Your health, your choices

06 Maret 2016

Introduction
Peritonitis is inflammation of the peritoneum, the thin layer of tissue that lines the
inside of the abdomen (tummy).

It is caused by an infection, which can rapidly spread around the body. Peritonitis requires
immediate treatment and is a medical emergency. Signs of peritonitis often develop quickly
and include:

sudden abdominal pain that becomes more severe

feeling sick (nausea)

a lack of appetite

a high temperature (fever) of 38C (100.4F) or above

not passing any urine or passing less than normal

Symptoms of peritonitis

Abdominal (tummy) pain is one of the main symptoms of peritonitis.

This usually begins as a sudden ache that develops into a severe pain. Other possible
symptoms include:

feeling sick (nausea)

vomiting

lack of appetite

chills

a high temperature (fever) of 38C (100.4F) or above

rapid heartbeat

not passing any urine or passing less than normal

swelling of the abdomen

If you are being treated with peritoneal dialysis because you have kidney failure, the fluid
that is passed into your collection bag will probably be cloudier than usual and may contain
white flecks or clumps.

If peritonitis results from cirrhosis, you may not have any pain at all. You may simply feel
unwell or develop other complications of liver disease, such as confusion or a build-up of
fluid in your abdomen.

When to get medical help

Sudden abdominal pain that gradually gets worse is usually a sign of a potentially serious
infection or illness.

If you have this type of pain, contact your GP immediately. If this is not possible, call NHS
111 or your local out-of-hours service

Causes of peritonitis

Peritonitis occurs when the thin layer of tissue lining the tummy (peritoneum) becomes
infected with bacteria or fungi.

The infection can either develop directly in the peritoneum or spread from another part of the
body.

Infection of other parts of the body

Most often, peritonitis is caused by an infection that spreads to the peritoneum from another
part of the body. This is known as secondary peritonitis.

Common causes of secondary peritonitis include:

a split stomach ulcer

a burst appendix

inflammation of the pancreas (acute pancreatitis)

severe trauma to the abdomen, such as a knife or gunshot wound

digestive disorders, such as Crohn's disease or diverticulitis

Both Crohn's disease and diverticulitis can cause the colon to become inflamed. If the
inflammation is particularly severe, the colon can split and leak the contents of the bowel into
the peritoneum, contaminating it with bacteria.

Direct infection
Peritonitis can occur when the peritoneum becomes directly infected, although this is rare.
This is known as primary or spontaneous peritonitis.
In most cases, primary peritonitis is caused by scarring of the liver or peritoneal dialysis.

Cirrhosis
Scarring of the liver, known as cirrhosis, can occur after liver damage. The most common
causes of cirrhosis in the UK are alcohol misuse, a hepatitis C infection, or obesity.

Cirrhosis can lead to a build-up of fluid inside the abdomen (ascites). This fluid is particularly
vulnerable to infection, and provides an environment where bacteria or fungi can grow and
spread.

This build-up of fluid affects around half of people with cirrhosis, usually many years after
cirrhosis was diagnosed. About 20% of people with cirrhosis who develop ascites will be
affected by peritonitis.

Peritoneal dialysis
People having peritoneal dialysis for kidney failure are at risk of developing peritonitis.
Dialysis is a medical treatment that replicates the main functions of the kidneys and removes
waste products from the body.

Peritoneal dialysis uses the peritoneum to replicate the main function of the kidneys, which is
to filter waste products out of the blood. A small tube called a catheter is implanted into the
peritoneum, which removes waste products.

Although rare, peritonitis can develop if the equipment becomes contaminated by bacteria or
fungi.

Diagnosing peritonitis

Peritonitis can often be diagnosed after a physical examination and tests.

Physical examination
Your GP will ask you about your symptoms and recent medical history, and will carry out a
detailed physical examination.

If you have peritonitis, parts of the body such as the abdominal (tummy) wall often become
tender to the touch. A physical examination will help rule out other conditions that can cause
similar symptoms, such as a hernia.

The risk of complications from peritonitis is high, so you'll be admitted to hospital if your GP
suspects you have it.

Tests
You may need blood tests and urine tests to check for infection. If you have a build-up of
fluid in your abdomen (tummy), a small sample may be removed using a thin needle so it can
be checked for infection.
Doctors may also recommend:

an X-ray where radiation is used to produce an image to look for

evidence of air leakage from the bowel

an ultrasound scan where sound waves are used to build a picture of the
inside of your peritoneum

a computerised tomography (CT) scan a series of X-rays are taken to

build up a more detailed three-dimensional picture of your peritoneum

These types of scans can often detect whether there is internal damage inside your abdomen,
such as a burst appendix, a ruptured stomach ulcer, or extensive inflammation of the colon.

Treating peritonitis

If you're diagnosed with peritonitis, you'll be admitted to hospital so you can be

carefully monitored.

This is because there is a risk of serious complications of peritonitis, such as blood poisoning.

Medicines
The initial treatment for peritonitis involves injections of antibiotics or antifungal medicines.
This usually lasts 10 to 14 days.

If your peritonitis was caused by peritoneal dialysis, antibiotics may be injected directly into
the peritoneum. Research has shown this is more effective than injecting antibiotics into a
vein.

You'll also need to use an alternative method of dialysis until the peritonitis has been
successfully treated. You may also be given painkilling medication if you are in pain.

Nutritional support
Many people with peritonitis have problems digesting food, so a feeding tube may be needed.

The feeding tube is either passed into your stomach through your nose (nasogastric tube) or
surgically placed into your stomach through your stomach.

If these are unsuitable, nutrition may be given directly into one of your veins (parenteral
nutrition).

Surgery
If part of the tissue of the peritoneum has been seriously damaged by infection, it may need to
be surgically removed.
Some people develop abscesses (pus-filled swellings) in their peritoneum that need to be
drained with a needle. This is carried out using an ultrasound scanner to guide the needle to
the abscess. Local anaesthetic is usually used so you don't feel any pain.

Treating an abscess

Abscesses can be treated in a number of different ways, depending on the type of

abscess and how large it is.

The main treatment options include:

antibiotics

a drainage procedure

surgery

Skin abscesses
Some small skin abscesses may drain naturally and get better without the need for treatment.
Applying heat in the form of a warm compress, such as a warm flannel, may help reduce any
swelling and speed up healing.

However, the flannel should be thoroughly washed afterwards and not used by other people,
to avoid spreading the infection.

For larger or persistent skin abscesses, your GP may prescribe a course of antibiotics to help
clear the infection and prevent it from spreading.

A course of antibiotics will usually start before a specific type of bacteria has been identified,
so "broad-spectrum" antibiotics will initially be given. These are designed to work against a
wide range of known infectious bacteria and will usually cure most common infections. Once
a specific bacterium has been identified from a pus sample, a more "focused" antibiotic can
be used.

Sometimes, especially with recurrent infections, you may need to wash off all the bacteria
from your body to prevent re-infection (decolonisation). This can be done using antiseptic
soap for most of your body and an antibiotic cream for the inside of your nose.

However, antibiotics alone may not be enough to clear a skin abscess, and the pus will need
to be drained to clear the infection. If a skin abscess is not drained, it may continue to grow
and fill with pus until it bursts, which can be very painful and can cause the infection to
spread or recur.
Incision and drainage
If your skin abscess needs draining, you will probably have a small operation carried out
under anaesthetic usually a local anaesthetic, where you remain awake and the area around
the abscess is numbed.

During the procedure, the surgeon will make a cut (incision) in the abscess, to allow the pus
to drain out. They may also take a sample of pus for testing.

Once all of the pus has been removed, the surgeon will clean the hole that is left by the
abscess using sterile saline (a salt solution).

The abscess will be left open but covered with a wound dressing, so if any more pus is
produced it can drain away easily. If the abscess is deep, an antiseptic dressing (gauze wick)
may be placed inside the wound to keep it open.

The procedure may leave a small scar.

Internal abscesses
The pus will usually need to be drained from an internal abscess, either by using a needle
inserted through the skin (percutaneous abscess drainage) or with surgery.

The method used will depend on the size of your abscess and where it is in your body.
Antibiotics will usually be given at the same time, to help kill the infection and prevent it
spreading. These may be given as tablets or directly into a vein (intravenously).

As with skin abscesses, broad-spectrum antibiotics will initially be given until a specific
bacteria has been identified from a pus sample.

Percutaneous drainage
If the internal abscess is small, your surgeon may be able to drain it using a fine needle.
Depending on the location of the abscess, this may be carried out using either a local or
general anaesthetic.

The surgeon may use ultrasound scans or computerised tomography (CT) scans to help guide
the needle into the right place.

Once the abscess has been located, the surgeon will drain the pus using the needle. They may
make a small incision in your skin over the abscess, then insert a thin plastic tube called a
drainage catheter into it.

The catheter will allow the pus to drain out into a bag, and may have to be left in place for up
to a week.

This procedure may be carried out as a day case procedure, which means you will be able to
go home the same day, although some people will need to stay in hospital for a few days.
As with the incision and drainage procedure for skin abscesses, percutaneous drainage may
leave a small scar.

Surgery
If your internal abscess is too large to be drained with a needle, if a needle cannot get to the
abscess safely, or if needle drainage has not been effective in removing all of the pus, you
may need to undergo surgery.

The type of surgery you have will depend on the type of internal abscess you have and where
it is in your body, but it will generally involve making a larger incision in your skin to allow
the pus to be washed out

Treating appendicitis

If you have appendicitis, your appendix usually needs to be removed as soon as possible.
This operation is known as an appendectomy or appendicectomy.

Surgery is usually also recommended if there's a chance you have appendicitis but it's not
been possible to make a clear diagnosis.

This is because it's considered safer to remove the appendix than run the risk of the appendix
bursting.

In humans, the appendix doesn't perform any important function and having it removed
doesn't cause any long-term problems.

The procedure
Appendectomies are carried out under general anaesthetic using either a keyhole or open
technique.

Keyhole surgery
Keyhole surgery (laparoscopy) is usually the preferred method of removing the appendix
because the recovery tends to be quicker than with open surgery.

This operation involves making three or four small cuts (incisions) in your tummy
(abdomen). Special instruments are then inserted, including:

a tube that gas is pumped through to inflate your abdomen this allows
the surgeon to see your appendix more clearly and gives them more room
to work

a laparoscope a small tube containing a light source and a camera,

which relays images of the inside of the abdomen to a television monitor

small surgical tools used to remove the appendix

Once the appendix has been removed, the incisions will usually be closed with
dissolvable stitches. Regular stitches may also be used, which need to be removed at your GP
surgery 7 to 10 days later.

Open surgery
In some circumstances, keyhole surgery isn't recommended and open surgery is performed
instead. These include:

when the appendix has already burst and formed a lump called an
appendix mass

when the surgeon isn't very experienced in laparoscopic removal

people who have previously had open abdominal surgery

In these cases, the operation involves making a single larger cut in the lower right-hand side
of your abdomen to remove the appendix.

When there's widespread peritonitis infection of the inner lining of the abdomen it's
sometimes necessary to operate through a long cut along the middle of the abdomen in a
procedure called a laparotomy.

As with keyhole surgery, the incision is closed using either dissolvable stitches or regular
stitches that need to be removed at a later date.

After both types of surgery, the removed appendix is routinely sent to a laboratory to check
there are no signs of cancer. This is a precautionary measure, although it's rare for a serious
problem to be found.

Recovery
One of the main advantages of keyhole surgery is the recovery time tends to be short and
most people can leave hospital a few days after the operation.

If the appendix is operated upon promptly, most patients can go home within 24 hours. With
open or complicated surgery for example, if you have peritonitis it may take up to a week
before you're well enough to go home.

For the first few days after the operation you're likely to experience some pain and bruising.
This improves over time, but you can take painkillers if necessary.

If you had keyhole surgery, you may experience pain in the tip of your shoulder for about a
week. This is caused by the gas that was pumped into the abdomen during the operation.

You may also experience some short-term constipation. You can help reduce this by not
taking codeine painkillers, eating plenty of fibre, and staying well hydrated. Your GP can
prescribe medication if the problem is particularly troublesome.
Before leaving hospital, you'll be advised about caring for your wound and what activities
you should avoid.

In most cases, you can return to normal activities in a couple of weeks, although more
strenuous activities may need to be avoided for four to six weeks after open surgery.

When to seek medical advice

While you recover, it's important to keep an eye out for signs of any problems.

Contact the hospital unit where the appendectomy was performed or your GP for advice if
you notice:

increasing pain and swelling

you start vomiting repeatedly

a high temperature (fever)

any discharge coming from the wound

the wound is hot to touch

These symptoms could be a sign of infection.

Risks
Appendectomies are one of the most commonly performed operations in the UK, and serious
or long-term complications are rare.

However, like all types of surgery, there are some risks. These include:

wound infection although antibiotics may be given before, during, or

after the operation to minimise the risk of serious infections

bleeding under the skin that causes a firm swelling (haematoma)

this usually gets better on its own, but you should see your GP if you're
concerned

scarring both surgical techniques will leave some scarring where the
incisions were made

a collection of pus (abscess) in rare cases, an infection caused by the

appendix bursting can lead to an abscess after surgery

hernia at the site of the open incision or any of the incisions used in the
laparoscopic approach

The use of general anaesthetic also carries some risks, such as the risk of an allergic reaction
or inhaling stomach contents, leading to pneumonia. However, serious complications like this
are very rare.
Alternatives to emergency surgery
In some cases, appendicitis can lead to the development of a lump on the appendix called an
appendix mass.

This lump, consisting of appendix and fatty tissue, is an attempt by the body to deal with the
problem and heal itself.

If an appendix mass is found during an examination, your doctors may decide it's not
necessary to operate immediately.

Instead, you'll be given a course of antibiotics and an appointment will be made for an
appendectomy a few weeks later, when the mass has settled.

Another possible alternative to immediate surgery is the use of antibiotics to treat

appendicitis.

However, studies have looked into whether antibiotics could be an alternative to surgery and
as yet there isn't enough clear evidence to suggest this is the case.

Complications of appendicitis

If appendicitis isn't treated, the appendix can burst and cause potentially life-
threatening infections.

Call 999 for an ambulance if you have abdominal (tummy) pain that suddenly gets much
worse and spreads across your abdomen. These are signs your appendix may have burst.

Peritonitis
If your appendix bursts, it releases bacteria into other parts of the body. This can cause a
condition called peritonitis if the infection spreads to the peritoneum, the thin layer of tissue
that lines the inside of the abdomen.

Symptoms of peritonitis can include:

severe continuous abdominal pain

feeling sick or being sick

a high temperature (fever)

a rapid heartbeat

shortness of breath with rapid breathing

swelling of the abdomen

If peritonitis isn't treated immediately, it can cause long-term problems and may even be fatal.
Treatment for peritonitis usually involves antibiotics and the surgical removal of the appendix
(appendectomy).

Read more about treating peritonitis.

Abscesses
Sometimes an abscess forms around a burst appendix. This is a painful collection of pus that
occurs as a result of the body's attempt to fight the infection.

It can also occur as a complication of surgery to remove the appendix in about 1 in 500 cases.

Abscesses can sometimes be treated using antibiotics, but in the vast majority of cases the pus
needs to be drained from the abscess.

This can be carried out under ultrasound or computerised tomography (CT) guidance using
local anaesthetic and a needle inserted through the skin, followed by the placement of a drain.

If an abscess is found during surgery, the area is carefully washed out and a course of
antibiotics is given.

Peritonitis. NHS choices (serial online) 2013 May 8 (diakses 10 Mar 2015). Diunduh
dari URL: http://www.nhs.uk/conditions/peritonitis/Pages/Introduction.aspx