2. Basics
●Visceral Peritoneum – mesothelial lining around viscera
●Parietal Peritoneum – the rest
●Total surface area ~ TBSA
●Exchanges about 500mL of fluid per hour
●However, only about 50mL of peritoneal fluid in cavity at any
given time
●Most fluid clearance occurs at the lymphatics along the
undersurface of the diaphragms.
3. Natural Therapy
●Omentum – double-layered peritoneal flap of vascularized fat
and lymphatics.
●The “duct-tape” of the peritoneal cavity
●It seals perforations – sometimes
●Provides vascular pedicled flaps to ischemic tissue
●Provides macrophages for bacterial clearance
7. Peritonitis
The etiologies are numerous and too exhaustive to discuss
here.
The tell-tell sign of peritoneal inflammation results in an acute
abdominal exam usually.
Remember that a benign exam does not exclude an abdominal
septic source.
Age and immunosuppression can modify the labs and exam
(i.e. the body’s response)
8. SBP
●Seen in cirrhotics
●Diagnose with paracentesis
●Fluid PMNs >250/mm3 (>25% PMNs)
●Often monomicrobial (75% grow nothing)
●pH <7.31
●Low protein in peritoneal fluid – also seen in nephrotic syndrome
●No obvious visceral or malignant source
9. SBP
Treat with antibiotics
No surgery
Cirrhotic admitted with variceal bleed gets prophylactic
norfloxacin
Other indications for prophylaxis exist but are not uniformly
agreed upon.
10. Familial Mediterranean
Fever Very rare
Seen in families with the MEFV gene mutation
that leads to production of pyrin
95% of patient with MFM will present with sterile
diffuse peritonitis
The pleura of the chest and scrotum can also be
involved, as well as joints
Acute attacks are treated with NSAIDs
Chronic colchicine is used for disease
suppression
NO SURGERY – this is where a thorough H&P
comes in to play.
11. Laparotomy
Most causes of peritonitis that we encountered are treated
with laparotomy or laparoscopy.
For focal peritonitis – suction debris at source
For diffuse peritonitis – with diffuse gross contamination, the
solution to pollution then becomes dilution
Be sure to suction every last drop possible so as not to dilute
innate opsonin and phagocyte concentrations.
13. Peritoneal Tuberculosis
Hematogenous seeding common
Present in about 0.5% of TB cases
50% have pulmonary effusion
Ascitic protein >3g/dL
Lymphocyte predominate cells
“Doughy Abdomen”
15. Peritoneal Tuberculosis
Often chronic in nature
Sometimes see an elevated CA-125
Treatment is same as for pulmonary TB
If you perform SBR or stricturoplasty for sequela of nodules,
continue Isoniazid and Rifampin x 18 mos.
16. Granulomatous Peritonitis
Catchall phrase for anything that causes granuloma formation,
for which TB is one.
Other causes include fungi, parasites, and surgical sponges,
gloves, talc, etc.
Treatment almost never requires surgery.
Should see prompt response with steroids and NSAIDs.
17. Chylous and Malignant
Ascites
Chylous if not cause by malignancy often resolves with non-
surgical management.
Malignant ascites is often seen in advanced cases where
palliation, periodic paracentesis, or peritoneovenous shunting
are options.
19. Adhesions
Laparoscopy has been shown to result in less adhesions than
laparotomy.
Adhesions develop as fibrin deposition goes unopposed from
inactivated plasminogen activators.
Seprafilm has questionable utility in select cases.
20. Mesothelioma
Pleural to peritoneal
prevalence 3:1
B-symptoms, distention, and
ascites
History of asbestos exposure.
Treat with surgical debulking,
intra-peritoneal cisplatin-
doxorubicin, and whole-
abdomen irradiation.
World J Gastrointest Surg. 2009 November 30;
1(1): 38-48.
22. Pseudomyxoma Peritonei
Gelatinous mucus with epithelial cells
Commonly seen in low-grade mucinous cystadenocarcinoma
of the appendix and ovaries.
Surgery is aimed at removing the primary tumor.
If one cannot be found, consider right hemicolectomy and
BSO.
Adjuvant intra-peritoneal 5-FU can be used.
23. Mesenteric Panniculitis
●Often seen in those over 50yo.
●Lipid-laden macrophages invade the root of the mesentery – most
often of jejunum.
●Most cases resolve spontaneously and are asymptomatic
●However, chronic cases can develop fibrosis with lymphatic and
venous obstruction becoming retractile mesenteritis, which becomes
fatal.
●Treatment involves surgery for obstructions; yet steroids,
cyclophosphamide, and azathioprine are the mainstay.
28. Retroperitoneal Fibrosis
●Several causes – autoimmune, drugs (methysergide, hydralazine, and beta-blockers), aortic
aneurysms w/ inflammation, infections, and cancers.
●Circulating antibodies to ceroid, a lipoproteinaceous by-product of vascular atheromatous
plaque oxidation, are present in >90% of patients with retroperitoneal fibrosis.
●You will most commonly see its effect on the ureters
●Hydroureter with hydronephrosis
●Medialization of the ureters
●Extrinsic ureter compression at L4-5
●Treat with stents, surgical freeing of ureters followed with an omental wrap, and possibly
steroids and tamoxifen.
30. Tumors of the
Retroperitoneum
●These encompass all of the organs contained within
●Duodenum (D2-D3)
●Pancreas
●Kidneys and ureters
●Adrenals
●Ascending and descending colons
●These will be covered later with each system.
