Peritonitis and abdominal abscess

Question 1

Causes of acute primary peritonitis (3)

Answer 1

1. Immunosuppression (e.g. post-splenectomy)
2. Ascites (nephrotic syndrome, cirrhosis)
3. Pelvic inflammatory disease

Question 2

Common organisms in acute primary peritonitis (3)

Answer 2

1. Haemolytic streptococci
2. E. coli
3. Klebsiella

Question 3

Causes of secondary peritonitis (3 categories)

Answer 3

1. Suppurative (perforated viscus, infection, ischaemia)
2. Chemical (bile leak, bleeding, urine leak)
3. Chronic sclerosing

Question 4

Common organisms in intra-abdominal abscess (7)

Answer 4

1. Bacteroides spp.
2. Streptococci spp.
3. Clostridia
4. Candida (prolonged antibiotics)
5. Skin flora (penetrating injury)
6. Neisseria gonorrhoeae (pelvic)
7. Chlamydia trachomatis (pelvic)

Question 5

Common sites of intra-abdominal abscess (3)

Answer 5

1. Pelvis
2. Right and left paracolic gutters
3. Subdiaphragmatic spaces

Question 6

Two stages of peritonitis

Answer 6

1. Localised - peritonitis contained by wrapping of greater omentum, adjacent bowel and fibrinous adhesions
2. Generalised - massive exudation of fluid, hypovolaemia, toxaemia and septicaemia, paralytic ileus

Question 7

Signs of peritonitis (9)

Answer 7

1. Tenderness
2. Rebound tenderness
3. Cross-tenderness
4. Guarding
5. Rigidity
6. Fever
7. Tachycardia
8. Hypotension
9. Paralytic ileus

Question 8

Investigations in peritonitis/intra-abdominal abscess (7)

Answer 8

1. FBE
2. UEC
3. LFTs
4. Blood cultures
5. Erect CXR (free gas)
6. Contrast CT
7. Aspiration for stain and culture

Question 9

Management of intra-abdominal abscess

Answer 9

1. Antibiotics (cef + met or imipenem alone)
2. Drainage (CT-guided percutaneous or surgical if failed or multi-abscess)
3. Definitive surgery (last resort)