Peritonitis in childhood: aspects of pathogenesis and therapy

The pathogenesis of peritonitis due to hollow-viscus perforation is current ly accepted as being mainly based on the local and systemic release of pro- and antiinflammatory mediators triggered by the presence of bacteria and b acterial products in the abdominal cavity. Therefore, treatment consists in focal restoration, intraoperative debridement and lavage, and postoperativ e measures such as drainage, continuous peritoneal lavage, or scheduled reo peration aiming at the removal of infectious agents from the peritoneal cav ity to prevent persisting peritonitis and sepsis. In order to evaluate the pathophysiologic relevance of the bacterial and endotoxin load of the perit oneal exudate, we examined the peritoneal fluid of 20 children with perfora ted appendicitis for qualitative and quantitative analysis of bacteria, ant ibiotic concentrations, and endotoxin content. The time period ranged in 12 -h intervals from intraoperatively to day 5. Eighteen of 20 fluid specimens (90%) showed endotoxin levels above 1.5 endotoxin units EU/ml (standard <0 .1 EU/ml). The most common bacterial species isolated was Escherichia coli, mostly in high concentrations. Despite persisting high endotoxin concentra tions and bacterial loads in the peritoneal cavity during the 5 postoperati ve days, the children recovered uneventfully and the systemic signs of infe ction disappeared rapidly. In conclusion, neither the bacterial nor the end otoxin load of the peritoneal cavity proved to be associated with the clini cal course. Therefore, we hypothesize that during peritonitis compartmental ization of the focus of infection prevents further systemic reactions and u ltimately leads to removal of the infectious agents by endogenous mechanism s. At least in peritonitis due to perforated appendicitis in children, adju vant surgical measures in addition to appendectomy and intraoperative debri dement are not necessary.