OBJECTIVES

•state the meaning of perforative peritonitis

•state the incidence of perforative peritonitis.
•list down the risk factors
•enlist the causes of perforative peritonitis.
•list the classification of perforative peritonitis.
•explain the pathophysiology of perforative peritonitis.
•enumerate the clinical manifestations.
•state the diagnostic findings.
•understand the condition clinically.
•explain the immediate management.
•explain the scoring system severity of perforative peritonitis using
POSSUM.
•explain the surgical management.
•discuss the nursing management.
•explain the prognosis of perforative peritonitis.
•enlist the post-operative complications of perforative peritonitis
INTRODUCTION
Perforative peritonitis is one of the commonest surgical
emergencies in our country. Despite advancements in surgical
techniques, anti-microbial therapy and intensive care,
management of perforative peritonitis continues to be highly
demanding, difficult and complex.
MEANING
•Peritonitis is inflammation of the peritoneum, the serous
membrane lining the abdominal cavity and covering the
viscera.
•When left untreated, peritonitis can rapidly spread in to the
blood (sepsis) and to other organs, resulting in multi organ
failure and death. This is called as perforative peritonitis.
INCIDENCE

In tropical countries like India, perforative peritonitis most

commonly affects men as compared to the studies in West.
The mean age is in between 30-50 years.
 CAUSES
•Acid peptic disease •Malignancy
•Appendicitis •Bowel strangulation
•Typhoid •Amoebic caecal perforation
•Tuberculosis •Bacterial infection
•Injury or trauma •Abdominal surgical procedures
•Peritoneal dialysis
• PERFORATIVE PERITONITIS CONTENT\SUZUKI2011_ARTICLE_ACASEOFPERFORATIVEPERITONITISC.PDF
 CLASSIFICATION OF PERFORATIVE
PERITONITIS
1. GIT perforation :
It is also called as ruptured bowel,
is a hole in the wall of GIT.
2. Bowel wall necrosis
Bowel infarction or gangrenous
bowel represents an irreversible
injury to the intestine resulting
from insufficient blood flow.
3. Pelviperitonitis
Clandestine induced abortion is responsible for significant
morbidity and maternal mortality, most often with peritonitis
Post-abortion peritonitis remains a serious and frequent
complication. Post insertion of IUD also remains a causative
factor.
4. Spontaneous bacterial peritonitis (SBP) is defined as an
ascitic fluid infection without an evident intra-abdominal
surgically treatable source.
The presence of SBP almost occurs in patients with cirrhosis
and ascites, is suspected because of suggestive signs and
symptoms, such as fever, abdominal pain, or altered mental
status, though some patients are asymptomatic and are
detected when they undergo paracentesis after being
admitted to the hospital for another reason.
SITES OF PERFORATION
PATHOPHYSIOLOGY
Due to the etiological factors like leakage of contents from
abdominal organs into the abdominal cavity

Inflammation of the peritoneal cavity

Edema of the tissues and exudation of fluid

Fluid in the peritoneal cavity becomes turbid with increasing
amounts of protein, white blood cells, cellular debris, and
blood

Abscess of infection-due to inflammation

Gangrene
 Spread of infection throughout the body

Multiorgan failure and death in severe cases

CLINICAL MANIFESTATIONS

Acute abdominal Altered bowel habit Nausea and vomiting

pain
Abdominal distension Abdominal guarding History of NSAID intake for
more than 6 months
Bloomberg’s sign Fever Tachycardia
 Hyponatremia,
Hypokalaemia,
Diminished peristalsis Right iliac fossa pain
Elevated serum
creatinine
DIAGNOSTIC FINDINGS:

•History collection
•An abdominal x-ray shows air, fluid levels, and distended
bowel loops.
On x-ray of the abdomen,
classically defined as gas under
diaphragm.
An abdominal
computerized tomography (CT)
scan may show
abscess formation.
•Peritoneal aspiration and
culture and sensitivity
studies of the aspirate.
•Patients had
pneumoperitoneum
on chest x-ray
in erect posture.
•Multiple air fluid levels on abdominal x-ray in erect position
were present.
•Spontaneous uterine rupture should be a differential
diagnosis in cases of perforative peritonitis in elderly
women.
Spontaneous
uterine rupture
Patients with liver disease often have an elevated INR and
thrombocytopenia.
It is not necessary to check for INR to perform a
paracentesis. In a series of 628 patients undergoing large
volume paracentesis, there were no bleeding complications
even with an INR as high as 8.7 and platelets as low as 19k.
INITIAL MANAGEMENT
•Patients with intestinal perforation can have severe volume
depletion. The severity of any electrolyte abnormalities
depends upon the nature and volume of material leaking
from the gastrointestinal tract. Intravenous (IV) fluid therapy
is the most suitable way of management. (crystalloids or
colloids can be given)
•Cessation of oral intake
•Broad-spectrum antibiotics the following initial empiric
regimens are appropriate in areas where the local rates of
resistance to these antibiotics are <10 percent
•Single-agent regimens – imipenem
cilastatin, meropenem, doripenem, or piperacillin-
tazobactam.
Combination regimens – cefepime or ceftazidime, each
administered with metronidazole.
• Drainage, gastrostomy, and feeding jejunostomy may be
appropriate.
• Monitoring should initially take place in an intensive care
unit.
•The administration of intravenous proton pump inhibitors is
appropriate for those suspected to have upper gastrointestinal
perforation.
The preferred regimen for empiric treatment of SBP is a
third-generation cephalosporin such as cefotaxime which
covers the three most common bacteria: escherichia coli,
klebsiella pneumoniae, and streptococcus pneumoniae.
POSSUM: A SCORING SYSTEM FOR
PERFORATIVE PERITONITIS
•Perforative peritonitis carries considerable morbidity and
mortality with the postoperative period unpredictable most
of the times.
•It therefore becomes necessary for a scoring system that
predicts the post-operative outcome.
POSSUM (Physiological and Operative Severity Score for
the enUmeration of Mortality and Morbidity) helps in
predicting the post-operative morbidity and mortality in
patients. POSSUM scores are based on 12 physiological
factors and 6 operative factors.
The physiological factors are The operative factors are
• Age (years) • Operative severity
• Cardiac signs (chest radiograph) • Multiple procedures
• Respiratory history/ chest radiograph • Total blood loss
• Systolic blood pressure • Peritoneal soiling
• Pulse • Presence of malignancy
• Glasgow coma scale • Mode of surgery
• Haemoglobin
• White cell count
• Perforation to operation time and
• Urea, sodium, potassium • Presence of co-morbidity
• Electrocardiogram
SURGICAL PROCEDURES DONE AFTER
DIAGNOSING WITH PERFORATIVE
PERITONITIS
•Omental patch
•Stoma
•Appendectomy
•Right hemicolectomy
NURSING DIAGNOSIS
Imbalanced nutrition less than body requirements related to
nausea and vomiting
Acute abdominal pain related to inflammation
Altered bowel habit related to accumulation of stool in the
intestines
Risk for infection related to abdominal surgery and re-
exploration.
NURSING MANAGEMENT
•Blood pressure monitoring. The patient’s blood pressure is
monitored by arterial line if shock is present.
•Medications. Administration of analgesic and anti-emetics
can be done as prescribed.
•Pain management- analgesics and positioning could help in
decreasing pain.
•I&O monitoring. Accurate recording of all intake and
output could help in the assessment of fluid replacement.
•Iv fluids. The nurse administers and closely monitors IV
fluids.
•Drainage monitoring. The nurse must monitor and record
the character of the drainage postoperatively.
•Antibiotics must be administered after sending the blood cultures.
•Keep the patient NPM and prepare the patient for surgery as
advised by the physician.
• Carry out the pre-operative work up of the patient.
• Nasogastric tube and aspiration alleviates vomiting and
abdominal distension and reduces the risk of aspiration
pneumonia.
Albumin administration with serum creatinine >1 mg/dl, BUN
>30 mg/dl, or total bilirubin >4 mg/dl.
The preferred regimen is 1.5 g/kg albumin within 6 hours of
diagnosis with a subsequent dose of 1 g/kg on day 3.
PROGNOSIS
•The mortality rate of perforation peritonitis are still high.
•It depends upon the exact recognition of the seriousness of
the diseases and an accurate assessment and classification of
the patient’s risks.
•One of the most important factors responsible for mortality
is septicemia.
POST-OPERATIVE COMPLICATIONS
•Fever •Burst abdomen
•Wound infection •Anastomotic leak
•Dyselectrolytaemia •Mortality
•Abdominal collection •Wound dehiscence
•Respiratory complication •Re suturing
CLINICAL REPORT
Perioperative management for a patient with hypermagnesemia-
induced shock with perforative peritonitis
Abstract
A 79-year-old Woman took magnesium citrate as part of the
pretreatment on the day before a scheduled colonoscopy. She
developed nausea and muscle weakness, and she was complaining
of left abdominal pain. Consciousness gradually worsened and
she developed shock. Intestinal obstruction was recognized
•On abdominal x-ray and computed tomography (CT), peritonitis
was suspected. An exploratory laparotomy was scheduled for
diagnosis and treatment. In the operating room, arterial blood gas
analysis showed metabolic acidosis and hypermagnesemia (Mg:
2.75 mEq/l). On laparotomy, adhesion around the sigmoid colon
and turbid ascites were recognized. The apparent region of
perforation could not be detected.
Based on these findings and the presence of hypermagnesemia,
it was diagnosed that the shock was caused by peritonitis due
to hypermagnesemia and absorption of laxative. Metabolic
acidosis was treated and hypermagnesemia was manged by
calcium hydrochloride administration and by continuous
hemodiafiltration after the operation. On day 4 of the illness,
the plasma Mg++ level was normalized. She was extubated on
day 12, and discharged on day 84.
• PERFORATIVE PERITONITIS CONTENT\T TUBE DRAINAGE FOR PERFORATION.PDF
 CONCLUSION
Perforative peritonitis is a surgical emergency. Patients with
peritonitis should be explored as early as possible. Surgical
exploration is the cornerstone of the management of peritonitis.
Delay in procedure leads onto further complications and
increased mortality rate. Early exploration saves the patient from
localized abscess and septicaemia. Early exploration can be a
lifesaving procedure in some complicated cases.
Cont.….
Early surgical intervention under the cover of broad spectrum
antibiotics preceded by adequate aggressive resuscitation and
correction of electrolyte imbalances is imperative for good
outcomes minimizing morbidity and mortality.
 REFERENCES
• Retrieved from www.Uptodate.In
• Abhay Y. Desai, B. P. (2016). Perforative peritonitis—gastrointestinal tract
may not always be the source. Indian journal of surgery.
• Dr sudershan kapoor, d. A. (2016). Early and late management of
perforation peritonitis - A comparative study of 50 cases. IOSR journal of
dental and medical sciences.
• Dr. Tushar dani1, P. L. (2015). Evaluation of progress in patients with
perforation peritonitis using mannheim's peritonitis index. International
journal of scientific and research publications.
• Renganathan, a. S. (2015). POSSUM: A scoring system for perforative
peritonitis. Journal of clinical and diagnostic research, 5-9.
• Tomoyuki wakahara, M. K. (2016). Intestinal perforation management
using t-tube. Japan.
• Rajandeep singh bali, s. V. (2014). Clinical study perforation peritonitis
and the developing world. ISRN surgery.
• Yasuhiro suzuki, M. M. (2011). A case of perforative peritonitis caused
by a piece of bamboo in a patient on peritoneal dialysis. Japan