Lecture 26 - Peritonitis

Question 1

Peritonitis - symptoms and signs

-primary vs secondary

Answer 1

Fever
increased heart rate 
Increase resp rate
nausea and vomiting
diffuse abdominal pain that may become localised
rebound tenderness
abdominal wall rigidity 

increase blood leukocytes
fluid accumulation, inflammation

-could be a generalised infection or could be diffuse

Primary - diffuse bacterial infection without loss of GI tract integrity, rare , associated with liver disease

Secondary - acute infection resulting from loss of GI tract integrity or from infected viscera . Related to visceral pathology or post surgical infection

tertiary - when it reoccurs

Question 2

How does it occur?

Answer 2

• Many different bacteria involved in the infection
• bacteria reflective of the source
• but want to know which bacteria - so can treat it
• normally enterobactericeae, or anaerobes

Route of transmission
-leaves gi tract via a perforation e.g appendicitis, diverticulitis, ulcer, infection, pelvic inflammatory disease ect.

Question 3

Risk factors

Answer 3

primary - liver disease
secondary - appendiciits, diverticulistis, surgery
Tertiary - when it coms back -
immune deficiencies,

Question 4

What happens in peritoneum

Answer 4

• bacteria gain entry, are not cleared by phagocytosis
• results in bacterial proliferation
• get an inflammation process - fluid exudate in the peritoneal cavity, dilution of antibacterial factors (e.g opsonins) , may lead to hypovolemia
• Get an absess formation
• firbrin deposited and traps bacteria
• this can prevent phagocytosis and other antimicrobial access
• microbial growth continues
• and get damage to the tissue

Question 5

Treatment -

Answer 5

laparoscopy, to see what you can diagnose

-also can do ultrasound to see fluid

Question 6

e.g what happens after an appendicitis

Answer 6

• have puss around the area
• gram stain of puss - gram negative rods, possible gram positive cocci
• anaerobic and aerobic cultures

Question 7

Diagnostic tests

Answer 7

Anaerobes and bacteriodes

• bacteriodes are difficult to isolate - often missed so need to think about this when culturing
• appropriate methods on way to lab so dont kill it
• they are gram negative rods
• ecoli - on macconkey agar
• bacteriodetes - need very specific conditions (needs to be carried anaerobically)
• synergey between bacteriodes fragilis and e.coli
• b fraglisi - capsule, allows fibrin formation so get absess formation, catalsye - reduce oxygen toxicity, contian iron to help this

E.coli - have a haem bndign protein - can intercept by b.fraglisis

• b.grafilis uses the iron that ecoli makes
• e.coli does not make black color on xld agar

Question 8

Treatment

Answer 8

symptoms - fluids, pain relief, removal drainage of pus
Source - establish cause and control origin of sepsis, removal, drainage of pus , tissue, corrective surgery to repair leak
-treat the microbial cause - antibiotics - triple theory

Question 9

Metronidazole

Answer 9

• good for bacteriodetes
• dont really know how it works
• pro drug, gets into bacteria
• bacteria modifies it and then interferes with dna sytnehsis and kills the bacteria
• only really works against anerobes
• also protozoa - e.g giardia

Question 10

Senario 1

• 40 year old women comes to emergency department with sudden onset of abdominal pain
• finds pain severe and she has been vomiting
• has no relevant medical history

Answer 10

What tets to confirm appendicitis and peritonitis

• see abdominal wall regiditiy
• use US/CT scan to see fluid accumulation (due to the inflammation)

Appendix ruptures - then we will take the puss away to test which microbes grow
-also would make sure that surigcally removed and repaired

What would you expect to see under gram stain?

• gram negative
• mainly bacteriodetes and e.coli
• can grow on many differnt growth agars

How to manage

• Give fluids
• make sure wound is repaired and doesnt become reinfected
• give broad specturm antibiotics to kill of antibiotics in abdominal caivty
• pain relief
• monitor
• make sure bowels are working

Question 11

Patient comes into medical center with vomiting, abdominal distention. He also noted that his bowels have not moved for 4 days and he is not passing wind

Answer 11

What other questions

• probably not apendicitis
• what would you ask the patient
• past 24 hours - pain has become quite severe, in lower quadrant

What further investigations

Most likely diagnsois - diverticulum has burst

• leaked and caused peritonitis, and blockage of GI tract
• want to clean out the puss - send it to lab for investigation

How should mans illness be managed?
-treatment - fluids, pain relief, remove infective tissue, repair colon, antibiotics to kill these form the colon