Peritonitis

Question 1

Define peritonitis

Answer 1

inflammation of the peritoneal lining of the abdominal cavity. It can be localised to one part of the peritoneum or generalised.

Question 2

Some causes of localised peritonitis?

Answer 2

Appendicitis

Cholecystitis

Diverticulitis

Salpingitis - inflammed fallopian tubes

Question 3

Some causes of primary generalised peritonitis

risk factors?

Answer 3

Bacterial infection of the peritoneal cavity without an obvious source

Could be via haematogenous or lymphatic spread or ascending infection from the female genital tract)

risk factors;
Ascites
Nephrotic syndrome

Primary peritonitis is RARE
Primary peritonitis is usually seen in adolescent females

Question 4

Some causes of secondary generalised peritonitis?

Answer 4

Caused by bacterial translocation from a localised focus

Could be non-bacterial due to spillage of bowel contents, bile and blood (e.g. perforated peptic ulcer)

Localised and secondary generalised peritonitis is COMMON in surgical patients

Question 5

Presenting symptoms?

Answer 5

Inflammation of the parietal peritoneum is usually continuous, sharp, localised, exacerbated by movement and coughing

Symptoms may be vague in those with liver disease and ascites (due to confusion caused by encephalopathy)

socrates!

Question 6

What are the signs of localised peritonitis on physical examination

Answer 6

Tenderness on examination

Guarding

Rebound tenderness

Question 7

signs of generalised peritonitis?

Answer 7

Very unwell

Systemic signs of toxaemia or sepsis (e.g. fever, tachycardia)

The patient will lie still

Shallow breathing

Rigid abdomen

Generalised abdominal tenderness

Reduced bowel sounds

DRE may show anterior tenderness (suggests pelvic peritonitis)

Question 8

investigations?

Answer 8

FBC; leukocytosis 
U&Es; creatinine high
LFTs ; low albumin. high biliru
ct abdomen; pneumoperitoneum in secondary peritonitis
blood cultures

If ascites;
ascites fluid neutrophil count > 250 neutrophils/mm3 points to spontaneous bacterial peritonitis.

ascitic fluid appearance; hazy cloudy
Gram stain and culture

Question 9

Management of localised peritonitis?

Answer 9

Depends on CAUSE

Some causes may require surgery (e.g. appendicitis)

Some causes can be treated with antibiotics (e.g. salpingitis)

Question 10

Management of generalised peritonitis?

Answer 10

Patient may be at risk of DEATH from sepsis or shock

IV fluids
IV antibiotics - ceftriaxone
Urinary catheter

NG tube
Central venous line (to monitor fluid balance)
Laparotomy

Remove the infected or necrotic tissue
Treat cause
Peritoneal lavage

Primary Peritonitis - should be treated with antibiotics

SBP - acute; ceftriaxone

Question 11

complications of peritonitis?

Answer 11

Septic shock

Respiratory failure

Multiorgan failure

Paralytic ileus - intestinal obstruction due to intestinal muscle paralysis

Wound infection

Abscesses