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Clinical Pathology - > CP24 - Intra-abdominal Infections > Flashcards

CP24 - Intra-abdominal Infections Flashcards

1
Q

which abdominal sites are sterile?

A

peritoneal cavity
hepatobiliary tree
stomach

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2
Q

which organisms are found in the proximal small intestine and why?

A

aerobic bacteria, candida

microbial growth is inhibited by bile

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3
Q

what are the sources of intra-abdominal infection?

A

GI contents - most common
blood
external, e.g. due to surgical errors (least common)

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4
Q

what are the mechanisms of intra-abdominal infections?

A
  1. translocation of micro-organisms from GIT lumen to the peritoneal cavity - intraperitoneal infections
  2. translocation of micro-organisms along a lumen - biliary tract/hepatobiliary infections
  3. translocation of micro-organisms from extra-intestinal source - penetrating trauma, haematogenous spread
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5
Q

how do micro-organisms translocated from GIT lumen to the peritoneal cavity?

A
  1. perforation eg. appendix, ulcers, diverticula, malignancy, could cause sepsis
  2. loss of integrity due to ischaemia - eg. blocked vessels or reduced supply
  3. loss of integrity due to strangulation- hernia through a tight orifice
  4. surgery - anastomotic leak during surgery, if anatomises being performed is not complete
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6
Q

how are micro-organisms kept out of the bill duct?

A

constant outflow of bile out the duct

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7
Q

how can bacteria colonise in the hepatobiliary tree?

A

blockage due to cholecystitis, cholangitis, malignancy, stones, worms or a hepatic abscess could stop the outflow of bile

iatrogenic - through the use of instrumentation

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8
Q

what is cholangitis?

A

inflammation of the bile duct system that is usually related to a bacterial infection
could be iatrogenic

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9
Q

what is the pathogenesis of a perforated appendix?

A

obstruction of lumen of appendix, possible causes include lymphoid hyperplasia or faecal obstruction
causes stagnation of luminal contents, bacterial growth and recruitment of inflammatory cells
build up in pressure could cause perforation

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10
Q

what are the clinical features of a perforated appendix?

A

severe generalised pain
shock
may localise to form an appendix mass
high temperature

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11
Q

what is an appendix mass?

A

an inflamed appendix with adherent covering of momentum and small bowel

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12
Q

which micro-organisms can cause infection due to a perforated appendix?

A

E. coli, bacteroides fragilis

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13
Q

how is a perforated appendix treated?

A

surgery, cefuroxime and metronidazole for 5 days

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14
Q

what is the pathogenesis of a perforated diverticulum?

A

herniations of mucosa or submucosa through the muscular layer, common in the sigmoid or descending colon

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15
Q

what are the complications of a diverticulum?

A

largely asymptomatic
diverticulitis - inflammation of diverticulum, causing pain and disturbance of bowl function
perforation
pericoli abscess - abscess outside the colon

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16
Q

what is the pathophysiology of infections causes by a primary bowel cancer?

A

caused by loss of bowel integrity due to abnormal malignant tissue, but the are infrequent

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17
Q

what are the clinical features of an infection caused by bowel malignancy?

A

consistent with those of the malignancy
weight loss
alteration of bowel habit
blood in stop, etc

18
Q

which species cause infections in bowel cancer?

A

Clostridium septicum

S. bovis

19
Q

what are the possible causes of post op bowel ischaemia?

A
  1. seeding at operation - spreading of cancer cells during the removal of abnormal tissue. this can be reduced with the use of prophylactic antibiotics
  2. anastomotic leak
20
Q

what is the result of bowel leaks during surgery?

A

acute infection - abode pain, tenderness, shock

intraperitoneal abscess - walled off abscess, more indolent condition

21
Q

what is the pathogenesis of cholecystitis?

A

inflammation of the gall bladder wall, bacterial infection could occur secondary to this inflammation
potentially due to the obstruction of the cystic duct
common bile duct patent

22
Q

what is emphysematous cholecystitis?

A

intramural gas in the gall bladder wall

23
Q

what are the clinical features of cholecystitis?

A

presents with fever
right upper quadrant pain
mild jaundice

24
Q

how does empyema form in the gall bladder?

A

empyema - frank pus (in the GB)

complication of cholecystitis

25
Q

what are the clinical features of empyema in the gall bladder?

A

cholecystitis + septic presentation - severe pain, high fever, chills and rigors

26
Q

what is the clinical presentation of cholangitis?

A

fever with riggers, jaundice and right upper quadrant pain, but representation may be non-specific
accompanied by sepsis, shock etc.

27
Q

what are the possible causes of a pyogenic liver abscess?

A
  1. biliary obstruction
  2. direct spread from other intra-abdominal infections
  3. haematogenous from mesenteric infection (via portal vein)
  4. systemic intravascular infection (via hepatic artery)
  5. penetrating trauma
  6. idiopathic
28
Q

what is an intraperitoneal abscess?

A

a localised area of peritonitis with a build up of pus

tends to be categorised by its anatomical site

29
Q

where can intraperitoneal abscesses be found?

A 
subphrenic
sub hepatic
parabolic
pelvic
etc
30
Q

what are the predisposing factors for an intra-peritoneal abscess?

A
  1. perforation
  2. cholecystitis
  3. mesenteric ischaemia/bowel infarction
  4. pancreatitis/pancreatic necrosis
  5. penetrating trauma
  6. post-op anastomotic leak
    this could be a late complication and present months after the predisposing factor
31
Q

what is the presentation of an intra-peritoneal abscess?

A 
non specific
sweating
anorexia
wasting
high swinging pyrexia -
32
Q

what features in a history can localise an intra-peritoneal abscess to the sub-phrenic region?

A

pain in shoulder on the affected side
persistent hiccup
intercostal tenderness
apparent hepatomegaly because the pus causes ipsilateral lung collapse with pleural effusion, displacing the liver downwards. could be misdiagnosed as a chest problem!!

33
Q

what features in a history can localise an intra-peritoneal abscess to the pelvic region?

A

urinary frequency

tenesmus - continual or recurrent inclination to empty bowels

34
Q

what is ascites?

A

fluid in the peritoneal cavity

35
Q

which conditions cause intra-abdominal sepsis?

A
  1. spontaneous bacterial peritonitis - due to infected ascitic fluid
  2. pancreatic and splenic abscesses
  3. amoebic abscess - entamoeba histolytica
  4. hydatid cyst (parasitic) - enchinococcus granulosus
  5. ileo-caecal tb - M. tuberculosis
36
Q

what determines the type of flora causing an intra-abdominal infection?

A

mode of translocation

if these infections are secondary to haematogenous spread or trauma, the micro-organisms involved may not be GI flora

37
Q

how are intra-abdominal infections generally diagnosed?

A
  1. history
  2. exam
  3. investigations
    - bloods
    - imaging
    - microbiological investigations
38
Q

what kind of blood tests need to be done to confirm diagnosis of intra-abdominal infections?

A

FBC to check for neutrophilia/neutropenia

CRP - raised
LFTs - abnormal in hepatobiliary disease

39
Q

what kind of imaging is required to confirm the diagnosis of an intra-abdominal infection?

A

CXR to look for consolidation, pleural effusion adjacent to infected area

Abdo US to look for abdominal masses, free fluid, dilated bile ducts

Abdo CT if HD needed

40
Q

what kind of microbiological investigations need to be done to confirm the diagnosis of an intra-abdominal infection?

A

sample blood, peritoneal fluid, US, CT guided fluid drainage

tests - microscopy, cultures, sensitivity testing

41
Q

what are the general treatment principles for intra-abdominal infections?

A

treat the underlying condition
start smart then focus
intestinal source - cefuroxime and metronidazole65y
extra intestinal - antibiotic of choice depends on source
switch to oral treatment after 48h pyrexial and normal WBCs

42
Q

how should intraperitoneal abscesses be managed?

A

CT/US guided drainage
surgical drainage for multi ocular abscesses
combine with antimicrobial therapy

Clinical Pathology - (15 decks)

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