Peritonitis
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Irritation (inflammation) of the peritoneum
Causes
Infection following:
- Perforation of the gut and leakage of its contents, e.g. burst appendix, perforated peptic ulcer
- Perforated bowel due to obstruction or injury
- Perforation of gall bladder, containing infected bile
- Perforation of the uterus
- Tuberculosis, abscess, typhoid ulcers
- Malignancy
- Post-operative peritonitis
Chemical causes
- Leakage of urine, blood, bile or stomach or pancreas content into the peritoneal cavity
Clinical features
- Severe and continuous pain
- Generalised if the whole peritoneum is affected
- Abdominal swelling (distension)
- Fever, vomiting, tachycardia, hypoxia
- Hypovolemic shock, reduced urinary volume
- Tender rigid abdomen
- Rebound tenderness - pressure on the abdomen and sudden release causes sharper pain
- Absent bowel sounds
Investigations
- Abdominal X-ray and/or ultrasound
- Blood: Complete blood cell count, culture and sensitivity
- Renal function and electrolytes
- Liver function tests
ManagementTreatment
- Refer to hospital
- Start initial treatment before referral
- Monitor temperature
- Monitor BP, pulse, Sp02, urine output, mentation
- Put up an IV drip with normal saline or ringer’s lactate or any other crystalloid: 1 L every 1-2 hours until BP is normal, then 1 L every 4-6 hours when BP is normal
- Nil by mouth. Pass a nasogastric tube and start suction
- Ask patient to lie on their side in a comfortable position
- Give oxygen if patient is hypoxic
- Pain control (avoid NSAIDs)
- Pethidine 50 mg IM or IV
- Child: 0.5-2 mg/kg
- Or Morphine 5-15 mg IV or IM or SC
- Child: 2.5-5 mg IM IV SC
- Pethidine 50 mg IM or IV
- Refer patient to hospital for further management, including possible exploratory laparotomy
In suspected bacterial infection and fever: (minimum 7-day course)
- Ceftriaxone 1-2 g IV once daily
- Child: 50 mg/kg per dose
- Plus gentamicin 7 mg/kg IV daily in divided doses
- Child: 2.5 mg/kg every 8 hours
- Plus metronidazole 500 mg by IV infusion every 8 hours; change when possible to 400 mg orally every 8 hours
- Child: 12.5 mg/kg IV per dose; change when possible to oral route
- Identify and control the source of infection
- Prevent and control complications through: proper nutrition, early ambulation, rehabilitation