a summary of what causes intraabdominal infection how to catch the diagnosis early and how to confirm the diagnosis and how to manage

1. ‫بسم‬
‫هللا‬
‫الرحمن‬
‫الرحيم‬
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‫هللا‬
‫العظيم‬
‫قالوا‬
‫سبحانك‬
‫ال‬
‫علم‬
‫لنا‬
‫إال‬
‫ما‬
‫علمتنا‬
‫إنك‬
‫أنت‬
‫العليم‬
‫الحكيم‬
‫سورة‬
‫البقرة‬
‫اآلية‬
:
32

2. INTRA-ABDOMINAL
INFECTION
Hamed Rashad
Professor Of Surgery Banha University

3. Introduction
• Doctors should be broud of themselves
• Surgeons have a special mission
• Who is the good surgeon

4. Introduction
• The only thing left to the patient is the scar ?
• The longer the incision the bigger the surgeon
• The metabolic response to surgery and trauma
a- Inevitable catabolic phase
b- Turning point phase
c- Anabolic phase
d- Late anabolic Fat gain phase

5. 5
Definition of Peritoneum
• The peritoneum is the largest serous membrane of the body
lining the abdominal cavity
Structure
• Consists of a closed sac, containing a small amount of
serous fluid, within the abdominal cavity.
Two layers
• The parietal layer - lines the abdominal wall
• Visceral layer – covers the organs (viscera) in the
abdominal and pelvic cavities

6. Anatomy
•Parietal peritoneum lines the anterior abdominal wall
•The two layers are actually in contact - friction prevented by
the presence of serous fluid secreted by the peritoneal cells
•Peritoneal cavity is only a potential cavity
•In women there is the communication of the peritoneal
cavity to the external atmosphere through the openings of the
fallopian tubes (at fimbrial ends)
•In males the peritoneal cavity is completely closed.

7. Functions of the Peritoneum
• Pain perception ( Parietal peritoneum )
• Visceral lubrication
• Fluid and particulate absorption
• Inflammatory and immune response
• Fibrinolytic activity

8. Intra abdominal infection
• Intraperitoneal = All intraabdominal organ
• Extraperitoneal = Duodenum - pancreas -
kidneys

9. Intra abdominal infection
Infection :
• Invasion of microorganisms to the healthy
tissue produces an inflammatory reaction
• Sepsis:
 Infection, (with local manifestations) plus
– >2 SIRS Criteria.
– Temp > 38oC or < 36oC
– HR > 90 bpm
– RR > 20 bpm or PaCO2 < 32 mmHg
– WBC > 12 x 109/L, < 4 x 109/L or >10% band form

10. Intra abdominal infection
• Severe Sepsis:
 Sepsis associated with hypotension,
hypoperfusion, and/or organ-dysfunction
 The hypotension can be corrected with fluid
replacement
• Septic shock: sepsis with hypotension
despite adequate fluid resuscitation

11. Intra abdominal infection
• Definition :
Bacterial inflammation that affect the visceral as
well as the parietal peritoneum and may diffuse
to neighboring tissues.
 Peritonitis
 Intraabdominal abscess

12. Highlight of intraabdominal infection
•Intra abdominal infections are still an
extremely difficult problem in surgery
– High incidence: ± 8 % of total hospital
mortality
– High mortality rate :
• < 20th century : 80-90
• > 1974: Recently 13 – 43 %
• Published epidemiologic data suggest that sepsis
causes one-third to half of in-hospital mortality in the
USA.

13. Intraabdominal infection
Classification
• Uncomplicated IAIs
The infectious process involves only a single
organ and does not proceed to the peritoneum
• Complicated IAIs
Infections that spread beyond the hollow
viscus of origin into the peritoneal space and
are associated with abscess formation or
peritonitis

14. Complicated intraabdominal infection
cIAIs
• cIAIs is an important cause of mortality and
morbidity if poorly managed
• A recent multicenter observational study
conducted on 132 medical institutions
worldwide enrolled 4553 patients with
cIAIs . The overall mortality was 9.2%

15. intraabdominal infection
• The infection may be in the retroperitoneal
space or in the peritoneal cavity and can
arise as a result of surgery
• Organs are retroperitoneal if they have
peritoneum on their anterior side only
- Duodenum
- Pancreas
- kidney

16. Commener Causes for
intraabdominal sepsis
• Infarcted tissue
(strangulated bowel,
intestinal ischaemia
following arterial embolus or
venous thrombosis
  Intestinal perforation
especially colonic origin
(faecal peritonitis)
  Biliary infection with
obstructed jaundice
  Pancreatitis; in predicted
severe disease (on Ranson or
Imrie criteria)

17. Complicated IAI Peritonitis
 Peritonitis is inflammation of the peritoneum, the serous
membrane lining the abdominal cavity and covering the
viscera that may be:
1- Primary (spontaneous bacterial peritonitis)
2- Secondary - Occurs as a result of spillage of gut
organisms through a hole in the gut wall
3- Tertiary - Peritonitis in a critically ill patient which
persists or recurs 48 hours after adequate treatment

18. Other Forms of Peritonitis
1. Aseptic / sterile peritonitis Ex. Chemical  peptic
ulcer
2. Drug-related peritonitis: isoniazid and erythromycin
estolate
3. Periodic peritonitis: familial dse (Jews, Arabs,
Armenians) Meditranian Tx: colchicine
4. Lead peritonitis
5. Hyperlipidemic peritonitis
6. Porphyrin peritonitis
7. Talc peritonitis (hypersensitivity response)
8. Foreign body peritonitis

19. Common Pathogens
Aerobic gm-ve bacteria
• E col
• Kledsiella
• Pseudomonas aeruginosa
• Extended-spectrum B-lactamase producing
enterobacteriaceae

20. Common Pathogens
Aerobic gm+ve bacteria
- Enterococcus faecalis
- Staph aureus
- Strepococci
Anaerobic bacteria
- Bacteroids

21. Diagnosis : Symptoms
• Acute spontaneous abdominal pain
exacerbated by movement or breathing
• Abdominal distension - fever – nausea –
vomiting – dyspnea – hypotension
• Irregular intestine (constipation/diarrhea

22. Clinical manifestations of PP
Fever (>37.8°C [100°F]) is the most common presenting sign,
50 to 80%, and may be present without abdominal signs or
symptoms.
Tenderness Rebound tenderness and paralytic ileus
may be present.
Symptoms and signs of the cause
Signs of toxemia or septicemia

23. Patients risk factors
Any cause for general ill health
• Immunological or
• Acquired

24. Specific Factors Affecting Operative
Risk
1. Cardiovascular
2. Respiratory
3. Genitourinary
4. Nutritional Status
5. Obesity
6. Diabetes
7. Jaundice
8. Coagulation Status
9. Immunological Status
10. Drugs
11. Pregnancy
12. Elderly patients

25. Specific Factors Affecting Operative
Risk

26. 26
•Generalized :
• 1-Primary peritonitis 2-Secondary
bacterial peritonitis
•3-tertiaty
•Localized (abscess)
• - pelvic – subphrenic – peritoneal
(supracolic gutter –
• infracolic gutter)
Acute peritonitis

27. GENERALIZED PERITONITIS

28. Secondary peritonitis (rupture
vicus)
1. Intraperitoneal:
• - Biliary tree source
• - GIT source
• - Female genital
2. Retroperitoneal
• - Pancreas
• - UT
3. Localized abscess:
• lesser sac, liver, subphrenic, pelvic, spleen, periappedicular
,Paracoilc
• Retroperitoneal,
4. Trauma

29. Causes of
infection

31. The effect of infection on the entire organ
•Total surface area of the peritoneum: 2 m²
•Inflamatory edema expanding the peritoneum to a
thickness of 5 mm results in fluid loss of 5 – 8 L
from the entire organ to the peritoneal cavity. This
leads to an initial Hypovolemic shock, followed by
dehydration, and finally, toxin-induced shock and
death of the patient

32. Damage to vital organ
•Heart :
–Dehydration, tachycardia, hypotension, reduction of
circulation time and cardiac output and venous return
with increased peripheral resistance ( blood pooling ),
hypoxia, shock
•Lung :
–Disturbance of pulmonary distribution with atrial
venous shunting, increase in pulmonary resistance,
alveolar cell destruction, an increase of oxygen transfer
distance, hypoxia, acute respiratory distress. Atelectasis
due to increased intra-abdominal pressure

33. Damage to vital organ
•Kidney:
–Reduced perfusion in the presence of hypovolemia,
increased intra-abdominal pressure and augmented
buildup of toxic metabolites, hypoxic and toxic damage
to renal epithelia, increase in urea nitrogen and
creatinine, renal insufficiency
•Intestines :
–Local hypoxia, increased sympathetic activity,
disproportionate bacterial growth, translocation,bowel
distention, reduction of perfusion and influx of toxin
into the circulation, increase of intra-abdominal
pressure with negative effects on renal and pulmonary
function

34. diagnoses:
• Blood Test
• Samples of fluid from the abdomen
• CT Scan
• Chest X-rays
• Peritoneal lavage.

35. Perforated Ulcer

36. Perforated Ulcer
• Diagnosis: upright CXR
• Air under the diaphragm

37. Plain x-ray abdomen ileus

38. CT Peritonitis

39. a, b. A 65-year-old man with hepatitis induced liver cirrhosis, fever, and
abdominal pain. Axial contrast-enhanced MDCT image (a) and schematic
drawing (b) show smooth, uniform thickening of the peritoneum (arrows)
due to spontaneous bacterial peritonitis.

40. Axial MDCT image shows free intraperitoneal air
(asterisks), ascites, smooth pelvic peritoneal thickening
(arrows), and bowel wall thickening (open arrows)
indicative of peritonitis caused by intestinal perforation.

41. Axial contrast-enhanced MDCT image shows a right tubo-
ovarian abscess (black arrows) with fluid collections
surrounded by smoothly thickened and enhanced peritoneum
(white arrows).

42. Initial Diagnostic Evaluation
1. Routine history, physical examination, and
laboratory studies will identify most patients
with suspected intra-abdominal infection for
whom further evaluation and management are
warranted (A-II).

43. Initial Diagnostic Evaluation
3. Further diagnostic imaging is unnecessary in
patients with obvious signs of diffuse peritonitis and
in whom immediate surgical intervention is to be
performed (B-III).
4. In adult patients not undergoing immediate
laparotomy, computed tomography (CT) scan is the
imaging modality of choice to determine the presence
of intra-abdominal infection and its source (A-II).

44. Microbiologic Evaluation
5. Blood cultures do not provide additional clinically
relevant information for patients with community-
acquired intraabdominal infection and are therefore
not routinely recommended for such patients (B-III).

45. Treatment Approach
• Hospitalization is recommended.
• Antibiotics are prescribed to control the
infection & intravenous therapy (IV) is
used to restore hydration.
• Surgery is often necessary to remove the
source of infection.

46. Medical Management
Fluid and electrolyte replacement.
Massive antibiotic therapy is usually
initiated early in the treatment of peritonitis.
Analgesics, Antiemetics are prescribed
Intestinal intubation and suction assist in
relieving abdominal distention and in
promoting intestinal function.

47. 3 pilars for optimal therapy Of IAI

48. The more you optimize the patient,
The better the post-op recovery
Early cases are opened early
Late cases are opened late

49. Preoperative critical care
1. Fluid resuscitation
2. Administration of antibiotics and oxygen
3. Nasogastric intubation
4. Urinary catheterization
5. Monitoring of vital signs and
biochemical and hemodynamic data

50. Preoperative evaluation
• Vital signs: temperature, blood pressure,
pulse rate, and respiratory rate are
continuously recorded
• Preoperative biochemical evaluation: Wbc,
serum levels of electrolytes, creatinine,
glucose, bilirubin, alkaline phosphatase, and
urinalysis

51. Preoperative evaluation
• Nasogastric intubation is performed to
evacuate the stomach, prevent further
vomiting, and reduce the accumulation of
additional air in the paralyzed bowel
• Urinary catheterization is used to record
initial bladder urine volume and to monitor
subsequent urinary output.

52. Fluid resuscitation
• Anesthesia can cause Myocardial
depression and vasodilatation
• Rehydration can increase a patient’s
tolerance to anesthesia and surgical stress

53. Fluid Resuscitation guidelines
5. Patients should undergo rapid restoration of intravascular
volume and additional measures as needed to promote
physiological stability (A-II).
6. For patients with septic shock, such resuscitation should
begin immediately when hypotension is identified (A-II).
7. For patients without evidence of volume depletion,
intravenous fluid therapy should begin when the diagnosis of
intra-abdominal infection is first suspected (B-III).

54. Clinical sign 0f extracellular fluid deficit
Mild Moderate severe
CNS Sleepy
Apatic
Delayed respons
Hypoactivit
↓tendon reflex
Distal acral
anaesthesia
Stupor,coma
Cardiovasc Tachicardia Tachycardia
Orthostatic
hypotension
Collapsed vein
Tiny pulse
Sianosis
Hipotension,shock
Acral :cold
Pulseless
Tissue Mouth mucosa :
dry
↓Turgor
↓ ↓ Toungue
↓ ↓ turgor
↓ ↓ ↓ turgor
Urine Yellowish ↓ and yellowih Oliguria
Deficit 3=5 % BW 6-8 % BW 10 % BW

55. Antibiotics
Empiric antibiotic therapy for established
secondary bacterial peritonitis plays an
important supplemental role.
• The choice of antibiotics depends on :
– The expected organism
– The estimate of the antibiotic susceptibility of the
expected organism ( community Vs hospital-acquired
infection )
– The extent of contamination
– The hemodynamic stability of the patient

56. Antibiotics
• Mild to moderate IAI
– 2 nd generation cephalosporin with
activity against anaerobes (
cefotetan,cefoxitin)
– Semisynthetic penicillin in combination
with ß lactamase inhibitor ( Ticarcilin-
clavulanic acid,ampicillin-sulbactam,or
piperacillin-tazobactam )

57. Antibiotics
Severe IAI
– Aminoglycoside +metronidazole or
clindamycin
– 3 rd gen cephalosporin +
metronidazole/clindamycin
– Semisynthetic penicilin Imipenem + ß
lactamase inhibitor
– Fluoroquinolone + anti anaerobe
– Levofloxacin or trofloxacin

58. Timing of Initiation of Antimicrobial Therapy
8. Antimicrobial therapy should be initiated once a patient
receives a diagnosis of an intra-abdominal infection or once
such an infection is considered likely. For patients with septic
shock, antibiotics should be administered as soon as possible
(A-III).
9. For patients without septic shock, antimicrobial therapy
should be started in the emergency department (B-III).
10. Satisfactory antimicrobial drug levels should be
maintained during a source control intervention, which may
necessitate additional administration of antimicrobials just
before initiation of the procedure (A-I).

59. Pain management
• Once a decision to operate has been made,
pain should be relieved with potent narcotics.
• Morphine 1-3 mg repeated every 20-30
minutes

60. Blood glucose level
• Aggressive perioperative insulin with the use
of insulin drip to maintain glucose levels
between 80 -110 mg/dL was associated with
decreased mortality in surgical critically ill
patients.

61. Hyper/Hypothermia
• Patients with hyper/hypothermia should have
their temperature corrected toward normal
before operation.
• Acetaminophen or cooling mattress is often
effective in reducing fever
• A warming mattress should be used for
hypothermic patient

62. Management of Intra-abdominal
Infection
• If source is controlled w/ early surgical
intervention, peritonitis responds to vigorous
antibiotics & supportive therapy.
• Failure to solved ---> continuous peritoneal
soiling ----> death

63. Parts of treatment:
A. Pre-operative preparation:
4. Administration of Broad Spectrum Antibiotic
5. NGT to evacuate the stomach and prevent vomiting
6. NPO
7. Relieve pain ONCE DECISION to operate has been
made: - Morphine IV 1-3 mg q 20-30 min
8. Monitor V/S, biochemical & hemodynamic data:
• Urine output monitoring – foley catheter
Management of Intra-abdominal
Infection

64. Management of Intra-abdominal Infection
B. Cleaning of the Abdominal Cavity:
1. Immediate evacuation of all purulent collection
• Resection/closure of all perforated bowel
• Primary anastomosis is not recommended in purulent
peritonitis due to an anastomotic leak
• Radical debridement
2. Intra-operative high volume lavage:
• To wash out pus, feces & necrotic material; endpoint
is clear fluid aspirated
• 8 – 12 L

65. Management of Intra-abdominal Infection
C - Primary closure of abdominal incision is difficult or
even unwise
– Increase intra-abdominal pressure ---> compression
of mesenteric & renal vein ---> renal failure & bowel
necrosis
– Fascial Prosthesis (Marlex Silastic) is used if one
plans to do a re-laparotomy. Removed once
abdominal & visceral edema resolved, and the
decision to close abd. wall definitely.

67. THANK YOU