this presentation includes anatomy physiology function of peritoneum ,also includes cause of peritonitis its severity ,various scoring system investigation and treatment.It includes the recent advancement and latest articles from latest books of surgery.
2. The peritoneum is single layered simple squamous epithelium of
mesodermal origin lying on thin connective tissue stroma.
The surface area is 1.0 to 1.7 m2 approximately that of total body
surface area.
In male peritoneal cavity is sealed whereas in female it is open to
the ostia of fallopian tube.
Consist of two part:
1.Parietal layer : covers anterior ,lateral and posterior
abdominal wall surface and inferior of diaphragm
2.Visceral layer : covers most of surfaces of
intraperitoneal organ and anterior aspect of retroperitoneal organ .
PERITONEUM
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4.
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6. PERITONEAL CAVITY
• The peritoneal cavity is subdivided into interconnected
compartments by 11 ligaments and mesenteries.
• The peritoneal ligaments includes:
1. Coronary ligaments
2. Gastrohepatic ligaments
3. Hepatoduodenal ligament
4. Falciform ligament
5. Gastrocolic ligament
9. • These structures partition the peritoneal cavity into nine
potential spaces which are :
Right & left subphrenic
Subhepatic
Supramesentric & inframesentric
Right & left paracolic
Lesser sac
Pelvis
These spaces , ligaments and mesenteries direct the
circulation of fluid in peritoneal cavity and thus useful in
predicting the route of spread of infection and malignancies.
10.
11. • The peritoneum is bidirectional semipermeable membrane
that control the amount of fluid in peritoneal cavity .
• Normally it contain only less than 100 ml of sterile serous
fluid.
• Microvilli are present on the apical surface of peritoneal
membrane which markedly increases the surface area and
promotes the rapid absorption of fluid from cavity to
lymphatics and portal and systemic circulation.
• The circulation of fluid in peritoneal cavity driven in part by
movement of diaphragm .
PHYSIOLOGY
12. • There are intracellular pores in peritoneum called
STOMATA present in inferior surface of diaphragm,
communicating with lymphatics pool of diaphragm .
• Lymph flows from diaphragmatic lymph channel through
subpleural to regional to thoracic duct.
• Relaxation of diaphragm during expiration opens the
stomata and negative intra thoracic pressure draws fluids
and particles like bacteria .
• Contraction of diaphragm during inspiration propel the
lymph through channels into thoracic duct. These
mechanism is so called diaphragmatic pump drive .
13. • The circulatory pattern of peritoneal fluid toward
diaphragm and into central lymphatic is consistent with
rapid appearance of sepsis in patients with generalized
intra-abdominal infection and occurrence of abscesses
distant from primary disease.
• When parietal peritoneum defects are created , healing
occurs not from the edges but by the development of new
mesothelial cells throughout the defect , so large defect
heals as rapidly as small defect.
15. PERITONITIS
• Peritonitis is inflammation of peritoneum and peritoneal
cavity caused by generalized or localized infection.
• Cause of peritonitis:
16. • Primary peritonitis : it results from bacterial , chlamydial ,
fungi or mycobacterium infection in absence of perforation
of GI tract.
• Secondary peritonitis : it occur in gastro intestinal
perforations.
• Spontaneous bacterial peritonitis : is defined as bacterial
infection of ascitic fluid in the absence of any intra-
abdominal source of infection and is monomicrobial. Usually
associated with cirrhosis , nephrotic syndrome . In adult
most common pathogen is E.coli or Klebsiella pneumonae.
In child age group nephrogenic or hepatogenic ascites group
A streptococci ,Staphylococci or Streptococci pneumonae .
18. BACTERIA FROM GASTROINTESTINAL TRACT
• The number of bacteria in gut lumen is normally low until
distal small bowel is reached. The bilary and pancreatic
tract is also normally free from bacteria.
• In case of diseased condition there is stasis and overgrowth
of bacteria (obstruction, chronic and acute motility
disturbances ).
• Gram negative bacteria contain endotoxins
(lipopolysaccharides)in their cell wall that have multiple
toxic effect on host like release of TNF from leukocytes ,
systemic absorption may leads to endotoxic shock
19. NON GASTROINTESTINAL CAUSE OF PERITONITIS
• Pelvic infection via fallopian tube is responsible for high
proportion of non gastrointestinal infection . Most common
organism is Chlamydia spp and Gonococci . These
organisms leads to thinning of mucous cervical plug and
allow bacteria from vagina causing infection and
infalmamtion.
21. LOCALIZED PERITONITIS
• Anatomical and pathological factors responsible for
localization of peritonitis:
1. The potential spaces , ligaments and mesenteries.
2. Clinical course of localized peritonitis is determined in
part by the manner in which adhesions form , around the
affected part. Glistening appearance of peritoneum
become red velvety , flakes of fibrin appears and loop of
intestine adherent to each other , there is outpouring of
exudates rich in leukocytes and plasma proteins which
soon become turbid then frank pus.
22. 3. Peristalsis retarded in affected bowel which prevent
further distribution of infection.
4. The grater omentum by enveloping and become adherent
to inflamed structure further reducing the spread of
infection.
23. DIFFUSE (GENERALIZED) PERITONITIS
• Factors favoring development of diffuse peritonitis:
1. Speed of peritoneal contamination. Eg . If an inflamed
appendix perforates before localization there is efflux of
content in the whole cavity.
2. Stimulation of peristalsis by ingestion of food or enema
hinders localization.
3. The virulence of infective organism
4. Young age due to small omentum
5. Disruption of localised collection by injudicious handling
6. Immune deficiencies like AIDS or steroids .
24. CLINICAL FEATURES
1. Localised peritonitis:
• Initial sign and symptom depends on underlying condition
• visceral inflammation leads to pain , specific GI symptom
like malaise anorexia and nausea
• Peritoneal inflammation : pathognomic sign is guarding ,
rebound tenderness and rigidity for protecting viscus
• Increase temperature
• Tachycardia
25. 2. Diffuse peritonitis:
• EARLY :
• Severe abdominal pain worsen on movement or breathing
• Patient lie still
• Tenderness and generalised guarding on palpation when
peritonitis affects ant abdominal wall
• Infrequent bowel sound still be heard for few hours but
ceases with onset of paralytic ileus
26. • LATE : If localisastion or resolution doesn’t occur
• Abdomen becomes rigid (generalised )
• Distention with no bowel sound
• Circulatory failure cold clammy extremities , sunken eyes,
dry tongue, irregular pulse , anxious face
• Finally unconscious
27.
28. DIAGNOSTIC AIDS
• Bedside :
1. Urine dipstix for UTI
2. ECG (If diagnosis in doubt for cause abdominal or
cardiac )
Blood investigations :
3. Baseline urea & creatinine
4. CBC TLC
5. SERUM AMYLASE & LIPASE
6. BLOOD GROUPING
29. • IMAGING:
1. ERECT CHEST Xray for free subdiaphragmatic
gases
2. SUPINE ABDOMINAl Xray for dilated bowel loops
3. In patients who are too ill for erect radioimaging a
lateral decubitus film is required
4. MULTIPLANAR CT for cause of peritonitis
5. USG
6. INVASIVE : PERITONEAL DIGNOSTIC
ASPIRATION has little value in era of high quality
CT imaging.
31. MANAGEMENT
• General care of patient
• Correction of fluid loss and circulating volume
• Patient are frequently hypovolemic with electrolyte
disturbance . Plasma volume must be restored and
monitored for ongoing losses
• Special measure for cardiac , pulmonary , renal support (If
septic shock present)including CVP monitoring.
• Urinary cathterisation and gastrointestinal decompression
through nasogastric tube until paralytic ileus has resolved.
32. • Antibiotic therapy : Parenteral broad spectrum (aerobic and
anaerobic)
• Analgesia : patient must be nursed in sitting up position and
must be relieved of pain before and after operation . Epidural
infusion is an excellent approach if possible
• Specific treatment of cause :
• Patients in whom specific treatment not guided by CT scanning
, early surgical approach is preferred to wait & watch policy.
• In peritonitis caused by pancreatitis or salpengitis or in case of
primary peritonitis of streptococcal or pneumococcal origin non
surgical treatment is preferred.
33.
34. PROGNOSIS AND COMPLICATION
• Several scoring systems have been developed in the past
two decades, like APACHE-II SCORE by Kanus et al,
SEPSIS SEVERITY SCORE by STEVENS , BIONOMIAL
CLASSIFICATIONS by MEAKINS , MULTIPLE ORGAN
FAILURE SCORE by GORIS et al. & MANNHEIM
PERITONITIS INDEX by BILLING et al. These scoring
systems scientifically compare the effectiveness of different
treatment regimens, health facilities and to inform patient’s
relatives with greater objectivity. They may also indicate
individual patients who may require a more aggressive
surgical approach.
• Diffuse peritonitis carries mortality rate of 10 percent in
37. SPONTANEOUS BACTERIAL PERITONITIS
• Acute bacterial infection of ascitic fluid ,its rare except in
patient with cirrhosis affecting 1.5-3.5 percent.
• Clinical features as of peritonitis with worsening liver and
renal function ,hepatic encephalopathy and GI bleed.
• Diagnosis :made by paracentesis
neutrophil count of ascitic fluid > 250/mm3
ascitic culture is negative in 60 percent
40 percent culture positive most common organism is E.coli ,
Streptococci or enterococci
38. • Treatment is third generation cephalosporin cefotaxim,
alternative is amoxicillin or quinolones .
• Complication of SBP is septic shock , GI bleed ,
hypoalbuminia .
• PRIMARY PNEUMOCOCCAL PERITONITIS
• In healthy children , girl aged 3 to 9 yrs route of infection is
via vaginal and fallopian tube and in boy the infection is
blood borne secondary to respiratory infection .
• Clinical onset is sudden with pain lower abdomen and
temperature raise . After 24-48 hours profuse diarrhoea is
characteristics and increase in frequency of urination.
39. • Leukocyte count > 30000 /ul , 90 percent polymorph
suggestive of pneumococcal peritonitis rather than
appendicitis.
• Management : Antibiotics and correction of dehydration and
electrolyte imbalance
• Early laparotomy odourless sticky exudates confirm
diagnosis
• The prevalence has declined greatly and now its rare .
40. TUBERCULAR PERITONITIS
• Intra abdominal tuberculosis is very common in resource
poor country but also rising in resource rich country due to
migration and immunosuppression where mycobacterium
avium-intracellulare is prevalent with widespread
increasing HIV virus co infection.
• Abdomen is involved in 11 percent of patients with extra
pulmonary TB. Ileocaecal involvement is most common.
• Tuberculosis can spread to peritoneum through GI tract via
mesenteric lymph node or directly through blood (milliary)
41. • Clinically ascites is the presenting complaint , multiple
tubercular deposits present in both the layer of peritoneum
• Diagnosis : USG/ CT to detect ascites + lymphadenopathy +
diffuse thickening of peritoneum ,mesentery or omentum .
• Ascitic fluid : Straw color
Exudate (protein >25g/l)
WBC > 500 mm3
Lymphocyte > 40 percent
• Management is supportive (nutrition ,hydration )with
systemic antituberculous drugs.
42.
43. PERIODIC PERITONITIS
• Familial Mediterrean fever (periodic peritonitis) characterized
by abdominal pain and tenderness ,mild pyrexia
,polymorphonuclear leukocytosis , pain in thorax and joint.
• Duration of attack is 24 hrs with compete remission but
exacerbation in regular interval.
• Most patient had undergone appendectomy in childhood and is
familial disease .
• This disease is limited to Arab, Armenia and cause is mutation
in MEFV(Mediterrean fever)gene.
• Peritoneum is inflamed in splenic and gall bladder vicinity ,
treatment is COLCHICINE during attack.
44. PERITONITIS ASSOCIATED WITH CHRONIC
AMBULATORY PERITONEAL DIALYSIS
• 6 percent of patient with chronic renal failure undergo
peritoneal dialysis
• Refractory or recurrent peritonitis is most common cause of
technical failure
• Patient presents with pain abdomen , fever , leucocyte count of
fluid >100 with 40 percent neutrophils.
• 70 percent caused by staph. Epidermidis and fungi are also
important cause .
• Treatment is antibiotics and removal of catheter and resumption
of hemodialysis.
45. CARCINOMA OF PERITONEUM
• PRIMARY TUMORS is rare and in most cases their origin
is not from the layers but adjacent structures.eg lipoma of
appendices epiploicea. Asbestos is recognized cause.
• SECONDARY TUMORS: Common terminal event in many
cases of carcinoma of abdominal organ , both the layers of
peritoneum studded with secondaries.
• Three main form 1.) descrete nodules 2.) plaque 3.) diffuse
adhesions late stage of disease which give rise to frozen
pelvis.
• Gravity determines the distribution of malignant cells
46. • Differential diagnosis is abdominal tuberculosis
• Cytoreductive surgery with hyperthermic intraperitoneal
chemotherapy is treatment of choice.
• PSEUDOMYXOMA PERITONEI : Rare condition occur
frequently in women
• Abdomen is filled with yellow jelly which are encysted .
• Associated with mucinous cystic tumor of ovary and appendix
• Treatment is laparotomy and scooping out jelly mass and
complete cytoreduction (right hemicoloectomy ,spleen ,
gallbladder, greater and lesser omentum along with stripping of
peritoneum ovary and uterus in female) and HIPEC with
mitomyocin C.
