Peritonitis: Introduction and Management m.j.lee@sheffield.ac.uk @wannabehawkeye Mr M Lee, Clinical Research Fellow in General Surgery

Outline What is peritonitis? Why is it important? What are the causes? How do we treat it?

Inflammation of the peritoneum 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 it’s better …or beg you not to examine

Clinical Examination Localised vs generalised Point-tenderness vs rigid abdomen Systemically shocked

Investigations Blood tests X-rays of chest and abdomen CT 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

Location of collection Abscess formation Patient position Location of collection Standing Pelvis Supine Left or right paracolic gutter Suprahepatic/ sub-phrenic

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 status Assessing risk (P-POSSUM, ASA) Conservative treatment Palliation

In summary Peritonitis is bad Toxins are absorbed Systemic upset Treat underlying cause and complications

Further learning Good for basic knowledge Lecture notes in General Surgery (Ellis, Calne, Watson) Bailey and Love’s Short Practice of Surgery Good for quick revision Oxford handbook of surgery Surgery at a glance Experience is the best tutor for emergency surgery and peritonitis. Visit the surgical admissions unit and emergency theatre to learn more m.j.lee@sheffield.ac.uk @wannabehawkeye