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1

Define peritonitis

Inflammation of the serosal membrane that lines the abdominal cavity and the organs contained therein

2

Describe causes of peritonitis

Usually sterile, reacts to chemical and mechanical stimuli. Abdominal infection can be peritonitis (generalised infection) or intra-abdominal abscess (localised).
Infection usually after perforation of an organ, but can be due to foreign bodies, bile acids or stomach acid entering the space.

3

Define classifications of peritoneal infection

• Primary: from haematogenous dissemination/bacteria across gut wall, usually in the setting of an immunocompromised state. Most often spontaneous bacterial peritonitis, seen mostly in patients with chronic liver disease
• Secondary: related to a pathologic process in a visceral organ, such as perforation or trauma, including iatrogenic trauma. The most common form of peritonitis encountered in clinical practice
• Tertiary: persistent or recurrent infection after adequate initial therapy. Often develops in the absence of the original visceral organ pathology. Usually immunocompromised individuals. TB peritonitis is a problem among HIV+ve individuals.

4

How is peritonitis diagnosed?

Usually clinical
Peritoneal lavage if non-conclusive signs/history not available
Need to find cause it secondary peritonitis (erect CXR for free gas, CT scan, amylase, lipase, bilirubin, ALP, lactate, ß-HCG, urinalysis, stool culture, toxin assays)

5

Describe pathophysiology of secondary peritonitis

• Secondary peritonitis results from direct spillage of luminal contents into the peritoneum (eg, perforated peptic ulcer, diverticulitis, appendicitis, iatrogenic perforation)
• With the spillage of the contents, gram-negative and anaerobic bacteria, including common gut flora, such as E. coli and Klebsiella pneumoniae, enter the peritoneal cavity
• Endotoxins produced by gram-negative bacteria lead to the release of cytokines that induce cellular and humoral cascades, resulting in cellular damage, septic shock, and multiple organ dysfunction.
• Usually polymicrobial if colonic rupture

6

Signs and symptoms of peritonitis

• Fever and chills (80%) (>38º, <36º)
• Abdominal pain or discomfort (70%) (dull and poorly localized-> more severe and more localized. Worse with movement and local pressure. Patients on steroids, with diabetic neuropathy and extremes of age may present with less pain)
• Worsening or unexplained encephalopathy
• Diarrhea
• Ascites that does not improve following administration of diuretic medication
• Worsening or new-onset renal failure
• Ileus

7

What Qs need to be asked with a pt presenting with ?peritonitis

• Recent abdominal surgery
• Previous episodes of peritonitis
• Travel history
• Use of immunosuppressive agents
• Presence of diseases (eg, inflammatory bowel disease, diverticulitis, peptic ulcer disease) that may predispose to intra-abdominal infections
• Anorexia and nausea

8

Differentials to peritonitis

• Chemical irritation
• Thoracic processes with diaphragmatic irritation (eg, empyema)
• Extraperitoneal processes (eg, pyelonephritis, cystitis, acute urinary retention)
• Abdominal wall processes (eg, infection, rectus hematoma)
• External hernias (rule out intestinal incarceration)
• Gynae conditions (chlamydia peritonitis, teratoma, salpingitis)
• Parasitic infections
• Vascular conditions (mesenteric embolus, ischaemic colitis)

9

Treatment of peritonitis

• Find cause (if primary, parecentesis, drain and irrigate)
• MC&S with pH (see if faecal contents or bile)
• Broad spectrum abx
• Drain abscess
• Laparotomy?

10

What are the causes of pancreatitis?

GET SMASHED
Gall stones (38%)
Ethanol (35%)
Trauma (1.5%)
Steroids
Mumps
Autoimmune
Scorpion bites (Trinidad)
Hyperlipidaemia, hypothermia, hypercalcaemia
ERCP and emboli
Drugs

11

How many people have unexplained pancreatitis?

10-30%

12

Mortality of pancreatitis

12%

13

How does pancreatitis cause mortality?

Oedema and fluid shifts-> hypovolaemia
Fluid trapped in gut, peritoneum, retroperitoneum
Enzyme mediated autodigestion -> necrosis and infection
Protease induced coagulation cascade, complement activation, kinin, fibrinolytic cascade, oxidative stress

14

Signs and symptoms of pancreatitis

Symptoms:
• Severe epigastric pain/central abdo pain
• Pain radiates to back, relieved by sitting forward
• Vomiting
Signs:
• Tachycardia
• Fever
• Jaundice
• Shock
• Ileus
• Rigid abdomen
• Periumbilical bruising (Cullen’s) and flank bruising (Grey Turner’s) due to blood vessel autodigestion and retroperitoneal haemorrhage

15

Differential diagnoses to pancreatitis

• Perforated duodenal ulcer
• Mesenteric infarction
• MI

16

What is the modified glasgow score?

Assesses severity and predicts mortality
Valid for alcohol and gallstones

17

What are the sections of the modified glasgow score?

PANCREAS
PaO2: <8
Age: >55
Neutrophils: >15
Ca2+: <2
Renal function: Urea>16
Enzymes: LDH>600, AST>200
Albumin: <32
Sugar: >10

18

What investigations need to be carried out in pancreatitis?

FBC: WCC raised
Raised amylase (>1000) and raised lipase
U&E: dehydration and renal failure
LFT: cholestatic picture (raised AST and LDH)
Low calcium, raised glucose
CRP: raised if severe (>150)
ABG: hypoxia if respiratory distress
Urine: glucose, conjugated bilirubin, decreased urobilinogen
CXR: exclude perforated duodenal ulcer, ARDS?
AXR: pancreatic calcification?
USS: Gallstones, dilated pancreatic ducts, inflammation
Contrast CT (look for pancreatic necrosis)

19

Management of pancreatitis

• Hourly obs and urine output
• IV fluids! Until UO>30ml/hr
• Pancreatic rest (nil by mouth, NG tube if vomiting, TPN to prevent catabolism)
• Analgesia (PETHIDINE/MORPHINE)
• Laparotomy and debridement
• ERCP and gall stone removal if progressive jaundice

20

Complications of pancreatitis

• Shock, ARDS, renal failure, DIC, sepsis, hyperglycaemia, hypocalcaemia
• Pancreatic necrosis and pseudocyst
• Abscess, bleeding, thrombosis, fistulae

21

Main causes of chronic pancreatitis

Chronic pancreatitis:
70% alcohol
Genetic (CF, HH), Immune, Raised triglycerides, Structural (obstruction by tumour/pancreatic divism)

22

Signs & symptoms of chronic pancreatitis

Pain exacerbated by alcohol/fatty food
Relieved by sitting back or hot water bottle
Steatorrhoea and weight loss
Diabetic signs (olyuria, polydipsia)
Epigastric mass (pseudocyst)

23

Management of chronic pancreatitis

• Diet: no alcohol, reduce fat, increase carbs
• Analgesia, Creon supplementation of enzymes, ADEK vitamins, diabetes treatment
• Surgery if unremitting pain, weight loss, duct blockage (Whipple’s or stenting)

24

10 causes of bowel obstruction

• Adhesions
• Hernia
• Colorectal neoplasm
• Diverticular stricture (IBD, surgery, ischaemic colitis, diverticulitis, radiotherapy)
• Volvulus
• Paralytic ileus-> Post –op/pancreatitis/drugs/metabolic/mesenteric ischemia
• Impacted faces/bezoar/worms
• Intussusception
• Gallstones
• Congenital atresia

25

Signs and symptoms of bowel obstruction

• Abdominal distention
• Nausea and vomiting
• Abdominal pain (colicky, central, if localised ?strangulation)
• Absolute constipation (no flatus or faeces)
• Abrupt onset of symptoms (acute obstructive event)
• Chronic constipation, straining at stools (diverticulitis/carcinoma)
• Changes to stool caliber (carcinoma)
• Recurrent left lower quadrant abdo pain over several years (diverticulitis/diverticular stricture)

26

What examinations need to be done in ?bowel obstruction?

• Bowel sounds? (increased in mechanical obstruction, decreased in ileus)
• Inspect, auscultate, percuss abdo (distention)
• Check for incarcerated hernia
• Surgical scars
• Anal patency in neonate? Content of anal vault, faecal occult blood test

27

Diagnosis of bowel obstruction needs what investigations?

• FBC (raised WCC)
• U&E: dehydration, electrolyte abnormalities
• Amylase (very high if strangulation/perforation)
• Group and save + clotting (for poss surgery)
• Erect CXR for perforation
• AXR (>3cm with valvulae coniventes=small bowel, >6cm with haustra=large bowel, >9cm caecum)
• CT can show transition point
• Gastrograffin studies (shows mechanical obstruction)
• Colonoscopy (may be used therapeutically to stent in volvulus, can perforate)

28

Treatment of bowel obstruction

• Resuscitate (drip and suck-> NMB, IV fluids, NG tube to prevent aspiration and stop vomiting, monitor urine output)
• Analgesia
• Abx cef + met if strangulation/perforation
• Gastrograffin study (oral/NG tube)
• Monitor
• Surgery if closed loop obstruction/neoplasm/strangulation/perforation/failure of conservative management
• Resection of obstructing lesion/bypass if unresectable
• Endoscopic metal stents in palliation

29

4 classifications of UTIs

• Uncomplicated (normal GU tract and function)
• Complicated (abnormal GU tract/outflow obstruction/reduced renal function/impaired host defence/virulent organism
• Recurrent with different organism
• Relapse with same organism

30

Risk factors for UTI

• Female
• Sex
• Pregnancy
• Menopause
• Diabetes mellitus
• Abnormal tract (stone/obstruction/catheter/malformation)