1. Peritonitis: Introduction and Management
@wannabehawkeye
Mr M Lee,
Clinical Research Fellow in General Surgery

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

3. Inflammation of the peritoneum
Peritonitis is…
Inflammation of the peritoneum

4. 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

5. Intraperitoneal space
The peritoneum can hold >5L of fluid/pus/blood
Large absorptive area

6. 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

7. 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

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

9. Investigations Blood tests X-rays of chest and abdomen
CT scan of abdomen
B-HCG!
ECG

10. Treatment ABC Treat the underlying cause and treat it early
Call a surgeon
Source control
Post-management support

11. Not just a belly problem…
Complication of peritonitis
Hypovolaemia
Kidney failure
Systemic Sepsis
Paralytic ileus
Pulmonary atelectasis/pneumonia
Portal pyaemia

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

13. Primary peritonitis

14. Primary Peritonitis Spontaneous Bacterial Peritonitis Ascites
Immunocompromised (lymphoma/peritoneal dialysis)
Diagnosis is an ascitic tap/blood cultures
Treatment is broad spectrum antibiotics
No operation!

15. Secondary peritonitis

16. 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

17. Diagnosis

18. Case 2 23 y.o. F Sudden onset low abdominal pain Acutely hypotensive
Missed last period
Referred to general surgery as ?appendicitis

19. Diagnosis?

20. Case 3 50 y.o. male Smoker, diabetic
Sudden onset abdominal pain, 10/10
Not settling with morphine

21. Diagnosis?

22. Case 4
75 year old smoker
B/g acid reflux, uses ibuprofen for arthritis
Previous MI
Sudden onset epigastric pain
Board like abdomen

23. Diagnosis?

24. Important considerations
Pre-morbid status
Assessing risk (P-POSSUM, ASA)
Conservative treatment
Palliation

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

26. 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
@wannabehawkeye