# Diffuse (generalised) peritonitis

Diffuse (generalised) peritonitis

This normally signifies the occurrence of  a life-threatening pathology . It means that regions (not just focal areas) of  the parietes (parietal peritoneum) are inflamed. It normally arises as a result of pressure-related perforation of a viscus (e.g. in the setting of  an obstructed colon), when large volumes of  blood abruptly enter the peritoneal cavity (ruptured aortic aneurysm) or when substantial volumes pour incessantly (albeit not under pressure) into the peritoneal cavity (e.g. perforated duodenal ulcer or anastomotic leak). The patient may describe acute or gradual onset abdomi nal pain of  considerable intensity . The pain may be localised at first and then become di ff use. The patient is gravely ill looking (Hippocratic facies) and usually lies as still as possible to mini mise fluid movement within the peritoneal cavity . The entirety Hippocrates of  Kos , Greek physician and surgeon, and by common consent ‘the father of  medicine’, was born on the island of  Kos, o ff Turkey , about 460 /uni00A0 and probably died in 375 /uni00A0 /b.sc/c.sc/e.sc . and feels board-like on palpation (‘board-like’ rigidity). In a thin patient, contraction of  the rectus abdominis muscles may be reflected in a scaphoid appearance of  the abdomen (see Chapter 63 ). A generalised ileus occurs and the abdomen may become distended. Vital signs are usually deranged. In advanced cases the patient is hypotensiv e, tachycardic and pyrexial. At first the - patient may seem confused, dr owsy and disoriented. If the underlying pathology is not corrected the patient will lose con - sciousness. Signs may be limited in obese patients or in patients on immunosuppressive medications. Investigation and treatment must be undertaken expedi - ently as the time available to salvage ma y be limited. Inves - tigations aim to identify the underlying cause and to guide p- treatment. An erect chest radiograph can be useful in identify - - ing subdiaphragmatic gas ( Figure 65.7 ). If  a patient is particu - larly unwell and a CT is not available, then a lateral decubitus radiograph serves the same purpose as an erect radiograph (provided the patient has been appropriately positioned for long enough for the gas to rise within the peritoneal cavity). tion, . Summary box 65.4 - Clinical features of peritonitis /uni25CF ). /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF /uni25CF m to Summary box 65.5 Management of peritonitis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF - /b.sc/c.sc/e.sc 

Abdominal pain, worse on movement, coughing and deep
respiration
Constitutional upset: anorexia, malaise, fever, lassitude
Gastrointestinal upset: nausea +/– vomiting
Pyrexia (may be absent)
Raised pulse rate
Tenderness +/– guarding/rigidity/rebound of abdominal wall
Pain/tenderness on rectal/vaginal examination (pelvic
peritonitis)
Absent or reduced bowel sounds
‘Septic shock’ (systemic in
/f_l
ammatory response syndrome
[SIRS] and multiorgan dysfunction syndrome [MODS]) in later
stages
General care of patient
Correction of
/f_l
uid and electrolyte imbalance
Insertion of nasogastric drainage tube and urinary catheter
Broad-spectrum antibiotic therapy
Analgesia
Vital system support
Surgical treatment of cause when appropriate
‘Source control’ by removal or exclusion of the cause
Peritoneal lavage +/– drainage



(b)
Figure 65.7
Intraperitoneal perforation.
(a)
Erect chest radiograph
demonstrating air under the diaphragm on the right side.
computed tomography image showing a segment of sigmoid divertic
ulosis with localised perforation (arrow).