General overview of Peritonitis

1. PERITONITIS
Sandeep Baral
LMCTH, Final year

2. Anatomy
Perietoneum:
• It is a serous membrane lining the abdominal cavity.
• Outer fibrous tissue layer, inner mesothelial cell layer.
• The surface area of its lining membrane is 2m.sq in an adult
• Closed sac in males, open at the ends of fallopian tubes in females.
PARTS OF PERITONEUM
1. Parietal peritoneum
2. Visceral peritoneum
PERITONEAL CAVITY
It is the potential space between the parietal and visceral peritoneum. Normally
it consists of <100ml of clear, straw colored fluid. It lubricates the viscera
allowing easy movement and peristalsis.

3. Function of peritoneum
IN HEALTH
• Visceral lubrication
• Fluid and particulate absorption
IN DISEASE
• Pain perception
• Inflammatory and immune responses
• Fibrinolytic activity
The peritoneum has the capacity to absorb large volumes of fluid, this ability is used during peritoneal
dialysis in the treatment of renal failure

4. Peritonitis
Peritonitis is defined as inflammation of the parietal
and serosal layer of peritoneum either due to chemicals
like gastric acids/bile or due to bacterial infection which
may be localized or generalized.

5. Causes of peritoneal inflammation:
Bacterial: gastrointestinal and non-gastrointestinal
Chemical: eg; bile, barium
Traumatic: operative handling
Ischemic: strangulated bowel, vascular occlusion

6. Types of acute peritonitis
Peritonitis can be chemical or bacterial or initially chemically induced later
bacterial.
TYPES
1. Primary
2. Secondary
3. Tertiary
Can also be classified as:
1. Localized
2. Generalized

7. 1. Primary:
• Common in cirrhotic patient with ascites , as spontaneous bacterial
peritonitis(SBP)
• Common in young girls between 3 to 9 years.
• Results from bacterial, fungal or mycobacterial infection in absence of
GI perforation.
• 90% of SBP infection is monomicrobial: E.coli( 40%)
• Commonly due to Pneumococci, ocassionly due to streptococci and
hemophilus and othe gram negative( E.coli)
• Ascitis fluid WBC count if more than 250 cells/mm3 with more than
50% cells are polymorphonuclear cell suggestive of primary
peritonitis.
• Total count is very high > 30,000/mm3

8. . Secondary:
• It occurs in GI perforation
• Duodenal perforation and brust appendicitis are
commonest cause.
• E.coli is most common organism involved.

9. Tertiary:
• Defined as persistent/ recurrent intraabdominal infection
after an adequate treatment for primary or secondary
peritonitis usually after 48 hours.
• It occurs after any abdominal surgeries which is usually
severe and patient may go in for SIRS/ MODS early.
• Common in immunocompromised individuals

10. Paths to peritoneal infection
• Gastrointestinal Perforation: e.g. perforated ulcer, appendix, diverticulum
• Transmural Translocation: e.g. pancreatitis, ischemic bowel, primary bacterial
peritonitis
• Exogenous contamination: e.g. drains, open surgery, trauma, peritoneal dialysis
• Female genital tract infection: Pelvic inflammatory disease
• Hematogenous: septicemia

11. CAUSES OF PERITONEAL INFLAMMATION
• Gastrointestinal:
Perforation of bowel
Spontaneous/transmural translocation of bacteria
Pancreatitis

12. • Non-Gastrointestinal
Female genital tract: PID, Torsion
Peritoneal dialysis
Surgery
Perforating injury to abdomen
Most common cause of peritonitis in adult male peptic ulcer perforation

13. Microorganisms in peritonitis
Gastrointestinal Source Other sources
E.Coli Chlamydia trachomatis
Streptococci Nisseria gonorrhea
Enterococci Hemolytic streptococci
Bacteroides spp Staphylococci
Clostridium spp Streptococcus pneumonia
Klebsiella pneumoniae Mycobacterium Tuberculosis
Most common bacteria
• During the phase of peritonitis is E.coli
• During abscess formation is Bacteroides fragilis

14. Pathogenesis

15. Clinical Features
Abdominal pain, worse on movement, coughing and deep respiration
Constitutional upset: anorexia, malaise, fever, lassitude
GI upset: nausea and vomiting
Pyrexia( may be absent)
Raised pulse rate
Tenderness: guarding/rigidity/rebound of abdominal wall
Pain/tenderness on rectal/vaginal examination
Absent / reduced bowel sounds
Eventually leading to Hippocrates facies
Septic shock, SIRS, and MODS in later satges

16. Investigations
BLOOD
• Total Leucocyte count: increased
• Amylase(if 4 times normal value then
significant)
• Lipase
• Urea and Creatinine
• Electrolytes

17. Imaging
• Plain x-ray abdomen
Erect: gas under diaphragm
Supine: ground glass appearance
• CT scan abdomen

18. Invasive
• Diagnostic laparoscopy
• Diagnostic peritoneal lavage

19. Differential diagnsosis
Pancreatitis
Intestinal Obstruction
Ruptured Ectopic Pregnancy
Acute mesenteric ischemia

20. Principle of therapy in peritonitis
1.To control source of infection
2.To eliminate bacteria and sepsis
3.To maintain vital organ functions- Cardiac, Pulmonary
and Renal
4.Nutrition and metabolic support

21. MANAGEMENT
GENERAL CARE OF THE PAIENT
• Correction of fluid and electrolyte loss and circulating
volume
• Urinary catheterization and nasogastric drainage insertion
• Antibiotics therapy
Systemic antibiotic therapy
• Analgesia
• Vital system support

22. SURGICAL TREATMENT
Exploratory Laparotomy
• Midline vertical incision with wide exposure
• Suction and collection of pus for culture& sensitivity
• Inspect for cause
 Bowel perforation: perforation closure
 Intestinal obstruction: Resection & anastomosis
 Appendicitis: appendicectomy
• Peritoneal wash
• Place drain and Tension suture

23. Post operative management
1.Proper critical care (icu)
2.Ventilatory support; monitoring vitals with urine
output, TLC, DLC, blood urea, serum creatinine,
LFT
3.Proper fluid and electrolyte management
4.Prevention of DVT

24. Complications
SYSTEMIC COMPLICATIONS
1.Septic sock
2.Systemic Inflammatory Response
Syndrome
3.Multi-organ dysfunction syndrome
4.Death

25. ABDOMINAL COMPLICATIONS
1.Paralytic ileus
2.Residual or recurrent abscess
3.Portal pyaemia
4.Adhesional small bowel obstruction

26. REFRENCES
• Bailey and love’s short practice of surgery 27th edition
• SRB’s manual of Surgery 5th edition