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51 Cards in this Set
- Front
- Back
Where is the peritoneal cavity? |
Extends from undersurface of diaphragm to the floor of the pelvis |
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What does the peritoneal cavity normally contain? |
50ml sterile serous fluid, low in protein, leukocytes and no fibrinogen |
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What does the normal GI microflora of the stomach consist of? |
H.pylori, Streptocci and Lactobacilli [Total bacterial count 0-10^8] |
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What does the normal GI microflora of the Upper Small Intestine consist of? |
Lactobacilli, Streptocci, Staphylocci, Enterocci, Enterobacteriae (E.coli, Klebsiella, Enterobacter) [Total bacterial count 0-10^5] |
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What does the normal GI microflora of the Lower Small Intestine consist of? |
Aerobes: Enterobacteriae (E.coli, Klebsiella, Enterobacter) Lactobacilli, Staphylocci Anaerobes: Bacteriodes (B.fragilis, B.thetaiotamicron, B.vulgatus) |
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What does the normal GI microflora of the Large Intestine consist of? |
Aerobes: Lactobacilli, Streptocci, Staphylocci, Enterocci, Enterobacteriacae (E.coli, Klebsiella, Enterobacter) Anaerobes: Bacteriodes (B.fragilis, B.thetaiotamicron, B.vulgatus) Pseudomonas aeruginosa, Candida |
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How do Aerobes set up the ideal environment for Anaerobes? (i.e. Bacterial Synergism)(3) |
1) Consumes O2 providing an anerobic environment 2) Produces waste used as nutrients by anaerobes 3) Produces enzymes which promote anaerobic tissue invasion |
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What are the signs and symptoms of fairly systemic intra-abdominal infections? |
1) Fever/Chills 2) Nasuea/Vomitting 3) Abdominal Pain 4) Tenderness 5) Guarding 6) Decreased Bowel Sounds |
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What organs are in the Right Upper Quadrant? |
Liver, Gall Bladder |
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What organs are in the Left Upper Quadrant? |
Pancreas |
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What organs are in the Right Lower Quadrant? |
Appendix |
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What is "Rebound Tenderness"? |
Pain felt when pressure is applied to the abdomen and is suddenly released |
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What is "Guarding"? |
Abdominal wall muscle spasm (Patient does not want you near them) |
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What are the Lab Values of Intra-Abdominal Infections? |
1) Increased PMN cells (>300/mm^3) shifted to the left 2) pH <7.35 3) Positive for Lactate 4) Positive for Protein 5) Positive for Gram Stain |
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What is the frequency of occurrence for Primary Peritonitis? |
Relatively uncommon 1) 10-25% of patients with ascites related to alcoholic cirrhosis 2) Risk increases with PPI |
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What is the frequency of occurrence for Peritoneal Dialysis Related Peritonitis? |
1) 60% of patients with chronic ambulatory peritoneal dialysis will have 1 episode in 1st year 2) Avg incidence in CAPD pts is 1.3-1.4 episodes per year |
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What is the frequency of occurrence for Intra-Abdominal Abscess? |
Commonly seen in Appendicitis, Diverticulitis, Pancreatis, female GU tract. [Can take days-years to form] |
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What is the frequency of occurrence for Acute Choleocystitis? |
Higher risk with 1) Gallstones 2) Tumors 3) Bile duct blockage |
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What are the typical causative organisms of Primary Peritonitis? |
Source is usually outside peritoneal cavity 1) E.coli (65%) 2) Klebsiella pneumoniae (15%) 3) Strep pneumonae (15%) 4) Anaerobes (<1%) |
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What are the typical causative organisms of Peritoneal Dialysis Related Peritonitis? |
Source is usually outside peritoneal cavity 1) Staph Aureus (4%) 2) Staph Epidermidis (8%) |
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What are the typical causative organisms of Secondary Peritonitis? |
Source is usually within the peritoneal cavity usually GI tract 1) E.coli (56-66%) 2) Proteus (11-26%) 3) Klebsiella (8-29%) 4) Streptocci (12-47%) 5) B.fragilis (40-93%) 6) Enterococcus 7) Candida |
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What are the typical causative organisms of Intra-Abdominal Abscess? |
Anaerobes - Bacteriodes (B.fragilis) |
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What are the typical causative organisms of Acute Appendicitis? |
Source is usually within the peritoneal cavity usually GI tract 1) E.coli (56-66%) 2) Proteus (11-26%) 3) Klebsiella (8-29%) 4) Streptocci (12-47%) 5) B.fragilis (40-93%) 6) Enterococcus 7) Candida |
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What are the typical causative organisms of Acute Choleocystitis? |
1) Enterobacteriacae 2) Enterococcus 3) Anaerobes |
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What are the typical causative organisms of Acute Cholangitis? |
1) Enterobacteriacae 2) Enterococcus 3) Anaerobes |
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What are the Treatment Options of Primary Peritonitis? |
Usually only requires antibiotics but no surgical intervention: -Treat for 10 days if blood culture is +ve, and 5-7 days if blood culture is -ve |
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What are the Treatment Options of Peritoneal Dialysis Related Peritonitis? |
Usually only requires antibiotics, IntraPeritoneal (IP) is superior to IV. [Watch for Abscess], and consider catheter removal. |
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What are the Treatment Options of Secondary Peritonitis? |
Usually one requires antibiotics, consider treating If Enterococcus or Candida |
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When would you consider treating Enterococcus in Secondary Peritonitis? |
1) Health care infections 2) Distal colon surgery 3) Hepatobilliary/pancreatic infection 4) Valvular disease 5) Prosthetic Heart Valve 6) Chronic/Immunocompromised 7) Previous Ab Use 8) If Enterococcus is the predominant organism in culture |
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When would you consider treating Candida in Secondary Peritonitis? |
Positive gram stain AND one of the following: 1) Intracellular yeast/hyphae 2) Immunocompromised 3) Multiple previous Abx 4) GI perforations 5) Post-operative abdominal infections 6) Recurrent IA infection |
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What are the Treatment Options of Intra-Abdominal Abscess? |
Should only use IntraPeritoneal antibiotics since PO does not penetrate well. Should drain the abscess. [Ultrasound or CT scan may be used to evaluate the severity] |
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What are the Treatment Options of Uncomplicated Acute Appenicitis? |
Empiric Therapy is Unnecessary. Surgical prophylaxis is recommended. |
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What are the Treatment Options of Complicated Acute Appenicitis? |
Empiric Therapy is Necessary |
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What are the Treatment Options of Acute Choleocystitis? |
Mild cases do not require Antibiotics. Therapy is usually 7 days [3-5 days if no perforation, abscess or cholangitis] {Don't cover Enteroccous unless elderly, immunocompromised, diabetic, bile duct obstructions} |
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What are the step-down criteria for IP/IV step-down criteria to PO? |
1) Able to tolerate oral medications 2) Afebrile 3) Normal WBC count 4) No residual fluid collection 5) Return of GI functions |
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What are the Surgical Options for Intra-abdominal infections? |
1) Prompt drainage of abscess and/or debridement 2) Resection of perforated colon, small intestine, ulcers 3) Repair Trauma |
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What are the Vital Functions Support infections? |
1) Blood pressure/fluid replacement 2) Monitor heart rate 3) Monitor urine output (0.5mL/kg/hr) |
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What are the typical Monitoring Parameters for Intra-Abdominal Infections? |
Re-check ascitic fluid at 48hrs: 1) Fluid is sterile 2) WBC<250/mm^3 3) Decreased Protein 4) Negative Culture 5) Patient feels clinically well |
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What is the DOC for Primary Peritonitis? |
Ceftriaxone or Cefotaxime |
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What is the DOC for Peritoneal Dialysis Related Peritonitis? |
Cefazolin (15mg/kg) IP + Gentamicin (0.6mg/kg) IP once a day |
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What is the DOC for Secondary Peritonitis (mild-mod)? |
3rd Gen Cephalosporin : Ceftriaxone (1-2g IV daily) + Metronidazole (500mg IV/PO BID) {other cephalosporins include Cefotetan, Cefoxitin, Ceftriazone} |
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What is the DOC for Secondary Peritonitis (severe)? |
Piperacillin /Tazobactam (4.5g IV q8h) ± Gentamicin (7mg/kg IV q24h) {Use AMG if septic shock, recent Abx use, ESBL/Carbaperamase organism} |
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What is the DOC for Acute Choleocystitis? |
3rd Gen Cephalosporin : Ceftriaxone (1-2g IV daily) + Metronidazole (500mg IV/PO BID) {other cephalosporins include Cefotetan, Cefoxitin, Ceftriazone} |
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What is the DOC for Acute Cholangitis? |
Piptazo 4.5g IV q8h (or 3.375g IV q6h) |
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What are the alternative drug therapies for Primary Peritonitis? |
1) Ampicillin+Gentamicin 2) Cefazolin+Gentamicin 3) Piperacillin/Tazobactam 4) Ertapenem 5) Imipenem or Meropenem 6) Fluroquinolones |
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What are the alternative drug therapies for Peritoneal Dialysis Related Peritonitis? |
1) Vancomycin (15mg/kg IP q7 days) + Gentamicin (0.6mg/kg IP daily) {can add cefazolin if very bad} [Ciprofloxacin is no longer recommended due to high resistance] |
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Why do you never recommend Cefazolin and Ceftazodime together? |
They are antagonistic |
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What are the alternative drug therapies for Secondary Peritonitis (mild-mod)? |
1) Ciprofloxacin (400mg IV BID) + Metronidazole (500mg IV/PO BID) 2) Levofloxacin + Metrondazole 3) Ertapenem (1g IV q24hrs) 4) Moxifloxacin (400mg IV q24hrs) 5) Ampicillin (2g IV q6hrs) + Gentamicin (5-7mg/kg IV q24hrs) + Metronidazole (500mg IV/PO BID) |
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What are the alternative drug therapies for Secondary Peritonitis (severe)? |
1) Imipenem (500mg IV q6hrs) ± AMG 2) Meropenem (500mg IV q6hrs)(1g IV q8hrs) ±AMG |
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What are the alternative drug therapies for Acute Cholecocystitis? |
1) Ciprofloxacin (400mg IV BID) + Metronidazole (500mg IV/PO BID) 2) Levofloxacin + Metrondazole 3) Ertapenem (1g IV q24hrs) 4) Moxifloxacin (400mg IV q24hrs) 5) Ampicillin (2g IV q6hrs) + Gentamicin (5-7mg/kg IV q24hrs) + Metronidazole (500mg IV/PO BID) |
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What are the alternative drug therapies for Acute Cholangitis? |
1) Imipenem (500mg IV q6h) 2) Meropenem (500mg IV q6h/ 1g IV q8h) 3) Ertapenem (1g IV q24h) 4) Ceftriaxone (1-2g IV daily) ± Metronidazole (500mg IV/PO BID) 5) Vancomycin (15mg/kg IV q12h) + Ciprofloxacin (400mg IV/500mg PO BID) ± Metronidazole (500mg IV/PO BID) |