1
Q
Define peritonitis
A
Inflammation of the serosal membrane that lines the abdominal cavity and the organs contained therein
2
Q
Describe causes of peritonitis
A
Usually sterile, reacts to chemical and mechanical stimuli. Abdominal infection can be peritonitis (generalised infection) or intra-abdominal abscess (localised).
Infection usually after perforation of an organ, but can be due to foreign bodies, bile acids or stomach acid entering the space.
3
Q
Define classifications of peritoneal infection
A
- Primary: from haematogenous dissemination/bacteria across gut wall, usually in the setting of an immunocompromised state. Most often spontaneous bacterial peritonitis, seen mostly in patients with chronic liver disease
- Secondary: related to a pathologic process in a visceral organ, such as perforation or trauma, including iatrogenic trauma. The most common form of peritonitis encountered in clinical practice
- Tertiary: persistent or recurrent infection after adequate initial therapy. Often develops in the absence of the original visceral organ pathology. Usually immunocompromised individuals. TB peritonitis is a problem among HIV+ve individuals.
4
Q
How is peritonitis diagnosed?
A
Usually clinical
Peritoneal lavage if non-conclusive signs/history not available
Need to find cause it secondary peritonitis (erect CXR for free gas, CT scan, amylase, lipase, bilirubin, ALP, lactate, ß-HCG, urinalysis, stool culture, toxin assays)
5
Q
Describe pathophysiology of secondary peritonitis
A
- Secondary peritonitis results from direct spillage of luminal contents into the peritoneum (eg, perforated peptic ulcer, diverticulitis, appendicitis, iatrogenic perforation)
- With the spillage of the contents, gram-negative and anaerobic bacteria, including common gut flora, such as E. coli and Klebsiella pneumoniae, enter the peritoneal cavity
- Endotoxins produced by gram-negative bacteria lead to the release of cytokines that induce cellular and humoral cascades, resulting in cellular damage, septic shock, and multiple organ dysfunction.
- Usually polymicrobial if colonic rupture
6
Q
Signs and symptoms of peritonitis
A
- Fever and chills (80%) (>38º, <36º)
- Abdominal pain or discomfort (70%) (dull and poorly localized-> more severe and more localized. Worse with movement and local pressure. Patients on steroids, with diabetic neuropathy and extremes of age may present with less pain)
- Worsening or unexplained encephalopathy
- Diarrhea
- Ascites that does not improve following administration of diuretic medication
- Worsening or new-onset renal failure
- Ileus
7
Q
What Qs need to be asked with a pt presenting with ?peritonitis
A
- Recent abdominal surgery
- Previous episodes of peritonitis
- Travel history
- Use of immunosuppressive agents
- Presence of diseases (eg, inflammatory bowel disease, diverticulitis, peptic ulcer disease) that may predispose to intra-abdominal infections
- Anorexia and nausea
8
Q
Differentials to peritonitis
A
- Chemical irritation
- Thoracic processes with diaphragmatic irritation (eg, empyema)
- Extraperitoneal processes (eg, pyelonephritis, cystitis, acute urinary retention)
- Abdominal wall processes (eg, infection, rectus hematoma)
- External hernias (rule out intestinal incarceration)
- Gynae conditions (chlamydia peritonitis, teratoma, salpingitis)
- Parasitic infections
- Vascular conditions (mesenteric embolus, ischaemic colitis)
9
Q
Treatment of peritonitis
A
- Find cause (if primary, parecentesis, drain and irrigate)
- MC&S with pH (see if faecal contents or bile)
- Broad spectrum abx
- Drain abscess
- Laparotomy?
10
Q
What are the causes of pancreatitis?
A
GET SMASHED Gall stones (38%) Ethanol (35%) Trauma (1.5%) Steroids Mumps Autoimmune Scorpion bites (Trinidad) Hyperlipidaemia, hypothermia, hypercalcaemia ERCP and emboli Drugs
11
Q
How many people have unexplained pancreatitis?
A
10-30%
12
Q
Mortality of pancreatitis
A
12%
13
Q
How does pancreatitis cause mortality?
A
Oedema and fluid shifts-> hypovolaemia
Fluid trapped in gut, peritoneum, retroperitoneum
Enzyme mediated autodigestion -> necrosis and infection
Protease induced coagulation cascade, complement activation, kinin, fibrinolytic cascade, oxidative stress
14
Q
Signs and symptoms of pancreatitis
A
Symptoms: • Severe epigastric pain/central abdo pain • Pain radiates to back, relieved by sitting forward • Vomiting Signs: • Tachycardia • Fever • Jaundice • Shock • Ileus • Rigid abdomen • Periumbilical bruising (Cullen’s) and flank bruising (Grey Turner’s) due to blood vessel autodigestion and retroperitoneal haemorrhage
15
Q
Differential diagnoses to pancreatitis
A
- Perforated duodenal ulcer
- Mesenteric infarction
- MI
16
Q
What is the modified glasgow score?
A
Assesses severity and predicts mortality
Valid for alcohol and gallstones
17
Q
What are the sections of the modified glasgow score?
A
PANCREAS PaO2: <8 Age: >55 Neutrophils: >15 Ca2+: <2 Renal function: Urea>16 Enzymes: LDH>600, AST>200 Albumin: <32 Sugar: >10
18
Q
What investigations need to be carried out in pancreatitis?
A
FBC: WCC raised
Raised amylase (>1000) and raised lipase
U&E: dehydration and renal failure
LFT: cholestatic picture (raised AST and LDH)
Low calcium, raised glucose
CRP: raised if severe (>150)
ABG: hypoxia if respiratory distress
Urine: glucose, conjugated bilirubin, decreased urobilinogen
CXR: exclude perforated duodenal ulcer, ARDS?
AXR: pancreatic calcification?
USS: Gallstones, dilated pancreatic ducts, inflammation
Contrast CT (look for pancreatic necrosis)
19
Q
Management of pancreatitis
A
- Hourly obs and urine output
- IV fluids! Until UO>30ml/hr
- Pancreatic rest (nil by mouth, NG tube if vomiting, TPN to prevent catabolism)
- Analgesia (PETHIDINE/MORPHINE)
- Laparotomy and debridement
- ERCP and gall stone removal if progressive jaundice
20
Q
Complications of pancreatitis
A
- Shock, ARDS, renal failure, DIC, sepsis, hyperglycaemia, hypocalcaemia
- Pancreatic necrosis and pseudocyst
- Abscess, bleeding, thrombosis, fistulae
21
Q
Main causes of chronic pancreatitis
A
Chronic pancreatitis:
70% alcohol
Genetic (CF, HH), Immune, Raised triglycerides, Structural (obstruction by tumour/pancreatic divism)
22
Q
Signs & symptoms of chronic pancreatitis
A
Pain exacerbated by alcohol/fatty food Relieved by sitting back or hot water bottle Steatorrhoea and weight loss Diabetic signs (olyuria, polydipsia) Epigastric mass (pseudocyst)
23
Q
Management of chronic pancreatitis
A
- Diet: no alcohol, reduce fat, increase carbs
- Analgesia, Creon supplementation of enzymes, ADEK vitamins, diabetes treatment
- Surgery if unremitting pain, weight loss, duct blockage (Whipple’s or stenting)
24
Q
10 causes of bowel obstruction
A
- Adhesions
- Hernia
- Colorectal neoplasm
- Diverticular stricture (IBD, surgery, ischaemic colitis, diverticulitis, radiotherapy)
- Volvulus
- Paralytic ileus-> Post –op/pancreatitis/drugs/metabolic/mesenteric ischemia
- Impacted faces/bezoar/worms
- Intussusception
- Gallstones
- Congenital atresia
25
Signs and symptoms of bowel obstruction
* Abdominal distention
* Nausea and vomiting
* Abdominal pain (colicky, central, if localised ?strangulation)
* Absolute constipation (no flatus or faeces)
* Abrupt onset of symptoms (acute obstructive event)
* Chronic constipation, straining at stools (diverticulitis/carcinoma)
* Changes to stool caliber (carcinoma)
* Recurrent left lower quadrant abdo pain over several years (diverticulitis/diverticular stricture)
26
What examinations need to be done in ?bowel obstruction?
* Bowel sounds? (increased in mechanical obstruction, decreased in ileus)
* Inspect, auscultate, percuss abdo (distention)
* Check for incarcerated hernia
* Surgical scars
* Anal patency in neonate? Content of anal vault, faecal occult blood test
27
Diagnosis of bowel obstruction needs what investigations?
* FBC (raised WCC)
* U&E: dehydration, electrolyte abnormalities
* Amylase (very high if strangulation/perforation)
* Group and save + clotting (for poss surgery)
* Erect CXR for perforation
* AXR (>3cm with valvulae coniventes=small bowel, >6cm with haustra=large bowel, >9cm caecum)
* CT can show transition point
* Gastrograffin studies (shows mechanical obstruction)
* Colonoscopy (may be used therapeutically to stent in volvulus, can perforate)
28
Treatment of bowel obstruction
* Resuscitate (drip and suck-> NMB, IV fluids, NG tube to prevent aspiration and stop vomiting, monitor urine output)
* Analgesia
* Abx cef + met if strangulation/perforation
* Gastrograffin study (oral/NG tube)
* Monitor
* Surgery if closed loop obstruction/neoplasm/strangulation/perforation/failure of conservative management
* Resection of obstructing lesion/bypass if unresectable
* Endoscopic metal stents in palliation
29
4 classifications of UTIs
* Uncomplicated (normal GU tract and function)
* Complicated (abnormal GU tract/outflow obstruction/reduced renal function/impaired host defence/virulent organism
* Recurrent with different organism
* Relapse with same organism
30
Risk factors for UTI
* Female
* Sex
* Pregnancy
* Menopause
* Diabetes mellitus
* Abnormal tract (stone/obstruction/catheter/malformation)
31
Signs and symptoms of UTI
* Pyelonephritis: fevers, rigors, loin pain, vomiting, oliguria
* Cystitis: frequency and urgency, polyuria, haematuria, dysuria, suprapubic tenderness, foul smelling urine
* Prostatitis: flu-like, low backache, dysuria, tender swollen prostate on PR
* Sterile pyuria-> TB? Appendicitis? Calculi? Papillary necrosis? Polycystic kidney? Chemical cystitis?
32
List 4 common organisms causing UTIs
E. coli
Staph. Saprophyticus
Proteus (alkaline urine)
Klebsiella
33
What investigations are done in UTI diagnosis
* Dipstick
* MSU for MCS
* FBC, U&E and blood cultures if systemic signs
* USS (in men, children, recurrence or pyelonephritis)
34
Treatment of UTIs
* Drink plenty, urinate often
| * Abx (trimethoprim/nitrofurantoin for cystitis) (cefotaxime for pyelonephritis)
35
3 categories of causes of urinary tract obstruction
Luminal
Mural
Extramural
36
3 luminal causes of urinary tract obstruction
Stones
Blood clots
Sloughed papilla
37
3 mural causes of urinary tract obstruction
* Congenital/acquired stricture (trauma/Gonorrhoea/chemo)
* Tumour (renal/ureteric/bladder)
* Neuromuscular dysfunction
38
3 extramural causes of urinary tract obstruction
* Prostatic enlargement
* Abdo/pelvic mass or tumour
* Retroperitoneal fibrosis
39
Acute versus chronic presentation of a urinary tract obstruction
Acute:
• Loin to groin pain (upper)
• Severe suprapubic pain and palpable distended bladder (lower)
Chronic:
• Renal failure and flank pain
• Frequency, hesitancy, poor stream, terminal dribbling, overflow incontinence
• Distended, palpable bladder +- large prostate
40
What investigations are undergone in urinary tract obstruction?
```
FBC, U&E, Creatinine/urea ratio
Urine dipstick
USS (hydronephrosis? Hydroureter?)
Uterograms (allow therapeutic drainage)
CT/MRI
Urodynamics
```
41
Management of urinary tract obstruction
Nephrostomy
Ureteric stent
Urethral/suprapubic catheter
42
Name 7 complications of ureteric stents
```
Infection
Haematuria
Trigonal irritation
Encrustation
Obstruction
Ureteric rupture
Stent migration
```
43
Name 12 causes of liver failure
* Viral (Hep B, C, CMV)
* Yellow fever
* Leptospirosis (bacteria from animals)
* Drugs (paracetamol OD, halothane, isoniazid)
* Toxins (Amanita phalloides mushroom, carbon tetrachloride)
* Veno-occlusive disease
* Alcohol
* Primary biliary cirrhosis
* Haematochromatosis
* Wilson’s disease
* α-1 antitrypsin deficiency
* Malignancy
* HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) in PET
44
Why does ascites occur in liver failure?
Hypersplenism so less blood in circulation-> RAAS-> fluid imbalance
+ Low albumin due to liver failure-> lower oncotic pressure, fluid not pulled back into capillaries
45
What causes hepatic encephalopathy
Raised ammonia as liver fails, brain converts it to glutamine, causes osmotic imbalance and cerebral oedema.
Confusion, drowsiness, coma
46
Signs of liver failure
* Jaundice
* Ascites
* Hepatic encephalopathy
* Fetor hepaticus (breath smells like pear drops)
* Liver flap (asterexisis)
* Constructional apraxia (can you draw a star?)
* Signs of chronic liver disease
* Signs of portal hypertension
47
Liver failure causes what type of jaundice?
Hepatic jaundice
| Unconjugated bilirubin in blood
48
Give 6 signs of portal hypertension
```
Caput medusa
Oesophageal varices & haematemesis
Melaena
Ascites
Haemorrhoids
```
49
What tests are done in a pt with liver failure
* CRP, WCC (infection)
* FBC (anaemia, GI bleed)
* Clotting & LFTS (extent of liver failure)
* Paracetamol levels
* Ferritin
* α-1 antitrypsin
* Autoantibodies
* Blood, urine and ascitic fluid MC&S
50
Treatment of ascites from hepatic failure
Fluid restriction, low salt, osmotic diuretic (MANNITOL)
51
Treatment of cerebral oedema due to hepatic failure
MANNITOL IV, hyperventilate, LACTULOSE & laxatives to alter gut bacteria
52
Which abx should be used for liver failure-> infection
Ceftriaxone (avoid Gent)
53
How do you treat bleeding associated with hepatic failure?
Vit K, platelets, FFP, blood
54
What should be avoided when treating hepatic failure
Avoid sedatives and hepatically metabolised drugs
| Avoid gentamycin
55
Management of someone in liver failure
* Be aware of hypoglycaemia, GI bleed, sepsis, encephalopathy
* Treat at 20º tilt in ITU
* Intubate & NG insertion
* Urinary and venous catheters (fluid balance)
* 10% dextrose IV to avoid hypoglycaemia
* Treat cause if known (sepsis/GI bleed, paracetamol OD ACETYL-CYSTEINE)
* Thiamine & folate supplements
* Monitor renal function (haemodialysis?)
* PPI (LANSOPRAZOLE)
* Transplant?
56
Name 5 poor prognostic indicators in liver failure
* Coma/stupor
* Age>40
* Albumin<30g/L
* Raised INR
* Drug induced
57
Define liver cirrhosis
| Common pathophysiology?
Irreversible liver damage with bridging fibrosis and nodular regeneration
Due to:
1) Chronic alcohol abuse, obesity & genes-> steatohepatitis-> fibrosis-> cirrhosis
2) Hepatitis virus -> fibrosis-> cirrhosis
Acute Care
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