Peritonitis is often secondary to perforated appendicitis. Primary bacterial peritonitis is an inflammatory process ofthe peritoneum without an identifiable intraabdominal source. Although this rare entity has been typically associated with underlying systemic processes such as nephrotic syndrome, liver failure, and the presence of ventriculoperitoneal shunt catheter, primary bacterial peritonitis may also occur in otherwise healthy children. The sonographic and CT finding of complex ascites is relatively nonspecific, most commonly thought to be associated with perforated appendicitis. However, when the imaging findings of peritonitis are disproportionately greater than the degree of abnormal appendiceal changes or are associated with non-visualization of the appendix, the diagnosis of primary bacterial peritonitis should be considered in addition to that of perforated appendicitis. The diagnosis can be confirmed by paracentesis and demonstration of a single species of gram-positive cocci on stained smears, findings that would be highly unlikely to be caused by appendicitis. The demonstration of multiple bacterial species, especially if gram-negative bacilli are present, still warrants exclusion of hollow viscus perforation (DaNN 2005).
Inflammation of the peritoneum caused by Mycobacterium tuberculosis can be produced by direct spread from gastrointestinal tuberculosis or after hematogenous dissemination from a pulmonary focus. Involvement of the omentum in peritoneal tuberculosis is diffuse and different to the focal involvement of the omentum in appendicitis or in omental infarction on US or CT. The correct diagnosis is suggested by additional findings such as lymphadenopathy, involvement of the mesentery, bowel wall thickening, or loculated ascites (vaN BREDa VRiEsmaN and PuyLaERt 2002).
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