Acute Secondary Peritonitis - Types, Causes, and Treatment

What Are the Types of Acute Secondary Peritonitis?

Peritonitis is inflammation of the peritoneum (lining of the abdomen) caused by pathogens or non-pathogenic factors. It is of the following types:

1. Primary Bacterial Peritonitis: There is spontaneous bacterial aggression of the peritoneal cavity. This primarily arises in infancy and pre-adolescence. It is present in cirrhotic patients and immunocompromised patients.

2. Secondary Bacterial Peritonitis: This condition occurs secondary to intra-abdominal lesions. It is present in conditions like perforation of the hollow viscus, bowel necrosis, nonbacterial peritonitis, or penetrating infectious processes.

3. Tertiary Peritonitis: This condition is characterized by persistent or recurrent infections with organisms having low intrinsic virulence. It occurs mainly in immunocompromised patients.

What Are the Causes of Acute Secondary Peritonitis?

Secondary peritonitis has several major causes:

1. Bacteria enter the peritoneal cavity through a perforation in the abdominal cavity and the digestive tract. This perforation is due to the rupture of the appendix, colon, and ulcers in the stomach caused by an injury like a gunshot or any wound caused by a sharp body or foreign object.

2. The pancreas secretes bile or chemicals in the abdominal cavity caused by sudden swelling and inflammation of the pancreas and associated parts. The swelling occurs due to the tubes or catheters implanted in the abdomen for peritoneal dialysis and feeding tubes.

3. Sepsis: Sepsis is an infection of the bloodstream that leads to an infection in the abdomen.

4. Necrotizing enterocolitis occurs in a newly born when the lining of the intestine falls off.

What Are the Risk Factors for Acute Secondary Peritonitis?

The following are the factors responsible for increasing the risk of peritonitis:

1. Peritoneal Dialysis: Patients undergoing peritoneal dialysis develop the risk of acute secondary peritonitis.

2. Medical Conditions: Following medical conditions are responsible for developing acute secondary peritonitis: Liver cirrhosis, appendicitis, Crohn’s disease, ulcers in the stomach, diverticulitis, and pancreatitis.

3. Previous History: Acute secondary peritonitis can relapse in patients who already suffered from this disease.

What Are the Signs and Symptoms of Acute Secondary Peritonitis?

The following are the symptoms of acute secondary peritonitis:

1. Swelling in the abdomen.

2. Pain in the abdomen.

3. Decrease in appetite.

4. Fever.

5. Reduced urine output.

6. Nausea.

7. Thirst.

8. Vomiting.

9. Diarrhea.

10. Confusion.

11. Fatigue.

12. Bloating.

How To Diagnose Acute Secondary Peritonitis?

Acute secondary peritonitis is diagnosed primarily by a physical examination in which the following parameters are noticed:

1. Body temperature.

2. Heart rate and breathing rate.

3. Blood pressure.

4. Pain in the abdomen.

Other tests for diagnosis are as follow:

1. Blood Culture: It is done to check the presence and type of bacteria.

2. Blood Chemistry: It is done to check how well the kidneys, liver, and other organs are functioning.

3. Complete Blood Count: It indicates the counts of white blood cells, red blood cells, and platelets, the concentration of hemoglobin, and the hematocrit.

4. Liver Function Tests: These blood tests measure enzymes and proteins such as serum bilirubin, serum albumin, serum alkaline phosphatase, prothrombin time, serum aminotransferase, and alanine transaminase.

5. Kidney Function Tests: These tests measure ACR (albumin to creatinine ratio) and GFR (glomerular filtration rate).

6. X-ray: Plain abdominal X-rays reveal dilated oedematous intestines seen in secondary peritonitis.

7. CT scan (Computed Tomography): This scan reveals a large amount of high-density fluid in the peritoneal cavity associated with diffuse thickening of the peritoneal lining.

8. Peritoneal fluid culture: It is a laboratory test performed on a sample of peritoneal fluid and measures albumin, proteins, and red and white blood cells.

9. Urinalysis: It is done to detect abdominal disorders.

What Are the Complications of Acute Secondary Peritonitis?

The following are the possible complications of acute secondary peritonitis:

1. Abscess (swelling in the wound containing thick-yellow colored fluid).

2. Gangrene bowel (dead intestinal tissues) that requires surgery.

3. Intraperitoneal adhesions (a pathological bond formed between the small and the large intestinal walls).

4. Septic shock: Septic shock is a widespread infection causing organ failure and low blood pressure. It is caused by a localized infection that requires immediate medical attention.

What Is the Treatment of Acute Secondary Peritonitis?

The following are the methods used to treat acute secondary peritonitis:

1. Antibiotics: It is the most common method used to treat the treatment of sepsis. Surgical sepsis shows inactivity towards antibiotics. The most antimicrobial agents are carbapenems and newer quinolones such as Imipenem, Cilastatin, or drug combinations like anti-anaerobes plus aminoglycoside, anti-anaerobes, and third-generation drugs like cephalosporins or quinolones, or Clindamycin and Monobactam. Antibiotics should be used for five to seven days. The following drugs are used to treat mild to moderate community-acquired infections- Cefoxitin, Cefotetan, Cefmetazole, and Ticarcillin-clavulanic acid. Antibiotic therapy is not used in the following conditions:

• Early acute appendicitis.

• Acute suppurative appendicitis.

• Simple acute cholecystitis.

• Simple dead bowel.

• Gastroduodenal ulcer perforation.

• Traumatic enteric perforations.

The following conditions should be maintained to continue antimicrobial drugs:

• Temperature.

• Normal white blood cells count.

Surgical Treatment: The intra-abdominal infection has been graded as follows:

• Contamination: It is nonperforated appendicitis (appendix infection) with no pus in the abdominal cavity. The treatment consists of appendectomy and lavage. Antibiotic therapy is not necessary in this case.

• Infection: It is an acute perforation of appendicitis with pus and inflammation in the local area. The treatment consists of the resection of the bowel and intra-abdominal lavage (surgical procedure for evaluating bleeding in the abdominal cavity) and closure of the abdomen.

• Sepsis: It is perforated diverticulitis (an inflammation in one or more small pouches in the digestive tract) associated with local and systemic infection. The treatment comprises source control, lavage, and a short course of antibiotics. The antibiotic treatment should be continued for five to seven days.

Relaparotomy: It is defined as an abdominal operation performed after an initial surgery within 60 days. This procedure controls the infectious focus and intra-abdominal lavage.

The site of infection and the corresponding required surgical treatment is as follows:

• Stomach - Resection or excision/suture.

• Duodenum - Resection or excision/suture.

• Small Bowel - Resection with primary anastomosis or enterostomy or suture.

• Large Bowel - Resection with Harttman procedure (involves primary anastomosis).

• Appendix - Appendectomy.

• Gallbladder - Cholecystectomy.

Open Abdominostomy: It is a laparotomy (a surgical procedure involving a surgical incision through the abdominal wall to enter into the abdominal cavity) without re-approximation (to bring separate parts together to close a wound or suture) and suture of the abdominal fascia. Following are the indications for open abdominostomy:

1. Patients in critical condition suffering from hemodynamic instability that includes definitive repair.

2. Excessive peritoneal edema.

3. Incomplete debridement of necrotic tissue.

4. Uncertainty about the viability of the remaining bowel.

5. Uncontrolled bleeding.

6. Massive abdominal wall loss.

Mesh Abdominostomy: It is defined as laparotomy without re-approximation and suture closure of the abdominal fascia (various types of fascia found in the abdominal region). The fascial gap is coated with a mesh consisting of different synthetic materials or lined up on the skin.

Conclusion

Acute secondary peritonitis is a peritoneal infection that occurs secondary to intra-abdominal lesions. It is characterized by swelling and pain in the abdomen. Peritoneal dialysis and other medical conditions such as stomach ulcers, pancreatitis, and liver cirrhosis are responsible for this disease. The article reviews the causes, risk factors, signs, symptoms, and treatment for acute secondary peritonitis.