Peritonitis

Question 1

What is peritonitis?

Answer 1

inflammation of peritoneum

Localised (prior to rupture) or generalised (after rupture)

Question 2

List 4 localised forms of peritonitis

Answer 2

Appendicitis
Cholecystitis
Diverticulitis
Salpingitis

Question 3

What is Primary Generalised Peritonitis? What is this AKA?

Answer 3

Spontaneous BP
Inflammation of peritoneum itself 
NO obvious source  
Via haematogenous/ lymphatic spread or ascending infection
RF:
Decompensated cirrhosis 
Nephrotic syndrome

Question 4

What is Secondary Generalised Peritonitis?

Answer 4

Bacterial translocation from adjacent organs or due to perforation

Question 5

Summarise the epidemiology of peritonitis

Answer 5

Primary = RARE: usually seen in adolescent females

Localised + secondary generalised = COMMON in surgical patients

Question 6

Describe the symptoms of peritonitis

Answer 6

Peritoneal pain: continuous, sharp, localised
Exacerbated by movement + coughing
Sx may be vague in those with liver disease + ascites (due to confusion caused by encephalopathy)

Question 7

List 2 signs of localised peritonitis on physical examination

Answer 7

Guarding

Rebound tenderness

Question 8

What are the appropriate blood investigations for peritonitis?

Answer 8

FBC: High WCC 
U+Es 
LFTs: Raised ALP + BR, Low albumin 
Amylase: exclude Pancreatitis
CRP: Inflammation  
Clotting  
X-match  
Blood cultures: Sepsis
Pregnancy test  
ABG

Question 9

What additional investigations may you perform in suspected peritonitis?

Answer 9

Erect CXR (air under diaphragm in perf) 
AXR (for bowel obstruction) 
USS (evidence of cirrhosis)

Question 10

What is the best diagnostic investigation to perform if there is ascites in peritonitis?

Answer 10

Paracentesis (Ascitic tap) + cell count
SBP = > 250 neutrophils/mm3
Gram stain + culture

Question 11

Describe the management of localised peritonitis

Answer 11

Depends on CAUSE
May require surgery (e.g. appendicitis)
May be treated with abx (e.g. salpingitis)

Question 12

Describe the management of generalised peritonitis

Answer 12

Risk of DEATH from sepsis or shock  
IV fluids  
IV abx 
Urinary catheter  
NG tube  
Central venous line (to monitor fluid balance)  
Laparotomy  
Remove infected or necrotic tissue  
Treat cause  
Peritoneal lavage

Question 13

List 6 early complications of peritonitis

Answer 13

Septic shock  
Respiratory failure  
Multiorgan failure  
Paralytic ileus  
Wound infection  
Abscesses

Question 14

List 2 late complications of peritonitis

Answer 14

Incisional trauma

Adhesions

Question 15

What is the prognosis in peritonitis?

Answer 15

Localised: usually resolves with tx of underlying cause
Generalised: much higher mortality (30-50%)
Primary peritonitis has a good prognosis with abx tx
SBP has a mortality > 30% if dx + tx is delayed

Question 16

List 6 signs of generalised peritonitis

Answer 16

Systemic signs of sepsis (e.g. fever, tachycardia)
Shallow breathing
Pt lies still with a rigid abdomen
Generalised abdo tenderness
Reduced bowel sounds (absent if paralytic ileus)
DRE may show anterior tenderness (suggests pelvic peritonitis)

Question 17

Give 2 risk factors for SBP

Answer 17

Cirrhosis

Ascites

Question 18

What drugs are used to treat spontaneous bacterial peritonitis?

Answer 18

Piperacillin with Tazobactam
OR
Cefotaxime 
OR 
Ciprofloxacin

Question 19

What is the most common causative organism of SBP?

Answer 19

E. coli