Materiały źródłowe

• #1 Peritonitis and Abdominal Sepsis: Background, Anatomy, Pathophysiology

  https://emedicine.medscape.com/article/180234-overview

  Peritonitis is defined as an inflammation of the serosal membrane that lines the abdominal cavity and the organs contained therein. The peritoneum, which is an otherwise sterile environment, reacts to various pathologic stimuli with a fairly uniform inflammatory response. Depending on the underlying pathology, the resultant peritonitis may be infectious or sterile (ie, chemical or mechanical). The abdomen is the second most common source of sepsis and secondary peritonitis. […] Intra-abdominal sepsis is an inflammation of the peritoneum caused by pathogenic microorganisms and their products. […] The inflammatory process may be localized (abscess) or diffuse in nature. […] Peritonitis is most often caused by introduction of an infection into the otherwise sterile peritoneal environment through organ perforation, but it may also result from other irritants, such as foreign bodies, bile from a perforated gall bladder or a lacerated liver, or gastric acid from a perforated ulcer.

• #1 Azthena logo with the word Azthena

  https://www.news-medical.net/health/What-Causes-Peritonitis.aspx

  Peritonitis indicates inflammation of the peritoneal layer in the abdominal cavity that arises when local mediator cascades are activated by different factors. Depending on the pathogenesis, it can be classified into three types that include primary, secondary, or tertiary peritonitis. Each of these types is considered a separate clinical entity. […] The pathogenesis of primary or spontaneous bacterial peritonitis is related to altered host defenses observed in end-stage liver disease, deficient ascitic fluid antibacterial activity, overgrowth of microorganisms, as well as bacterial translocation from the intestinal lumen to mesenteric lymph nodes. […] There is a principal, surgically pertinent causal problem in most forms of peritonitis that is related to abdominal sepsis. Nevertheless, peritonitis is inhomogeneous in regards to its cause, pathophysiology, and severity; therefore, every single case necessitates a meticulous approach.

• #1 Pathogenesis of spontaneous bacterial peritonitis – UpToDate

  https://www.uptodate.com/contents/pathogenesis-of-spontaneous-bacterial-peritonitis/print

  Pathogenesis of spontaneous bacterial peritonitis is defined as an ascitic fluid infection without an evident intra-abdominal surgically treatable source. The presence of infection is documented by a positive ascitic fluid bacterial culture and an elevated ascitic fluid absolute polymorphonuclear leukocyte (PMN) count (≥250 cells/mm³). […] This topic will review our understanding of the pathogenesis of SBP. […] When the phrase spontaneous bacterial peritonitis was coined in 1964, the descriptor „spontaneous” was used because the pathogenesis of the infection was not apparent. Over the past decades, this void of information has been at least partially filled. […] One of the early steps in the development of SBP is a disturbance in gut flora with overgrowth and extraintestinal dissemination of a specific organism, most commonly Escherichia coli. Cirrhosis predisposes to the development of bacterial overgrowth, possibly because of altered small intestinal motility, and the presence of hypochlorhydria due to use of proton pump inhibitors. In addition, patients with cirrhosis may have increased intestinal permeability.

• #1 Azthena logo with the word Azthena

  https://www.news-medical.net/health/What-Causes-Peritonitis.aspx

  Secondary peritonitis arises as a result of an inflammatory process in the peritoneal cavity secondary to inflammation, perforation, or gangrene of an intra-abdominal or retroperitoneal structure. […] Tertiary peritonitis is defined as the persistence or recurrence of intra-abdominal infection following ostensibly adequate therapy of primary or secondary peritonitis. This type of inflammation of the peritoneum is associated with higher mortality rates as compared to secondary peritonitis. […] The age of the patient, malnutrition, underlying etiology of peritonitis, and presence of multidrug-resistant microorganisms are some of the risk factors that predispose to the development of tertiary peritonitis. In this type of peritonitis, opportunistic and nosocomial facultative pathogenic bacteria, as well as certain fungi, predominate as the main microbial causes.

• #1 Peritonitis bacteriana espontánea

  https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082011000500006

  Spontaneous bacterial peritonitis (SBP) is a common, serious complication in patients with cirrhosis and ascites. […] The key pathogenic mechanism that starts SBP is bacterial translocation (BT), a process by which both viable and non-viable enteric bacteria, as well as their products (endotoxins, DNA), cross the intestinal mucosal barrier to infect mesenteric lymph nodes, whence they enter the bloodstream and then ascitic fluid (AF). […] All three major defense mechanisms preventing BT in normal subjects are impaired during cirrhosis -intestinal flora stability, intestinal epithelium integrity, and the host’s immune defense. […] In advanced cirrhosis, intestinal motility is highly reduced because of sympathetic nervous system hyperactivation, which leads to intestinal bacterial overgrowth.

• #1 Spontaneous Bacterial Peritonitis: Physiopathological Mechanism and Clinical Manifestations | IntechOpen

  https://www.intechopen.com/chapters/76103

  Bacterial translocation is defined as the passage of bacteria or bacterial products that go from the intestine to the mesenteric lymph nodes. […] Due to the close anatomical and physiological connections between the liver and gut, barrier dysfunction results in translocation of viable bacteria and its product to the liver via the portal circulation, thereby causing liver dysfunction. […] Several experimental studies showed that cirrhotic patients had increased intestinal permeability which might be a critical contributing factor to cirrhosis development. […] Bacterial translocation (BT) initiates a cycle of dysfunctional immune activation, and systemic inflammatory response, facilitating the worsening of pre-existing hepatic and hemodynamic abnormalities in cirrhosis. […] Identification of bacterial DNA has been associated with worsening of intrahepatic endothelial dysfunction and extra-hepatic (peripheral) vasodilation.

• #1 SBP: Symptoms & Antibiotic Treatment – EM Board Bombs Podcast

  https://www.emboardbombs.com/study-guide/spontaneous-bacterial-peritonitis-deadly-balloon/

  From the gut lumen, bacteria translocate across the intestinal wall and colonize mesenteric lymph nodes. […] From here, these lymphatics can rupture secondary to high portal pressure in cirrhotic patients, or the bacteria continue to migrate from the lymphatics into the systemic circulation. […] The exact pathogenesis is still unclear. Currently, the leading theory is that portal hypertension, acquired immunodeficiency, and intestinal hypomotility, all emanating from cirrhosis, lead to intestinal bacterial overgrowth.

• #1 Peritonitis bacteriana espontánea

  https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082011000500006

  Bacterial overgrowth has been shown to favor BT. […] On the other hand, in patients with advanced cirrhosis intestinal mucosal permeability is increased, a direct consequence of portal hypertension and local proinflammatory events mainly triggered by endotoxin release. […] Lastly, defective local and systemic defense mechanisms have been seen in cirrhotic patients: neutrophile and macrophage phagocytosis is reduced, as is the effector function of immunocompetent cells circulating in the blood, which limits the bacteriostatic ability of serum and AF. […] The on-and-off passage of bacterial products (endotoxins, bacterial DNA) into the systemic circulation leads to a chronic inflammatory status characterized by persistent innate immunity and cytokine synthesis activation. […] The activation of the systemic immune-inflammatory system in turn contributes to the worsened circulatory dysfunction seen in cirrhosis.

• #1 Spontaneous Bacterial Peritonitis: Physiopathological Mechanism and Clinical Manifestations | IntechOpen

  https://www.intechopen.com/chapters/76103

  Furthermore, systemic inflammatory response syndrome (SIRS) with bacterial infection shows an increased risk of 67% in cirrhotic patients suggesting that SIRS also contributing to cirrhosis prognosis. […] Bacterial dysbiosis is characterized by the pathogenic shift in quantity or quality from the symbiotic state existing between the host and indigenous bacteria. […] The pathogenic shift in the proportion of bacterial taxa is also associated with decompensation of cirrhosis. […] The disruption of microbial balance in cirrhosis leads to accumulation of harmful bacterial metabolites that damage the intestinal epithelial barrier. […] Gut dysbiosis also leads to intestinal immune system dysregulation by changing the composition of short-chain fatty acids produced by the microbiota. […] This immune dysregulation with functional proinflammatory switch contributes to mucosal barrier dysfunction and BT and thus, bile acids (BA) derangement, which plays a causal role in the gut dysbiosis.

• #1 Spontaneous Bacterial Peritonitis: Physiopathological Mechanism and Clinical Manifestations | IntechOpen

  https://www.intechopen.com/chapters/76103

  Nevertheless, in cirrhosis, intestinal barrier dysfunction, increased permeability and extensive inflammation occurs due to SBP. […] The intestinal barrier consists of several layers, including mucus layer, intestinal epithelial cells, lamina propria and Peyers patches. They determine the extent to which gut microbes and their products (endotoxin) can access the host vasculature. […] Therefore, the intestinal vascular barrier is considered an important layer controlling the entry of gut bacterial products into the portal circulation and liver. […] SBP is a frequent and severe complication in cirrhotic patients with ascites. […] The proinflammatory cytokine milieu in the intestinal lumen plays a critical role in disrupting the tight junction protein integrity, leading to BT. […] Bacterial endotoxin and harmful pathogenic bacterial species translocate to the liver through portal vein further exacerbate the already prevalent hepatic inflammation and fibrosis in the liver, causing a cyclic progression of liver injury.

• #1 Spontaneous Bacterial Peritonitis: Physiopathological Mechanism and Clinical Manifestations | IntechOpen

  https://www.intechopen.com/chapters/76103

  In cirrhotic patients, intraluminal BA reduction was shown to increase deconjugation by enteric bacteria. […] Moreover, defect in intestinal BA concentration accelerates BT and develops susceptibility to bacterial endotoxin. […] Increased intestinal permeability exerts a pivotal role in the pathogenesis of SBP in cirrhosis following elevated systemic endotoxemia. […] The intestinal barrier comprises tight junction (TJ) proteins that allow specific passage of gut bacterial products and metabolites, thus maintaining intestinal structural integrity and regulating intestinal permeability following SBP. […] The TJ proteins expression and turnover are predisposed by oxidative stress and inflammation following SBP in cirrhosis, consequently, disruption of the intestinal barrier allows bacterial endotoxin from the intestinal lumen to pass into the portal circulation and thus reaches the liver culminating hepatic complications.

• #1 Spontaneous Bacterial Peritonitis (SBP): Background, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/789105-overview

  An alternative proposed mechanism for bacterial inoculation of ascites is hematogenous transmission in combination with an impaired immune system. Nonetheless, the exact mechanism of bacterial displacement from the GI tract into ascites fluid remains controversial. […] A variety of factors contributes to peritoneal inflammation and bacterial growth in ascitic fluid. A key predisposing factor may be the intestinal bacterial overgrowth found in people with cirrhosis, mainly attributed to delayed intestinal transit time. Intestinal bacterial overgrowth, along with impaired phagocytic function, low serum and ascites complement levels, and decreased activity of the reticuloendothelial system, contributes to an increased number of microorganisms and decreased capacity to clear them from the bloodstream, resulting in their migration into and eventual proliferation within ascites fluid.

• #1

  https://www.termedia.pl/Spontaneous-bacterial-peritonitis-therapeutic-challenges-in-the-era-of-increasing-drug-resistance-r-nof-bacteria,80,34315,1,1.html

  SBP-causing bacteria can also enter the peritoneal cavity via the blood circulation system or lymphatic system from extra-gastrointestinal foci such as the urinary tract, lungs, dermatitis and subcutaneous tissue, pharyngitis and often neglected odontogenic foci. […] The frequent occurrence of SBP is often associated with an impaired immune response in patients with cirrhosis, expressed by reduced activity of mononuclear phagocytes and deficiency of complement components in the blood, especially in ascitic fluid. […] Among the iatrogenic factors, the risk of SBP development is increased by proton pump inhibitors in the mechanism of enhancing the bacterial translocation, and additionally by impairing the respiratory burst generated by phagocytes. […] The risk of SBP increases with the progression of liver disease expressed as bilirubin 3.2 mg/dl and PLT.

• #1 Peritonitis and Abdominal Sepsis: Background, Anatomy, Pathophysiology

  https://emedicine.medscape.com/article/180234-overview

  Infections of the peritoneum are further divided into generalized (peritonitis) and localized (intra-abdominal abscess). […] In peritonitis caused by bacteria, the physiologic response is determined by several factors, including the virulence of the contaminant, the size of the inoculum, the immune status and overall health of the host (eg, as indicated by the Acute Physiology and Chronic Health Evaluation II [APACHE II] score), and elements of the local environment, such as necrotic tissue, blood, or bile. […] Intra-abdominal sepsis from a perforated viscus (ie, secondary peritonitis or suppurative peritonitis) results from direct spillage of luminal contents into the peritoneum (eg, perforated peptic ulcer, diverticulitis, appendicitis, iatrogenic perforation). […] Endotoxins produced by gram-negative bacteria lead to the release of cytokines that induce cellular and humoral cascades, resulting in cellular damage, septic shock, and multiple organ dysfunction syndrome (MODS).

• #1 Peritonitis: Causes, Symptoms, Diagnosis & Treatment

  https://my.clevelandclinic.org/health/diseases/17831-peritonitis

  Secondary infection is the most common cause of peritonitis. It can be caused by a burst appendix (appendicitis), a perforated stomach ulcer (peptic ulcer disease), a perforated intestinal ulcer from diverticulitis or inflammatory bowel disease, infectious pancreatitis, a ruptured tubo-ovarian abscess from pelvic inflammatory disease, a ruptured ectopic pregnancy, trauma or injury to your abdomen, or abdominal surgery. […] Treatment typically begins with IV fluids and broad-spectrum antibiotics to treat or prevent infection. If later tests reveal the exact bacterium or pathogen causing your infection, you may be given a more specific antibiotic for it then. Your healthcare team will work to stabilize your condition before moving on to address the underlying cause. Some causes will require emergency surgery to repair. […] Peritonitis can lead to septicemia and sepsis, if the infection enters your bloodstream. Sepsis can lead to death.

• #1 Spontaneous Bacterial Peritonitis: Physiopathological Mechanism and Clinical Manifestations | IntechOpen

  https://www.intechopen.com/chapters/76103

  Pathogenic bacteria and endotoxins also translocate to blood causes systemic inflammatory responses induced by cytokines, chemokines and interferons resulting cytokine storm syndrome and hemodynamic abnormalities, thereby promotes liver injury followed by multiorgan failure and eventually it causes death. […] Peritonitis occurs in patients with cirrhosis and ascites, in the absence of any other intra-abdominal cause of infection, such as an abscess or intestinal perforation. […] The spontaneous bacterial peritonitis (SBP) is defined as an infection of the ascites fluid, which produces an inflammatory reaction of the peritoneum and as previously described. […] It has been associated with intestinal dysbiosis, since it leads to dysfunction of the intestinal barrier that can cause bacterial translocation of very small quantities of viable or dead bacteria, constituting a physiologically important reinforcement for the immune system.

• #1 Spontaneous Bacterial Peritonitis: Physiopathological Mechanism and Clinical Manifestations | IntechOpen

  https://www.intechopen.com/chapters/76103

  Inflammation and oxidative stress are other key players contributing to mucosal damage and cirrhosis progression by triggering cytokine productions. […] In cirrhosis, SBP is a major precipitating factor initiates gut-liver axis dysfunction. […] It is suggested that there is a lot of task to do in public health, in order to control the self-medication and the excess of antibiotic therapy, in order to avoid microbiota dysbiosis and SBP.

• #1 Peritonitis in Dogs (Canis) | Vetlexicon

  https://www.vetlexicon.com/canis/gastrohepatology/articles/peritonitis/

  Peritonitis may be diffuse (when the whole of the peritoneal cavity is involved) or localized (where the process becomes walled-off, generally by the omentum). […] Cause: usually the result of bacterial peritoneal contamination. […] The risk of septic peritonitis following gastrointestinal surgery is greatest at 3-5 days post-operatively and careful monitoring is imperative during this time. Any signs of deterioration should be followed with thorough patient assessment to rule out septic peritonitis. […] Leakage of intestinal bacteria into the peritoneal cavity induces inflammation of the mesothelial cells lining the peritoneal cavity resulting in activation of pro-inflammatory mediators. […] Consequent increased microvascular permeability to causes transudation of plasma protein, electrolytes and phagocytic cells. Excessive nitrous oxide release results in arteriovenous dilation and decreased systemic vascular resistance, systemic hypotension and compensatory tachycardia.

• #1 Peritonitis in Dogs (Canis) | Vetlexicon

  https://www.vetlexicon.com/canis/gastrohepatology/articles/peritonitis/

  Bacteria or bacterial components, such as gram-negative lipopolysaccharide, may be absorbed resulting in bacteremia and potentially septic shock. […] A systemic response due to inflammatory mediator release will then result in the release of catcholamines and adrenocortical hormones. […] Exudation of fluid into the peritoneal cavity (third spacing) results in profound electrolyte derangements, hypovolemia and hypoalbuminemia. […] Systemic inflammatory response syndrome, multiple organ dysfunction syndrome, disseminated intravascular coagulation death.

• #1 Tertiary peritonitis: A disease that should not be ignored

  https://www.wjgnet.com/2307-8960/full/v9/i10/2160.htm

  Intra-abdominal infections can be classified into uncomplicated or complicated (peritonitis). […] Tertiary peritonitis is the less common but the most severe among peritonitis stratifications, being defined as a recurrent intra-abdominal infection that occurs 48 h after a well-succeeded control of a secondary peritonitis. This disease has a complex pathogenesis that is closely related to the capacity of the peritoneal cavity to activate immunological processes. […] The microbiological profile of organisms causing tertiary peritonitis is often different from that observed in other types of peritonitis. In addition, there is a high prevalence of multidrug-resistant pathogens causing this condition, and an appropriate and successful clinical management depends on an early diagnosis, which can be made easier with the use of clinical scores presenting a good prediction value during the intensive care unit admission.

• #1 Tertiary peritonitis: A disease that should not be ignored

  https://www.wjgnet.com/2307-8960/full/v9/i10/2160.htm

  The peritoneum is essential to provide an immunocompetent cavity system that is able to promote the activation, differentiation, proliferation, and recruitment of components of the immune system. […] Infections or surgical traumas to the peritoneum trigger an immune response with an initial predominance of monocytes, which produce pro-inflammatory cytokines such as tumor necrosis factor alpha, interleukin (IL)-1, and interferon- aiming to recruit other cells in order to establish a robust immune response. […] If there is a decrease of more than 30% in the human leukocyte antigen-DR isotype expression by monocytes, then an immunological paralysis can be found, a phenomenon that is believed to be the basis for the development of the TP. […] Neutrophils seem to affect the microbicidal function of other immune cells, hindering the occurrence of an effective type 1 T helper response and, therefore, playing a role in the above-mentioned immunological phenomenon.

• #1 Peritonitis in Animals – Digestive System – Merck Veterinary Manual

  https://www.merckvetmanual.com/digestive-system/peritonitis/peritonitis-in-animals

  Peritoneal inflammation results from a variety of possible pathogenetic pathways. […] These pathways are species dependent (eg, peritoneal inflammatory response in cattle is characterized by extensive fibrin formation, and horses tend to develop exudative peritonitis) and mainly influenced by etiology (eg, primary or secondary, septic or nonseptic, acute or chronic). […] Because the peritoneum releases inflammatory mediators after contact with mechanical, chemical, or infectious agents, serosal capillary permeability is increased and results in leakage of plasma proteins, solutes, and water into the peritoneal cavity. […] Exudation of protein-rich fluid can result in hypoproteinemia and facilitates bacterial proliferation. […] The combined effect of large fluid losses into the peritoneal cavity and vasodilatory effects of absorbed toxins can produce profound hypotension and hypovolemia.

• #1 Peritonitis in Animals – Digestive System – Merck Veterinary Manual

  https://www.merckvetmanual.com/digestive-system/peritonitis/peritonitis-in-animals

  Inflammation can also decrease antioxidative capacity and result in oxidative stress. […] Rupture or perforation of the forestomach, stomach, intestine, or infected uterus results in spillage of ingesta or contaminated contents into the abdomen, leading to acute septic peritonitis. […] Toxins produced by bacteria and tissue breakdown are readily absorbed through the peritoneum and have severe systemic effects leading to hypotension, shock, systemic inflammatory response syndrome (SIRS), and DIC. […] Endotoxins, acid-base disturbances, and electrolyte disturbances directly affect cardiac function, resulting in decreased cardiac output and circulatory failure. […] Acute peritonitis frequently results in paralytic ileus, leading to functional GI obstruction and increased mortality. […] Chronic peritonitis is often characterized by extensive secretion of fibrinogen and subsequent formation of fibrinous or fibrous adhesions. […] Such adhesions help localize the inflammatory process (as in traumatic reticuloperitonitis in cattle or type 3 abomasal ulcers in cattle); however, they can lead to mechanical or functional GI tract obstruction.

• #1 Peritonitis – Wikipedia

  https://en.wikipedia.org/wiki/Peritonitis

  Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and covering of the abdominal organs. […] Causes include perforation of the intestinal tract, pancreatitis, pelvic inflammatory disease, stomach ulcer, cirrhosis, a ruptured appendix or even a perforated gallbladder. […] Perforation of part of the gastrointestinal tract is the most common cause of peritonitis. […] Leakage of sterile body fluids into the peritoneum, such as blood, gastric juice, bile, urine, menstruum, pancreatic juice, or even the contents of a ruptured dermoid cyst. […] In normal conditions, the peritoneum appears greyish and glistening; it becomes dull 24 hours after the onset of peritonitis, initially with scarce serous or slightly turbid fluid. Later on, the exudate becomes creamy and evidently suppurative; in people who are dehydrated, it also becomes very inspissated. The quantity of accumulated exudate varies widely. It may be spread to the whole peritoneum, or be walled off by the omentum and viscera. Inflammation features infiltration by neutrophils with fibrino-purulent exudation.

• #1 Peritonitis and Abdominal Sepsis: Background, Anatomy, Pathophysiology

  https://emedicine.medscape.com/article/180234-overview

  Bacterial load and the nature of the pathogen also play important roles. […] Bacterial virulence factors that interfere with phagocytosis and with neutrophil-mediated bacterial killing mediate the persistence of infections and abscess formation. […] Enterococci may be important in enhancing the severity and persistence of peritoneal infections. […] Abscess formation occurs when the host defense is unable to eliminate the infecting agent and attempts to control the spread of this agent by compartmentalization. […] The role of cytokines in the mediation of the body’s immune response and their role in the development of the systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) have been a major focus of research over the past decade.

• #1 Peritonitis bacteriana espontánea

  https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082011000500006

  The impact of BT also extends to AF. […] Bacterial product (LPS, DNA) and proinflammatory cytokine (IL-6, TNF-) hyperproduction activates peritoneal macrophages and the synthesis of proangiogenic and vasodilator molecules (VEGF, nitric oxide). […] Finally, as a consequence of arterial vasodilation endogenous vasoactive systems become activated, and renal function is ultimately impaired, which usually complicates the natural course of SBP.

• #1

  https://www.termedia.pl/Spontaneous-bacterial-peritonitis-therapeutic-challenges-in-the-era-of-increasing-drug-resistance-r-nof-bacteria,80,34315,1,1.html

  In studies conducted in the last century in positive cultures of ascitic fluid in patients with SBP, G-negative intestinal bacteria sensitive to third generation cephalosporins were most commonly cultured. […] However, with increasing frequency of hospitalization, the use of invasive procedures, increased exposure to broad-spectrum antibiotics and the widespread SBP antibiotic prophylaxis with fluoroquinolones, the profile of pathogens causing spontaneous bacterial peritonitis began to change. […] Currently, multi-drug resistant pathogens that is, resistant to antibiotics from 3 or more groups, including -lactams are increasingly isolated. […] Enterobacteriaceae producing ESBL (extended spectrum -lactamases) are a particular problem, especially in HA infections, as in addition to resistance to third generation cephalosporins they often contain genes that cause resistance to other antibiotic groups, e.g. quinolones and tetracyclines.

• #1

  https://www.termedia.pl/Spontaneous-bacterial-peritonitis-therapeutic-challenges-in-the-era-of-increasing-drug-resistance-r-nof-bacteria,80,34315,1,1.html

  The profile of SBP-inducing bacteria varies depending on the geographical region and can be different even between individual hospitals in a given country. […] Characteristics of SBP-inducing pathogens vary depending on where the infection was acquired. In hospital-acquired infections, multi-drug resistant pathogens are more often cultivated, which in turn contributes to less effective treatment and worse prognosis. […] Other risk factors for multi-drug resistant bacteria infection include long-term prophylactic use of norfloxacin, previous multi-drug resistant bacterial infection, recent treatment with b-lactams and advanced liver disease expressed by the MELD score.

• #1

  https://link.springer.com/article/10.1007/s003830050719

  The pathogenesis of peritonitis due to hollow-viscus perforation is currently accepted as being mainly based on the local and systemic release of pro- and anti-inflammatory mediators triggered by the presence of bacteria and bacterial products in the abdominal cavity. […] In conclusion, neither the bacterial nor the endotoxin load of the peritoneal cavity proved to be associated with the clinical course. Therefore, we hypothesize that during peritonitis compartmentalization of the focus of infection prevents further systemic reactions and ultimately leads to removal of the infectious agents by endogenous mechanisms.

• #2 Peritonitis in Dogs (Canis) | Vetlexicon

  https://www.vetlexicon.com/canis/gastrohepatology/articles/peritonitis/

  Peritonitis may be diffuse (when the whole of the peritoneal cavity is involved) or localized (where the process becomes walled-off, generally by the omentum). […] Cause: usually the result of bacterial peritoneal contamination. […] The risk of septic peritonitis following gastrointestinal surgery is greatest at 3-5 days post-operatively and careful monitoring is imperative during this time. Any signs of deterioration should be followed with thorough patient assessment to rule out septic peritonitis. […] Leakage of intestinal bacteria into the peritoneal cavity induces inflammation of the mesothelial cells lining the peritoneal cavity resulting in activation of pro-inflammatory mediators. […] Consequent increased microvascular permeability to causes transudation of plasma protein, electrolytes and phagocytic cells. Excessive nitrous oxide release results in arteriovenous dilation and decreased systemic vascular resistance, systemic hypotension and compensatory tachycardia.

• #2 PERITONITIS | Harrison’s Manual of Medicine

  https://harrisons.unboundmedicine.com/harrisons/view/Harrisons-Manual-of-Medicine/623639/all/PERITONITIS?q=Ascites

  Peritonitis is a life-threatening event that is often accompanied by bacteremia and sepsis. […] Primary peritonitis has no apparent source, whereas secondary peritonitis is caused by spillage from an intraabdominal viscus. The etiologic organisms and the clinical presentations of these two processes are different.

• #2 Tertiary peritonitis: A disease that should not be ignored

  https://www.wjgnet.com/2307-8960/full/v9/i10/2160.htm

  Intra-abdominal infections can be classified into uncomplicated or complicated (peritonitis). […] Tertiary peritonitis is the less common but the most severe among peritonitis stratifications, being defined as a recurrent intra-abdominal infection that occurs 48 h after a well-succeeded control of a secondary peritonitis. This disease has a complex pathogenesis that is closely related to the capacity of the peritoneal cavity to activate immunological processes. […] The microbiological profile of organisms causing tertiary peritonitis is often different from that observed in other types of peritonitis. In addition, there is a high prevalence of multidrug-resistant pathogens causing this condition, and an appropriate and successful clinical management depends on an early diagnosis, which can be made easier with the use of clinical scores presenting a good prediction value during the intensive care unit admission.

• #2 Pathogenesis of spontaneous bacterial peritonitis – UpToDate

  https://www.uptodate.com/contents/pathogenesis-of-spontaneous-bacterial-peritonitis

  Pathogenesis of spontaneous bacterial peritonitis is defined as an ascitic fluid infection without an evident intra-abdominal surgically treatable source. […] This topic will review our understanding of the pathogenesis of SBP. […] When the phrase spontaneous bacterial peritonitis was coined in 1964, the descriptor „spontaneous” was used because the pathogenesis of the infection was not apparent. […] One of the early steps in the development of SBP is a disturbance in gut flora with overgrowth and extraintestinal dissemination of a specific organism, most commonly Escherichia coli. […] Cirrhosis predisposes to the development of bacterial overgrowth, possibly because of altered small intestinal motility, and the presence of hypochlorhydria due to use of proton pump inhibitors. […] In addition, patients with cirrhosis may have increased intestinal permeability.

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