Diffuse Peritoneal Stranding/Edema: Diagnosis and Management
Diffuse peritoneal stranding and edema on imaging is a sign of peritoneal inflammation that requires prompt evaluation and management for intra-abdominal infection or perforation, as it often indicates a surgical emergency requiring immediate intervention.
Understanding Peritoneal Stranding/Edema
Peritoneal stranding and edema refers to inflammatory changes in the peritoneum visible on CT imaging, characterized by:
- Haziness and increased density of the peritoneal fat
- Thickening of the peritoneal lining
- Fluid accumulation between peritoneal layers
Common Causes
Intra-abdominal infection/peritonitis
- Perforated viscus (colon, small bowel)
- Appendicitis
- Diverticulitis with perforation
- Intra-abdominal abscess
Non-infectious causes
- Surgical manipulation
- Pancreatitis
- Mesenteric ischemia
- Malignancy
- Peritoneal dialysis complications
Diagnostic Approach
Imaging
- CT scan with contrast is the imaging modality of choice for evaluating peritoneal stranding/edema 1
- Look for:
- Free intraperitoneal air (pneumoperitoneum)
- Free fluid
- Source of infection/inflammation
- Bowel wall thickening
- Abscesses
Laboratory Tests
- Complete blood count (elevated WBC suggests infection)
- C-reactive protein (CRP)
- Procalcitonin (useful for delayed presentation >12 hours) 1
- Blood cultures (if patient appears toxic or is immunocompromised) 1
Management Algorithm
1. Immediate Assessment
- Evaluate for signs of septic shock or diffuse peritonitis
- If present, proceed to emergency surgical intervention 1
- If hemodynamically unstable, begin immediate fluid resuscitation 1
2. For Stable Patients with Peritoneal Stranding/Edema
A. If Diffuse Peritonitis is Present:
- Emergency surgical exploration is required 1
- Start broad-spectrum antibiotics immediately 1
- Fluid resuscitation to restore intravascular volume 1
B. If Localized Peritonitis or No Overt Peritonitis:
- CT scan to identify source 1
- Start empiric antibiotics covering anaerobes and gram-negative bacteria 2
- Source control based on etiology:
- Perforated diverticulitis: Surgical resection with primary anastomosis for stable patients; Hartmann's procedure for unstable patients 2
- Small bowel perforation: Primary repair for small perforations; resection and anastomosis for larger defects 1
- Contained perforation: Surgical intervention is preferred over conservative management due to high failure rate (57-60%) with conservative approach 2
3. Source Control Principles
- Remove infected material
- Control ongoing contamination
- Restore anatomic and physiological function 1
- For well-localized fluid collections, percutaneous drainage may be preferable to surgical drainage 1
Special Considerations
Peritoneal Dialysis Patients
In patients on peritoneal dialysis, peritoneal stranding/edema may indicate:
- Dialysate leakage through peritoneal defects 3, 4, 5
- Fluid imbalance or volume overload 6
- Inguinal hernia (often occult) 5
Intra-abdominal Hypertension
- Peritoneal edema can contribute to intra-abdominal hypertension (IAH)
- IAH should be monitored as it can lead to visceral ischemia and organ dysfunction 1
Pitfalls to Avoid
- Delaying surgical intervention in patients with diffuse peritonitis 2
- Overreliance on CT findings without considering clinical status 2
- Inappropriate antibiotic selection not covering anaerobes and gram-negative bacteria 2
- Missing occult sources of peritoneal inflammation, especially in peritoneal dialysis patients 5
Follow-up
- For patients with resolved peritonitis related to diverticular disease, colonoscopy is recommended 6-8 weeks after resolution to rule out malignancy 2
- Monitor for development of tertiary peritonitis or persistent infection
- Assess for resolution of peritoneal stranding on follow-up imaging
Remember that peritoneal stranding/edema is a radiological finding indicating inflammation that requires prompt evaluation and appropriate management based on the underlying cause to prevent progression to severe sepsis and multi-organ failure.