Type Of Peritonitis Research Articles

CURRENT APPROACHES IN DIAGNOSIS AND TREATMENT OF PATIENTS WITH PERITONITIS

Background: Intra-abdominal infections (IAIs) are a wide range of pathological conditions that affect all intra-abdominal tissues and organs. These include both inflammation of individual organs and any type of peritonitis (primary, secondary, tertiary), where the severity of the disease often depends on the spread of inflammation - local or diffuse peritonitis. Methods: In this article ,we present a review and analysis of current definitions, classifications, and approaches in the diagnosis and treatment of intra-abdominal infections. Results and Conclusions: IAIs remain an important cause of morbidity and mortality in modern surgical practice worldwide. Early and accurate clinical diagnosis, adequate local control, appropriate antimicrobial therapy according to the patient's risk factors and infection, and prompt resuscitation in critically ill patients are the cornerstones of IAI management. The application of the principles of evidence-based medicine and the individual approach to patients is crucial for optimizing results.

MECONIUM PERITONITIS IN NEWBORNS: FEATURES OF DIAGNOSTICS AND SURGICAL TREATMENT

The purpose of research - to conduct the analysis of meconium peritonitis treatment outcomes in newborns and develop an optimal algorithm for the diagnosis and treatment strategy. Materials and methods. Based on the results of examination and treatment of 24 newborns with meconium peritonitis (MP), which operated in the pediatric surgery clinic Ivano-Frankivsk National Medical University for the past 12 years. All children operated on in the first days of life. Patients were divided into 2 groups. The first group included 11 patients who were operated in the first period of the study (2002-2008.) The second group - 13 patients operated after 2008. When treating patients of the second group we applied a differentiated approach to the choice of surgical treatment depending on the type of MP. Results and discussion. In 79.2% of patients the cause of MP were congenital defects of intestines (atresia, doubling, volvulus), which complicated by necrosis and perforation. In 3 infants observed volvulus and bowel atresia, 4 children had multiple atresia. Localization of perforation in most patients was at the level of the small intestine, only two children - at the level of the colon, in one case - perforation of the stomach. In the majority of operated newborns was detected fibro-adhesive form of MP, a third of children had diffuse peritonitis and two patients - cystic form of MP. We have used tactics of differentiated approach to surgical treatment MP depending on the type of peritonitis in children of the second group (after 2008). Applied differentiated approach to the treatment of infants with MP allowed improve outcomes in children of the second group. Conclusions. The most common cause of MP in our observations was congenital intestinal obstruction. In most cases congenital intestinal obstruction was the indication for surgery in MP. Results of treatment of children with MP depends on its form and pathology that caused it. The worst outcomes we obtained in fibrous- adhesive form of MP. Applied differentiated approach to the surgical treatment depending on the form of MP allowed to reduce the incidence of postoperative complications and mortality in operated neonates. Great importance in the improving treatment outcomes of children with MP has its antenatal diagnosis.

Local and systemic innate immune response to secondary human peritonitis

IntroductionOur aim was to describe inflammatory cytokines response in the peritoneum and plasma of patients with peritonitis. We also tested the hypothesis that scenarios associated with worse outcome would result in different cytokine release patterns. Therefore, we compared cytokine responses according to the occurrence of septic shock, mortality, type of peritonitis and peritoneal microbiology.MethodsPeritoneal and plasma cytokines (interleukin (IL) 1, tumor necrosis factor α (TNFα), IL-6, IL-10, and interferon γ (IFNγ)) were measured in 66 patients with secondary peritonitis.ResultsThe concentration ratio between peritoneal fluid and plasma cytokines varied from 5 (2 to 21) (IFNγ) to 1310 (145 to 3888) (IL-1). There was no correlation between plasma and peritoneal fluid concentration of any cytokine. In the plasma, TNFα, IL-6, IFNγ and IL-10 were higher in patients with shock versus no shock and in nonsurvivors versus survivors (P ≤0.03). There was no differential plasma release for any cytokine between community-acquired and postoperative peritonitis. The presence of anaerobes or Enterococcus species in peritoneal fluid was associated with higher plasma TNFα: 50 (37 to 106) versus 38 (29 to 66) and 45 (36 to 87) versus 39 (27 to 67) pg/ml, respectively (P = 0.02). In the peritoneal compartment, occurrence of shock did not result in any difference in peritoneal cytokines. Peritoneal IL-10 was higher in patients who survived (1505 (450 to 3130) versus 102 (9 to 710) pg/ml; P = 0.04). The presence of anaerobes and Enterococcus species was associated with higher peritoneal IFNγ: 2 (1 to 6) versus 10 (5 to 28) and 7 (2 to 39) versus 2 (1 to 6), P = 0.01 and 0.05, respectively).ConclusionsPeritonitis triggers an acute systemic and peritoneal innate immune response with a simultaneous release of pro and anti-inflammatory cytokines. Higher levels of all cytokines were observed in the plasma of patients with the most severe conditions (shock, non-survivors), but this difference was not reflected in their peritoneal fluid. There was always a large gradient in cytokine concentration between peritoneal and plasma compartments highlighting the importance of compartmentalization of innate immune response in peritonitis.

English

Peritonitis is the inflammation of the peritoneum and is most commonly due to localized or generalized infection. It is most common surgical emergency in India. Most common causes in India are perforated gastric /duodenal ulcer. Any type of peritonitis can be very serious and life threatening if not evaluated and treated properly. Prognosis in peritonitis is decisively influenced by the health status of the patients at beginning of treatment. Accurate prediction of the outcome of the disease can initially be made on the basis of the prognostic scoring systems, currently several scoring systems are employed. The APACHE prognostic scoring system for measuring severity of illness in critically ill patients was developed in 1981 by William A Knaus 1. APACHE - II introduced in 1985 was a simplified modification of original APACHE. APACHE - II was further refined to APACHE - III in 1991. It is important for surgeons to develop at least a rudimentary knowledge of scoring system for perforation peritonitis, as it will play an increasing role to explain the prognosis of the disease. Aims & objectives of study are to predict the outcome of the patients with perforation peritonitis on the basis of APACHE - III scoring system. This study was conducted on 72 patients, admitted to emergency ward of Rama Medical college hospital & Research centre, Mandhana Kanpur, who were diagnosed as cases of perforation peritonitis from January 2009 - January 2011. All the patients were evaluated according to APACHE - III scoring system within 24 hours of admission. All the patients admitted in emergency ward initially examined clinically then required investigations were done. Total APACHE III score range for (0-299). Patients with lower scores have more favourable prognosis than patients with higher scores. Thus it was concluded from this study that patients with low scores have favourable outcome as compared to patients with high scores.

Relapsing and Recurrent Peritoneal Dialysis–Associated Peritonitis: A Multicenter Registry Study

The causes, predictors, treatment, and outcomes of relapsed and recurrent peritoneal dialysis (PD)-associated peritonitis are poorly understood. Observational cohort study using Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data. All Australian PD patients between October 1, 2003, and December 31, 2007, with first episodes of peritonitis. Demographic, clinical, and facility variables and type of peritonitis; relapse (same organism or culture-negative episode occurring within 4 weeks of completion of therapy of a prior episode or 5 weeks if vancomycin used); recurrence (different organism occurring within 4 weeks of completion of therapy of a prior episode or 5 weeks if vancomycin used); control (first peritonitis episode without relapse or recurrence). Hospitalization, catheter removal, hemodialysis therapy transfer, death. Of 6,024 PD patients studied, first episodes of relapsed, recurrent, and control peritonitis occurred in 356, 165, and 2,021 patients, respectively. Coagulase-negative staphylococci and Staphylococcus aureus accounted for 48% of relapsing peritonitis (adjusted OR, 1.26 [95% CI, 0.94-1.70] and 1.54 [95% CI, 1.08-2.19], respectively), but were much less likely to be isolated in recurrent peritonitis. Recurrent peritonitis was associated more frequently with fungi (13%; OR, 2.16; 95% CI, 1.12-4.17). The empirical antimicrobial approaches to relapsing and recurrent peritonitis were similar and their subsequent clinical outcomes were comparable. Compared with uncomplicated peritonitis, relapsed and recurrent peritonitis were associated with higher rates of catheter removal (22% vs 30% vs 37%, respectively; P < 0.001) and permanent hemodialysis therapy transfer (20% vs 25% vs 32%; P < 0.001), but similar rates of hospitalization (73% vs 70% vs 70%) and death (2.8% vs 2.0% vs 1.2%). Limited covariate adjustment. Residual confounding and coding bias could not be excluded. Relapsed and recurrent peritonitis are caused by different spectra of micro-organisms, but are not readily clinically distinguishable at presentation. Empirical treatment with broad-spectrum antibiotics and subsequent adjustment according to antimicrobial susceptibilities results in similar clinical outcomes, albeit with appreciably higher rates of catheter removal and hemodialysis therapy transfer than for uncomplicated peritonitis.

Mystery or Misery? Primary Group A Streptococcal Peritonitis in Women: Case Report

Acute primary peritonitis in the absence of other comorbid conditions such as liver cirrhosis, immunosuppression, or nephrotic syndrome is a rare disorder in young adults. In women, ascending genital infections are thought to be a major pathogenic cause of this type of peritonitis. Pus was detected in the peritoneal cavity by abdominal paracentesis in a 27-year-old woman who had no predisposing features for severe peritonitis. Abdominal computed tomography showed perirectal edema. Laparotomy was performed, but no intra-abdominal focus of infection could be detected. The abdomen was irrigated via a subhepatic and retroperitoneal presacral approach, and broad-spectrum antibiotic therapy was started. Blood cultures revealed group A streptococci, usually a common cause of upper respiratory tract infections or erysipelas. Within a few days, the patient recovered completely and returned to normal life.

Non-Pseudomonas Gram-negative peritonitis

Non-Pseudomonas Gram-negative organisms account for over 10% of cases of peritoneal dialysis-associated peritonitis. The key findings from a paper by Szeto et al. are discussed and compared with those from previous publications. This type of peritonitis has a high rate of catheter removal and technique failure. Results may be better with more aggressive antibiotic treatment. Other developments in the field are reviewed.

Severe Secondary Peritonitis following Gastrointestinal Tract Perforation

Early prognostic evaluation of abdominal sepsis is useful in the assessment of the severity of the disease and to select high-risk patients for early surgical reintervention. The aim of this study was to identify prognostic factors in a well-defined patient population most likely to benefit from early reoperation. Retrospective analysis of 66 consecutive patients with secondary peritonitis caused by gastrointestinal tract perforation and requiring postoperative treatment in an intensive care unit was performed using univariate and multivariate analysis to identify risk factors for hospital mortality. The overall hospital mortality rate was 36 %. Significant risk factors in the univariate analysis included advanced age (p = 0.000), pre-existing illness (p = 0.000), chronic medication (p = 0.028), hospital transfer (p = 0.036), non-traumatic cause of perforation (p = 0.031), high Mannheim peritonitis index (MPI) score (p = 0.001), and high C-reactive protein (CRP) level in the early postoperative phase (p = 0.015). In a multivariate analysis, only advanced age (odds ratio 1.1008, p = 0.000) and high postoperative CRP level (odds ratio 1.0095, p = 0.008) were identified as independent prognostic factors for hospital mortality. In addition to factors associated with the physiological reserve of the patient, type of peritonitis and high MPI score, elevated CRP levels in the early postoperative phase in patients operated for severe secondary peritonitis have prognostic significance. However, before a properly designed randomized study on the value of planned relaparotomy in secondary peritonitis can be initiated, more reliable methods to identify high-risk patients need to be found.

Diverticular Disease and Treatment with Gastric Acid Inhibitors do not Predispose to Peritonitis of Enteric Origin in Peritoneal Dialysis Patients

Enteric peritonitis (EP) is an infrequent complication of peritoneal dialysis (PD), with severe consequences for peritoneal membrane viability and patient outcome. Factors such as diverticular disease and gastric acid inhibitors have been implicated in its appearance. We investigated several risk factors, including those mentioned below, that can influence the development of EP. Retrospective cross-sectional study. Tertiary-care public university hospital. Fifty-seven PD patients treated in our PD unit during August 1998. A barium enema was performed on 50 of the 57 patients (the remaining 7 patients refused it) in order to exclude the presence of diverticulosis. All episodes of peritonitis occurring in those patients, including EP, were registered. Enteric peritonitis was defined as that caused by gram-positive, gram-negative, or fungus micro-organisms that colonized the intestinal tract, excluding episodes secondary to genitourinary tract or peritoneal catheter exit-site infections. Twenty-four patients showed diverticular disease in the barium enema, but only 5 of them (21%) had any EP episode. Five of the 26 patients with no diverticula (19%) had EP. Fifty-five episodes of peritonitis were reported in 21 patients; 15 episodes of EP (27.3% of all) developed in 11 patients. Seven of the 11 patients (64%) required peritoneal catheter removal and 3 of them (27%) finally were transferred to hemodialysis due to consequences of the EP episode. Logistic regression analysis did not find any of the independent variables analyzed (age, sex, time on PD, type of PD, peritoneal transport parameters, presence of polycystic kidney disease, constipation or diverticulosis, or treatment with gastric acid inhibitors, or phosphate-binding agents) to be risk factors for developing EP. Neither diverticulosis nor treatment with gastric acid inhibitors seem to be risk factors for developing peritonitis of enteric origin in PD patients. This type of peritonitis has to be promptly identified and treated in order to diminish the high frequency of peritoneal catheter removal and PD dropout due to such episodes.

Inflammatory cytokine response in patients with septic shock secondary to generalized peritonitis.

The aims of this study were the following: a) to assess the proinflammatory cytokine (tumor necrosis factor [TNF]-alpha, interleukin [IL]-1, and IL-6) response in patients with septic shock secondary to generalized peritonitis; and b) to evaluate the influence of bacteremic status, type of peritonitis (acute perforation or postoperative), and peritoneal microbial status (mono- or polymicrobial) on cytokine expression and mortality. Prospective study. Surgical intensive care unit of a university hospital. Fifty-two consecutive patients with septic shock caused by generalized peritonitis. Routine blood tests, blood cultures, and cytokine assays were performed during the first 3 days after onset of shock. Serum TNF-alpha and IL-6 concentrations were measured by using a radioimmunoassay, and IL-1 concentrations were measured by using ELISA. Median serum concentrations on day 1 were: TNF-alpha, 90 pg/mL; IL-1, 7 pg/mL; and IL-6, 5000 pg/mL. TNF-alpha and IL-6 concentrations decreased significantly between the first and third days of septic shock (p = .0001), whereas IL-1 concentrations remained low. The decrease in IL-6 tended to be more pronounced in the survivors group (p = .057). Median TNF-alpha serum concentrations were higher in bacteremic compared with nonbacteremic patients (151 vs. 73 pg/mL, p = .003). TNF-alpha, IL-1, and IL-6 serum concentrations and mortality were not different between acute perforation vs. postoperative peritonitis and mono- versus polymicrobial peritonitis. The systemic release of TNF-alpha and IL-6 during septic shock caused by generalized peritonitis was maximal on day 1 and decreased rapidly during the next days. No systemic release of IL-1 was observed. IL-6 serum concentrations remained higher in patients who subsequently died. Among the different features of peritonitis studied, only bacteremia influenced the systemic cytokine response (higher TNF-alpha).

Excellent Technique Survival on Home Peritoneal Dialysis: Results of a Regional Program

To examine peritoneal dialysis technique survival in our regional, continuous ambulatory peritoneal dialysis (CAPD) program. Retrospective analysis. Tertiary care dialysis program at an academic medical center. 155 patients representing all those in the peritoneal dialysis program between October 1, 1987 and October 1, 1990. The study analyzed patient and technique survival as well as the reasons for discontinuation of dialysis. In addition, the incidence and type of peritonitis and exit-site infection were also analyzed. Three-year actuarial patient survival was 66% and three-year technique survival was 86%, with data censored for death and transplant patients. Fifty-seven percent of transfers to hemodialysis were due to peritonitis, usually fungal or multiorganism bacterial. Only 1 patient failed due to exit-site and tunnel infection, and 1 due to inadequate dialysis. The catheter removal rate was 0.04 per patient-year. Excellent CAPD technique survival can be achieved if exit-site and tunnel infection rates are low.

The Antimicrobial Implications of the Pharmacokinetics of Cotrimoxazole in CAPO Patients

Cotrimoxazole (TMP/SMX) has been used to treat continuous ambulatory peritoneal dialysis (CAPD) associated peritonitis. It is considered bactericidal for some species. The most common single organism responsible for this type of peritonitis is Staph. epidermidis (SE). When the drug is given orally, the typical ratio of TMP to SMX achieved in the peritoneal fluid is 1:5, which is different from the optimal combination for antimicrobial synergy of 1:19. This study investigated the antimicrobial activity of TMP alone and TMP/SMX by agar dilution at ratios of 1:19, 1:10 and 1:5 against 99 strains of Staphylococcus epidermis (SE). The majority of strains were susceptible to TMP and to all ratios of TMP/SMX by the routine agar dilution methods. We studied the bactericidal activity of TMP/SMX against one strain each of SE and of Staph. aureus (SA) in pooled uninfected spent dialysate by killing curve experiments. TMP at concentrations of 0.5 to 2.0 μg/ml was bacteriostatic. TMP/SMX became slowly bactericidal when 5 % lysed horse blood, a source of thymidine phosphorylase, was added to the dialysate. It is concluded that susceptibility tests of inhibition do not predict bactericidal activity of TMP/SMX in recovered dialysate. Inhibition of TMP/ SMX is most likely due to thymidine present in dialysate. TMP alone was as effective against SE as TMP/ SMX. Until it is shown that bactericidal activity is not required for cure of CAPD-related peritonitis, cotrimoxazole should not be used routinely for its treatment.

Experimental peritonitis produced by gastric juice, bile or feces.

Seventy-four patients of acute diffuse peritonitis were briefly reviewed. Fecal peritonitis due to perforation of the colon showed a remarkably high mortality, though the operation was carried out in general earlier than in other types of peritonitis. Three types of peritonitis, fecal, gastric juice and bile peritonitis, were produced experimentally in dogs. Changes in blood pressure, hematocrit, plasma protein, plasma volume, water contents of the intestine, acid-base balance and bacterial culture of the blood were studied in each type of peritonitis. Severe hypovolemia was considered to be an important factor in the early development of shock in fecal peritonitis, but hypovolemia alone was not sufficient to account for the extreme severity of fecal peritonitis. Blood culture became positive within a few hours after the onset of fecal peritonitis and severe septicemia, seemed to be another important factor which contributed to aggravation of symptoms in this disease. The present authors, however, could not demonstrate endotoxin-like substance in the circulating blood of dogs with severe fecal peritonitis.

The use of oxygen and oxygen liberating substances in the treatment of anaerobic peritonitis in guinea pigs

P RIMARY peritonitis is that type which is due to pathogenic bacteria that have reached the peritoneum by way of the blood stream, a single species of bacteria such as the pneumococcus or streptococcus being responsibIe. Secondary peritonitis is due to pathogenic bacteria which have reached the peritoneum through breaks in the continuity of the gastrointestina1 tract, more than one species of bacteria being responsibIe through thdir combined effects. Extension of infection from adjacent abscesses may also bring about a secondary type of peritonitis. Accidental and surgical wounds may Iikewise introduce bacteria into the peritonea1 cavity which resuIt in secondary peritonitis. From time to time articIes have appeared in medica literature which cite cases of “Gas Peritonitis” or “Anaerobic Peritonitis.” Differences of opinion exist over the abiIity of strictIy anaerobic bacteria to produce peritonitis without being in association with other bacteria. Bacteria reported to be present in the exudate of secondary peritonitis incIude coIon baciIIi, streptococci, staphylococci, WeIch baciIIi and anaerobic non-hemoIytic streptococci. A summary of the Iiterature reviewed reveaIs conAicting opinions on the existence of “Gas Peritonitis” or “Anaerobic Peritonitis ” as an entity. VeiIIon and Zuber30 are generaIIy credited with being the first to isoIate an anaerobic non-hemoIytic streptococcus under the name of Micrococcus faetidus, a strictIy anaerobic coccus growing in short chains and producing gas and a fetid odor in cuhures. This organism had been isoIated in pure cuIture from a case of suppurative barthoIinitis, and in association with other organisms from cases of appendicitis, Ludwig’s angina and perinephritic abscess. Since VeiIIon’s report there have appeared in the Iiterature numerous articIes, some reporting series of cases, others deaIing with isoIated observations on the recovery of anaerobic non-hemoIytic streptococci in pure cuIture and in association with other organisms from various Iesions, as we11 as from heaIthy body cavities and surfaces. Tissier2g was abIe to isoIate from cases of putrid enteritis anaerobic nonhemoIytic streptococci which he described as a new species under the name of LanceoIatus anaerobicus. WhiIe undoubtedIy the anaerobic streptococcus is a norma inhabitant of the human gastrointestina1 tract, it is possibIe that some may be introduced from the mouth in the process of swaIIowing saIiva. McDonaId, Henthorne and Thompson’* reported a case of perforated duodena1 uIcer which was foIlowed two and onehaIf months after surgica1 cIosure by a subdiaphragmatic abscess, empyema thoracis, and muItipIe Iiver abscesses. The anaerobic non-hemoIytic streptococcus was obtained in pure cuIture from the Iatter. PresumabIy the organisms originated from the spiIIed duodena1 contents. GiIbert and Lippman” recovered these organisms in 25 per cent of their cases of suppurative ChoIecystitis. There is an abundance of Iiterature on the bacterioIogy of acute appendicitis, and numerous investigators1,%4,12,21,32 h ave shown that the anaerobic non-hemoIytic streptococcus forms part of the bacteria1 flora of acute suppurative appendicitis, gangrenous appendi-

AbstractThe Roentgen Diagnosis of Fœtal Meconium Peritonitis, NeuhauserE. B. D.,Amer. Journ. Roentg., April 1944, li, 42.

The first reported series of observations of fœtal peritonitis were made by James Simpson in 1838. Abt states that meconium peritonitis is by far the commonest type in infancy. This type of peritonitis has been described by Markavitz and Loar as a non-bacterial chemical inflammation of the peritoneum caused by the escape of sterile meconium into the peritoneal cavity through a perforation of the bowel.

PERITONITIS

In a previous communication, 1 it was shown that active immunity can be produced in dogs against a fatal outcome following bacillusgum tragacanth peritonitis. Since one of the more common causes of peritoneal infection is soiling of the peritoneum by intestinal contents, this investigation was undertaken to determine whether active immunity can also be developed against a fatal outcome in this type of peritonitis. Since colon bacillus is found with and without other organisms in a high percentage of cases of peritonitis due to rupture of the appendix or perforation of intestines, it was determined to investigate the capacity of the colon bacillus alone to produce active immunity against the fatal outcome of fecal peritonitis. EXPERIMENTAL METHOD AND EXPERIMENTS Method. —In preliminary experiments, it was found that the intraperitoneal injection into a dog of a saline suspension of 5 Gm. of solid feces from the lower portion of the