Peritonitis

Question 1

True or false: the peritoneal cavity is the largest cavity in the human body

Answer 1

True

Question 2

The peritoneum is the serous membrane lining the abdominal cavity, composed of m____ cells that are supported by a thin layer of _____ tissue

Answer 2

mesothelial
fibrous

Question 3

What is the peritoneum derived from embryologically?

Answer 3

Mesoderm

Question 4

The peritoneal cavity is made of the v___ peritoneum, the p____ peritoneum and the peritoneal fluid

Answer 4

visceral, parietal

Question 5

In health, the peritoneum is involved with visceral l_____ and fluid and particle absorption

Answer 5

lubrication

Question 6

In disease, the peritoneum is involved with pain perception, inflammatory and immune response and f_____ activity

Answer 6

fibrinolytic (peritoneal fluid contains plasminogen)

Question 7

Is pain in the visceral peritoneum well or poorly localised?

Answer 7

Poorly localised.
Same as organ it lines, represented in dermatomes.

Sensitive to extension and chemical irritation

Question 8

Is the pain in the parietal peritoneum well or poorly localised?

Answer 8

Well localised
Same innervation as abdominal wall
Sensitive to pressure, temperature and laceration

Question 9

What innervates T5-T9 (epigastric region)?

Answer 9

Greater splanchnic nerve (foregut up to 2nd part of duodenum)

Question 10

What innervates the umbilical region, T10-T11?

Answer 10

Lesser splanchnic nerve (midgut up to 2/3 transverse colon)

Question 11

What innervates the hypogastric region, T12?

Answer 11

Least splanchnic nerve (hindgut, up to rectum)

Question 12

What are 5 causes of peritonitis?

Answer 12

Bacterial

Chemical

Traumatic eg. operative handling

Ischaemia eg. strangulated bowel, vascular occlusion

Miscellaneous eg familial Mediterranean fever

Question 13

What are chemical causes of peritonitis?

Answer 13

Intestinal perforation
Bile
Old clotted blood
Ruptured ectopic pregnancy

All of these ultimately get infected

Question 14

Name some gram negative bacterial causes of peritonitis

Answer 14

E Coli
Klebsiella

(coliform bacilli)

Question 15

Name a gram positive bacterial cause of peritonitis

Answer 15

Staph aureus (cocci)

Question 16

What are common signs and symptoms of localised peritonitis?

Answer 16

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

Question 17

What are the key symptoms of severe peritonitis?

Answer 17

Sudden onset severe abdominal pain
Collapse
Septic shock
Fever
Ascites (usually)

Question 18

What are early signs of generalised peritonitis?

Answer 18

Abdominal pain worse when moving or breathing
Tenderness
Generalised guarding
Infrequent bowel sounds
Fever
Tachycardia

Question 19

What are later signs of generalised peritonitis?

Answer 19

Generalised rigidity
Distension
Absent bowel sounds
Circulatory failure
Thready irregular pulse
Loss of consciousness

Question 20

True or false: rigidity helps the pain in peritonitis

Answer 20

True
How to differentiate from renal colic where patient can’t lie still

Question 21

What investigations should be carried out for peritonitis?

Answer 21

Ascitic tap:
Neutrophilia
Cultures (MC&S) show causative organism

Increased ESR and CRP

Exclude pregnancy as cause with B-hCG test

Abdominal XR to check for bowel obstruction

Erect CXR:
air under diaphragm indicates perforated colon

[Urine dipstick for UTI
ECG and cardiac history
Bloods, U&E
Serum amylase (to see whether pancreas damaged)]

Question 22

How do you treat peritonitis?

Answer 22

ABCDE
Treat underlying cause
IV antibiotics (eg cefotaxime)
IV fluid
Surgery - peritoneal lavage

Question 23

If peritonitis is not treated promptly, what can happen?

Answer 23

Risk of septicaemia

Question 24

What are complications of peritonitis?

Answer 24

Sepsis
Subphrenic/pelvic abscesses
Paralytic ileus (temporary cessation of normal bowel movement)

Question 25

What causes portal hypertension

Answer 25

Cirrhosis (including ALD, NAFLD, hepatitis)

Portal Vein Thrombosis

Primary biliary cholangitis

Budd-Chiari syndrome
:

Question 26

How does cirrhosis lead to portal hypertension?

Answer 26

Extensive scarring disrupts normal architecture of liver, leading to increased resistance to blood flow through liver

Question 27

How does portal vein thrombosis lead to portal hypertension?

Answer 27

Clot restricts blood flow causing increased pressure

Question 28

How does PBC lead to portal hypertension?

Answer 28

Inflammation and damage to intralobular bile ducts causes cholestasis and liver fibrosis disrupting normal architecture. Increased resistance impairs hepatic blood flow and portal hypertension.

Question 29

How does Budd Chiari syndrome lead to portal hypertension?

Answer 29

Rare condition of obstructed blood flow out of liver eg blood clots. Means increased pressure in liver and portal hypertension.

Question 30

What is Hepatic encephalopathy?

Answer 30

Impaired neuropsychiatric function
Usually mild symptoms:
slurred speech
changes in behaviour
changes in sleep pattern
mild confusion

Can be more severe:
lethargy
coma

Associated with ammonia (not seen from blood test levels)

Treated with lactulose (decreases ammonia absorption in GI tract)