Peritonitis: Causes, Types, Symptoms and Nursing Care
Peritonitis is inflammation of the peritoneum, the membrane lining the abdominal cavity and covering many abdominal organs. It may be localised or widespread, infectious or chemical. Secondary bacterial peritonitis from a perforated or leaking abdominal organ is a time-critical surgical emergency because contamination, fluid shifts and sepsis can rapidly cause shock and organ failure.
These lecture notes explain peritonitis terminology, common causes, pathophysiology, clinical features, assessment, investigations, medical and surgical principles, and nursing care. They also distinguish secondary surgical peritonitis from spontaneous bacterial peritonitis in ascites and peritoneal-dialysis-associated peritonitis, which have separate diagnostic and treatment pathways. Individual care must follow the responsible clinical team and current local protocols.
Emergency reminder: severe or worsening abdominal pain with guarding or rigidity, fever or hypothermia, rapid pulse, low blood pressure, confusion, breathlessness, reduced urine output or collapse needs immediate assessment and escalation. Do not delay emergency referral while waiting for routine investigations.
Quick overview: Suspect peritonitis when abdominal pain is accompanied by tenderness, involuntary guarding, rigidity, distension, reduced bowel activity or systemic illness. Stabilisation, early appropriate antimicrobial treatment and timely control of the source of infection are central to care. “Source control” may require drainage, repair, resection or another procedure selected by the surgical team.
Contents
Learning Objectives
By the end of this lesson, the learner should be able to:
- Define peritonitis and identify the parietal and visceral peritoneum.
- Classify peritonitis as primary, secondary or tertiary, and distinguish localised from generalised disease.
- Explain the common causes and the progression from inflammation to fluid loss, ileus, sepsis and shock.
- Recognise typical and atypical symptoms and signs and identify when immediate escalation is needed.
- Describe core assessment priorities and the role and limitations of laboratory tests, imaging and peritoneal-fluid studies.
- Outline treatment principles, including resuscitation, antimicrobials and source control.
- Plan safe preoperative, postoperative and ongoing nursing care.
Definition and Classification
The peritoneum is a thin serous membrane with a parietal layer lining the abdominal wall and a visceral layer covering many abdominal organs. Peritonitis is inflammation of this membrane. Infection is common in acute surgical peritonitis, but blood, bile, gastric contents, pancreatic enzymes, urine or other irritants can also cause chemical inflammation. Infection may follow chemical contamination.
| Classification | Meaning | Common context |
|---|---|---|
| Primary (spontaneous) bacterial peritonitis | Infection of ascitic fluid without a surgically treatable source of contamination in the abdomen. | Often occurs in people with cirrhosis and ascites. It is diagnosed and treated using a medical/hepatology pathway; it is not the same as a perforated viscus. |
| Secondary peritonitis | Peritoneal infection or inflammation caused by contamination from an identifiable abdominal source. | Perforated appendix, peptic ulcer or bowel; ischaemic or necrotic bowel; anastomotic leak; penetrating injury; or infected intra-abdominal collection. |
| Tertiary peritonitis | Persistent or recurrent intra-abdominal infection after treatment and apparently adequate source control of secondary peritonitis. | Usually affects seriously ill or immunocompromised patients and needs specialist reassessment for persistent infection, resistant organisms or another uncontrolled source. |
| Peritoneal-dialysis-associated peritonitis | Infection involving the peritoneal cavity in a person receiving peritoneal dialysis. | May present with cloudy dialysis effluent, abdominal pain or fever. Follow the dialysis service and ISPD pathway. |
| Localised or generalised | Localised disease is confined or walled off; generalised disease involves a broader area of the peritoneal cavity. | A local abscess may be contained by bowel or omentum. Diffuse contamination can cause widespread peritonitis and sepsis. |
| Acute or chronic | Describes the course and duration of inflammation. | Acute bacterial peritonitis is an emergency. Chronic peritoneal inflammation has different causes, including tuberculosis, and needs cause-specific evaluation. |
Important distinction: The word “peritonitis” describes inflammation; it does not by itself identify the cause, extent, organism or severity. Complicated intra-abdominal infection extends beyond the organ of origin into the peritoneal space and may be associated with peritonitis, with or without an abscess. A clinician must identify whether the source needs urgent procedural or surgical control.
Causes and Pathophysiology
Common causes
- Perforated gastrointestinal organ: perforated peptic ulcer, appendix, diverticulum, bowel tumour or other bowel perforation.
- Ischaemia, necrosis or obstruction: compromised bowel may become necrotic or perforate, allowing bacteria and intestinal contents to enter the peritoneal cavity.
- Postoperative leak or infection: anastomotic breakdown, contamination, infected collection or another complication after abdominal surgery.
- Abdominal injury: penetrating trauma or blunt injury causing organ rupture, bowel perforation or blood in the peritoneal cavity.
- Spread from infection: an intra-abdominal abscess, pelvic infection or another contiguous source.
- Spontaneous bacterial peritonitis: bacterial infection of ascites, commonly in advanced chronic liver disease, with no surgically treatable source.
- Peritoneal dialysis: contamination associated with exchanges, catheter infection or another dialysis-related route.
- Chronic or less common causes: abdominal tuberculosis, fungal infection, malignancy-related inflammation or chemical irritation. These require cause-specific assessment and should not be managed as routine perforation without evidence.
How secondary peritonitis can progress
- Contamination or irritation: bacteria or a chemical irritant enters the peritoneal cavity through a perforation, leak, injury or spread from infection.
- Inflammatory response: local blood vessels dilate and become more permeable; fluid, proteins and white blood cells move into the peritoneal space.
- Pain and protective response: irritation of the parietal peritoneum causes tenderness, pain on movement and involuntary muscle guarding. The patient may keep still because coughing or movement worsens pain.
- Fluid sequestration and ileus: capillary leak, vomiting and third spacing reduce circulating volume. Inflamed bowel may become distended and temporarily stop moving normally.
- Local containment or spread: the omentum and adjacent bowel may wall off contamination and form an abscess; uncontrolled leakage may produce diffuse peritonitis.
- Systemic infection: infection and reduced circulating volume can cause sepsis, poor tissue perfusion, acute kidney injury, respiratory distress, shock and multiple-organ dysfunction.
The pace of deterioration varies. Older adults, young children, pregnant people, people taking immunosuppressive medicines and patients with major comorbidities may have less obvious fever or abdominal signs despite serious disease.
Clinical Features and Danger Signs
Symptoms
- Abdominal pain: may be sudden and severe after a perforation or gradual with infection. Pain may begin near the source and become widespread.
- Pain with movement: coughing, walking, deep breathing or bumps during transport may aggravate pain; some patients prefer to lie still.
- Nausea and vomiting: can contribute to dehydration and may accompany ileus or the underlying abdominal cause.
- Loss of appetite and inability to eat or drink.
- Abdominal swelling or fullness: may occur with ileus, fluid accumulation or distension.
- Change in bowel function: constipation, reduced passage of flatus or, in some causes, diarrhoea.
- Fever, chills or feeling very unwell: fever can be absent, particularly in older or immunosuppressed patients.
Signs on assessment
- Local or generalised abdominal tenderness.
- Involuntary guarding, rebound tenderness or a rigid “board-like” abdomen in advanced or widespread peritoneal irritation. These signs are assessed by trained clinicians; repeated painful testing is unnecessary.
- Abdominal distension and reduced or absent bowel sounds, although bowel sounds alone cannot diagnose or exclude peritonitis.
- Tachycardia, fever or hypothermia, tachypnoea, dehydration or reduced urine output.
- Weakness, restlessness, lethargy, pallor, cool clammy skin or delayed capillary refill.
- Hypotension, altered mental state, breathlessness or collapse when sepsis or shock is developing.
Presentation in special groups
- Spontaneous bacterial peritonitis: a patient with cirrhosis and ascites may have fever or abdominal discomfort, but can present mainly with worsening confusion, kidney function, jaundice, appetite, mobility or overall condition. Do not wait for dramatic abdominal rigidity.
- Peritoneal dialysis: cloudy effluent, abdominal pain, fever or a change in dialysis tolerance should prompt immediate contact with the dialysis team and urgent fluid sampling according to protocol.
- Children, older adults and immunocompromised people: pain history or fever may be difficult to elicit; deterioration, poor feeding, confusion, reduced interaction or unexplained physiological change may be the first clue.
- Pregnancy: abdominal pain has pregnancy-related and non-pregnancy causes. A low threshold for appropriate obstetric and surgical review is important.
Danger signs—escalate immediately: generalised severe pain or a rigid abdomen; rapidly worsening tenderness; repeated vomiting; temperature instability; rapid breathing or pulse; falling blood pressure; fainting, confusion or reduced alertness; cool mottled skin; reduced urine output; rising lactate if measured; or any concern for sepsis or shock. Activate the local emergency response and surgical referral pathway.
Assessment
Peritonitis is a clinical emergency when acute infection, perforation or sepsis is suspected. Start a primary survey and escalate early; detailed history-taking and imaging must not delay resuscitation in an unstable patient.
Focused history
- Onset, site, character, severity, duration and spread of pain; whether onset was sudden; what makes it worse; and whether movement or coughing increases pain.
- Vomiting, fever or chills, appetite, bowel movements, flatus, abdominal swelling, urinary symptoms, faintness and recent change in function.
- Prior abdominal surgery or endoscopy, previous ulcer disease, gallstones, appendicitis, diverticular disease, bowel obstruction, hernia or intra-abdominal infection.
- Trauma, including mechanism and timing, and any concern for internal bleeding or organ injury.
- Known cirrhosis, ascites, renal disease, peritoneal dialysis, malignancy, immunosuppression, diabetes or other comorbidity.
- Current medicines, recent antibiotics, anticoagulants, allergies, substance use when relevant and last oral intake.
- Pregnancy possibility and gynaecological symptoms when appropriate; ask sensitively, with privacy and consent.
Physical assessment and ongoing observation
- Primary survey: assess airway, breathing, circulation, disability and exposure. Identify shock, sepsis, respiratory compromise, bleeding or severe dehydration at once.
- Vital signs: measure and trend temperature, pulse, blood pressure, respiratory rate, oxygen saturation, pain score, mental state and urine output as indicated by condition and local protocol.
- General appearance: observe mobility, preferred position, pallor, sweating, hydration, distress and ability to speak or interact.
- Abdominal examination: a trained clinician should inspect, listen and gently palpate as appropriate, noting distension, scars, hernias, tenderness, guarding, rigidity or a mass. Begin away from the most painful area where appropriate and protect dignity.
- Look for the source: groin, chest, urinary, pelvic or other examination may be required by the clinical team. Explain, obtain consent and use a chaperone as appropriate.
- Reassess: record findings with time and promptly report a change. A stable first set of observations does not exclude evolving sepsis or perforation.
Communication: Give a concise SBAR handover: the suspected source and pain timeline; current and changing observations; fluid balance and urine output; relevant ascites, dialysis or postoperative history; investigations already taken; treatment given; and what urgent review is needed.
Investigations
Investigation choices depend on the suspected cause, stability, pregnancy status, age, renal function and available resources. Results support clinical decisions but should not delay resuscitation or urgent source control in a deteriorating patient.
| Investigation | Purpose | Limitations and nursing points |
|---|---|---|
| Full blood count | May show leukocytosis, neutrophilia, anaemia or thrombocytopenia. | Results can be normal early or abnormal for other reasons. Interpret alongside examination and clinical course. |
| CRP and other inflammatory markers | Support assessment of inflammation and may help follow trends. | Nonspecific; a single result does not identify the source or rule out infection. |
| Electrolytes, urea and creatinine | Assess dehydration, kidney function and electrolyte disturbance; inform fluid and contrast decisions. | Trend and report results; acute kidney injury can develop with sepsis or poor perfusion. |
| Liver tests, coagulation and albumin | Help assess comorbidity, cirrhosis, bleeding risk and procedural preparation. | Use the full clinical context, especially for patients with chronic liver disease or ascites. |
| Lactate and blood gas when indicated | Assess perfusion, acid-base disturbance and severity of illness in a sick patient. | A normal early lactate does not exclude serious disease. Escalate based on the whole presentation. |
| Blood cultures when indicated | May identify bloodstream infection and support antimicrobial adjustment in selected patients with systemic illness or resistant-organism risk. | Collect before antimicrobials only when this can be done promptly without delaying urgent treatment; follow local sepsis protocol. |
| Urinalysis, urine culture and pregnancy test when relevant | Assess urinary alternatives and pregnancy-related risks and guide imaging or treatment. | Collect correctly and protect privacy. A pregnancy test should be offered when clinically relevant and with appropriate explanation. |
| Abdominal ultrasound | May identify free fluid, ascites, gallbladder disease, pelvic causes or an accessible collection. | Operator dependent; gas, body habitus and anatomy may limit views. A nondiagnostic study does not necessarily exclude disease. |
| CT abdomen and pelvis | Can help locate perforation, bowel inflammation, abscess, free air or another source in a stable patient when available. | Consider contrast risks, renal function, pregnancy, radiation and local protocol. Do not delay urgent intervention for imaging when the patient is unstable and the surgical team directs otherwise. |
| Diagnostic paracentesis for ascites | Ascitic fluid cell count and differential, culture and other tests help assess suspected spontaneous bacterial peritonitis and alternative causes. | In suspected SBP, ascitic fluid polymorphonuclear neutrophils (PMN) at or above 250 cells/mm³ strongly support the diagnosis. Obtain fluid culture before antibiotics if feasible without unsafe delay; bedside inoculation into blood-culture bottles can improve organism recovery. The treating team interprets results and considers a secondary source when findings suggest it. |
| Peritoneal dialysis effluent tests | Assess cell count/differential, Gram stain and culture when dialysis-associated peritonitis is suspected. | ISPD criteria use at least two of the following: compatible symptoms/cloudy effluent; effluent WBC over 100/µL after a dwell of at least two hours with more than 50% neutrophils; or a positive effluent culture. Contact the PD team urgently and follow its sampling protocol. |
| Intra-abdominal fluid culture at source control | Can help direct antimicrobial therapy in complicated infection treated by a procedure. | Use aseptic collection, correct containers and prompt lab transport. Culture results guide later therapy but do not replace source control. |
Differential Diagnosis
| Possible alternative or source | Examples and assessment clues |
|---|---|
| Other acute abdominal conditions | Pancreatitis, bowel obstruction, acute cholecystitis, appendicitis, mesenteric ischaemia or severe gastroenteritis. Pain pattern and associated features overlap; urgent assessment may be needed. |
| Gynaecological or pregnancy-related | Ectopic pregnancy, ovarian torsion, ruptured ovarian cyst or pelvic inflammatory disease. Consider pregnancy testing and appropriate pelvic review. |
| Urinary or renal | Pyelonephritis, ureteric stone, urinary retention or bladder injury. Flank-to-groin pain, urinary symptoms or haematuria may help but do not rule out intra-abdominal disease. |
| Thoracic or cardiac | Lower-lobe pneumonia, pleurisy or, particularly in older adults, cardiac ischaemia can present with abdominal discomfort. |
| Ascites without infection or chronic peritoneal disease | Decompensated liver disease, malignancy, tuberculosis or other causes of fluid and chronic abdominal symptoms. |
Management Principles
Peritonitis treatment addresses the cause, infection, circulation and organ function. The exact plan depends on whether infection is primary, secondary, tertiary or dialysis associated; whether disease is localised or diffuse; and the patient's age, stability, comorbidities, microbiology and available services. Surgical, medical, critical-care, radiology, microbiology and nursing teams may all be involved.
1. Stabilisation and initial treatment
- Activate emergency assessment and obtain urgent senior and surgical review when secondary peritonitis or perforation is suspected.
- Support airway and breathing; give oxygen if indicated and prescribed; monitor circulation, mental state, temperature and urine output.
- Establish IV access and give prescribed isotonic fluids with frequent reassessment. Fluid choice and volume are clinician-directed, especially with heart failure, renal impairment or cirrhosis.
- Keep the patient nil by mouth when an urgent procedure or anaesthesia is possible, as directed by the clinical team and facility policy.
- Provide timely prescribed analgesia and antiemetics; reassess and document response. Pain relief does not replace ongoing assessment.
- Administer empirical antimicrobials promptly when prescribed for suspected bacterial intra-abdominal infection. Selection and duration depend on source, severity, cultures, allergies, resistance patterns, renal function and local antimicrobial guidance.
- Collect cultures or other samples before treatment only when doing so will not cause unsafe delay.
- Insert a nasogastric tube or urinary catheter only when clinically indicated and prescribed; monitor output and comfort.
- Prepare for imaging, transfer, drainage or theatre. Communicate any deterioration immediately.
2. Source control for secondary peritonitis
Source control means stopping ongoing contamination and controlling infected material, while restoring anatomy and function as far as possible. Depending on the cause and the patient's condition, a surgeon may perform laparoscopic or open exploration, repair or remove a perforated segment, resect nonviable bowel, wash out contamination, drain a collection or create a diversion. Image-guided drainage may be an option for selected, accessible abscesses. Timing and method are specialist decisions; widespread peritonitis, ongoing leakage or shock needs rapid coordinated management.
Antibiotics alone may not control an ongoing perforation or leak. If infection persists or the patient worsens after treatment, reassessment is needed for inadequate source control, an abscess, resistant organisms or another complication. Cultures from complicated infection can help the team refine antimicrobial therapy.
3. Spontaneous bacterial peritonitis in ascites
Suspected SBP requires prompt diagnostic paracentesis and clinician-directed antimicrobials. A PMN count of at least 250 cells/mm³ in ascitic fluid supports SBP, even if culture is negative; a culture can identify the organism and guide treatment. The team should assess severity, kidney function and the possibility of a secondary surgical source, especially if the patient is not improving or the fluid pattern is atypical. Intravenous albumin may be considered by the treating team for selected patients with cirrhosis and SBP. Do not substitute a surgical peritonitis pathway for an SBP assessment or assume that all ascites is infected.
4. Peritoneal-dialysis-associated peritonitis
Cloudy effluent or abdominal pain in a person receiving peritoneal dialysis is urgent. Contact the renal/dialysis team, collect effluent for cell count and culture using aseptic technique, and begin protocol-directed treatment after samples are taken when feasible. Follow the ISPD guideline and local dialysis pathway for route and choice of antimicrobials, review of response and decisions about the catheter. Do not independently stop dialysis or remove a catheter; those decisions belong to the specialist team unless an emergency protocol directs otherwise.
5. General supportive care
Patients with sepsis or organ dysfunction may need high-dependency or intensive-care support, haemodynamic monitoring, respiratory support, renal support, nutrition planning, glucose management, venous-thromboembolism prevention and rehabilitation. These interventions are individualised and should not delay treatment of the source.
Nursing Management
Nursing care focuses on detecting deterioration early, supporting stabilisation, preparing for treatment, preventing avoidable harm, monitoring response and supporting recovery. Follow prescribed orders, local emergency policies and the surgical or specialty team's plan.
A. Immediate and preoperative nursing care
| No. | Nursing action | Rationale |
|---|---|---|
| 1 | Recognise the emergency and escalate suspected peritonitis promptly to the clinician and surgical team; activate the local sepsis response when indicated. | Perforation, peritoneal contamination and sepsis can progress rapidly. |
| 2 | Record a baseline assessment and repeat vital signs, pain, mental status, perfusion, abdominal findings and urine output at the prescribed frequency. | Trends can reveal deterioration earlier than a single observation. |
| 3 | Provide oxygen and position for comfort as indicated; maintain IV access and administer prescribed fluids while observing for overload. | Supports oxygenation and circulation while accounting for comorbidities. |
| 4 | Keep nil by mouth when ordered; explain the reason and record last oral intake. | May reduce aspiration risk if urgent anaesthesia or intervention is required. |
| 5 | Collect ordered blood, urine, ascitic-fluid or dialysis-effluent samples using correct identification, aseptic technique and timely transport. | Reliable samples support diagnosis and targeted treatment; correct technique reduces contamination. |
| 6 | Give prescribed antimicrobials, analgesia, antiemetics and other treatment promptly; check allergies, dose, route and timing and document response. | Supports timely treatment and medication safety. |
| 7 | Monitor intake, output, IV fluids, vomiting, drains and urine output; report oliguria or an unexpected change. | Fluid shifts, vomiting and poor perfusion can cause rapid volume and kidney problems. |
| 8 | Prepare for imaging, transfer or theatre using the local safety checklist; confirm identity, consent status, allergies, investigations and handover information. | Promotes safe and coordinated urgent care. |
| 9 | Explain each step calmly, preserve privacy and include family or a chosen support person with the patient's permission. | Acute illness and possible surgery can create significant fear and uncertainty. |
| 10 | Document findings, times, communications, treatment, response and escalation; use SBAR during handover. | Supports continuity and makes changes visible across the team. |
B. Postoperative and ongoing nursing care
- Airway, breathing and circulation: receive a structured handover; assess consciousness, airway, respiratory effort, oxygenation, pulse and blood pressure; report concerning trends immediately.
- Sepsis and perfusion: monitor temperature, capillary refill, skin, mental status, lactate if ordered, fluid balance and urine output. Follow the prescribed observation frequency and escalation criteria.
- Pain and comfort: assess location, severity and change; give prescribed analgesia and reassess. New, increasing or widespread pain requires review.
- Abdominal assessment: monitor distension, tenderness, nausea, vomiting, bowel activity and ability to tolerate oral intake according to the clinical plan.
- Wound, drains and stoma: use aseptic technique; observe wound appearance, bleeding, discharge and drain amount/colour/patency; assess a stoma for colour, output and surrounding skin if present.
- Fluid and renal monitoring: chart intake and output accurately; administer IV fluids as prescribed; monitor electrolytes and renal tests when ordered; report oliguria, oedema or signs of fluid overload.
- Antimicrobial safety: administer as prescribed, monitor for allergy or adverse effects, obtain requested cultures, and support review/de-escalation when results return.
- Mobility, breathing and prevention: assist safe progressive mobilisation and respiratory exercises when appropriate; follow venous-thromboembolism prevention orders and fall precautions.
- Nutrition and recovery: follow the surgical team's plan for oral intake; coordinate dietetic or nutritional support for prolonged illness, sepsis or bowel surgery.
- Psychological support: explain procedures and recovery in plain language, listen to concerns and involve chosen support persons with consent.
- Discharge and handover: teach wound, drain or stoma care as relevant; explain medicines, follow-up, result review and urgent warning signs; document understanding using teach-back.
C. Example nursing care plan
| Nursing problem | Expected outcome | Key nursing interventions |
|---|---|---|
| Acute abdominal pain related to peritoneal inflammation, infection or surgery. | Patient reports pain at a tolerable level and any worsening is promptly assessed. | Assess pain pattern and severity; position for comfort; administer prescribed analgesia; reassess effect; observe abdomen and escalate new or spreading pain. |
| Risk of deficient fluid volume / impaired perfusion related to third spacing, vomiting, fever or poor intake. | Observations and urine output remain within the target set by the clinical team. | Monitor vital signs, intake/output and perfusion; administer prescribed fluids; assess response and signs of overload; report hypotension, tachycardia, oliguria or confusion. |
| Risk of sepsis and organ dysfunction related to intra-abdominal infection. | Clinical deterioration is recognised, communicated and treated without avoidable delay. | Trend observations and mental status; give prescribed antimicrobials promptly; obtain ordered cultures without delaying treatment; escalate red flags; use infection-prevention measures. |
| Impaired gastrointestinal function related to inflammation, ileus or surgery. | Patient's abdominal symptoms, bowel function and oral tolerance are monitored and concerns reported. | Assess distension, vomiting, flatus and bowel activity as directed; maintain ordered fasting and nasogastric care; chart output; follow diet-advancement orders. |
| Anxiety related to acute illness, surgery and uncertain outcome. | Patient can describe the immediate plan and feels supported. | Give timely explanations, allow questions, avoid false reassurance, protect privacy and involve a chosen support person with consent. |
| Knowledge need related to postoperative care or recurrence prevention. | Patient or caregiver can explain the care plan, medicines, follow-up and warning signs. | Assess language and learning needs; teach in small steps; use teach-back; give written information where available; provide clear return instructions. |
Complications and Prognosis
- Sepsis and septic shock due to ongoing infection and impaired circulation.
- Intra-abdominal abscess or persistent infected collection.
- Paralytic ileus and bowel distension.
- Acute kidney injury due to hypovolaemia, sepsis or underlying disease.
- Respiratory complications related to sepsis, pain, abdominal distension or prolonged immobility.
- Electrolyte imbalance, malnutrition and poor wound healing during prolonged illness.
- Adhesions or bowel obstruction after intra-abdominal inflammation or surgery.
- Multiple-organ dysfunction and death in severe or delayed cases.
- Postoperative complications such as wound infection, bleeding, leak, fistula, stoma complications or recurrent collection.
Outcome depends on the underlying source, speed of recognition, adequacy of source control, organism and resistance, physiological reserve, comorbidities and response to treatment. Persistent fever, pain, ileus, organ dysfunction or inflammatory signs after treatment require clinical reassessment for an unresolved source or another complication.
Patient and Family Education
- Explain the likely source, planned treatment and any remaining uncertainty in language the patient understands.
- Describe why prescribed antibiotics, surgery, drainage, fluid monitoring or intensive observation may be needed; do not advise self-treatment or leftover antibiotics.
- After discharge, follow the team's instructions for wound, drain or stoma care, medicines, activity, diet and follow-up.
- Seek urgent care for increasing abdominal pain or swelling, fever or chills, repeated vomiting, wound discharge, breathlessness, fainting, confusion, very little urine or inability to eat or drink.
- For cirrhosis with ascites, follow the liver team's review plan and report fever, new abdominal pain, confusion or sudden deterioration promptly.
- For peritoneal dialysis, contact the dialysis team immediately for cloudy effluent, abdominal pain, fever or difficulty completing an exchange; follow the individual PD infection-prevention plan.
- Use teach-back: ask the patient or caregiver to explain the follow-up plan and warning signs in their own words.
Exam Revision: High-Yield Points
- Peritonitis is inflammation of the peritoneum; it can be infectious or chemical, localised or generalised.
- Primary (spontaneous) bacterial peritonitis usually involves ascites without a surgically treatable source; secondary peritonitis results from an identifiable abdominal source such as perforation or leak.
- Secondary peritonitis with generalised contamination is a surgical emergency: assess, resuscitate, give prescribed antimicrobials and arrange timely source control.
- Peritoneal irritation may cause pain with movement, tenderness, involuntary guarding and rigidity; absence of fever or classic signs does not safely exclude serious illness.
- In ascites, ascitic-fluid PMN at or above 250 cells/mm³ supports SBP; in dialysis-associated peritonitis use the ISPD-specific criteria and contact the PD team.
- Investigations help identify the source but must not delay stabilisation or urgent intervention in an unstable patient.
- Nursing priorities include serial observations, accurate fluid balance, prompt escalation, timely prescribed medicines, safe specimen handling, preparation for procedures and clear safety-netting.
Revision Questions
- Define peritonitis and distinguish the parietal from the visceral peritoneum.
- Compare primary, secondary and tertiary peritonitis.
- List five causes of secondary peritonitis.
- Explain how peritoneal inflammation can lead to shock and acute kidney injury.
- List six symptoms or signs that may occur in acute generalised peritonitis.
- Identify danger signs that require immediate escalation.
- What is the role of diagnostic paracentesis in a patient with cirrhosis and ascites?
- State the ISPD criteria used to diagnose peritoneal-dialysis-associated peritonitis.
- Define source control and give three examples of source-control procedures.
- Outline preoperative and postoperative nursing care for a patient with secondary peritonitis.
References and Further Reading
- Bonomo RA, Chow AW, Edwards MS, et al. IDSA 2024 Guideline Update on the Risk Assessment, Diagnostic Imaging, and Microbiological Evaluation of Complicated Intra-abdominal Infections in Adults, Children, and Pregnant People. Clinical Infectious Diseases. 2024; ciae346. doi:10.1093/cid/ciae346.
- De Simone B, Sartelli M, Coccolini F, et al. Source control in emergency general surgery: WSES, GAIS, SIS-E, SIS-A guidelines. World Journal of Emergency Surgery. 2023;18:41. doi:10.1186/s13017-023-00509-4.
- Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the AASLD. Hepatology. 2021. doi:10.1002/hep.31884.
- Li PK-T, Chow KM, Cho Y, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Peritoneal Dialysis International. 2022;42(2):110–153. doi:10.1177/08968608221080586.
- Republic of Uganda, Ministry of Health. Uganda Clinical Guidelines, 2023. Consult current Ministry of Health guidance and facility protocols.
Related Notes
- Appendicitis lecture notes
- Chronic appendicitis lecture notes
- Intestinal obstruction lecture notes
- Cholecystitis lecture notes
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Last updated: October 2026. These notes support learning and do not replace clinical assessment, a qualified prescriber's decision or current local guidance.