Fig 3.
Management algorithm. Patients with localized peritonitis who are hemodynamically stable should receive broad spectrum antibiotics and cross sectional imaging.5 41 42 43 Those with evidence of bowel compromise, feculent, or four quadrant contamination should have laparotomy.19 44 Patients with acute appendicitis, acute cholecystitis, or perforated peptic ulcer may undergo laparoscopic resection or repair. Select patients with purulent peritonitis or in whom the diagnosis is unclear may undergo laparoscopy with lavage or conversion to laparotomy as necessary.45 46 47 48 Those with contained perforation should be managed with a trial of conservative management or percutaneous drainage depending on the accessibility and size of the abscess.49 50 51 Failure to improve clinically with conservative management or after intervention should prompt repeat imaging with percutaneous drainage or exploration as needed. Patients with generalized peritonitis or localized peritonitis with hemodynamic instability should receive fluid resuscitation and broad spectrum antibiotics, with vasopressors if necessary.28 Once patients have been resuscitated, they should be taken for urgent laparotomy. We advise that the rare patient with abdominal sepsis who cannot be stabilized with appropriate fluids, antibiotics, and vasopressors should not be taken for surgery because of the negligible chance of survival. In some cases, these patients may be candidates for bedside procedures. Patients without peritonitis should be evaluated for clinical risk of bowel compromise. Patients over 65 years, or with significant cardiovascular disease or bowel obstruction, should be considered to be at high risk of bowel compromise and should receive cross sectional imaging (see “Identification of patients at high risk of bowel compromise”).52 53 54 Patients without peritonitis or high risk of bowel compromise should undergo focused investigation guided by the clinical presentation (see “Imaging to clarify diagnosis”). The management of these patients is beyond the scope of this review. This algorithm deliberately excludes hemodynamically unstable patients with abdominal pain but without peritonitis. This combination of symptoms covers a broad range of diagnoses that are beyond the scope of this review