What is the initial management for acute peritoneal signs?

Initial Management of Acute Peritoneal Signs

Patients with acute peritoneal signs require immediate resuscitation with intravenous fluids and broad-spectrum antibiotics, followed by urgent surgical evaluation—those with diffuse peritonitis and signs of perforation need emergency surgical intervention as soon as possible, even if physiologic stabilization is incomplete. 1, 2

Immediate Resuscitation (First Hour)

• Fluid resuscitation should begin immediately upon identification of peritoneal signs, particularly if hypotension or signs of septic shock are present 1
• Antimicrobial therapy must be initiated once intra-abdominal infection is diagnosed or considered likely; for septic shock, antibiotics should be given as soon as possible (ideally within 1 hour) 1, 2
• Recommended antibiotic regimens for severe cases include Meropenem 1 g every 6 hours by extended infusion or continuous infusion 1
• Laboratory evaluation should include white blood cell count and C-reactive protein to assess inflammation severity 1

Diagnostic Imaging Strategy

The imaging approach depends critically on whether the patient has obvious diffuse peritonitis:

• No imaging is needed in patients with obvious signs of diffuse peritonitis who require immediate surgical intervention—diagnostic imaging should not delay surgery 1
• For 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 plain radiographs for detecting free air and can help determine if non-operative management is feasible in cases with localized peritoneal signs 1

Surgical vs. Conservative Management Decision

Indications for Emergency Surgery:

• Diffuse peritonitis requires emergency surgical procedure as soon as possible, with ongoing resuscitation continued during the procedure 1, 2
• Patients with peritoneal signs plus radiological evidence of pneumoperitoneum and free fluid require surgical exploration 1
• Unstable patients with hemorrhagic shock who are non-responders to resuscitation need immediate surgery 1
• The surgical goals are to drain infected foci, control ongoing peritoneal contamination by diversion or resection, and restore anatomic and physiological function 1, 2

Criteria for Conservative Management (Highly Selected Cases Only):

• Hemodynamically stable patients without acute organ failure may have intervention delayed up to 24 hours if appropriate antimicrobials are given and careful clinical monitoring is provided 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
• Conservative treatment consists of serial clinical and imaging monitoring every 3-6 hours, absolute bowel rest, intravenous fluids, and intravenous broad-spectrum antibiotics 1

Critical Pitfalls to Avoid

• Do not delay surgery for complete physiologic stabilization in patients with diffuse peritonitis—this increases mortality; resuscitation should continue concurrently with surgical intervention 2
• Do not rely on clinical assessment alone for severity stratification, as it misclassifies approximately 50% of patients 3
• Ensure antimicrobial drug levels are maintained during source control intervention, which may necessitate additional administration just before the procedure 1, 2
• Do not pursue imaging in patients with obvious diffuse peritonitis, as this delays definitive surgical management 1

Special Considerations

• Where feasible, percutaneous drainage of abscesses and well-localized fluid collections is preferable to surgical drainage 1
• Damage control surgery with temporary abdominal closure is important for patients requiring intestinal resection, allowing reassessment of bowel viability 1
• Patients with ongoing signs of infection beyond 7 days of antibiotic treatment warrant further diagnostic investigation 1