What Is Peritonitis?
Peritonitis is inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera. It is usually bacterial, with organisms tracking in from GI tract disease or, in women, from the internal reproductive organs. Acute inflammatory bowel processes feed it: appendicitis and diverticulitis both can perforate and seed the cavity.
Pathophysiology
Contents leak from abdominal organs into the cavity and bacteria proliferate. Tissue edema follows, and fluid exudes into the peritoneal cavity within a short time, turning turbid with protein, white blood cells, cellular debris, and blood. The intestinal tract first answers with hypermotility, then drops into paralytic ileus as air and fluid accumulate in the bowel.
Causes
Trauma such as gunshot or stab wounds opens the cavity to contamination. Inflammation extending from an organ outside the peritoneal area, such as the kidneys, can reach it. The bacteria most often implicated are Escherichia coli, Klebsiella, Proteus, Pseudomonas, and Streptococcus, with E. coli the single most common isolate from peritoneal cultures (Medscape).
Clinical Manifestations
Findings track the extent and location of inflammation. Pain starts diffuse, then becomes constant, localized, and more intense over the involved site. The affected abdomen turns extremely tender and distended, the muscles go rigid, and movement makes it worse. Expect a temperature of 37.8C to 38.3C with an increased pulse rate.
Complications
Widespread infection drives the danger. Sepsis is the major cause of death from peritonitis. Mortality stays under 5% for uncomplicated, promptly treated cases but rises above 30% in severe or delayed infection, especially once septic shock develops (Septic Peritonitis, StatPearls). Shock follows from septicemia or hypovolemia. The inflammatory process can also cause intestinal obstruction, mostly from bowel adhesions.
Assessment and Diagnostic Findings
The white blood cell count is almost always elevated. Serum electrolyte studies may show altered potassium, sodium, and chloride. An abdominal xray may show air and fluid levels and distended bowel loops. Abdominal ultrasound may reveal abscesses and fluid collections, a CT scan of the abdomen may reveal abscess formation, and MRI may be used to diagnose intra-abdominal abscesses.
Medical Management
Fluid, colloid, and electrolyte replacement is the focus. Several liters of an isotonic solution are prescribed, with analgesics for pain. Intestinal intubation and suction relieve abdominal distention and promote return of intestinal function. Oxygen by nasal cannula or mask supports adequate oxygenation. Antibiotic therapy starts early.
Surgical Management
Surgery removes infected material and corrects the cause. Treatment is directed toward excision, especially when the appendix is involved. Resection of the intestines may be done with or without anastomosis. With extensive sepsis, a fecal diversion may be created.
Nursing Management
Patients with peritonitis often need intensive care.
Nursing Assessment
Assess continuously. Pain should be assessed and acted on, GI function monitored to gauge response to interventions, and fluid and electrolytes kept in balance.
Nursing Diagnosis
Acute pain related to peritoneal irritation. Deficient fluid volume related to massive shifting of fluids toward the intestinal lumen and depletion of the vascular space. Risk for shock related to septicemia or hypovolemia.
Nursing Care Planning and Goals
Reduce pain, restore fluid and electrolyte balance, prevent complications, and restore normal GI function.
Nursing Interventions
Monitor blood pressure by arterial line if shock is present. Give analgesics and antiemetics as prescribed, and use positioning along with analgesics to ease pain. Record all intake and output accurately to guide fluid replacement, and administer and closely monitor IV fluids. Postoperatively, monitor and record the character of the drainage.
Evaluation
Pain is reduced, fluid and electrolyte balance is restored, complications are prevented, and normal GI function returns.
Discharge and Home Care Guidelines
If the patient goes home with drains still in place, teach the patient and family to care for the incision and drains. Refer for home care when further monitoring and patient and family teaching are needed.
Documentation Guidelines
Document the client's description of and response to pain, the acceptable level of pain, prior medication use, degree of deficit, current sources of fluid intake, intake and output, fluid balance, presence of edema, results of diagnostic tests, vital signs, plan of care, and teaching plan. Record response to interventions, teaching, and actions performed, attainment or progress toward desired outcomes, modifications to the plan of care, long term needs, and specific referrals made.
Frequently Asked Questions
What is the most common cause of secondary peritonitis? Secondary peritonitis usually follows a breach of the GI tract, most often a perforated appendix, perforated diverticulitis, or a perforated peptic ulcer, which spills bacteria and intestinal contents into the normally sterile peritoneal cavity (Medscape).
Which bacteria most often cause peritonitis? Gram-negative and anaerobic gut flora dominate. Escherichia coli is the single most common isolate, followed by Klebsiella, Proteus, Pseudomonas, and Streptococcus. This is why empiric antibiotics target gram-negative and anaerobic coverage.
Why is peritonitis a surgical emergency? Source control matters as much as antibiotics. Surgery removes infected material and repairs or resects the leaking organ. Without timely source control, bacteria keep seeding the cavity and the patient progresses toward sepsis and septic shock.
What are the hallmark signs of peritonitis? Diffuse pain that becomes constant and localized, a rigid boardlike abdomen with guarding, rebound tenderness, distention, fever (about 37.8C to 38.3C), and a rising pulse. Pain worsens with movement, so patients lie still.
What is the leading cause of death in peritonitis? Sepsis is the major cause of death. Mortality is low for uncomplicated cases treated early but climbs above 30% once severe infection and septic shock set in (StatPearls).
How is fluid balance managed in peritonitis? Large volumes of protein-rich fluid third-space into the inflamed cavity, so several liters of isotonic IV fluid are given with close intake and output monitoring. Intestinal intubation and suction relieve distention while the bowel recovers from paralytic ileus.