Peritonitis

Introduction

Peritonitis is an inflammation of the peritoneum, which can occur locally or generalized throughout the peritoneum. Depending on the cause of the inflammation, a distinction is made between primary and secondary peritonitis. If the therapy is insufficient or too late, it can take a lethal course.

Information on the anatomy can be found here: Peritoneum, peritoneal cavityA local inflammation of the peritoneum causes severe localized abdominal pain, such as appendicitis. Often there is a strong local pressure pain, possibly also a pain of release and a defence tension in the area of the inflammation. Pain may be caused by tensing the thigh and lifting the thigh against a force that causes pain in the area of the inflammation.

This is called psoas pain. The general condition is often not affected and at rest the pain can stop. Generalised peritonitis, on the other hand, makes the patient look seriously ill. At first glance, it is obvious that the patient is life-threatened.

The face is often very sunken and grey, and breathing is accelerated. Patients suffer from severe abdominal pain throughout the entire abdominal cavity with an increasing defence tension. This causes the abdominal muscles to harden, making the abdomen hard as a board.

The entire symptomatology of an acute generalised peritonitis is called acute abdomen and is usually accompanied by intestinal obstruction. This is caused by inflammation and is therefore called paralytic ileus. Bowel sounds are then no longer audible.

Furthermore, generalised peritonitis is usually accompanied by symptoms such as nausea, vomiting, constipation and fever. If not treated quickly enough, the symptoms can lead to shock symptoms with low blood pressure, palpitations (tachycardia) or massive slowing of the heartbeat (bradycardia), clouding of consciousness and even death. The diagnosis is more difficult in older patients with atrophic abdominal muscles.

In this case the typical symptoms of the acute abdomen are not always present. If peritoneal dialysis is the cause of the inflammation, the first thing that is often noticed is the altered dialysate, which is clouded due to numerous inflammatory cells. The most common cause of peritonitis is appendicitis.

In this case, germs such as Escherichis coli, enterococci, rarely also salmonella, staphylococci or streptococci are released. If the appendicitis is detected in time and operated on, the peritoneum is only locally inflamed. In the event of a rupture of the appendix (appendix perforation) or a perforation of other organs in the abdomen, an acute and life-threatening generalised peritonitis results very quickly.

Furthermore, acute biliary inflammation is a frequent cause of peritonitis in the right upper abdomen. The causes of peritonitis are numerous. If the peritonitis is caused by a previous operation, it is called postoperative peritonitis.

There are also many causes for this. It is generally true that no matter what the cause, peritonitis is always life-threatening. The increased life-threatening potency is due to the fact that the intestinal contents are very rich in bacteria (especially enterococci and coli bacteria (Escherichia coli)).

Peritonitis caused by intestinal contents can occur, for example, in the course of an appendicitis or can also be triggered by a colonoscopy when a perforation (rupture) of the intestine occurs. If the blood supply to intestinal loops is cut off by an operation (intestinal artery occlusion) or if an operation provokes an intestinal obstruction (ileus), this part of the intestine dies at some point and the intestinal wall becomes permeable to bacteria, which can then enter the abdominal cavity. This process is called peritonitis.

  • On the one hand, a lack of sterility during the operation can cause germs to be carried into the operating area, which then trigger an inflammation there and thus lead to peritonitis. – Often peritonitis is also caused by a wound suture that opens again, causing secretions to escape from the “leaking” organ, such as the pancreas (pancreas), gall bladder and intestine, and leading to severe inflammatory reactions. This progresses particularly quickly in the context of an inflammation of the gall bladder, for example, when an inflammation is currently taking place in the “leaking” organ.

However, a simultaneous inflammation is not a prerequisite for peritonitis. The discharge of body fluids alone is sufficient, because gastric juice, bile and pancreatic secretion attack the peritoneum, among other things, due to their aggressive pH values, and thus trigger a chemical peritonitis. This is particularly life-threatening when large quantities of intestinal contents enter the peritoneal cavity.

Laboratory tests show that peritonitis initially leads to significantly increased inflammation parameters. These include the CRP and a clearly too high leukocyte count in the blood count. In addition, the blood sedimentation rate (BSG) is greatly accelerated due to the high cell count.

As the inflammation progresses, changes in the coagulation parameters (Quick, PTT and drop in platelet count) occur as a sign of significantly increased consumption (consumption coagluopathy). Changes in kidney values with increasing creatinine and urea as well as increasing transaminases and a decreasing cholinesterase as signs of liver failure and a drop in hemoglobin are the first signs of multiorgan failure. Ultrasound (sonography) of the abdomen shows free fluid and free air as signs of organ perforation.

In addition, a significantly reduced movement of the intestine is visible as a sign of intestinal obstruction. In many cases it is possible to find the cause, such as an organ perforation or an organ inflammation, with the help of ultrasound. With a simple X-ray image without contrast medium while standing and lying on one side, fluid levels in the intestine and free air under the diaphragmatic caps are often visible.

The diagnostic signs of peritonitis mentioned above refer to a generalised peritonitis. In the case of local inflammation of the peritoneum, often only the inflammation values are slightly elevated. It is possible that some free fluid is visible sonographically in the area of the inflammation as a sign of inflammation-related oedema.

Free air hanging occurs only in the context of a hollow organ perforation. The therapy of an acute local inflammation of the peritoneum is always surgical. The aim is to perform the operation as early as possible to avoid serious complications and generalised peritonitis.

The basic principles of the therapy of peritonitis are the removal of the focus of the inflammation, i.e. a definitive surgical treatment of the underlying disease. This means that, depending on the cause, the appendix, the gall bladder or parts of the intestine are removed. Existing ulcerations are sutured over and thus firmly closed.

If parts of the intestine have to be removed, an artificial intestinal outlet (enterostoma) is often created first, as anastomoses of intestinal sections in inflammatory tissue often do not hold. The repositioning and final anastomosis closure of the intestinal parts then takes place after a few weeks and the inflammation has subsided. In addition, all necroses, pus coatings and fibrin coatings are repaired and removed.

These represent an ideal breeding ground for bacteria and germs and must therefore be removed thoroughly. In generalised peritonitis, purulent ascites are often found throughout the peritoneal cavity. In order to completely free the peritoneal cavity from pus remains, the abdomen is thoroughly rinsed with saline solution or Ringer’s solution.

A drainage is then always provided to drain off any accumulating secretions. Since generalised peritonitis is a life-threatening septic clinical picture with possible organ failure, follow-up treatment is always first carried out in the intensive care unit. Many patients must continue to be ventilated during this time, as the circulatory situation can be critical.

This also facilitates adequate pain medication, since most highly potent painkillers such as morphine dampen the respiratory drive. Furthermore, broad-spectrum antibiotics are administered to combat blood poisoning. Fluid and organ-supporting drugs are given intravenously depending on the individual situation.

Depending on the severity of the peritonitis, the timing of the appropriate therapy and the patient’s general condition, the lethality rate of a pronounced peritonitis is 50%. The duration of peritonitis depends on its course. It can be a localised infection or an inflammation that has spread throughout the body via the bloodstream, resulting in blood poisoning (sepsis).

The duration of the disease also depends on its cause and treatment. In very few cases is a targeted antibiotic therapy sufficient, which is then administered for at least five to seven days. In 99% of the cases peritonitis must be treated surgically. Surgical treatment also involves subsequent antibiotic treatment. Due to the individual course of the disease and the various factors, such as cause, condition and age of the patient, no general duration can be predicted.