What are the other Names for this Condition? (Also known as/Synonyms)

• Acute Abdomen

What is Secondary Peritonitis? (Definition/Background Information)

• The peritoneum is a thin double-layered membrane that lines the inside of the abdominal cavity, covering organs within it. Peritonitis is inflammation of the peritoneum, which may be caused by bacteria, fungi, or even by chemicals. The most common type of peritoneal inflammation is Secondary Peritonitis
• Broadly, peritonitis is divided into three types:
  • Primary peritonitis: The infection comes from the bloodstream or lymphatics. This is rare i.e., less than 1% of those affected by peritonitis have this form. Also known as spontaneous peritonitis, this type of infection occurs without any rupture or perforation of the peritoneum, and develops in individuals with large fluid build-up in the abdominal cavity or chronic liver disease
  • Secondary Peritonitis: This type occurs when the peritoneum is infected from the gastrointestinal or biliary tract, or through perforation of the abdominal wall
• Secondary Peritonitis is more common among immunocompromised individuals, those with liver cirrhosis, appendicitis, bowel diseases, stomach ulcers, and/or pancreatitis. It is also observed frequently in individuals on peritoneal dialysis
• Trauma, hollow organ perforation, and pancreatitis can cause spillage of blood, intestinal contents, and digestive pancreatic juices into the peritoneal cavity. This results in an inflammation and predisposes the peritoneal cavity to infections
• Some medical procedures, such as peritoneal dialysis, paracentesis (inserting a hollow needle into a body cavity) and abdominal catheters that may be used to drain urine, can directly introduce infection into the abdominal cavity predisposing the individual to Secondary Peritonitis
• The condition commonly presents with abdominal pain, fever and chills, decreased urination, constipation, distended or bloated abdomen, and in severe cases, shock. Secondary Peritonitis is a medical emergency that requires prompt diagnosis and treatment
• Careful and thorough history taking, physical exams, and blood tests are required for diagnosing the condition. Depending on the cause, a healthcare professional may also request X-rays, computed tomography (CT) scans, or test peritoneal fluid for the presence of bacteria
• If left untreated, the condition can cause serious life-threatening complications. These include sepsis (spread of bacteria into bloodstream causing multi-organ failure), lung conditions (such as acute respiratory distress syndrome), and disseminated intravascular coagulation (DIC)
• The treatment involves administering intravenous antibiotics and surgical removal of the infected tissue. Surgery may also be required to treat the underlying cause of Secondary Peritonitis
• There are no known methods for prevention of Secondary Peritonitis. Seeking medical attention for abdominal pain that does not resolve may help in early diagnosis of this infection
• The prognosis of Secondary Peritonitis is determined by the overall health of the affected individual, duration of infection prior to treatment, and response to treatment. Despite aggressive treatment, most individuals require prolonged hospital and intensive care unit (ICU) stays; some may also succumb to the condition

Who gets Secondary Peritonitis? (Age and Sex Distribution)

• Secondary Peritonitis may occur among individuals of all ages, especially if exposed to trauma or gastrointestinal pathologies (e.g. peptic ulcer)
• Males and females are equally susceptible to the condition
• People of all racial groups, ethnicities, and nationalities may be affected 

What are the Risk Factors for Secondary Peritonitis? (Predisposing Factors)

Some known risk factors for Secondary Peritonitis include: 

• Appendicitis (inflammation of the appendix)
• Stomach or duodenal ulcers
• Torn or twisted intestine (volvulus)
• Pancreatitis (inflammation of the pancreas)
• Inflammatory bowel disease, such as Crohn’s disease or ulcerative colitis
• Diverticulitis
• Abdominal injury caused by a surgery
• Peritoneal dialysis
• Trauma (such as stab wounds and motor vehicle accidents)
• Necrotizing enterocolitis (infection of the intestinal wall) can cause Secondary Peritonitis in premature babies
• A history of the condition may increase the risk of developing Secondary Peritonitis again
• In general, individuals with reduced immunity are more vulnerable to Secondary Peritonitis

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Secondary Peritonitis? (Etiology)

The causes of Secondary Peritonitis include:

• Perforation of a hollow organ, such as the intestine, can rupture and spill its contents into the peritoneum, causing inflammation. Common causes of perforation include the following:
  • Peptic ulcers
  • Diverticulitis (inflammation of small bulging pouches in the colon)
  • Ruptured appendix following appendicitis
• Inflammation of the peritoneum by any blood, pus, or body fluids that leak within the peritoneal cavity
• Medical procedures, in which compromised hygiene or contaminated equipment may lead to infection. Such procedures may include:
  • Peritoneal dialysis, in which tubes (catheters) are used to remove waste products from blood, when the kidneys can no longer adequately do so
  • Gastrointestinal surgery
  • Use of feeding tubes
  • Paracentesis (a procedure to withdraw fluid or gas from a body cavity, such as the intestine) 
  • Colonoscopy and endoscopy
• Inflammation of the pancreas (or pancreatitis) can cause the release of digestive enzymes into the peritoneal cavity
• Trauma: Examples include stab or gunshot wounds, which can directly introduce bacteria into the abdominal cavity. Gunshot wounds may also perforate the gut, causing Secondary Peritonitis

The following are some agents identified to cause inflammation of the peritoneum:

• Bacteria that include:
  • Enterococcus spp.
  • Escherichia coli
  • Enterbacter spp.
  • Bacteriodes spp.
  • Klebsiella spp.
  • Staphylococcus aureus
  • Coagulase-negative Staphylococci
  • Pseudomonas spp.
  • Streptococcus spp.
• Fungi: Candida spp.
• Chemicals that include:
  • Bile
  • Pancreatic enzymes

What are the Signs and Symptoms of Secondary Peritonitis?

The signs and symptoms manifested in Secondary Peritonitis are:

• Abdominal pain and tenderness that gets worse with touch or movement
• Distended or bloated abdomen
• Fever and chills
• Thirst
• Loss of appetite
• Nausea and vomiting
• Reduced urine output
• Low output of stools or gas
• Signs of shock that include:
  • Low blood pressure
  • Increased heart rate
  • Shortness of breath
  • Confusion, lethargy
  • Clammy skin

How is Secondary Peritonitis Diagnosed?

Secondary Peritonitis is a medical emergency that may be life-threatening. Therefore, it requires prompt diagnosis and immediate medical attention. The diagnosis of Secondary Peritonitis is made by the following tools:

• A thorough physical examination and an assessment of symptoms
• An evaluation of the individual’s medical history
• Complete blood count (increased white blood cells may indicate an infection)
• Blood cultures (to identify pathogens causing infection)
• X-rays (to rule out organ perforation)
• Computed tomography (CT) scan of the abdomen, to identify the cause of inflammation
• Paracentesis: This is done by inserting a needle into the abdomen and extracting a sample of peritoneal fluid for testing and culture
• Depending on the cause, other tests may be required, such as serum lipase for pancreatitis, or ultrasounds for trauma.

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis

What are the possible Complications of Secondary Peritonitis?

The possible complications associated with Secondary Peritonitis include:

• Intra-abdominal abscess: Fluid or pus collecting in the abdominal cavity
• Sepsis: Infection that spreads to the bloodstream causing multi-organ failure and even fatality
• Acute respiratory distress syndrome (ARDS): Severe infection of the lungs
• Disseminated intravascular coagulation (DIC): A clotting disorder that can also progress to shock and multi-organ failure
• Recurrence of peritonitis after treatment
• Intra-peritoneal adhesions: Fibrous tissues that join the abdominal organs to each other; these can later cause intestinal obstruction

How is Secondary Peritonitis Treated?

The treatment for Secondary Peritonitis includes:

• Antibiotics to treat the infection
• Surgery to remove infected tissue and/or to treat the underlying cause of the peritonitis
• IV fluids for maintenance of electrolyte and fluid balance
• Painkillers
• Oxygen supplementation for breathing problems
• Total parenteral nutrition (intravenous feeding)
• Blood transfusions 

How can Secondary Peritonitis be Prevented?

• At the present time, there are no methods or guidelines available for the prevention of Secondary Peritonitis
• If an individual has abdominal pain that does not resolve soon, seeking immediate medical attention can help prevent serious complications
• Regular medical screening at periodic intervals with tests and physical examinations are highly recommended

What is the Prognosis of Secondary Peritonitis? (Outcomes/Resolutions)

• The prognosis of Secondary Peritonitis is determined by the duration of symptom manifestation prior to treatment, the overall health of the affected individual, as well as his/her response to treatment
• Without complications, it is possible for an individual to recover completely from the condition with adequate treatment
• However, complications may lead to prolonged hospitalization and extended recovery times, as well as fatalities. This is particularly true for advanced age individuals, and those with reduced/compromised immunity
• Depending on the cause of the condition (surgery, gastrointestinal perforation, trauma), the mortality rate ranges from 20% to 36%

Additional and Relevant Useful Information for Secondary Peritonitis:

Secondary Peritonitis is a life-threatening complication of abdominal perforation and trauma. It presents with severe abdominal pain, fever and shock. Urgent diagnosis and treatment is necessary to prevent morbidity and mortality. IV antibiotics and surgical debridement of infected tissue is the mainstay of treatment.