33 Peritonitis Slides Tutorial JD 2024 PDF

Leading the world to better health Multidisciplinary Teaching  RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn GIHEP MDT 1 Dr. James Donnelly (Clin...

Leading the world to better health Multidisciplinary Teaching  RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn GIHEP MDT 1 Dr. James Donnelly (Clinical Microbiology) Dr. Sally McGrath (Pathology) Dr. Sneha Singh (Radiology) Dr. Adel AlGhazwi (Surgery) Date: 23rd September 2024 LEARNING OUTCOMES AT THE END OF THIS SESSION, YOU SHOULD NOW BE ABLE TO… Identify a patient with an acute abdomen and diagnose the likely underlying cause Formulate a management plan for a patient with bowel perforation and peritonitis, including surgical management, investigations and empiric antibiotics Justify your empiric antibiotic choice based on the likely pathogens Describe the pathological features of diverticular disease and its complications Describe the pathogenesis, complications and management of severe C. difficile infection SESSION OBJECTIVE As a team, operate as the junior surgical doctor on call to manage the cases you have been assigned At the end of the session, you will have to present a short summary of the case: – Differential diagnosis (3-5 justified selections) – Investigations -> did it narrow the differential – Initial / empiric management – Definitive management (if possible) RULES FOR CASE MANAGEMENT All cases are initially being managed in an on-call setting (after 9pm on a Friday) As a group, you must decide on differential diagnosis and develop an initial plan You can ‘consult’ with the specialties present to help narrow your differential and guide your management All the specialities have information on your case, you must determine the order you need to consult them & how it impacts your clinical management decisions You can ‘consult’ in groups of 2 from each team CONSULTING Surgery: – Can come ‘assess’ your patient and provide a summary of clinical exam findings and help narrow your differential diagnosis – Can advise on surgery required (if enough information has been gathered) Pathology: – Can provide blood results for patients (ask specifically for test) – Can give results of pathological specimens if sent from theatre Microbiology: – Can give advice on empiric antimicrobials (if required) – Can give microbiological results (if specimens sent) Radiology: – Will confirm/deny imaging requests and give preliminary results of same RULES FOR CASE MANAGEMENT Try to have a concise clinical question for the specialty you are ‘consulting’ When presenting, you will have to comment on any relevant imaging and pathology findings You have 30 minutes to come to a consensus & complete the management plan for the assigned case You will then have 5 minutes to prepare a short summary of the case to be presented to the class  NORMAL VALUE RANGES Haemoglobin: Urea = 2.8 – 8.1 mmol/L – Males = 13.5 – 18.0 g/dL Creatinine = – Females = 11.5 – 16.5 g/dL – Males = 59 – 104 µmol/L WBC = 4.0 – 11.0 x 109/L – Females = 45 – 84 µmol/L Platelets = 140 – 450 x D-dimer = < 0.50 109/L CRP = 0 – 5 mg/L Lactate = 0.4 – 2.0 mmol/L CASE 1 CASE 1 Jim, a 68yo male, presents to the ED Complaining of: – Feeling bloated – Severe, worsening abdominal pain x 3/7 – Constipation x 1/52 Past medical history: – Usually well – No previous hospital admissions – HTN – Hypercholesterolaemia – Colonoscopy x 6/12 ago showed significant diverticulosis KEY EXAM/BLOOD FINDINGS Vitals: – Febrile 38.6, BP 90/40, HR 110, RR 22 Bloods: – WBC 22.1, CRP 306, Lactate 3.6 – Normal LFTs, coagulation screen, U&Es On exam: – Clammy and febrile – Tenderness in LIF with guarding and rebound tenderness – Absent bowel sounds, mild distension – Impression: ?large bowel obstruction due to diverticulitis/tumour v. perforated diverticulitis RADIOLOGY ERECT CXR - FREE AIR UNDER THE DIAPHRAGM PFA – RIGLER’S SIGN PFA – RIGLER’S SIGN DO YOU WANT ANY MORE IMAGING? A. Yes B. No WHAT WOULD BE YOUR NEXT MODALITY OF CHOICE? A. Ultrasound B. CT C. MRI D. Nuclear Medicine WILL YOU USE INTRAVENOUS CONTRAST? A. Yes B. No WHAT BIOCHEMICAL VALUE IS OF VITAL IMPORTANCE? UNDERSTANDING ABDOMINAL CT UNDERSTANDING ABDOMINAL CT DIVERTICULOSIS DIVERTICULITIS BACK TO OUR PATIENT... CT REPORT Pneumoperitoneum with free air visible in the upper abdomen. Mural thickening of the sigmoid colon with adjacent inflammatory fat stranding. There is an air and fluid filled collection within the pelvis adjacent to the sigmoid colon. RADIOLOGICAL DIAGNOSIS Perforated sigmoid diverticulitis with pneumoperitoneum and associated pelvic collection. WHAT IS YOUR INITIAL MANAGEMENT PLAN? DOES THIS PATIENT REQUIRE ANTIBIOTICS? IS HE LIKELY TO HAVE RESISTANT ORGANISMS?  WHAT IS SEPSIS? 1. Infection 2. Triggering a host response 3. Leads to organ dysfunction  THIS PATIENT HAS SEPSIS AND NEEDS… Sepsis 6 in 1st hour 3 to take 3 to give 1. Blood cultures & 1. O2 (94-98% or 88-92%) other appropriate cultures 2. FBC, Lactate 2. IV antibiotics 3. Assess urinary output 3. IV fluids WHICH OF THE FOLLOWING COMBINATIONS OF ORGANISMS IS MOST REPRESENTATIVE OF THE BOWEL COMMENSAL FLORA? A. Group A Streptococcus, Enterococcus faecalis and Clostridium difficile B. MRSA, Clostridium perfringens and Aspergillus fumigatus C. E. coli, Enterococcus faecalis and Bacteroides fragilis D. VRE, Clostridium tetani and Staphylococcus epidermidis E. Salmonella enterica, Campylobacter jejuni, Bacteroides fragilis IS HE LIKELY TO HAVE RESISTANT ORGANISMS? No He has community-onset infection and no significant healthcare exposure But always remember to Check previous microbiology- any resistant organisms? Ask about healthcare exposure and recent antibiotics- may be at risk of resistant organisms MANAGEMENT Sepsis 6, IV fluids, fast for emergency surgery (nothing by mouth – NPO) Abx: – Penicillin allergy - rash, not severe allergy – Empiric cefuroxime, metronidazole, gentamicin START SMART Aim of empiric treatment Cover bowel organisms- Gram negatives and anaerobes BUT Antibiotics are not going to fix the hole in Jim’s bowel… SURGERY THE MOST COMMON INCISION FOR LAPAROTOMY IS WHICH ONE OF THE FOLLOWING? A. Pfannenstiel incision B. Kocher's incision C. Right or left Paramedian incision D. Midline incision E. Rutherford Morrison incision SURGERY: LAPAROTOMY Findings: – Faecal contamination – Sigmoid perforation – Peritonitis Appropriate samples sent to Pathology and Microbiology Hartmann’s procedure performed with Robinson’s drain left in situ HARTMANNS PROCEDURE Emergency recto-sigmoid resection End to end anastomosis not suitable Rectal stump remains Proximal bowel exteriorised: – End-colostomy +/- reversal PATHOLOGY DIVERTICULOSIS Congenital Acquired – All 3 layers of wall – Lack or have an attenuated – Prototype is muscularis propria Meckel diverticulum – Anywhere in bowel – Affects >50% of people >60years – Western society DIVERTICULAR DISEASE: AETIOLOGY Abnormally high intraluminal pressure caused by exaggerated contractility of the muscularis propria Herniation occurs at anatomic weak points: – the site of blood vessel supply to the colon – between the taenia coli (longitudinal muscle layer) Herniation of the mucosa of the colon through the muscularis propria  outpouches of the bowel lumen and thickening of the muscularia propria DIVERTICULITIS COMPLICATIONS 1. Abscess 2. Luminal obstruction / stenosis 3. Peritonitis / perforation 4. Bleeding 5. Fistula – Colo-enteric – Colo-vesical – Colo-vaginal – Colo-cutaneous MICROBIOLOGY Abdominal fluid has Gram-negative bacilli seen on microscopy Culture: – E. coli – resistant to co-amoxiclav, susceptible to cefuroxime – Mixed anaerobes Advised to stop gentamicin at 48hrs, continue cefuroxime and metronidazole for 5-7 days postoperatively CASE 2 CASE 2 Mary, a 66yo female is currently an inpatient on the surgical ward being treated for diverticulitis Day 12 of admission (Day 12 antibiotics) Nurse calls intern on call: – New confusion – Febrile 38.2°C – HR 120 bpm – BP 110/65 Nursing staff report new diarrhoea over the last few hours, foul smelling, large volume, associated with new abdominal pain KEY EXAM/BLOOD FINDINGS Bloods: – WBC 36, CRP 54, Lactate 4.2, creatinine 250 (baseline 84) On exam: – Clammy and febrile – Abdomen is firm and grossly distended – Generalised tenderness and guarding – Absent bowel sounds – Impression: Severe colitis WHAT IS THE MOST LIKELY DIAGNOSIS? REMEMBER.. FOR SUSPECTED C. DIFFICILE Apron and gloves Soap and water, not alcohol gel NORMAL PFA On a normal PFA: Small bowel should be ≤ 3cm Large bowel should be ≤ 6cm Caecum should be ≤ 9cm Small vs Large Bowel? Small bowel: Centrally located Valvulae conniventes traverse the entire loop of bowel PFA – DILATED BOWEL Dilated small bowel loops – Dilated large bowel loops – small bowel obstruction large bowel obstruction CASE 2 IMAGING PFA CT abdomen – non-contrast Diagnosis – Toxic megacolon HOW SHOULD A PATIENT WITH TOXIC MEGACOLON DUE TO C. DIFFICILE BE MANAGED? C. DIFFICILE TOXIC MEGACOLON MANAGEMENT  Urgent discussion with surgical team and clinical microbiologist  Stop offending antibiotics and begin C. diff therapy – fidaxomicin +/- IV metronidazole  Isolate patient with enhanced contact precautions  Stabilise the patient if haemodynamically unstable +/- discuss with intensive care doctors C. DIFFICILE TOXIC MEGACOLON MANAGEMENT  Surgery is considered on a case by case basis – earlier surgery associated with better outcomes  Subtotal colectomy with end-ileostomy is the treatment of choice  Subsequent re-anastomosis END & LOOP ILEOSTOMY Plaques of yellow fibrin and inflammatory debris adherent to reddened mucosa FAVOURED DIAGNOSIS Pseudomembranous colitis Characterised by formation of an adherent inflammatory exudate (pseudomembrane) overlying sites of mucosal injury Not a true membrane – the coagulum is not an epithelial layer Caused by two protein exotoxins (A&B) of Clostridioides difficile Plaquelike adhesion of fibrinopurulent debris and mucus CASE 3 CASE 3 Ciara, a 42yo female, presents to the ED Complaining of: – Loss of appetite – Nausea + 1 episode of vomiting – Intermittent, severe lower abdominal pain x 5/7 Past medical history: – Asthma as a child, not currently using any inhalers – OCP: Microlite – No allergies Vitals: Febrile (38.3), otherwise haemodynamically normal KEY FINDINGS Exam: – Tender RIF with guarding – Rebound tenderness at McBurney’s point – Peritonitis – Classical features of appendicitis Bloods: WBC 14.5, CRP 155, Lactate 2.4 CASE 3 CT-AP MANAGEMENT Blood cultures, IV fluids, fast for emergency surgery Empiric Abx: cefuroxime + metronidazole + gentamicin Emergency laparoscopic appendicectomy – 300ml pus – Retrocaecal appendix with perforation – No faecalent contamination CASE 3 CASE 3 MICROBIOLOGY Pus sample received from theatre: – Gram-negative bacilli seen on microscopy – E.coli grew on culture – Resistant to co-amoxiclav, susceptible to cefuroxime + gentamicin Aim to complete 5-7 days of antibiotics post-op if no further complications, stop gentamicin after 48-72hrs with culture results CASE 4 CASE 4 Emily, a 37yo female, is recovering on the Orthopaedic ward – She underwent Open Reduction Internal Fixation (ORIF) of her right ankle earlier that day – She had a fall off a ladder 3 days before with no other significant injuries 2 hours ago, she began complaining of severe, constant upper abdominal pain, 10/10 Past medical history: – Non-insulin dependent diabetes mellitus (currently diet- controlled) KEY FINDINGS Vitals: BP low 96/55, RR 24 Exam findings: – Diaphoretic and in distress – Rigid abdomen with tenderness in all quadrants, not distended – Bowel sounds absent – ?Perforated peptic ulcer or small bowel obstruction Bloods: – WBC 16, CRP 55, Lactate 2.2 CASE 4: ERECT CXR CASE 4: CT-AP W/CONTRAST MANAGEMENT Sepsis 6, fast for emergency surgery Abx: empiric cefuroxime, metronidazole, gentamicin, and fluconazole (empiric antifungal coverage for upper GI perforation/peritonitis) Surgery: – Perforated peptic ulcer – Emergency laparoscopic or open laparotomy with repair of bowel – Peritoneal fluid sample sent to microbiology CASE 4 CASE 4 CASE 4 MICROBIOLOGY Peritoneal fluid sample has Gram-negative bacilli and yeast seen on microscopy Culture: – E.coli - fully susceptible – Candida albicans – fluconazole susceptible Abx: – Rationalise to Amoxicillin, metronidazole, and fluconazole – Aim to complete 5-7 days post-op if no complications CASE 5 CASE 5 Roger, a 75yo male, presents to the ED in acute distress Complaining of: – Acutely confused – Severe, sudden abdominal pain – Associated with nausea, bloating – Wife explains he has been complaining of dark, smelly stools over the last 2 days Past medical history: – HTN (poorly-controlled, pt not compliant) – Hypercholesterolaemia – Wife says he sometimes complains of palpitations KEY EXAM FINDINGS Vitals: – Febrile 38.0, BP 92/45 – HR 140 (irregular irregular) -> Atrial fibrillation – RR 24, 02 sats 93% on room air Bloods: – WBC 17, CRP 200, lactate 4.8 On exam: – Pale, diaphoretic, in acute distress – Generalised abdominal tenderness but no guarding/rigidity Clinical features out of proportion with exam – ? Mesenteric ischaemia or large bowel ischaemia CASE 5 CT-AP MANAGEMENT Sepsis 6, fast for emergency surgery Abx: empiric cefuroxime, metronidazole, gentamicin Surgery: – Emergency laparotomy with resection of small bowel (ileum) and formation of end ileostomy (stoma) – Specimens sent to pathology – No evidence of perforation/peritoneal contamination – Peritoneal fluid sample sent to microbiology CASE 5 CASE 5 MICROBIOLOGY No growth on peritoneal fluid sample or blood cultures Patient’s antibiotics stopped after 48-72hrs with negative microbiology results CASE 6 CASE 6 Susan, a 61yo female, presents to the ED Complaining of: – Progressively worsening upper abdominal pain x 2/7 – Nausea but no vomiting – Started off as colicky pain but now constant, 7-8/10 – Aggravated by movement Past medical history: – Hypothyroidism – Cholelithiasis, currently on elective waiting list for laparoscopic cholecystectomy – Penicillin allergy - anaphylaxis KEY EXAM FINDINGS Vitals: – Febrile 38.3, HR 115, RR 22 Bloods: – WBC 19.2, CRP 155, GGT 159, ALP 163, AST/ALT normal, Bilirubin normal, amylase normal On exam: – Diaphoretic and in distress – RUQ tenderness with guarding and rebound tenderness – ?Acute cholecystitis v. ascending cholangitis v. perforated gallbladder CASE 6: CT-AP MANAGEMENT Blood cultures, IV fluids, fast for imaging and potential emergency surgery Abx: – Penicillin anaphylaxis – Empiric agents: Ciprofloxacin, metronidazole, gentamicin Surgery: – Decision for percutaneous cholecystostomy (drain inserted into gallbladder via skin) by radiology – Sample sent to microbiology – Delayed laparoscopic cholecystectomy once stabilized IF PATIENT DIDN’T IMPROVE Decision for emergency cholecystectomy Specimens sent to histology CASE 6 CASE 6 CASE 7  CASE 7 Malik, a 66yo male, is present on the general medical ward – He was admitted 2 days ago with a CAP & CURB-65 score of 2 (age + low systolic BP) – Currently on IV amoxicillin + PO clarithromycin Nursing staff concerned about: – New onset confusion – Acute onset of abdominal pain Past medical history: – Non-alcoholic liver cirrhosis, Child-Pugh Class A – Previous laparoscopic cholecystectomy x 10 yrs ago – Smoker, 5-pack year history KEY EXAM/BLOOD FINDINGS Vitals: – Febrile 38.1, HR 120, RR 22 Bloods: – WBC 10.5, PLT 104, CRP 33, On exam: – Flushed but not in distress – Abdomen moderately distended – Diffuse tenderness with guarding, no rebound or rigidity – Bowel sounds present (muffled) – Impression: Not an acute abdomen, concern for spontaneous bacterial peritonitis (SBP) -> discuss with microbiology/medical team MANAGEMENT Medical consult for SBP management Microbiology: – Send blood cultures – Send peritoneal fluid for culture and white cell count – Empiric ceftriaxone 2g OD IV White cell count on peritoneal fluid: – Leucoctyes 1500, 95% polymorphs Culture: – Klebsiella pneumoniae cultured, resistant to amoxicillin and co- amoxiclav PATIENT RECOVERS AND EVENTUALLY UNDERGOES LIVER TRANSPLANT – LIVER SENT TO HISTOPATHOLOGY AT TIME OF SURGERY CASE 7 CASE 7 CASE 7 CASE 7 Thank you