Doctors Revision

Gastrointestinal & Hepatic System

Peritonitis

Inflammation of the peritoneum, the membrane lining the abdominal cavity and covering the abdominal organs. Usually caused by bacterial infection following perforation of an abdominal organ or other source of contamination.

Also known as: Acute Abdomen, Inflamed Peritoneum

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Referral and warning signs

When to refer

IMMEDIATE surgical referral/transfer to hospital (H/RR) required for ALL cases of suspected secondary peritonitis for resuscitation, diagnosis, and urgent exploratory laparotomy.

Red flags

  • Severe abdominal pain with guarding and rebound tenderness
  • Rigid ('board-like') abdomen
  • Absent bowel sounds
  • Signs of shock (hypotension, tachycardia, cool peripheries)
  • High fever or hypothermia
  • Free air under diaphragm on X-ray

Signs and symptoms

  • Severe, constant, diffuse abdominal pain.
  • Pain worsened by any movement, coughing, or bumping the bed (patients often lie very still).
  • Abdominal tenderness (generalized or localized initially).
  • Abdominal guarding (involuntary muscle rigidity).
  • Rebound tenderness (pain worse on rapid release of pressure).
  • Abdominal distension.
  • Absent or reduced bowel sounds (paralytic ileus).
  • Fever, chills.
  • Tachycardia, tachypnea.
  • Nausea, vomiting.
  • Signs of dehydration/hypovolemic shock/sepsis (hypotension, cool peripheries, altered mental status, reduced urine output).

Risk factors

  • Perforated viscus (e.g., appendix, peptic ulcer, diverticulum, bowel obstruction/ischemia, gallbladder, typhoid ulcer).
  • Penetrating abdominal trauma.
  • Post-operative complication (anastomotic leak).
  • Pelvic Inflammatory Disease (PID) - ascending infection.
  • Spontaneous Bacterial Peritonitis (SBP) in patients with ascites (cirrhosis, nephrotic syndrome).
  • Peritoneal dialysis-related infection.
  • Tuberculosis (TB peritonitis).

Diagnosis

Clinical assessment

Clinical diagnosis based on characteristic signs of peritoneal irritation (severe pain, tenderness, guarding, rebound tenderness), often with systemic signs of infection/sepsis. Identify potential underlying cause based on history and associated symptoms.

Investigations

  • Abdominal X-ray (Erect chest X-ray and Supine/Erect abdominal X-rays): Look for free air under the diaphragm (pneumoperitoneum - indicates perforation), dilated bowel loops (ileus/obstruction).
  • Abdominal Ultrasound: May identify source (appendicitis, cholecystitis, abscess, free fluid/ascites).
  • CT Scan (Abdomen/Pelvis): Often modality of choice to identify source of peritonitis (perforation site, abscess, inflammation) and guide management.
  • Blood tests: CBC (leucocytosis), U&Es, Creatinine, LFTs, Amylase/Lipase, Blood cultures.
  • Diagnostic Paracentesis (if ascites present): Cell count (neutrophils >250/mm³ suggests SBP), Gram stain, culture.

Diagnostic criteria

Primarily clinical diagnosis based on physical examination findings of peritonism, supported by imaging identifying cause or complications.

Management

Non-pharmacological management

  • Surgical Emergency (usually requires laparotomy):
  • - Urgent surgical consultation.
  • - Exploratory Laparotomy: To identify and control the source of contamination (e.g., repair perforation, appendectomy, bowel resection), followed by peritoneal lavage (washout).
  • Resuscitation:
  • - NPO (Nil by mouth).
  • - Insert Nasogastric (NG) Tube for decompression/suction.
  • - Aggressive IV Fluid Resuscitation: Crystalloids (Normal Saline, Ringer's Lactate) to restore circulating volume and maintain organ perfusion. Monitor urine output (insert Foley catheter).
  • - Oxygen therapy if hypoxic.
  • - Monitor vital signs closely (BP, HR, RR, SpO2, Temp).

Pharmacological treatment

  • Broad-Spectrum IV Antibiotics: Start immediately after diagnosis suspected/cultures taken. Cover Gram-negatives, Gram-positives, and anaerobes.
  • - Example Regimen (UCG): Ceftriaxone 1-2g IV daily PLUS Gentamicin 5-7mg/kg IV daily PLUS Metronidazole 500mg IV Q8H.
  • - Adjust based on suspected source, local resistance patterns, and culture results when available.
  • - Duration typically 7-10 days or longer depending on source control and clinical response.
  • Analgesia: Opioids (e.g., Morphine IV, Pethidine IV/IM) for severe pain. Avoid NSAIDs.
  • Supportive medications: Antiemetics, vasopressors (if septic shock).
  • Specific treatment for SBP: Third-generation cephalosporin (e.g., Cefotaxime, Ceftriaxone) + Albumin infusion.

Monitoring

  • Frequent monitoring of vital signs, urine output, abdominal exam.
  • Monitor response to fluids and antibiotics.
  • Monitor electrolytes, renal function, CBC.
  • Monitor for complications (ongoing sepsis, abscess formation, organ failure).

Complications

  • Sepsis / Septic shock
  • Multi-organ failure (renal, respiratory, hepatic)
  • Intra-abdominal abscess formation
  • Paralytic ileus
  • Wound infection / Dehiscence
  • Adhesive small bowel obstruction (late)
  • Death

Prevention

  • Early diagnosis and treatment of conditions that can lead to perforation (appendicitis, PUD, diverticulitis, obstruction).
  • Appropriate management of ascites (diuretics, SBP prophylaxis if indicated).

Patient education

  • Explanation of the serious condition and the need for urgent surgery.
  • Post-operative care, potential complications (wound infection, abscess).
  • Explanation of underlying cause if identified.

Uganda-specific notes

Often presents late with established sepsis. Common causes include perforated typhoid ulcers, appendicitis, PUD. Access to imaging (CT) and critical care is limited. Early recognition, fluid resuscitation, broad-spectrum antibiotics, and timely laparotomy are crucial.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 6, Section 6.1.4

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