Peritonitis case based discussion PDF

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Pt w Peritonitis – CEX O/E  

board-like rigid abdo (guarding) – most specific for peritonitis Percussion pain

Signs of Peritonitis T R A P P E D

tender & tachy rigidity (reflex guarding) – localised before rupture, generalised after. absent BS pyrexia percussion pain (and on coughing) extremely unwell (grey, sweaty, panting & shallow resps to avoid moving diaphragm) distant palpation -> local tenderness (eg. appx Rovsing = LIF pain for RIF organ)

Also Reduced urine output Bloating, nausea, vomiting as intestinal paralysis occurs Causes 1

2

No rupture a. spontaneous bacterial peritonitis – often 2® cirrhosis -> ascitic fluid infected Tx = Cefotaxime b. pelvic inflammatory disease c. pancreatitis with rupture – see pneumoperitoneum on erect CXR as air under diaphragm a. ruptured appendix b. perforation of bowel – sudden onset pain if small bowel, more gradual if lg bowel. i. Most common cause of peritonitis ii. Produces constant type pain. iii. Can perforate from diverticulitis, duodenal ulcer, ascariasis, CRD, typhoid fever, NSAIDS, magnet ingestion, c. stomach ulcer -> chemical peritonitis fm gastric acid d. dermoid cyst contents, blood from endometriosis, bile fm liver biopsy or post lap chole e. trauma f. iatrogenic – drains, tubes, intraoperative perf w endoscope or catheter, anastomotic leak

RF Peritoneal dialysis Liver disease -> ascites Hinchey classification of diverticular perforation (based on CT findings)  

Hinchey I - localised abscess (para-colonic) Hinchey II - pelvic abscess – need hospitalisation – drain abscess >4cm; abx Hartmans w stoma formation. Diverticulosis = outpouching of bowel mucosa and submucosa through weakness in muscle layer of bowel wall where blood vessels enter/exit. Seen as bloody stool w cramping, D or C.  

15% diverticulosis - > diverticulitis 15% diverticulitis -> perforation

Diverticulitis = inflammation of diverticulae. Causes lwr abdo pain, change in bowel habit (D or C), signs of inflammation (T®, N or V). Not usu assoc w bleeding. Complic = perforation. Mx Mild   

clear fluids 2-3d analgesia – Pmol & buscopan 7-10d Abx

 Cipro + metro  Co-Amox  Moxifloxacin (for patients intolerant of both metronidazole and beta-lactam agents) Modify diet to incl more fibre Moderate uncomplicated Abx = IV Ceftriaxone & metro Complicated Morphine better than NSAIDS (greater risk of perf on NSAIDS) IV Abx = Cef & Met or Taz Surgical indications Pneumoperitoneum w faecal peritionitis due to perforation Uncontrolled sepsis Obstruction Abscess >4cm (can’t be drained percutaneously) Ruptured abscess -> perforation & pus Fistula formation

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Surgical options 1 2

Colectomy w 1® anastomosis (risk of anastomotic leak) Hartmans –> stoma. Abx and reconnect once inflammation resolved after 6m. Closes distal bowel intraperitoneally & proximal bowel out as stoma.

Layers cut through Skin Camper’s fascia (fatty) Scarpa’s fascia (membranous) Muscle Transversalis fascia Extraperitoneal fascia Parietal peritoneum Visceral peritoneum (around organs) Intraperitoneal organs Liver Small bowel Transverse colon Stomach (pouch of douglas created behind uterus) Retroperitoneal Pancreas Kidneys AA & IVC Asc & desc colon Duodenum (except pyloric part)...