e.g., gastric juice, bile, pancreatic enzymes, blood, or urine) or sterile foreign bodies (e.g.,
surgical sponges or instruments, starch from surgical gloves) in the peritoneal cavity or as a
complication of rare systemic diseases such as lupus erythematosus, porphyria, or familial
Mediterranean fever (Chap. 323). Chemical irritation of the peritoneum is greatest for acidic
gastric juice and pancreatic enzymes. In chemical peritonitis, a major risk of secondary bacterial
infection exists.
Clinical Features
The cardinal manifestations of peritonitis are acute abdominal pain and tenderness, usually with
fever. The location of the pain depends on the underlying cause and whether the inflammation is
localized or generalized. Localized peritonitis is most common in uncomplicated appendicitis
and diverticulitis, and physical findings are limited to the area of inflammation. Generalized
peritonitis is associated with widespread inflammation and diffuse abdominal tenderness and
rebound. Rigidity of the abdominal wall is common in both localized and generalized peritonitis.
Bowel sounds are usually absent. Tachycardia, hypotension, and signs of dehydration are
common. Leukocytosis and marked acidosis are common laboratory findings. Plain abdominal
films may show dilation of large and small bowel with edema of the bowel wall. Free air under
the diaphragm is associated with a perforated viscus. CT and/or ultrasonography can identify the
presence of free fluid or an abscess. When ascites is present, diagnostic paracentesis with cell
count (>250 neutrophils/
L is usual in peritonitis), protein and lactate dehydrogenase

levels, and culture is essential. In elderly and immunosuppressed patients, signs of peritoneal
irritation may be more difficult to detect.
Therapy and Prognosis

Treatment relies on rehydration, correction of electrolyte abnormalities, antibiotics, and surgical

correction of the underlying defect. Mortality rates are <10% for uncomplicated peritonitis
associated with a perforated ulcer or ruptured appendix or diverticulum in an otherwise healthy
person. Mortality rates of
40% have been reported for elderly people, those with

underlying illnesses, and when peritonitis has been present for >48 h.