Peritonitis Flashcards
what is peritonitis?
Inflammation of the serosal membrane that lines the abdominal cavity and the organs contained therein
what are the pathological effects of peritonitis?
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
what are the different types of peritonitis?
primary
secondary
tertiary
what are the causes of primary peritonitis?
hematogenous dissemination, immunocompromised patient e.g. SBP in liver disease
what are the causes of secondary peritonitis?
pathology in visceral organ, as perforation, trauma e.g. surgical peritonitis
what are the causes of tertiary peritonitis?
persistent or recurrent infection after adequate initial therapy
what are the causes of peritonitis?
• 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
what are the common gram negative organisms associated with peritonitis?
Escherichia coli, Enterobacter/klebsiella, proteus, pseudomonas
what are the common gram positive organisms associated with peritonitis?
streptococci, enterococci, staphylococci
what are the common anaerobic organisms associated with peritonitis?
Bacteroides, eubacteria, clostridia, pepitosteptococci, peptococci,
what are the common fungal organisms associated with peritonitis?
candida
what are the different sources of secondary peritionitis?
oesophagus stomach duodenum biliary tract pancreas small bowel large bowel and appendix uterus, salpinx and ovaries
through which processes can the oesophagus cause peritonitis?
Boerhaave syndrome, malignancy, trauma (penetrating), iatrogenic
through which processes can the stomach cause peritonitis?
peptic ulcer perforation, malignancy (e.g. adenocarcinoma, lymphoma, GI stromal tumour), trauma (penetrating), iatrogenic
through which processes can the duodenum cause peritonitis?
peptic ulcer perforation, trauma (blunt + penetrating), iatrogenic
through which processes can the biliary tract cause peritonitis?
cholecystitis, stone perforation from gallbladder (i.e. gallstone ileus) or common duct, malignancy, choledochal cyst (rare), trauma (mostly penetrating), iatrogenic
through which processes can the pancreas cause peritonitis?
pancreatitis (e.g. alcohol, drugs, gallstones), trauma (blunt + penetrating), iatrogenic
through which processes can the small bowel cause peritonitis?
ischemic bowel, incarcerated hernia (internal + external), closed loop obstruction, Crohn’s disease, malignancy (rare), Meckel diverticulum, trauma (mostly penetrating)
through which processes can the large bowel and appendix cause peritonitis?
ischaemic bowel, diverticulitis, malignancy, ulcerative colitis and Crohn’s disease, appendicitis, colonic volvulus, trauma (mostly penetrating), iatrogenic
through which processes can the cause Uterus, salpinx and ovaries peritonitis?
PID (e.g. salpingo-oophorititis, tubo-ovarian abscess, ovarian cyst), malignancy (rare), trauma (uncommon)
what are SOCRATEs features of pain in peritonitis?
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
what are the examination features of peritonitis?
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?
what are the clinical features of advanced peritonitis?
Distension of abdomen, tympanic abdo, rapid feeble pulse, faecal vomiting, eyes sunken, skin moist, cold and cyanosed
what bloods are useful in peritonitis?
FBC, LFTS, Amylase, U&Es
what will an ABG in peritonitis show?
acidosis and high lactate
what bedside tests are useful in peritonitis?
Bladder scan, Urine dip, pregnancy test
what imaging methods are useful in peritonitis diagnosis?
CXR AXR CT Scan US MRI
what features may be present in in an CXR in peritonitis?
air under diaphragm, lower lobe pneumonia, rib fractures
what features may be present in in an AXR in peritonitis?
closed loop obstruction, SBO and LBO, air between bowel
what is thh first choice imaging method in peritonitis?
CT
when is US used in peritonitis?
in pregnant and young females
what is the management of peritonitis?
ABCDE
Sepsis 6
Non-operative
Operative
What are the non-operative management options for peritonitis?
o Percutaneous abscess drainage (intervention radiology)
o Endoscopic stent placement (e.g. ERCP)
o Gastric Aspiration
What are the operative management options for peritonitis?
o Control the infection source (remove the inflamed appendix, repair perforated gastric ulcer)
o Clean the bacteria and toxins (washout)
