Peritonitis

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Peritonitis is an inflammation of the peritoneum.

Causes

Primary peritonitis is spontaneous peritonitis that occurs in the absence of other intraabdominal abnormalities.

Secondary peritonitis (more common) affects those with pre-existing acute abdominal disease:

  • Hollow organ perforation: peptic ulcer, diverticula, cholecystitis
  • Inflammation of intra-abdominal organs: appendicitis, diverticulitis, necrotizing pancreatitis
  • Postoperative complications: anastomosis insufficiency, unsterile puncture site, or aseptic surgical procedures
  • Traumatic (external perforation)
  • Peritoneal dialysis
  • Intra-abdominal abscesses

Signs and symptoms

  • Diffuse abdominal pain with abdominal guarding and/or rebound tenderness
  • Nausea and vomiting
  • Fever and chills (esp. with underlying infection)
  • Shoulder pain(referred)
  • Ascites 
  • Patient has knees drawn up when supine and avoids movement
  • Diminished bowel sounds (absent in ileus)

Differential diagnosis

  • Liver abscess
  • Acute cholecystitis
  • Acute cholangitis
  • Splenic rupture
  • Appendicitis
  • Sigmoid diverticulitis
  • Gastric or duodenal ulcer perforation
  • Acute pancreatitis
  • Acute coronary syndrome
  • Intestinal obstruction
  • Pelvic inflammatory disease
  • Ectopic pregnancy

Investigations

  • Complete blood cell count
  • Peritoneal fluid analysis: biochemistry, microbiology, cytology, etc.
  • Ultrasound to detect underlying disease e.g. pancreatitis, appendicitis, cholangitis
  • Abdominal x-ray may detect air-fluid levels and free air under the diaphragm secondary to organ perforation

Treatment objectives

  • Identify source of infection
  • Remove the source of infection
  • Treat underlying causes
  • Provide supportive care

Pharmacological treatment

First line

Replace fluid losses as they happen with the appropriate IV fluids (Dextrose Ringers Lactate)

Ceftriaxone IV

1-2 g/day intravenously in single daily dose or divided every 12 hours for 5 to 7 days

PLUS

Metronidazole IV

15 mg/kg intravenously; not to exceed 4g per day  

Maintenance dose: 7.5 mg/kg  every 8 hours till conditions improve

 

Second line

Ciprofloxacin IV

200mg intravenously every 12 hours for 2 days

PLUS

Metronidazole IV

15 mg/kg intravenously; not to exceed 4 g/day  

Maintenance dose: 7.5 mg/kg every 8 hours

Duration:  5-7 days or longer depending on the severity.

Referral

  • Refer for surgical extensive irrigation (lavage), debridement, drainage