Peritonitis: Introduction and Management

+ [email protected] @wannabehawkeye Peritonitis: Introduction and Management Mr M Lee, Clinical Research Fellow in General Surgery + Outline What Why

is it important? What How is peritonitis? are the causes? do we treat it? + Peritonitis is Inflammation of the peritoneum

+ Causes of peritonitis Type Causative agent Possible cause Bacterial Gram negative (coliforms) Gram positive (Staphylococcus)

Perforated viscus Spontaneous bacterial peritonitis Chemical Bile Bile leak (post-op) Haematologic Blood Ruptured ectopic pregnancy

+ Intraperitoneal space The peritoneum can hold >5L of fluid/pus/blood Large absorptive area + Peritoneum Visceral Parietal Location On organs

Abdominal wall Innervation Autonomic Somatic Sensation Poorly localised Well localised Foregut

Midgut Hindgut Anatomical limits Lower oesophagus to D2 D2 to 2/3 across Transverse colon

Transverse colon to upper rectum Site of autonomic pain Epigastric Periumbilical Suprapubic +

History Sudden onset (perforation) Poorly localised moving to one point of abdomen Lying still Speedbumps Rest

my hand on it its better or beg you not to examine + Clinical Examination Localised vs generalised Point-tenderness Systemically

vs rigid abdomen shocked + Investigations Blood X-rays CT tests of chest and abdomen scan of abdomen B-HCG!

ECG + Treatment ABC Treat the underlying cause and treat it early Call a surgeon Source control Post-management support + Not just a belly problem Complication of peritonitis Hypovolaemia Kidney failure Systemic Sepsis

Paralytic ileus Pulmonary atelectasis/pneumonia Portal pyaemia + Abscess formation Patient position Location of collection Standing Pelvis

Supine Left or right paracolic gutter Suprahepatic/ sub-phrenic Supine + Primary peritonitis + Primary Peritonitis

Spontaneous Bacterial Peritonitis Ascites Immunocompromised (lymphoma/peritoneal dialysis) Diagnosis is an ascitic tap/blood cultures

Treatment is broad spectrum antibiotics No operation! + Secondary peritonitis + Case 1 25 y.o. male

1 day history of umbilical pain, poorly localised, going to right iliac fossa Off food Low grade fever Raised WCC (15).

O/E Rebound tenderness and guarding in RIF + Diagnosis + Case 2 23 y.o. F

Sudden onset low abdominal pain Acutely hypotensive Missed last period Referred to general surgery as ?appendicitis + Diagnosis?

+ Case 3 50 y.o. male Smoker, diabetic Sudden onset abdominal pain, 10/10

Not settling with morphine + Diagnosis? + Case 4 75 year old smoker B/g acid reflux, uses ibuprofen for arthritis

Previous MI Sudden onset epigastric pain Board like abdomen + Diagnosis? +

Important considerations Pre-morbid Assessing status risk (P-POSSUM, ASA) Conservative Palliation treatment + In summary Peritonitis

Toxins are absorbed Systemic Treat is bad upset underlying cause and complications + Further learning

Good for basic knowledge Lecture notes in General Surgery (Ellis, Calne, Watson) Bailey and Loves Short Practice of Surgery Good for quick revision Oxford handbook of surgery Surgery at a glance xperience is the best tutor for emergency surgery and peritoniti t the surgical admissions unit and emergency theatre to learn m [email protected] @wannabehawkeye