PERITONITIS

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

Management

  • 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
  • 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