The Acute Abdomen + Peritonitis Flashcards by Eilidh Seaton

What is peritonitis

Inflammation of the peritoneum

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What is primary

No cause found at laparotomy

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What is secondary peritonitis

Underlying disease

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What is localised

Certain part of abdomen

e.g. abscess, cholecystitis

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What is generalised

Affects whole abdomen
>2 quadrants
Tenderness diffuse and inflammation widespread
Often due to rupture

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What causes peritonitis

Inflammation / obstruction
\+- perforation of
- GI / biliary / female tract
- Ulcer / gall bladder / appendix / IBD / malignancy
Perforation of abdominal wall 
Rupture or organ - ectopic / aorta / spleen 
Haematogenous spread of infection 
Post-op - anastomotic leak
Ischaemia
Kidney / liver failure
PD

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How does peritonitis present

Sudden severe abdominal pain 
Lying still 
Vomiting 
Fever
Loss of appetite
No urine
High temp / RR / HR
Shock
Absence of bowel sounds

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How does colic present to peritonitis

Pace about

Peritonitis lie still as don’t want fluid to track (prostration)

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What are signs of peritonitis

Guarding
Rebound tenderness
Percussion tenderness - use to localise
Rigid abdomen
No bowel sounds

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What are bowel sounds like in obstruction

High pitched

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How do you investigation peritonitis

Urine dip in all abdo pain 
Bloods - FBC, U+E, LFT, CRP, amylase, BG 
VBG = quick result 
- Lactate - mesenteric ischaemia ?
- Biochemical / sig electrolyte 
- Acidotic 
Urine and serum hCG to exclude ectopic if female + abdominal pain  
ECG to exclude cardiac  
Blood culture if spiking temp

Imaging 
Erect CXR for free air 
AXR 
USS
CT abdo 
Gastrograffin
Laparoscopy

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What is CI

Endoscopy

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What does CXR show

Gas under diaphragm - pneumoperitoneum

Suggests perforation

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What is USS / CT used for

Show abscess

Fluid collection

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What is Gastrograffin useful for

Detect anastomotic leak/ perforation

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How do you deal with peritonitis

ABCDE
NBM 
IV access with largest as possible 
- Analgesia
- Fluid if unstable
- Anti-emeitc
- Ax 
Bloods - G+S 
Resuscitate 
Ensure tissue perfusion and oxygenation
SEPSIS 6 
Catheter 
NBM if surgery 
NG tube if vomiting and suspect obstruction 
Imaging

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How do you sort out the tissue

Drain abscess
Surgery - repair peritoneum
Treat cause

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What are complications of peritonitis

Abscess formation
Localized ileus 
Sepsis 
Septic shock
Adhesions

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When does peritonitis not localise

Contamination too rapid
Abscess ruptures
Immunocompromised

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What is the acute abdomen

Severe abdo pain which results in patient being referred for urgent surgical opinion

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What are emergencies/. difficult to Dx conditions

Mesenteric ischaemia
Acute pancreatitis
Leaking/ ruptured AAA
Peritonitis after ruptured appendix
Always think as may cause mild signs

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Pancreatitis

Causes peritonitis signs but does not require laparotomy to Dx

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How does AAA present

Retroperitoneal back pain
Shock
Sudden collapse

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Why is appendix rupture difficult

Study These Flashcards

Unusual distribution of pain

What is somatic / parietal pain pain

Arise from abdominal wall Peritoneum irritated Intercostal nerves supply Localised pain which tracks where fluid goes

What is visceral pain

``` Arise for organ / gut Insensitivite to mechanical or thermal Sensitive to distension / ischaemia / spasm Autonomic Poorly differentiate ```

What are signs of rupture

Shock Abdo swelling Peritonitis signs

What suggests abscess

Swinging fever Swelling Increased WCC

What will be seen on examination

Guarding | Rebound tenderness

What should you do prior to surgical referral n acute abdomen

``` Hx - SOCRATES Urine dip + MSSU Urine bHCG for ectopic Bloods GROUP AND SAVE OR X-MATCH ABG for oxygen VBG for electrolyte and lactate Blood culture ECG for diseases above diaphragm Imaging ```

What bloods and why

``` FBC - bleeding (Hb) / WCC U+E - kidney function LFT CRP Amylase / lipase - any inflammation in pancreas Lactate - mesenteric ischaemia Glucose Calcium - pancreatitis severity INR / clotting - liver function / coag prior to procedures ```

Why is it important to do ECG

Diseases above diaphragm

What imaging

``` USS abdo / pelvis = 1st line - Need full bladder and fasted AXR - Erect CXR CT if time often diagnostic CT angio CT-KUB ```

What do you do USS

Abscess Gall stone Dilatation of biliary tree Gynae issue

What is AXR useful for and erect CXR

Obstruction Show dilatation of bowel loop Erect CXR may show gas under diaphragm indicative of perforation

When is CT angio indicated

If bruit suggest aneurysm

CT KUB

If suspect renal stone

How do you treat

SURGEY

What do you do before surgery

``` ABCDE Resuscitate - shock compounds anaesthesia unless blood lost faster than can replace e.g. aneurysm / trauma IV access NBM if scan / surgery Fluid If needed Catheterise for fluid balance X-match and transfuse Analgesia Anti-emetic IV Ax if evidence of infection Thrombo-prophylaxis - Dalteparin NG aspiration if evidence of obstruction Nutrition ```

What is seen on a CT scan if perforation

Air between abdominal wall and skin | Same as hernia

What are common causes of acute abdomen

``` Acute appnedicitis Obstruction Urinary tract Biliary tract Trauma Malignancy Perforated ulcer / gall stone Pancreatitis ```

Surgical Sleeve

``` Hepatobiliary Upper GI Lower GI Urology Gynae Infection Metaboli Trauma Vascular ```

What causes epigastric pain

``` Gastritis Peptic ulcer Biliary colic Pancreatitis Perforation Diseases above diaphragm ```

What diseases above diaphragm

``` Inferior MI PE DKA Poisin Pneumonia- L lower lobe ```

What should you do for diseases above

CXR ECG Blood glucose

What causes umbilical pain

``` Chrons Small bowel obstruction Appendicits Adhesions Malignancy Mesenteric ischaemia Ruptured AA ```

What causes hypogastriac pain

``` COnstipation Diverticulitis COlon cancer Volvulus Gina / testicular / ovarian ```

What causes RLQ / LLQ pain

``` Appendicits Ruptured ectopic Renal stone Pyelonephrititis Cholecystitis Hernia Mesenteric adenitis Perforation Diverticulitis Testicular / ovarain torsion PID ```

What causes LUQ pain

``` Ruptured spleen Ruptured AA Pyelonephritis Pneumonia Renal colic ```

What causes RUQ pain

``` Appendicits Pneumonia Acute cholecystitis Cholangitis Choledohcolithathis Biliary colic Ulcers Hepatitis Pyelonephritis Renal colic ```

What causes abdominal distension

``` Pregnancy Obstruction Volvulus Ascites Retention Ovarian cancer Constipaiton ```

When is obstruction likely

Surgery Hx due to adhesions | Cancer

When is ascites likely

Alcohol CF Stomach / liver

What are 5Fs

``` Fat Faeces Flatus Fetus Fluid ```

What is most likely cause of shock in surgical patient

Hypovolaemia from blood loss | Check UO, GCS and CRT as measure of perfusion

What do you do if anastomotic leak

Emergency surgery

Why do you want lactate

Sepsis

What gives definite Dx

CT abdo pelvis | If suspect triple A then CT angio

The Acute Abdomen + Peritonitis Flashcards

(58 cards)