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DEFINITIONS

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Inflammation of the peritoneal lining of the abdominal cavity

  • Primary: without an intra-abdominal source

  • Secondary: caused by viscus rupture/perforation, bowel necrosis, or extension of an intraperitoneal organ infection or abscess

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ETIOLOGY

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Most commonly associated with nephrotic syndrome, liver failure, acute abdominal infections (i.e., appendicitis)

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COMMON ORGANISMS

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  • Pneumococci

  • Group A streptococci

  • Gram-negative enteric organisms: Escherichia. coli, Klebsiella

  • Staphylococci

  • Enterococci

  • Candida

  • Pasteurella multocida

  • Mycobacteria tuberculosis

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CAUSES OF SECONDARY PERITONITIS

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  • Ruptured appendicitis

  • Incarcerated hernia

  • Midgut volvulus

  • Meckel's diverticulum

  • Intussusception

  • Necrotizing enterocolitis (NEC)

  • Hemolytic uremic syndrome (HUS)

  • Ruptured peptic ulcer

  • Trauma

  • Genital tract infections and pelvic inflammatory disease (PID): mixed flora, Neisseria, Chlamydia, anaerobes

  • Foreign bodies: ventriculoperitoneal (VP) shunts, peritoneal dialysis (PD) catheters

  • Autoimmune disorders: systemic lupus erythematosus (SLE)

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CLINICAL MANIFESTATIONS

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  • Fever, abdominal pain, anorexia, vomiting, diarrhea, acute abdomen, mental status changes, toxic appearance, shock.

  • Clinical signs may be unreliable; therefore, have a low threshold for diagnostic paracentesis.

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DIAGNOSIS

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LABORATORY EVALUATION

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  • Complete blood count (CBC): increased white blood cells (WBCs) with neutrophil predominance

  • Urinalysis (UA): proteinuria

  • Ascitic fluid: >250 polys/mm2, increased lactate, decreased pH (<7.35), Gram stain with organisms

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IMAGING

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  • Upright abdominal x-ray: may show free air in patients with ruptured viscus

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TREATMENT

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See Surviving Sepsis Guidelines to reverse shock.

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ANTIMICROBIAL THERAPY

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  • Empiric IV antibiotics:

    • Ampicillin or ceftriaxone + an aminoglycoside

    • Anaerobic coverage (metronidazole or clindamycin) if secondary peritonitis suspected

  • Switch to enteral antimicrobial: afebrile and able to tolerate enteral medications

  • Narrow antimicrobial therapy: based on culture results

  • Duration: 10 to 14 days

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SURGICAL INTERVENTION

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  • Drainage of abscess

  • Repair of perforated viscus

  • Excision of necrotic bowel

  • Removal of foreign body

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SUGGESTED READINGS

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Rangel SJ, Moss RL. Chapter 69: Peritonitis. In: Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases. 3rd ed. Churchill Livingstone–An Imprint of Elsevier Science; 2009:420.
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Solomkin JS, Mazuski JE, Bradley JS,  et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50:133–164.  [PubMed: 20034345]

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