INTRODUCTION

• Three classes of peritonitis, according to microbiological profile and clinical presentation• Affect peritoneal cavity, filled with serous fluid, white cells, and proteins• Three classes are include:– Primary peritonitis– Secondary peritonitis– Tertiary peritonitis

PRIMARY PERITONITIS

• No apparent source of contamination!• Affects mostly alcoholic liver cirrhosis, and those patients on peritoneal dialysis• In 80% of cases single organism involved– High index of suspicion for secondary peritonitis if more thanone organism!– E. coli and Streptococci pneumonia involved• Speculations about the spread– Haematogenous spread (damaged liver and altered portal circulation)– Translocation through an intact bowel, failing liver implicated

SECONDARY PERITONITIS

Bacterial contamination of peritoneum due to spillage from a raptured intraabdominal viscus– Primary disorder of abdominal viscera, blunt/penetrating injury, or abdominal surgery• Organisms involved differs according to site of injury– Stomach: acidic environment, acid resistant MOS eg Candida; oropharyngeal origin MOS, Bacteroids, Streps etc– Colon: E coli, Bacterois fragillis, Enterobacter, Klebsella, Pseudomonas

Table 1 : Penyebab Peritonitis Sekunder

Source Regions Causes

EsophagusMalignancyTrauma (mostly penetrating) Iatrogenic*

Stomach

Peptic ulcer perforationMalignancy (eg, adenocarcinoma, lymphoma, gastrointestinal stromal tumor) Trauma (mostly penetrating)Iatrogenic*

DuodenumPeptic ulcer perforationTrauma (blunt and penetrating) Iatrogenic*

Biliary tract

CholecystitisStone perforation from gallbladder (ie, gallstone ileus) or common ductMalignancyCholedochal cyst (rare) Trauma (mostly penetrating) Iatrogenic*

*Trauma iatrogenik diantaranya dikarenakan prosedur endoskopi, post operasi terjadi anastomosis dan luka pada usus, mungkin dikarenakan efek mekanik atau termal atau adanya kebocoran

hingga menimbulkan adhesi dan lainnya.

PancreasPancreatitis (eg, alcohol, drugs, gallstones)Trauma (blunt and penetrating) Iatrogenic*

Small bowel

Ischemic bowelIncarcerated hernia (internal and external) Closed loop obstructionCrohn diseaseMalignancy (rare) Meckel diverticulumTrauma (mostly penetrating)

Large bowel and appendix

Ischemic bowelDiverticulitisMalignancyUlcerative colitis and Crohn diseaseAppendicitisColonic volvulusTrauma (mostly penetrating) Iatrogenic

Uterus, salpinx, and ovaries

Pelvic inflammatory disease (eg, salpingo-oophoritis, tubo-ovarian abscess, ovarian cyst) Malignancy (rare) Trauma (uncommon)

Tabel 2. Etiologi Peritonitis Primer, Sekunder, dan Tersier

Peritonitis(Type)

Etiologic OrganismsAntibiotic Therapy

(Suggested)Class Type of Organism

Primary Gram-negative

E coli (40%)K pneumoniae (7%)Pseudomonas species (5%)Proteus species (5%)Streptococcus species (15%)Staphylococcus species (3%)Anaerobic species (<5%)

Third-generation cephalosporin

Secondary

Gram-negative

E coliEnterobacter speciesKlebsiella speciesProteus species

Second-generation cephalosporinThird-generation cephalosporinPenicillins with anaerobic activityQuinolones with anaerobic activityQuinolone and metronidazoleAminoglycoside and metronidazole

Gram-positiveStreptococcus speciesEnterococcus species

Anaerobic

Bacteroides fragilisOther Bacteroides speciesEubacterium speciesClostridium speciesAnaerobic Streptococcus species

Tertiary Gram-negativeEnterobacter speciesPseudomonas speciesEnterococcus species

Second-generation cephalosporinThird-generation cephalosporinPenicillins with anaerobic activityQuinolones with anaerobic activityQuinolone and metronidazoleAminoglycoside and metronidazoleCarbapenemsTriazoles or amphotericin (considered in fungal etiology)(Alter therapy based on culture results.)

Diagnosis :

• Anamnesis:– Keluhan nyeri seluruh perut (akut abdomen)– Keluhan perubahan kesadaran– Demam– Anoreksia, vomitus, perut kembung, tidak bisa

b.a.b., flatus.• Pemeriksaan Fisik:– Tanda vital : Kesadaran menurun, Tekanan

darah(MAP) , takipneu, takikardi, subfebris/febris.

Diagnosis :

– Thoraks: dapat ditemukan tanda-tanda pneumoni, empyema.

– Abdomen: distensi abdomen, nyeri tekan, nyeri lepas, defance musculair, tanda-tanda ileus paralitik : bising usus menurun.

– Colok Dubur: Sphincter lemah, nyeri tekan.– Produksi urin berkurang.

Diagnosis :

• Pemeriksaan Laboratorium :– Hemoglobin : Mungkin anemi– Leukositosis/ Leukopeni.– Komplikasi : Ureum, kreatinin, gula darah, Natrium,

Kalium, AGD.– Kultur : cairan peritoneum/ pus (abses/peritonitis tersier).

• Diagnostik pencitraan :– Foto 3 posisi: Free air, dilatasi, preperitoneal fat (-).– CT-Scan,USG = koleksi cairan (abses).

Terapi Peritonitis Sekunder (Akut)

• Operasi untuk mengontrol sumber primer kontaminasi bakteri

• Terapi suportif: oksigen, dekompresi, resusitasi cairan dan elektrolit.

• Antibiotika : Spektrum luas : gram positif, negatif, dan anaerob.

• “Surveillance” infeksi residual

Terapi Empirik pada Peritonitis Akut

Antibiotics choice Dosing/d

• Single drug– Cefotixin 8-16 g– Cefotetan 4 g– Ceftizoxime 4-6 g– Ampicillin/sulbactam 12-18 g– Ticarcillin/clavulanate 12.4-18.6 g

Terapi Empirik pada Peritonitis Akut

Double drugGentamicin + 5 mg/kgClindamycin or 2.4-3.6 gMetronidazole 2 g

Triple drugGentamicin + 2.4 - 3.6 gClindamycin or 2 gMetronidazole 4-6 g

Laparotomi untuk Peritonitis Akut

• Disertai pembilasan sebersih mungkin• Debridement radikal• Penutupan sumber kontaminasi : simple

closure, diversi, reseksi + reanastomosis.• Lavase peritoneal pasca bedah• Luka abdomen terbuka

Staged laparotomyEtappen lavage

Prinsip Laparotomi

• Prinsip I : RepairKontrol sumber infeksi

• Principle 2: PurgeEvakuasi inokulasi bakteri , pus, dan adjuvants (peritoneal “toilet”)

Prinsip Laparotomi

• Prinsip 3: DekompresiTerapi “abdominal compartment syndrome”

• Prinsip 4 : KontrolPencegahan & terapi infeski yg. persisten/rekuren atau pembuktian “ repair” & “ purge”

Prognosis

• Prognosis dari peritonitis tergantung dari berapa lamanya proses peritonitis sudah terjadi. Semakin lama orang dalam keadaan peritonitis akan mempunyai prognosis yang makin buruk. Pembagian prognosis dapat dibagi menjadi tiga, tergantung lamanya peritonitis, yaitu :

– Kurang dari 24 jam : prognosisnya > 90 %– 24 – 48 Jam : prognosisnya 60 %– > 48 jam : prognosisnya 20 %

• Adanya beberapa faktor juga dapat memperparah prognosis suatu peritonitis, diantaranya adalah adanya penyakit penyerta, usia, dan adanya komplikasi.