(a) (i) Describe the clinical features and diagnostic workup of a suspected case of peritonitis. (ii) Enumerate the principles of…

(a) Peritonitis

(i) Clinical features and diagnostic workup

Peritonitis is inflammation of the peritoneum. Most surgical cases are secondary peritonitis from hollow-viscus perforation, appendicitis, anastomotic leak or trauma. Primary (spontaneous bacterial) peritonitis occurs in cirrhotic ascites, and tertiary peritonitis is persistent infection after adequate source control.

Symptoms: severe abdominal pain, localised at first and then generalised, made worse by movement and coughing, so the patient lies still with the knees drawn up. Anorexia, nausea and vomiting follow, with abdominal distension and failure to pass flatus as paralytic ileus sets in.

Signs: tenderness with involuntary guarding, board-like rigidity (typical of peptic perforation), rebound tenderness (Blumberg sign), and a distended, silent abdomen. Liver dullness is lost when there is free gas. Pelvic peritonitis gives tenderness on digital rectal examination.

Systemic features: fever, tachycardia, tachypnoea, hypotension, oliguria, cold periphery and the pinched, sunken "Hippocratic facies" of advanced peritonitis. Elderly, immunosuppressed and steroid-treated patients may show few signs.

Diagnostic workup:

1. Blood tests: complete blood count (neutrophil leucocytosis; leucopenia in overwhelming sepsis), urea, creatinine and electrolytes, liver function tests, serum amylase/lipase to exclude acute pancreatitis, arterial blood gas and serum lactate for acidosis and hypoperfusion, coagulation profile, blood culture before antibiotics, and blood grouping and cross-match.
2. Diagnostic paracentesis (ascites, or doubtful cases): an ascitic neutrophil count ≥250 cells/mm³ diagnoses spontaneous bacterial peritonitis. Runyon's criteria (total protein >1 g/dL, glucose <50 mg/dL, LDH above the serum upper limit), polymicrobial Gram stain, or high fluid amylase or bilirubin point to secondary peritonitis from perforation.
3. Imaging: an erect chest X-ray shows free gas under the diaphragm; a left lateral decubitus film is used if the patient cannot sit up. Ultrasonography shows free fluid and collections and is useful in pelvic and biliary disease. Contrast-enhanced CT of the abdomen is the most informative test for the site of perforation, abscess, ischaemia or leak.
4. Severity scoring: qSOFA/SOFA for sepsis, and the Mannheim Peritonitis Index or APACHE II for prognosis.
5. Diagnostic laparoscopy: used when the diagnosis is still uncertain.

(ii) Principles of management

1. Resuscitation: start immediately and in parallel with investigations. Insert two wide-bore cannulas and give balanced crystalloid, 30 mL/kg within the first 3 hours if the patient is hypotensive or lactate is ≥4 mmol/L, following the Surviving Sepsis Campaign. Give oxygen, keep the patient nil by mouth, pass a nasogastric tube for decompression, and place a urinary catheter to track hourly urine output (target ≥0.5 mL/kg/h). If hypotension persists, add noradrenaline to keep MAP ≥65 mmHg.
2. Early antibiotics: give empirical broad-spectrum IV antibiotics within 1 hour of recognising septic shock. These must cover Gram-negative bacilli, enterococci and anaerobes, for example piperacillin–tazobactam, or a third-generation cephalosporin plus metronidazole. Carbapenems are reserved for severe or healthcare-associated infection. De-escalate according to culture, and after adequate source control a short course of about 4 days is usually enough.
3. Source control: for secondary peritonitis, carry out emergency laparotomy or laparoscopy as soon as the patient is resuscitated. This removes the cause (closure of the perforation with an omental patch, appendicectomy, resection with anastomosis or stoma) and is followed by thorough peritoneal lavage with warm saline. Localised abscesses are drained percutaneously under image guidance. In unstable patients, damage-control laparotomy with a temporary abdominal closure is used.
4. Primary (spontaneous bacterial) peritonitis is treated medically, without surgery: give a third-generation cephalosporin such as cefotaxime, plus IV albumin to prevent hepatorenal syndrome.
5. Supportive and postoperative care: nutrition (early enteral feeding, parenteral if the gut cannot be used), analgesia, thromboprophylaxis, glycaemic control, stress-ulcer prophylaxis, and ICU organ support (ventilation, vasopressors, renal replacement). Monitor for recurrent sepsis.

(iii) Important complications

1. Systemic: septic shock, multi-organ dysfunction syndrome, ARDS, acute kidney injury and disseminated intravascular coagulation.
2. Residual abscesses: subphrenic, pelvic and interloop.
3. Anastomotic leak and enterocutaneous fistula.
4. Prolonged paralytic ileus, and later adhesive intestinal obstruction.
5. Wound complications: wound infection, burst abdomen, incisional hernia and abdominal compartment syndrome.
6. Tertiary peritonitis and death.

(b) Anaemia Mukt Bharat (AMB)

Anaemia Mukt Bharat was launched in 2018 under POSHAN Abhiyaan. It succeeded the National Iron Plus Initiative, and its target was to reduce anaemia prevalence by 3 percentage points every year among children, adolescents and women of reproductive age. Its design is the 6×6×6 strategy: six target groups, six interventions and six institutional mechanisms.

Interventions (six)

1. Prophylactic iron and folic acid (IFA) supplementation, given as age-specific doses (listed below).
2. Deworming: albendazole 400 mg twice a year (200 mg for children aged 12–24 months) through National Deworming Day, and for pregnant women in the second trimester.
3. Intensified year-round behaviour change communication (BCC): the "Solution for Anaemia" campaign, promoting IFA compliance, iron-rich and vitamin C-rich diets, infant and young child feeding, and delayed cord clamping (at least 3 minutes, or until the cord stops pulsating) at delivery.
4. Testing and treatment of anaemia using digital methods and point-of-care tools: digital invasive haemoglobinometers are used for camp-mode screening of adolescents and pregnant women, and cases are managed by severity, with referral of severe anaemia.
5. Mandatory provision of IFA-fortified foods in public health programmes: fortified rice, double-fortified salt (iodine + iron) and fortified wheat flour through ICDS, PM-POSHAN (mid-day meal) and the public distribution system.
6. Addressing non-nutritional causes of anaemia in endemic pockets, with a focus on malaria, haemoglobinopathies (sickle cell disease, thalassaemia) and fluorosis.

Specific measures under the programme

The supplementation schedule is as follows:

1. Children 6–59 months: 1 mL IFA syrup (20 mg elemental iron + 100 µg folic acid) twice a week.
2. Children 5–9 years: one pink IFA tablet (45 mg iron + 400 µg folic acid) weekly.
3. Adolescents 10–19 years: one blue IFA tablet (60 mg iron + 500 µg folic acid) weekly.
4. Non-pregnant, non-lactating women of reproductive age: one red IFA tablet (60 mg iron + 500 µg folic acid) weekly.
5. Pregnant women: one red tablet daily for 180 days from the fourth month of pregnancy.
6. Lactating mothers: one red tablet daily for 180 days after delivery.

Treatment of anaemia follows a severity-based protocol, and severe anaemia in pregnancy is managed with IV iron (ferric carboxymaltose/iron sucrose) or referral for transfusion.

The six institutional mechanisms support these measures:

1. Intra-ministerial coordination.
2. A National Anaemia Mukt Bharat Unit.
3. The National Centre of Excellence and Advanced Research on Anaemia Control at AIIMS, New Delhi.
4. Convergence with the ministries of Women and Child Development, Education, and Consumer Affairs, Food and Public Distribution.
5. Strengthened supply chain and logistics.
6. An AMB dashboard with digital reporting of performance through HMIS, and state ranking on the AMB index.

Target population groups (six)

1. Children 6–59 months.
2. Children 5–9 years.
3. Adolescent girls and boys 10–19 years, both in school and out of school.
4. Women of reproductive age (20–24 years) who are neither pregnant nor lactating.
5. Pregnant women.
6. Lactating mothers of children aged 0–6 months.

(c) Infertility and assisted reproduction

(i) Definition and investigation of tubal factors

The WHO and ICMART define infertility as a disease of the male or female reproductive system: failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. For women aged 35 years or more, evaluation begins after 6 months (ASRM). Infertility is primary if there has never been a pregnancy and secondary if there has been at least one prior pregnancy.

Tubal and peritoneal factors account for about 25–35% of female infertility. The main causes are pelvic inflammatory disease (chlamydia, gonorrhoea), genital tuberculosis (important in India), endometriosis, previous pelvic surgery and ectopic pregnancy.

Tubal factors are investigated in this order:

1. History and screening: history of PID, septic abortion, TB or surgery. Chlamydia antibody testing is a cheap screen, and a positive result calls for direct tubal assessment.
2. Hysterosalpingography (HSG): radio-opaque contrast is injected through the cervix under fluoroscopy in the early follicular phase, after menses end and before ovulation (about days 7–10), which avoids an early pregnancy. HSG shows tubal patency, the site of block (cornual or fimbrial), hydrosalpinx, salpingitis isthmica nodosa and the tubercular "beaded" or "lead-pipe" tube, and it also outlines the uterine cavity. It is the first-line test for women without comorbidity.
3. Hysterosalpingo-contrast sonography (HyCoSy / HyFoSy): transvaginal ultrasound during intrauterine injection of echogenic contrast or foam, which assesses tubal patency and the uterus together without radiation. (Plain saline infusion sonography assesses only the uterine cavity.)
4. Laparoscopy with chromopertubation (dye test): the gold standard. Dilute methylene blue is injected through the cervix under general anaesthesia and its spill from the fimbrial ends is watched directly. It also detects and treats peritubal adhesions and endometriosis, and it allows salpingectomy or proximal clipping of hydrosalpinges before IVF. It is indicated for women with comorbidity or an abnormal HSG.
5. Hysteroscopy: shows the tubal ostia, and selective tubal cannulation can clear a proximal block. Falloposcopy and salpingoscopy are research tools for mucosal assessment.
6. Tests for genital tuberculosis where suspected: endometrial biopsy in the premenstrual phase for histopathology, AFB culture and CBNAAT/GeneXpert.

(ii) Assisted reproductive technology (ART) procedures

1. Intrauterine insemination (IUI), with the husband's or donor semen, often combined with ovarian stimulation.
2. In vitro fertilisation and embryo transfer (IVF-ET): controlled ovarian stimulation, oocyte retrieval under ultrasound guidance, fertilisation in the laboratory, and transfer of the embryo into the uterus.
3. Intracytoplasmic sperm injection (ICSI): a single sperm is injected into a mature metaphase-II oocyte. It is used for severe male factor and failed fertilisation.
4. Gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT): laparoscopic transfer into a patent tube. Both are now rarely used.
5. Surgical sperm retrieval for azoospermia: PESA, MESA, TESA/TESE and micro-TESE.
6. Cryopreservation (vitrification) of oocytes, sperm, embryos and ovarian or testicular tissue, including fertility preservation before cancer therapy.
7. Assisted hatching and in vitro maturation (IVM) of oocytes.
8. Pre-implantation genetic testing: PGT-A, PGT-M and PGT-SR.
9. Third-party reproduction: donor oocytes, sperm or embryos, and gestational surrogacy. In India these are regulated by the Assisted Reproductive Technology (Regulation) Act, 2021 and the Surrogacy (Regulation) Act, 2021.