Peritonitis (GI)

Question 1

What is peritonitis?

Answer 1

Inflammation of the peritoneal lining of the abdominal cavity - can be localised or generalised

Question 2

What are some examples of localised peritonitis? (3)

Answer 2

• appendicitis
• cholecystitis
• diverticulitis

Question 3

What is spontaneous bacterial peritonitis (SBP)?

Answer 3

A form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis - infection of ascitic fluid that cannot be attributed to any intra-abdominal, ongoing inflammatory or surgically correctable condition

Question 4

What is the most common pathogen causing peritonitis?

Answer 4

Escherichia coli

Question 5

What are the clinical features of peritonitis? (6)

Answer 5

• abdominal pain / tenderness
• ascites
• fever
• nausea and vomiting
• diarrhoea
• altered mental status

Question 6

What might you see on examination of a patient with peritonitis? (6)

Answer 6

• signs of ascites
• fever
• altered mental status
• hypothermia
• hypotension
• tachycardia

Question 7

What are the features of spontaneous bacterial peritonitis?

Answer 7

Abdominal pain and fever in a patient with ascites (secondary to cirrhosis)

Question 8

What are the risk factors for spontaneous bacterial peritonitis? (7)

Answer 8

• decompensated hepatic state (cirrhosis)
• low ascitic protein/complement
• GI bleeding
• endoscopy sclerotherapy for oesophageal varices
• ascites due to malignancy, renal insufficiency or congestive HF
• extra-intestinal infection
• invasive procedures

Question 9

What is the main investigation done for peritonitis, and what type of peritonitis is this diagnostic for?

Answer 9

Paracentesis (ascitic fluid absolute neutrophil count) –> >250cells/mm3

Diagnostic for spontaneous bacterial peritonitis

Question 10

How can we determine causative organism in peritonitis?

Answer 10

Ascitic fluid culture

Question 11

What might FBC show in peritonitis?

Answer 11

Leukocytosis and anaemia

Question 12

What is the 1st-line management for peritonitis? (3 + 1)

Answer 12

• empirical IV Abx - cefotaxime or ceftriaxone
• consider IV albumin
• consider large-volume paracentesis (LVP)
• (if nosocomial/septic shock/resistant species: empirical IV Abx: piperacillin/tazobactam + consider vancomycin or daptomycin)

Question 13

When should continuous Abx prophylaxis be given for peritonitis and what antibiotics should be given? (2 + 1)

Answer 13

• if ascitic fluid protein concentration <15g/L
• there has been a previous episode of spontaneous bacterial peritonitis and either Child-Pugh score >/=9 or hepatorenal syndrome
• Abx: oral ciprofloxacin or norfloxacin

Question 14

What are some complications of peritonitis? (4)

Answer 14

• sepsis
• renal failure
• tense ascites
• paracentesis - bleeding, bowel perforation, leakage from puncture site

Question 15

What is the prognosis of peritonitis? (3)

Answer 15

• 1 year spontaneous bacterial peritonitis recurrence rates are as high as 69%
• renal dysfunction is the best predictor of mortality
• alcoholic liver disease is a marker of poor prognosis for SBP