Mild colic and pyrexia - peritonitis diagnosis and treatment

Question 1

Diagnosis of mild colic

Answer 1

• History
• Physical exam
• Rectal exam
• NGT
  – Negative reflux on NGT expected for peritonitis
• ± Haematology / biochemistry
• Abdominocentesis

Question 2

Common differentials for colic + pyrexia

Answer 2

• peritonitis
• colitis
  – may feel fluid filled colon
• enteritis
  – distension of the SI or fluid filled SI

Non-GI
- pleuropneumonia
- other infections

Question 3

Haematology

Answer 3

• Leukopaenia
  – neutropenia common in more severe cases (result of inflammation in the peritoneum and so most of circulating neutrophils pool/go to the peritoneum)
• Haemoconcentration / azotemia / acidosis
  – all a result of hypovolaemia
• Increased acute phase proteins

Question 4

Abdominocentesis

Answer 4

• TNCC – greater than 5x109cells/L
• Cytology
• Lactate – greater than 2mmol/L
• Glucose – less than 2mmol/L
• Culture & Sensitivity

Question 5

Treatment

Answer 5

• Antimicrobials
  – Assuming infection
  – Pen and gent
• IV fluids
  – Many cases don’t feel well -> anorexic and stop drinking
  – IV fluids helps them feel better and less hypovolaemic
• ± Abdominal lavage/drainage
  – Put 35 french catheter through most pendant part of abdo and try to lavage it 20-50L of fluids daily and leave to drain
  – sounds good on paper but in practice it is frustrating
  – get omentum or guts sitting on the catheter and so nothing seems to come out
  – If tried everything then could try it but hopes of it working are limited

Question 6

Prognosis

Answer 6

Depends on source of contamination
- Poor with GI rupture
- Following abdominal surgery guarded
- Without rupture generally good

Question 7

What on haematology is a good prognostic indicator?

Answer 7

• lack of leukopaenia
• hints inflammation is not as severe

Question 8

TNCC (abdominocentesis)

Answer 8

= total nucleated cell count
- high TNCC doesn’t necessarily mean infection, can just mean inflammation

Question 9

How will bacterial infections (abdominocentesis) present?

Answer 9

• with >90% neutrophils in the peritoneal fluid alongside increased TNCC

Question 10

Which tubes should you use for peritoneal fluid samples

Answer 10

• EDTA and plain tube
• Plain for C&ST