Peritonitis

Question 1

What is peritonitis?

Answer 1

Inflammation of the peritoneum

Question 2

What are some causes of peritonitis?

Answer 2

• Gastrointestinal perforation (perforated ulcer, appendix or diverticulum)
• Transmural translocation (no perforation) (pancreatitis, ischaemic bowel, primary bacterial peritonitis)
• Exogenous contamination (drains, open surgery, trauma, peritoneal dialysis)
• Female genital tract infection (PID)
• Haematogenous spread - rare (septicaemia)

Question 3

What are the most common organisms causing peritonitis in developed and developing countries?

Answer 3

Developed: E coli, streptococci, enterococci
Developing: Chlamydia

Question 4

Clinical features of localised peritonitis?

Answer 4

• Signs and symptoms of underlying condition
• Pain
• Nausea and vomiting
• Fever
• Tachycardia
• Localised guarding
• Rebound tenderness
• Shoulder tip pain (subphrenic)
• Tender rectal and or vaginal examination (pelvic peritonitis)

Question 5

Clinical features of diffuse or generalised peritonitis? Early and late presentation

Answer 5

• *EARLY**
• Abdo pain (worse by moving or breathing)
• Tenderness
• Generalised guarding
• Infrequent bowel sounds → cease (paralytic ileus)
• Fever
• Tachycardia
• *LATE**
• Generalised rigidity
• Distension
• Absent bowel sounds
• Circulatory failure
• Thready irregular pulse
• Hippocratic face - thready pulse, sunken eyes, loss of consciousness - rarely seen now
• Loss of consciousness

Question 6

Investigations for peritonitis?

Answer 6

• Urine dipstick for UTI
• ECG if diagnostic doubt (as cause of abdo pain) or cardiac history
• Bloods
  → U&E
  → FBC (WCC mainly)
  → Serum amylase (acute pancreatitis or upper GI perforation)
  → Group and save

Imaging X ray showing sub-diaphragmatic free gas with patient in erect position.

Question 7

Management of peritonitis?

Answer 7

• ABC
• Correction of fluid loss and circulating volume as we expect them to be hypovolemic
• Urinary catheterisation with or without gastrointestinal decompression
  → minimum urine output 1mL per kg per hour
• Antibiotic therapy
  → IV and broad spectrum until we have results from lab and then we can change to more specific Abx.
• Analgesia

- Treat specific cause 
→ repair perforated viscus in peptic ulcer
→ excision of perforated organ
→ without or without drainage
→ with or without restoring continuity

Question 8

What is SBP?

Answer 8

Spontaneous bacterial peritonitis

• rare but acute bacterial infection - diagnosis made by parencetesis and sample should be sent for those with cirrhosis and ascites.
• > 250 neutrophils is diagnostic of SBP
• Usually gram negative bacteria (E coli and Klebsiella pneumoniae).