Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 1999  |  Volume : 5  |  Issue : 2  |  Page : 89-91
Primary peritonitis revisited

Department of Surgery, College of Medicine, King Khalid University (Formerly King Saud University) - Abha and Asir Central Hospital, Abha, Saudi Arabia

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Date of Submission05-Nov-1997
Date of Acceptance22-Sep-1998

How to cite this article:
Ajao OG, Al Shehri MY, Al Naami M, Saif SA, Refeidi AS, Al Ahmary AM, Al Jarallah M A, Assiri AH, Al Faki AM. Primary peritonitis revisited. Saudi J Gastroenterol 1999;5:89-91

How to cite this URL:
Ajao OG, Al Shehri MY, Al Naami M, Saif SA, Refeidi AS, Al Ahmary AM, Al Jarallah M A, Assiri AH, Al Faki AM. Primary peritonitis revisited. Saudi J Gastroenterol [serial online] 1999 [cited 2022 Jun 25];5:89-91. Available from:

The causes and predisposing factors for most cases of primary peritonitis are well-known. But primary peritonitis without any obvious cause or predisposing factors had been reported [1] . We are reporting here also four similar cases of primary peritonitis with no obvious cause or predisposing factor.

   Report of cases Top

Case No. 1

This 52-year-old Saudi male was admitted on 17­07-1417 H (28-11-1996 G) with a 3-day history of abdominal pain and a 2-day history of fever, chills and rigors. His appetite was good until the right iliac fossa pain became severe. Apart from hemorrhoidectomy performed a year before this admission, as well as upper and lower gastrointestinal tract endoscopy performed, nothing else was remarkable in the past medical history. On examination, the patient was toxic looking, temperature was 38.5°C. There was guarding and rebound tenderness all over the abdomen, but more severe in the right lower quadrant. He had leucocytosis of 26.3 x 10 9 /L, but other laboratory studies were within normal limits. He was thought to have a perforated appendix with septicaemia. He was therefore hydrated, and ampicillin, metronidazole and gentamycin treatment was initiated. Within 4 hours of admission, he was operated upon through a transverse incision. As soon as the peritoneum was incised, pus oozed out of the peritoneal cavity. Grossly, the appendix appeared relatively normal. The incision was then converted to right paramedian. All the abdominal organs appeared normal. Appendectomy was performed, peritoneal pus taken for culture and abdominal toileting performed with copious amount of normal saline. Within six hours of exploration, his temperature dropped to 36.8°C and post­operative course was uneventful. The peritoneal swab showed no growth after 24 hours and histopathology of the removed appendix showed questionable mild degree of acute appendicitis. This fording of the appendix did not explain the high temperature, the rigors and the large amount of pus found in the peritoneal cavity. In fact one can argue that the peritonitis gave rise to the findings in the appendix. He was discharged in good condition on 26-7-1417 H (7-12-1996 G) nine days after admission. Barium enema performed on outpatient basis after discharge was normal, also, investigations for  Brucellosis More Details,  Salmonella More Details, amoebiasis and malaria parasites were negative.

Case No. 2

This 25-year-old Bangladeshi male was seen in the emergency room on 14-01-1418 H (19-05-1997 G) complaining of abdominal pain. There was no vomiting, or diarrhoea. There was loss of appetite but no vomiting. On examination, patient was toxic looking, temperature was 38°C. There was generalised tenderness and guarding, more in the right upper quadrant of the abdomen and in the epigastric region. Clinical impressions were cholecystitis, perforated duodenal ulcer and acute appendicitis. White blood cell count (WBC) was 17.2 x 10 9 /L, haemoglobin was 16.5 g/dl and hematocrit 54.1. The other laboratory studies were within normal limits. He was started on intravenous fluids and mefoxine. Laparotomy was performed using a midline supra and infra umbilical incision. Pus oozed out from the right iliac fossa mainly after abdominal incision. No obvious source of pus was found. All the abdominal organs appeared normal. Appendectomy was performed, biopsies of the liver that appeared nodular and from the omentum were taken. He made an uneventful recovery and was discharged nine days after admission. Peritoneal culture grew gram-negative bacilli, histopathologically, the liver showed acute suppurative cholangitis with tiny foci of residual liver tissue showing acute and chronic inflammation. The appendix, histopathologically showed focal suppurative serositis. The omental biopsy showed foci of suppurative neutrophilic inflammation. None of these findings could be regarded as the source of the peritoneal abscess. It is felt that these are secondary to the peritonitis.

Case No. 3

This 55-year-old Saudi female presented with one­day history of generalised abdominal pain more severe in the lower abdomen with fever and rigors. No diarrhoea, but she vomited twice. She was not a diabetic and past medical history was unremarkable. On examination the patient was toxic looking, temperature was 39°C. There was generalised tenderness and guarding in the lower abdomen. White blood cell count was 11.3 x 10 9 /L, haemoglobin was 14.5 g/dl. All other laboratory studies were within normal limits. She was thought to have perforated appendix and therefore started on intravenous fluids, mefoxin and metronidazole. The abdomen was explored through a right paramedian equivocal incision. As soon as the peritoneal cavity was entered, pus oozed out from the abdominal cavity. Abdominal lavage and toileting was performed. No source of pus could be identified as all the organs appeared normal and appendectomy was done. Post-operatively, she was continued on the same antibiotics and she made an uneventful recovery. Peritoneal pus culture grew  Staphylococcus epidermidis Scientific Name Search and Streptococcus viridians. There was no evidence to regard these as contamination. Histopathology of the appendix was negative for acute appendicitis but showed periappendicular serositis. Blood test for brucellosis was negative. She was discharged on 24-10-1417 H (03-03-1997 G) five days after admission.

Case No. 4

This 70-year-old Saudi male presented with a 3­day history of abdominal pain, abdominal distention and vomiting. Patient was not diabetic but past medical history included previous cerebrovascular accident and Parkinson's disease. On examination patient looked ill although not febrile. Temperature was 36.5°C , there was abdominal tenderness and guarding. White blood cell count was 13.0 x 10 9 /L, serum amylase 205, hemoglobin 17.5 and hematocrit 50.4. Plain abdominal roentgenogram showed multiple fluid levels. He was thought to have intestinal obstruction most probably due to ischaemic bowel. He was started on ampicillin, metronidazole and gentamycin and within 4 hours of admission he was explored. There was peritoneal fluid and hyperaemic, slightly dilated small bowel loops, all other abdominal organs appeared normal. The peritoneal fluid culture grew serratia. Post­operative course was uneventful.

   Discussion Top

It is known that primary peritonitis can occur in association with liver cirrhosis [2] , nephrotic syndrome in children [3] , and in patients with acquired immunodeficiency syndrome (AIDS) especially with cytomegalovirus enteritis [4] . All the four cases operated upon and presented here are cases of primary peritonitis for which no cause could be found. All the possible sites of infection like the chest, urinary tract etc., were excluded as the source of peritonitis. The appendix was removed in three of the cases, and abdominal lavage and peritoneal toileting performed with copious amount of saline in all the cases operated upon. The use of iodine-providone (betadine) irrigation of peritoneal cavity could be dangerous and fatal because of systemic absorption of iodine. They all responded to this measure and adequate antibiotics. To cover all the spectra of bacteria that could be responsible, a combination of gentamycin, ampicillin and metronidazole was frequently used.

Salmonella infection has also been shown to produce symptoms of peritoneal irritation, even without perforation of the gut. This is often referred to as peritonism [6],[7] . Organisms that have been described by others in cases of primary peritonitis include gram-positive cocci, gram-negative bacilli [3] ,  Escherichia More Details coli, Streptococcus, Streptococcus pneumoniae[6],[8],[9] and Mycobacterium tuberculosis [2]. Organisms that have been found in the reported cases of "idiopathic" intra-abdominal abscess [1] are Escherichia coli, Proteus morganni, Proteus mirabilis, Klebsiella spp., Staphylococcus albus and P. rettgeri. In this group of patients, the first case had a sterile culture, but we suspect that the infection must have been caused by anaerobes. The culture from the second case grew gram-negative bacilli and from the third case, Streptococcus viridans and Staphylococcus epidermidis. The fourth case grew Serratia.

   References Top

1.Ajao OG, Ajao OA. "Idiopathic" intra-abdominal abscess. Trans Roy Soc Trop Med Hyg 1982;76:75-6.  Back to cited text no. 1    
2.Pollock AB. Non-operative antinfective treatment of intraabdominal infections. World J Surg 1990;14:227-30.  Back to cited text no. 2    
3.Tapaneya OC, Tapaneya OW. Primary peritonitis in childhood nephrotic syndrome: A changing trend in causative organisms. J Med Assoc Thai. 1991;74:502-6.  Back to cited text no. 3    
4.Wilcox CM, Forsmark CE, Darragh TM, Yen TS, Cello JP. Cytomegalovirus peritonitis in a patient with acquired immunodeficiency syndrome. Dig Dis Sci. 1992;37:1288-91.  Back to cited text no. 4    
5.Jastaniah S, Abu Eshy S, Batouk AN, Al Shehri M. Intestinal obstruction in a Saudi Arabian population. Eat Afr Med J. 1996;73:764-6.  Back to cited text no. 5    
6.Laurens E, Poirier T, Viuad JY, Fabre X. Lorre G. Primary salmonella brandenburg peritonitis in a non­immunosuppressed female patient. J Chir Paris. 1991;128:240-2.  Back to cited text no. 6    
7.Ajao Og. Typhoid perforations: Factors affecting mortality and morbidity. Int Surg. 1982;67:317-9.  Back to cited text no. 7    
8.Mathisen SR, Skrede O, Gudmundsen TE, Hals J. Primary peritonitis in children. Tidsskr Nor Laegeforen. 1991;111:780.  Back to cited text no. 8    
9.Hoiby EA, Gaustad P, Aasen S, Martin PR. Diseases caused by Streptococcus pyogenes in Norway, 1975-1989. A microbiologic and epidemiological survery. Tidsskr Nor Laegeforen. 1990; 110:2625-8.  Back to cited text no. 9    

Correspondence Address:
Oluwole Gbolagunte Ajao
College of Medicine, King Khalid University - Abha, P.O. Box 641, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

PMID: 19864751

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