Peritonitis

Alternative Name: Abdominal wall inflammation

Definition:
Peritonitis is defined as inflammation of the peritoneum (the serous membrane which lines part of the abdominal cavity and some of the viscera it contains). It may be localised or generalised, generally has an acute course, and may depend on either infection (often due to rupture of a hollow organ as may occur in abdominal trauma) or on a non-infectious process.

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There are three types of Peritonitis:

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1.primary (spontaneous)
2.secondary (anatomic)………click to see
3.tertiary (peritoneal dialysis related)

Primary peritonitis is caused by the spread of an infection from the blood and lymph nodes to the peritoneum. This type of peritonitis is rare — less than 1% of all cases of peritonitis are primary. The more common type of peritonitis, called secondary peritonitis, is caused when the infection comes into the peritoneum from the gastrointestinal or biliary tract. Both cases of peritonitis are very serious and can be life threatening if not treated quickly

Signs and Symptoms:
The signs and symptoms of peritonitis include:

•Swelling and tenderness in the abdomen with pain ranging from dull aches to severe, sharp pain
•Fever and chills
•Loss of appetite
•Thirst
•Nausea and vomiting
•Limited urine output
•Inability to pass gas or stool

Risk Factors:
The following factors may increase the risk for primary peritonitis:

•Liver disease (cirrhosis)
•Fluid in the abdomen
•Weakened immune system
•Pelvic inflammatory disease
Risk factors for secondary peritonitis include:

•Appendicitis (inflammation of the appendix)
•Stomach ulcers
•Torn or twisted intestine
•Pancreatitis
•Inflammatory bowel disease, such as Crohn’s disease or ulcerative colitis
•Injury caused by an operation
•Peritoneal dialysis
•Trauma

Diagnosis and investigations
Diagnosing peritonitis is accomplished through a medical procedure often colloquially referred to as a “cough test“.

Patient is asked to lie flat (in position for undertaking abdominal examination) and to give a deep cough.
Sometimes the patient is asked to stand, and then asked to turn their head and cough.
If this produces pain/tenderness/obvious discomfort, peritonitis can be considered as a differential diagnosis.
Obviously this is not a particularly specific or sensitive test, but may be highly suggestive when combined with other physical signs of peritonitis such as absent bowel sounds.
It is important to look at the patient’s face when carrying out this test, as they may later deny that they experienced pain.

A diagnosis of peritonitis is based primarily on clinical grounds, that is on the clinical manifestations described above; if they support a strong suspicion of peritonitis, surgery is performed without further delay from other investigations. Leukocytosis, hypokalemia, hypernatremia and acidosis may be present, but they are not specific findings. Plain abdominal X-rays may reveal dilated, edematous intestines, although it is mainly useful to look for pneumoperitoneum (free air in the peritoneal cavity), which may also be visible on chest X-rays.

Definitive diagnosis of peritonitis is achieved via paracentesis (abdominal tap). More than 250 polymorphonuclear cells per ?L is considered diagnostic. In addition, gram stain, and culture with sensitivity of the peritoneal fluid can determine the underlying etiologic organism.

Causes

Infected peritonitis:-
*Perforation of a hollow viscus is the most common cause of peritonitis. Examples include perforation of the distal oesophagus (Boerhaave syndrome), of the stomach (peptic ulcer, gastric carcinoma), of the duodenum (peptic ulcer), of the remaining intestine (e.g. appendicitis, diverticulitis, Meckel diverticulum, inflammatory bowel disease (IBD), intestinal infarction, intestinal strangulation, colorectal carcinoma, meconium peritonitis), or of the gallbladder (cholecystitis). Other possible reasons for perforation include abdominal trauma, ingestion of a sharp foreign body (such as a fish bone, toothpick or glass shard), perforation by an endoscope or catheter, and anastomotic leakage. The latter occurrence is particularly difficult to diagnose early, as abdominal pain and ileus paralyticus are considered normal in patients who just underwent abdominal surgery. In most cases of perforation of a hollow viscus, mixed bacteria are isolated; the most common agents include Gram-negative bacilli (e.g. Escherichia coli) and anaerobic bacteria (e.g. Bacteroides fragilis). Fecal peritonitis results from the presence of faeces in the peritoneal cavity. It can result from abdominal trauma and occurs if the large bowel is perforated during surgery.

*Disruption of the peritoneum, even in the absence of perforation of a hollow viscus, may also cause infection simply by letting micro-organisms into the peritoneal cavity. Examples include trauma, surgical wound, continuous ambulatory peritoneal dialysis, intra-peritoneal chemotherapy. Again, in most cases mixed bacteria are isolated; the most common agents include cutaneous species such as Staphylococcus aureus, and coagulase-negative staphylococci, but many others are possible, including fungi such as Candida.

*Spontaneous bacterial peritonitis (SBP) is a peculiar form of peritonitis occurring in the absence of an obvious source of contamination. It occurs either in children, or in patients with ascites. See the article on spontaneous bacterial peritonitis for more information.

*Systemic infections (such as tuberculosis) may rarely have a peritoneal localisation.

Non-infected peritonitis:-
*Leakage of sterile body fluids into the peritoneum, such as blood (e.g. endometriosis, blunt abdominal trauma), gastric juice (e.g. peptic ulcer, gastric carcinoma), bile (e.g. liver biopsy), urine (pelvic trauma), menstruum (e.g. salpingitis), pancreatic juice (pancreatitis), or even the contents of a ruptured dermoid cyst. It is important to note that, while these body fluids are sterile at first, they frequently become infected once they leak out of their organ, leading to infectious peritonitis within 24-48h.

*Sterile abdominal surgery normally causes localised or minimal generalised peritonitis, which may leave behind a foreign body reaction and/or fibrotic adhesions. Obviously, peritonitis may also be caused by the rare, unfortunate case of a sterile foreign body inadvertently left in the abdomen after surgery (e.g. gauze, sponge).

*Much rarer non-infectious causes may include familial Mediterranean fever, porphyria, and systemic lupus erythematosus.

Pathology:-
The peritoneum normally appears greyish and glistening; it becomes dull 2–4 hours after the onset of peritonitis, initially with scarce serous or slightly turbid fluid. Later on, the exudate becomes creamy and evidently suppurative; in dehydrated patients, it also becomes very inspissated. The quantity of accumulated exudate varies widely. It may be spread to the whole peritoneum, or be walled off by the omentum and viscera. Inflammation features infiltration by neutrophils with fibrino-purulent exudation.

Treatment:-
Depending on the severity of the patient’s state, the management of peritonitis should be done.

Peritonitis is a potentially life-threatening condition, and you should see immediate emergency medical attention when symptoms occur. You will likely need to be hospitalized for treatment. You may need surgery to remove the source of infection, such as an inflamed appendix, or to repair a tear in the walls of the gastrointestinal or biliary tract. Antibiotics are used to control infection. Integrative therapies may also be used for supportive care when recovering from peritonitis.

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Medications
Your doctor will prescribe antibiotics to kill bacteria and prevent the infection from spreading. The antibiotics prescribed vary, depending on the type of peritonitis and the organism causing the condition.

Surgery and Other Procedures
People with peritonitis often need surgery to remove infected tissue and repair damaged organs.

Nutrition and Dietary Supplements
Peritonitis is a medical emergency and should be treated by a medical doctor. Do not try to treat peritonitis with herbs or supplements. However, a comprehensive treatment plan for recovering from peritonitis may include a range of complementary and alternative therapies. Ask your team of health care providers about the best ways to incorporate these therapies into your overall treatment plan. Always tell your health care provider about the herbs and supplements you are using or considering using.

When recovering from any serious illness, it is important to follow good nutrition habits:

•Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes) and vegetables (such as squash and bell peppers).
•Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables.
•Avoid refined foods, such as white breads, pastas, and especially sugar.
•Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy), or beans for protein.
•Use healthy oils in foods, such as olive oil or vegetable oil.
•Avoid caffeine and other stimulants, alcohol, and tobacco.
•Drink 6 – 8 glasses of filtered water daily.
•Ask your doctor about taking a multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium.
•Probiotic supplement (containing Lactobacillus acidophilus among other species), 5 – 10 billion CFUs (colony forming units) a day, for gastrointestinal and immune health. Probiotics can be especially helpful when taking antibiotics, because probiotics can help restore the balance of “good” bacteria in the intestines.

Herbs
Herbs are generally a safe way to strengthen and tone the body’s systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 – 10 minutes for leaf or flowers, and 10 – 20 minutes for roots. Drink 2 – 4 cups per day. You may use tinctures alone or in combination as noted.

Herbs can be used as a supportive therapy when you are recovering from peritonitis, but do not use herbs alone to treat peritonitis. Ask your doctor before taking any of the herbs listed below.

•Green tea (Camellia sinensis) standardized extract, 250 – 500 mg daily, for antioxidant, anti-inflammatory, and heart health effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
•Cat’s claw (Uncaria tomentosa) standardized extract, 20 mg three times a day, to reduce inflammation. Cat’s claw also has antibacterial and antifungal effects.
Olive leaf (Olea europaea) standardized extract, 250 – 500 mg one to three times daily, for antibacterial and antifungal effects. You may also prepare teas from the leaf of this herb.
•Milk thistle (Silybum marianum) seed standardized extract, 80 – 160 mg two to three times daily, for liver health.

Homeopathy

Few studies have examined the effectiveness of specific homeopathic remedies. A professional homeopath, however, may recommend one or more of the following treatments for peritonitis based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person’s constitutional type — your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

•Belladonna — for people who are hypersensitive to touch, have sudden attacks of pain that come and go, and have a high fever
•Arsenicum album — for people with a swollen abdomen, unquenchable thirst, extreme chills, and symptoms that worsen at night

Other Considerations:
Prognosis and Complications:-

Complications from peritonitis can include:

•Sepsis — an infection throughout the blood and body that can cause shock and multiple organ failure
•Abnormal clotting of the blood (generally due to significant spread of infection)
•Formation of fibrous tissue in the peritoneum
•Adult respiratory distress syndrome
— a severe infection of the lungs
The prognosis for peritonitis depends on the type of the condition. For example, the outlook for people with secondary peritonitis tends to be poor, especially among the elderly, people with compromised immune systems, and those who have had symptoms for longer than 48 hours before treatment. The long-term outlook for people with primary peritonitis due to liver disease also tends to be poor. However, the prognosis for primary peritonitis among children is generally very good after treatment with antibiotics.
Supporting Research
Bell DR, Gochenaur K. Direct vasoactive and vasoprotective properties of anthocyanin-rich extracts. J Appl Physiol. 2006;100(4):1164-70.

Cabrera C, Artacho R, Gimenez R. Beneficial effects of green tea — a review. J Am Coll Nutr. 2006;25(2):79-99.

Cvetnic Z, Vladimir-Knezevic S. Antimicrobial activity of grapefruit seed and pulp ethanolic extract. Acta Pharm. 2004;54(3):243-50.

Doron S, Gorbach SL. Probiotics: their role in the treatment and prevention of disease. Expert Rev Anti Infect Ther. 2006;4(2):261-75.

Gonclaves C, Dinis T, Batista MT. Antioxidant properties of proanthocyanidins of Uncaria tomentosa bark decoction: a mechanism for anti-inflammatory activity. Phytochemistry. 2005;66(1):89-98.

Heitzman ME, Neto CC, Winiarz E, Vaisberg AJ, Hammond GB. Ethnobotany, phytochemistry and pharmacology of Uncaria (Rubiaceae). Phytochemistry. 2005;66(1):5-29.

LaValle JB, Krinsky DL, Hawkins EB, et al. Natural Therapeutics Pocket Guide. Hudson, OH:LexiComp; 2000: 452-454.

Rotsein OD. Oxidants and antioxidant therapy. Crit Care Clin. 2001;17(1):239-47.

Schwartz SI, et al. Principles of Surgery. 8th ed. Vol. 2. New York, NY: McGraw-Hill; 2005.

Singer P, Shapiro H, Theilla M, Anbar R, Singer J, Cohen J. Anti-inflammatory properties of omega-3 fatty acids in critical illness: novel mechanisms and an integrative perspective. Intensive Care Med. 2008 Sep;34(9):1580-92.

Tok D, Ilkgul O, Bengmark S, Aydede H, Erhan Y, Taneli F, et al. Pretreatment with pro- and synbiotics reduces peritonitis-induced acute lung injury in rats. J Trauma. 2007 Apr;62(4):880-5.

Wang HK. The therapeutic potential of flavonoids. Expert Opin Investig Drugs. 2000;9(9):2103-19.

Yeh SL, Lai YN, Shang HF, Lin MT, Chiu WC, Chen WJ. Effects of glutamine supplementation on splenocyte cytokine mRNA expression in rats with septic peritonitis. World J Gastroenterol. 2005 Mar 28;11(12):1742-6.

Yoon JH, Baek SJ. Molecular targets of dietary polyphenols with anti-inflammatory properties. Yonsei Med J. 2005;46(5):585-96.

Yue GG, Fung KP, Tse GM, Leung PC, Lau CB. Comparative studies of various ganoderma species and their different parts with regard to their antitumor and immunomodulating activities in vitro. J Altern Complement Med. 2006 Oct;12(8):777-89.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://en.wikipedia.org/wiki/Peritonitis
http://www.umm.edu/altmed/articles/peritonitis-000127.htm

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