The patients of peritonitis usually present with abdominal pain, moderate fever and gastrointestinal disturbances (such as vomiting and constipation). In primary bacterial peritonitis, there may be a history of liver disease along with blood in the vomitus or black stools. Secondary bacterial peritonitis often has a more acute onset.

The physical examination of the abdomen shows marked tenderness. There may be distention, rigidity and rebound tenderness. Abdomen does not move with respiration and the bowel sounds are absent.

• Hemophilia A

  Aggressive periosteal reactions can not only be seen with malignant tumors, but also with more benign processes like infection, eosinophilic granuloma (Langerhans cell histiocytosis), aneurysmal bone cyst, osteoid osteoma, hemophilia 4, and trauma. [radiopaedia.org]

  People with hemophilia usually need a replacement of clotting factor, which is a small part of whole blood. People with sickle-cell disease may require frequent blood transfusions. [en.wikipedia.org]

• Pain

  Regularly assess his pain level, using a pain-intensity rating scale, and manage pain appropriately. Be alert for a sudden increase in pain severity (or a sudden decrease in severe pain), which may indicate perforation. [journals.lww.com]

  Seek immediate medical attention if you develop abdominal pain so severe that you're unable to sit still or find a comfortable position. Call 911 or emergency medical assistance if you have severe abdominal pain following an accident or injury. [mayoclinic.org]

  Somatic pain is sharp and fairly easy to pinpoint. Referred pain is pain perceived distant from its source (see Figure: What Is Referred Pain? ). [merckmanuals.com]

• Fever

  Pain, fever, and guarding are common presenting symptoms. Polymicrobial infections are common, including gram positive, gram negative, and anaerobes. [visualdx.com]

  Signs of SBP may include fever, malaise, encephalopathy, worsening hepatic failure, and unexplained clinical deterioration. [merckmanuals.com]

  Rheumatic pleuritis has been frequently described and is recognized clinically in many instances of acute rheumatic fever. [annals.org]

  On the second week of treatment, after an initial good response, the patient experienced severe abdominal pain, with fever and a turbid fluid. [revistanefrologia.com]

  The patient, a 53-year-old Caucasian woman from the Faroe Islands was admitted to the National Hospital reporting of constant abdominal pain and a fever. Peritoneal cultures were positive for growth of L. monocytogenes. [ncbi.nlm.nih.gov]

• Sepsis

  Sepsis indicates an infection causing systemic symptoms and usually occurs when bacteria from local reactions enter the bloodstream. One reason the terms are often confused is peritonitis is sometimes called abdominal sepsis. [apollomd.com]

  Unlike selenium, glutamine could be a sepsis biomarker for individuals with peritonitis. We recommend including glutamine as a biomarker for sepsis severity assessment in addition to the commonly used clinical indicators. [ncbi.nlm.nih.gov]

  Left untreated, peritonitis can rapidly spread into the blood ( sepsis ) and to other organs, resulting in multiple organ failure and death. [webmd.com]

  Sepsis Sepsis can occur if the infection spreads through the blood (septicaemia) and then to other organs. If sepsis is not treated, it can progress to a more serious phase known as severe sepsis. [your.md]

• Chills

  Other symptoms may include: Fever and chills Passing little or no stools or gas Excessive fatigue Passing less urine Nausea and vomiting Racing heartbeat Shortness of breath The health care provider will perform a physical exam. [nlm.nih.gov]

  Some of the principal symptoms of peritonitis are: severe, steady abdominal pain, abdominal distention, fever (over 38.0° C), chills, associated with abundant perspiration, weakness, vomiting and nausea, loss of appetite, the skin turns pale and cold, [peritonitis-disease.com]

  Pain may persist for several hours and is worsened by movement or pressure on the abdomen Board-like rigidity of the abdomen, due to contraction of the muscles of the abdominal wall Swollen or bloated abdomen Chills and fever, with profuse perspiration [healthcentral.com]

• Hypothermia

  The most common presenting symptoms and signs were abdominal distention, emesis, obstipation, and hypothermia. [jpedsurg.org]

  In serious cases, peritonitis can cause life-threatening issues like shock, sepsis, hypothermia, internal bleeding, or an obstruction in the intestines. The severity of these symptoms often depends on what caused the inflammation in the first place. [verywellhealth.com]

  A high fever is present in the initial stages but in severe peritonitis there may be hypothermia. Tachycardia is usually present. The classic abdominal signs are tenderness on palpation, guarding and rebound tenderness. [patient.info]

• Dyspnea

  Note respiratory rate, rhythm, and depth and report dyspnea and accessory muscle use. Auscultate the lungs bilaterally for adventitious or diminished breath sounds. [journals.lww.com]

  Mild symptoms (myalgia, headache, nausea, dyspnea, arthralgia, low back pain, asthenia and anxiety) precede attacks and last about 17 hours. [orpha.net]

  (b) Clinical features (Abdominal pain, distention of abdomen, vomiting, fever, cold peripheries, decreased urine output, constipation, dyspnea, duration of symptoms. [jusurgery.com]

  1994, a new definition was recommended by the American-European Consensus Conference Committee [4][8] which recognized the variability in severity of pulmonary injury.[39] The definition required the following criteria be met: acute onset, persistent dyspnea [en.wikipedia.org]

• Abdominal Pain

  If you develop new abdominal pain or have a new injury Peritonitis may result from a burst appendix or trauma-related abdominal injury. [mayoclinic.org]

  Alerts and Notices Synopsis   Inflammation of the visceral and parietal peritoneum resulting in acute, severe abdominal pain with fever and diffuse abdominal tenderness with rigidity and guarding, most often secondary to an infectious or inflammatory [visualdx.com]

  Patients with peritonitis usually present with cloudy fluid and abdominal pain. [scielo.isciii.es]

• Nausea

  Symptoms Signs and symptoms of peritonitis include: Abdominal pain or tenderness Bloating or a feeling of fullness (distention) in your abdomen Fever Nausea and vomiting Loss of appetite Diarrhea Low urine output Thirst Inability to pass stool or gas [mayoclinic.org]

  Patients typically present with severe abdominal pain and guarding, as well as nausea and vomiting. In most cases, peritonitis constitutes a surgical emergency. [amboss.com]

  Other symptoms may include: Fever and chills Passing little or no stools or gas Excessive fatigue Passing less urine Nausea and vomiting Racing heartbeat Shortness of breath The health care provider will perform a physical exam. [nlm.nih.gov]

• Abdominal Tenderness

  She had no abdominal tenderness, and exit site looked normal. Fluid was negative for Mycobacterium tuberculosis. [ncbi.nlm.nih.gov]

  On physical exam, there is abdominal distension, diffuse abdominal tenderness to palpation, flank dullness, and a positive fluid wave. [medbullets.com]

  It pertains to a symptom complex characterized by vomiting, pain or abdominal tenderness, and shock. The pain may be localized or generalized. These symptoms are associated with the inflammation of any of the abdominal viscera. [biology-online.org]

  Peritoneal signs (eg, abdominal tenderness and rebound) are present but may be somewhat diminished by the presence of ascitic fluid. [merckmanuals.com]

  Signs and Symptoms [ ✎ edit | edit source ] abdominal pain fever flatulence hepatic encephalopathy resistance to treatment of ascites abdominal tenderness signs of peritoneal irritation (not necessary) shock but about 10% is asymptomatic ! [wikilectures.eu]

• Acute Abdomen

  Am 16.10.2017 veröffentlicht This video “Appendicitis” is part of the Lecturio course “General Surgery” ► WATCH the complete course on http://lectur.io/appendicitis3 ► LEARN ABOUT: - Acute abdomen - practical case - Definition of acute abdomen - Layers [youtube.com]

  Amylase and lipase may be done if pancreatitis is suspected as a differential diagnosis for acute abdomen. Amylase and lipase may be done if pancreatitis is suspected as a differential diagnosis for acute abdomen. [medicaljoyworks.com]

  Patient was discharged on the 7th post-operative day. common complication [ 5 ], that often present with acute abdomen. [aclr.com.es]

  Acute abdomen; Spontaneous bacterial peritonitis; SBP; Cirrhosis - spontaneous peritonitis Kuemmerle JF. Inflammatory and anatomic diseases of the intestine, peritoneum, mesentery, and omentum. In: Goldman L, Schafer AI, eds. [nlm.nih.gov]

• Abdominal Distension

  Auscultate his abdomen for bowel sounds and assess for abdominal distension. If distension occurs, measure his abdominal girth daily to monitor changes. Keep him N.P.O. until his bowel function returns. [journals.lww.com]

  At day 51 she developed abdominal distension and was referred to a pediatric surgeon by day 54 with pneumoperitoneum. Her abdomen was soft with minimal tenderness and no evidence of erythema or edema. [ncbi.nlm.nih.gov]

  On physical exam, there is abdominal distension, diffuse abdominal tenderness to palpation, flank dullness, and a positive fluid wave. [medbullets.com]

  Clinically all patents presented with jaundice and abdominal distension, 92% of patents presented with abdominal pain,60 % with vomitng, 58 % with fever. Such patents are found to have lower ascitc fuid albumin and high PMN cell count. [pmjn.org.np]

• Heart Failure

  This problem is found in people with long-term liver damage, certain cancers, and heart failure. Peritonitis may be a result of other problems. This is known as secondary peritonitis. [nlm.nih.gov]

  It is most commonly found in patients with underlying cirrhosis and ascites, but may be found in patients with congestive heart failure, systemic lupus erythematosus, chronic viral hepatitis, or acute viral hepatitis. [visualdx.com]

• Sweating

  Pallor, sweating, fever and bloody diarrhoea are already indications of a blood disease. Peritonitis is a life-threatening disease which must be diagnosed and treated quickly. [hirslanden.ch]

  Burkitt’s lymphoma can cause fever, weight loss, and night sweats. Other symptoms of Burkitt’s lymphoma vary according to type. [healthline.com]

  A comfortable-appearing person rarely has a serious problem, unlike one who is anxious, pale, sweating, or in obvious pain. [merckmanuals.com]

  If he's lost excessive fluid, electrolytes, and proteins into the abdominal cavity, you may note excessive sweating; cool, clammy skin; pallor; abdominal distension, and signs of dehydration (such as dry mucous membranes). [journals.lww.com]

• Arthritis

  See Answer From Healthy Resources When Prostate Cancer Spreads 10 Rheumatoid Arthritis Symptoms You Shouldn't Ignore Wet Age-Related Macular Degeneration and Vision Loss Featured Centers Good and Bad Foods for Psoriasis Health Solutions From Our Sponsors [rxlist.com]

  Periostitis can be found alone or can be associated with clubbing and arthritis that define hypertrophic osteoarthropathy (HOA)1. [jrheum.org]

  Arthritis Rheum1994;37:187–92. ↵ Fauci AS, Haynes BF, Katz P, Wolff SM. Wegener’s granulomatosis: prospective clinical trial and therapeutic experience with 85 patients for 21 years. [ard.bmj.com]

  […] osteomyelitis with proliferative periostitis of the mandibular body: report of a case and review of the literature. 61 Liu D...Wang X 30855166 2019 9 Syphilis with Charcot arthropathy: A case report. 61 Wang M...Li L 30758895 2019 10 Animal model of arthritis [malacards.org]

  These include steroids used to control arthritis and asthma; some drugs used to treat seizures; some cancer drugs; and, too much thyroid hormone. [orthohyd.com]

• Irritability

  Signs and Symptoms [ ✎ edit | edit source ] abdominal pain fever flatulence hepatic encephalopathy resistance to treatment of ascites abdominal tenderness signs of peritoneal irritation (not necessary) shock but about 10% is asymptomatic ! [wikilectures.eu]

  The present study was undertaken because of the apparent lack of proof that vomiting in peritonitis is really due to irritation of the peritoneum. [jamanetwork.com]

  Aetiology is unknown and probable causes are infections, irritant agents and allergic reactions. A case of SEP in a young female with ventriculo-peritoneal shunt for hydrocephalus is reported. [moh-it.pure.elsevier.com]

  Peritonitis is when the tissue that covers the inside wall of the abdomen gets swollen and irritated, usually due to an infection. Appendicitis can cause peritonitis if it isn't treated before the appendix bursts. [kidshealth.org]

  Intraperitoneal blood from any source (eg, ruptured aneurysm, trauma, surgery, ectopic pregnancy ) is irritating and results in peritonitis. [merckmanuals.com]

• Anuria

  52 years of age, a farmer in the Focsani county (observation sheet no. 49104 from 21.01.2008), presented to our hospital at one of the medical clinics then admitted directly in the ICU due to her altered general status and acute renal failure: oligo-anuria [ncbi.nlm.nih.gov]

  Our result is consistent with previous studies, which showed that the number of peritonitis episode is an independent predictor of progression to anuria [ 20 ]. [journals.plos.org]

The following investigations are helpful in establishing the diagnosis of peritonitis.

• Complete blood count: Complete blood count will show leukocytosis or leukopenia.
• Examination of ascitic fluid: Ascitic fluid is obtained by paracentesis. There is an increased cellularity. Gram stain can be used to visualize the bacteria. Culture is also positive for around 70% of the cases [7]. The amount of protein, glucose, lactate dehydrogenase and amylase in the ascitic fluid is also abnormal [8].
• Abdominal imaging: Imaging of the abdomen by radiography, ultrasonography and computerized tomography (CT) can help detect any pathology that is responsible for the development of secondary bacterial peritonitis.

• Atelectasis

  Repositioning into the prone position (face down) might improve oxygenation by relieving atelectasis and improving perfusion. [en.wikipedia.org]

  In patients with subdiaphragmatic abscesses, irritation of contiguous structures may produce shoulder pain, chest pain, cough, shortness of breath, hiccup, and pulmonary findings, such as signs of a pleural effusion, basal atelectasis, or pneumonia. [infectiousdiseaseadvisor.com]

• Hemorrhagic Ascites

  Identified risk factors for the development of SBP include ascitic fluid total protein less than 1 g/dL, gastrointestinal hemorrhage, and a previous history of SBP. [hepatitisc.uw.edu]

• Leukocytosis

  Laboratory tests CBC significant for leukocytosis Peritoneal fluid analysis Diagnostic paracentesis should be performed before administration of antibiotics. [amboss.com]

  On the fifth day, the patient had severe abdominal pain, fever of 38 ºC, leukocytosis with increasing neutrophilia, a shift to the left, and a significant increase in Creactive protein levels (CRP). [revistanefrologia.com]

  Complete blood count: Complete blood count will show leukocytosis or leukopenia. Examination of ascitic fluid: Ascitic fluid is obtained by paracentesis. There is an increased cellularity. Gram stain can be used to visualize the bacteria. [symptoma.com]

  If the patient has peritonitis, his white blood cell count is likely to reveal leukocytosis (more than 11,000/mm 3 ), and his serum electrolyte levels may be abnormal, reflecting dehydration. [journals.lww.com]

Primary bacterial peritonitis is treated by antibiotic therapy [9]. The drugs commonly used include cefotaxime, ceftriaxone, ampicillin and quinolones. No specific drug is better than the other. Supportive treatment is also provided. Lactulose is given to prevent the development of hepatic encephalopathy.

In secondary bacterial peritonitis, in addition to antibiotic therapy, the control of the source of the infection is also essential. Surgery may be required for the treatment of the cause (e.g. if there is perforated peptic ulcer, perforated appendix, perforated colon and so on). The antibiotic therapy should cover both aerobic and anaerobic organisms. Piperacillin-tazobactam is often used.

In tertiary bacterial peritonitis, the source of infection should be cured. The drug used should be in accordance with the culture report. Abdominal washout with open laparotomy may also be needed.

Peritonitis generally has a poor prognosis. The mortality rate in primary bacterial peritonitis is up to 30%. However, there is a high incidence of recurrence. By 6 months, recurrence is seen in up to 43% of the cases and by 1 year, in 69% of the cases. There is a 50-70% mortality in recurrent cases. This high mortality is due to the development of complications such as gastrointestinal bleeding and renal dysfunction [4] [5].

In secondary bacterial peritonitis, the mortality is associated with the etiology. Perforation of the stomach or colon implies a particularly poor prognosis whereas appendicitis has the lowest risk of mortality.

Prompt diagnosis and treatment improves the prognosis in all types of peritonitis. Host related factors also play a key role in determining the outcome of these infections [6].

Each type of peritonitis has its own etiology.

Primary bacterial peritonitis

Primary bacterial peritonitis is most commonly related to ascites due to liver cirrhosis [1]. The notable risk factors include large volume ascites and ascites with a protein content greater than 1 g/dL [2]. Ascites originating from disorders of the heart and kidneys, or due to any neoplastic condition can also lead to bacterial peritonitis. The following organisms are commonly responsible for the infection.

• Escherichia coli
• Klebsiella
• Streptococcus species
• Pseudomonas
• Proteus

Secondary bacterial peritonitis

Secondary bacterial peritonitis is due to any preexisting infectious source in the abdomen. It results from causes such as acute appendicitis, cholecystitis, pancreatitis, perforated peptic ulcer and perforated bowl. Pelvic inflammatory disease can also cause peritonitis. The causative organisms include:

• Escherichia coli
• Klebsiella
• Proteus
• Streptococcus species
• Enterococcus species
• Bacteroides
• Clostridium species

Tertiary bacterial peritonitis

The causative organism in tertiary bacterial peritonitis is often the same as that of secondary bacterial peritonitis. Malnutrition, massive blood transfusion and infection with antibiotic resistant organisms greatly increases the chance of developing bacterial peritonitis [3].

Primary bacterial peritonitis is a common complication of cirrhosis in both adults and children. It occurs in as many as 10 to 30% of the patients with cirrhosis and associated ascites. The highest incidence of primary bacterial peritonitis in children is seen at two stages; one is the neonatal period and the other is the age of 5 years.

In all types of peritonitis, the pathology starts with the contamination of the peritoneum by bacteria. In primary bacterial peritonitis, bacteria enter the ascitic fluid by translocation whereas in secondary bacterial peritonitis, they infect the peritoneum from any preexisting source in the viscera. There is inflammation of the peritoneum with exudations of serum, fibrin, cells and pus.

Up to 22% of the patients of cirrhosis with gastrointestinal hemorrhage develop primary bacterial peritonitis. Therefore, primary bacterial peritonitis can be prevented by the use of prophylactic antibiotic therapy in the patients of cirrhosis associated with gastrointestinal hemorrhage [10].

Tertiary bacterial peritonitis can be prevented by ensuring adequate control of the source of infection and the treatment of etiology of secondary bacterial peritonitis.

Peritonitis is the acute inflammation of peritoneum - the serous membrane that lines the walls and invests the viscera of the abdomen. Both the parietal and visceral components of the peritoneum are involved. Peritonitis has the following types:

• Primary bacterial peritonitis: Primary bacterial peritonitis occurs commonly in the case of ascites associated with cirrhosis. It refers to the infection of previously sterile ascitic fluid without any other detectable source of infection.
• Secondary bacterial peritonitis: Secondary bacterial peritonitis refers to the infection of the peritoneum from any infected visceral source.
• Tertiary bacterial peritonitis: Tertiary bacterial peritonitis is the recurrent infection of the peritoneum despite adequate treatment.

Peritonitis is the infection of the membrane that covers the abdominal walls and organs. It usually results from liver failure or from preexisting sources of infection in the organs. It is a serious disease and often leads to death if not treated promptly. The treatment consists of the administration of antibiotics and supportive care.

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6. Marshall JC. Intra-abdominal infections. Microbes and infection / Institut Pasteur. Sep 2004;6(11):1015-1025.
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8. Runyon B. Management of adult patients with ascites due to cirrhosis. Hepatology. Mar 2004;39(3):841-856.
9. Blot S, De Waele JJ. Critical issues in the clinical management of complicated intra-abdominal infections. Drugs. 2005;65(12):1611-1620.
10. Saab S, Hernandez JC, Chi AC, Tong MJ. Oral antibiotic prophylaxis reduces spontaneous bacterial peritonitis occurrence and improves short-term survival in cirrhosis: a meta-analysis. The American journal of gastroenterology. Apr 2009;104(4):993-1001; quiz 1002.