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Peritonitis

  • Inflammation of the peritoneum and peritoneal cavity to bacteria, endotoxin, bile or gastric juice
    • Transudation of fluid occurs in response to inflammation
  • Normal volume of the peritoneum is 100ml
    • This increases rapidly with passage of transudate which is rich in polymorphonuclear leukocyte

Primary peritonitis

  • Diffuse bacterial infection without apparent intra-abdominal source of infection
  • Most common in young girls between 3-9 years old
    • In children, most common pathogens are pneumococcus, streptococcus
    • Spread of infection
      • From genitals through to fallopian tubes
      • From upper respiratory tract
      • From middle ear (more common in males)
  • It can also occur in adults with cirrhosis, ascites or indwelling catheter for peritoneal dialysis
    • The most common pathogen is E.coli

Secondary peritonitis

  • From a known source – occurs secondary to bowel/visceral pathology
    • E.g. perforation, appendicitis, pancreatitis, cholangitis
  • Other causes
    • Chemical/iatrogenic – from barium contrast
    • Traumatic
    • Drug induced
    • Granulomatous

Teritiary peritonitis

  • Persistent or recurrent intra-abdominal infection after adequate treatment for primary or secondary peritonitis
    • Usually occurs after 48 hours
  • More common in immunosuppressed patients
  • Common pathogens – E. faecalis, S. epidermidis, P. aeruginosa, C. albicans
  • Treatment is by aggressive antibiotic therapy, maintenance of haemodynamic stability, exploration of abdomen, transfusions
    • ICU care is often needed
  • Mortality rate is >50%

Classification

Pathoanatomical classification

  • Fibrinous – clear fluid
  • Serofibrinous
  • Purulent – exudate is thin, greenish yellow or opaque white
  • Putrid – thin, green, gangrenous
  • Haemorrhage

Surgical classification

  • Local – inflammation localised in 1 anatomic region
  • Diffuse – inflammation spreads in over 2 area but only 2/3 abdominal floors (upper, middle, lower)
  • Total – inflammation spreads through all abdominal space including subdiaphragmatic space

Stages of peritonitis

  • Initial (reactive) stage – up to 24hrs
  • Toxic stage – 24-72hrs
  • Terminal stage – >72hrs

Clinical features

  • Abdominal pain – abrupt onset, initially local then more diffuse
  • Abdominal tenderness and distension
  • Nausea and vomiting – first gastric contents, then duodenal, then intestinal
  • Abdominal guarding (AKA ‘defence musculaire’) – tensing of anterior abdominal wall muscles to guard inflamed peritoneum
  • Fever and tachycardia
  • positive Blumberg sign – perform slow deep palpation and observe rebound tenderness

Investigations

  • Medical history – gall stones, peptic ulcer disease, previous operations
  • Physical exam – heart rate, blood pressure, respiration
    • Start abdominal exam from mid femur
    • Palpation – Blumberg
  • Bloods – ↑WCC and CRP
  • XR – shows gas under diaphragm
  • USS, CT
  • Laparoscopy, diagnostic laparotomy

Management

  • NG tube
  • Fluid resuscitation
  • Insert urine catheter to assess urine output
  • Antibiotics and analgesics
    • Only give when diagnosis has been confirmed as they can mask clinical picture of peritonitis
    • Patient can show false signs of improvement before suddenly deteriorating
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