Mild Colic and Pyrexia: Peritonitis Diagnosis and Treatment

what needs to change if pyrexia with colic

Reassess the assumption of uncomplicated colic

Repeat the complete physical examination

Look for gastrointestinal and extra-abdominal disease

Track pain, temperature and cardiovascular status

Escalate investigation if abnormalities persist

dont jsut focus on the git

gi ddx for colic with pyrexia

Septic or non-septic peritonitis

Enteritis, often with substantial reflux

Colitis, before or after diarrhoea develops

Abdominal abscessation

Compromised or leaking intestine

non gi ddx for colic with pyrexia

Pleuropneumonia

Other respiratory infection

Postoperative incisional infection

Jugular thrombophlebitis

Other systemic inflammatory disease

non septic causes on peritonitis

Neoplasia

Chemical or inflammatory irritation

Urine, bile or other sterile fluid

Recent abdominal surgery

septic causes of peritonitis

Gastrointestinal leakage or rupture→ cant lavage the abd → poor prognosis

Haematogenous bacterial spread

Abdominal abscessation→ usually medical management (mo of abx)

Postoperative contamination or dehiscence

Penetrating or iatrogenic injury

clinical investigation for colic with pyrexia

History, medication and recent surgery

Full physical examination and perfusion assessment

Gastrointestinal auscultation, rectal examination and ultrasonography

Nasogastric intubation when indicated

haem and biochem

Thoracic auscultation and imaging when respiratory disease is possible

Abdominocentesis to confirm peritoneal inflammation

how to confirm peritonitis

adbomino centesis

what is assessed in abdominocentesis

Assess colour, turbidity and volume

Measure cell count and total protein

Examine cytology for degeneration and intracellular bacteria

Compare peritoneal and blood lactate or glucose where useful

Submit aerobic and anaerobic culture before antimicrobials if possible

Interpret postoperative samples cautiously→ handing in surgery can show incrs wbcc and nucleated cell count → probs not infection

what is the intial treatment for peritonitis

Broad-spectrum intravenous antimicrobials for suspected sepsis

Intravenous fluids and electrolyte correction

Analgesia with repeated assessment

Management of endotoxaemia and ileus where indicated (sepsis, SIRs)

Nutritional support when gastrointestinal function allows

Refine treatment when culture and source are known

what abx to use for peritonitis

• penicillin-gentamycin

  • broad spec, hospital

• oxytetracycline or tmps

  • ambulatory

when will treatment succeed

onyl if source of contam is controlled

how to control the source

Identify and treat the source, not only the peritoneal inflammation

Gastrointestinal leakage usually carries a poor prognosis

Abdominal lavage or drainage benefits selected cases

Abscessation may require treatment for months

Surgery requires a defined, surgically accessible target

Exploratory surgery alone may not improve outcome

what complications should be monitored in peritonitis

Ileus and persistent reflux

Adhesion formation

Endotoxaemia (sepsis) and laminitis

Abdominal abscessation

Organ dysfunction

what extra abd complications should be monitored for

Jugular thrombophlebitis

Incisional infection

Catheter-associated infection

Antimicrobial adverse effects

NSAIDs adverse effects

how can the prognosis differ

The underlying cause determines outcome

Ongoing gastrointestinal leakage has a poor prognosis

Haematogenous infection can have a good outcome

Postoperative cases depend on source control and complications

Clinical trajectory is more informative than one test result

what key clinical decisions need to be made

Confirm peritoneal inflammation with abdominocentesis

Differentiate septic from non-septic disease

Search for the abdominal or extra-abdominal source

Treat sepsis and systemic consequences promptly

Reassess source control and complications repeatedly

Align prognosis with the cause and clinical trajectory

what additional diagnostic information can be gathered

Haematology and biochemistry assess systemic effects

Acute-phase proteins help monitor the inflammatory response

Ultrasonography identifies fluid, fibrin, bowel disease or a mass

Culture guides antimicrobial refinement

Serial examinations show response or deterioration

Thoracic assessment may reveal the primary disease

mild colic respond to

-flunixin

-withholding food

diagnosis of mild colic

-history

-physical exam

-rectal exam for fluid filled colon

-NGT

-haem and biochem

-abdominocentesis

haem and biochem of mild colic

-hypovolaemia

-neutropenia

abdominocentesis of mild colic

increased neutrophils in peritoneal fluid

haematology show

-leukopenia

-haemoconcentration/azotaemia/acidosis

-increased acute phase proteins (confirm inflam and monitor response to treatment)

abdominocentesis show

-total nucleated cell count larger than 5x10^9 cells/L

-cytology

-lactate >2mmol/L

-glucose <2mmol/L

-culture and sensitivity

what tube should be used for culture and sensitivity

plain

why give iv fluids

dehydrated because they feel sick so do not eat or drink

-oral fluids last resort

if antimicrobials and iv fluids fail, what to give

adbo lavage and drainage but not much success