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

What are some of the causes of Localised Peritonitis?

Answer 2

Appendicitis
Cholecystitis
Diverticulitis
Salpingitis

Question 3

What is the aetiology of Primary Generalised Peritonitis?

Answer 3

Bacterial infection of the peritoneal cavity without an obvious source
Could be via haemotogenous or lymphatic spread or ascending infection from the female genital tract

Question 4

What are the risk factors for Primary Generalised Peritonitis?

Answer 4

Ascites

Nephrotic Syndrome

Question 5

What is the aetiology of Secondary Generalised Peritonitis?

Answer 5

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)

Question 6

What is the epidemiology of Peritonitis?

Answer 6

Primary Peritonitis is RARE
Primary Peritonitis is usually seen in adolescent females
Localised and secondary generalised Peritonitis is common in surgical patients

Question 7

What are the presenting symptoms of Peritonitis?

Answer 7

Do a full SOCRATES for Peritonitis
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)

Question 8

What are the general signs of Peritonitis on physical examination?

Answer 8

Check vital signs and look for signs of dehydration or compromised perfusion (e.g. due to sepsis or hypovolaemia)

Question 9

What are the signs of Localised Peritonitis?

Answer 9

Tenderness on examination
Guarding
Rebound tenderness

Question 10

What are the signs of Generalised Peritonitis?

Answer 10

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 (may be absent due to paralytic ileus)
DRE may show anterior tenderness (suggests pelvic Peritonitis)

Question 11

What bloods do you do for Peritonitis?

Answer 11

FBC
U&Es
LFTs
Amylase 
CRP
Clotting 
Group & Save or Cross-match
Blood cultures 
Pregnancy test 
ABG

Question 12

What imaging do you do for Peritonitis?

Answer 12

Erect CXR (check for air under the diaphragm)
AXR (check for bowel obstruction)
USS or CT abdomen
Laparoscopy

Question 13

What do you do if there is Ascites in Peritonitis?

Answer 13

Ascitic tap and cell count
SBP = > 250 neutrophils/mm^3
Gram stain and culture

Question 14

What is the management plan for Localised Peritonitis?

Answer 14

Depends on CAUSE
Some causes may require surgery (e.g. appendicitis)
Some causes can be treated with antibiotics (e.g. salpingitis)

Question 15

What is the management plan for Generalised Peritonitis?

Answer 15

Patient may be at risk of death from sepsis or shock
IV fluids
IV antibiotics
Urinary Catheter
NG tube
Central venous line (to monitor fluid balance)
Laparotomy

Question 16

How does Laparotomy work for Generalised Peritonitis?

Answer 16

Remove the infected or necrotic tissue
Treat Cause
Peritoneal lavage

Question 17

How should Primary Peritonitis be treated?

Answer 17

With Antibiotics

Question 18

What is the management plan for Spontaneous Bacterial Peritonitis (SBP)?

Answer 18

Quinolone antibiotics
OR
Cefuroxime + Metronidazole

Question 19

What are the early complications of Peritonitis?

Answer 19

Septic shock
Respiratory failure
Multiorgan failure 
Paralytic ileus 
Wound infection
Abscesses

Question 20

What are the Late Complications of Peritonitis?

Answer 20

Incisional Hernia

Adhesions

Question 21

What are the Late Complications of Peritonitis?

Answer 21

Incisional Hernia

Adhesions

Question 22

What is the prognosis for patients with Peritonitis?

Answer 22

Localised Peritonitis usually resolves with treatment of the underlying cause
Generalised Peritonitis has a much higher mortality (30-50%)
Primary Peritonitis has a good prognosis with antibiotic treatment
SBP has a mortality > 30% if diagnosis and treatment is delayed