Special
forms of peritonitis
Postoperative
The patient is ill, with raised pulse and
peripheral circulatory failure. Following an anastomotic dehiscence the general
condition of a patient is usually more serious than if the patient had suffered
leakage from a perforated peptic ulcer with no preceding operation. Local
symptoms and signs are less definite. Abdominal pain may not be prominent and is
often difficult to assess because of normal wound pain and postoperative
analgesia. The patient’s deterioration may be wrongly attributed to
cardiopulmonary collapse which is usually concomitant.
Peritonitis
follows abdominal operations more frequently than is realised. The principles of
treatment do not differ from those of peritonitis of other origin. Antibiotic
therapy alone is inadequate; no antibiotic can stay the onslaught of bacterial
peritonitis due to leakage from a suture line, which must be dealt with by
operation.
In
patients under treatment with steroids
Pain is frequently slight or absent. Physical
signs are similarly vague and misleading.
In
children
The diagnosis is in some ways more difficult,
in other ways easier, than in adults. If a history can be taken it
is plain and
unembroidered. Any physical signs elicited by a gentle, patient and sympathetic
examiner are meaningful.
In
senile patients
These can be as fractious as children and
unable to give a reliable history. Abdominal tenderness is usually well
localised, but guarding and rigidity are less marked because the abdominal
muscles are thin and weak.
Bile
peritonitis
Unless there is reason to suspect that a bile
duct was damaged at an operation, it is improbable that bile as a cause of peritonitis will be thought of
until the abdomen has been opened and bile is seen therein. The common causes of
bile peritonitis are shown in Table 56.6. Unless the bile has extravasated
slowly and the collection becomes shut off from the general peritoneal cavity
there are signs of diffuse peritonitis. After a
Meconium
peritonitis
Meconium is a sterile mixture of epithelial
cells, mucin,
salts, fats and bile
and is formed
when the foetus commences to swallow amniotic fluid. By the third month of intrauterine life the upper third of the small intestine
has become filled
with meconium; by the fourth month the accumulation has reached the ileocaecal valve; during
the remainder of intrauterine life the colon becomes increasingly filled.
Meconium
peritonitis is an aseptic peritonitis which develops late in intrauterine life
or during, or just after, delivery. Meconium enters the peritoneal cavity
through an intestinal perforation and in over 50 per
Meconium
remains sterile until about 3 hours after birth; thereafter, unless the perforation has become sealed, sterile meconium
peritonitis gives place to acute bacterial peritonitis which, unless treated promptly, is rapidly fatal.
Clinical
features. Meconium
peritonitis
should always he considered when a baby is born with a tense abdomen. There is
vomiting and failure to discharge meconium. The differential diagnosis between
neonatal intestinal obstruction and peritonitis is, in many cases, virtually
impossible; indeed in half the cases both are present. Free fluid in the
peritoneal cavity
is often sufficient to give a fluid thrill. Meconium ileus occurs in 5—10 per
cent of newborn babies with cystic fibrosis (mucoviscidosis) who have an inherited
autosomal recessive abnormality of mucus secretion. This leads to secondary
damage to the pancreas, lungs, liver and small bowel. Bronchial obstruction by
mucus plugs can cause fatal pneumonia.
Radiography
(Fig. 56.11). Free air in the peritoneal cavity, an abundant quantity of abdominal
fluid, fluid
levels, calcification (often most distinct on the surface of the liver or the
spleen and most readily seen in a lateral view) are characteristic findings, all
of which are unlikely to be present in every case. Meconium peritonitis has been
diagnosed by radiography of the foetus in utero 2
days before birth.
Treatment.
The prognosis
is bad, but recovery may follow prompt operation. The greatest chance of survival is in those patients who have an
intestinal perforation but no intestinal obstruction, in which case closure of
the perforation and drainage of the peritoneal cavity are performed
expeditiously. Intestinal lavage can prevent reformation of meconium bolos
obstruction and supplements of pancreatic exocrine enzymes are often necessary
throughout life. If there is an associated pulmonary problem, the condition
requires special treatment (e.g. oxygen, bronchial lavage, nebulisers and
long-term use of antibiotics).
Pneumococcal
peritonitis
There are two forms of this disease: (1) primary, and (2) secondary to pneumonia.
Primary
pneumococcal peritonitis is much more common. The patient is often an undernourished girl between 3 and 6 years of age, and it
is
Clinical
features. The onset is
sudden and the earliest symptom
is pain localised
to the lower half
of the abdomen. The temperature
is raised to 39.80C
or more
and there is
usually frequent vomiting. After 24—48 hours profuse diarrhoea, occasionally blood-stained, is characteristic.
There is usually
increased frequency
of micturition. The last two symptoms
are due
to severe pelvic peritonitis. Herpes on the lip or nostril is often present. In acute forms of the disease,
even in cases where there is no involvement of a lung, there is a tinge of cyanosis
of the lips and
cheeks and movement of the alae nasi is often discernible. On examination
rigidity is usually bilateral but is less than in most cases of acute
appendicitis with peritonitis.
Differential
diagnosis. A leucocytosis of 30000/mm3 (30 x 109/litre) or more with approximately 90 per cent polymorphs suggests
pneumococcal peritonitis rather than appendicitis. Even so, it
is often
impossible, especially in males to exclude perforated appendicitis. The other
condition which is extremely difficult to differentiate from primary peritonitis
in its early stage is pneumonia. An unduly high respiratory rate and the absence
of abdominal rigidity are the most
important signs supporting the diagnosis of pneumonia, which is usually clarified by a chest X-ray.
Treatment.
Early operation is always required. After starting antibiotic therapy and
correcting dehydration and electrolyte imbalance, a short midline incision is
made. The peritoneum is incised. Should the exudate be odourless and sticky, the
diagnosis of pneumococcal peritonitis is practically certain, hut it
is essential to
perform a routine laparotomy to exclude other lesions. Assuming that no other
cause for the peritonitis is discovered some of the excudate is removed with a
syringe and sent
to the laboratory
for culture and
sensitivity tests. Thorough peritoneal lavage is carried out and the incision closed. The patient is returned to
bed, and antibiotic and fluid replacement
therapy continued. Nasogastric suction drainage is essential. Recovery is usual.
Primary
streptococcal peritonitis of infants and children
Primary streptococcal peritonitis of infants
and children is rather more frequent than pneumococcal peritonitis but still
uncommon. When a streptococcus is the infecting organism the peritoneal exudate
is thin and slightly clouded and contains flecks of fibrin. The clinical
presentation and treatment of streptococcal peritonitis in infants and children
are similar to those of pneumococcal peritonitis (see above), hut the mortality
is higher. An intravaginal foreign body should always be looked for in female
patients.
Idiopathic
streptococcal and staphylococcal peritonitis in adults
Idiopathic streptococcal and staphylococcal peritonitis in adults is fortunately rare,
for prior to the antibiotic era it was nearly always fatal and the
mortality is still very high. Rightly, in early cases the abdomen is opened,
usually on a
diagnosis of acute appendicitis. In streptococcal peritonitis the peritoneal
exudate is odourless, thin, contains some flecks of fibrin and may he blood stained. In these circumstances pus is removed by suction, the abdomen closed with
drainage and nonoperative treatment of peritonitis performed. Recently the use
of intravaginal tampons has led to an increased incidence of Staphylococcus
aureus infections: these can be associated with toxic shock syndrome’ and
disseminated intravascular coagulopathy.
Peritonitis
following abortion/patturition
The abortionist has usually pushed an
instrument through the uterine vault and streptococcal peritonitis follows.
Peritonitis following puerperal infection is more common after first deliveries.
Rigidity is seldom much in evidence; this, at any rate in part, is due to the
stretched condition of the abdominal musculature. The lochia may he offensive
but not necessarily so. Diarrhoea is common.
Treatment.
Provided the infection is limited strictly to the pelvis, the correct treatment
is to rest the gastrointestinal tract and provide intravenous fluids, the
required antibiotics and attention to electrolyte balance. Posterior colpotomy
may be necessary if a pelvic abscess forms. If the peritonitis is generalised,
the patient is usually extremely ill and drainage is advisable. This may
be carried out by
making a small suprapubic incision under local anaesthesia and inserting a
drain, which can be done with the patient in bed, if necessary.
In
the pre
antibiotic
era the mortality of general peritonitis following parturition or
abortion was at
least 50 per cent; with antibiotic therapy and timely operation, the mortality
has fallen to less than 10 per cent (Brews).
Familial
Mediterranean fever (periodic peritonitis)
Familial Mediterranean fever (periodic
peritonitis) is characterised by abdominal pain and tenderness, mild pyrexia,
polymorphonuclear leucocytosis and occasionally pain in the thorax and joints.
The duration of an attack is 24—72 hours, when it is followed by complete remission but exacerbations
recur at regular intervals. Most of the patients have undergone appendicectomy in childhood. This disease,
often familial, is limited principally to Arabs, Armenians and Jews; other races
are occasionally affected. The aetiology is unknown. Usually children are
affected hut it is
not rare for the disease to make its first appearance in early adult life when
females outnumber males by two to
one.
Exceptionally the disease becomes manifest in patients over 40 years of age. At
laparotomy, which may be necessary to exclude other causes, the peritoneum —
particularly in
the vicinity of the spleen and the gall bladder — is inflamed. There is no evidence that the interior of these organs is
abnormal. Colchicine may prevent recurrent attacks.
Differential
diagnosis. Patients with abdominal epilepsy do not have positive physical signs
of pyrexia and their attacks are usually controlled by anticonvulsive
medication.