Acute abdomen
Peritonitis is a serious condition, and it needs urgent attention.
Peritonitis is an inflammation of the peritoneum, a thin layer of tissue that lines the inner abdominal wall and covers most abdominal organs. It usually occurs due to infection, which can result from a perforation in the digestive tract, injury, or medical procedures. It requires urgent medical attention, because the infection can rapidly spread to the bloodstream and lead to sepsis.
FRCSEd (General Surgery)Five clinics in Singapore
In short
Sudden
How it comes on
Symptoms of peritonitis often develop suddenly and can worsen quickly, starting with intense, widespread abdominal pain.
Urgent
Why it cannot wait
Peritonitis requires urgent medical attention, because the infection can rapidly spread to the bloodstream and lead to sepsis.
Hospital
Where it is treated
Treatment usually begins with intravenous antibiotics, and hospitalisation is typically required for close monitoring.
Surgery
When a perforation is the cause
If peritonitis is due to a perforation or blockage, surgery is usually necessary to locate and repair it.
What every patient should know
What every patient should know
Urgent
Why peritonitis is treated as an emergency
Source: Dr Sulaiman Bin Yusof, clinical practice
A hole, an injury, a procedure
A perforation in the digestive tract, an injury, or a medical procedure
The peritoneum is infected
The lining of the abdominal wall becomes inflamed
It can spread to the blood
Rapidly, which is what makes this urgent
Sudden
How the symptoms arrive
Source: Dr Sulaiman Bin Yusof, clinical practice
Hospital
Where peritonitis is treated
Source: Dr Sulaiman Bin Yusof, clinical practice
His story
Dr Sulaiman Bin Yusof
Senior Consultant Colorectal and General Surgeon, seeing patients at five clinics in Singapore.
- MBChB (Sheffield), M.Med (Surgery), FRCSEd (General Surgery)
- Consults in English and Malay
- MOH Fellowship, Peter MacCallum Cancer Centre, Melbourne
- Singapore Health Quality Service Star Award 2023
- Dean's Honour Roll for Teaching
What peritonitis is
A thin lining wraps the abdominal organs, and it becomes inflamed.
Peritonitis is an inflammation of the peritoneum, a thin layer of tissue that lines the inner abdominal wall and covers most abdominal organs.
It is a serious condition that usually occurs due to infection, which can result from a perforation, meaning a hole, in the digestive tract, injury, or medical procedures. Peritonitis requires urgent medical attention as the infection can rapidly spread to the bloodstream, potentially leading to sepsis, a life-threatening complication.
That is the whole reason peritonitis is treated as something to act on rather than something to watch. The symptoms build over hours, and the infection does not stay in the abdomen.
Symptoms
They tend to arrive suddenly, and then get worse quickly.
Symptoms of peritonitis often develop suddenly and can worsen quickly. Common symptoms include the following.
Severe abdominal pain and a rigid abdomen
Inflammation in the peritoneum causes intense, widespread abdominal pain. Movement often worsens the pain as it stretches or shifts the inflamed tissue. The abdominal muscles may also tense, creating a rigid or hard abdomen.
Swelling and tenderness
The inflammation from peritonitis often causes fluid to build up in the abdominal cavity, leading to visible swelling. The affected area becomes extremely tender, making the abdomen sensitive to touch or pressure.
Fever and chills
The immune system's response to infection causes fever and chills, which are part of the body's efforts to fight off bacteria.
Nausea and vomiting
Peritoneal inflammation can disrupt digestion, resulting in nausea and vomiting. It affects the surrounding organs, causing digestive upset and slowing food movement through the intestines, both of which contribute to nausea.
Loss of appetite
Appetite loss is common due to abdominal pain, nausea, and overall digestive disruption. The body may naturally avoid eating to relieve digestive strain on already irritated and inflamed tissues.
A faster heartbeat and faster breathing
The body's response to infection and inflammation stresses the system, resulting in a faster heartbeat and breathing. These may also indicate early signs of sepsis, where infection spreads to the bloodstream.
Fatigue and confusion
A severe infection can affect overall body function, causing fatigue and confusion. This is especially common if the infection has started affecting multiple systems, signalling potential sepsis.
Causes and risk factors
In nearly every case, bacteria have reached the peritoneum.
Peritonitis generally results from bacterial infection, with common causes including the following.
Three
Common routes the infection takes
Source: Dr Sulaiman Bin Yusof, clinical practice
A perforation in the abdomen
A hole in the digestive tract, often caused by conditions like a ruptured appendix, stomach ulcer, or diverticulitis, can release bacteria into the abdominal cavity, causing peritonitis. These conditions heighten the risk of perforation.
Medical procedures
Procedures like abdominal surgery or peritoneal dialysis, a treatment for kidney failure, can introduce bacteria into the abdominal cavity. Patients undergoing peritoneal dialysis have a higher infection risk, requiring careful hygiene practices.
Complications of liver disease
Chronic liver conditions like cirrhosis can lead to fluid build-up, called ascites, in the abdomen, increasing infection risk. This can lead to spontaneous bacterial peritonitis, where infection occurs without any rupture or injury.
Two of the conditions named above have pages of their own, with the symptoms that precede a perforation and what is done about them: appendicitis and diverticulitis.
Diagnosis
An examination first, then the tests that find the source.
Diagnosing peritonitis typically involves a physical exam and a combination of tests to confirm infection and identify the source.
Physical examination
During a physical exam, the doctor will press on different areas of the abdomen to check for tenderness, swelling, or a hard, board-like feel, which can indicate inflammation. Increased pain when pressure is applied and released, called rebound tenderness, is a common indicator of peritonitis and can aid in the diagnosis.
Blood tests
Blood tests can reveal elevated white blood cell counts, which indicate that the body is responding to an infection. These tests can also help identify the specific bacteria causing the infection, which can guide treatment decisions.
CT scans and X-rays
CT scans or X-rays provide detailed images of the abdomen, helping detect any perforations or abnormal fluid accumulation that may be causing or resulting from peritonitis. These imaging methods can also reveal other potential issues, such as abscesses or blockages, which may require surgical intervention.
Testing the abdominal fluid
If fluid is present in the abdominal cavity, called ascites, a sample may be collected with a needle through a procedure called paracentesis. This fluid is tested for the presence of bacteria and high white blood cell counts, which confirm infection and help pinpoint the type of bacteria involved.
Finding the source matters as much as confirming the infection. What the imaging shows, a perforation, an abscess, a blockage, is what decides whether an operation is needed at all.
Treatment
Whether an operation is needed depends on what caused it.
In cases where peritonitis is not caused by a perforation, non-surgical treatment is often appropriate, and hospitalisation is typically required for close monitoring.
No perforation
Antibiotics and supportive care, in hospital
A perforation or a blockage
Surgery, to locate and repair the source
An abscess has formed
Drainage, in surgery or with imaging guidance
Antibiotics
Treatment usually begins with intravenous antibiotics administered directly into the bloodstream to rapidly target and control the infection. The specific antibiotic regimen may be modified based on lab results to ensure effective treatment of the identified bacteria.
Supportive care
In addition to antibiotics, supportive care helps manage symptoms and maintain stability during recovery. This includes IV fluids to prevent dehydration and balance electrolytes, pain medications to relieve discomfort, and anti-nausea medications to control digestive upset. Regular monitoring of vital signs, such as heart rate and blood pressure, is also necessary to detect early signs of complications, such as sepsis.
If peritonitis is due to a perforation or blockage, surgery is usually necessary.
Laparoscopic surgery
For less severe cases, laparoscopic surgery, a minimally invasive procedure, may be used. This method involves making small incisions in the abdomen, through which a camera and surgical instruments are inserted to locate and repair the perforation. Laparoscopic surgery generally involves less pain and scarring, with shorter recovery times than open surgery.
Laparotomy, or open surgery
In severe cases, a laparotomy, meaning open surgery, may be needed. The surgeon makes a large incision to access and repair the infection source, such as a tear in the intestine. They thoroughly clean the abdominal cavity to remove infected tissue or contaminants, ensuring a more extensive infection treatment.
Abscess drainage
Abscesses, which are pockets of pus that form in the abdomen as a result of infection, must be drained to prevent further spread. Drainage can be performed during surgery or using a small tube inserted into the abscess with imaging guidance. This procedure helps to clear the infection and support recovery, as untreated abscesses can lead to further complications.
Scar tissue can form inside the abdomen after an operation, and some people notice it long after the infection itself has settled. What adhesions are and what is done about them is on the intra-abdominal adhesions page.
Prevention
Prevention matters most for the people already at higher risk.
Preventing peritonitis involves measures to reduce infection risk, especially for high-risk individuals.
Patients on peritoneal dialysis should practice strict hygiene, including careful catheter cleaning and handling equipment with clean hands. Prompt treatment of digestive issues, such as appendicitis or stomach ulcers, can also help prevent rupture-related infections.
Common questions
The questions that come up in consultation.
How long does recovery from peritonitis take?
Recovery time varies based on infection severity and treatment. Hospitalisation may last several days to weeks, and full recovery may take additional weeks or months after discharge, often with follow-up care.
Can peritonitis come back after treatment?
Yes, peritonitis can recur, especially in individuals with risk factors like liver disease or those on peritoneal dialysis. Regular monitoring and preventive care are necessary to reduce the risk of recurrence.
Are there lasting effects after peritonitis?
Most people recover fully, but some may experience mild digestive issues or abdominal discomfort during recovery. In severe cases, scar tissue or adhesions, bands of tissue, may form in the abdomen, which can cause persistent discomfort or digestive issues.
Will I need surgery for peritonitis?
Not always. In cases where peritonitis is not caused by a perforation, non-surgical treatment is often appropriate, and hospitalisation is typically required for close monitoring. If peritonitis is due to a perforation or blockage, surgery is usually necessary. For less severe cases that need an operation, laparoscopic surgery uses small incisions, a camera and surgical instruments to locate and repair the perforation. In severe cases a laparotomy, or open surgery, is needed, so that the source of the infection can be repaired and the abdominal cavity thoroughly cleaned.
What is spontaneous bacterial peritonitis?
Chronic liver conditions like cirrhosis can lead to fluid build-up, called ascites, in the abdomen, which increases infection risk. This can lead to spontaneous bacterial peritonitis, where infection occurs without any rupture or injury. For those with liver disease, regular check-ups to monitor for fluid build-up are necessary, and preventive antibiotics may be recommended to reduce infection risk.
Get it looked at
Abdominal pain that came on suddenly and keeps getting worse? Do not wait it out.
Consult Dr Sulaiman for an assessment and a personalised treatment plan today. Appointments are available across five clinic locations in Singapore, and self-referrals are welcome.