Management of Peritoneal Signs
Patients with diffuse peritonitis require immediate surgical exploration, while those with localized clinical signs may undergo further evaluation before determining management approach. 1
Initial Assessment and Stabilization
- Rapid restoration of intravascular volume should begin immediately when hypotension is identified in patients with septic shock 1
- For patients without evidence of volume depletion, intravenous fluid therapy should begin when intra-abdominal infection is first suspected 1
- Laboratory evaluation should include white blood cell count and C-reactive protein to assess inflammation severity 1, 2
- Antimicrobial therapy should be initiated once intra-abdominal infection is diagnosed or considered likely 1
- For patients with septic shock, antibiotics should be administered as soon as possible 1
Diagnostic Approach
- Further diagnostic imaging is unnecessary in patients with obvious signs of diffuse peritonitis who require immediate surgical intervention 1
- In patients not undergoing immediate laparotomy, CT scan is the imaging modality of choice to determine the presence and source of intra-abdominal infection 1
- CT is more sensitive than standard abdominal radiographs for detecting free air 1, 2
- Double contrast enhanced CT can help determine if non-operative management is feasible in cases with localized peritoneal signs 1
Surgical Management
Indications for Immediate Surgery
- Diffuse peritonitis requires emergency surgical procedure as soon as possible, even if ongoing measures to restore physiologic stability need to be continued during the procedure 1
- Patients with peritoneal signs and radiological evidence of pneumoperitoneum and free fluid within the peritoneal cavity require surgical exploration 1
- Unstable patients presenting with hemorrhagic shock and non-responders to resuscitation need immediate surgery 1
Surgical Approach
- An appropriate source control procedure to drain infected foci, control ongoing peritoneal contamination by diversion or resection, and restore anatomic and physiological function is recommended for nearly all patients with intra-abdominal infection 1
- Where feasible, percutaneous drainage of abscesses and other well-localized fluid collections is preferable to surgical drainage 1
- Damage control surgery with temporary abdominal closure is an important adjunct for patients who require intestinal resection, allowing reassessment of bowel viability and management of severe abdominal sepsis 1
- In hemodynamically unstable patients with free perforation and generalized peritonitis or toxic megacolon, an open approach is recommended 1
Conservative Management
- For hemodynamically stable patients without evidence of acute organ failure, intervention may be delayed for up to 24 hours if appropriate antimicrobial therapy is given and careful clinical monitoring is provided 1
- Highly selected patients with minimal physiological derangement and a well-circumscribed focus of infection may be treated with antimicrobial therapy alone without a source control procedure, provided that very close clinical follow-up is possible 1
- Conservative management may be appropriate in selected patients with localized pain, free air without diffuse free fluids, hemodynamic stability, and absence of fever 1, 2
- Conservative treatment consists of serial clinical and imaging monitoring (every 3-6 hours), absolute bowel rest, intravenous fluids, and intravenous broad-spectrum antibiotics 1
Antimicrobial Therapy
- For patients with septic shock and peritonitis, recommended antibiotics include:
- Meropenem 1 g q6h by extended infusion or continuous infusion
- Doripenem 500 mg q8h by extended infusion or continuous infusion
- Imipenem/cilastatin 500 mg q6h by extended infusion
- Eravacycline 1 mg/kg q12h 1
- For patients with inadequate/delayed source control, consider:
- Ertapenem 1 g q24h or
- Eravacycline 1 mg/kg q12h 1
- Satisfactory antimicrobial drug levels should be maintained during source control intervention, which may necessitate additional administration of antimicrobials just before the procedure 1
Special Considerations
- Intra-abdominal hypertension (IAH) should be monitored as it can lead to visceral ischemia and is associated with adverse outcomes in critically ill patients 1
- IAH can adversely affect the entire body through both physical and humoral mechanisms, potentially leading to multi-system organ failure 1
- Surgical management is recommended for immunocompromised patients and transplant recipients regardless of perforation size 2
- The most common causes of acute peritonitis include duodenal perforation (26.2%), typhoid ileal perforation (24.2%), and ruptured appendix (16.8%) 3
Monitoring and Follow-up
- Continuous and strict clinical and biochemical follow-up is recommended for all patients 2
- Clinical improvement should gradually occur within 24 hours if conservative treatment is successful 2
- Patients who have ongoing signs of infection or systemic illness beyond 7 days of antibiotic treatment warrant further diagnostic investigation 1
- Higher complication rates and longer hospital stays are associated with delayed surgical intervention after failed conservative management 2