Types of peritonitis and management. J olita Augus te, PGY-5 SUNY Downs tate Grand Rounds 11/3/2016

Transcription

1 Types of peritonitis and management J olita Augus te, PGY-5 SUNY Downs tate Grand Rounds 11/3/2016

2 Case Presentation xx year old patient presents to ED with complaints of one day of abdominal pain s ince his dis charge from an OSH. Patient was recently admitted to Hos pital 7 days prior for Colonoscopy and suffered a perforation. He was taken urgently to the OR and underwent an Exploratory laparotomy, sigmoid res ection with primary anas tomos is. PMHx: HIV (viral load undetectable as per patient) PSHx: (1980s) Exploratory Laparotomy, small bowel resection with anastomosis for GSW; (10 days prior) Exploratory Laparotomy, sigmoid resection and anastomosis Meds: Atripla NKDA

3 Case Presentation Vitals: afebrile, 106, 99/56 Labs: Lactate 1.7 PE: Moderately distended, tender near incision site, wound had a 1 cm inferiorly which was being packed previously, serous drainage noted but no purulence Given 1L bolus and and Zosyn for presumed sepsis CT PE: negative for PE CT A/P: Small bowel obstruction likely secondary to adhesions. Small areas of pneumatosis intestinalis and portal venous gas, concerning for bowel ischemia. Free air and post surgical changes, compatible with known recent laparotomy Coags: WNL

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52 Hospital Course HD # 1 P OD # 1-2 Taken to OR for Exploratory Laparotomy, abdominal washout, diverting loop ileostomy creation, and pelvic drain placement Findings : 1.5L of purulent/feculent fluid; multiple interloop abscesses EBL: 50cc, IVF: 1500 Peritoneal fluid was pos itive for GNRs ; Zosyn was continued NGT removed and patient advanced to clears

53 Hospital Course P OD # 4 P OD # 5-6 P OD # 8-12 WBC normalized, Micro res ulted with ESBL E coli, s witched to Meropenem NPO for vomiting Regular diet Rehab cons ulted and recommended Acute rehab J P drain removed ID recommended 14 days IV Meropenem Dis charged with VNS services

54 Questions???

55 Peritonitis Inflammation of the peritoneal surface caused by irritants such a bile, microorganisms, foreign bodies, or barium

56 Bacteria may gain access to the peritoneal fluid from hematogenous or lymphogenous spread Bacteria gain access to peritoneal fluid via perforated vis cus Pers is tent infection despite adequate control of secondary Primary Peritonitis Secondary Peritonitis Tertiary Peritonitis Fever is most common pres enting s ymptom Pain is most common pres enting s ymptom

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58 Bacteria may gain access to the peritoneal fluid from hematogenous or lymphogenous spread Bacteria gain access to peritoneal fluid via perforated vis cus Pers is tent infection despite adequate control of secondary Primary Peritonitis Secondary Peritonitis Tertiary Peritonitis Fever is most common pres enting s ymptom Pain is most common pres enting s ymptom

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62 Bacteria may gain access to the peritoneal fluid from hematogenous or lymphogenous spread Bacteria gain access to peritoneal fluid via perforated vis cus Pers is tent infection despite adequate control of secondary Primary Peritonitis Secondary Peritonitis Tertiary Peritonitis Fever is most common pres enting s ymptom Pain is most common pres enting s ymptom

63 Treatment Primary: Antibiotics (Third gen Cephalos porin; Broad s pectrum PCN) Secondary: Drainage (s urgical or percutaneous ) and definitive control of inciting agent Tertiary: re operation often fails to reveal a source; newer studies using pro inflammatory s timulators (INF-Y or G-CSF) look promising