Peritonitis Flashcards
How can you differentiate between peritonitis and renal colic?
Peritonitis features pain when coughing and moving.
Renal colic features pain when staying still, relieved by moving. “Cannot sit still”
Name 3 clinic symptoms of peritonitis?
Anorexia
Pyrexia
Several generalised abdominal pain, radiating to shoulders and back
Pain worse with movement, coughing, sneezing
What scenario may feature peritonitis with apyrexia?
Patients taking corticosteroids
How can the causes of peritonitis be grouped?
Primary (rare)
Secondary (common)
Name 3 clinical signs of peritonitis
Pyrexia
Tachycardia
Peritonism: Tenderness and guarding, Rebound tenderness
Localised pain during distant palpation (Rovsing’s sign)
What is the most likely cause of primary peritonitis?
Streptococcal infection via blood stream.
Rare, usually occurs in immunocompromised patients.
List 4 common causes of secondary peritonitis
Acute perforated appendicitis Acute perforated diverticular disease Upper GI perforation Perforated tumour (colonic or gastric) Perforated ischaemic bowel Acute pancreatitis Peritoneal dialysis Post-surgical intervention
What is the commonest cause of secondary peritonitis in under 45s?
Acute perforated appendicitis
What is the commonest cause of secondary peritonitis in elderly?
Acute perforated diverticular disease
How is a perforation diagnosis confirmed?
Laparotomy - surgical incision to examine abdominal organs
What is acute peritonitis?
Acute inflammation of the peritoneal cavity
Name 3 features that suggest a perforated viscus
Sudden onset of pain Constant severe pain Pain aggravated by movement, coughing, sneezing Diffuse tenderness Silent rigid abdomen
What investigation may be raised in perforated bowel?
Serum amylase - suggestive of pancreatitis
What laboratory investigations may be done in acute peritonitis?
FBC U&E CRP Amylase - pancreatitis ABG - if shocked or pancreatitis suspected
What is the investigation of choice for diagnosing acute peritonitis?
Abdominal CT
Excludes acute pancreatitis, and often locates the probable source of pathology.
Outline the early treatment of acute peritonitis
IV antibiotics when diagnosis is unclear. Especially useful if surgery is likely.
Analgesia
Correct fluid balance
Monitor
Outline the definitive management of acute peritonitis
Management depends on the cause of peritonitis.
Differentiate between local and generalised peritonitis
Local: peritonism over a single area
General: peritonism over entire abdomen with board-like rigidity
Generalised peritonitis is also more likely to have signs of:
- Ileus (distension, vomiting, tympanic abdomen with reduced/absent bowel sounds)
- Systemic shock (tachycardia, tachypnoea, hypotension, low urine output).
What is the management of generalised peritonitis?
*Surgical emergency* IV fluid resuscitation IV ABX Laparotomy/Laparoscopy - peritoneal wash-out and treatment of underlying condition Monitor for post-op complications
What are the causes of generalised peritonitis?
Bacterial infection - faecal matter from diverticulitis Progression from localised inflammatory peritonitis Leakage of body fluids -Gastric juice -Bile -Urine -Pancreatic juice -Blood
*Body fluids are initially sterile but become infected with 24-48hr of leaking.
In what scenario can a CT abdomen be considered in generalised peritonitis?
If it can be performed urgently and the patient is stable.
*Does not change management
Name 3 bedside tests useful for diagnosing local peritonitis
Rebound tenderness
Cough test
Hip flexion test
What would indicate the development of a peritoneal abscess?
Swinging fever
Swelling
Raised WCC
Increasing or sustained pain
How is a peritoneal abscess managed?
Percutaneous drainage or laparotomy
What investigations should be done in generalised peritonitis?
CT abdomen - if quick and patient is stable
Serum amylase - to exclude pancreatitis
What is the complication of delaying treatment of generalised peritonitis?
Further toxaemia, septicaemia, and multi organ-failure
What initial radiological test should be performed for suspected perforation? What sign is evident?
Erect CXR to look for pneumoperitoneum
AXR would show Rigler sign (double wall)
