Management of Septic Peritonitis
Related to mortality in IBD
Doni Priambodo Wijisaksono
Subdivision of Tropical Medicine and Infectious Diseases
Internal Medicine Department
Faculty of Medicine Gajah Mada University / Dr Sardjito General Hospital Jogjakarta
Peritonitis is an inflammation of the membrane which lines the inside of the abdomen
and all of the internal organs. This membrane is called the peritoneum. Left untreated,
peritonitis can rapidly spread into the blood (sepsis) and to other organs, resulting in multiple
organ failure and death.
Inflammatory bowel disease (IBD) involves chronic inflammation of all or part of
your digestive tract. IBD primarily includes ulcerative colitis and Crohn's disease. Both
usually involve severe diarrhea, pain, fatigue and weight loss. IBD can be debilitating and
sometimes leads to life-threatening complications. Ulcerative colitis is an inflammatory
bowel disease that causes long-lasting inflammation and sores (ulcers) in the innermost lining
of your large intestine (colon) and rectum. Crohn's disease is an IBD that cause inflammation
of the lining of your digestive tract. In Crohn's disease, inflammation often spreads deep into
affected tissues. The inflammation can involve different areas of the digestive tract the
large intestine, small intestine or both.
Perforation and toxic megacolon are the most frightening complications of ulcerative
colitis. Intestinal perforation can occur in the presence of fulminant disease, even in the
absence of toxic megacolon. The mortality rate is 50% if perforation occurs. Occurs when
chronic inflammation and ulceration of the intestine weakens the intestinal wall to such an
extent that a hole develops. This complication is potentially life-threatening, and generally
linked to toxic megacolon. In Crohns disease, perforation may occur as a result of abscess or
fistula.
The current approach to peritonitis and peritoneal abscesses targets correction of the
underlying process, administration of systemic antibiotics, and supportive therapy to prevent
or limit secondary complications due to organ system failure. Treatment success is defined as
adequate source control with resolution of sepsis and clearance of all residual intra-abdominal
infection.Early control of the septic source is mandatory and can be achieved by operative
and nonoperative means.The general principles guiding the treatment of infections are as
follows.
1. Control the infectious source
2. Eliminate bacteria and toxins
3. Maintain organ system function
4. Control the inflammatory process
Treatment of peritonitis and intra-abdominal sepsis always begins with volume
resuscitation, correction of potential electrolyte and coagulation abnormalities, and empiric
broad-spectrum parenteral antibiotic coverage. Aggressive fluid resuscitation to treat
intravascular fluid depletion should be instituted. Pressor agents are avoided if possible. Fluid
administration requires frequent monitoring of blood pressure, pulse, urine output, blood
gases, hemoglobin and hematocrit, electrolytes, and renal function.
Antibiotic therapy is used to prevent local and hematogenous spread of infection and
to reduce late complications. [16] Several different antibiotic regimens are available for the
treatment of intra-abdominal infections. [16] Both single-agent broad-spectrum therapy and
combination therapies have been used. However, no specific therapy has been found to be
superior to another therapy. Infection of the abdominal cavity requires coverage for gram-
positive and gram-negative bacteria, as well as for anaerobes. Antipseudomonal coverage is
recommended in patients who have had previous treatment with antibiotics or who have had a
prolonged hospitalization.
The optimal duration of antibiotic therapy must be individualized and depends on the
underlying pathology, severity of infection, speed and effectiveness of source control, and
patient response to therapy. Antibiotics can be discontinued once clinical signs of infection
have resolved. Recurrence is a concern with certain infections, such as those
from Candida and Staphylococcus aureus, and treatment should be continued for 2-3 weeks.
Drainage refers to evacuation of an abscess. This can be performed operatively or
percutaneously under ultrasound or CT guidance. If the abscess is localized at the level of the
skin and underlying superficial tissues, simple removal of sutures or opening of the wound
may be sufficient. Percutaneous techniques are preferred when an abscess can be completely
drained, and debridement and repair of the anatomic structures are not needed. Factors that
may prevent successful source control with percutaneous drainage include diffuse peritonitis,
lack of localization of the infectious process, multiple abscesses, anatomic inaccessibility, or
the need for surgical debridement. [4]
In general, patients with peritonitis develop some degree of gut dysfunction (eg, ileus)
after exploration. Consider establishing some form of nutritional support early in the course
of treatment because most patients have an insufficient enteral intake for a variable amount of
time preoperatively. The existing data support that enteral nutrition is superior to parenteral
hyperalimentation. Enteral nutrition has been found to have fewer complications in patients
who are severely ill. If enteral feeding is contraindicated or not tolerated, parenteral nutrition
should be instituted.Nutritional demands increase during sepsis, with caloric requirements of
25-35 kcal/kg/d. Patients with sepsis should be fed a high-protein isocaloric diet.
Hypercaloric diets cannot prevent the intense protein catabolism associated with sepsis. [19]
The treatment of intra-abdominal sepsis requires a multidisciplinary approach. In the
treatment of secondary peritonitis, a surgeon must be consulted. Interventional radiology may
need to be consulted if ultrasound or CT-guided drainage of an abscess is being considered.
Other consultations may include the following:
Gastroenterology
Infectious disease
Critical care
Diet/nutrition
