Week 5: Peritonitis
Diagnosis Cholecystitis Cholecystolithiasis Ulcer disease Pancreatitis Perforation of GI Appendicitis Diverticulitis
organ
Definition Inflammation of the Gallstones = most Most commonly in the Often due to alcohol Results in generalised Most common cause Inflamed diverticula –
gallbladder – often due common cause of stomach or duodenum abuse (40%) or peritonitis of the acute abdomen can perforate:
to cholecystolithiasis biliary tract disease – sometime gallstones (40%) peritonitis
Often begins with oesophagus
physical and chemical
inflammation – later
bacterial infection
Tests Patient is systemically Exclude Test for H. pylori: History Increased leucocytes + Clinical suspicion + Most common site =
unwell: fever and haematological and Stool antigen test Investigations: CRP ultrasound or CT scan sigmoid/descending
tachycardia liver abnormalities – Serum anti-H. pylori Pancreatic Free air in the Point of McBurney = colon
Increased blood test for CRP, IgG enzymes in abdomen on X-ray or where the appendix Mild left iliac fossa
inflammatory markers FBC, liver enzymes and Hydrogen breath test plasma CT scan comes out of the tenderness
Tenderness in RUQ – pancreatic enzymes Endoscopic biopsies CRP caecum – localised Faecal loading
more marked in Establish if gallstones with urease testing Plasma lipase peritonitis Endoscopy = to
inspiration are present – Endoscopy esophago- ALAT Tenderness to confirm diagnosis and
Tender, inflammatory ultrasound gastro-duodenoscopy Liver function palpation exclude malignancy
gallbladder mass may Assess integrity and or gastroscopy – tests Fever: 37.5-38.5 CT or contract enema
be palpable patency of the bile gastritis Ultrasound of the Guarding = to diagnose abscess
Murphy sign = pain at duct system and the Biopsies is to gallbladder Board-like rigidity
the RUQ when the pancreatic duct: distinguish benign Severe pancreatitis Rebound tenderness =
doctor palpates the Non-jaundiced: from malignant + H. criteria (3): Blumberg’s sign
gallbladder while the intraoperative pylori >55 yrs or >75 yrs Systemic toxicity:
patient holds his/her cholangiography Contrast radiography = for gallstone Fever
breath Jaundice: MRCP – effectiveness of gastric Leucocytosis Malaise
Increased liver no results: ERCP emptying – barium High blood sugar Tachycardia
enzymes or endoscopic meal High LDH Leucocytosis
Attack lasts more than sphincterotomy High ASAT When in doubt: admit
24h or papillotomy During next 48 hrs: the patient – monitor
70%: a pathogen can Endoscopic >10% haematocrit every few hours
be cultured ultrasound = to Increased plasma
Ultrasound = to assess lower end urea
support diagnosis of the common Hypocalcaemia
bile duct + Low PaO2
ampulla + head of Metabolic
the pancreas acidosis
Increased fluid
sequestration
Clinical Charcot’s triad: Epigastrium or RUQ Epigastric pain Severe abdominal pain At first: localised At first: poorly Chronic, grumbling
presentation Pain in RUQ pain Severe retrosternal Often radiates to the peritonitis = when localised and central diverticular pain: low-
Ever Intermittent and acute pain + dysphagia = back small perforation pain = visceral pain grade recurrent
Jaundice pain: colicky pain oesophagus Vomiting becomes an After 12-24 hours: pain inflammation bowel
Decreased RR and Jaundice = when the Exacerbation by acidic Restlessness – keeps intraabdominal localised to the spasm episodic
consciousness stone obstructs the or spicy food = changing position abscess + NO faecal affected area: diarrhoea and
, common bile duct stomach Distended, tender spillage RLQ/right iliac fossa constipation
Steatorrhea Relieved by food = abdomen – NO Generalised peritonitis Exacerbation by Acute peritonitis =
Hypocoagulopathy = duodenum – coming guarding = due to chemical muscle movement local extension of
due to reduced vitamin back when hungry = Absent bowel sounds and/or bacterial Nausea diverticular
K uptake hunger pain Jaundice irritation Vomiting inflammation –
Nausea Anorexia Minimal or rapidly Hypovolaemia Local peritonitis: pericolic tissues and
Vomiting Weight loss resolving abdominal Toxaemia guarding and rebound peritoneum:
Pain is often triggered Chronic anaemia signs: abdominal Sepsis = when tenderness Left iliac fossa
by fat meals Abdominal fullness distension, tenderness, infection is Tachycardia pain
Pain radiates to the and bloating guarding and absent present Fever Systemically ill
back Weight gain = with bowel sounds Rigid and tender Facial flush patient: pyrexia
Upper abdominal duodenal ulcers – pain Severe: abdomen Perforation: and tachycardia
tenderness often comes at night: Severe toxaemia Absent bowel generalised peritonitis Mild left iliac
relieved by bland and shock sounds and systemic toxicity fossa tenderness
foods and milk Generalised Obvious local
Perforation = localised peritonitis peritonitis
or generalised ARDS = early Pericolic abscess:
peritonitis: severe complication Swinging fever
abdominal pain and Persistent pain
shock and tenderness
Haemorrhage: massive Incomplete
haematemesis and obstruction
melaena Septicaemia
Intermittent Purulent
symptomatic episodes diarrhoea
Patient Cause = often Women are affected Risk factors: Causes: Causes: Age: <40 – esp. 10-20 Main cause = too low
obstruction by stones 4x more Bad diet Affected more Perforation of an yrs rare <10 fibre intake
or stenosis (e.g. due to Predisposing factors: Stress Idiopathic ulcer Cause = obstruction Females are affected
pancreatic tumour) – Pregnancy H. pylori – Gallstones Perforation of the with faeces – common more than males
stasis of bile – Obesity infection is often Ethanol small bowel – due in low fibre diets
ascending infection Diabetes acquired in Trauma to something
from the duodenum childhood Steroids sharp and
Alcohol = erosion Mumps distension
of the mucosal Autoimmune Transmural
wall Scorpion/snakes inflammation of
NSAIDs – Hyperlipidaemia the bowel:
blockage of COX1 and appendicitis,
Smoking – hypercalcaemia diverticulitis and
elevated gastrin ERCP Crohn’s
Elevated gastrin Drugs Transmural
inflammation of
other organs:
salpingitis and
cholecystitis
Rupture of colon
due to
constipation =
, often fatal faecal
peritonitis
Typical onset Acute Chronic Chronic Acute Acute Acute Acute
>50 years >40 years Duodenal = 30-50 Alcoholic = <44 Any age 10-20 years >50 years
Stomach = >60 Gallstones = >45
History Systemically unwell + Women + Epigastric pain + History of gallstones or Local peritonitis – First poorly localised + History of constipation
palpable inflammatory epigastrium/RUQ pain triggered by alcohol + severe severe pain and then pain in RLQ + + mild tenderness of
gallbladder mass + + colicky pain + spicy/acidic food + abdominal pain guarding and patient systemically the left iliac fossa +
RUQ tenderness esp. triggered by fat meals hunger pain radiating to the back + tenderness + unwell + young patient grumbling pain +
upon inspiration jaundice generalised peritonitis erratic bowel
– shock and sepsis movements
Treatment Acute cholecystectomy Normally surgery: Control predisposing Mild attacks: Surgical emergency – Preference = Take out Sigmoid
within a few days after cholecystectomy – or aggravating cause: Fluid resuscitation treat on clinical laparotomy – view of colon:
the attack gold standard = Lifestyle Analgesia suspicion the adjacent structures Hartmann
ABs: when the patient laparoscopy Stop aspirin or Treat Local peritonitis: treat In women always procedure = make
has bacterial infection Only laparotomy with NSAIDs predisposing the underlying laparoscopy a stoma
ERCP with papillotomy unexpected difficulties Stress factors problem Resuscitation Anastomosis of
= to relieve obstruction or complications Elimination of H. Severe attacks: Generalised Antibiotic prophylaxis: the colon to the
If patient is not fit for pylori: omeprazole + ARDS – peritonitis: metronidazole rectum
surgery: antibiotics ventilatory 1. Fluid resuscitation (anaerobic) + Lifestyle: high-fibre
chenodeoxycholic acid (clarithromycin + support 2. High dose if IV sometimes diet
– 50% recurrence after amoxicillin) – Supportive ABs cephalosporin ABs
2 years eradication of often measures: O2, 3. Urgent (aerobic) 2 hrs IV fluids = to rest the
Side effects: long-term within 1 fluids and laparotomy before surgery bowel
Severe diarrhoea week nasogastric tube Conservative = in suppository
Hepatic damage Diminishing irritant CRP patients unfit for Peritoneal toilet = if
Indications for surgery effects of acid-pepsin: measurements surgery: pus or faeces were
= symptomatic antacids Regular liver Nasogastric found
gallstones or gallstones Administration of enzyme tests to aspiration
that could become mucosal protective test for biliary IV fluids
symptomatic in the agents: sucralfate obstruction Gastric acid
future Reduction in acid Renal function suppression
Relief jaundice before secretion: tests ABs
surgery by endoscopic H2 receptor NO ABs
sphincterotomy = blocking agents = Endoscopic
stone extraction and cimetidine and surgery for
bile duct stenting ranitidine gallstones
Proton-pump
inhibitors:
omeprazole
Surgical
vasectomy = rare
Partial gastrectomy =
removal of affected
tissue
Correction of
secondary anatomic
Diagnosis Cholecystitis Cholecystolithiasis Ulcer disease Pancreatitis Perforation of GI Appendicitis Diverticulitis
organ
Definition Inflammation of the Gallstones = most Most commonly in the Often due to alcohol Results in generalised Most common cause Inflamed diverticula –
gallbladder – often due common cause of stomach or duodenum abuse (40%) or peritonitis of the acute abdomen can perforate:
to cholecystolithiasis biliary tract disease – sometime gallstones (40%) peritonitis
Often begins with oesophagus
physical and chemical
inflammation – later
bacterial infection
Tests Patient is systemically Exclude Test for H. pylori: History Increased leucocytes + Clinical suspicion + Most common site =
unwell: fever and haematological and Stool antigen test Investigations: CRP ultrasound or CT scan sigmoid/descending
tachycardia liver abnormalities – Serum anti-H. pylori Pancreatic Free air in the Point of McBurney = colon
Increased blood test for CRP, IgG enzymes in abdomen on X-ray or where the appendix Mild left iliac fossa
inflammatory markers FBC, liver enzymes and Hydrogen breath test plasma CT scan comes out of the tenderness
Tenderness in RUQ – pancreatic enzymes Endoscopic biopsies CRP caecum – localised Faecal loading
more marked in Establish if gallstones with urease testing Plasma lipase peritonitis Endoscopy = to
inspiration are present – Endoscopy esophago- ALAT Tenderness to confirm diagnosis and
Tender, inflammatory ultrasound gastro-duodenoscopy Liver function palpation exclude malignancy
gallbladder mass may Assess integrity and or gastroscopy – tests Fever: 37.5-38.5 CT or contract enema
be palpable patency of the bile gastritis Ultrasound of the Guarding = to diagnose abscess
Murphy sign = pain at duct system and the Biopsies is to gallbladder Board-like rigidity
the RUQ when the pancreatic duct: distinguish benign Severe pancreatitis Rebound tenderness =
doctor palpates the Non-jaundiced: from malignant + H. criteria (3): Blumberg’s sign
gallbladder while the intraoperative pylori >55 yrs or >75 yrs Systemic toxicity:
patient holds his/her cholangiography Contrast radiography = for gallstone Fever
breath Jaundice: MRCP – effectiveness of gastric Leucocytosis Malaise
Increased liver no results: ERCP emptying – barium High blood sugar Tachycardia
enzymes or endoscopic meal High LDH Leucocytosis
Attack lasts more than sphincterotomy High ASAT When in doubt: admit
24h or papillotomy During next 48 hrs: the patient – monitor
70%: a pathogen can Endoscopic >10% haematocrit every few hours
be cultured ultrasound = to Increased plasma
Ultrasound = to assess lower end urea
support diagnosis of the common Hypocalcaemia
bile duct + Low PaO2
ampulla + head of Metabolic
the pancreas acidosis
Increased fluid
sequestration
Clinical Charcot’s triad: Epigastrium or RUQ Epigastric pain Severe abdominal pain At first: localised At first: poorly Chronic, grumbling
presentation Pain in RUQ pain Severe retrosternal Often radiates to the peritonitis = when localised and central diverticular pain: low-
Ever Intermittent and acute pain + dysphagia = back small perforation pain = visceral pain grade recurrent
Jaundice pain: colicky pain oesophagus Vomiting becomes an After 12-24 hours: pain inflammation bowel
Decreased RR and Jaundice = when the Exacerbation by acidic Restlessness – keeps intraabdominal localised to the spasm episodic
consciousness stone obstructs the or spicy food = changing position abscess + NO faecal affected area: diarrhoea and
, common bile duct stomach Distended, tender spillage RLQ/right iliac fossa constipation
Steatorrhea Relieved by food = abdomen – NO Generalised peritonitis Exacerbation by Acute peritonitis =
Hypocoagulopathy = duodenum – coming guarding = due to chemical muscle movement local extension of
due to reduced vitamin back when hungry = Absent bowel sounds and/or bacterial Nausea diverticular
K uptake hunger pain Jaundice irritation Vomiting inflammation –
Nausea Anorexia Minimal or rapidly Hypovolaemia Local peritonitis: pericolic tissues and
Vomiting Weight loss resolving abdominal Toxaemia guarding and rebound peritoneum:
Pain is often triggered Chronic anaemia signs: abdominal Sepsis = when tenderness Left iliac fossa
by fat meals Abdominal fullness distension, tenderness, infection is Tachycardia pain
Pain radiates to the and bloating guarding and absent present Fever Systemically ill
back Weight gain = with bowel sounds Rigid and tender Facial flush patient: pyrexia
Upper abdominal duodenal ulcers – pain Severe: abdomen Perforation: and tachycardia
tenderness often comes at night: Severe toxaemia Absent bowel generalised peritonitis Mild left iliac
relieved by bland and shock sounds and systemic toxicity fossa tenderness
foods and milk Generalised Obvious local
Perforation = localised peritonitis peritonitis
or generalised ARDS = early Pericolic abscess:
peritonitis: severe complication Swinging fever
abdominal pain and Persistent pain
shock and tenderness
Haemorrhage: massive Incomplete
haematemesis and obstruction
melaena Septicaemia
Intermittent Purulent
symptomatic episodes diarrhoea
Patient Cause = often Women are affected Risk factors: Causes: Causes: Age: <40 – esp. 10-20 Main cause = too low
obstruction by stones 4x more Bad diet Affected more Perforation of an yrs rare <10 fibre intake
or stenosis (e.g. due to Predisposing factors: Stress Idiopathic ulcer Cause = obstruction Females are affected
pancreatic tumour) – Pregnancy H. pylori – Gallstones Perforation of the with faeces – common more than males
stasis of bile – Obesity infection is often Ethanol small bowel – due in low fibre diets
ascending infection Diabetes acquired in Trauma to something
from the duodenum childhood Steroids sharp and
Alcohol = erosion Mumps distension
of the mucosal Autoimmune Transmural
wall Scorpion/snakes inflammation of
NSAIDs – Hyperlipidaemia the bowel:
blockage of COX1 and appendicitis,
Smoking – hypercalcaemia diverticulitis and
elevated gastrin ERCP Crohn’s
Elevated gastrin Drugs Transmural
inflammation of
other organs:
salpingitis and
cholecystitis
Rupture of colon
due to
constipation =
, often fatal faecal
peritonitis
Typical onset Acute Chronic Chronic Acute Acute Acute Acute
>50 years >40 years Duodenal = 30-50 Alcoholic = <44 Any age 10-20 years >50 years
Stomach = >60 Gallstones = >45
History Systemically unwell + Women + Epigastric pain + History of gallstones or Local peritonitis – First poorly localised + History of constipation
palpable inflammatory epigastrium/RUQ pain triggered by alcohol + severe severe pain and then pain in RLQ + + mild tenderness of
gallbladder mass + + colicky pain + spicy/acidic food + abdominal pain guarding and patient systemically the left iliac fossa +
RUQ tenderness esp. triggered by fat meals hunger pain radiating to the back + tenderness + unwell + young patient grumbling pain +
upon inspiration jaundice generalised peritonitis erratic bowel
– shock and sepsis movements
Treatment Acute cholecystectomy Normally surgery: Control predisposing Mild attacks: Surgical emergency – Preference = Take out Sigmoid
within a few days after cholecystectomy – or aggravating cause: Fluid resuscitation treat on clinical laparotomy – view of colon:
the attack gold standard = Lifestyle Analgesia suspicion the adjacent structures Hartmann
ABs: when the patient laparoscopy Stop aspirin or Treat Local peritonitis: treat In women always procedure = make
has bacterial infection Only laparotomy with NSAIDs predisposing the underlying laparoscopy a stoma
ERCP with papillotomy unexpected difficulties Stress factors problem Resuscitation Anastomosis of
= to relieve obstruction or complications Elimination of H. Severe attacks: Generalised Antibiotic prophylaxis: the colon to the
If patient is not fit for pylori: omeprazole + ARDS – peritonitis: metronidazole rectum
surgery: antibiotics ventilatory 1. Fluid resuscitation (anaerobic) + Lifestyle: high-fibre
chenodeoxycholic acid (clarithromycin + support 2. High dose if IV sometimes diet
– 50% recurrence after amoxicillin) – Supportive ABs cephalosporin ABs
2 years eradication of often measures: O2, 3. Urgent (aerobic) 2 hrs IV fluids = to rest the
Side effects: long-term within 1 fluids and laparotomy before surgery bowel
Severe diarrhoea week nasogastric tube Conservative = in suppository
Hepatic damage Diminishing irritant CRP patients unfit for Peritoneal toilet = if
Indications for surgery effects of acid-pepsin: measurements surgery: pus or faeces were
= symptomatic antacids Regular liver Nasogastric found
gallstones or gallstones Administration of enzyme tests to aspiration
that could become mucosal protective test for biliary IV fluids
symptomatic in the agents: sucralfate obstruction Gastric acid
future Reduction in acid Renal function suppression
Relief jaundice before secretion: tests ABs
surgery by endoscopic H2 receptor NO ABs
sphincterotomy = blocking agents = Endoscopic
stone extraction and cimetidine and surgery for
bile duct stenting ranitidine gallstones
Proton-pump
inhibitors:
omeprazole
Surgical
vasectomy = rare
Partial gastrectomy =
removal of affected
tissue
Correction of
secondary anatomic
