Peritonitis

Notes

## Basic introduction

  • Peritoneum is serous membrane lining the cavity of the abdomen and covering the abdominal organs.
  • Peritonitis is the inflammation of the peritoneum.
  • It can be localized or generalized.

## Causes of peritonitis

  • Aseptic causes such as chemical irritants and leakage of sterile body fluids (such as blood, gastric juice, bile, urine, menstruum and pancreatic juice) into the peritoneum
  • Infections arising from perforations of appendix and intestines
  • Spontaneous bacterial peritonitis (SBP)
  • Systemic infections such as TB
  • Intra-peritoneal dialysis
  • PID

## Statistics

  • Untreated peritonitis is fatal.
  • Globally, the prevalence of spontaneous bacterial peritonitis (SBP) is about 10% in a hospital setting.
  • Globally, the mortality of peritonitis is < 10% if properly treated
  • The mortality is higher in elderly, patients who present late with the disease or with other co-morbidities.
Symptoms
  • Abdominal pain (acute abdomen)
  • Blumberg's sign (rebound tenderness or pain upon removal of pressure) in the right lower quadrant of the abdomen
  • Abdominal distension
  • Altered bowel sounds
  • Guarding
  • Rigidity
  • Fever
  • Sinus tachycardia
  • Ileus paralyticus (manifested as nausea, vomiting and bloating).

## Complications of peritonitis

  • Adhesions (which may end up causing bowel obstruction in future)
  • Site infections (especially after surgery)
  • Formation of abscess
  • Wound dehiscence (rupture of wound along a surgical incision)
  • Enterocutaneous fistulae
  • Multiple organ failures such as acute renal failure.
  • Sequestration of fluid and electrolytes may cause electrolyte disturbances, hypovolemia, shock, and acute renal failure
Diagnosis
  • Clinical review
  • Abdominal radiograph
  • Full blood count (FBC)
  • Urea & Electrolyte
  • Pus for culture & sensitivity
Differential
  • Acute cholecystitis
  • Acute intestinal obstruction
  • Acute pancreatitis
  • Acute diverticulitis
  • Adrenal crisis
  • Abdominal aortic aneurysm
  • Appendicitis
  • Bowel volvulus
  • Drugs such as NSAIDs
  • Ectopic pregnancy
  • Gastroenteritis
  • Mittelschmerz disease
  • Acute pyelonephritis
  • Ovarian torsion
  • Pelvic inflammatory disease (PID)
  • Peptic ulcer disease (PUD)
  • Renal colic
  • Renal stone
  • Ruptured or twisted ovarian cyst
  • Ruptured spleen
  • Urinary tract infections (UTIs)
Prevention
  • Not applicable
Reference

1. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf

2. Ljubin-Sternak, Suncanica; Mestrovic, Tomislav (2014). "Review: Chlamydia trachomatis and Genital Mycoplasmas: Pathogens with an Impact on Human Reproductive Health". Journal of Pathogens. 2014 (183167): 1.

3. Ministry of Health, Kenya. Kenya Essential Medicine List (2016). http://publications.universalhealth2030.org/uploads/KEML-2016Final-1.pdf

Management
  • IV fluids
  • A broad-spectrum antibiotic combination such as IV Cefuroxime 750mg TID x 1/52 AND IV Metronidazole 500mg TID x 1/52.
  • After the diagnosis has been made, administer an analgesic such as IM Diclofenac 75mg BD PRN
  • Treatment of underlying cause(s)
  • Nasogastric suction may be required
  • When a secondary peritonitis occurs, laparotomy is carried out to remove necrotic debris and pus (peritoneal lavage) as well as offering an opportunity to repair or remove any necrotic organ that may be there.
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