Dusan Jovanovic, Zlatibor Loncar, Krstina Doklestic, Aleksandar Karamarkovic


Intra-abdominal infections are multifactorial and present an complex inflammatory response of the peritoneum to microorganisms followed by exudation in the abdominal cavity and systemic response Despite advances in management and critical care of patients with acute generalized peritonitis due to hollow viscus perforation, prognosis is still very poor, with high mortality rate. Early detection and adequate treatment is essential to minimize complications in the patient with acute abdomen. Prognostic evaluation of complicated IAI by modern scoring systems is important to assess the severity and the prognosis of the disease. Control of the septic source can be achieved either by nonoperative or operative means. Nonoperative interventional procedures include percutaneous drainages of abscesses. The management of primary peritonitis is non-surgical and antibiotic- treatment. The management of secondary peritonitis include surgery
to control the source of infection, removal of toxins, bacteria, and necrotic tissue, antibiotic therapy, supportive therapy and nutrition. "Source control" is sine qua non of success and adequate surgical procedure involves closure or resection of any openings into the gastrointestinal tract, resection of inflamed tissue and drainage of all abdominal and pelivic collections.
Key words: Intra-abdominal infection, secondary peritonitis, source control, surgery.

Full Text:



Malangoni MA, Inui T. Peritonitis — the Western experience. World J Emerg Surg. 2006; 1:25.

Menichetti F, Sganga G: Definition and classification of intra-abdominal infections. J Chemother. 2009; 21(Suppl 1): 3–4.

Wacha H, Hau T, Dittmer R, Ohmann C. Risk factors associated with intraabdominal infections: a prospective multicentre study. Peritonitis Study Group. Langenbecks Arch Surg. 1999; 384(1): 24–32.

Pieracci FM, Barie PS.Management of severe sepsis of abdominal origin. Scand J Surg. 2007; 96(3): 184–196.

Giessling U, Petersen S, Freitag M, Kleine-Kraneburg H, Ludwig K. Surgical management of severe peritonitis. Zentralbl Chir. 2002; 127(7): 594–7.

Mulari K, Leppäniemi A. Severe secondary peritonitis following gastrointestinal tract perforation. Scand J Surg. 2004; 93(3): 204–8.

Giamarellos-Bourboulis EJ, Norrby-Teglund A, Mylona V, et al. Risk assessment in sepsis: a new prognostication rule by APACHE II score and serum soluble urokinase plasminogen activator receptor. Crit Care. 2012; 16(4): R149.

Mulier S, Penninckx f, Verwaest C, et al. Factors affecting mortality in generalized postoperative peritonitis: multivariate analysis in 96 patients. World J Surg. 2003; 27(4): 379–84.

Horiuchi A, Watanabe Y, Doi T, et al. Evaluation of prognostic factors and scoring system in colonic perforation. World J Gastroenterol. 2007; 13(23): 3228–31.

Koperna T, Semmler D, Marian F. Risk stratification in emergency surgical patients: is the APACHE II score a reliable marker of physiological impairment? Arch Surg. 2001; 136(1): 55–9.

Malik AA, Wani KA, Dar LA, Wani MA, Wani RA, Parray FQ. Mannheim Peritonitis Index and APACHE II — prediction of outcome in patients with peritonitis. Ulus Travma Acil Cerrahi Derg. 2010; 16(1): 27–32.

Correia MM, Thuler LCS, Velasco E, Vidal EM, Schanaider A. Peritonitis Index in oncologic patients. Revista Brasileira de Cancerologia. 2001; 47(1): 63–8.

Notash AY, Salimi J, Rahimian H, Fesharaki MH, Abbasi A. Evaluation of Mannheim peritonitis index and multiple organ failure score in patients with peritonitis. Indian J Gastroenterol. 2005; 24(5): 197–200.

Billing A, Fröhlich D, Schildberg FW. Prediction of outcome using the Mannheim peritonitis index in 2003 patients. Peritonitis Study Group. Br J Surg. 1994; 81(2): 209–13.

Panhofer P, Izay B, Riedl M, et al. Age, microbiology and prognostic scores help to differentiate between secondary and tertiary peritonitis. Langenbecks Arch Surg. 2009; 394(2): 265–71.

Inui T, Haridas M, Claridge JA, Malangoni MA. Mortality for intraabdominal infection is associated with intrinsic risk factors rather than the source of infection. Surgery. 2009; 146(4): 654–61.

Emmi V, Sganga G. Diagnosis of intra-abdominal infections: Clinical findings and imaging. Infez Med. 2008; 16 (Suppl 1): 19–30.

Bone RC, Balk RA, Cerra FB et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992; 101(6): 1644–55.

Novotny AR, Emmanuel K, Hueser N, et al. Procalcitonin ratio indicates successful surgical treatment of abdominal sepsis. Surgery. 2009; 145(1): 20–6.

Foinant M, Lipiecka E, Buc E, et al. Impact of computed tomography on patient’s care in nontraumatic acute abdomen: 90 patients. J Radiol. 2007; 88(4): 559–66.

Grundmann RT, Petersen M, Lippert H, Meyer F. The acute (surgical) abdomen — epidemiology, diagnosis and general principles of management. Z Gastroenterol. 2010; 48(6): 696–706.

Roland SPH, Brunkhorst MF. Sepsis biomarkers and pathogen detection methods-state of the art. Sanamed. 2014; 9(1): 49–61.

Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis. 2003; 37(8): 997–1005.

Suding PN, Orrico RP, Johnson SB, Wilson SE. Concordance of inter-rater assessments of surgical methods to achieve source control of intra-abdominal infections. Am J Surg. 2008; 196(1): 70–3.

Blot S, De Waele JJ. Critical issues in the clinical management of complicated intra-abdominal infections. Drugs. 2005; 65(12): 1611–20.

Mazuski JE, Sawyer RG, Nathens AB, et al. Therapeutic Agents Committee of the Surgical Infections Society. The Surgical Infection Society guidelines on antimicrobial therapy for intra-abdominal infections: evidence for the recommendations. Surg Infect (Larchmt). 2002; 3(3): 175–233.

Mazuski JE. Antimicrobial treatment for intra-abdominal infections. Expert Opin Pharmacother. 2007; 8(17): 2933–45.

Adkins AL, Robbins J, Villalba M, Bendick P, Shanley CJ. Open abdomen management of intra-abdominal sepsis. Am Surg. 2004; 70(2): 137–40.

Barker DE, Kaufman HJ, Smith LA, Ciraulo DL, Richart CL, Burns RP. Vacuum pack technique of temporary abdominal closure: A 7-year experience with 112 patients. J trauma. 2000; 48(2): 201–6.

Miller Pr, Meredith JW, Johnson JC, Chang MC. Prospective evaluation of vacuum-assisted fascial closure after open abdomen: Planned ventral hernia rate is substantially reduced. Ann Surg. 2004; 239(5): 608–14.

Perez D, Wildi S, Demartines N, Bramkamp M, Koehler C, Clavien PA. Prospective evaluation of vacuum-assisted closure in abdominal compartment syndrome and severe abdominal sepsis. J Am Coll Surg. 2007; 205(4): 586–92.

Jansen JO, Loudon MA. Damage control surgery in a non-trauma setting. Br J Surg. 2007; 94(7): 789–90.

Wild T, Stortecky S, Stremitzer S, et al. Abdominal dressing — a new standard in therapy of the open abdomen following secondary peritonitis?. Zentralbl Chir. 2006; 131 (Suppl 1): S111–4.

Ozgüç H, Yilmazlar T, Gürlüler E, Ozen Y, Korun N, Zorluo—lu A. Staged abdominal repair in the treatment of intra-abdominal infection: analysis of 102 patients. J Gastrointest Surg. 2003; 7(5): 646–51.

Van Ruler O, Mahler CW, Boer KR, et al. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: A randomized trial. JAMA. 2007; 298(8): 865–72.

Mason RJ. Surgery for appendicitis: is it necessary? Surg Infect (Larchmt). 2008; 9(4): 481–8.

Eriksson S, Granström L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg. 1995; 82(2): 166–9.

Styrud J, Eriksson S, Nilsson I,et al. Appendectomy versus antibiotic treatment in acute appendicitis. a prospective multicentre randomized controlled trial. World J Surg. 2006; 30(6): 1033–7.

Hansson J, Körner U, Khorram-Manesh A, Solberg A, Lundholm K. Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg. 2009; 96(5): 473–81.

Corfield L.Interval appendicectomy after appendiceal mass or abscess in adults: What is “best practice”? Surg Today. 2007; 37(1): 1–4.

Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: A systematic review and meta-analysis. Ann Surg. 2007; 246(5): 741–8.

Deakin DE, Ahmed I. Interval appendicectomy after resolution of adult inflammatory appendix mass — is it necessary? Surgeon. 2007; 5(1): 45–50.

Sauerlenad S, Agresta F, Bergamaschi R, et al. Laparoscopic for abdominal emergencies: Evidence based guidelines of the European Association for Endoscopic Surgery. Surg Endosc. 2006; 20(1): 14–29.

Sanabria AE, Morales CH, Villegas MI. Laparoscopic repair for perforated peptic ulcer disease. Cochrane Database Syst Rev. 2005; 19(4): CD004778.

Ergul E, Gozetlik EO. Emergency spontaneous gastric perforations: ulcus versus cancer. Langenbecks Arch Surg. 2009; 394(4): 643–6.

McCafferty MH, Roth L, Jorden J. Current management of diverticulitis. Am Surg. 2008; 74(11): 1041–9.

Salem L, Flum DR. Primary anastomosis or Hartmann’s procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum. 2004; 47(11): 1953–64.

Chandra V, Nelson H, Larson DR, Harrington JR. Impact of primary resection on the outcome of patients with perforated diverticulitis. Arch Surg. 2004; 139(11): 1221–4.

Martín-Pérez J, Delgado-Plasencia L, Bravo-Gutiérrez A, et al. Gallstone ileus as a cause of acute abdomen. Importance of early diagnosis for surgical treatment. Cir Esp. 2013; 91(8): 485–9.

Lau H, Lo CY, Patil NG, Yuen WK. Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis. A meta-analysis. Surg Endosc. 2006; 20(1): 82–7.

Papi C, Catarci M, D’Ambrosio L, et al. Timing of cholecystectomy for acute cholecystitis: A meta-analysis. Am J Gastroenterol. 2004; 99(1): 147–55.

Gurusamy KS, Samraj K. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Cochrane Database Syst Rev. 2006; 18(4): CD005440.

Shikata S, Noguchi Y, Fukui T. Early versus delayed cholecystectomy for acute cholecystitis: A meta-analysis of randomized controlled trials. Surg Today. 2005; 35(7): 553–60.

González-Rodríguez FJ, Paredes-Cotoré JP, Pontón C, et al. Early or delayed laparoscopic cholecystectomy in acute cholecystitis? Conclusions of a controlled trial. Hepatogastroenterology. 2009; 56(89): 11–6.

Casillas RA, Yegiyants S, Collins JC. Early laparoscopic cholecystectomy is the preferred management of acute cholecystitis. Arch Surg. 2008; 143(6): 533–7.

Werner J, Büchler MW. Infectious complications in necrotizing pancreatitis. Zentralbl Chir. 2007; 132(5): 433–7.

Amano H, Takada T, Isaji S, et al. Therapeutic intervention and surgery of acute pancreatitis. J Hepatobiliary Pancreat Sci. 2010; 17(1): 53–9.

Milian J W, Portugal S J, Laynez Ch R, Rodríguez A C, Targarona J, Barreda C L. Necrotic acute pancreatitis in the intensive care unit: a comparison between conservative and surgical medical treatment. Rev Gastroenterol Peru. 2010; 30(3): 195–200.

Ara C, Sogutlu G, Yildiz R, et al. Spontaneous small bowel perforations due to intestinal tuberculosis should not be repaired by simple closure. J Gastrointest Surg. 2005; 9(4): 514–7.

Doklesti? K., Karamarkovic A. Ileum perforation due to accidental chicken bone ingestion — a rare couse of the acute abdomen. Sanamed. 2012; 7(1): 31–4.

Ghosheh B, Salameh JR. Laparoscopic approach to acute small bowel obstruction: review of 1061 cases. Surg Endosc. 2007; 21(11): 1945–9.

Babadzhanov BD, Teshaev OR, Beketov GI. New approaches to the treatment of postoperative peritonitis. Vestn Khir Im I I Grek. 2002; 161(4): 25–8.

Chichom Mefire A, Weledji PE, Verla VS, Lidwine NM. Diagnostic and therapeutic challenges of isolated small bowel perforations after blunt abdominal injury in low income settings: analysis of twenty three new cases. Injury. 2014; 45(1): 141–5.



  • There are currently no refbacks.

Copyright (c) 2016 SANAMED

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.