SECONDARY PERITONITIS

Question 1

Pertinent Anatomy of a patient with Secondary Peritonitis.

Answer 1

(1) Recall the peritoneum is a serous membrane.
(2) It has two components:
(a) a portion that covers the abdominal wall,
(b) a visceral portion that covers the abdominal organs.
(3) The surface area of the peritoneum is approximately 150% of the total skin surface area
hence the entire ABD anatomy is involved.

Question 2

a potentially catastrophic illness caused by infectious organisms attacking the peritoneum.

Answer 2

Acute Peritonitis

Question 3

The mechanisms of bacterial contamination of the peritoneal cavity are

Answer 3

(a) hematogenous spread of bacteria
(b) contiguous spread from extra- peritoneal infection,
(c) migration of intestinal bacteria
(d) an ascension via the female genitalia

Question 4

the five most common causes of acute peritonitis are

Answer 4

(a) appendicitis,
(b) cholecystitis,
(c) diverticulitis,
(d) pancreatitis,
(e) bowel perforation

Question 5

Symptoms
Vitals
Inspection
Auscultation
Percussion
Palpation

Answer 5

(1) Vitals: fever, tachycardia and possible hypotension
(2) Inspection: Patient often in fetal position, because any movement worsens pain. Visible
peristalsis suggests bowel obstruction.
(3) Auscultation: Absence of bowel sounds in all four quadrants suggests peritonitis. Always
auscultate before doing percussion or palpation.
(4) Percussion: Absence of dullness over the liver suggests free air and perforation.
(5) Palpation:
(a) Begin with very gentle palpation away from the area of maximal symptoms;
(b) board-like abdomen is unmistakable and indicates obvious peritonitis;
(c) shake the pelvis to assess rebound tenderness;
(d) iliopsoas and obturator signs are suggestive for retroperitoneal inflammation.

Question 6

Differential Diagnosis

Answer 6

(1) Appendicitis
(2) Cholecystitis
(3) Pancreatitis
(4) Diverticulitis
(5) Perforated ulcer

Question 7

Lab

Answer 7

(1) CBC/DIFF: Moderate leukocytosis (10-20K) and neutrophilia is common.
(2) Urinalysis
(3) Blood cultures for infection

Question 8

RAD

Answer 8

(1) Abdominal X-ray, especially upright may reveal
(2) Free air, dilated loops of bowel, air-fluid levels or
(3) Other findings suggestive of the etiology

Question 9

Treatment

Answer 9

(1) Broad spectrum IV antibiotics with Bacteroides, Enterococcus, Gram-negative and
Anaerobic coverage.
(a) Ertapenem 1g IV Q 24 hrs
(2) IV access- 2 large bore (18-16 gauge)
(3) Fluid replenishment- Require fluids to maintain adequate blood pressure and prevent cardiovascular collapse.
(4) NPO
(5) NG tube with intermittent suction
(6) Monitor I&O (foley), maintain urine output of 0.5-1.0 ml/kg/hr
(7) Pain meds- narcotic (morphine) likely required
(8) Anti-emetics
(a) Promethazine (Phenergan) - 1st generation antihistamine, anti-nausea and
vomiting medication
1) Dose: 12.5-25mg IV Q 6 hrs
2) MOA: non-selectively antagonizes central and peripheral histamine H1 receptors;
possesses anticholinergic properties, resulting in antiemetic and sedative effects
3) Adverse Reactions: respiratory depression, seizures, hallucinations, heat stroke,
drowsiness, sedation, photosensitivity
4) Contraindications: comatose patients, respiratory depression, elderly patients,
seizure disorder, asthma
(b) Ondansetron (Zofran) – antiemetic
1) Dose: 4mg PO/IV q8 hours as needed
2) MOA: selectively antagonizes serotonin 5-HT3 receptors
3) Adverse Reactions: QT prolongation, Stevens-Johnson Syndrome, serotonin
syndrome, HA, diarrhea, agitation, pruritus
4) Contraindications: ventricular arrhythmias, recent MI, CHF, hepatic impairment
(9) PROPAQ monitor
(10) MEDEVAC
(11) Consult General Surgery

Question 10

Initial Care

Answer 10

(1) When detected, IV access, prevent further infection, pain control, and prep for surgery.
(2) Surgery is needed to treat disease.