Peritonitis

Florian Tiefenböck studied human medicine at the LMU Munich. In March 2014, he joined as a student and has supported the editorial team with medical articles ever since. After receiving his medical license and practical work in internal medicine at the University Hospital Augsburg, he has been a permanent member of the team since December 2019 and, among other things, ensures the medical quality of the tools.

More posts by Florian Tiefenböck All content is checked by medical journalists.

Peritonitis (medical: peritonitis) is an inflammation of the peritoneum (peritoneum) in the abdomen. It is often preceded by another illness. This usually depends on the location, spread and treatment of the peritonitis. Find out everything you need to know about peritonitis here.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. N73K35K65

Peritonitis: description

Peritonitis, known medically as peritonitis, is a life-threatening, inflammatory disease in the abdomen. Below the diaphragm up to the entrance of the small pelvis, a kind of skin surrounds the organs located there. This skin is known as the peritoneum. It usually produces a liquid that acts as a kind of lubricant, making it easier for the abdominal organs to move against each other. If too much fluid is secreted, it is pathological and is called ascites.

In peritonitis, a distinction is made between a primary and a secondary form. The primary form occurs spontaneously through bacteria and is therefore also called spontaneous bacterial peritonitis. The secondary form of peritonitis, on the other hand, is based on other inflammatory diseases in the abdominal cavity. If the inflammation is limited to a certain area, it is called local peritonitis. If it affects the entire abdominal cavity, it is a diffuse peritonitis.

Pseudoperitonitis

This apparent peritonitis can occur with blood sugar disease (diabetes) or in the course of acute and severe hypofunction of the adrenal cortex (Addison's crisis in Addison's disease). Those affected often have severe abdominal pain. Although the symptoms are similar to peritonitis, no inflammation is found on closer examination. The cause of pseudoperitonitis is unclear, but the symptoms are often associated with increased blood sugar levels. Pseudoperitonitis is treated according to the underlying disease, for example by lowering blood sugar levels.

CAPD peritonitis

If a patient's kidneys hardly work or not at all, their blood-cleaning function must be taken over by kidney replacement procedures (dialysis). One form of dialysis is the so-called peritoneal dialysis (CAPD: continuously ambulatory peritoneal dialysis), in which the body is detoxified via the abdominal cavity. Under certain circumstances, the peritoneum becomes inflamed and CAPD peritonitis occurs. This is a dreaded complication and the most common cause of discontinuation of peritoneal dialysis.

Frequency of peritonitis

According to the Federal Statistical Office, around 9502 patients with peritonitis were treated in hospital in 2012. A specific gender distribution or a typical age cannot be determined. Peritonitis was fatal in 569 cases.

Peritonitis: symptoms

Symptoms depend in part on the type of peritonitis.

Primary peritonitis: symptoms

The symptoms of spontaneous bacterial peritonitis are not always easy to grasp. Usually no clinical signs can be found in patients. Fever and abdominal pain may indicate peritonitis. Therefore, the patient should be questioned carefully. Typical diseases associated with peritonitis can often be identified. These include primarily cirrhosis of the liver, chronic liver disease and ascites.

Secondary peritonitis: symptoms

If the peritonitis develops as a result of another inflammation in the abdomen, those affected often have severe abdominal pain.Since the abdominal muscles are tense reflexively, the abdominal wall is often 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, symptoms are initially localized. In the further course they spread unclearly over the entire abdominal cavity.

CAPD peritonitis: symptoms

Peritonitis after peritoneal dialysis causes few or only weak symptoms. The patients feel only moderately ill. As a rule, the temperature is only slightly increased (subfebrile temperature) up to 38 ° C.

Peritonitis: causes and risk factors

When it comes to the causes of peritonitis, two factors must be taken into account: on the one hand, the trigger of the inflammatory process in the peritoneum, on the other hand, the underlying pre-existing diseases.

Peritonitis pathogen

The most common pathogen causing peritonitis, accounting for around fifty percent, is the intestinal bacterium Escherichia coli. This is followed by certain spheroidal bacteria (about thirty percent) and rod bacteria, the so-called Klebsiella, with ten percent. Both are also intestinal bacteria.

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.

Small protrusions of the intestinal wall, so-called diverticula, can also become inflamed (diverticulitis) and cause peritonitis in the further course.

In the upper abdomen, the risk of peritonitis increases if the gallbladder is inflamed (cholecystitis). The same applies to inflammation of the stomach or pancreas. The pathogens are transferred to the peritoneum via the blood or the lymphatic system.

Risk factor breakthrough or leak

Life-threatening conditions are reached when there is a so-called breakthrough in the abdominal organs. This complication can occur as a result of appendicitis or gallbladder inflammation, but also as a result of traumatic events such as an operation or external injuries. A deep, inflammatory defect in the mucous membrane of the intestinal wall (ulcer) can also break open; the natural barrier through the intestinal wall no longer exists. As a result, disease-causing intestinal bacteria are flushed out into the abdominal cavity on a massive scale. These then trigger a diffuse peritonitis.

If the stomach, pancreas, or bile leaks without prior inflammation, this can still lead to peritonitis. Because gastric juice, bile and pancreatic secretions attack the peritoneum and thereby trigger what is known as chemical peritonitis.

Risk factor liver disease with ascites

The blood flow to the liver can be disturbed, for example, by tumors, inflammatory remodeling processes of the liver tissue or blood clots. This increases the pressure in the vessels that lead to the liver. In addition, liver disease leads to decreased protein production. Both factors lead via different mechanisms to an increase in the supply of fluid and a decrease in its removal. A lot of free fluid accumulates in the abdomen, which is called ascites. With this ascites disease, bacteria can also increasingly be washed out, which then attack the peritoneum. In addition to heartburn, shortness of breath and hernias, peritonitis is therefore one of the dangerous complications of ascites. Around fifteen percent of those affected develop such peritonitis, which is also known as spontaneous bacterial or primary peritonitis.

Risk factor circulatory disorders

Abdominal vessels may become blocked by a clot of blood or may no longer be open after an operation in this area. The affected organ is no longer properly supplied with blood and can become inflamed. If the circulatory disorder affects a section of the intestine, it can no longer properly transport its contents. In addition, the intestinal wall then dies and becomes permeable. The doctor speaks of functional intestinal obstruction (paralytic ileus). As a result, the bacteria multiply at this point and produce toxins. This eventually inflames the peritoneum and can lead to life-threatening peritonitis.

Rare cause: cancer

A rare cause of peritonitis is the infestation of the peritoneum with malignant tumor cells, the peritoneal carcinosis. This leads to a non-bacterial inflammatory reaction. In addition, a considerable amount of fluid usually accumulates in the abdomen, which in this case is called malignant ascites.

Peritonitis: diagnosis and examination

When diagnosing a possible peritonitis, it is usually important to be in a hurry. Purulent secondary peritonitis in particular quickly becomes a life-threatening emergency that must be treated quickly.

Interview and physical examination

As with any disease, the doctor first asks the patient about the symptoms they are experiencing. The patient should also inform the doctor about previous operations. The same applies to existing diseases, such as abnormal liver changes and inflammatory bowel diseases such as Crohn's disease. They favor peritonitis. But past infections and diseases also play a role, such as pancreas or stomach inflammation.

During the physical examination, the abdomen is thoroughly examined in order to narrow down the exact area of the pain and to find possible sources of inflammation. If the patient reacts to certain pressure points with pain, this can indicate appendicitis. Inflammation of everted intestinal vesicles (diverticulitis) is mainly found in the left lower abdomen. And a diseased gallbladder manifests itself in a painful episode of the upper abdomen (biliary colic). In addition, there may be indications of ascites.

In order to find the exact cause of peritonitis, the doctor will quickly carry out some tests:

Blood test

With a comprehensive examination of the blood one checks values, the change of which speaks for the disease of a certain organ. In addition, inflammation parameters may be increased. The determination of blood sugar is useful in order to take possible pseudoperitonitis into account.

X-ray examination with contrast agent

The X-ray of the abdomen is done either while standing or lying on the left side. In this way there may be free air in the abdomen, a sign of an intestinal rupture. To confirm the diagnosis, the gastrointestinal tract is displayed using a contrast medium. In this way you can usually find the point of the breakthrough that triggered the peritonitis.

Ultrasound examination

An ultrasound provides information, especially in the case of appendicitis (enlarged, lack of bowel movement, looks like a target). Free fluid (ascites) or free air can also be found in the abdomen. This is how you can narrow down the cause of peritonitis.

Abdominal puncture (ascites puncture)

This is the most important test used 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 liquid obtained is immediately examined in the laboratory (for example to count certain blood cells), on the other hand, so-called cultures are set up, which in some cases can be used to determine the exact pathogen causing the peritonitis.

Computed tomography (CT)

In some cases, CT can be used to find accumulations of pus in the abdomen. In addition, any existing breakthrough point can be shown more precisely.

Examination of the dialysis fluid

If the patient develops peritonitis as a result of peritoneal dialysis, the appearance of the dialysis fluid is groundbreaking. In almost all cases it is cloudy and white blood cells can be found in it.

Peritonitis: Treatment

The treatment of peritonitis depends primarily on what triggers it.

Treatment of primary peritonitis

The spontaneous bacterial peritonitis is treated with antibiotics. If it is the first primary peritonitis, it is treated with so-called quinolones, a group of antibiotics. For example, the person concerned receives ciprofloxacin in tablet form.

However, if the patient is often ill or has already had inflammation of the peritoneum that requires therapy, experts recommend therapy with certain other antibiotics, so-called cephalosporins (group 3a, for example cefotaxime). They are given by infusion into a vein.

Some pathogens have already developed mechanisms that make them resistant to some of these antibiotics. The choice of antibiotic in the treatment of peritonitis is adapted to this development. In order to check the success of the treatment, the doctor again takes ascites off 48 hours after the first administration of the antibiotic in order to have it again examined for germs and white blood cells.

Treatment of secondary peritonitis

Secondary peritonitis is usually associated with a poor, sometimes life-threatening general condition of the patient. The blood pressure drops and the heart rate increases - signs of circulatory shock. First of all, therefore, the circulation must be stabilized. Intensive medical monitoring and care of the patient is almost always necessary.

Since peritonitis is preceded by an underlying disease, it must be treated. Usually there is a defect in the abdomen, for example a rupture of the appendix. This will be remedied operationally. If the defect is small, in some cases a minimal surgical procedure (laparoscopic surgery) with only small incisions is sufficient. In the case of major damage, the doctor opens almost the entire abdominal wall (laparotomy). During the procedure, the abdomen is rinsed (peritoneal lavage). This is intended to remove bacteria, pus, blood and dead tissue.

If the surgeons need to remove sections of the intestine, they may place an artificial anus. This is shifted back after complete healing. In most cases, the abdomen is also drained, with the help of which abnormal and increased fluid is drained away.

Peritonitis itself is treated with certain antibiotics (3rd generation cephalosporins, aminoglycosides, metronidazole). The patient remains in the hospital in order to check the success of the therapy and to be able to monitor his vital body functions.

If the secondary peritonitis develops without organ damage, an operation is not necessary. As a rule, drug treatment with antibiotics is then sufficient.

Peritonitis: disease course and prognosis

In about 90 percent of cases, spontaneous bacterial peritonitis heals with correct and, above all, rapid antibiotic therapy. But relapses are common. It is therefore advisable to give another antibiotic afterwards. The effect of the quinolone norfloxacin was proven in an early study at a clinic in Barcelona. The probability of getting peritonitis again within a year fell from 68 to 20 percent.

The course of primary peritonitis depends on various risk factors. According to several studies, the following have a negative impact:

old age of the patient
Need for intensive care treatment
hospital-acquired spontaneous bacterial peritonitis
poor Child-Pugh score, which assesses cirrhosis of the liver
high kidney value (creatinine)
high level of the blood breakdown product bilirubin (yellow bile pigment)
a brain dysfunction due to the abnormal liver not detoxifying the blood
lack of regression of the infection
Bacteria washed into the blood (bacteremia)

Basically, the prognosis of a patient with liver damage and ascites is worse if a spontaneous bacterial peritonitis occurs. The hospital death rate is then between 21 and 50 percent.

The prognosis of secondary peritonitis depends heavily on the underlying disease and its successful treatment.

Tags: Diagnosis pregnancy drugs