Dr.Dinesh.M.G Professor of Surgery J.J.M.M.C Davangere

1. Dr. Dinesh. M.G
Professor of Surgery
J.J.M.M.C.
Davangere

2. Peritoneum
 Two parts
 Visceral
 Parietal
 Large surface area 2m2 – equal to that of skin
 Lined by flattened mesothelium beneath which lie rich
plexus of capillaries and lymphatics
 Made use of in peritoneal dialysis
 Few ml of peritoneal fluid lubricates the viscera
 Rapid healing of defects of peritoneum occurs from new
mesothelial cell throughout the surface of the defect

3. Peritoneum
Functions of peritoneum
 Pain perception(parietal)
 Visceral lubrication
 Fluid and particulate absorption
 Inflammatory and immune responses
 Fibrinolytic activity

4. Peritoneum

5. Peritonitis
Inflammatory response of peritoneum to
 Micro-organisms
 Blood, bile, urine or meconeum
 Chemicals like starch or foreign bodies
Types
 Acute
 Acute secondary bacterial peritonitis
 Acute primary bacterial peritonitis
 Acute non bacterial peritonitis
 Chronic
 Chronic bacterial peritonitis(tuberculous)
 Chronic non-bacterial peritonitis

6. Acute peritonitis
Source of infection
 Perforated hollow viscus
 Perforated ulcer, diverticulum
 Exogenous contamination
 Trauma, drains
 Transmural bacterial translocation
 Appendicitis, ischaemic bowel
 Female genital tract infection
 PID
 Haematogenous spread
 Septicaemia

7. Bacteriology
 From gastrointestinal tract
 E. coli
 Aerobic and anaerobic streptococci
 Bacteroides
 Clostridium
 Non gastrointestinal organisms
 Gonococcus
 Chlamydia
 M. tuberculosis

8. Acute peritonitis
 Clinical types
 Localised peritonitis
 Acute appendicitis
 Acute cholecystitis
 Diffuse(generalised) peritonitis
 Acute pancreatitis
 Duodenal ulcer perforation

9. Acute peritonitis
Pathology
 Initially serous fluid turns turbid and purulent
 Peritoneum appears dull
 Fibrin flakes deposit on viscera

10. Acute peritonitis
Clinical features
 Localised peritonitis
 Increased abdominal pain
 Vomiting
 Rise in pulse rate
 Local tenderness and rebound tenderness
 Localised Guarding and rigidity

11. Acute peritonitis
Clinical features
 Diffuse peritonitis
 Severe generalised abdominal pain
 Abdominal distension
 Vomiting
 Rise in pulse rate, fever
 Restricted abdominal movements with respiration
 Diffuse tenderness
 Generalised rigidity
 Absent bowel sounds
 Features of shock and septicaemia

12. Acute peritonitis
Investigations
 Leucocytosis
 X-ray erect abdomen
 Ultrasound abdomen
 CT abdomen
 Serum amylase
 Diagnostic peritoneal aspiration
 Serum electrolytes, creatinine

13. Investigations
 Plain x-ray erect abdomen

14. Acute peritonitis
Treatment
 General care
 Correction of fluid and electrolyte imbalance
 Ryles tube aspiration
 Antibiotics
 Analgesia
 Input-output chart
 Cardiac, pulmonary and renal support
 Specific treatment
 Laparotomy and appropriate surgery
 Peritoneal lavage

15. Acute peritonitis
Complications
 Abdominal complications
 Adhesive small bowel obstruction
 Paralytic ileus
 Residual intra-abdominal abscess
 Portal pyaemia and liver abscess
 Systemic complications
 Endotoxic shock
 Bronchopneumonia /respiratory failure
 Renal failure
 Bone marrow suppression
 Multisystem failure
 Prognosis : Mortality of about 10%

16. Intra-abdominal abscess

17. Subphrenic abscess
 CT abdomen
Subphrenic abscess

18. Subphrenic abscess

19. Tubercular peritonitis
 Acute
 Chronic (common)
Origin of infection
 Tuberculous mesenteric lymph nodes
 Tuberculosis of ileocaecal region
 Tuberculous pyosalpinx
 Blood borne from lung tuberculosis

20. Tubercular peritonitis
Types
 Ascitic form
 Generalised ascites
 Rolled up omentum
 Peritoneal tubercles
 Encysted form
 Fibrous(plastic) form
 Widespread adhesions
 Matted coils of small bowel
 Purulent form(rare)

21. Mesenteric cyst

22. Mesenteric cyst

23. Points to remember
 Features of acute localised peritonitis are
 Increased abdominal pain
 Vomiting
 Rise in pulse rate
 Local tenderness and rebound tenderness
 Localised Guarding and rigidity
 Features of acute diffuse peritonitis are
 Severe generalised abdominal pain
 Abdominal distension
 Vomiting
 Rise in pulse rate, fever
 Restricted abdominal movements with respiration
 Diffuse tenderness
 Generalised rigidity
 Absent bowel sounds
 Features of shock and septicaemia

24. Points to remember
 Common sites of residual intra-abdominal abscesses are
 Subphrenic abscess
 Pelvic abscess
 Para colic abscess
 Around appendix in right iliac fossa
 Types of chronic tubercular peritonitis are
 Ascitic form
 Encysted form
 Fibrous(plastic) form
 Purulent form

25. Thank you