Peritonitis

Hx.
A teenage boy visit ER with evolve abdomimal pain 3hr before.He doesn' t have fever.
He deny underlying disease.
2 yrs ago he had appendectomy at surin Hospital .

PE
A teenage boy looked distress by pain
Lieing on bed
BP 120/80 PR 94 BT 37.5 RR 20
HEENT Normal
Heart and lung audible S1 S2 no murmur , normal breath sound
Abd : Boardlike rigidity
generalized tender , rebound positive
Resonance on percussion RUQ
PR : Normal

LAB : CBC Hct 37.0 wbc 12,000 PMN 78 Lymphocyte 20 Mono 2 plt 160,000
Film acute abdomen series : free air of Rt diaphram

Peritonitis
Peritonitis is defined as inflammation of peritoneum.it may be localised or generalized,generally has an acute course,and may depended on either infection(often due to rupture of hallow organ as may occur inabdominal trauma) or non infection process
Three type of peritonitis
1. Primary(spontaneous)
2. Secondary (anatomic)
3. tertiary (peritoneal dialysis related)

Mechanisms and manifestations
Abdominal pain and tenderness

The main manifestations of peritonitis are acute abdominal pain, abdominal tenderness, and abdominal guarding, which are exacerbated by moving the peritoneum, e.g. coughing, flexing the hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness, as the peritoneum snaps back into place). The presence of these signs in a patient is sometimes referred to as peritonism.[1]

The localization of these manifestations depends on whether peritonitis is localized (e.g. appendicitis or diverticulitis before perforation), or generalized to the whole abdomen. In either case pain typically starts as a generalized abdominal pain (with involvement of poorly localizing innervation of the visceral peritoneal layer), and may become localized later (with the involvement of the somatically innervated parietal peritoneal layer). Peritonitis is an example of an acute abdomen.
Causes

Infected peritonitis
Perforation of a hollow viscus is the most common cause of peritonitis. Examples include perforation of the distal oesophagus (Boerhaave syndrome), of the stomach (peptic ulcer, gastric carcinoma), of the duodenum (peptic ulcer), of the remaining intestine (e.g. appendicitis, diverticulitis, Meckel diverticulum, inflammatory bowel disease (IBD), intestinal infarction, intestinal strangulation, colorectal carcinoma, meconium peritonitis), or of the gallbladder (cholecystitis).
Other possible reasons for perforation include abdominal trauma, ingestion of a sharp foreign body (such as a fish bone, toothpick or glass shard), perforation by an endoscope or catheter, and anastomotic leakage.
The latter occurrence is particularly difficult to diagnose early, as abdominal pain and ileus paralyticus are considered normal in patients who just underwent abdominal surgery.
In most cases of perforation of a hollow viscus, mixed bacteria are isolated; the most common agents include Gram-negative bacilli (e.g. Escherichia coli) and anaerobic bacteria (e.g. Bacteroides fragilis). Fecal peritonitis results from the presence of faeces in the peritoneal cavity. It can result from abdominal trauma and occurs if the large bowel is perforated during surgery.
Disruption of the peritoneum, even in the absence of perforation of a hollow viscus, may also cause infection simply by letting micro-organisms into the peritoneal cavity. Examples include trauma, surgical wound, continuous ambulatory peritoneal dialysis, intra-peritoneal chemotherapy. Again, in most cases mixed bacteria are isolated; the most common agents include cutaneous species such as Staphylococcus aureus, and coagulase-negative staphylococci, but many others are possible, including fungi such as Candida.

Spontaneous bacterial peritonitis (SBP) is a peculiar form of peritonitis occurring in the absence of an obvious source of contamination. It occurs either in children, or in patients with ascites. See the article on spontaneous bacterial peritonitis for more information.
Systemic infections (such as tuberculosis) may rarely have a peritoneal localisation.

Non-infected peritonitis

Treatment
Depending on the severity of the patient's state, the management of peritonitis may include:
General supportive measures such as vigorous intravenous rehydration and correction of electrolyte disturbances.
Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. The empiric choice of broad-spectrum antibiotics often consist of multiple drugs, and should be targeted against the most likely agents, depending on the cause of peritonitis (see above); once one or more agents are actually isolated, therapy will of course be targeted on them.
Surgery (laparotomy) is needed to perform a full exploration and lavage of the peritoneum, as well as to correct any gross anatomical damage which may have caused peritonitis.[2] The exception is spontaneous bacterial peritonitis, which does not benefit from surgery. http://en.wikipedia.org/wiki/Peritonitis