Peritonitis

Peritonitis

Q. 1

Primary peritonitis is more common in females because :

 A

Ostia of Fallopian tubes communicate with ab­dominal cavity

 B

Peritoneum overlies the uterus

 C

Rupture of functional ovarian cysts

 D

None of the above

Q. 1

Primary peritonitis is more common in females because :

 A

Ostia of Fallopian tubes communicate with ab­dominal cavity

 B

Peritoneum overlies the uterus

 C

Rupture of functional ovarian cysts

 D

None of the above

Ans. A

Explanation:

Ans. is a i.e. Ostia of fallopian tubes communicate with abdominal cavity

Primary peritonitis refers to inflammation of peritoneal cavity without a documented source of contamination.

“It occurs more commonly in children than adults and in women than in men. The later distribution is explained by entry of organisms into the peritoneal cavity through the fallopian tubes.”



Q. 2

A posteriorly perforating ulcer in the pyloric antrum of stomach is most likely to produce initial localized peritonitis or abscess formation in which of the following location?

 A

Greater sac

 B

Omental bursa (lesser sac)

 C

Right subphrenic space

 D

Hepato renal space (pouch of Morison)

Q. 2

A posteriorly perforating ulcer in the pyloric antrum of stomach is most likely to produce initial localized peritonitis or abscess formation in which of the following location?

 A

Greater sac

 B

Omental bursa (lesser sac)

 C

Right subphrenic space

 D

Hepato renal space (pouch of Morison)

Ans. B

Explanation:

Ulcer in the pyloric antrum of stomach which perforate posteriorly produce peritonitis in the omental bursa (lesser sac).

It is difficult to diagnose when perforation occur to lesser sac and patient may not have obvious signs of peritonitis.

Ref: Bailey and Love’s Short Practice of Surgery, 23rd Edition, Page 1045.


Q. 3

A patient with abdominal injury presents to the emergency department with signs of peritonitis and shock. His airway and breathing were secured and IV fluids were started with 2 large bore cannulas. The next line of management should be:

 A

FAST

 B

Exploratory Laparotomy under general anesthesia

 C

Insertion of abdominal drain followed by laparotomy

 D

Laproscopy

Q. 3

A patient with abdominal injury presents to the emergency department with signs of peritonitis and shock. His airway and breathing were secured and IV fluids were started with 2 large bore cannulas. The next line of management should be:

 A

FAST

 B

Exploratory Laparotomy under general anesthesia

 C

Insertion of abdominal drain followed by laparotomy

 D

Laproscopy

Ans. B

Explanation:

Patient with abdominal stab injury showing signs of shock and peritonitis require urgent exploratory laparotomy.
 
Ref: Textbook of orthopedics and trauma By GS Kulkarni, Page1331.

 


Q. 4

Apart from Escherichia coli, which of the following is the other most common organism implicated in acute suppurative bacterial peritonitis?

 A

Klebsiella

 B

Bacteroides

 C

Pseudomonas

 D

Peptostreptococcus

Q. 4

Apart from Escherichia coli, which of the following is the other most common organism implicated in acute suppurative bacterial peritonitis?

 A

Klebsiella

 B

Bacteroides

 C

Pseudomonas

 D

Peptostreptococcus

Ans. B

Explanation:

E coli is the most common aerobic bacteria involved in the pathogenesis of acute suppurative bacterial peritonitis, whereas the most common anaerobic bacteria involved is Bacteroides.

Acute suppurative bacterial peritonitis (secondary bacterial peritonitis) usually occur as a result of acute infection of peritoneum resulting from perforation following appendicitis or diverticulitis.

Ref: Principles of Surgical Patient Care By C. J. Mieny, 2nd Edition, Pages 825-8.


Q. 5

A 23-year-old man is admitted to the hospital through the emergency department with probable appendicitis. He has been having right lower quadrant abdominal pain for several days, which has been becoming increasingly worse. His temperature 39.2 C (102.6 F), blood pressure is 80/40 mm Hg, Pulse is 120/min, and Respiratory rate is 35/min. The abdomen is rigid with guarding. Multiple petechiae and purpura are present, and the patient is oozing blood from his oral mucosa. According to the patient’s wife, he has not had bleeding problems in the past. The fact the abdomen is rigid with guarding suggests which of the following?

 A

Colon cancer

 B

Diverticulitis

 C

Liver failure

 D

Peritonitis

Q. 5

A 23-year-old man is admitted to the hospital through the emergency department with probable appendicitis. He has been having right lower quadrant abdominal pain for several days, which has been becoming increasingly worse. His temperature 39.2 C (102.6 F), blood pressure is 80/40 mm Hg, Pulse is 120/min, and Respiratory rate is 35/min. The abdomen is rigid with guarding. Multiple petechiae and purpura are present, and the patient is oozing blood from his oral mucosa. According to the patient’s wife, he has not had bleeding problems in the past. The fact the abdomen is rigid with guarding suggests which of the following?

 A

Colon cancer

 B

Diverticulitis

 C

Liver failure

 D

Peritonitis

Ans. D

Explanation:

The usual reason for a patient to have a rigid abdomen is that peritonitis is present, and is causing severe pain related to perineal nerve fiber stimulation.

The probable cause of the peritonitis is a ruptured appendix.

This patient is also probably in shock, as indicated by the hypotension with increased respirations and heart rate, but this would not cause the abdominal guarding.

The other answers are distractors.


Q. 6

You are called to assess a neonate who has a tense abdomen and the findings are suggestive of peritonitis. You make a diagnosis of meconium peritonitis in the child and advise immediate surgery. When can meconium peritonitis occur in a child ?

 A

Just before birth only

 B

Just after birth only

 C

During birth only

 D

Any of the above

Q. 6

You are called to assess a neonate who has a tense abdomen and the findings are suggestive of peritonitis. You make a diagnosis of meconium peritonitis in the child and advise immediate surgery. When can meconium peritonitis occur in a child ?

 A

Just before birth only

 B

Just after birth only

 C

During birth only

 D

Any of the above

Ans. D

Explanation:

Meconium peritonitis is an aseptic peritonitis which can occur in late intrauterine life, during birth or just after delivery.

It occurs due to intestinal perforation usually as a result of some form of neonatal intestinal obstruction.

The meconium may remain sterile upto 3 hours after birth, after that the child may develop acute bacterial peritonitis which is rapidly fatal.

Ref: Bailey, Edition 24, Page – 1141


Q. 7

Which of the following is the management of choice in a patient presenting with peritonitis and massive contamination because of duodenal leak?

 A

Four quadrant peritoneal lavage

 B

Duodenostomy + feeding jejunostomy + Peritoneal lavage

 C

Total parenteral nutrition

 D

Duodenojejunostomy

Q. 7

Which of the following is the management of choice in a patient presenting with peritonitis and massive contamination because of duodenal leak?

 A

Four quadrant peritoneal lavage

 B

Duodenostomy + feeding jejunostomy + Peritoneal lavage

 C

Total parenteral nutrition

 D

Duodenojejunostomy

Ans. C

Explanation:

Duodenal leakage occurs through the stump that is left after operations for duodenal ulcer and gastric ulcer.

Treatment:
  • Adequate drainage: It is achieved by insertion of large stump catheter through subcostal incision. This catheter is passed down to the duodenal stump area and a constant suction is applied.
  • Total parenteral nutrition: Should be instituted and attention must be directed towards fluid and electrolyte therapy. This will lead to healing of fistula within 2-3 weeks.
Ref: Schwartz 7/e, Page 468.

Q. 8

Primary peritonitis is more common in females because:

 A

Ostia of Follopian tubes communicate with abdominal cavity

 B

Peritoneum overlies the uterus

 C

Rupture of functional ovarian cysts

 D

None of the above

Q. 8

Primary peritonitis is more common in females because:

 A

Ostia of Follopian tubes communicate with abdominal cavity

 B

Peritoneum overlies the uterus

 C

Rupture of functional ovarian cysts

 D

None of the above

Ans. A

Explanation:

Ostia of fallopian tubes communicate with abdominal cavity & therfore provides a natural route for spread of infection from the female genital tract to the peritonium & explains why peritonitis is more common in females.

Ref: NMS Medicine By Allen R. Myers, 2004, Page 455 ; Sabiston Textbook Of Surgery, 16th Edition, Page 777

Q. 9

Primary peritonitis is more common in females because:

 A

Ostia of Follopian tubes communicate with abdominal cavity

 B

Peritoneum overlies the uterus

 C

Rupture of functional ovarian cysts

 D

None of the above

Q. 9

Primary peritonitis is more common in females because:

 A

Ostia of Follopian tubes communicate with abdominal cavity

 B

Peritoneum overlies the uterus

 C

Rupture of functional ovarian cysts

 D

None of the above

Ans. A

Explanation:

Ostia of fallopian tubes communicate with abdominal cavity & therfore provides a natural route for spread of infection from the female genital tract to the peritonium & explains why peritonitis is more common in females.

Ref: NMS Medicine By Allen R. Myers, 2004, Page 455 ; Sabiston Textbook Of Surgery, 16th Edition, Page 777

Q. 10

Primary peritonitis is more common in females because:

 A

Ostia of Follopian tubes communicate with abdominal cavity

 B

Peritoneum overlies the uterus

 C

Rupture of functional ovarian cysts

 D

None of the above

Q. 10

Primary peritonitis is more common in females because:

 A

Ostia of Follopian tubes communicate with abdominal cavity

 B

Peritoneum overlies the uterus

 C

Rupture of functional ovarian cysts

 D

None of the above

Ans. A

Explanation:

Ostia of fallopian tubes communicate with abdominal cavity & therfore provides a natural route for spread of infection from the female genital tract to the peritonium & explains why peritonitis is more common in females. Ref: NMS Medicine By Allen R. Myers, 2004, Page 455 ; Sabiston Textbook Of Surgery, 16th Edition, Page 777


Q. 11

Prophylaxis against spontaneous bacterial peritonitis ( SBP) in case of cirrhosis with ascites is indicated in:

 A

Patients with high protein ascites

 B

Prior history of SBP

 C

Serum creatinine 1 mg/dl

 D

Child pugh < 8

Q. 11

Prophylaxis against spontaneous bacterial peritonitis ( SBP) in case of cirrhosis with ascites is indicated in:

 A

Patients with high protein ascites

 B

Prior history of SBP

 C

Serum creatinine 1 mg/dl

 D

Child pugh < 8

Ans. B

Explanation:

The risk factors for SBP are

1.Ascitic fluid protein < 1 g/dl
2.Variceal hemorrhage
3.Prior episode of SBP
Acute variceal bleeding patients  need prophylaxis against SBP & Drugs used for prophylaxis are:
1.Inj.Ceftriaxone 1 g/day                                                                            
2. Oral. Ofloxacin 400 mg/day or Norfloxacin 400 OD
 
Primary prophylaxis is indicated in patients with features of :
 
Ascitic fluid protein < 1.5 g/dl With at least one of the following
1. Serum creatinine > 1.2 mg/dl
2. BUN > 25 mg/dl
3. Serum Na < 130 mEq/L
4. CTP > 9  points  with bilirubin > 3 mg/dl
5. DRug is Norfloxacin 400 mg OD for long time.
Ref: AASLD practice  guidelines:Hepatology, Vol.49 ,No.6 ,2009.

Q. 12

To distinguish between primary bacterial peritonitis from secondary peritonitis the following biochemical parameters in ascitic fluid has been used, EXCEPT:

 A

Total protein > 1 g/dl

 B

LDH greater than the upper limit of the normal of the serum

 C

Glucose < 50 mg/dl

 D

PMN count < 250 cells/mm3

Q. 12

To distinguish between primary bacterial peritonitis from secondary peritonitis the following biochemical parameters in ascitic fluid has been used, EXCEPT:

 A

Total protein > 1 g/dl

 B

LDH greater than the upper limit of the normal of the serum

 C

Glucose < 50 mg/dl

 D

PMN count < 250 cells/mm3

Ans. D

Explanation:

Secondary bacterial peritonitis is the ascitic fluid infection caused by a surgically treatable intraabdominal source of infection. It can be divided into two groups

1. Those with free perforation of a viscus eg : duodenal ulcer perforation
2. Those with loculated abscess eg : perinephric abscess
 
The characteristic ascitic fluid findings in the setting of secondary                                        bacterial peritonitis are                                                           
Ascitic fluid PMN > 250 cells/mm 3                          
with at least two of the following criteria
1. Ascitic fluid total protein > 1 g/dl
2. LDH greater than the upper limit of the normal of the serum
3. Glucose < 50 mg/dl
 
If Ascitic fluid carcinoembryonic antigen (CEA) is  > 5 ng/mL and alkaline  phosphatase > 240 U/L indicates gut perforation.                                                      
Ref: AASLD practice guidelines: Hepatology, Vol.49, No.6 , 2009.

Q. 13

Albumin treatment along with antibiotic in the setting of SBP(spontaneous bacterial peritonitisis indicated to prevent the development of hepatorenal syndrome is in all , EXCEPT:

 A

Serum creatine is > 1 mg/dl

 B

BUN > 30mg/dl

 C

Total bilirubin is > 4 mg/dl

 D

INR > 2

Q. 13

Albumin treatment along with antibiotic in the setting of SBP(spontaneous bacterial peritonitisis indicated to prevent the development of hepatorenal syndrome is in all , EXCEPT:

 A

Serum creatine is > 1 mg/dl

 B

BUN > 30mg/dl

 C

Total bilirubin is > 4 mg/dl

 D

INR > 2

Ans. D

Explanation:

In patients with SBP along  with cefotaxime albumin infusion is indicated in the setting , when

1.Serum creatine is  > 1 mg/dl
2. BUN >   30 mg/dl
3. Total bilirubin is > 4 mg/dl
 
Dose o f albumin: 1. g/Kg within 6 hours of antibiotic treatment and 1 g/kg  on day 3.
A decrease in mortality from 30%to 10 % is noted.
Ref: AASLD practice  guidelines:Hepatology, Vol.49 ,No.6 ,2009.

Q. 14

Primary bacterial peritonitis is reported in all these conditions, EXCEPT:

 A

Chronic active hepatitis

 B

Acute viral hepatitis

 C

Congestive heart failure

 D

Acute nephritis

Q. 14

Primary bacterial peritonitis is reported in all these conditions, EXCEPT:

 A

Chronic active hepatitis

 B

Acute viral hepatitis

 C

Congestive heart failure

 D

Acute nephritis

Ans. D

Explanation:

Primary bacterial peritonitis (PBP) occurs most commonly in conjunction with cirrhosis 

Other conditions which may cause PBP are
  • Metastatic malignant disease, 
  • Postnecrotic cirrhosis, 
  • Chronic active hepatitis, 
  • Acute viral hepatitis, 
  • Congestive heart failure, 
  • Systemic lupus erythematosus
  • Lymphedema 
  • No underlying disease
Ref: Harrison, E-18, P-1080.

Q. 15

All are true about primary bacterial peritonitis, EXCEPT:

 A

Ascitic fluid PMN count > 250 is diagnostic

 B

Microbiology of PBP is distinctive

 C

Some patients may be totally asymptomatic

 D

Usually does not respond to routine antimicrobial therapy

Q. 15

All are true about primary bacterial peritonitis, EXCEPT:

 A

Ascitic fluid PMN count > 250 is diagnostic

 B

Microbiology of PBP is distinctive

 C

Some patients may be totally asymptomatic

 D

Usually does not respond to routine antimicrobial therapy

Ans. D

Explanation:

PBP is commonly present with fever, but it can present without any symptoms too. Ascitic fluid analysis should be performed in all suspected cases and PMN > 250/l is diagnostic of PBP.

Escherichia coli are most commonly encountered as the cause of PBP.
In PBP, a single organism is typically isolated. PBP is usually treated with cefotaxime and it responds very well to it.
Ref: Harrison, E-18, P-1081.


Q. 16

A posteriorly perforating ulcer in the pyloric antrum of the stomach is likely to produce initial localized peritonitis or abscess formation in the:

 A

Greater sac

 B

Left subhepatic and hepatorenal spaces (pouch of Morrison)

 C

Omental bursa

 D

Right subphrenic space

Q. 16

A posteriorly perforating ulcer in the pyloric antrum of the stomach is likely to produce initial localized peritonitis or abscess formation in the:

 A

Greater sac

 B

Left subhepatic and hepatorenal spaces (pouch of Morrison)

 C

Omental bursa

 D

Right subphrenic space

Ans. C

Explanation:

C i.e. Omental Bursa


Q. 17

Which of the following statement is true about Bacteroides ‑

 A

It is gram positive bacilli

 B

It is strictly aerobic

 C

It may cause peritonitis

 D

Presence in stool culture indicates need for treatment

Q. 17

Which of the following statement is true about Bacteroides ‑

 A

It is gram positive bacilli

 B

It is strictly aerobic

 C

It may cause peritonitis

 D

Presence in stool culture indicates need for treatment

Ans. C

Explanation:

Ans. is ‘c’ i.e., It may cause peritonitis 

  • Bacteroides are strict anaerobes.

.  These are gram negative bacilli.

.  Bacteroides species are normal inhabitants of bowel and other sites and they are the most abundant anaerobes in the normal stool, their presence in the stool is not an indication for treatment.

.  They are particularly isolated from infections associated with contamination by contents of the colon where they may cause suppuration eg. peritonitis after bowel injury.


Q. 18

Most common infection in a child nephrotic syndrome-

 A

Spontaneous bacterial peritonitis

 B

Pneumonia

 C

UTI

 D

Cellulitis

Q. 18

Most common infection in a child nephrotic syndrome-

 A

Spontaneous bacterial peritonitis

 B

Pneumonia

 C

UTI

 D

Cellulitis

Ans. A

Explanation:

Ans. is ‘a’ i.e., Spontaneous bacterial peritonitis


Q. 19

Omental bursa (lesser sac)A posteriorly perforating ulcer in the pyloric antrum of the stomach is most likely to produce initial localized peritonitis or abscess formation in the following 

 A

Omental bursa (lesser sac)

 B

Greater sac

 C

Right subphrenic space

 D

Hepato renal space (pouch of Morison)

Q. 19

Omental bursa (lesser sac)A posteriorly perforating ulcer in the pyloric antrum of the stomach is most likely to produce initial localized peritonitis or abscess formation in the following 

 A

Omental bursa (lesser sac)

 B

Greater sac

 C

Right subphrenic space

 D

Hepato renal space (pouch of Morison)

Ans. A

Explanation:

Ans. is ‘a’ i.e., Omental bursa 

  • BDC writes – “The posterior surface of the stomach is related to structures forming the stomach bed, all of which are separated from the stomach by the cavity of the lesser sac.”
  • Thus an ulcer on the posterior wall of stomach would perforate into the lesser sac.
  • Also remember
  • Most perforated ulcers are located on the anterior wall.
  • The mortality rate for perforated gastric ulcer is higher than that for duodenal ulcer. This is generally due to the gastric ulcer patients’ more advanced age, increased medical comorbidities, delay in seeking medical attention, and the larger size of gastric ulcers.

Q. 20

A post-op pt. presents with peritonitis and massive contamination because  of duodenal  leak.

Management of choice is –

 A

Four quadrant peritoneal lavage

 B

Duodenostomy + feeding jejunostomy + Peritoneal lavage

 C

Total parentral nutrition

 D

Duodenojejunostomy

Q. 20

A post-op pt. presents with peritonitis and massive contamination because  of duodenal  leak.

Management of choice is –

 A

Four quadrant peritoneal lavage

 B

Duodenostomy + feeding jejunostomy + Peritoneal lavage

 C

Total parentral nutrition

 D

Duodenojejunostomy

Ans. C

Explanation:

Ans. is ‘c’ i.e. Total parentral nutrition 

  • Duodenal leakage occurs through the stump that is left after operations for duodenal ulcer and gastric ulcer.

Treatment

(I) Adequate drainage ‑

–  It is acheived by insertion of large stump catheter through subcostal incision. This catheter is passed down to the Duodenal Stump area and a constant suction is applied (2) Total parenteral nutrition ‑

– Should be instituted and attention must be directed towards fluid and electrolyte therapy.

– This will lead to healing of fistula within 2-3 weeks.


Q. 21

Meconium peritonitis occurs –

 A

Just before birth

 B

Just after birth

 C

Before and after birth

 D

Due to birth trauma

Q. 21

Meconium peritonitis occurs –

 A

Just before birth

 B

Just after birth

 C

Before and after birth

 D

Due to birth trauma

Ans. C

Explanation:

Answer is ‘c’ i.e. Before and after birth

Meconium peritonitis is an aseptic peritonitis, develops late in intrauterine life or during or just after delivery. – Bailey & Love

Meconium Peritonitis

  • Meconium is a sterile mixture of epithelial cells, mucin, salts, fats and bile and is formed when the fetus commences to swallow amniotic fluid.
  • Meconium peritonitis is due to intestinal perforation mostly the result of some form of neonatal intestinal obstruction (eg. meconium ileus in cystic fibrosis patients).
  • When meconium enters the peritoneal cavity, an exudate is secreted that organizes rapidly, matting of intestinal loops occur, and in many cases in a matter of weeks, the extruded becomes calcified.
  • Meconium remains sterile until about 3 hrs after birth; thereafter, unless the perforation has become sealed, sterile meconium peritonitis gives place to acute bacterial peritonitis which unless treated promptly is rapidly fatal.
  • Clinical picture may be that of peritonitis and/or intestinal obstruction.

– Meconium peritonitis should always be suspected when a baby is born with a tense abdomen, who is vomiting and in whom there is failure to discharge meconium.

  • Treatment

Prognosis is poor but recovery may follow prompt operation.

Treatment consists of elimination of intestinal obstruction, closure of perforation and drainage of peritoneal cavity.


Q. 22

Most common cause of peritonitis in adult male is

 A

Duodenal ulcer perforation

 B

Abdominal tuberculosis

 C

Enteric perforation

 D

Perforated appendix

Q. 22

Most common cause of peritonitis in adult male is

 A

Duodenal ulcer perforation

 B

Abdominal tuberculosis

 C

Enteric perforation

 D

Perforated appendix

Ans. D

Explanation:

Ans. is ‘d’ i.e. Perforated appendix 


Q. 23

Apart from Escherichia coli, the other most common organism implicated in acute suppurative bacterial peritonitis is-

 A

Bacteroides

 B

Klebsiella

 C

Peptostreptococcus

 D

Pseudomonas

Q. 23

Apart from Escherichia coli, the other most common organism implicated in acute suppurative bacterial peritonitis is-

 A

Bacteroides

 B

Klebsiella

 C

Peptostreptococcus

 D

Pseudomonas

Ans. A

Explanation:

Ans. is ‘a’ i.e. Bacteroides 


Q. 24

Primary peritonitis with pneumococcus is associated with –

 A

Lymphomas

 B

Nephrotic syndrome

 C

Carcinoids

 D

None of the above

Q. 24

Primary peritonitis with pneumococcus is associated with –

 A

Lymphomas

 B

Nephrotic syndrome

 C

Carcinoids

 D

None of the above

Ans. B

Explanation:

Ans. is ‘b’ i.e., Nephrotic syndrome 


Q. 25

Early surgery is indicated in –

 A

Amoebiasis peritonitis

 B

Biliary peritonitis

 C

Typhoid peritonitis

 D

b and c

Q. 25

Early surgery is indicated in –

 A

Amoebiasis peritonitis

 B

Biliary peritonitis

 C

Typhoid peritonitis

 D

b and c

Ans. D

Explanation:

Ans. Two options are correct i.e., `b & c’ 


Q. 26

Most common cause of generalised peritonitis in a 40 year old adult male is –

 A

Enteric perforation

 B

Ruptured liver abscess

 C

Duodenal Ulcer perforation

 D

Perforated Ca stomach

Q. 26

Most common cause of generalised peritonitis in a 40 year old adult male is –

 A

Enteric perforation

 B

Ruptured liver abscess

 C

Duodenal Ulcer perforation

 D

Perforated Ca stomach

Ans. C

Explanation:

Ans. is ‘c’ i.e., Duodenal Ulcer perforation 


Q. 27

Infra-abdominal calcificaition in a plane X-ray abdomen is most often seen in –

 A

Meconium ileus

 B

Meconium peritonitis

 C

Meconium plug syndrome

 D

Necrotising enterocolitis

Q. 27

Infra-abdominal calcificaition in a plane X-ray abdomen is most often seen in –

 A

Meconium ileus

 B

Meconium peritonitis

 C

Meconium plug syndrome

 D

Necrotising enterocolitis

Ans. B

Explanation:

Ans. is ‘b’ i.e., Meconium peritonitis 


Q. 28

Which one of the following statements regarding Meconium peritonitis is NOT correct –

 A

It is a septic peritonitis

 B

It develops in later infra-uterine life or during or just after delivery

 C

This condition should always be considered when a baby is born with tense abdomen

 D

Plain X-ray abdomen of this condition reveals calcification on liver and spleen

Q. 28

Which one of the following statements regarding Meconium peritonitis is NOT correct –

 A

It is a septic peritonitis

 B

It develops in later infra-uterine life or during or just after delivery

 C

This condition should always be considered when a baby is born with tense abdomen

 D

Plain X-ray abdomen of this condition reveals calcification on liver and spleen

Ans. A

Explanation:

Ans. is ‘a’ i.e., It is a septic peritonitis 


Q. 29

The commonest organism seen in peritonitis is –

 A

Escherichia coli

 B

Clostridium welchii

 C

Staphylococci

 D

Klebsiella

Q. 29

The commonest organism seen in peritonitis is –

 A

Escherichia coli

 B

Clostridium welchii

 C

Staphylococci

 D

Klebsiella

Ans. A

Explanation:

Ans. is ‘a’ i.e., Escherichia coli 


Q. 30

Which of the following complications is not seen with peritonitis –

 A

Renal failure

 B

Residual abscess

 C

Endoxic shock

 D

None

Q. 30

Which of the following complications is not seen with peritonitis –

 A

Renal failure

 B

Residual abscess

 C

Endoxic shock

 D

None

Ans. D

Explanation:

Ans. is ‘None’ 

  • Systemic complications of peritonitis Bacteraemic/endotoxic shock Bronchopneumonia/respiratory failure

Renal failure

Bone marrow suppression Multisystem failure

  • Abdominal complications of peritonitis

–  Adhesional small bowel obstruction Paralytic ileus

Residual or recurrent abscess Portal pyaemiafiiver abscess


Q. 31

A 25 years old female presents with pyrexia for ten days, develops acute pain in periumblical region spreading all over the abdomen. What would be the most likely cause ?

 A

Perforation peritonitis due to intestinal tuberculosis

 B

Generalised peritonitis due to appendicular perforation

 C

Typhoid enteric perforation and peritonitis

 D

Acute salpingo-oophoritis with peritonitis

Q. 31

A 25 years old female presents with pyrexia for ten days, develops acute pain in periumblical region spreading all over the abdomen. What would be the most likely cause ?

 A

Perforation peritonitis due to intestinal tuberculosis

 B

Generalised peritonitis due to appendicular perforation

 C

Typhoid enteric perforation and peritonitis

 D

Acute salpingo-oophoritis with peritonitis

Ans. C

Explanation:

Ans. is ‘c’ i.e., Typhoid enteric perforation and peritonitis


Q. 32

Spontaneous peritonitis in cirrhosis patients; the polymorphonuclear cells are –

 A

More than 200 cells/cumm

 B

More than 300 cell/cumm

 C

More than 400 cells/cumm

 D

More than 500 cells/cumm

Q. 32

Spontaneous peritonitis in cirrhosis patients; the polymorphonuclear cells are –

 A

More than 200 cells/cumm

 B

More than 300 cell/cumm

 C

More than 400 cells/cumm

 D

More than 500 cells/cumm

Ans. A

Explanation:

Ans. is ‘a’ i.e., More than 200 cells/cumm 


Q. 33

Which of the following statements about preoperative optimization for perforation peritonitis is incorrect‑

 A

High technology intensive care unit environment is required

 B

Patients may require large volume of crystalloid infusion

 C

Hypovolemia and sepsis contribute to tissue underperfusion

 D

Base deficit >6 is marker of significant metabolic acidosis

Q. 33

Which of the following statements about preoperative optimization for perforation peritonitis is incorrect‑

 A

High technology intensive care unit environment is required

 B

Patients may require large volume of crystalloid infusion

 C

Hypovolemia and sepsis contribute to tissue underperfusion

 D

Base deficit >6 is marker of significant metabolic acidosis

Ans. A

Explanation:

Ans is a i.e. High technology intensive care unit environment is required 


Q. 34

The most common intraperitoneal abscess following peritonitis is

 A

Subphrenic

 B

Pelvic

 C

Paracolic

 D

Interloop

Q. 34

The most common intraperitoneal abscess following peritonitis is

 A

Subphrenic

 B

Pelvic

 C

Paracolic

 D

Interloop

Ans. B

Explanation:

Ans is b i.e. Pelvic 


Q. 35

Paralytic ileus is caused by –

 A

Peritonitis

 B

Hyperkalemia

 C

Acute intestinal obstruction

 D

Head injury

Q. 35

Paralytic ileus is caused by –

 A

Peritonitis

 B

Hyperkalemia

 C

Acute intestinal obstruction

 D

Head injury

Ans. A

Explanation:

Ans. is ‘a’ i.e., Peritonitis 


Q. 36

Diffuse peritonitis in acute appendicitis is caused due to:

 A

Early rupture of appendix

 B

Late rupture of appendix

 C

Fecolith

 D

Old age

Q. 36

Diffuse peritonitis in acute appendicitis is caused due to:

 A

Early rupture of appendix

 B

Late rupture of appendix

 C

Fecolith

 D

Old age

Ans. A

Explanation:

Ans is ‘a’ i.e. Early rupture of appendix

Perforation of appendix in acute appendicitis commonly leads to an abscess cavity walled off by the small bowel loops and the omentum, forming a phlegmon. Rarely the appendix may perforate freely into the peritoneal cavity and cause generalized peritonitis. This usually occurs in cases of early rupture of the appendix as inflammatory process did not get time to be localized by the omentum and bowel loops.

Usually the rupture of appendix is a late sequelae of appendicitis, usually occurring 48 to 72 hours from the onset of symptoms.


Q. 37

Diffuse peritonitis following appendicitis is usually seen –

 A

When appendicular perforation occurs early (within 24 hours)

 B

When perforation occurs late (after 24 hours)

 C

Particularly in non-obstructive appendicitis

 D

When antibiotics are withheld

Q. 37

Diffuse peritonitis following appendicitis is usually seen –

 A

When appendicular perforation occurs early (within 24 hours)

 B

When perforation occurs late (after 24 hours)

 C

Particularly in non-obstructive appendicitis

 D

When antibiotics are withheld

Ans. A

Explanation:

Ans. is ‘a’ i.e., When appendicular perforation occurs early (within 24 hours) 


Q. 38

A posteriorly perforating ulcer in the pyloric antrum of the stomach is most likely to produce initial localized peritonitis or abscess formation in the following:

 A

Omental bursa (lesser sac)

 B

Greater sac

 C

Right subphrenic space

 D

Hepato renal space (pouch of Morison)

Q. 38

A posteriorly perforating ulcer in the pyloric antrum of the stomach is most likely to produce initial localized peritonitis or abscess formation in the following:

 A

Omental bursa (lesser sac)

 B

Greater sac

 C

Right subphrenic space

 D

Hepato renal space (pouch of Morison)

Ans. A

Explanation:

Answer is A (Omentum bursa)

“Gastric ulcers perforate into the lesser sac, which can be particularly difficult to diagnose” – Bailey

“A gastric ulcer perforates into the lesser sac, then no signs of generalised peritonitis can be seen but misleading symptoms may appear” – Schwartz

As can be seen from the figure, a posteriorly perforating ulcer of the stomach will localize in the lesser sac or omental bursa only. (lesser sacis synonymous with omental bursa)


Q. 39

A patient was on long term antibiotic therapy for peritonitis. During the course of treatment, he develops mucus diarrhea. Most likely cause of diarrhea is:

September 2012

 A

Peritonitis

 B

Antibiotic associated diarrhea

 C

Immunocompromised state

 D

Altered bowel habits

Q. 39

A patient was on long term antibiotic therapy for peritonitis. During the course of treatment, he develops mucus diarrhea. Most likely cause of diarrhea is:

September 2012

 A

Peritonitis

 B

Antibiotic associated diarrhea

 C

Immunocompromised state

 D

Altered bowel habits

Ans. B

Explanation:

Ans. B i.e. Antibiotic associated diarrhea

Antibiotic-associated diarrhea (AAD)

  • It results from an imbalance in the colonic microbiota caused by antibiotic therapy.
  • Microbiota alteration changes carbohydrate metabolism with decreased short-chain fatty acid absorption and an osmotic diarrhea as a result.
  • Another consequence of antibiotic therapy leading to diarrhea is overgrowth of potentially pathogenic organisms such as Clostridium difficile.
  • It is defined as frequent loose and watery stools with no other complications.



Q. 40

All of the following regarding diagnosis of acute peritonitis are correct except:    

March 2008

 A

Raised WBC count in peritoneal aspirate

 B

Moderately raised amylase levels are diagnostic of peritonitis

 C

CT scan may aid in diagnosis

 D

Upright films shows free air under the diaphragm

Q. 40

All of the following regarding diagnosis of acute peritonitis are correct except:    

March 2008

 A

Raised WBC count in peritoneal aspirate

 B

Moderately raised amylase levels are diagnostic of peritonitis

 C

CT scan may aid in diagnosis

 D

Upright films shows free air under the diaphragm

Ans. B

Explanation:

Ans. B: Moderately raised amylase levels are diagnostic of peritonitis

Free air is present in radiographs in most cases of anterior gastric and duodenal perforation but is much less frequent with perforations of the small bowel and colon and is unusual with appendiceal perforation.

Upright films are useful for identifying free air under the diaphragm (most often on the right) as an indication of a perforated viscus.

Presence of dilated gas-filled loops of the bowel can also be seen which is consistent with a paralytic ileus.

Serum amylase estimation may establish the diagnosis of acute pancreatitis, but moderately raised levels may be seen in other abdominal catastrophes and operations.

Diagnostic peritoneal lavage (DPL) may be helpful in patients who do not have conclusive signs on physical examination or who cannot provide an adequate history.

A DPL with more than 500 leukocytes/mL is considered positive and suggests peritonitis.

The fluid in bacterial peritonitis generally demonstrates low pH and glucose as well as elevated protein and LDH levels. The drop in peritoneal fluid pH (and P02) is more pronounced in mixed infections and severe bacterial contamination, with increased numbers of anaerobic bacteria in these circumstances.

USG and CT scan are increasingly used to identify the cause of peritonitis (acute pancreatitis).


Q. 41

A patient on antibiotics for treatment for peritonitis presents with mucus diarrhoea. Most probable cause could be:           

September 2009

 A

Ulcerative colitis

 B

Activation of latent tuberculosis

 C

Antibiotic associated diarrhoea

 D

Gastritis

Q. 41

A patient on antibiotics for treatment for peritonitis presents with mucus diarrhoea. Most probable cause could be:           

September 2009

 A

Ulcerative colitis

 B

Activation of latent tuberculosis

 C

Antibiotic associated diarrhoea

 D

Gastritis

Ans. C

Explanation:

Ans. C: Antibiotic associated diarrhoea

Nearly 25% of antibiotic associated diarrhoeas (AAD) is caused by Clostridium difficile, making it the commonest pathogen. Other pathogens implicated infrequently include Clostridium perfringens, Staphylococcus aureus, Klebsiella oxytoca, Candida spp. and Salmonella spp.

Most mild cases of AAD are due to non-infectious causes which include reduced break down of primary bile acids and decrease metabolism of carbohydrates, allergic or toxic effects of antibiotic on intestinal mucosa and pharmacological effect on gut motility.

The antibiotics most frequently associated with C. difficile associated diarrhoea are clindamycin, cephalosporin, ampicillin and amoxicillin.

Clinical presentation may vary from mild diarrhoea to severe colitis and pseudomembranous colitis associated with high morbidity and mortality.

The most sensitive and specific diagnostic test for C. difficile infection is tissue culture assay for cytotoxicity of toxin B. Commercial ELISA kits are available. Though less sensitive, they are easy to perform and are rapid.

Withdrawal of precipitating antibiotic is all that is needed for control of mild to moderate cases.

For severe cases of AAD, oral metronidazole is the first line of treatment, and oral vancomycin is the second choice.


Q. 42

In nephrotic syndrome, which infection is more commoner in children:   

September 2010

 A

Cellulitis

 B

Pneumonia

 C

UTI

 D

Bacterial peritonitis

Q. 42

In nephrotic syndrome, which infection is more commoner in children:   

September 2010

 A

Cellulitis

 B

Pneumonia

 C

UTI

 D

Bacterial peritonitis

Ans. D

Explanation:

Ans. D: Bacterial peritonitis



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