Peritonitis

Question 1

How can you differentiate between peritonitis and renal colic?

Answer 1

Peritonitis features pain when coughing and moving.

Renal colic features pain when staying still, relieved by moving. “Cannot sit still”

Question 2

Name 3 clinic symptoms of peritonitis?

Answer 2

Anorexia
Pyrexia
Several generalised abdominal pain, radiating to shoulders and back
Pain worse with movement, coughing, sneezing

Question 3

What scenario may feature peritonitis with apyrexia?

Answer 3

Patients taking corticosteroids

Question 4

How can the causes of peritonitis be grouped?

Answer 4

Primary (rare)

Secondary (common)

Question 5

Name 3 clinical signs of peritonitis

Answer 5

Pyrexia
Tachycardia
Peritonism: Tenderness and guarding, Rebound tenderness
Localised pain during distant palpation (Rovsing’s sign)

Question 6

What is the most likely cause of primary peritonitis?

Answer 6

Streptococcal infection via blood stream.

Rare, usually occurs in immunocompromised patients.

Question 7

List 4 common causes of secondary peritonitis

Answer 7

Acute perforated appendicitis
Acute perforated diverticular disease
Upper GI perforation
Perforated tumour (colonic or gastric)
Perforated ischaemic bowel
Acute pancreatitis
Peritoneal dialysis
Post-surgical intervention

Question 8

What is the commonest cause of secondary peritonitis in under 45s?

Answer 8

Acute perforated appendicitis

Question 9

What is the commonest cause of secondary peritonitis in elderly?

Answer 9

Acute perforated diverticular disease

Question 10

How is a perforation diagnosis confirmed?

Answer 10

Laparotomy - surgical incision to examine abdominal organs

Question 11

What is acute peritonitis?

Answer 11

Acute inflammation of the peritoneal cavity

Question 12

Name 3 features that suggest a perforated viscus

Answer 12

Sudden onset of pain
Constant severe pain
Pain aggravated by movement, coughing, sneezing
Diffuse tenderness
Silent rigid abdomen

Question 13

What investigation may be raised in perforated bowel?

Answer 13

Serum amylase - suggestive of pancreatitis

Question 14

What laboratory investigations may be done in acute peritonitis?

Answer 14

FBC
U&E
CRP
Amylase - pancreatitis
ABG - if shocked or pancreatitis suspected

Question 15

What is the investigation of choice for diagnosing acute peritonitis?

Answer 15

Abdominal CT

Excludes acute pancreatitis, and often locates the probable source of pathology.

Question 16

Outline the early treatment of acute peritonitis

Answer 16

IV antibiotics when diagnosis is unclear. Especially useful if surgery is likely.

Analgesia
Correct fluid balance
Monitor

Question 17

Outline the definitive management of acute peritonitis

Answer 17

Management depends on the cause of peritonitis.

Question 18

Differentiate between local and generalised peritonitis

Answer 18

Local: peritonism over a single area
General: peritonism over entire abdomen with board-like rigidity

Generalised peritonitis is also more likely to have signs of:

• Ileus (distension, vomiting, tympanic abdomen with reduced/absent bowel sounds)
• Systemic shock (tachycardia, tachypnoea, hypotension, low urine output).

Question 19

What is the management of generalised peritonitis?

Answer 19

*Surgical emergency*
IV fluid resuscitation
IV ABX
Laparotomy/Laparoscopy - peritoneal wash-out and treatment of underlying condition
Monitor for post-op complications

Question 20

What are the causes of generalised peritonitis?

Answer 20

Bacterial infection - faecal matter from diverticulitis
Progression from localised inflammatory peritonitis
Leakage of body fluids
-Gastric juice
-Bile
-Urine
-Pancreatic juice
-Blood

*Body fluids are initially sterile but become infected with 24-48hr of leaking.

Question 21

In what scenario can a CT abdomen be considered in generalised peritonitis?

Answer 21

If it can be performed urgently and the patient is stable.

*Does not change management

Question 22

Name 3 bedside tests useful for diagnosing local peritonitis

Answer 22

Rebound tenderness
Cough test
Hip flexion test

Question 23

What would indicate the development of a peritoneal abscess?

Answer 23

Swinging fever
Swelling
Raised WCC
Increasing or sustained pain

Question 24

How is a peritoneal abscess managed?

Answer 24

Percutaneous drainage or laparotomy

Question 25

What investigations should be done in generalised peritonitis?

Answer 25

CT abdomen - if quick and patient is stable

Serum amylase - to exclude pancreatitis

Question 26

What is the complication of delaying treatment of generalised peritonitis?

Answer 26

Further toxaemia, septicaemia, and multi organ-failure

Question 27

What initial radiological test should be performed for suspected perforation? What sign is evident?

Answer 27

Erect CXR to look for pneumoperitoneum

AXR would show Rigler sign (double wall)