Acute peritonitis

Question 1

What is acute peritonitis

Answer 1

Inflammation of the visceral and parietal peritoneum i.e. inflammation of the peritoneal cavity

Question 2

What can acute peritonitis be divided into? Which is more common?

Answer 2

Primary/spontaneous peritonitis (rare) and secondary peritonitis (rare)

Question 3

What causes secondary peritonitis?

Answer 3

• Secondary peritonitis is most often, but not always, infectious in origin (either localized or diffuse) resulting from perforation of the appendix,
  colonic diverticula, or the stomach and duodenum.
• It may also occur as a complication of bowel infarction or incarceration, cancer. inflammatory bowel disease,intestinal obstruction or volvulus. (table is more extensive)
• Aseptic peritonitis is most commonly caused by the abnormal
  presence of physiologic fluids such as gastric juice, bile, pancreatic
  enzymes, blood, or urine.
• It can also be caused by the effects of normally sterile foreign bodies such as surgical sponges or instruments.
  More rarely, it occurs as a complication of systemic diseases such as
  lupus erythematosus, porphyria, and familial Mediterranean fever.
• The chemical irritation caused by stomach acid and activated pancreatic
  enzymes is extreme, and secondary bacterial infection may occur

Question 4

What disease leads to primary peritonitis that is infectious in origin?

Answer 4

Over 90% of the cases of primary
or spontaneous bacterial peritonitis occur in patients with ascites or
hypoproteinemia (<1 g/L).

Question 5

What are the clinical features of peritonitis?

Answer 5

• The cardinal signs and symptoms of peritonitis are acute, typically
  severe, abdominal pain (sometimes radiating to shoulders and back) with tenderness and fever.
• How patients’ complaints of pain are manifested depends on their overall physical health and whether the inflammation is diffuse or localized.
• Elderly and immunosuppressed patients may not respond as aggressively to
  the irritation.
• Diffuse, generalized peritonitis is most often recognized as diffuse abdominal tenderness with local guarding, rigidity, and other evidence of parietal peritoneal irritation.
• Abdominal pain worse with movement, coughing, and sneezing may be present
• Physical findings may only
  be identified in a specific region of the abdomen if the intraperitoneal
  inflammatory process is limited or otherwise contained as may occur
  in patients with uncomplicated appendicitis or diverticulitis
• Anorexia may be present
• Bowel sounds are usually absent to hypoactive.
• Most patients present with tachycardia and signs of volume depletion
  with hypotension.

Question 6

What does laboratory testing reveal in acute peritonitis?

Answer 6

Laboratory testing typically reveals a significant leukocytosis, and patients may be severely acidotic

Question 7

What imaging show in acute peritonitis?

Answer 7

• Radiographic studies may show dilatation of the bowel and associated bowel wall edema
• Free air or other evidence of leakage requires attention and could
  represent a surgical emergency.

Question 8

Testing in ascites patients with suspected acute periotonitis

Answer 8

In stable patients in whom ascites is
present, diagnostic paracentesis is indicated, where the fluid is tested
for protein and lactate dehydrogenase and the cell count is measured.

Question 9

Mortality rate of acute peritonitis

Answer 9

Whereas mortality rates can be <10% for reasonably healthy patients with relatively uncomplicated, localized peritonitis, mortality rates >40% have been reported for the elderly or immunocompromised

Question 10

Treatment and testing of acute peritonitis

Answer 10

• Successful treatment depends on correcting any electrolyte abnormalities,
  restoration of fluid volume and stabilization of the cardiovascular
  system, appropriate antibiotic therapy, and surgical correction of any
  underlying abnormalities
• Most causes of acute peritonitis require surgery to correct them, but surgery
  is contraindicated in acute pancreatitis, except later if complicated or
  cholecystectomy is required to prevent future attacks
• Initial diagnostic investigations, along with plain AXR and erect CXR, may
  be sufficient to proceed to surgery to save time. In peritonitis: speedy
  source control of sepsis = improved survival.
• If diagnostic uncertainty exists, then abdominal CT scanning is the investigation of choice. It can often locate the probable source of peritonitis if proper history is given to the radiologist
• In emergency situations where resuscitation is necessary, establish large- calibre IV access in a straight vein., Catheterize and place on a fluid balance chart, Send bloods for FBC (Hb, WCC), U&Es (eGFR), CRP, amylase, clotting,
  LFTs, and group and save, ABGs if shocked or ischaemic bowel/ pancreatitis suspected

Question 11

Commonest cause of acute peritonitis in the elderly

Answer 11

Acute perforated diverticular disease