Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
The Abdomen
Laparotomy and Abdominal Trauma
Abdominal trauma
Acute Abdominal Conditions
Assessment and diagnosis
Intestinal obstruction
Stomac and duodenum
Abdominal Wall Hernia
Groin hernia
Surgical repair of inguinal hernia
Surgical repair of femoral hernia
Surgical treatment of strangulated groin hernia
Surgical repair of umbilical and para-umbilical hernia
Surgical repair of epigastric hernia
Incisional hernia
Urinary Tract and Perineum
The urinary bladder
The male urethra
The perineum

Peritonitis is an acute life-threatening condition caused by bacterial or chemical contamination of the peritoneal cavity. Neglected chemical peritonitis will progress to bacterial peritonitis. The treatment of peritonitis is the treatment of the underlying cause.


The major causes of peritonitis include:

:: Appendicitis
:: Perforated peptic ulcer
:: Anastomotic leak following surgery
:: Strangulated bowel
:: Pancreatitis
:: Cholecystitis
:: Intra-abdominal abscess
:: Haematogenous spread of infective agents such as typhoid or tuberculosis
:: Typhoid perforation
:: Ascending infection: for example, in salpingitis and postpartum infection.

Clinical features

Clinical features of peritonitis include:

:: Sharp pain, which is worse on movement or coughing
:: Fever
:: Abdominal distension, tenderness and guarding
:: Diminished or absent bowel sounds
:: Shoulder pain (referred from diaphragm)
:: Tenderness on rectal or vaginal examination (suggests pelvic peritonitis).

These features may be minimal in elderly patients, the very young and those with immune suppression.


1 Make a differential diagnosis of the most likely underlying cause of the peritonitis/abscess.
2 Administer normal saline or Ringer’s lactate, depending on the serum electrolyte results.
3 Insert a nasogastric tube and commence aspirations.
4 Give triple antibiotic therapy intravenously, providing aerobic, gram negative and anaerobic coverage. For example, ampicillin 2 g IV every 6 hours plus gentamicin 5 mg/kg body weight IV every 24 hours plus metronidazole 500 mg IV every 8 hours.
5 Record fluid balance and vital signs on the bedside chart every six hours.

Surgical intervention will depend on the diagnosis of the cause of the peritonitis: for example, appendectomy, closure of a perforation or drainage of an abscess.

Intestinal obstruction may respond to non operative management, but peritonitis indicates gangrene or perforation and therefore requires surgery.

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