Peritonitis

Question 1

ESSENCE

Answer 1

Inflammation of peritoneum

Question 2

CLINICAL FEATURES

Signs

Answer 2

• Guarding - involuntary tensing abdominal muscles when palpated
• Rigidity - involuntary persistent tensing abdominal muscles
• Rebound tenderness - rapidly releasing pressure worsengs pain than pressure itself
• Coughing test - coughing causes pain
• Percussion tenderness

Question 3

Types of peritonitis

Answer 3

• Localised
  
  • Caused by underlying organ inflammation, such as appendicitis or cholecystitis
• Generalised
  
  • May be caused by perforation of abdominal organ (eg perforated duodenal ulcer or ruptured appendix)
• Spontaneous bacterial peritonitis
  
  • Associated with spontanous infection of ascites in patients with liver disease

Question 4

AETIOLOGY

Main organisms that cause bacterial peritonitis

Answer 4

• E-coli - particularly in cases of perforation
• Staph aureus - particularly in post op cases

Question 5

CLINICAL FEATURES

Presentation

Answer 5

• Abdominal pain
  
  • May be insidious, dull and poorly localised or more localised or generallised
  • Tenderness and guiarding
• Weight loss, nausea and vomiting
• Hypo or hyperthermia
• Bowel sounds may be absent
• May be signs of shock/sepsis (eg tachycardia and tachypnoea)

Question 6

INVESTIGATIONS

First choice

Answer 6

• Acute abdomen investigations
• Chest x-ray
• FBC, U&E, LFTs
• Blood cultures
• Amylase
• Contrast (oral) CT

Question 7

MANAGEMENT

General principles

Answer 7

• Initial assessment - ABCDE
• Fluid and electroylyte replacement
• NG suction and nil by mouth
• Antibiotics
• Maybe surgery to remove source of infection

Question 8

MANAGEMENT

Antibiotic choice

Answer 8

• In severe disease
  
  • Piperacillin/Tazobactum IV
• In incidental finding
  
  • Cotrimoxazole
• In intra-abdominal sepsis following surgery
  
  • Amoxicillin IV and metranidazole IV and gentamicin IV