Peritonitis in Children
Introduction to Peritonitis in Children
Peritonitis is an inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the abdominal organs. In children, peritonitis can be a serious and potentially life-threatening condition that requires prompt diagnosis and treatment. It can occur as a primary infection or secondary to other abdominal pathologies. The management of peritonitis in the pediatric population presents unique challenges due to the varied etiology, rapid progression of disease, and the need for age-appropriate care.
Etiology of Pediatric Peritonitis
Peritonitis in children can be classified based on its origin:
- Primary Peritonitis:
- Spontaneous bacterial peritonitis (SBP) in children with ascites
- Pneumococcal peritonitis in young children
- Tuberculosis peritonitis
- Secondary Peritonitis:
- Perforation of hollow viscus (e.g., appendicitis, peptic ulcer)
- Trauma (blunt or penetrating abdominal injuries)
- Postoperative complications
- Intra-abdominal abscesses
- Tertiary Peritonitis: Persistent or recurrent infection after initial adequate treatment of secondary peritonitis
- Chemical Peritonitis: Due to irritants like gastric acid or bile in the peritoneal cavity
- Peritoneal Dialysis-associated Peritonitis: In children undergoing peritoneal dialysis for renal failure
Common Pathogens:
- Gram-negative bacteria: E. coli, Klebsiella, Pseudomonas
- Gram-positive bacteria: Streptococcus, Staphylococcus
- Anaerobes: Bacteroides fragilis (in cases of bowel perforation)
- Fungi: Candida species (especially in immunocompromised patients)
Clinical Presentation of Peritonitis in Children
The clinical presentation of peritonitis in children can vary depending on the underlying cause, age of the child, and duration of illness. Common signs and symptoms include:
- Abdominal Pain: Often generalized, severe, and worsening over time
- Abdominal Distension: Due to ileus or ascites
- Fever: Usually high-grade, may be absent in neonates or immunocompromised children
- Vomiting: May be bilious in cases of intestinal obstruction
- Altered Bowel Habits: Constipation or diarrhea
- Decreased Appetite and Lethargy
- Tachycardia and Tachypnea: As part of the systemic inflammatory response
Physical Examination Findings:
- Abdominal tenderness, often with guarding and rigidity
- Rebound tenderness
- Decreased or absent bowel sounds
- Signs of dehydration
- In severe cases, signs of septic shock (hypotension, poor perfusion)
In neonates and young infants, the presentation may be more subtle, with nonspecific symptoms like irritability, poor feeding, and lethargy.
Diagnosis of Peritonitis in Children
Prompt and accurate diagnosis is crucial in managing pediatric peritonitis. The diagnostic approach includes:
- Clinical Assessment: Thorough history and physical examination
- Laboratory Tests:
- Complete blood count: Usually shows leukocytosis with left shift
- C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): Elevated in inflammation
- Blood cultures: To identify systemic infection
- Liver and kidney function tests
- Serum electrolytes and blood gas analysis: To assess metabolic derangements
- Imaging Studies:
- Abdominal X-ray: May show free air, air-fluid levels, or dilated bowel loops
- Ultrasound: Can detect free fluid, abscesses, and some causes of peritonitis (e.g., appendicitis)
- CT scan: Gold standard for diagnosing intra-abdominal pathologies, but radiation exposure is a concern in children
- MRI: Used in select cases, especially when avoiding radiation is crucial
- Paracentesis: In cases of ascites or suspected spontaneous bacterial peritonitis
- Cell count and differential
- Gram stain and culture
- Biochemical analysis (protein, LDH, glucose)
- Laparoscopy or Laparotomy: May be both diagnostic and therapeutic in certain cases
The choice of diagnostic tests depends on the clinical presentation, suspected etiology, and the child's age and condition.
Management of Peritonitis in Children
The management of peritonitis in children requires a multidisciplinary approach and often involves:
- Resuscitation and Supportive Care:
- Fluid and electrolyte replacement
- Correction of acid-base imbalances
- Nutritional support (often parenteral initially)
- Pain management
- Antimicrobial Therapy:
- Empiric broad-spectrum antibiotics, later tailored based on culture results
- Common regimens include:
- Third-generation cephalosporin + metronidazole
- Piperacillin-tazobactam
- Carbapenem (for severe cases or hospital-acquired infections)
- Antifungal therapy may be added in high-risk cases
- Surgical Intervention:
- Required in most cases of secondary peritonitis
- Procedures may include:
- Laparotomy or laparoscopy for source control (e.g., appendectomy, repair of perforations)
- Peritoneal lavage
- Drainage of abscesses
- Intensive Care: Often necessary for hemodynamic support and close monitoring
- Management of Underlying Conditions: Such as treatment of inflammatory bowel disease or optimization of peritoneal dialysis in relevant cases
The duration of treatment depends on the underlying cause, severity of illness, and clinical response. Ongoing assessment and adjustment of the treatment plan are crucial.
Complications of Pediatric Peritonitis
Peritonitis can lead to several complications, which can be both acute and long-term:
- Sepsis and Septic Shock: A life-threatening complication requiring aggressive management
- Intra-abdominal Abscesses: May require percutaneous or surgical drainage
- Intestinal Obstruction: Due to adhesions or ileus
- Multiorgan Dysfunction: Including acute kidney injury, respiratory failure, and coagulopathy
- Wound Complications: In cases requiring surgery (e.g., wound infection, dehiscence)
- Nutritional Deficiencies: Due to prolonged ileus and need for parenteral nutrition
- Adhesions: Can lead to chronic abdominal pain or future bowel obstructions
- Peritoneal Fibrosis: Especially in recurrent cases or peritoneal dialysis-associated peritonitis
Early recognition and management of these complications are essential for improving outcomes.
Prevention and Prognosis of Peritonitis in Children
Prevention Strategies:
- Early diagnosis and treatment of predisposing conditions (e.g., appendicitis, peptic ulcer disease)
- Proper peritoneal dialysis technique and exit-site care in children on PD
- Antibiotic prophylaxis in high-risk patients (e.g., children with nephrotic syndrome)
- Vaccination against encapsulated organisms in children with asplenia or functional hyposplenism
- Proper surgical technique and perioperative care to prevent postoperative peritonitis
Prognosis:
- Overall mortality has decreased significantly with advances in critical care and surgical techniques
- Prognosis depends on:
- Underlying cause
- Time to diagnosis and treatment
- Presence of complications
- Patient's age and overall health status
- Primary peritonitis generally has a better prognosis than secondary peritonitis
- Long-term follow-up is important to monitor for recurrence and manage chronic complications
With prompt diagnosis, appropriate treatment, and good supportive care, most children with peritonitis recover well. However, it remains a serious condition with potential for significant morbidity and mortality, emphasizing the importance of prevention and early intervention.
Peritonitis in Children
- What is peritonitis?
Answer: Inflammation of the peritoneum, the membrane lining the abdominal cavity - What are the two main types of peritonitis?
Answer: Primary (spontaneous) and secondary peritonitis - What is the most common cause of secondary peritonitis in children?
Answer: Perforated appendicitis - What is the classic triad of symptoms in peritonitis?
Answer: Abdominal pain, fever, and vomiting - What is the significance of rebound tenderness in peritonitis?
Answer: It indicates peritoneal irritation - What is the most common cause of primary peritonitis in children?
Answer: Spontaneous bacterial peritonitis in patients with ascites - Which imaging modality is often used first in evaluating suspected peritonitis?
Answer: Abdominal ultrasound - What is the role of CT scan in diagnosing peritonitis?
Answer: It can identify the source of infection and detect complications - What is the significance of free air on abdominal X-ray in peritonitis?
Answer: It suggests perforation of a hollow viscus - Which laboratory test is most useful in diagnosing peritonitis?
Answer: Complete blood count (CBC) showing elevated white blood cell count - What is the role of C-reactive protein (CRP) in peritonitis?
Answer: It can help assess the severity of inflammation and monitor treatment response - What is the gold standard for diagnosing bacterial peritonitis?
Answer: Positive culture of peritoneal fluid - What is the most common organism causing spontaneous bacterial peritonitis in children?
Answer: Escherichia coli - What is the initial management of peritonitis in children?
Answer: Fluid resuscitation, broad-spectrum antibiotics, and pain management - What is the role of surgery in managing peritonitis?
Answer: To address the underlying cause (e.g., appendectomy for perforated appendicitis) - What is tertiary peritonitis?
Answer: Persistent or recurrent intra-abdominal infection after treatment of secondary peritonitis - What is the significance of abdominal compartment syndrome in severe peritonitis?
Answer: It can lead to organ dysfunction due to increased intra-abdominal pressure - What is the role of peritoneal lavage in managing peritonitis?
Answer: It can help remove infectious material and reduce bacterial load - What is the typical duration of antibiotic treatment for uncomplicated peritonitis?
Answer: 7-10 days - What is the role of procalcitonin in managing peritonitis?
Answer: It can help guide antibiotic therapy and assess treatment response - What is chemical peritonitis?
Answer: Peritoneal inflammation caused by irritants like bile or gastric contents without infection - What is the significance of paralytic ileus in peritonitis?
Answer: It can complicate the course of peritonitis and delay recovery - What is the role of intra-abdominal pressure monitoring in severe peritonitis?
Answer: It can help detect and manage abdominal compartment syndrome - What is the significance of hypoalbuminemia in peritonitis?
Answer: It can indicate severity of inflammation and risk of complications - What is the role of nutritional support in managing peritonitis?
Answer: It is crucial for promoting healing and supporting immune function - What is the significance of fungal peritonitis in children?
Answer: It can occur in immunocompromised patients or after prolonged antibiotic use - What is the role of percutaneous drainage in managing peritonitis?
Answer: It can be used to drain localized abscesses without open surgery - What is the significance of tuberculosis peritonitis in children?
Answer: It should be considered in endemic areas or immunocompromised patients - What is the role of negative pressure wound therapy in managing open abdomens in severe peritonitis?
Answer: It can help manage complex wounds and facilitate staged abdominal closure - What is the significance of early enteral nutrition in managing peritonitis?
Answer: It can help maintain gut barrier function and reduce infectious complications
