Peritonitis

Question 1

Anatomy of the peritoneum

Answer 1

The peritoneal cavity is the largest cavity in the
body.

two parts – the visceral peritoneum and the
parietal peritoneum.

peritoneal fluid.

Nerve supply

Question 2

Functions of the peritoneum in health?

Answer 2

Visceral lubrication

Fluid and particulate absorption

Question 3

Functions of the peritoneum in disease?

Answer 3

Pain perception.

Inflammatory and immune responses

Fibrinolytic activity

Question 4

What is peritonitis?

Answer 4

Inflammation of the peritonium.

Question 5

How do we classify peritonitis?

Answer 5

Onset
-Acute
-Chronic

Source of origin
-Primary
-Secondary

Question 6

Causes of peritonitis:

Answer 6

Bacterial, gastrointestinal and non-gastrointestinal

Chemical, e.g. bile, barium

Traumatic, e.g. operative handling

Ischaemia, e.g. strangulated bowel, vascular occlusion

Miscellaneous, e.g. familial Mediterranean fever

Question 7

What are the locations of peritonitis?

Answer 7

Generalised and localised

Question 8

Pathophysiology of SBP

Answer 8

• Direct spread:bacterial translocation across the bowel wall
• Haematogenous spread:bacteria enter ascites via the blood stream in the context of an immunosuppressed state

Question 9

What are the paths to peritonitis?

Answer 9

Gastrointestinal perforation, e.g. perforated ulcer, appendix, diverticulum

Transmural translocation (no perforation), e.g. pancreatitis, ischaemic bowel,
primary bacterial peritonitis

Exogenous contamination, e.g. drains, open surgery, trauma, peritoneal dialysis

Female genital tract infection, e.g. pelvic inflammatory disease

Haematogenous spread (rare), e.g. septicaemia

Question 10

Gastrointestinal microorganisms in peritonitis

Answer 10

E.Coli
S. Aureus
Klebsiella penumoniae
And more

Question 11

Other microorganisms in peritonitis?

Answer 11

Chlamydia trachomatis
Neisseria gonorrhoeae
Streptococcus pneumoniae
And others

Question 12

Clinical features of localised peritonitis?

Answer 12

Pain
Ascites
Fever
Tachycardia
Localised guarding
Rebound tenderness
Shoulder tip pain ( subphrenic)
Tender rectal and / or vaginal examination
(pelvic peritonitis).

Question 13

Clinical features of diffuse (generalised) peritonitis (Early)

Answer 13

Abdominal pain ( worse by moving or breathing)
Tenderness
Generalised guarding
Infrequent bowel sounds 🡪cease ( paralytic ileus)
Fever
Tachycardia

Question 14

Clinical features of diffuse (generalised) peritonitis (Late)

Answer 14

Generalised rigidity
Destension
Absent bowel sounds
Circulatory failure
Thready irregular pulse
(Hippocratic face)
Loss of consciousness

Question 15

Investigations for peritonitis

Answer 15

FBC - raised WCC and CRP
- Human Chorionic Gonadotrophin (HCG):
- Hormone secreted in pregnancy
- Obviously there is abdominal pain in pregnancy
- This test is to exclude pregnancy as cause
CXR
CT abdomen

Urine dipstix for urinary tract infection.
ECG if diagnostic doubt (as to cause of abdominal pain) or cardiac history.

Question 16

Management of peritonitis

Answer 16

• ABC (airways, breathing, circulation)
• Insertion of nasogastric tube
• IV fluids
• Treat underlying cause and treat early
• Broad spectrum antibiotics like cephalosporin
  SBP - rifaximin

Question 17

Investigations for SBP

Answer 17

• Ascitic tap - high white cell count
• Blood cultures

Question 18

When do we do surgery for peritonitis?

Answer 18

Remove or divert cause:
- Repair of perforated viscus – peptic ulcer
- Excision of perforated organ
With or without drainage
With or without restoring continuity

Peritoneal lavage

Question 19

What are the affects of perforation?

Answer 19

Irritate through the leaked chemicals such as bile, acids and old clotted blood

Question 20

Surgery for secondary peritonitis

Answer 20

• laparotomy - perform a full exploration and lavage (clean) of the peritoneum.
• Specific treatment of the underlying condition