Can Peritonitis Cause Bowel Obstruction?
Yes, peritonitis can cause bowel obstruction, though it is an uncommon mechanism—peritoneal inflammation leads to adhesion formation that mechanically obstructs the bowel, and this represents a distinct clinical entity from the more common causes of obstruction.
Mechanism of Peritonitis-Related Obstruction
Peritoneal inflammation triggers a cascade that results in mechanical bowel obstruction through several pathways:
- Adhesion formation from recurrent peritonitis is a well-documented cause of adhesive small bowel obstruction, particularly in conditions like Familial Mediterranean Fever where repeated episodes of sterile peritonitis occur 1
- Sclerosing encapsulating peritonitis represents the most severe form, where chronic peritoneal inflammation creates a thick fibrous membrane that encases the bowel in a "cocoon-like" fashion, causing mechanical obstruction 2, 3, 4
- Post-inflammatory adhesions can develop after any episode of peritonitis, contributing to the 55-75% of small bowel obstructions caused by adhesions overall 5
Clinical Context and Frequency
The relationship between peritonitis and obstruction must be understood in proper clinical context:
- Sclerosing encapsulating peritonitis causes bowel obstruction in approximately 3% of patients with recurrent peritonitis (such as in Familial Mediterranean Fever), making it the most frequent complication of that condition 1
- Less than 300 cases of primary sclerosing encapsulating peritonitis have been reported worldwide, emphasizing its rarity as a cause of obstruction 3
- Peritonitis itself is more commonly a complication OF bowel obstruction rather than a cause—signs of peritonitis during obstruction indicate strangulation, ischemia, or perforation requiring emergency surgery 5
Diagnostic Considerations
When evaluating whether peritonitis has caused obstruction, specific clinical features help distinguish this from other etiologies:
- History of recurrent abdominal pain episodes suggests inflammatory conditions like Familial Mediterranean Fever that predispose to adhesive obstruction 1
- Chronic peritoneal dialysis history is the most common association with sclerosing peritonitis, though idiopathic cases occur in young males and adolescent girls 2, 6
- CT scan findings show bowel encasement by fibrous membrane in sclerosing peritonitis, with characteristic "cocoon" appearance 3, 4
- Laboratory markers of peritonitis (CRP >75, WBC >10,000/mm³, elevated lactate) during acute obstruction indicate complications requiring emergency surgery rather than peritonitis as the primary cause 5
Critical Pitfall to Avoid
The most important clinical distinction is recognizing that peritonitis during bowel obstruction is usually a sign of life-threatening complications (perforation, ischemia, strangulation) requiring immediate surgery 5. The presence of fever, diffuse tenderness, guarding, or rebound during obstruction mandates emergency surgical exploration 5. Only in rare cases of chronic recurrent peritonitis (like Familial Mediterranean Fever) or sclerosing peritonitis does the inflammatory process itself cause the mechanical obstruction 1, 2.
Management Implications
When peritonitis has caused obstruction through adhesion formation or sclerosing peritonitis:
- Surgical intervention with adhesiolysis and membrane excision is the definitive treatment for sclerosing encapsulating peritonitis 2, 3, 4
- Conservative management fails in most cases of sclerosing peritonitis-related obstruction, necessitating operative intervention 3, 4
- Short-course steroids may prevent recurrence in cases of sclerosing peritonitis after surgical treatment 4
- Mortality risk is significant when obstruction from sclerosing peritonitis leads to bowel necrosis or enterocutaneous fistulae 6