This afternoon, at around 13:50, I heard scream from the bedroom. Maxine tumbled on the bed with the most pathetique agony I've ever seen. Benson and I rushed her to Cardinal Tien Hospital. First emergency aid, then soon transferred to the out-patient dept. of obstetrics and gynecology, Maxine was diagnosed by Dr. Huang Wen-yu as 'peritonitis due to rupture of ovarian dermoid cyst or salpingitis', which is a life-threatening fatal disease. So the doctor summoned for a brief diagnoses meeting and decided to conduct an endoscopic cyst removal operation in no time. After two hours anxious waiting and sad tears of Benson, his mom's life was saved. Dr. Huang did, or, He did. Well, for most of us, we would have much less emotional stirring as Benson did when coming up with such case. However, we're supposed to know what on earth the so-called 'peritonitis' is like. Here's some excerpts from Wiki and www.pertonitis-disease.com :
Peritonitis is an inflammation of the peritoneum, the serous membrane which lines part of the abdominal cavity and viscera. Peritonitis may be localized or generalized, and may result from infection (often due to rupture of a hollow organ as may occur in abdominal trauma or appendicitis) or from a non-infectious process.
Typically, this disorder follows the rupture of an organ in the abdomen, allowing bacteria within the organ to spread into the abdominal cavity. Often caused by a burst appendix or gallbladder, it can also result from a perforation in the wall of the stomach or intestine. The main manifestations of peritonitis are acute abdominal pain, abdominal tenderness, and abdominal guarding, which are exacerbated by moving the peritoneum, e.g. coughing (forced cough may be used as a test), flexing one's hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness, meaning that pressing a hand on the abdomen elicits less pain than releasing the hand abruptly, which will aggravate the pain, as the peritoneum snaps back into place). The presence of these signs in a patient is sometimes referred to as peritonism. The localization of these manifestations depends on whether peritonitis is localized (e.g. appendicitis or diverticulitis before perforation), or generalized to the whole abdomen. In either case pain typically starts as a generalized abdominal pain (with involvement of poorly localizing innervation of the visceral peritoneal layer), and may become localized later (with the involvement of the somatically innervated parietal peritoneal layer). Peritonitis is an example of an acute abdomen. Some other collateral manifestations are like diffuse abdominal rigidity ("washboard abdomen") often presented, especially in generalized peritonitis, fever, sinus tachycardia, nausea, and vomiting.
Complications
Sequestration of fluid and electrolytes, as revealed by decreased central venous pressure, may cause electrolyte disturbances, as well as significant hypovolemia, possibly leading to shock and acute renal failure. A peritoneal abscess may form (e.g. above or below the liver, or in the lesser omentum sepsis may develop, so blood cultures should be obtained. The fluid may push on the diaphragm, causing splinting and subsequent breathing difficulties.
Diagnosis and investigations
A diagnosis of peritonitis is based primarily on the clinical manifestations described above. If peritonitis is strongly suspected, then surgery is performed without further delay for other investigations. Leukocytosis, hypokalemia, hypernatremia and acidosis may be present, but they are not specific findings. Abdominal X-rays may reveal dilated, edematous intestines, although such X-rays are mainly useful to look for pneumoperitoneum, an indicator of gastrointestinal perforation. The role of whole-abdomen ultrasound examination is under study and is likely to expand in the future. Computed tomography (CT or CAT scanning) may be useful in differentiating causes of abdominal pain. If reasonable doubt still persists, an exploratory peritoneal lavage or laparoscopy may be performed. In patients with ascites, a diagnosis of peritonitis is made via paracentesis (abdominal tap): more than 250 polymorphonucleate cells per μL is considered diagnostic. In addition, Gram stain and culture of the peritoneal fluid can determine the microrganism responsible and determine their sensibility to antimicrobial agents.
Treatment
Depending on the severity of the patient's state, the management of peritonitis may include: General supportive measures such as vigorous intravenous rehydration and correction of electrolyte disturbances. Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. The empiric choice of broad-spectrum antibiotics often consist of multiple drugs, and should be targeted against the most likely agents, depending on the cause of peritonitis; once one or more agents are actually isolated, therapy will of course be targeted on them. Surgery (laparotomy or endoscope) is needed to perform a full exploration and lavage of the peritoneum, as well as to correct any gross anatomical damage which may have caused peritonitis. The exception is spontaneous bacterial peritonitis, which does not always benefit from surgery and may be treated with antibiotics in the first instance.
Prognosis
If properly treated, typical cases of surgically correctable peritonitis (e.g. perforated peptic ulcer, appendicitis, and diverticulitis) have a mortality rate of about <10% in otherwise healthy patients, which rises to about 40% in the elderly, and/or in those with significant underlying illness, as well as in cases that present late (after 48h). If untreated, generalised peritonitis is almost always fatal.
Pathology
The peritoneum normally appears greyish and glistening; it becomes dull 2–4 hours after the onset of peritonitis, initially with scarce serous or slightly turbid fluid. Later on, the exudate becomes creamy and evidently suppurative; in dehydrated patients, it also becomes very inspissated. The quantity of accumulated exudate varies widely. It may be spread to the whole peritoneum, or be walled off by the omentum and viscera. Inflammation features infiltration by neutrophils with fibrino-purulent exudation.
I would have told Benson there was no need for tears, not because of the timely hospitalization, the decisive first-aide, nor of the cowish stalwart as the patient might be, but our being beneath the arms of careful cuddle and merciful healing of His All Mighty...
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