CHAPTER III

CLINICAL DIAGNOSIS

III.1 CLINICAL
The presence of blood or fluid in the peritoneum cavity will give a sign - a sign
stimulus peritoneum. Stimulation peritonium defans cause tenderness and muscular, liver
dullness may disappear due to the free air under the diaphragm. Decreased bowel peristalsis
is lost due to temporary paralyzed. When bacterial peritonitis has occurred, the patient's body
temperature will rise and occurs tachycardia, hypotension, and the patient was lethargic and
syok.1 This stimulation causes pain on any movement that causes a shift in the peritoneum.
Pain is a subjective form of pain with movement such as walking, breathing, coughing, or
straining. Lots of pain if the pain is driven as palpation, tenderness loose, psoas tests, or any
test.

DIAGNOSIS
Diagnosis of peritonitis can be enforced by the clinical, laboratory and X-Ray. The
clinical features depend on the extent of peritonitis, severe peritonitis and types of organisms
responsible. Peritonitis can be local, spread, or the public. Clinical features that are common
in the presence of primary bacterial peritonitis, abdominal pain, fever, pain and loose bowel
press decreased or disappeared. While the clinical picture in secondary bacterial peritonitis is
the existence of acute abdominal pain. Pain is a sudden, severe, and in patients with
perforation (eg perforated ulcer), the pain being spread throughout the abdomen. In other
situations (eg, appendicitis), the pain at first because the main cause, and then gradually
spread from the focus of infection. In addition to pain, patients usually exhibit other signs and
symptoms are nausea, vomiting, shock (hypovolemic, septic, and neurogenic), fever,
abdominal distension, abdominal tenderness and rigidity of the local, diffuse or general, and
classical bowel weakened or disappeared . Clinical features for non bacterial peritonitis with
acute bacterial peritonitis.1.3 Chronic bacterial peritonitis (tuberculous) gives an overview of
the clinical presence of night sweats, weakness, weight loss, and abdominal distention;
moderate granulomatous peritonitis showed clinical severe abdominal pain, fever and signs of
peritonitis who turned up 2 weeks after surgery.
a. laboratory test
In laboratory tests found the lekositosis, increased hematocrit and metabolic acidosis.
In tuberculosa peritonitis peritoneal fluid contains a lot of protein (more than 3 gram/100 ml)
and many lymphocytes; identified with the culture of the tubercle bacillus. Peritoneal biopsy
percutaneous or laparoscopic tuberculomas show characteristic granulomas, and is the basis
of culture results obtained before diagnosis.
b. X-Ray
Ileus is a discovery that is not typical of peritonitis; small intestine and large intestine dilated.
Free air can be seen in cases of perforation.

III.2 Radiological
Radiological examination is the investigation for consideration in estimating a patient
with an acute abdomen. In plain abdominal peritonitis done three positions, namely:
1.Backs (supine), the rays of the vertical projection of anteroposterior (AP).
2.Or half sitting or standing, if possible, with a horizontal beam projection AP.
3.Skewed to the left (left lateral decubitus = LLD), with a horizontal beam, AP projection.
Shooting should be made using the film cassette that can cover the entire abdomen
and its walls. Need to set the size of the tape and the film size 35 x 43 cm. 3 Prior to the
peritonitis, if the cause is a disturbance passage intestine (ileus) obstructive then on plain
abdominal radiological 3 positions available are:
1.Sleep, to see the distribution of the intestine, preperitonial fat, presence or absence of
propagation. Picture obtained by the dilation of intestinal obstruction in the proximal region,
thickening intestine, such as fish spines picture (Herring bone appearance).
2.LLD, to see the fluid level and the possibility of bowel perforation. Of water fluid level can
be expected passage of intestinal disorders. When water is short-fluid level layout means
there ileus high, moderate if the long - term possibility of interference in the colon. The
picture obtained is the infra-diaphragmatic free air and water fluid level.
3.Half sitting or standing. Radiological obtained the water fluid level and step ladder
appearance.
So radiological in obstructive ileus is a partial bowel distension, air fluid levels, and herring
bone appearance. While in paralytic ileus radiological obtained as follows:
- Intestinal general, where a thorough bowel dilation that sometimes difficult to
distinguish between hugely dilated intestinum tenue or intestinum crassum.
- air fluid level
- Herring bone appearance
The difference with obstructive ileus: intestinal dilation fluid thoroughly so the water
level was short (small intestine) and long (colon) due to colon lumen diameter wider than the
small intestine. If prolonged ileus obstructive ileus can be paralitik. 2 In the case of peritonitis
due to bleeding, the images are not clear on plain abdomen. Picture will be clearer in the
USG (ultrasonography) .
Peritonitis due to perforation of the radiological picture can be seen on plain
abdominal examination 3 positions. On the allegation whether due to peptic ulcer perforation,
ruptured appendix or for any other reason, the main radiological signs are:
1.Lie, obtained preperitonial fat disappears, psoas line disappeared, and blurring the
abdominal cavity.
2.Sitting or standing, free water obtained subdiafragma crescent (semilunair shadow).
3.LLD, got free water peritonial intra abdominal highest. It is located between the
heart of the abdominal wall or the pelvis to the abdominal wall. So radiological
peritonitis is a vagueness in the abdominal cavity, preperitonial fat and psoas line
disappears, and the presence of free air or intra subdiafragma peritoneal.
III.3 THERAPY
The general principle is replacement therapy lost fluids and electrolytes intravenously
performed, appropriate antibiotics, gastrointestinal decompression by nasogastric suction and
intestinal disposal of septic focus (appendix, etc.) or other inflammatory causes, if possible
drain the pus out and act- pain relief measures. Great resuscitation with isotonic saline
solution is important. Returns intravascular volume improve tissue perfusion and delivery of
oxygen, nutrients, and defense mechanisms. Urine output of central venous pressure, and
blood pressure should be monitored to assess the adequacy of resuscitation.
Antibiotic therapy should be administered as soon as the diagnosis of bacterial
peritonitis was made. Broad-spectrum antibiotics are given empirically, and then changed its
kind after culture results come out. Antibiotic selection based on which organisms are
suspected to be the cause. Broad-spectrum antibiotics are also additional surgical drainage.
Must be available a sufficient dose during surgery, because bacteremia will develop during
the operation.5
Disposal of septic focus or other inflammatory performed by laparotomy surgery. Incision is
selected vertical incision middle underlined that generate access to the entire abdomen and
easily opened and closed. If localized peritonitis, an incision above the intended sites of
inflammation. Surgery technique used to control contamination depends on the location and
nature of pathologic gastrointestinal tract. In general, a continuous peritoneal contamination
can be prevented by closing. Lavase peritoneum performed on the diffuse peritonitis, which is
using crystalloid solution (saline). To prevent spread out, antibiotic is the main effort( ex :
sefalosporin). If located peritonitis dont make peritoneum lavage move, because can make
spread out in peritoneum.2.3

III.4 DIFFERENTIAL DIAGNOSIS

The differential diagnosis of peritonitis is appendicitis, pancreatitis, gastroenteritis,
cholecystitis, salpingitis, ruptured ectopic pregnancy, etc.

III.5 COMPLICATION
Complication can occur in acute secondary bacterial peritonitis, where complication
can be divided into early and advanced complication, :
a. septicemia and septic syok, hipovolemik shock. Intra abdominal sepsis that can not
be controlled with multi-system failure residua intraperitoneal portal pyemia
abcess.(hepatic absess)
b. Advanced complication intestinal obstruction
III.6 PROGNOSIS
The prognosis for peritonitis is both local and lightweight is fine, while the general
prognosis of peritonitis is lethal due to virulen of organism.