A PRESENTATION ON THE BASIC ASPECTS OF PERITONITIS, ITS TYPES AND MANAGEMENT. IT IS DIRECTED TOWARDS THE BEGINNER IN SURGERY - MEDICAL STUDENT AND THE SURGERY RESIDENT.

1. DR. PRADEEP DEB
ASSISSTANT PROFESSOR OF SURGERY
SCHOOL OF MEDICAL SCIENCES & RESEARCH, SHARDA UNIVERSITY, GREATER NOIDA, INDIA

2.  PERITONIAL CAVITY
◦ THE LARGEST CAVITY OF HUMAN BODY
◦ LINED BY PERITONIUM WITH A SURFACE AREA OF
2m2 ≈ skin
◦ CLOSED SAC IN MALES
◦ OPEN AT THE END OF FALLOPIAN TUBES IN
FEMALES
 PERITONIAL MEMBRANE
◦ SINGLE LAYER OF MESOTHELIUM , RESTING UPON
FIBROELASTIC TISSUE
◦ NETWORK OF LYMPHATICS AND CAPILLARIES
◦ VISCERAL LAYER
◦ PARIETAL LAYER

5.  PERITONIAL FLUID
◦ AMOUNT < 10ML (VARIES IN FEMALES WITH
MENSTRUAL CYCLE)
◦ CLEAR / PALE YELLOW, VISCID
◦ CONTAINS LYMPHOCYTES AND LEUCOCYTES
◦ LUBRICATION
◦ ANY PATHOLOGY ALTERS THE QUALITY AND
QUANTITY OF PERITONEAL FLUID
◦ NEVER CONTAINS GAS UNDER NORMAL
CONDITIONS
◦ CIRCULATION OF PERITONEAL FLUID

6. IN HEALTH
Visceral lubrication
Fluid and particulate absorption
IN DISEASE
Pain perception
Inflammatory & immune responses
Fibrinolytic activity

7.  Capacity to absorb large amounts of fluids
 Capacity to produce large amounts of fluids
 Can produce an inflammatory exudate
 Healing by development of new mesothelial
cells throughout the surface of the defect
 Large parietal peritoneal defects heal rapidly

8.  Peritonitis
 Abscess
 Ascites
 Tumours
 Adhesions

9.  AN INFLAMMATION OF THE
PERITONEUM
LOCALISED
GENERALISED
Mostly acute bacterial peritonitis
Non bacterial peritonitis, transmural spread of
organisms
(Acute pancreatitis, hemoperitoneum, intraperitoneal
rupture of urinary bladder)

11.  PRIMARY
 INFECTION OF ASCITIC FLUID WITHOUT
SURGICALLY TREATABLE INTRA-ABDOMINAL
SOURCE OF INFECTION
 SECONDARY
 WITH PERFORATION OF GIT

12.  BACTERIAL – gastrointestinal/non-
gastrointestinal
 CHEMICAL–e.g. bile, barium
 ALLERGIC-e.g. starch peritonitis
 TRAUMATIC- e.g. operative handling
 ISCHEMIC- e.g. strangulated bowel, vascular
occlusion
 MISCELLANEOUS- e.g. familial mediterranean
fever

13.  BACTERIAL INFECTIONS
◦ GASTROINTESTINAL
 PERFORATION OF BOWEL
 SPONTANEOUS / TRANS MURAL TRANSLOCATION OF
BACTERIA
 A/C PANCREATITIS
◦ NON-GASTROINTESTINAL
 FEMALE GENITIAL TRACT
 PID, TORSION OF OVARY
 PERITONIAL DIALYSIS
 SURGERY / PERFORATING INJURY TO ABDOMEN

14.  Gastrointestinal perforation – perforated
peptic ulcer,appendix,diverticulum,ileum
 Transmural translocation- acute pancreatitis,
strangulated bowel, vascular occlusion
 Exogenous contamination- drains, open
surgery,trauma
 Female genital tract infection- pelvic
inflammatory disease
 Hematogenous spread- septicemia

15.  GASTROINTESTINAL SOURCE
◦ Escherichia coli
◦ Streptococci
◦ Bacteroides
◦ Clostridium
◦ Klebsiella pneumoniae
 OTHER SOURCES
◦ Chlamydia trachomatis
◦ Neisseria gonorrhoeae
◦ Haemolytic streptococci
◦ Staphylococcus, Streptococcus pneumoniae
◦ Mycobacterium tuberculosis and other spp.
◦ Fungal infections

16.  LOCALISED – anatomical &
pathological factors
◦ SUBPHRENIC SPACES
◦ PELVIS
◦ PERITONEAL CAVITY PROPER- supracolic &
infracolic compartments
 GENERALISED/DIFFUSE

17.  SPEED OF CONTAMINATION
 STIMULATION OF PERISTALSIS
 VIRULENCE OF ORGANISM
 YOUNG CHILDREN HAVE A SMALL OMENTUM
 DISRUPTION OF LOCALIZED COLLECTION
 IMMUNE DEFICIENCY

18.  Localised peritonitis – pain, nausea, fever,
tachycardia, localised guarding, positive
release sign, rigidity, shoulder tip pain, pelvic
peritoneal irritation
 Diffuse/generalised peritonitis – early
features & late features

19.  Abdominal pain - coughing,
movement,inspiration
 Constitutional upset- fever, malaise ,anorexia,
lassitude
 GI upset- nausea, vomiting
 Pyrexia
 Raised pulse rate
 Tenderness (guarding/rigidity/rebound
tenderness)
 Pain/tenderness on PR/PV exam
 Absent/reduced bowel sounds
 Septic shock

21.  BLOOD INVESTIGATIONS
◦ FULL BLOOD COUNT
 INCREASED
 NOT IN SEVERE PERITONITIS
◦ AMYLASE / LIPASE
◦ ELECTROLYTES
◦ UREA, CREATININE

22.  IMAGING
◦ ULTRA SONOGRAM
◦ PLAIN X-RAY ABDOMEN
 ERECT : FREE SUBDIAPHRAMATIC GAS
 SUPINE : GROUND GLASS APPEARANCE
◦ CT SCAN ABDOMEN
 INVASIVE
◦ PERITONIAL DIAGNOSTIC ASPIRATION (NOT USED
NOW)
◦ DIAGNOSTIC LAPAROSCOPY

25.  GENERAL CARE OF PATIENT
◦ CORRECTION OF FLUID/ELECTROLYTE LOSS &
CIRCULATORY VOLUME
◦ BROAD SPECTRUM ANTIBIOTICS PARENTERALLY
◦ GASTRIC DECOMPRESSION & URNARY
CATHETERISATION
◦ ANALGESIA
◦ VITAL SYSTEM SUPPORT
 OPERATIVE TREATMENT OF CAUSE
◦ Remove or divert cause
◦ Peritoneal lavage and drainage

26.  SYSTEMIC COMPLICATIONS
◦ Bactermic/endotoxic shock
◦ Systemic inflammatory response syndrome
◦ Multiorgan dysfunction syndrome
◦ Death
 ABDOMINAL COMPLICATIONS
◦ Paralytic ileus
◦ Residual/recurrent abscess/inflammatory mass
◦ Portal pyemia/liver abscess
◦ Adhesional small bowel obstruction

27.  SPONTANEOUS BACTERIAL PERITONITIS
 NO INTRA-ABDOMINAL SOURCE OF INFECTION
 CHILDREN, WITH NEPHROTIC SYNDROME
 ADULT WITH CIRRHOSIS
 THROUGH FALLOPIAN TUBES IN GIRLS - COMMONEST
 HEMATOGENOUS SPREAD FROM RESPIRATORY TRACT OR OTITIS MEDIA
 E-COLI (COMMONEST) , KLEBSIELLA
 PNEUMOCOCCI, STREPTOCOCCI, ENTEROCOCCI
 BACTEROIDS (ANAEROBES)
 HIGH FEVER, NEUTROPHILIA
 DIARRHOEA

28.  SPONTANEOUS BACTERIAL PERITONITIS….
◦ ASCITIC FLUID STUDY
 >250 WBC/CM3
 LEUCOCYTE ESTERASE, USING COLORIMETRIC
LEUKOCYTE ESTERASE REAGENT STRIPS
◦ 3RD GEN CEPHALOSPORINS

29.  BILE PERITONITIS
◦ Perforated cholecystitis
◦ Post-cholecystectomy complications
 Cystic duct stump leakage
 Leakage from an accessory duct of Luschka
 Bile duct injury
 T-tube drain dislodgement
◦ Following other procedures
 Leaking duodenal stump postgastrectomy
 Leaking biliary–enteric anastomosis
 Leakage around percutaneous placed biliary drains
◦ Following liver/gall bladder/bile duct trauma

30.  ACUTE
 CHRONIC
 FINDINGS
◦ ABDOMINAL PAIN,LOW GRADE FEVER, SWEATS, MALAISE
◦ WEIGHT LOSS FREQUENT
◦ SUBACUTE INTESTINAL OBSTRUCTION
◦ ASCITES COMMON, MAY BE LOCULATED
◦ CASEATING PERITONEAL NODULES ARE COMMON
 INTESTINAL OBSTRUCTION MAY RESPOND TO
ANTITUBERCULOUS TREATMENT WITHOUT
SURGERY

31.  1) wet/ ascitic type
 2)encysted/loculated type – ocalised
abdominal swelling
 3) dry/ fibrotic type – mesenteric and omental
thickening and caking , leading to matted
bowel loops and “ABDOMINAL COCOON”
 4) a combination of the above

32.  GRANULOMATOUS PERITONITIS
 DUE TO ALLERGY TO TALC/STARCH FROM SURGICAL
GLOVES
 GONOCOCAL PERITONITIS WITH PERIHEPATITIS
 CURTIS-FITZ-HUGH SYNDROME
 FAMILIAL PERIODIC PERITONITS
 FAMILIAL MEDITERRANEAN FEVER
 FEMALE, POST APPENDICECTOMY
 PERITONEUM ADJACENT TO SPLEEN AND GB IS
INFLAMED
 PRESENTS WITH UPPER ABDOMINAL PAIN
 TREATMENT IS CONSERVATIVE WITH COLCHICINES