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Chapter 4: Clinical 143

Table 4.2 Alarm symptoms and signs The most common type of peritonitis is acute suppu-
rative secondary to visceral disease (see section on The
Unintentional weight loss Unexplained iron deficiency
(≥3 kg) anaemia Acute Abdomen).
Gastrointestinal bleeding Dysphagia or odynophagia Postoperative peritonitis may result from persistence
Previous gastric surgery Persistent continuous of infection present at the time of surgery or from
vomiting complications such as anastomotic breakdown.
Epigastric mass Suspicious barium meal
Previous gastric ulcer
Clinical features
Peritonitis presents with pain, tenderness, rebound ten-
derness and excessive guarding. Movement exacerbates
undergo an upper gastrointestinal endoscopy. Antise-
the pain, so patients often lie very still and have a rigid
cretorydrugs(i.e.H 2 antagonistsandprotonpumpin-
abdomen on attempted palpation (stiff as a board).
hibitors)maymasksignificantdiagnosesatendoscopy
and should be avoided for 4 weeks before investiga-
Complications
tion. At endoscopy, biopsy and urease tests should be
Infection may spread to the blood stream (septicaemia)
performed.
form subphrenic or subhepatic abscesses.
In patients under the age of 55 years with significant

symptoms but without any ‘alarm symptoms or signs’
antisecretory agents may be commenced. It is recom- Microscopy
An acute inflammatory exudate is seen with cellular in-
mended that such patients should undergo Helicobac-
filtration of the peritoneum.
ter pylori testing and where appropriate, eradication
therapy (see later in this chapter).
Investigations
The diagnosis is clinical, further investigation depends
on the possible underlying cause.
Peritonitis
Definition Management
Peritonitis is inflammation of the peritoneal lining of the Managementinsecondaryperitonitisisaimedatprompt
abdomen. Peritonitis may be acute or chronic, primary surgical treatment of the underlying cause (after ag-
or secondary. gressive resuscitation). Primary or postoperative peri-
tonitis, which is non-surgical in origin, is managed
medically.
Aetiology/pathophysiology Nilby mouth, i.v. fluids and nasogastric tube with
Infection can reach the peritoneal cavity from pene- aspiration (drip and suck).
trating trauma or surgery, from the abdominal viscera, Broad-spectrum antibiotics.
from the female genital tract or as a result of a septica- Drainage of any abscess or collection (either surgically
emia. or ultrasound guided aspiration).
Primary acute peritonitis is rare: It is most commonly

duetoEscherichiacoli:Bacteriaarethoughttobetrans-
ferred from the gut or bloodstream. Patients undergo- Intestinal obstruction
ing peritoneal dialysis are at particular risk of recur- Definition
rent acute peritonitis, which may result in fibrosis and Intestinal obstruction results from any disease or process
scarring preventing further use of this type of dialysis. that impedes the normal passage of contents. It may be
Chronic liver disease patients with ascites are at risk acute, subacute, chronic or acute on chronic.
of developing a less symptomatic form called sponta-
neous bacterial peritonitis. Aetiology
Chronic infective peritonitis occurs from tuberculous The common causes vary according to age. Neonatal ob-

peritoneal infections. structionmayresultfromameconiumileus,anatresiaof