Intended for healthcare professionals

Clinical Review State of the Art Review

Secondary peritonitis: principles of diagnosis and intervention

BMJ 2018; 361 doi: (Published 18 June 2018) Cite this as: BMJ 2018;361:k1407
  1. James T Ross, surgical resident1,
  2. Michael A Matthay, professor2,
  3. Hobart W Harris, professor1
  1. 1Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
  2. 2Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143, USA
  1. Correspondence to: J T Ross james.ross2{at}


Secondary peritonitis accounts for 1% of urgent or emergent hospital admissions and is the second leading cause of sepsis in patients in intensive care units globally. Overall mortality is 6%, but mortality rises to 35% in patients who develop severe sepsis. Despite the dramatic growth in the availability and use of imaging and laboratory tests, the rapid diagnosis and early management of peritonitis remains a challenge for physicians in emergency medicine, surgery, and critical care. In this article, we review the pathophysiology of peritonitis and its potential progression to sepsis, discuss the utility and limitations of the physical examination and laboratory and radiographic tests, and present a paradigm for the management of secondary peritonitis.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: JTR did the literature search, wrote the draft article, and revised the manuscript. MAM edited early and revised versions of the manuscript and contributed as author to sections of the manuscript. HWH edited early and revised versions of the manuscript, contributed as author to sections of the manuscript, and is the guarantor.

  • Funding: JTR and HWH are supported by NIH T32DK007573-23. MAM is supported in part by HHLBI R37 HL51856.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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