View source for Peritonitis

{{About|peritonitis in human beings|a specific cause of peritonitis in cats|Feline infectious peritonitis}}
{{Infobox_Disease |
  Name           = Peritonitis |
  Image          = |
  Caption        = |
  DiseasesDB     = 9860 |
  ICD10          = {{ICD10|K|65||k|65}} |
  ICD9           = {{ICD9|567}} |
  ICDO           = |
  OMIM           = |
  MedlinePlus    = |
  eMedicineSubj  = med |
  eMedicineTopic = 2737 |
  MeshID         = D010538 |
}}
'''Peritonitis''' is an [[inflammation]] of the [[peritoneum]], the [[serous membrane]] that lines part of the [[abdomen|abdominal cavity]] and [[viscera]]. Peritonitis may be localised or generalised, and may result from [[infection]] (often due to [[gastrointestinal perforation|rupture of a hollow organ]] as may occur in [[abdominal trauma]] or [[appendicitis]]) or from a non-infectious process.

==Signs and symptoms==
===Abdominal pain and tenderness===
The main manifestations of peritonitis are acute '''[[abdominal pain]]''', '''[[abdominal tenderness]]''', and '''[[abdominal guarding]]''', which are exacerbated by moving the peritoneum, e.g., coughing (forced cough may be used as a test), flexing one's hips, or eliciting the [[Blumberg sign]] (a.k.a. [[rebound tenderness]], meaning that pressing a hand on the abdomen elicits less pain than releasing the hand abruptly, which will aggravate the pain, as the peritoneum snaps back into place). The presence of these signs in a patient is sometimes referred to as peritonism.<ref name="titleBiology Online's definition of peritonism">{{cite web |url=http://www.biology-online.org/dictionary/Peritonism |title=Biology Online's definition of peritonism |accessdate=2008-08-14 |format= |work=}}</ref> The localization of these manifestations depends on whether peritonitis is localized (e.g., [[appendicitis]] or [[diverticulitis]] before perforation), or generalized to the whole [[abdomen]]. In either case, pain typically starts as a generalized abdominal pain (with involvement of poorly localizing innervation of the visceral [[Peritoneum#Layers|peritoneal layer]]), and may become localized later (with the involvement of the somatically innervated parietal peritoneal layer). Peritonitis is an example of an [[acute abdomen]].

===Collateral manifestations===
* Diffuse abdominal rigidity ("[[washboard abdomen]]") is often present, especially in generalized peritonitis
* [[Fever]]
* [[Sinus tachycardia]]
* Development of [[ileus|ileus paralyticus]] (i.e., intestinal paralysis), which also causes [[nausea]] and [[vomiting]]

===Complications===
* Sequestration of [[fluid]] and [[electrolyte]]s, as revealed by decreased [[central venous pressure]], may cause [[electrolyte disturbance]]s, as well as significant [[hypovolemia]], possibly leading to [[Shock (circulatory)|shock]] and [[acute renal failure]].
* A [[peritoneal abscess]] may form (e.g., above or below the [[liver]], or in the [[lesser omentum]]
* [[Sepsis]] may develop, so [[blood cultures]] should be obtained.
* The fluid may push on the diaphragm, causing splinting and subsequent breathing difficulties.

==Causes==
===Infected peritonitis===
* '''[[Gastrointestinal perforation|Perforation of part of the gastrointestinal tract]]''' is the most common cause of peritonitis. Examples include perforation of the distal [[oesophagus]] ([[Boerhaave syndrome]]), of the [[stomach]] ([[peptic ulcer]], [[gastric carcinoma]]), of the [[duodenum]] ([[peptic ulcer]]), of the remaining [[intestine]] (e.g., [[appendicitis]], [[diverticulitis]], [[Meckel diverticulum]], [[inflammatory bowel disease]] (IBD), [[Bowel infarction|intestinal infarction]], intestinal strangulation, [[colorectal carcinoma]], [[meconium peritonitis]]), or of the [[gallbladder]] ([[cholecystitis]]). Other possible reasons for perforation include [[abdominal trauma]], ingestion of a sharp [[foreign body]] (such as a fish bone, toothpick or glass shard), perforation by an [[endoscope]] or [[catheter]], and [[anastomosis|anastomotic]] leakage. The latter occurrence is particularly difficult to diagnose early, as [[abdominal pain]] and [[ileus|ileus paralyticus]] are considered normal in patients who just underwent [[abdominal surgery]]. In most cases of perforation of a hollow viscus, mixed [[bacteria]] are isolated; the most common agents include [[Gram-negative]] [[bacilli]] (e.g., ''[[Escherichia coli]]'') and [[anaerobic bacteria]] (e.g., ''[[Bacteroides fragilis]]''). Fecal peritonitis results from the presence of [[faeces]] in the peritoneal cavity.  It can result from abdominal trauma and occurs if the [[large bowel]] is perforated during surgery.
* '''Disruption of the [[peritoneum]]''', even in the absence of perforation of a hollow viscus, may also cause infection simply by letting [[micro-organisms]] into the peritoneal cavity. Examples include [[physical trauma|trauma]], [[surgical wound]], continuous ambulatory [[peritoneal dialysis]], and intra-peritoneal [[chemotherapy]]. Again, in most cases, mixed [[bacteria]] are isolated; the most common agents include cutaneous species such as ''[[Staphylococcus aureus]]'', and [[coagulase]]-negative [[staphylococci]], but many others are possible, including [[fungi]] such as [[Candida (genus)|Candida]].
* '''Spontaneous bacterial peritonitis''' (SBP) is a peculiar form of peritonitis occurring in the absence of an obvious source of contamination. It occurs in patients with [[ascites]], in particular, in [[children]]. See the article on [[spontaneous bacterial peritonitis]] for more information.
* '''Intra-peritoneal dialysis''' predisposes to peritoneal infection (sometimes named "tertiary peritonitis" in this context).
* '''Systemic infections''' (such as [[tuberculosis]]) may rarely have a peritoneal localisation.

===Non-infected peritonitis===
* '''Leakage of [[sterilization (microbiology)|sterile]] [[body fluids]] into the peritoneum''', such as [[blood]] (e.g., [[endometriosis]], blunt abdominal [[physical trauma|trauma]]), [[gastric juice]] (e.g., [[peptic ulcer]], [[gastric carcinoma]]), [[bile]] (e.g., [[liver biopsy]]), [[urine]] (pelvic [[physical trauma|trauma]]), [[menstruum]] (e.g., [[salpingitis]]), [[pancreatic juice]] ([[pancreatitis]]), or even the contents of a ruptured [[dermoid cyst]]. It is important to note that, while these [[body fluids]] are sterile at first, they frequently become infected once they leak out of their organ, leading to infectious peritonitis within 24 to 48 hours.
* '''Sterile abdominal surgery''', under normal circumstances, causes localised or minimal generalised peritonitis, which may leave behind a [[foreign body reaction]] and/or fibrotic [[adhesion (medicine)|adhesion]]s. However, peritonitis may also be caused by the rare, unfortunate case of a [[sterile technique|sterile]] [[foreign body]] inadvertently left in the [[abdomen]] after [[surgery]] (e.g., [[gauze]], [[sponge]]).
* Much rarer non-infectious causes may include [[familial Mediterranean fever]], [[porphyria]], and [[systemic lupus erythematosus]].

==Diagnosis==
A [[medical diagnosis|diagnosis]] of peritonitis is based primarily on the clinical manifestations described above. If peritonitis is strongly suspected, then [[surgery]] is performed without further delay for other investigations. [[Leukocytosis]], [[hypokalemia]], [[hypernatremia]], and [[acidosis]] may be present, but they are not specific findings. Abdominal [[X-rays]] may reveal dilated, edematous intestines, although such X-rays are mainly useful to look for [[pneumoperitoneum]], an indicator of [[gastrointestinal perforation]]. The role of whole-abdomen [[ultrasound]] examination is under study and is likely to expand in the future. [[Computed tomography]] (CT or CAT scanning) may be useful in differentiating causes of abdominal pain. If reasonable doubt still persists, an exploratory [[peritoneal lavage]] or [[laparoscopy]] may be performed. In patients with [[ascites]], a diagnosis of peritonitis is made via [[paracentesis]] (abdominal tap): More than 250 [[polymorphonucleate cells]] per μL is considered diagnostic. In addition, Gram stain and culture of the peritoneal fluid can determine the microorganism responsible and determine their sensibility to antimicrobial agents.

===Pathology===
In normal conditions, the [[peritoneum]] appears greyish and glistening; it becomes dull 2–4 hours after the onset of peritonitis, initially with scarce [[serous]] or slightly [[turbid]] fluid. Later on, the [[exudate]] becomes creamy and evidently [[suppurative]]; in dehydrated patients, it also becomes very inspissated. The quantity of accumulated [[exudate]] varies widely. It may be spread to the whole [[peritoneum]], or be walled off by the [[omentum]] and [[viscera]]. [[Inflammation]] features infiltration by [[neutrophils]] with fibrino-purulent exudation.

==Treatment==
Depending on the severity of the patient's state, the management of peritonitis may include:

* '''General supportive measures''' such as vigorous [[intravenous]] [[rehydration]] and correction of [[electrolyte disturbance]]s.
* '''[[Antibiotics]]''' are usually administered [[intravenous]]ly, but they may also be infused directly into the peritoneum. The empiric choice of [[broad-spectrum antibiotics]] often consist of multiple drugs, and should be targeted against the most likely agents, depending on the cause of peritonitis (see above); once one or more agents are actually isolated, therapy will of course be targeted on them.
* '''[[Surgery]]''' ([[laparotomy]]) is needed to perform a full exploration and lavage of the [[peritoneum]], as well as to correct any gross anatomical damage that may have caused peritonitis.<ref name="titlePeritonitis: Emergencies: Merck Manual Home Edition">{{cite web |url=http://www.merck.com/mmhe/sec09/ch132/ch132g.html |title=Peritonitis: Emergencies: Merck Manual Home Edition |accessdate=2007-11-25 |format= |work=}}</ref> The exception is [[spontaneous bacterial peritonitis]], which does not always benefit from [[surgery]] and may be treated with antibiotics in the first instance.

==Prognosis==
If properly treated, typical cases of surgically correctable peritonitis (e.g., perforated [[peptic ulcer]], [[appendicitis]], and [[diverticulitis]]) have a [[mortality rate]] of about <10% in otherwise [[healthy]] [[patient]]s, which rises to about 40% in the [[elderly]], and/or in those with significant underlying [[illness]], as well as in cases that present late (after 48 hours). If untreated, generalised peritonitis is almost always fatal.

==References==
<references/>

==External links==
* [http://www.peritonitis-disease.com Peritonitis disease causes, treatment]
* [http://health.allrefer.com/health/peritonitis-symptoms.html Article on peritonitis] at AllRefer.com
* Genuit T and Napolitano L. 2004.  [http://www.emedicine.com/med/topic2737.htm Peritonitis and Abdominal Sepsis] at Emedicine.com
* [http://www.healthsquare.com/mc/fgmc9043.htm Peritonitis] at HealthSquare.com

{{Gastroenterology}}
{{Inflammation}}

[[Category:Inflammations]]
[[Category:Diseases involving the fasciae]]
[[Category:Medical emergencies]]
[[Category:Surgery]]

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