Synopsis
Recognise peritoneal irritation and infection-associated deterioration, distinguish their meaning from a definitive diagnosis, and connect urgent physiological treatment to timely control of a surgical source.
- Peritonism describes signs of peritoneal irritation; it does not identify the organism, organ or need for a particular operation.
- Sepsis assessment requires possible infection plus the degree of illness, with attention to current physiology and trajectory.
- Guarding may be subtle in frail or immunosuppressed people; concerning organ dysfunction can precede dramatic abdominal signs.
Key red flags
A rigid or generally guarded abdomen with new confusion, hypotension or increasing respiratory support needs demands urgent escalation; absence of fever does not make it safe.
New confusion, mottling, reduced urine production, respiratory distress or circulatory compromise may be more important than fever. Infection should remain possible when temperature is normal or low. In people with recent surgery or impaired immune function, identify the departure from baseline and review recent treatment because the presentation may be less typical.
Reasoning priorities
Determine the urgency of treatment and the required level of clinical review.
Record the complete observation set and use NEWS2 in the adult hospital population to which it applies. Treat the score as a structured summary rather than a diagnosis. Clinical concern, a concerning single parameter or deterioration can require a higher-risk response. Document when risk was identified so time-sensitive treatments can be assessed accurately.
Worked reasoning
On the fifth day after bowel surgery, an adult develops abdominal pain, new guarding and confusion. They are considered at high risk from suspected sepsis. Initial treatment improves blood pressure slightly, but pain and respiratory rate continue to worsen.
- Continue immediate physiological reassessment and request urgent senior surgical and critical-care input. The partial blood-pressure response is one observation, not evidence that the underlying problem has resolved.
- Obtain source-relevant cultures and urgent blood tests, and give broad-spectrum intravenous antibiotics within one hour of the initial NEWS2 assessment identifying high risk in the emergency department or on ward deterioration, as specified by NG253. Choose the regimen using the source, applicable antimicrobial policy, allergy history, renal function and previous microbiology.
- Explicitly raise concern for a postoperative intra-abdominal source, including a possible leak or collection. Discuss the safest urgent imaging and intervention route with the teams who can deliver source control.
- The decision is to pursue an urgent source-control assessment alongside ongoing resuscitation, rather than waiting until the next routine ward round because one measurement improved. The appropriate operation or drainage procedure depends on the confirmed anatomy and the patient’s condition.
- Verify antibiotic administration, response to each intervention, the senior plan and whether imaging or theatre arrangements are actually progressing. If deterioration continues, repeat escalation and revise the destination and support requirements.