Diverticulitis peritonitis

O Primary peritonitis develops in up to 25% of patients with alcoholic cirrhosis.3 Patients undergoing continuous ambulatory peritoneal dialysis (CAPD) average one episode of peritonitis every 2 years.4 Secondary peritonitis may be caused by perforation of a peptic ulcer traumatic perforation of the stomach, small or large bowel, uterus, or urinary bladder appendicitis pancreatitis diverticulitis bowel infarction inflammatory bowel disease cholecystitis operative contamination of the peritoneum or diseases of the female genital tract such as septic abortion, postoperative uterine infection, endometritis, or salpingitis. Appendicitis is one of the most common causes of intraabdominal infection. In 1998, 278,000 appendectomies were performed in the United States for suspected appendicitis.5... 

An abscess occurs if peritoneal contamination is localized but bacterial elimination is incomplete. The location of the abscess often is related to the site of primary disease. For example, abscesses resulting from appendicitis tend to appear in the right lower quadrant or the pelvis those resulting from diverticulitis tend to appear in the left lower quadrant or pelvis. A mature abscess may have a fibrinous capsule that isolates bacteria and the liquid core from antimicrobials and immunologic defenses. 

Besides causing loss of appetite and quality of life, longstanding and severe constipation can lead to diverticulosis, diverticulitis and in worst cases perforation of the large intestine with life threatening peritonitis (McConnell et al. 2003). Diverticulosis, irritable bowel syndrome and haemorrhoids are caused by chronic constipation and can lead to bleeding and anaemia. 

Q12 Irritation and damage to other structures in the abdomen may occur if the diverticulitis is not treated. Abdominal muscles may go into painful spasm and a minority of patients might have rectal bleeding. A major problem could be development of an intestinal obstruction or an abscess in the wall of the intestine. The abscess may eventually cause perforation of the intestinal wall leakage of infected material into the peritoneal cavity and then infection of the peritoneal membranes (peritonitis) may occur. Peritonitis is a very serious condition. 

The causes of intraabdominal abscess overlap those of peritonitis and, in fact, may occur sequentially or simultaneously. Appendicitis is the most frequent cause of abscess. Other potential causes of intraabdominal abscess include pancreatitis, diverticulitis, lesions of the biliary tract, genitourinary tract infections, perforating tumors in the abdomen, trauma, and leaking intestinal anastomoses. In addition, pelvic inflammatory disease in women may lead to tuboovarian abscess. For certain diseases, such as appendicitis and diverticulitis, abscesses occur more frequently than generalized peritonitis. 

Diverticulosis is usually clinically asymptomatic. About 80-85% of patients with diverticulosis have no symptoms (Cheskin et al. 1990), but it is predisposing for complications such as diverticulitis, perforation, peritonitis, fistulas and even bleeding. For a clear overview presentation of diverticulosis contrast enema has been the diagnostic gold standard for many years. 

The differential diagnosis of acute diverticulitis is wide (Gritzmann et al. 2002). One important reason for left lower quadrant pain can be a torsion or necrosis of appendices epiploicae of the left colon. A well-defined point of pain is typical, and is the effect of a local peritonitis. 

A patient with an acute abdomen should not he inflated with room air or CO2, and a consultation with a surgeon is most appropriate. Patients with active diverticulitis should not he referred to CT colonography. If an abscess or free air is suspected, a CT of the abdomen and pelvis can be performed with oral and IV contrast. Insufflation of the colon is contraindicated and may cause perforation and widespread peritonitis. Similarly, if a patient has recently undergone pelvic or abdominal surgery. 

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