Peritonitis Flashcards
True or false: the peritoneal cavity is the largest cavity in the human body
True
The peritoneum is the serous membrane lining the abdominal cavity, composed of m____ cells that are supported by a thin layer of _____ tissue
mesothelial
fibrous
What is the peritoneum derived from embryologically?
Mesoderm
The peritoneal cavity is made of the v___ peritoneum, the p____ peritoneum and the peritoneal fluid
visceral, parietal
In health, the peritoneum is involved with visceral l_____ and fluid and particle absorption
lubrication
In disease, the peritoneum is involved with pain perception, inflammatory and immune response and f_____ activity
fibrinolytic (peritoneal fluid contains plasminogen)
Is pain in the visceral peritoneum well or poorly localised?
Poorly localised.
Same as organ it lines, represented in dermatomes.
Sensitive to extension and chemical irritation
Is the pain in the parietal peritoneum well or poorly localised?
Well localised
Same innervation as abdominal wall
Sensitive to pressure, temperature and laceration
What innervates T5-T9 (epigastric region)?
Greater splanchnic nerve (foregut up to 2nd part of duodenum)
What innervates the umbilical region, T10-T11?
Lesser splanchnic nerve (midgut up to 2/3 transverse colon)
What innervates the hypogastric region, T12?
Least splanchnic nerve (hindgut, up to rectum)
What are 5 causes of peritonitis?
Bacterial
Chemical
Traumatic eg. operative handling
Ischaemia eg. strangulated bowel, vascular occlusion
Miscellaneous eg familial Mediterranean fever
What are chemical causes of peritonitis?
Intestinal perforation
Bile
Old clotted blood
Ruptured ectopic pregnancy
All of these ultimately get infected
Name some gram negative bacterial causes of peritonitis
E Coli
Klebsiella
(coliform bacilli)
Name a gram positive bacterial cause of peritonitis
Staph aureus (cocci)
What are common signs and symptoms of localised peritonitis?
Pain
Nausea and vomiting
Fever
Tachycardia
Localised guarding
Rebound tenderness
Shoulder tip pain (subphrenic)
Tender rectal/vaginal examination (pelvic peritonitis)
What are the key symptoms of severe peritonitis?
Sudden onset severe abdominal pain
Collapse
Septic shock
Fever
Ascites (usually)
What are early signs of generalised peritonitis?
Abdominal pain worse when moving or breathing
Tenderness
Generalised guarding
Infrequent bowel sounds
Fever
Tachycardia
What are later signs of generalised peritonitis?
Generalised rigidity
Distension
Absent bowel sounds
Circulatory failure
Thready irregular pulse
Loss of consciousness
True or false: rigidity helps the pain in peritonitis
True
How to differentiate from renal colic where patient can’t lie still
What investigations should be carried out for peritonitis?
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)]
How do you treat peritonitis?
ABCDE
Treat underlying cause
IV antibiotics (eg cefotaxime)
IV fluid
Surgery - peritoneal lavage
If peritonitis is not treated promptly, what can happen?
Risk of septicaemia
What are complications of peritonitis?
Sepsis
Subphrenic/pelvic abscesses
Paralytic ileus (temporary cessation of normal bowel movement)
What causes portal hypertension
Cirrhosis (including ALD, NAFLD, hepatitis)
Portal Vein Thrombosis
Primary biliary cholangitis
Budd-Chiari syndrome
:
How does cirrhosis lead to portal hypertension?
Extensive scarring disrupts normal architecture of liver, leading to increased resistance to blood flow through liver
How does portal vein thrombosis lead to portal hypertension?
Clot restricts blood flow causing increased pressure
How does PBC lead to portal hypertension?
Inflammation and damage to intralobular bile ducts causes cholestasis and liver fibrosis disrupting normal architecture. Increased resistance impairs hepatic blood flow and portal hypertension.
How does Budd Chiari syndrome lead to portal hypertension?
Rare condition of obstructed blood flow out of liver eg blood clots. Means increased pressure in liver and portal hypertension.
What is Hepatic encephalopathy?
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)
