Peritonitis

Question 1

What are causes of septic peritonitis? What clinical signs and history are associated?

Answer 1

• intestinal perforation
  
  • FB ingestion
  • scavenger
  • vomiting
  • pain
• haematogenous
  
  • distributive shock
• external - penetrating
  
  • usually obvious
• iatrogenic
  
  • eg. recent surgery
  • pain
  • distributive shock
  • vomiting
• urinary ascension
  
  • reduced volume/increased frequency
  • stranguria/dysuria
  • pain
  • haematuria

Question 2

What are causes of aseptic peritonitis? What clinical signs and history are associated?

Answer 2

• pancreatitis - enzyme leakage
• hepatitis
• cholangitis
• splenitis
• nephritis

Same history and clinical signs
- acute abdomen - pain
- vomiting
- PUPD
- organ specific signs

• neoplasia
  
  • pain
  • weight loss
  • age - usually older
  • specific signs depending on location
• bile
  
  • acute abdomen - pain
  • jaundice
  • vomiting
• urine
• blood
• gastric perforation
  
  • abdo pain - rupture -> reduced pain
  • vomiting
  • anorexia
  • history of scavenging/chronic vomiting

Question 3

How can you diagnose peritonitis?

Answer 3

• POCUS - any patient with abdominal discomfort should have POCUS performed.
• Free Fluid? - > Tap it!
• Diagnostic Peritoneal Lavage - Instill 22ml/kg warmed saline into the abdomen via a large bore catheter, then retrieve a sample (Lactate and Glucose less useful with this). Do cytology on this. - ALWAYS do a Culture and Sensitivity - it won’t help now, but will in the future!
• Xray - can be useful, can tell you where the problem is
  
  • GIT perforation - free gas in the abdomen

Question 4

How can you differentiate a septic penitonitis from an aseptic peritonitis?

Answer 4

Physical appearance of the fluid - Septic or not septic?
Bacteria use glucose for energy:
* Glucose measurement on the fluid - 1 mmol/l less than blood supportive of septic fluid ]
◦ glucose can move freely so glucose in fluid is the same as in blood, if is being used by bacteria then will be lower than blood
◦ if blood and fluid glucose are both low then is likely to be septicaemia
* Lactate measurement on the fluid - 2mmol/l more than blood supportive of septic fluid
◦ anaerobic resp
* Cytology - Intracellular Bacteria, but remember this takes some time and takes you away from the patient