WordNet

of critical importance and consequence; "an acute (or critical) lack of research funds"
having or demonstrating ability to recognize or draw fine distinctions; "an acute observer of politics and politicians"; "incisive comments"; "icy knifelike reasoning"; "as sharp and incisive as the stroke of a fang"; "penetrating insight"; "frequent penetrative observations" (同)discriminating, incisive, keen, knifelike, penetrating, penetrative, piercing, sharp
extremely sharp or intense; "acute pain"; "felt acute annoyance"; "intense itching and burning" (同)intense
having or experiencing a rapid onset and short but severe course; "acute appendicitis"; "the acute phase of the illness"; "acute patients"
of an angle; less than 90 degrees
inflammation of the peritoneum (同)peritoneal inflammation

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(先の)『鋭い』,とがった / (痛み・感情などが)『激しい』,強い / (知力・感覚などが)『鋭い』,鋭敏な / (事態が)重大な / (病気が)急性の / (音が)高い,鋭い / 鋭角の
腹膜炎

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2014/04/30 07:26:01」(JST)

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This article is about peritonitis in human beings. For a specific cause of peritonitis in cats, see Feline infectious peritonitis.

Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. Peritonitis may be localized or generalized, and may result from infection (often due to rupture of a hollow organ as may occur in abdominal trauma or appendicitis) or from a non-infectious process.

Signs and symptoms

Abdominal pain and tenderness

The main manifestations of peritonitis are acute abdominal pain, abdominal tenderness, and abdominal guarding, which are exacerbated by moving the peritoneum, e.g., coughing (forced cough may be used as a test), flexing one's hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness, meaning that pressing a hand on the abdomen elicits less pain than releasing the hand abruptly, which will aggravate the pain, as the peritoneum snaps back into place). The presence of these signs in a patient is sometimes referred to as peritonism.^[1] The localization of these manifestations depends on whether peritonitis is localized (e.g., appendicitis or diverticulitis before perforation), or generalized to the whole abdomen. In either case, pain typically starts as a generalized abdominal pain (with involvement of poorly localizing innervation of the visceral peritoneal layer), and may become localized later (with the involvement of the somatically innervated parietal peritoneal layer). Peritonitis is an example of an acute abdomen.

Collateral manifestations

Diffuse abdominal rigidity ("washboard abdomen") is often present, especially in generalized peritonitis
Fever
Sinus tachycardia
Development of ileus paralyticus (i.e., intestinal paralysis), which also causes nausea, vomiting and bloating.

Complications

Sequestration of fluid and electrolytes, as revealed by decreased central venous pressure, may cause electrolyte disturbances, as well as significant hypovolemia, possibly leading to shock and acute renal failure.
A peritoneal abscess may form (e.g., above or below the liver, or in the lesser omentum
Sepsis may develop, so blood cultures should be obtained.

Causes

Infected peritonitis

Perforation of part of the gastrointestinal tract is the most common cause of peritonitis. Examples include perforation of the distal esophagus (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 have just undergone 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, and 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 in patients with ascites, in particular, in children.
Intra-peritoneal dialysis predisposes to peritoneal infection (sometimes named "primary peritonitis" in this context).
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 to 48 hours.
Sterile abdominal surgery, under normal circumstances, causes localised or minimal generalised peritonitis, which may leave behind a foreign body reaction and/or fibrotic adhesions. However, peritonitis may also be caused by the rare 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, TNF receptor associated periodic syndrome, porphyria, and systemic lupus erythematosus.

Diagnosis

A diagnosis of peritonitis is based primarily on the clinical manifestations described above. If peritonitis is strongly suspected, then surgery is performed without further delay for other investigations. Leukocytosis, hypokalemia, hypernatremia, and acidosis may be present, but they are not specific findings. Abdominal X-rays may reveal dilated, edematous intestines, although such X-rays are mainly useful to look for pneumoperitoneum, an indicator of gastrointestinal perforation. The role of whole-abdomen ultrasound examination is under study and is likely to expand in the future. Computed tomography (CT or CAT scanning) may be useful in differentiating causes of abdominal pain. If reasonable doubt still persists, an exploratory peritoneal lavage or laparoscopy may be performed. In patients with ascites, a diagnosis of peritonitis is made via paracentesis (abdominal tap): More than 250 polymorphonucleate cells per μL is considered diagnostic. In addition, Gram stain is almost always negitive, whereas culture of the peritoneal fluid can determine the microorganism responsible and determine their sensitivity to antimicrobial agents.

Pathology

In normal conditions, the peritoneum 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 may include:

General supportive measures such as vigorous intravenous rehydration and correction of electrolyte disturbances.
Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. The empiric choice of broad-spectrum antibiotics often consist of multiple drugs, and should be targeted against the most likely agents, depending on the cause of peritonitis (see above); once one or more agents are actually isolated, therapy will of course be targeted on them.
Gram positive and gram negative organisms must be covered. Out of the Cephalosporins, cefoxitin and cefotetan can be used to cover gram positives, gram negatives, and anaerobes. Beta-lactams with beta lactamase inhibitors can also be used, examples include ampicillin/sulbactam, piperacillin/tazobactam, and ticarcillin/clavulanate.^[2] Carbapenems are also an option when treating primary peritonitis as all of the carbapenems cover gram positives, gram negatives, and anaerobes except for ertapenem. The only fluoroquinolone that can be used is moxifloxacin because this is the only fluoroquinolone that covers anaerobes. Finally, tigecycline is a tetracycline that can be used due to its coverage of gram positives and gram negatives. Empiric therapy will often require multiple drugs from different classes.
Surgery (laparotomy) is needed to perform a full exploration and lavage of the peritoneum, as well as to correct any gross anatomical damage that may have caused peritonitis.^[3] The exception is spontaneous bacterial peritonitis, which does not always benefit from surgery and may be treated with antibiotics in the first instance.

Prognosis

If properly treated, typical cases of surgically correctable peritonitis (e.g., perforated peptic ulcer, appendicitis, and diverticulitis) have a mortality rate of about <10% in otherwise healthy patient. The mortality rate rises to about 40% in the elderly, and/or in those with significant underlying illness, as well as in cases that present late (after 48 hours).

If untreated, generalised peritonitis is almost always fatal.

Famous Cases

Famous magician and escape artist Harry Houdini died of peritonitis after a fan asked to punch him in the stomach. At the time Houdini had been suffering from appendicitis, rupturing his already weakened appendix and eventual infection of his peritoneum. Refusing to get medical help he died two days later.

The Swiss Freudian psychiatrist and psychoanalyst Hermann Rorschach, best known for developing a projective test known as the Rorschach inkblot test, died of peritonitis in 1922 at the age of 37.

References

^ "Biology Online's definition of peritonism". Retrieved 2008-08-14.
^ Appropriate Prescribing of Oral Beta-Lactam Antibiotics
^ "Peritonitis: Emergencies: Merck Manual Home Edition". Retrieved 2007-11-25.

External links

Peritonitis disease causes, treatment treatment basis
Article on peritonitis at AllRefer.com
Genuit T and Napolitano L. 2004. Peritonitis and Abdominal Sepsis at Emedicine.com
Peritonitis at HealthCentral.com
openabdomen.org - Peritonitis, Medical and Surgical Therapy Reviewed

UpToDate Contents

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1. 成人における特発性細菌性腹膜炎：治療および予防 spontaneous bacterial peritonitis in adults treatment and prophylaxis
2. 成人における腹痛に対する診断的アプローチ diagnostic approach to abdominal pain in adults
3. 腹膜透析における腹膜炎の臨床症状および診断 clinical manifestations and diagnosis of peritonitis in peritoneal dialysis
4. 成人における腹痛の鑑別診断 differential diagnosis of abdominal pain in adults
5. 成人における特発性細菌性腹膜炎：診断 spontaneous bacterial peritonitis in adults diagnosis

English Journal

Accidentally ingested toothpicks causing severe gastrointestinal injury: a practical guideline for diagnosis and therapy based on 136 case reports.

Steinbach C, Stockmann M, Jara M, Bednarsch J, Lock JF.Author information Department of General, Visceral and Transplantation Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.AbstractBACKGROUND: Ingested toothpicks are a relatively rare event, but may cause serious gut injuries with peritonitis, sepsis, or death. Numerous case reports describing the clinical course in this setting are available but there is no concise guideline. The aim of the present study was to develop practical guidelines to aid clinicians in the diagnosis and management of acute tooth pick ingestion.
World journal of surgery.World J Surg.2014 Feb;38(2):371-7. doi: 10.1007/s00268-013-2307-z.
BACKGROUND: Ingested toothpicks are a relatively rare event, but may cause serious gut injuries with peritonitis, sepsis, or death. Numerous case reports describing the clinical course in this setting are available but there is no concise guideline. The aim of the present study was to develop practi
PMID 24166027

Barium Peritonitis in Small Animals.

Ko JJ, Mann FA.Author information Department of Veterinary Medicine and Surgery, University of Missouri-Columbia, Veterinary Medical Teaching Hospital.AbstractBarium peritonitis is extremely rare, but is difficult to treat and may be life-threatening. Barium suspension leakage from the gastrointestinal tract into the abdominal cavity has a time-dependent and synergistically deleterious effect in patients who have generalized bacterial peritonitis. The severity of barium peritonitis is dependent on the quantity of barium in the abdominal cavity. Barium sulfate leakage results in hypovolemia and hypoproteinemia by worsening the exudation of extracellular fluid and albumin. Abdominal fluid analysis is a useful and efficient method to diagnose barium peritonitis. Serial radiographs may not be a reliable or timely diagnostic technique. Initial aggressive fluid resuscitation and empirical broad-spectrum antibiotic treatment should be instituted promptly, followed quickly by celiotomy. During exploratory surgical intervention, copious irrigation and direct wiping with gauze are employed to remove as much barium as possible. Omentectomy should be considered when needed to expedite barium removal. Despite aggressive medical and surgical treatments, postoperative prognosis is guarded to poor due to complications such as acute vascular shock, sepsis, diffuse peritonitis, hypoproteninemia, electrolyte imbalance, cardiac arrest, small bowel obstruction related to progression of granulomas, and adhesions in the abdominal cavity. Therefore, intensive postoperative monitoring and prompt intervention are necessary to maximize chances for a positive outcome. For those that do survive, small bowel obstruction is a potential consequence due to progression of abdominal adhesions.
The Journal of veterinary medical science / the Japanese Society of Veterinary Science.J Vet Med Sci.2014 Jan 16. [Epub ahead of print]
Barium peritonitis is extremely rare, but is difficult to treat and may be life-threatening. Barium suspension leakage from the gastrointestinal tract into the abdominal cavity has a time-dependent and synergistically deleterious effect in patients who have generalized bacterial peritonitis. The sev
PMID 24430662

Japanese Journal

A Case of Peristomal Pyoderma Gangrenosum after Restorative Proctocolectomy for Ulcerative Colitis

松岡宏樹,内野基,坂東俊宏,池内浩基,竹末芳生,富田尚裕
日本大腸肛門病学会雑誌 66(3), 188-193, 2013
… From POD 12, he had strong pain around the stoma and acute ulcers around the stoma and at the operative wound. … However, as he had concurrent generalized peritonitis due to intestinal perforation at POD 57, he underwent stoma closure as an emergency surgery, following which the pyoderma gangrenosum was almost resolved. … In case of acute peristomal ulcer with strong pain, peristomal pyoderma gangrenosum should be suspected after disproving infection, and early diagnosis and treatment are required. …
NAID 130003369841

子宮留膿症からの子宮穿孔により急性汎発性腹膜炎を発症した子宮頸癌の１例

梅田杏奈,串本卓哉,福井薫,小野良子,数見久美子,宮西加寿也,朴康誠,山本敏也
産婦人科の進歩 65(1), 83-89, 2013
子宮穿孔は比較的まれな疾患である．原因の多くは妊娠中や子宮に関する手術後，子宮留膿症などの良性疾患であり，子宮頸癌を合併した症例の報告はこれまでに6例のみである．今回われわれは，子宮留膿症からの子宮穿孔により急性汎発性腹膜炎を発症した子宮頸癌の症例を経験したので報告する．症例は41歳，未経妊．数カ月前より不正性器出血を自覚していた．徐々に下腹部痛が出現，発熱を認めたため近医内科受診し，補液，解熱剤 …
NAID 130003362657