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Rare types of peritonitis

Spontaneous bacterial peritonitis

  • Bacterial infection of ascitic fluid in the absence of an intra-abdominal source of infection
  • Most common in
    • Infants and children
    • Nephritic syndrome
    • Adults with cirrhosis – poor phagocytosis causes poor control of bacterial load
    • Patientss who undergo splenectomy
    • Malnutrition and malignancy
    • Patients with ascites due to any cause

Causative organisms

  • G negative bacilli – E.coli, Klebsiella
  • G postiive cocci – pneumococci, streptococci, enterococci
  • Anaerobes

Clinical features

  • Features of peritonitis but initially with dull aching pain
  • Features of shock
  • High fever with neutrophilia
  • Diarrhoea

Management

  • Antibiotics
  • Drainage purulent fluid from peritoneal cavity
  • Laparoscopy or laparotomy

Tuberculous peritonits

  • Infection originates from TB in mesenteric lymph nodes or disseminates from pulmonary TB

Acute TB peritonitis

  • Similar to acute peritonitis
  • On laparotomy – straw coloured fluid and tubercles are seen on the peritoneum

Chronic TB peritonitis

  • Abdominal pain, fever, weight loss, ascites, night sweats, abdominal mass

Sclerosing peritonitis

  • Usually B-blocker induced peritonitis
  • It is fibrinous peritonitis causing thickening of the bowel and other contents of the abdomen
  • Leads to intestinal obstruction and malnutrition

Biliary peritonitis

Causes

  • Trauma
  • Post operative leak after surgery for gallbaldder, common bile duct, or leak from choledochojejunal anastomosis

Clinical features

  • Features of peritonitis – abdominal distention, guarding, rigidity
  • Jaundice
  • Toxicity
  • Features of shock

Investigations

  • Abdominal XR
  • Diagnostic peritoneal lavage

Treatment

  • Laparotomy, wash, drainage
  • US guided percutaneous drainage
  • High mortality

Postoperative peritonitis

  • Development of peritonitis in the post operative period due to anastomotic or biliary leak
    • Leads to collection of pus in the peritoneal cavity
  • Paralytic ileus is common in post operative patients for 3-5 days – however, if this persists for longer, post operative peritonitis should be suspected
  • Other features suggestive of peritonitis
    • Persisting toxaemia despite antibiotics
    • Oliguria
    • Fever
    • Very high or very low WBC count
    • Increasing leak from drain site
    • Increasing abdominal distension, pain and tenderness

Investigations

  • Immediate US/CT abdomen
  • Assessment of urinary output, LFTs, blood urea and creatinine

Treatment

  • Immediate exploration with wide exposure of the abdomen – to identify cause of infection
  • Irrigation and drainage
  • Antibiotics
  • Ventilator support

Other types of peritonitis

  • Meconium peritonitis
  • Gonococcal peritonitis with perihepatitis – Curtis-Fitz-Hugh syndrome
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