Peritonitis - Clinicals, Diagnosis, and Management

Gastroenterology

Clinicals - History

Fact Explanation
Usually occurs due to an infection This is a common emergency. peritoneum is the serosal memebrane which lines the abdominal cavity. When this serosal membrane gets inflamed, it's known as Peritonitis. It is either infectious or sterile or either primary or secondary. Infective microorganisms can cause infectious peritonitis. Perforation of a viscus which releases blood, bile acid, feces is another method in which peritonitis occurs. There's usually no underlying pathology for primary or spontaneous peritonitis but secondary is due to an underlying secondary cause. Usually occurs due to an infection
This is a common emergency. peritoneum is the serosal memebrane which lines the abdominal cavity. When this serosal membrane gets inflamed, it's known as Peritonitis. It is either infectious or sterile or either primary or secondary. Infective microorganisms can cause infectious peritonitis. Perforation of a viscus which releases blood, bile acid, feces is another method in which peritonitis occurs. There's usually no underlying pathology for primary or spontaneous peritonitis but secondary is due to an underlying secondary cause.
Fever with chills Underlying sepsis is the cause. Micro-organisms, white blood cells release interleukins which act on the thermo regulatory centre in the hypothalamus anc causes high temperature. Fever with chills
Underlying sepsis is the cause. Micro-organisms, white blood cells release interleukins which act on the thermo regulatory centre in the hypothalamus anc causes high temperature.
Abdominal pain or discomfort Pain is diffuse when visceral peritoneum is inflamed but rather sharp and localized when it involves the parietal peritoneum. Diagnosis of peritonitis is usually clinical. Patient usually lies still as the movement exacerbates the pain. In the history previous abdominal surgery, previous history of peritonitis, Immunosuppressive agents, and history of pepitc ulcer disease, diverticlulits, inflammatory bowel disease need to be inquired. Abdominal pain or discomfort
Pain is diffuse when visceral peritoneum is inflamed but rather sharp and localized when it involves the parietal peritoneum. Diagnosis of peritonitis is usually clinical. Patient usually lies still as the movement exacerbates the pain. In the history previous abdominal surgery, previous history of peritonitis, Immunosuppressive agents, and history of pepitc ulcer disease, diverticlulits, inflammatory bowel disease need to be inquired.
Anorexia, nausea, vomiting Intestinal obstruction due to underlying pathology Ex: obstruction of the proximal intestine can cause nausea and vomiting. Anorexia, nausea, vomiting
Intestinal obstruction due to underlying pathology Ex: obstruction of the proximal intestine can cause nausea and vomiting.
Diarrhea Due to underlying ileus/ paralysis of intestines. The intestinal paralysis that follows peritonitis is explained as the result of local inflammation of the overlying serosa (Stokes's law). When peritonitis was achieved, all motor activity ceased in the intracavitary loops. Diarrhea
Due to underlying ileus/ paralysis of intestines. The intestinal paralysis that follows peritonitis is explained as the result of local inflammation of the overlying serosa (Stokes's law). When peritonitis was achieved, all motor activity ceased in the intracavitary loops.
Ascites This is due to transudation of fluid through serosal membranes when these are inflamed. Ascites
This is due to transudation of fluid through serosal membranes when these are inflamed.
Inability to pass urine, confusion These symptoms usually indicate the presence of acute renal failure. Because of fluid transduation and causes hypovolemia. This leads to inadequate perfusion of the kidney and acute renal failure. Inability to pass urine, confusion
These symptoms usually indicate the presence of acute renal failure. Because of fluid transduation and causes hypovolemia. This leads to inadequate perfusion of the kidney and acute renal failure.

Clinicals - Examination

Fact Explanation
Fever/ Hypothermia Most of the patients are febrile and Elevated temperature is due to release of inflammatory mediators from micro-organisms which act on the thermo-regulatory centre in the hypothalamus. Septicemia can sometimes present with hypothermia Fever/ Hypothermia
Most of the patients are febrile and Elevated temperature is due to release of inflammatory mediators from micro-organisms which act on the thermo-regulatory centre in the hypothalamus. Septicemia can sometimes present with hypothermia
Toxic/ ill looking Patient maybe severely septic and appear ill looking. Toxic/ ill looking
Patient maybe severely septic and appear ill looking.
Tachycardia Tachycardia is also due to release of inflammatory mediators Tachycardia
Tachycardia is also due to release of inflammatory mediators
Signs of dehydration Vomiting, increased fluid transduation into the peritoneal cavity can cause intravascular hypovolemia therefore signs of dehydration may appear. Signs of dehydration
Vomiting, increased fluid transduation into the peritoneal cavity can cause intravascular hypovolemia therefore signs of dehydration may appear.
Hypotension Intravascular hypovolemia can result in hypotension. Hypotension
Intravascular hypovolemia can result in hypotension.
Guarding/ Rigidity Abdominal wall rigidity is a phenomenon that is observed during abdominal examination in which is the patient voluntarily increases the muscle tone when anticipating palpation of the abdomen due to pain. Guarding is involuntary increase in the tone. Guarding/ Rigidity
Abdominal wall rigidity is a phenomenon that is observed during abdominal examination in which is the patient voluntarily increases the muscle tone when anticipating palpation of the abdomen due to pain. Guarding is involuntary increase in the tone.
Tenderness on abdominal palpation Tenderness to palpation is common usually indicates the underlying pathology. Tenderness on abdominal palpation
Tenderness to palpation is common usually indicates the underlying pathology.
Distension of the abdomen/ Abdominal mass The abdomen is often distended due to ascitis. Occasionally a mass can be present such as inflammatory mass like inflamed appendix. Distension of the abdomen/ Abdominal mass
The abdomen is often distended due to ascitis. Occasionally a mass can be present such as inflammatory mass like inflamed appendix.
Absent bowel sounds Stokes's law implies the intestinal paralysis which follows peritonitis as a result of local inflammation of the overlying serosa. Therefore all motor activity ceased in the intracavitary loops and ileus results, bowel sounds maybe absent. Absent bowel sounds
Stokes's law implies the intestinal paralysis which follows peritonitis as a result of local inflammation of the overlying serosa. Therefore all motor activity ceased in the intracavitary loops and ileus results, bowel sounds maybe absent.
pain during digital rectal examination (DRE) Inflamed pelvic appendix may cause pain only during a DRE due to it's location. pain during digital rectal examination (DRE)
Inflamed pelvic appendix may cause pain only during a DRE due to it's location.
Pain during vaginal examination (VE) If the cause for peritonitis is endometritis, salpingo-oophoritis, tubo-ovarian abscess there will be pain in VE Pain during vaginal examination (VE)
If the cause for peritonitis is endometritis, salpingo-oophoritis, tubo-ovarian abscess there will be pain in VE

Investigations - Diagnosis

Fact Explanation
Full blood count Mostly a high white blood cell count is obeserved. But severe sepsis may even cause a leukopenia. Hypersplenism in spontaneous bacterial peritonitis, may reduce the white cell count. Full blood count
Mostly a high white blood cell count is obeserved. But severe sepsis may even cause a leukopenia. Hypersplenism in spontaneous bacterial peritonitis, may reduce the white cell count.
Liver function tests Spontaneous bacterial peritonitis (SBP) may occur in the presence of liver cirrhosis, therefore to assess liver function, this is done. Liver function tests
Spontaneous bacterial peritonitis (SBP) may occur in the presence of liver cirrhosis, therefore to assess liver function, this is done.
Amylase and lipase may be done if pancreatitis is suspected as a differential diagnosis for acute abdomen. Amylase and lipase
may be done if pancreatitis is suspected as a differential diagnosis for acute abdomen.
Blood culture When a patient is in sepsis, this can be postive and may help guide antibiotic therapy as well. Blood culture
When a patient is in sepsis, this can be postive and may help guide antibiotic therapy as well.
serum albumin This measurement of the serum-to-ascites albumin gradient (SAAG) more than 1.1 is noted in SBP. serum albumin
This measurement of the serum-to-ascites albumin gradient (SAAG) more than 1.1 is noted in SBP.
Arterial blood gas analysis Patient may be in an acidotic state due to intravascular hypovolaemia and hypoxemia. Arterial blood gas analysis
Patient may be in an acidotic state due to intravascular hypovolaemia and hypoxemia.
Urineanalysis To rule out pyelonephritis. Urineanalysis
To rule out pyelonephritis.
Peritoneal fluid analysis An ascitic fluid neutrophil count of greater than 500 cells/µL points towards the diagnosis of spontaneous bacterial peritonitis and the fluid should be evaluated for glucose, lactate dehydrogenase (LDH), protein, cell count, Gram stain, and aerobic and anaerobic cultures and also for AFB as well. Amylase analysis is helpful if pancreatitis is suspected Peritoneal fluid analysis
An ascitic fluid neutrophil count of greater than 500 cells/µL points towards the diagnosis of spontaneous bacterial peritonitis and the fluid should be evaluated for glucose, lactate dehydrogenase (LDH), protein, cell count, Gram stain, and aerobic and anaerobic cultures and also for AFB as well. Amylase analysis is helpful if pancreatitis is suspected
Bedside reagent strips A portable spectrophotometric device is used to for diagnosis Bedside reagent strips
A portable spectrophotometric device is used to for diagnosis
Abdominal x-ray Perforated viscus may show air under the diaphragm. Abdominal x-ray
Perforated viscus may show air under the diaphragm.
Abdominal ultrasound Intra-abdominal abscesses, ascitis, can be assessed Abdominal ultrasound
Intra-abdominal abscesses, ascitis, can be assessed
CT-abdomen This also shows ascitis with a high sensitivity and can also detect abscesses CT-abdomen
This also shows ascitis with a high sensitivity and can also detect abscesses
MRI- abdomen Intra-abdominal abscesses are diagnosed with a high sensitivity due to increased soft tissue resolution. MRI- abdomen
Intra-abdominal abscesses are diagnosed with a high sensitivity due to increased soft tissue resolution.
Contrast studies Upper GI follow through with gastrograffin, colorectal enema with contrast, fistulogram are done when peritoneal abscess are suspected. Contrast studies
Upper GI follow through with gastrograffin, colorectal enema with contrast, fistulogram are done when peritoneal abscess are suspected.
Peritoneal biopsy To diagnose tuberculous peritonitis, or any malignancies which cause ascitis. Peritoneal biopsy
To diagnose tuberculous peritonitis, or any malignancies which cause ascitis.

Investigations - Management

Fact Explanation
Blood culture To follow up a patient with sepsis with treatment, blood cultures are done. Blood culture
To follow up a patient with sepsis with treatment, blood cultures are done.
Peritoneal fluid analysis To see the drop in polymorphonuclear count in response to therapy Peritoneal fluid analysis
To see the drop in polymorphonuclear count in response to therapy
USS abdomen To detect whether abscesses are fully drained after drainage procedures. USS abdomen
To detect whether abscesses are fully drained after drainage procedures.
CT abdomen To detect whether abscesses are fully drained after drainage procedures. CT abdomen
To detect whether abscesses are fully drained after drainage procedures.
MRI abdomen To detect whether abscesses are fully drained after drainage procedures. MRI abdomen
To detect whether abscesses are fully drained after drainage procedures.
Coagulation profile In spontaneous bacterial peritonitis (SBP), associated with liver cirrhosis, a diagnostic paracentesis is done to diagnose SBP. Prior to that a coagulation profile is needed to exclude any bleeding tendency. Coagulation profile
In spontaneous bacterial peritonitis (SBP), associated with liver cirrhosis, a diagnostic paracentesis is done to diagnose SBP. Prior to that a coagulation profile is needed to exclude any bleeding tendency.

Management - Supportive

Fact Explanation
Fluid resuscitation As there's hypovolemia, fluid replacement is done and regular monitoring of vital parameters such as blood pressure, pulse, urine output are done and blood gas analysis, hemoglobin and hematocrit, serum electrolytes and renal function tests are done to detect any complications. Fluid resuscitation
As there's hypovolemia, fluid replacement is done and regular monitoring of vital parameters such as blood pressure, pulse, urine output are done and blood gas analysis, hemoglobin and hematocrit, serum electrolytes and renal function tests are done to detect any complications.
Nutrition Enteral nutrition is considered better thatn parenteral nutrition as it has a low complications rate . However parenteral nutrition is used if there are any contraindications for enteral nutrition. Sepsis leads to increased catabolism therefore high calorie diet may be required Nutrition
Enteral nutrition is considered better thatn parenteral nutrition as it has a low complications rate . However parenteral nutrition is used if there are any contraindications for enteral nutrition. Sepsis leads to increased catabolism therefore high calorie diet may be required
Patient education Patient should be education the aetiology of the disease, nature and course, importance of treatment and the options available for treatment. Patient education
Patient should be education the aetiology of the disease, nature and course, importance of treatment and the options available for treatment.

Management - Specific

Fact Explanation
Antibiotic therapy Many antibiotic regimes are available for the treatment of intra-abdominal infections mainly with broad spectrum antibiotics. Gram-positive, gram-negative bacteria and anaerobic coverage is essential. Agents which are commonly used are cefotaxime, aminoglycoside, ampicillin, and sulfamethoxazole.Carbapenems such as Meropenem, Fluroquinolones are also used. Antibiotic therapy
Many antibiotic regimes are available for the treatment of intra-abdominal infections mainly with broad spectrum antibiotics. Gram-positive, gram-negative bacteria and anaerobic coverage is essential. Agents which are commonly used are cefotaxime, aminoglycoside, ampicillin, and sulfamethoxazole.Carbapenems such as Meropenem, Fluroquinolones are also used.
No operative drainage (Percutaneous drainage) Percutaneous drainage under ultrasound or CT guidance for abscesses is carried out. No operative drainage (Percutaneous drainage)
Percutaneous drainage under ultrasound or CT guidance for abscesses is carried out.
Surgical drainage Open drainage or laparoscopic drainage is carried out in deep seated abscesses. Surgical drainage
Open drainage or laparoscopic drainage is carried out in deep seated abscesses.
Therapeutic paracentesis Sometimes in patients with ascitis, serial paracentesis are needed when fluid is keep on accumulating. This is done as a supportive management. Therapeutic paracentesis
Sometimes in patients with ascitis, serial paracentesis are needed when fluid is keep on accumulating. This is done as a supportive management.
Antibiotic prophylaxis Prophylaxis is indicated for patients with a history of SBP, Presenting with an upper GI hemorrhage, Low total protein level in ascitic fluid and antibiotics used are Norfloxacin , Ciprofloxacin, trimethoprim-sulfamethoxazole Antibiotic prophylaxis
Prophylaxis is indicated for patients with a history of SBP, Presenting with an upper GI hemorrhage, Low total protein level in ascitic fluid and antibiotics used are Norfloxacin , Ciprofloxacin, trimethoprim-sulfamethoxazole

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