Peritonitis is an infection bacterial or fungal infection of the peritoneum, or a tissue type silk membrane covering the abdominal wall and internal organs inside the abdomen.
Infectious peritonitis may result from a rupture (perforation) in the abdomen or may be a complication of other diseases.
Peritonitis requires immediate medical attention to combat infection and, if necessary, to treat the underlying disease.
The septic peritonitis is characterized by local or generalized infection in the abdominal cavity. It may be primitive or caused by bacteria.
The acute peritonitis is a sudden infection of the peritoneum, for example, it is the result of perforation of an organ.
The chronic peritonitis is an inflammation of the peritoneum long term.
The causes can be:
- Repeat infections, such as pelvic inflammatory disease (PID),
- Foreign substances such as talc,
- Chronic diseases within the abdomen such as tuberculosis , cirrhosis or chronic alcoholism.
There are two main types of peritonitis.
The primary peritonitis or spontaneous bacterial peritonitis occurs when the infection spreads from the blood and lymph nodes in the peritoneum. This type of peritonitis is rare – less than 1% of cases of peritonitis.
It usually occurs if the patient suffers from cirrhosis and ascites (fluid in the abdomen).
If this fluid becomes infected with certain bacteria (for example, pneumococci and streptococci) they can cause spontaneous bacterial peritonitis, which is a very serious and often deadly 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 a chemical peritonitis because other harmful substances can enter the peritoneum as well as bacteria: gastric and pancreatic juices, mucus , bile, and urine.
Both cases of peritonitis are very serious and can be a threat to life if not treated quickly.
Causes of Acute Peritonitis
The infection may develop directly in the peritoneum, or it may spread to another part of the body.
Infection of other parts of the body
Often, peritonitis is caused by an infection that spreads into the peritoneum of another part of the body. This is known as secondary peritonitis.
Common causes of secondary peritonitis are:
- Stomach ulcer
- Acute appendicitis
- Acute pancreatitis ( inflammation of the pancreas)
- Severe trauma to the abdomen, such as a knife wound or a firearm.
- Digestive disorders such as diverticulitis or Crohn’s disease .
Biliary peritonitis occurs when bile fluid escapes from the gallbladder or bile ducts. It is a serious complication and can be caused by inflammation or gallbladder stones.
Both Crohn’s disease and diverticulitis can inflame the colon .
If the inflammation is particularly severe, the colon may break and may discharge the contents of the intestine into the peritoneum, contaminating it with the bacteria.
Rarely, peritonitis occurs when the peritoneum has an infection.
This is known as primary or spontaneous peritonitis.
In most cases, primary peritonitis is caused by cirrhosis of the liver or peritoneal dialysis.
fibrosis (known as cirrhosis) can occur due to liver damage. The most common causes of cirrhosis are alcohol abuse, hepatitis C infection, or obesity.
Cirrhosis can lead to an accumulation of fluid inside the abdomen (called ascites). This fluid is especially vulnerable to infection and creates an environment where bacteria or fungi can grow and spread.
This accumulation of fluid affects about half of people with cirrhosis, usually many years after it was diagnosed.
About 20% of people who develop cirrhosis with ascites develop spontaneous bacterial peritonitis.
People with renal failure who undergo a therapy known as peritoneal dialysis are at risk of developing peritonitis. Dialysis is a medical treatment that replicates the main functions of the kidneys and removes waste products from the body.
Peritoneal dialysis is done using the peritoneum to perform the main function of the kidneys, that is, to filter the waste from the blood. A small tube called a catheter is implanted into the blood vessels of the peritoneum to remove the waste.
The following factors may increase the risk of primary peritonitis:
- Liver disease (cirrhosis),
- Liquid in the abdomen,
- Impaired immune system,
- Pelvic inflammatory disease.
Risk factors for secondary peritonitis:
- Appendicitis (inflammation of the appendix),
- Ulcers of stomach,
- Intestinal torsion or laceration,
- Inflammatory bowel disease, such as Crohn’s disease or ulcerative colitis ,
- Injury caused by surgery,
- Peritoneal dialysis,
Symptoms of Acute Peritonitis
The first symptoms of peritonitis are loss of appetite, nausea and dull abdominal pain that quickly turns into very strong and persistent belly pain that is aggravated by any movement.
Other signs and symptoms related to peritonitis are:
- Abdominal distension or numbness,
- Chills ,
- Fever ,
- Fluid in the abdomen,
- Excessive thirst,
- Urinate little or less than usual,
- Difficulty in digestion,
- Vomiting .
If peritonitis is not treated it can extend beyond the peritoneum where it can cause:
1. A blood infection (bacteremia).
2. A whole body infection (sepsis or sepsis). Sepsis is a rapidly progressive disease, is dangerous and can cause shock and insufficiency of some organs.
3. Retroperitoneal abscesses.
4. Abdominal and intestinal adhesions.
Diagnosis of peritonite
Those who have symptoms of peritonitis should call their doctor.
Patients on peritoneal dialysis who have a combination of belly pain and cloudy peritoneal fluid should go to the doctor immediately because the cause may be a buildup of white blood cells that fight infection.
Because peritonitis can quickly lead to life-threatening complications such as sepsis and septic shock that causes a huge drop in blood pressure , organ failure and death, it is essential to receive a rapid diagnosis followed by proper treatment.
The doctor asks for the symptoms and medical history and then performs a thorough physical examination to assess the pain and hardness of the abdomen.
The exams for peritonitis are:
- Blood tests ,
- Image exams such as radiography and computed tomography (CT).
- Exploratory surgery,
- The doctor may also perform a paracentesis, a procedure in which fluid from the abdominal cavity is removed with a fine needle to look for infection. Paracentesis is useful for identifying primary and secondary spontaneous peritonitis caused by pancreatitis.
Treatment for peritonitis
If you get a diagnosis of peritonitis, your doctor probably prescribes a hospitalization for control.
In many cases, emergency surgery is needed, especially if peritonitis was caused by diseases such as:
- Perforated gastric ulcer,
- Perforation of the gallbladder
- Colon perforation caused by ulcerative colitis , Crohn’s disease or toxic megacolon
The infected tissue, for example in the case of appendicitis or abscess, should be removed surgically.
The surgeon must also remove the peritoneal tissue severely damaged by the infection.
In the case of peritonitis caused by pancreatitis or pelvic inflammatory disease, in the early stages surgery is not done because the patient could heal without surgery.
Other supportive measures are required if the patient has an organ failure caused by sepsis which is a possible complication of peritonitis.
These therapies include injecting intravenous fluids, medicines to keep blood pressure at an adequate level, and nutritional support (nasogastric tube).
Initial treatment of peritonitis requires injections of antibiotics (cefotaxime, Cefriaxone, Cefocid, etc.) or antifungal medicines. This treatment usually lasts for 10 to 14 days.
If peritonitis is caused by peritoneal dialysis, antibiotics can be injected directly into the tissue of the peritoneum. Studies have shown that it is more effective than a vein injection.
In addition, it is necessary to use an alternative method of dialysis, such as hemodialysis (the blood goes through a machine through a filter) until the peritonitis is present.
If peritonitis causes pain, the doctor may prescribe pain medications.
Support for nutrition
Many people with peritonitis have problems with digestion and food processing, so you may need a feeding tube.
The tube enters the stomach through the nose (nasogastric tube) or is inserted surgically into the stomach through the belly.
If these are inadequate, nutrition can be administered directly into one of the veins (parenteral nutrition).
If a part of the peritoneal tissue has been seriously damaged by the infection, surgical removal may be necessary.
Some people develop abscesses (swollen areas of pus) in the peritoneum that need to be drained with a needle.
This is done using a machine to perform the ultrasound to guide the needle.
Usually local anesthesia is used to not feel pain.
If necessary, the cause of peritonitis can be treated surgically.
Surgery is usually performed in laparotomy, with a vertical incision below the navel.
For example, if an appendicitis caused peritonitis, the appendix should be removed.
Prognosis of peritonitis
The prognosis depends on the cause of peritonitis. Prospects for people with secondary peritonitis are worse, especially for the elderly, people with weakened immune systems and those who have had symptoms for more than 48 hours before starting treatment.
Long-term expectations for people with primary peritonitis due to liver disease tend to be short.
However, the prognosis for primary peritonitis in children is generally very good after antibiotic treatment .
Although peritonitis can be a complication of peritoneal dialysis, it is much less common when using state-of-the-art technologies and self-treatment techniques that the doctor teaches during initial training.
If peritoneal dialysis is performed, the peritonitis risk can be reduced by following these tips:
- Wash hands, including areas between fingers and under fingernails before touching the catheter ,
- Wear a nose / mouth mask during dialysis,
- Follow the correct technique of sterile dialysis,
- Apply an antibiotic cream where the catheter comes out every day,
- Report any contamination of the fluid from the dialysis catheter to the nurse who is doing the peritoneal dialysis. In many cases, a single dose of antibiotic can prevent contamination in an infection.