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Peritonitis Inraabdominal abscess Liver and biliary system inf. Pancreas infections Splenic inf. Appendicitis and diverticulitis
Approach
Abd. pain, fever, tenderness, leukocytosis
intraabdominal inf.? History and PE Surgery consultation Emprical Tx Culture (blood, peritoneal fluidı...) +
other studies
Peritonitis
Primary peritonitis Secondary peritonitis Tertiary peritonitis
Primary peritonitisPrimary peritonitis
1. Spontaneous peritonitis in children (<1-2%) postnecrotic cirrhosis, nephrotic syndrome 2. Spontaneous peritonitis in adults (10-30% of
hospitalised cirrhotics) alcoholic cirrhosis, postnecrotic cirrhosis, viral
hepatitis, heart failure, metastasis, autoimmune…
3. Tuberculous peritonititis
Microbiology
70% enteric pathogens 70% enteric pathogens Escherichia coli Klebsiella pneumoniae Streptococcus pneumoniae Enterococci Staphylococcus aureus (rare) Anaerops
For anaerobs, 75% bacteremia For anaerobs, 75% bacteremia
Pathogenesis
Hematogenous Lymphatic transmural
migration through GI tract
Vaginal Through Fallopian
tubes
S&S
Acute fever Abd. pain Nausea, vomiting Tenderness, rebound Hypoactive bowel sounds
In patients with ascites, peritoneal irritation findings may not be seen
Fever >37.8˚C
TB peritonitis Fever Weight loss Fatigue Night sweats Abdominal distension Multiple nodules on peritoneum and
omentum (in laparoscopy)
Laboratuvar
In ascitis fluid Cell count (>250 PMN/mm3, > 500 leukocyte/mm3) Protein (serum-ascites albumin gradient <1,1)
LDH (ascites/serum >0,4)
Gram Staining (60-80% negative) Culture (40% negative)
CT: to exclude any primary focus of intaabdominal inf.
Response to emprical antibiotics within 48-72 h.
Tx
Emprical ampicillin+aminoglycoside 3rd gen. Ceph. piperacilin piperacilin-tazobactam, ampicillin- sulbactam carbapenems levofloxacine, moxifloxacin
Secondary peritonitis
The integrity of GI tract is broken Etiology depend upon the damaged site Polymicrobial E.coli (early mortality) B. fragilis (late abscess development)
Secondary peritonitisSecondary peritonitis
1. Gastrointestinal perforation (appendicitis, gastroduodenal ulcer perforation, cancer perforation, bile duct perforation…)
2. Intestinal ischemia-perforation (mesenteric occlusion, strangulation of hernia)
3. Postoperative peritonitis (anastomosis leak, blind loop leak, iatrogenic peroperative damages)
4. Posttraumatic peritonitis (penetrating, blunt trauma)
5. Pelvic peritonitis (septic abortus, puerperal sepsis, salpyngitis, purulant prostatitis)
Microbiology
AeropsAerops
Escherichia coli %65
Proteus spp. %25 Klebsiella spp. %20 Pseudomonas spp. %15 Enterococcir %15 Streptococcir %10
AnaeropsAnaerops Bacteroides fragilis %80
Bacteroides spp. %30 Clostridium spp. %65 Peptostreptococcus spp. %25 Peptococcus spp. %15 Fusobacterium spp. %20
Clinical
Abd. pain (severe on the inflamed site, increases on movement), anorexia, nausea, vomiting, dehydration due to hypovolemia, chills, fever.
Hypotention, tachycardia, oliguria, tachypnea (due to hypovolemia, hypoxia, and acidosis
Adynamic ileus
Tenderness, guarding, rebound: helpful for localising the site and the diagnosis.
Bowel sounds: initially hyperactive then silence….
Dx
Leukocytosis, left-shift (stabs) Hemoconcentration and dehydration: high
hematocrit and BUN High ALT/AST, low platelets, acidosis, high D-
dimer Plain abdominal X-ray, chest X-ray Abdominal US, CT Surgical or CT-guided sample: gram and culture,
BC (20-30% bacteremia)
Prognosis
Age Co-morbidity Peritoneal contamination time “Foreign” substance (biliary and
pancreatic secretions) Microorganism Mortality: 3.5-60%
Tx
Surgery + supportive+ antibiotics (leukocytes, fever, bowel sounds…)
5- 7 days after an appropriate surgical control
Ampirik antibiyoterapi
Community-acq.Community-acq. mild-moderate cefazolin+metronidazol severe piperacillin-tazobactam ceftriaxon+metronidazol clindamicin+gentamicin imipenem Hospital acq.Hospital acq. piperacillin+metronidazol +aminoglycoside imipenem+/-aminoglycoside
Enterokococci , Candida ??
Treatment Guidelines for Intra-abdominal Infections • CID 2003:37 (15 October)
