Peritonitis is a bacterial or fungal infection of the peritoneum, that is, a membrane of silk-like tissue that lines the inner abdominal wall and organs inside the abdomen.
Infectious peritonitis can result from a rupture (perforation) in the abdomen or from a complication of other diseases.
Peritonitis requires immediate medical attention to fight the infection and, if necessary, to treat the underlying diseases.
The septic peritonitis is characterized by local or widespread infection to the abdominal cavity. It can be primary or caused by bacteria.
The acute peritonitis is a sudden infection of the peritoneum, which may result from the drilling of an organ.
The chronic peritonitis is an inflammation of the peritoneum long term.
Possible causes include:
- Repeated infections, such as pelvic inflammatory disease (PID),
- Foreign substances such as talc,
- Chronic diseases inside the abdomen, such as tuberculosis , cirrhosis or chronic alcoholism.
Classification of peritonitis
There are two main types of peritonitis.
The primary peritonitis or spontaneous bacterial peritonitis occurs when the infection spreads from the lymph nodes to the peritoneum. This type of peritonitis is rare (less than 1% of cases of peritonitis).
It usually occurs if the patient suffers from cirrhosis of the liver and in the presence of ascites (fluid in the abdomen).
If this liquid is infected with certain bacteria (for example pneumococci or streptococci) it can cause spontaneous bacterial peritonitis, which is a very serious and often fatal disease.
The secondary peritonitis is the most common type and occurs when the infection enters the peritoneum through a hole in the abdominal wall. Secondary peritonitis often becomes chemical peritonitis, because in addition to bacteria, other harmful substances such as gastric and pancreatic juices, mucus , bile and urine can enter the peritoneum .
Both cases of peritonitis are very serious and can be life-threatening if not treated quickly.
Causes of acute peritonitis
The infection can develop directly in the peritoneum or be transmitted from other parts of the body.
Infections of other parts of the body
Peritonitis often has its origin in an infection that spreads to the peritoneum from another part of the body.
This is called secondary peritonitis.
The most common causes of secondary peritonitis are:
- Stomach ulcers
- appendicitis acute
- Acute pancreatitis (inflammation of the pancreas)
- Severe trauma to the abdomen, such as a wound with a knife or a firearm
- Digestive disorders, such as diverticulitis or Crohn’s disease
Biliary peritonitis occurs if the bile fluid leaks out of the gallbladder or bile ducts. It is a serious complication and may be due to inflammation or gallbladder calculus.
Both Crohn’s disease and diverticulitis can inflame the colon .
If the inflammation is especially severe, the colon can break and expel the contents of the intestine to the peritoneum, contaminating it with bacteria.
Rarely, peritonitis occurs when the peritoneum is directly infected.
This is called primary or spontaneous peritonitis.
In most cases, primary peritonitis has its origin in liver cirrhosis or peritoneal dialysis.
Liver fibrosis, known as cirrhosis, can occur due to liver damage. The most common causes of cirrhosis are excess alcohol, hepatitis C infection or obesity.
Cirrhosis can lead to an accumulation of fluid inside the abdomen (called ascites ). This fluid is particularly vulnerable to infection and creates an environment where bacteria or fungi can grow and spread.
This accumulation of fluid affects approximately half of people with cirrhosis, usually many years after the diagnosis of cirrhosis.
About 20% of people with cirrhosis who develop ascites also develop spontaneous bacterial peritonitis.
People with kidney failure undergoing treatment known as peritoneal dialysis are at risk of developing peritonitis. Dialysis is a medical treatment that replaces the main functions of the kidneys and eliminates waste products from the body.
Peritoneal dialysis is carried out using the peritoneum to perform the primary function of the kidneys, ie to filter the waste products from the blood. A small tube, called a catheter, is implanted in the blood vessels to remove waste products.
Risk factors for peritonitis
The following factors may increase the risk of primary peritonitis:
- Liver diseases (cirrhosis),
- Liquid in the abdomen,
- Poor immune system,
- Pelvic inflammatory disease.
Risk factors for secondary peritonitis:
- Appendicitis (inflammation of the appendix),
- Stomach ulcers ,
- Intestine twisted or torn,
- Inflammatory bowel diseases, such as Crohn’s disease or ulcerative colitis ,
- Injury caused by an operation,
- Peritoneal dialysis,
Symptoms of acute peritonitis
The first symptoms of peritonitis are loss of appetite , nausea and dull abdominal painthat quickly turns into persistent and very strong stomach pain that gets worse with any movement.
Other signs and symptoms related to peritonitis are:
- Numbness or bloating,
- Chills ,
- fever ,
- Liquid in the abdomen,
- But the bottoms;
- Urinate little or less than usual,
- Difficulty digestion ,
- Vomit .
Complications of peritonitis
If the peritonitis is not treated it can extend beyond the peritoneum, where it can cause:
- A blood infection (bacteremia).
- An infection throughout the body (sepsis). Sepsis has a rapid progression, is dangerous and can cause hypovolemic shock and insufficiency of some organs.
- Retroperitoneal abscesses
- Abdominal and intestinal adhesions.
Diagnosis of peritonitis
People who experience the symptoms of peritonitis should see their doctor immediately.
Patients undergoing peritoneal dialysis who present with a combination of abdominal pain and turbid peritoneal fluid should immediately seek medical advice, as the cause may be an accumulation of white blood cells that fight infection.
Since peritonitis can quickly lead to life-threatening complications, such as sepsis and septic shock, which causes a massive drop in blood pressure , organ failure and death, it is essential to obtain a rapid diagnosis, followed by appropriate treatment.
The doctor asks about the symptoms and medical history, then performs a complete physical examination to evaluate the pain and the hardness of the abdomen.
The tests for peritonitis are:
- Blood tests ,
- Instrumental imaging tests such as radiography and CT,
- Exploratory surgery
- The doctor may also perform a paracentesis, a procedure in which the fluid is removed from the abdominal cavity by a fine needle to look for infection. Paracentesis is useful to identify spontaneous primary and secondary peritonitis caused by pancreatitis.
Treatment for peritonitis
If peritonitis is diagnosed, it is usual for the doctor to order a hospitalization to monitor the patient.
In many cases, emergency surgery is required, especially if the peritonitis has its origin in diseases such as:
- Perforated stomach ulcer,
- Perforation of cholecystitis (gallbladder),
- Perforation of the colon caused by ulcerative colitis , Crohn’s disease or toxic megacolon,
Infected tissue, for example in case of appendicitis or abscess, should be surgically removed.
It is also necessary to remove the peritoneal tissue that has been severely damaged by the infection.
In the case of peritonitis caused by pancreatitis or pelvic inflammatory disease, surgery is not carried out in the early stages, since the patient can be cured without intervention.
Other supportive treatments may be necessary if the patient develops organ failure due to sepsis, which is a possible complication of peritonitis.
Among these treatments, it is worth mentioning the intravenous injection of fluids, the administration of drugs to maintain blood pressure in normal values and nutritional support (nasogastric tube).
Initial treatment for peritonitis involves the injection of antibiotics (cefotaxine, cefriaxone, etc.) or antifungal drugs. This treatment usually lasts 10-14 days.
If peritonitis is due to peritoneal dialysis, antibiotics can be injected directly into the peritoneal tissue. Research has shown that it is more effective than vein injection.
In addition, it is necessary to adopt an alternative method of dialysis, such as hemodialysis (blood passes to a machine through a filter), until the peritonitis disappears.
If peritonitis causes pain, the doctor may administer pain medications.
Many people with peritonitis suffer from digestive problems and food processing, so they may need a feeding tube.
The tube can enter the stomach through the nose (nasogastric tube) or surgically inserted into the stomach through the abdomen.
If these probes are not adequate, nutrition can be administered directly into a vein (parenteral nutrition).
If part of the peritoneum tissue has been severely damaged by the infection, surgical removal may be required.
Some people develop abscesses (inflamed areas of pus) in the peritoneum that must be drained with a needle, for which ultrasound devices are used to guide the needle.
Generally, local anesthesia is used to not feel pain.
If necessary, the cause of peritonitis can be treated surgically.
The surgery is usually performed by laparotomy through a vertical incision under the navel.
For example, if the peritonitis is due to an appendicitis, the appendix must be eliminated.
Prognosis of peritonitis
The prognosis of peritonitis depends on the cause.
The outlook for people with secondary peritonitis is worse, especially for the elderly, people with a weakened immune system and those who have symptoms for more than 48 hours before starting treatment.
The long-term prognosis for people with primary peritonitis, due to liver disease, also tends to be short. However, the prognosis of primary peritonitis among children is generally very good after treatment with antibiotics.
Prevention of peritonitis
Although peritonitis can be a complication of peritoneal dialysis, it is much less common if the state-of-the-art technology and self-treatment techniques taught during initial training are used.
If peritoneal dialysis is performed, the risk of peritonitis can be reduced by following these tips:
- Wash hands thoroughly, including the areas between the fingers and under the nails before touching the catheter.
- Use a nose / mouth mask during dialysis.
- Follow the correct technique of sterile dialysis.
- Apply an antibiotic cream at the point where the catheter comes out every day.
- Immediately report any contamination of dialysis fluid or catheter to nurses doing peritoneal dialysis. In many cases, a single dose of antibiotics can prevent the transformation of contamination into infection.