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peritonitis

peritonitis

Introduction

  • peritonitis is a life threatening inflammation within the peritoneal fluid - usually due to bacterial sepsis
  • it may be spontaneous as in spontaneous bacterial peritonitis (SBP), or secondary to either inflammation of an intra-abdominal organ or following a penetrating wound
  • it may initially be localised and then spread to become generalised peritonitis
  • if associated with perforation of a hollow viscus, there may be free gas under the diaphragm on an erect CXR

Aetiology

DDx

Clinical features

  • symptoms can be subtle in the very young, the elderly, and those who are immunocompromised or who have neuropathy
  • unlike colic pain, peritonitis pain is generally worse on movement, on walking, and on coughing
  • it is usually associated with anorexia, nausea and often vomiting
  • clinical examination generally reveals:
    • early signs may be minimal when only the visceral peritoneum is inflamed as this generally causes dull, poorly localized pain
    • when the parietal peritoneum becomes inflamed the pain becomes sharper, and more localized, initially with voluntary guarding and then involuntary guarding
    • when the peronitis becomes generalized, the involuntary guarding becomes generalized and then develops into * abdominal wall rigidity - this is usually a late feature (but may occur early such as in pancreatitis and perforated viscus) and generally indicates need for urgent surgery
    • patients often prefer to keep hips flexed to reduce abdominal wall tension
    • reduced or absent bowel sounds
    • may have abdominal distension
    • there is often a fever with tachycardia and dehydration (due to third space losses), and will usually eventually develop septic shock

ED Mx of suspected peritonitis

  • IV access
  • FBE, U&E, LFTs, lipase, CRP, glucose, consider blood cultures, lactate and if female, HCG
  • IV fluid therapy
  • if known ascites or risk, consider Mx as per spontaneous bacterial peritonitis (SBP)
  • erect CXR if suspect perforated viscus - eg. sudden onset rigidity
  • erect/supine AXR if suspect small bowel obstruction
  • contact surgery team ASAP
  • consider empirical broad cover IV antibiotics according to likely cause
  • consider CT abdomen (with contrast if time allows and adequate eGFR) or direct to theatre for exploratory laparatomy depending upon suspected cause and severity/urgency of theatre
peritonitis.txt · Last modified: 2018/04/03 18:53 (external edit)