Medical symptom checker- Abdominal distention / swollen stomach - Peritonitis

Medical symptom checker – abdominal distention / swollen stomach - Peritonitis symptoms

Introduction

What is peritonitis?

What causes peritonitis?

How common is peritonitis?

How do peritonitis present?

What is the pathology behind peritonitis?

How to investigate peritonitis?

How to treat peritonitis?

What is the complication of peritonitis ?

What is the prognosis of peritonitis?


What is peritonitis?

Peritonitis is an inflammation process. It will lead to an inflammation of parietal and visceral peritoneum. Peritonitis commonly affects the cardiac, gastrointestinal, metabolic and endocrine systems.

Peritonitis can be divided into 4 categories:

-Spontaneous bacterial peritonitis (SBP) which is an intra abdominal bacterial infection that cannot be treated surgically.

Secondary bacterial peritonitis is an intra abdominal bacterial infection that can be treated surgically.

-Persistent peritonitis

-Recurrent peritonitis which is commonly associated with previously treated condition such as chronic liver disease.


What causes peritonitis?

There are a lot of causes of peritonitis (spontaneous bacterial peritonitis / secondary bacterial peritonitis). The causes are:

Spontaneous bacterial peritonitis is caused by cardiac or nehprogenic associated ascites, malignancy related ascites, cirrhosis with ascites, viral hepatitis and excessive alcohol intakes.

Secondary bacterial peritonitis is caused by continuous ambulatory peritoneal dialysis, appendicitis, pancreatitis, acute cholecystitis, inflammatory/ infective colitis, perforated peptic ulcer, abdominal trauma, perforated bowel, peritoneal abscess, diverticulitis, post- operative intra abdominal surgery and gangrene of the bowel.


Associated risk factors for peritonitis may include indwelling IV urinary bladder catheter, ischemia and reperfusion of the gut, low total protein level in the ascitic fluid and prior episodes of spontaneous bacterial peritonitis.


How common is peritonitis?

Predominantly it affects men > women. No predominant age is identified but elderly tend to suffer a greater extent of peritonitis.

1/3 of cases of bacterial infection in cirrhotic patient is due to spontaneous bacterial peritonitis. 3% - 5 % cases of spontaneous bacterial peritonitis commonly affect cirrhotic and ascites patient who is asymptomatic. 10% - 30% cases of spontaneous bacterial peritonitis commonly affect cirrhotic and ascites patient who is symptomatic.


How do peritonitis present?

The patient typically complains of abdominal pain / tenderness which is precipitated by movement. The patient may also complain of rebound tenderness, abdominal guarding and rigidity. Abdominal ascites , chills, nausea, vomiting, fever > 37.8 C/ 100F. (In moderate cases patient may suffer from mild hypothermia) and shortness of breath /dyspnea.

The patient may also suffer from decreased renal function. Besides that alteration of gastrointestinal motility may also happen. 54% of cirrhotic patient may suffer from alter mental status as a result of hepatic dysfunction or infection (bacterial peritonitis).


On examination, patient will present with abdominal tenderness. In severe case, the abdominal tenderness will disappear as a result of separation of visceral and parietal peritoneum.


What is the pathology behind peritonitis?

In spontaneous bacterial peritonitis, there will be an overgrowth of bacteria in the liver as a result of the decrease in gastrointestinal motility due to cirrhosis. The gram negative bacteria will translocate from the intestine to the mesenteric lymph nodes. The mesenteric lymph nodes will rupture as a result of increase in pressure due to portal hypertension. This will lead to bacteria that lead to the seeding of the liver which later progress to the seeding of the ascitic fluid. Bacterium seeding also happens in pneumococcal sepsis, pharyngitis, dental infection and cellulites as well as urinary tract infection.

In secondary bacterial peritonitis, the peritoneum will be seeded with bacteria as a result of perforated bowel, peritoneal abscess.


How to investigate peritonitis?

Differential full blood count study, blood culture, liver function test, amylase, lipase test, ascitic fluid analysis, (differential cell count, total protein level, amylase, lactase dehydrogenase, glucose, albumin, gram stains and culture) and consider urine culture and sensitivity.


Spontaneous bacterial peritonitis may present with one organism on the culture and polymorphonuclear cells > 250 cells/mm3.

Secondary bacterial peritonitis may present with multiple type of organism and polymorphonuclear cells > 250 cells/mm3.


The imaging technique may include:

Plain chest x ray - elevated diaphragm.

Upright and flat abdominal x ray - extravasation of water soluble gut contrast, dilation of large bowel, dilation of small bowel and air filled in the peritoneal cavity.

CT- scan may reveals ascites and intra abdominal mass.


Other diagnostic tests may include:

Diagnostic paracentesis

Diagnostic laparotomy and colonoscopy (80% mortality in unnecessary diagnostic laparotomy) in patient > 65 years of age.


Other conditions that may mimic peritonitis may include:

Mesenteric adenitis, volvulus, intussuception , abscess ( subdiaphragmtic abscess, subhepatic abscess, pelvic abscess and peritoneal abscess), rupture of ectopic pregnancy, tubo- ovarian cysts, appendicitis, pelvic inflammatory disease, pancreatitis, pyelonephritis, cholecystitis.


How to treat peritonitis?

Generally the treatment involves:

-Observation and bed rest (treatment for any signs of dehydration with IV fluid)

-Nasogastric tube insertion for any cases of paralytic ileus

-Antibiotic started empirically which cover a broad range of microorganism.

The choice of antibiotic is altered based on the culture and sensitivity.


Treatment with antibiotic is only performed if the polymorphonuclear cell count is > 250 cells/ mm3.

The patient is not allowed to take food or drink orally (nil per OS). The patient requires IV fluid and electrolytes as a replacement of oral intake.

Oral feeding is only allowed if the patient passes the flatus and faces and the return of the bowel sounds.

Total parenteral nutrition may also be considered.

Specifically the drugs involve are:

(First line of drugs - Spontaneous bacterial peritonitis )

Cefotaxime for 5 days.

This drug has an excellent effect in treating ascites. A common side effect includes rash.

Amoxicillin - clavulanic acid for 2 days.

Common side effects include nephrotoxicity.

(First line of drugs- Secondary bacterial peritonitis)

Includes, cefotetan, imipenem, cefotoxin, piperacillin - tazobactam, ampicillin - sulbactam and ticarcillin - clavulanate which are active against anaerobic organism.

Instillation of vancomycin and gentamicin is required in peritoneal cavity for continuous ambulatory peritoneal dialysis.

Patient with cirrhosis and gastrointestinal bleeding may require norfloxacin or trimethoprim / sulfomethoxazole for 7 days.

A patient who suffer from recurrent episodes of peritonitis may require also require norfloxaxin or trimethoprim / sulfomethoxazole for a day.

Patient with ascitic fluid and < 1g/dl of total protein level may need to be hospitalized and prophylactic antibiotics are given. Any breakthrough infection needs to be treated with cefotaxime.

Second line of the drug may include olfoxacin and diuretic therapy.Surgery is only needed to treat the underlying disorder of peritonitis.

What are the complications of peritonitis?

Acute respiratory failure, acute renal failure, acute liver failure, septicaemia, septic shock , hypovolemic shock and abscess formation.

What is the prognosis of peritonitis?

The patient is admitted if he is sick and if he is not sick he is treated in the outpatient department and prescribed with antibiotics.

The mortality rate is 10% - 30% in spontaneous bacterial peritonitis and 50% of death are caused by liver failure, renal failure and GI bleeding. The prognostic indicator of mortality includes, ileus, increase in Child - Purgh scores and peripheral leucocytosis. Patient with hospital acquired spontaneous bacterial peritonitis has a greater mortality rate then community acquired spontaneous bacterial peritonitis. The usage of empiric antibiotic may lead to shock in spontaneous bacterial peritonitis patient. This patient is unlikely to survive. 100% mortality of secondary bacterial peritonitis will happen if non surgical intervention is given but focusing on antibiotic.







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treatment guideline for spontaneous bacterial peritonitis

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Comments 2 comments

SimpleGiftsofLove profile image

SimpleGiftsofLove 4 years ago from Colorado

Great informative hub.


stefanwirawan1 profile image

stefanwirawan1 4 years ago from Malaysia Author

thank you

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