4-83
gastroenterologist should see all second attacks of pancreatitis.
NOTES: *Ranson's Criteria for Severity (1 point each)
At Admission (5 criteria)
Age > 55 years
WBC > 16,000/mm^3
[If available: Glucose > 200 mg/dl, Lactate dehydrogenase > 350 IU/L, and Aspartate transaminase >
250 U/L]
During Initial 48 hours (6 criteria)
HCT decrease of 10 mg/dl
PaO2 < 60 mm Hg
[If available: Blood urea nitrogen increase of > 5 mg/dl, Calcium < 8 mg/dl, Base Decit > 4 mEq/L, Fluid
sequestration > 6 L]
Number of Ranson's Criteria Predicted MORTALITY Rate
< 2 5%
3-5 10%
6 60%
GI: Acute Peritonitis
COL (Ret) Peter McNally, MC, USAIntroduction: Acute peritonitis is a potentially catastrophic illness caused by infectious organisms attacking
the peritoneum. It is usually characterized by rapid onset of symptoms and rapid medical deterioration. The
ve most common causes of acute peritonitis are appendicitis, cholecystitis, diverticulitis, pancreatitis, and
bowel perforation. Each has a characteristic pattern of symptoms to suggest the etiology. When abscess
or perforation complicates any of these causes, generalized peritonitis ensues. Generalized peritonitis requir-
ing surgical intervention is caused by perforated peptic ulcer (40%), appendicitis (20%), gangrene of bowel/
gallbladder (15%), post-op complications (10%) or other causes (15%). Exact details of the onset of the pain,
and associated symptoms (e.g., change in bowel or menstrual habits) are helpful in drawing attention to
the affected organ. Mortality is high in many groups, especially in the elderly and patients suffering organ
failure before development of peritonitis. Peritonitis secondary to appendicitis or perforated duodenal ulcer is
associated with >90% survival, whereas peritonitis from other causes, including postoperative peritonitis, has
only approximately 50% survival.
Subjective: Symptoms
Pain and fever. See handbook sections on Appendicitis, Cholecystitis and Pancreatitis.
Appendicitis: Generalized abdominal pain that becomes localized to the right lower quadrant (and eventually
McBurney’s Point); anorexia; sensation of “gas blockage” and need for bowel movement, but no improvement
after enema or defecation. Cholecystitis: 90% of patients will be symptomatic, with epigastric or right upper
quadrant pain that peaks over 30 minutes, then plateaus for 1-2 hours before gradual decreasing; some relate
pain to fatty meals, or radiation to the right scapula. Diverticulitis: More common in the elderly; pain may
occur after straining to have a bowel movement, and is initially localized to the left lower quadrant (95%);
associated with fever (60-100%) and elevated WBC count (70-80%). Pancreatitis: Chronic, excessive alcohol
abuse and gallstones cause most pancreatitis, with acute onset of rapidly progressive, incapacitating, diffuse
abdominal pain, radiating to the back; patients are typically in the fetal position for comfort. Bowel Perfora-
tion: Immediate onset of severe abdominal pain; several causes, including perforation of gastric or duodenal
ulcer, appendix, diverticula, or other hollow viscus (due to foreign body ingestion, abscess, etc.).
Objective: Signs
Using Basic Tools: Vital Signs: Fever 100-101°F, tachycardia