Related Subjects:Acute Cholecystitis
|Acute Appendicitis
|Chronic Peritonitis
|Abdominal Aortic Aneurysm
|Ectopic Pregnancy
|Acute Cholangitis
|Acute Abdominal Pain/Peritonitis
|Assessing Abdominal Pain
|Penetrating Abdominal Trauma
Peritonitis is a surgical emergency. It can be anything from acute appendicitis to a ruptured AAA. The first steps are always ABC. Signs may be masked in those on steroids or the elderly
About
- Usually generalised in response to perforation of an abdominal viscus
- In most cases the ones we will see with acute abdomen are acute suppurative peritonitis
Aetiology
- Inflammation of the peritoneum causes a localised pain
- Peritoneum lines the abdominal cavity and organs
- Inflammation caused by Infection, Chemical causes or mechanical
Classifications
- Acute or Chronic Peritonitis (See topic)
- Septic and Aseptic, Primary and secondary
Causes of acute peritonitis
- Perforated Duodenal ulcer and gastric acid leak
- Appendix abscess and rupture of pus into the abdomen
- Diverticular abscess and rupture with faeces and pus leak
- Perforated gall bladder and bile leak
- Perforation of the ischaemic gut with faeces leak
- Trauma - stabbing with bowel or other organ perforation
- Operative - colonic polypectomy with faeces leak
- Uterine perforation with instrumentation and spread of infection
- Infected peritoneal dialysis catheters cause Chronic Peritonitis (See topic)
- Spontaneous bacterial peritonitis in those with cirrhosis
- Typhoid perforations, Chronic Peritonitis usually TB (See topic)
Microbiology
- Gram-negative: Escherichia coli, Klebsiella pneumoniae, Bacteroides
- Gram-positive: Streptococcus pneumoniae
- Tuberculous: See chronic peritonitis
Clinical
- Acute onset of abdominal pain or referred pain to shoulder from the diaphragm
- Abdomen is tender and rigid and hard as a board. There is guarding
- Bowel sounds reduced or absent and the patient looks awful
- May be Tachycardia, fever and hypotension and signs of complications
Investigations
- FBC, WCC, U&E, Amylase, CRP, lactate
- ECG: AF may suggest mesenteric embolism
- Pregnancy test where appropriate beta HCG
- Erect CXR, Supine AXR
- CT abdomen may be needed
- USS abdomen may be needed
Complications
- Sepsis, SIRS, Septic shock, AKI, ARDS, Ileus, Death
Management
- ABC as needed. O₂ if low sats. Stabilise.
- IV fluids resuscitation nay be needed
- Nil by mouth, IV Broad spectrum antibiotics
- IV analgesia as needed e.g. Morphine 2.5-5 mg IV + Cyclizine 50 mg TDS or Ondansetron 4-8 mg TDS
- Urinary catheterisation may be needed
- Urgent Surgical referral for assessment for laparotomy
Surgical management of Acute Peritonitis is key
- Delays only to allow resuscitation and achieving volume status
- Antibiotic cover e.g. Tazocin or Gentamicin or Amoxycillin/Metronidazole
- Removal of infarcted tissue or perforated bowel
- Repair of any viscus perforation
- Removal of infective foci or drainage
- Peritoneal lavage is performed.
Images online
References