Brief overview
- Symptoms: Depending on the type of peritonitis, abdominal pain, hard tense abdominal wall, distended abdomen, possibly fever, in some cases only a few symptoms.
- Course and prognosis: Serious to life-threatening disease, course depends on cause, patient’s health condition and timely treatment, usually fatal without treatment
- Causes and risk factors: Bacterial infection of the abdominal cavity in primary peritonitis, often accompanying liver disease (e.g., cirrhosis) or renal dysfunction, in secondary peritonitis caused by disease of other abdominal organs, e.g., cholecystitis, diverticulitis, or appendicitis
- Treatment: Depending on the cause of peritonitis, antibiotics, in case of secondary peritonitis therapy of the causes (e.g. surgery in case of appendicitis).
- Prevention: People with severe liver disease (e.g., cirrhosis) and/or ascites, as well as those who have already had primary peritonitis, receive prophylactic antibiotics; otherwise, no general preventive measures are taken.
What are the symptoms?
The symptoms of peritonitis depend, among other things, on the type of peritonitis.
Primary peritonitis: symptoms
Secondary peritonitis: symptoms
If acute peritonitis develops as a result of another inflammation in the abdomen, severe abdominal pain is a common symptom of peritonitis. If the physician palpates the abdomen, he or she usually notices that the patient reflexively tenses the abdominal muscles and that the abdominal wall often feels as hard as a board. Patients feel bad, have a fever and often lie in bed with their legs drawn up.
Depending on where the original focus of inflammation is located, symptoms are initially found locally and later spread diffusely across the abdomen. Pathogens such as chlamydia or gonococcus sometimes cause peritonitis in women, causing symptoms such as pain in the lower abdomen. In this case, the inflammation is limited to the pelvic cavity. Doctors then speak of pelveoperitonitis.
Symptoms of peritonitis in peritoneal dialysis (CAPD)
Peritonitis: course and prognosis
The course of peritonitis depends on the type of peritonitis and other health factors of the patient. In many cases, spontaneous bacterial peritonitis heals with proper and, most importantly, prompt antibiotic therapy. Individuals who have had primary peritonitis before have a higher risk of peritonitis recurring. Therefore, physicians usually recommend preventive antibiotic therapy following the illness.
The course of primary peritonitis depends on several risk factors, including:
- Advanced age of the patient
- Need for intensive care treatment
- Hospital-acquired spontaneous bacterial peritonitis
- Liver cirrhosis of high severity
- High kidney level (creatinine)
- High level of the blood breakdown product bilirubin (yellow bile pigment)
- Lack of regression of the infection
- Bacteria being washed into the blood (bacteremia)
Basically, the prognosis of a patient with liver damage and ascites is worse when spontaneous bacterial peritonitis occurs. The reason is probably that the body is already weakened by the existing disease. The hospital mortality rate is then between ten and 50 percent when peritonitis first occurs.
The prognosis of secondary peritonitis depends largely on the underlying disease and its successful treatment.
Causes and risk factors
When considering the causes of peritonitis, it is important to consider two factors: first, the triggers of the inflammatory event in the peritoneum, and second, the underlying pre-existing conditions.
The causative agent of peritonitis
Risk factor inflammation in the abdomen
Acute appendicitis is one of the most common causes of peritonitis in the lower abdomen. Released germs attack the peritoneum and trigger inflammatory reactions.
Sometimes small protrusions of the intestinal wall, so-called diverticula (diverticulitis), become inflamed and cause peritonitis in the further course.
In the upper abdomen, the risk of peritonitis increases with an inflamed gallbladder (cholecystitis). The same applies to inflammation of the stomach (for example, if a gastric ulcer has broken through) or the pancreas. The pathogens are transmitted to the peritoneum via the blood or the lymphatic system.
Peritonitis in women sometimes occurs as a result of infection with chlamydia or gonococcus (the causative agent of gonorrhea). However, the inflammation then affects the peritoneum of the pelvic cavity. Doctors also refer to this as pelveoperitonitis.
Life-threatening conditions are reached when a so-called perforation occurs in the abdominal organs. This complication occurs, for example, as a result of appendicitis or gallbladder inflammation, but also as a result of traumatic events such as surgery or external injuries. An ulcer (ulcer) of the intestinal wall also sometimes ruptures; as a result, the natural barrier through the intestinal wall no longer exists. As a result, masses of pathogenic intestinal bacteria are flushed out into the abdominal cavity. These then trigger diffuse peritonitis.
If the stomach, pancreas or gall bladder leaks without being preceded by inflammation, this still leads to peritonitis in some cases. This is because gastric juice, bile and pancreatic secretions attack the peritoneum, triggering what is known as chemical peritonitis.
Risk factor liver disease with ascites
Risk factor circulatory disorders
Abdominal vessels may become clogged by a blood clot or no longer pass through after an operation in the area. The affected organ is no longer properly supplied with blood and becomes inflamed. If the circulatory disorder affects a section of the intestine, it no longer transports its contents properly. In addition, the intestinal wall dies and becomes permeable. The medical profession refers to this as functional intestinal obstruction (paralytic ileus). As a result, bacteria multiply at this site and produce toxins. This eventually inflames the peritoneum and sometimes results in life-threatening transit peritonitis.
Rare cause: cancer
What helps against peritonitis?
The treatment of peritonitis depends primarily on its trigger.
Treatment of primary peritonitis
Spontaneous bacterial peritonitis is treated with antibiotics. If it is an uncomplicated primary peritonitis, doctors use antibiotics from the group of active substances known as group 3a cephalosporins. Uncomplicated in this case means that the affected person does not have shock, intestinal obstruction, bleeding from the gastrointestinal tract or other complications. In severe cases, the physician administers the antibiotic directly into the patient’s bloodstream via a venous drip. This allows the antibiotic to work more quickly.
In patients who have additional complications or are allergic to the aforementioned group of active ingredients, antibiotics from the carbapenem group may be considered.
Treatment of secondary peritonitis.
Secondary peritonitis is usually accompanied by a poor, sometimes life-threatening general condition of the patient. In this case, the blood pressure drops and the heart rate increases – signs of circulatory shock. The first step is therefore to stabilize the circulation. Intensive medical monitoring and care of the patient is almost always necessary.
If the surgeons have to remove sections of intestine, they may insert an artificial anus. This is repositioned after complete healing. In most cases, the abdominal cavity is also drained to remove any abnormal and increased fluid.
The peritonitis itself is treated with certain antibiotics (such as 3rd generation cephalosporins). The patient remains an inpatient in the hospital. This allows the success of the therapy to be monitored and the patient’s vital bodily functions to be monitored.
If secondary peritonitis develops without organ damage, surgery is not necessary. As a rule, medical treatment with antibiotics is then sufficient.
What is peritonitis?
Peritonitis is divided into a primary and a secondary form. The primary form occurs spontaneously due to bacteria and is therefore also called spontaneous bacterial peritonitis. The secondary form of peritonitis, on the other hand, originates from other inflammatory diseases in the abdominal cavity. If the inflammation is limited to a specific area, it is called local peritonitis. If it affects the entire abdominal cavity, it is diffuse peritonitis.
Pseudoperitonitis
CAPD peritonitis
If a patient’s kidneys are barely working or no longer working at all, blood washing (dialysis) is usually required. It takes over the kidneys’ task of removing waste products of metabolism from the blood. One particular form of dialysis is called continuous ambulatory peritoneal dialysis (CAPD), in which the body is detoxified through the abdominal cavity. Under certain circumstances, the peritoneum can become inflamed, resulting in CAPD peritonitis. This is a feared complication and the most common cause for discontinuation of peritoneal dialysis.
Incidence of peritonitis
Primary peritonitis is common especially in liver disease associated with ascites.
Diagnosis and examination
The diagnosis of possible peritonitis usually requires urgency. Especially a purulent secondary peritonitis quickly becomes a life-threatening emergency that must be treated quickly.
As with any disease, the doctor first asks the patient about the symptoms that occur. The patient should also inform the doctor about previous operations. The same applies to existing diseases, for example pathological liver changes and chronic inflammatory bowel diseases such as Crohn’s disease. They favor peritonitis. But past infections and diseases also play a role, for example pancreatitis or gastritis.
To find the exact cause of peritonitis, the doctor will quickly perform (have performed) some tests:
Blood test
During a comprehensive examination of the blood, the doctor checks values whose changes indicate the disease of a certain organ (such as liver or kidney values). In addition, inflammation parameters may be elevated. Determination of blood sugar is useful to consider possible pseudoperitonitis.
Ultrasound examination
An ultrasound provides information, especially in the case of appendicitis (enlarged, lack of bowel movement, looks like a target). In addition, free fluid (ascites) or free air in the abdomen can be detected. This is how the doctor narrows down the cause of peritonitis.
X-ray examination with contrast medium
Abdominal puncture (ascites puncture).
This is the most important examination to diagnose primary peritonitis. The doctor takes a sample of the abdominal fluid with a hollow needle that he sticks into the abdominal wall. On the one hand, the fluid obtained is immediately examined in the laboratory (for example, to count certain blood cells), and on the other hand, so-called cultures are created, which are used to determine the type of bacteria involved in the peritonitis.
Computer tomography (CT)
In some cases, CT can be used to find accumulations of pus in the abdominal cavity. It also allows for more accurate visualization of a possible perforation site.
Examination of the dialysis fluid
If the patient develops peritonitis due to peritoneal dialysis, the appearance of the dialysis fluid is indicative. In almost all cases, it is turbid and white blood cells can be found in it.
