What is the treatment for abdominal encapsulating peritonitis?

Treatment of Abdominal Encapsulating Peritonitis

The treatment of abdominal encapsulating peritonitis requires prompt surgical intervention with adhesiolysis to release the encased bowel, followed by appropriate antimicrobial therapy covering gram-negative bacteria and anaerobes. 1

Diagnostic Approach

• CT scan is the imaging modality of choice for diagnosing abdominal encapsulating peritonitis, showing characteristic findings of small bowel loops congregated to the center of the abdomen encased by a soft-tissue density mantle 2
• Laboratory tests should include WBC count, PCT, and CRP to assess the severity of infection and monitor response to treatment 1

Treatment Algorithm

Surgical Management (Primary Treatment)

• Complete surgical source control should be performed as soon as the patient has been maximally resuscitated 1
• Surgical intervention involves:
  • Adhesiolysis to release the encased bowel from the fibrous membrane 2, 3
  • Debridement of necrotic tissue 1
  • Restoration of anatomic and physiological function 1
• Early re-laparotomy is the most effective means of treating peritonitis and should not be delayed more than 24 hours 1
• Laparoscopic approach may be considered in hemodynamically stable patients, though caution is needed due to potential acid-base disturbances from pneumoperitoneum 1

Antimicrobial Therapy

• Initiate broad-spectrum antibiotics as soon as diagnosis is made or suspected 1
• For patients with septic shock, antibiotics should be administered immediately 1
• Antimicrobial coverage should include:
  • Gram-negative bacteria (Bacteroides species including B. fragilis group) 4
  • Anaerobes (Clostridium species, Peptostreptococcus species) 4
• Metronidazole is specifically indicated for intra-abdominal infections including peritonitis 4
• Duration of antimicrobial therapy:
  • Continue until resolution of physiological abnormalities 1
  • Generally 3-5 days after adequate source control 1

Alternative Management Approaches

• In highly selected cases with minimal physiological derangement, medical management may be attempted with:
  • Steroids and immunosuppressive agents (e.g., mycophenolate mofetil) 5
  • Liquid diet program 5
• Percutaneous drainage may be considered for well-localized fluid collections without signs of generalized peritonitis 1

Monitoring and Follow-up

• Close clinical monitoring is mandatory during treatment 1
• Monitor for signs of persistent infection or treatment failure:
  • Persistent fever, abdominal pain, or distension 1
  • Rising inflammatory markers (WBC, CRP, PCT) 1
• Follow-up CT scan is recommended after 5-7 days to exclude residual peritonitis or abscess formation 1
• Thromboprophylaxis is recommended during hospitalization due to increased risk of thrombosis with inflammatory response 1

Pitfalls and Caveats

• Delay in surgical intervention beyond 24 hours significantly increases mortality rates 1
• Inadequate source control is associated with intolerably high patient mortality 1
• Atypical clinical presentation may lead to delay in diagnosis and intervention 1
• The diagnosis may be difficult to make preoperatively, requiring high clinical suspicion 2
• Patients may present with intermittent subacute intestinal obstruction rather than acute peritonitis 3, 5
• Prolonged ileus and need for total parenteral nutrition should be anticipated postoperatively 6