Peritonitis

Question 1

What is peritonitis?

Answer 1

inflammation of peritoneum
Localised (prior to rupture) or generalised (after rupture)

Most commonly caused by gastrointestinal perforation

Question 2

List 4 localised forms of peritonitis

Answer 2

Appendicitis
Cholecystitis
Diverticulitis
Salpingitis

Question 3

What is Primary Generalised Peritonitis? What is this AKA?

Answer 3

Spontaneous Bacterial Peritonitis
Ascitic fluid infection w/o an evident intra-abdominal surgically treatable source

Question 4

What is Secondary Generalised Peritonitis?

Answer 4

Bacterial translocation from adjacent organs or due to perforation

Question 5

Summarise the epidemiology of peritonitis

Answer 5

Primary = RARE
Localised + secondary generalised = COMMON in surgical patients

Question 6

Give 4 symptoms of peritonitis

Answer 6

Acute severe abdo pain
Exacerbated by movement + coughing
N+V
Fever

Question 7

Why may symptoms be vague in those with liver disease and ascites?

Answer 7

Due to confusion caused by encephalopathy

Question 8

Describe the pain in localised peritonitis

Answer 8

Initially: dull + poorly localised (due to inflammation of visceral peritoneum)

Becomes severe, sharp + localised as parietal peritoneum becomes involved

Question 9

List 7 signs of peritonitis

Answer 9

Tenderness on palpation
Guarding
Rigidity
Fever
Tachycardia
Absent/ reduced bowel sounds
Features of septic shock: hypotension, oliguria, confusion

Question 10

What is the difference between guarding and rebound tenderness?

Answer 10

Guarding: voluntary contraction of abdo muscles (to protect from pain)
Rigidity: involuntary muscle contraction due to underlying inflammation

Question 11

What imaging is firstline in suspected peritonitis?

Answer 11

CT

Question 12

What is the best diagnostic investigation to perform if there is ascites in peritonitis?

Answer 12

Paracentesis (Ascitic tap) + cell count
SBP = > 250 neutrophils/mm3
Gram stain + culture

Question 13

What are the appropriate blood investigations for peritonitis?

Answer 13

FBC: High WCC
U+Es
LFTs: Raised ALP + BR, Low albumin
Amylase: r/o Pancreatitis
CRP: Inflammation
Clotting
X-match
Blood cultures: Sepsis
Pregnancy test
ABG

Question 14

What older imaging may you perform in suspected peritonitis?

Answer 14

Erect CXR (air under diaphragm in perf)
AXR (for bowel obstruction)
USS (evidence of cirrhosis)

Question 15

Describe the management of localised peritonitis

Answer 15

Depends on CAUSE
May require surgery (e.g. appendicitis)
May be treated with abx (e.g. salpingitis)

Question 17

Describe the management of generalised peritonitis

Answer 17

IV fluids
IV abx
Urinary catheter
NG tube
Central venous line (to monitor fluid balance)
Laparotomy
Remove infected or necrotic tissue
Treat cause
Peritoneal lavage

Question 18

List 6 early complications of peritonitis

Answer 18

Septic shock
Respiratory failure
Multiorgan failure
Paralytic ileus
Wound infection
Abscesses

Question 19

List 2 late complications of peritonitis

Answer 19

Incisional trauma
Adhesions

Question 20

What is the prognosis in peritonitis?

Answer 20

Localised: usually resolves with tx of underlying cause
Generalised: much higher mortality (30-50%)
Primary peritonitis has a good prognosis with abx tx
SBP has a mortality > 30% if dx + tx is delayed

Question 21

Give a risk factors for SBP

Answer 21

Ascites secondary to Cirrhosis

Question 22

What drugs are used to treat spontaneous bacterial peritonitis?

Answer 22

Cefotaxime IV

Question 23

What is the most common causative organism of SBP?

Answer 23

E. coli

Question 24

Name a marker of poor prognosis in SBP

Answer 24

Alcoholic liver disease

Question 25

Which patients with ascites should be given antibiotic prophylaxis?

Answer 25

If have had an episode of SBP
If fluid protein <15g/l + either Child-Pugh score >9 OR hepatorenal syndrome

Question 26

What antibiotics are used for prophylaxis of SBP?

Answer 26

Ciprofloxacin PO
Norfloxacin PO