Makindo Medical Notes.com

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 and check not a STEMI
• Pregnancy test where appropriate beta HCG
• Erect CXR, Supine AXR
• CT abdomen may be needed - is it a leaking AAA needing urgent surgery
• 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

• Images available online

References