PERITONITIS: symptoms and causes of inflammation of the peritoneum

There peritonitis it's a process inflammatory, which can be acute, and therefore limited in time, or chronic, del peritoneum, there serous membrane thin and transparent that covers the abdominal cavity, as well as the organs contained therein.

What is the peritoneum?

The peritoneal sac, which has the main function of supporting the organs of the abdominal cavity, and is composed of two "sheets", or the peritoneal serous membranes, one parietal, which lines the inner walls of the abdominal cavity, and one visceral, which envelops the organs it contains, i.e. the intra-abdominal part of the intra-abdominal esophagus, the stomach, the duodenum, the small intestine (jejunum and ileum), the appendix, the large intestine (colon, rectum and sigma) , gallbladder, biliary tree and bladder). Between the two peritoneal serous sheets there is a so-called virtual space (peritoneal cavity), containing a minimal amount of serous fluid. This allows the two peritoneal serous sheets to move over each other, making the active and passive movements of abdominal organs and tissues simple.

The peritoneum protects itself from infectious agents both by means of an innate antibacterial action, and thanks to the ability to stop - within certain limits - the infectious focus, through an abundant fibrinous exudation. Therefore, unless the contamination is continuous and from an uncontrolled source (such as an intestinal loop or a perforated gallbladder, the inflamed peritoneum can heal with a simple systemic treatment (such as antibiotic therapy).

Causes of peritonitis

What are the main causes of inflammation of the peritoneum? The main cause of peritonitis is the rupture of an abdominal organ, which allows bacteria and food / fecal material inside it to contaminate the peritoneum. In relation to the type of initial damage, they are classified primary peritonitis is secondary peritonitis.

In relation to the extension we speak instead of localized peritonitis (sign of a suitable defense reaction of the peritoneum which manages to limit the inflammatory process) e diffuse peritonitis (condition much more serious than the previous one, consequence of the inability to limit inflammation). Finally, wanting to classify the inflammation of the peritoneal cavity according to the speed of onset and its duration, we talk about chronic peritonitis, (infrequent, such as tuberculous peritonitis), or of acute peritonitis, in which the symptomatological onset is more abrupt and relevant from the symptomatological point of view.

Primary peritonitis

To the class of primary peritonitis all those situations in which inflammation is consequent to the spread of bacteria through the bloodstream are included; there spontaneous bacterial peritonitis (PBS) is the second most common type of infection in patients with advanced cirrhosis, and can be life-threatening if not promptly treated. Other examples are the pneumococcal peritonitis and the tuberculous peritonitis.

Secondary peritonitis

Secondary peritonitis, on the other hand, can be the result of many causes, the most frequent of which is break or drilling of a abdominal organ (e.g. inflammation and perforation of the appendix in the case of appendicitis, rupture of the duodenum or stomach in the case of a perforated peptic ulcer, rupture of the gallbladder following acute cholecystitis, perforation of a diverticulum in diverticulitis, intestinal obstruction or complications during flare-ups of ulcerative colitis or chron's disease).

In this case, the harmful action of the microorganisms is added to the equally harmful action of the digestive juices contained in the perforated viscera (bile acids, gastric and pancreatic juices), the faeces, mucus and / or blood that spread into the abdominal cavity; the bacterial peritonitis is therefore superimposed on a chemical peritonitis. In case the feces are the pollutant the peritoneum, we speak of stercoraceous peritonitis.

A common cause of secondary peritonitis is the complication of one acute pancreatitis, an inflammation of the pancreas which may or may not be linked to a stone occluding the biliary or pancreatic ducts, and which occurs after the pancreatic juices, highly damaging to the tissues, are poured into the circulation and into the abdominal cavity.

Peritonitis can also express the outcome of one abdominal contusion following a traumatic event, of penetrating intra-abdominal wounds, of invasive diagnostic maneuvers with perforation of the viscera (such as a colonoscopy o an esophagogastroduodenoscopy - EGDS - complicated by perforation), an inflammatory disease of the pelvis or a vascular event (embolism or thrombosis of the mesenteric arteries). However, the most common cause, especially in children and young adults (18-30 years), remains the perforation of an inflamed and not readily diagnosed caecal appendix.

Signs and symptoms of peritonitis

What are the main symptoms of peritonitis? Primary peritonitis causes the appearance of abdominal bloating, accompanied to algie (aches), fever is weight loss.

Secondary peritonitis presents with acute symptoms such as:

  • abdominal pain, at first confined to the abdominal site of rupture, and then spread. The pain is accentuated on palpation and the subsequent sudden release of the hand (Blumberg maneuver); the abdominal wall is rigid (wooden or table abdomen), and auscultation does not show bowel movements (absent peristalsis). In acute localized forms, pain and contracture of the abdominal muscles are limited to a single abdominal sector.
  • abdominal bloating
  • nausea
  • He retched,
  • temperature,
  • tachycardia,
  • hypotension, i.e. low blood pressure linked to dehydration and the release of inflammatory cytokines that cause vascular vasodilation
  • there closure of the hive to faeces and gases, i.e. the inability to defecate or even just to emit gas,
  • abdominal distension, linked to the dilation of the intestinal viscera and / or the accumulation of fluid in the peritoneal cavity
  • intense thirst due to dehydration, up to hypovolemic shock.

On blood tests we could see an increase in White blood cells, of the protein C reactive and of procalcitonin, indexes of systemic inflammation. It will also be possible to find an increase of the lactic dehydrogenase (LDH), a kidney dysfunction (increase of the creatinine) and an alteration in the concentrations of mineral salts in the blood.

Inflammation, in fact, determines the formation of considerable quantities of exudate, which in the long run causes considerable losses of liquids, salts and proteins; the blocking of intestinal peristalsis (paralytic ileus or adynamic) contributes to aggravate these losses. For this reason it is very important to promptly rehydrate by infusing intravenously crystalloid solutions saline and / or glucose to the patient.

Please note: the symptoms of peritonitis are often comparable with in symptoms of appendicitis (the symptoms of an inflamed appendix more common in fact are abdominal pain, fever, hypotension and tachycardia, dehydration), so much so that many people mistakenly associate the two pathologies. In reality, appendicitis is just one of the many diseases that can progress to peritonitis if not treated promptly.

Peritonitis Diagnosis

How is peritonitis diagnosed? Diagnosis often starts with recognizing specific symptoms: careful anamnesis and one thorough visit they can help the doctor diagnose a pathology of the abdominal cavity, even before performing blood tests and / or radiological examinations, such as an ultrasound of the abdomen or a CT scan of the abdomen.

In case there is peritoneal effusion (inflammatory transudate or ascites), it will be possible to take a small amount of them through a procedure called paracentesis, and send them to the analysis laboratory, in order to carry out investigations relating to the type of fluid and the possible presence of microorganisms, such as bacteria or mycobacteria (in case of positive bacterial growth, for example, it is possible to obtain an antibiogram which allows to choose the most suitable antibiotic therapy for the isolated germ).

Peritonitis therapy

What is the better care for peritonitis? It is possible to ask remedy to this serious pathology? In diffuse acute forms not related to intestinal perforation, the therapy is basically systemic intravenous, it includes the administration of antibiotics and of rehydrating solution (or saline, glucose solution, lactated ringer's) for adequate fluid and electrolyte support, analgesic therapy, in addition to the placement of a nasogastric tube for aspiration and removal of any ingestions (avoiding vomiting episodes), the respiratory support and, of course, the fasting absolute.

In spontaneous bacterial peritonitis in cirrhotic patients, the collection of peritoneal fluid (fluid in the belly) is part of the therapeutic protocol through paracentesis the first and third day of illness: this allows to count the number of neutrophilic leukocytes present in the ascitic fluid, indicating the efficacy and appropriateness of the antibiotic treatment in place.

In the forms of acute peritonitis, both localized and diffuse, secondary to visceral perforation, with the exception of acute pancreatitis and pelvic inflammatory disease, the main therapy is surgery, performed to remove the source of contamination or the organ from which the inflammation began, reclaiming the peritoneal cavity and allowing, secondarily, systemic therapy to take effect. In fact, a robust medical therapy aimed at obtaining metabolic balance and haemodynamic parameters, associated with broad-spectrum antibiotic therapy, will still be necessary before and after the intervention.

Prognosis of peritonitis

Peritonitis, as emerged from the previous paragraphs, is a serious disease, which can be life threatening if not treated promptly. An immediate diagnosis, an antibiotic and rehydrating therapy, and a surgical evaluation, assisted by diagnostic and laboratory tests, allow to identify the type of abdominal cavity pathology and to treat it effectively in the vast majority of cases.


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