Peritonitis

Question 1

what is peritonitis?

Answer 1

Inflammation of the serosal membrane that lines the abdominal cavity and the organs contained therein

Question 2

what are the pathological effects of peritonitis?

Answer 2

o Widespread absorption of toxins from the large, inflamed surface
o The associated paralytic ileus with the following:
o Gross abdominal distension with the elevation of the diaphragm = lung collapse and pneumonia

Question 3

what are the different types of peritonitis?

Answer 3

primary
secondary
tertiary

Question 4

what are the causes of primary peritonitis?

Answer 4

hematogenous dissemination, immunocompromised patient e.g. SBP in liver disease

Question 5

what are the causes of secondary peritonitis?

Answer 5

pathology in visceral organ, as perforation, trauma e.g. surgical peritonitis

Question 6

what are the causes of tertiary peritonitis?

Answer 6

persistent or recurrent infection after adequate initial therapy

Question 7

what are the causes of peritonitis?

Answer 7

• Introduction of infection through organ perforation
• Other irritants
o Foreign bodies
o Bile (perforated gall bladder/lacerated liver)
o Gastric acid (perforated ulcer)
o Blood

Question 8

what are the common gram negative organisms associated with peritonitis?

Answer 8

Escherichia coli, Enterobacter/klebsiella, proteus, pseudomonas

Question 9

what are the common gram positive organisms associated with peritonitis?

Answer 9

streptococci, enterococci, staphylococci

Question 10

what are the common anaerobic organisms associated with peritonitis?

Answer 10

Bacteroides, eubacteria, clostridia, pepitosteptococci, peptococci,

Question 11

what are the common fungal organisms associated with peritonitis?

Answer 11

candida

Question 12

what are the different sources of secondary peritionitis?

Answer 12

oesophagus
stomach
duodenum
biliary tract
pancreas
small bowel
large bowel and appendix 
uterus, salpinx and ovaries

Question 13

through which processes can the oesophagus cause peritonitis?

Answer 13

Boerhaave syndrome, malignancy, trauma (penetrating), iatrogenic

Question 14

through which processes can the stomach cause peritonitis?

Answer 14

peptic ulcer perforation, malignancy (e.g. adenocarcinoma, lymphoma, GI stromal tumour), trauma (penetrating), iatrogenic

Question 15

through which processes can the duodenum cause peritonitis?

Answer 15

peptic ulcer perforation, trauma (blunt + penetrating), iatrogenic

Question 16

through which processes can the biliary tract cause peritonitis?

Answer 16

cholecystitis, stone perforation from gallbladder (i.e. gallstone ileus) or common duct, malignancy, choledochal cyst (rare), trauma (mostly penetrating), iatrogenic

Question 17

through which processes can the pancreas cause peritonitis?

Answer 17

pancreatitis (e.g. alcohol, drugs, gallstones), trauma (blunt + penetrating), iatrogenic

Question 18

through which processes can the small bowel cause peritonitis?

Answer 18

ischemic bowel, incarcerated hernia (internal + external), closed loop obstruction, Crohn’s disease, malignancy (rare), Meckel diverticulum, trauma (mostly penetrating)

Question 19

through which processes can the large bowel and appendix cause peritonitis?

Answer 19

ischaemic bowel, diverticulitis, malignancy, ulcerative colitis and Crohn’s disease, appendicitis, colonic volvulus, trauma (mostly penetrating), iatrogenic

Question 20

through which processes can the cause Uterus, salpinx and ovaries peritonitis?

Answer 20

PID (e.g. salpingo-oophorititis, tubo-ovarian abscess, ovarian cyst), malignancy (rare), trauma (uncommon)

Question 21

what are SOCRATEs features of pain in peritonitis?

Answer 21

o Site - Local (at site of organ source), or generalised
o Onset: acute
o Character: sharp
o Radiation
o Associated symptoms: all fever, vomiting, ileus, diarrhoea, jaundice, tachycardia
o Exacerbating by any movement: car/ambulance trip to the hospital (speedbumps)
o Severity: very severe

Question 22

what are the examination features of peritonitis?

Answer 22

o	Tender
o	Rebound tenderness
o	Guarding
o	Rigid
o	Distended 
o	Localized peritonitis (localized tenderness and rebound)
generalized peritonitis (generalized tenderness, guarding and rigidity= washboard) 
o	Abdomen silent?

Question 23

what are the clinical features of advanced peritonitis?

Answer 23

Distension of abdomen, tympanic abdo, rapid feeble pulse, faecal vomiting, eyes sunken, skin moist, cold and cyanosed

Question 24

what bloods are useful in peritonitis?

Answer 24

FBC, LFTS, Amylase, U&Es

Question 25

what will an ABG in peritonitis show?

Answer 25

acidosis and high lactate

Question 26

what bedside tests are useful in peritonitis?

Answer 26

Bladder scan, Urine dip, pregnancy test

Question 27

what imaging methods are useful in peritonitis diagnosis?

Answer 27

CXR
AXR
CT Scan
US
MRI

Question 28

what features may be present in in an CXR in peritonitis?

Answer 28

air under diaphragm, lower lobe pneumonia, rib fractures

Question 29

what features may be present in in an AXR in peritonitis?

Answer 29

closed loop obstruction, SBO and LBO, air between bowel

Question 30

what is thh first choice imaging method in peritonitis?

Answer 30

CT

Question 31

when is US used in peritonitis?

Answer 31

in pregnant and young females

Question 32

what is the management of peritonitis?

Answer 32

ABCDE
Sepsis 6
Non-operative
Operative

Question 33

What are the non-operative management options for peritonitis?

Answer 33

o Percutaneous abscess drainage (intervention radiology)
o Endoscopic stent placement (e.g. ERCP)
o Gastric Aspiration

Question 34

What are the operative management options for peritonitis?

Answer 34

o Control the infection source (remove the inflamed appendix, repair perforated gastric ulcer)
o Clean the bacteria and toxins (washout)