1. Dr Imad Al Fahd
M.B.Ch.B - F.I.M.S.(G.S)
Assistant Professor - Baghdad Medical College
Consultant Laparoscopic & Bariatric Surgeon
BaghdadTeaching Hospital
2. At the end of this lecture, students will be able to:
➢ Describe the acute Bacterial Peritonitis along with its path
physiology.
➢ Identify the clinical manifestations of acute Bacterial Peritonitis .
➢ Discuss assessment and diagnostic findings of acute Bacterial
Peritonitis .
➢ Describe the medical and surgical care of a patient with acute
Peritonitis.
➢ Describe the acute Peritonitis complications, and their surgical
management .
3. Peritonitis is inflammation of the peritoneum, the serous
membrane lining the abdominal cavity and covering the
viscera, which maybe localised or generalised.
It results from bacterial infection; the organisms come from
diseases of the GI tract or, in women, from the internal
reproductive organs.
Peritonitis can also result from injury or trauma (eg, gunshot
wound, stab wound).
The most common bacteria implicated are Escherichia coli,
Klebsiella, Proteus, and Pseudomonas.
Peritonitis may also be associated with abdominal surgical
procedures and peritoneal dialysis.
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4. ▪ Peritonism – refers to specific features found on
abdominal examination in those with peritonitis
▪ Characterised by tenderness with guarding,
rebound/percussion tenderness on examination.
▪ Peritonism is eased by lying still and exacerbated by any
movement.
▪ Maybe localised or generalised.
▪ Generalised peritonitis is a surgical emergency
requires resuscitation and immediate surgery.
5.
6. 7
Autopsy of infant showing abdominal distension, intestinal
necrosis and hemorrhage, and peritonitis due to
perforation .
7. Peritonitis is caused by leakage of contents from abdominal
organs into the abdominal cavity due to :
➢ inflammation,
➢ infection,
➢ ischemia,
➢ trauma,
➢ or tumor perforation.
Edema of the tissues results, and exudation of fluid develops
in a short time. Fluid in the peritoneal cavity becomes turbid
with increasing amounts of protein, white blood cells,
cellular debris, and blood.
The immediate response of the intestinal tract is hyper
motility, followed by paralytic ileus with an accumulation of
air and fluid in the bowel.
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8. Infective – bacteria cause peritonitis e.g. due to gangrene or
perforation of a viscous :
▪ Appendicitis.
▪ Diverticulitis.
▪ perforated ulcer. ...this is the most common cause of peritonitis
Non-infective – leakage of certain sterile body fluids into the
peritoneum can cause peritonitis.
Gastric juice (peptic ulcer).
Bile (liver biopsy, post-cholecystectomy).
Urine (pelvic trauma).
Pancreatic juice (pancreatitis).
Blood (endometriosis, ruptured ovarian cyst, abdominal trauma).
Note: although sterile at first these fluids often become infected
within 24-48 hrs of leakage from the affected organ resulting in a
bacterial peritonitis .
9. Pain
Constant and severe (site will give clue as to cause, or maybe generalised)
Worse on movement (hence shallow breathing in those with generalised
peritonitis to keep the abdomen still)
Eased by lying still
If localised peritonitis – peritonism is in a single area of the abdomen
If generalised peritonitis – peritonism is all over abdomen with board like rigidity
Signs of ileus (generalised peritonitis > localised peritonitis)
Distention.
Vomiting.
Tympanic abdomen with reduced bowel sounds.
Signs of systemic shock
Tachycardia, tachypnoea, hypotension, low urine output.
More prominent with generalised than localised peritonitis.
‘Septic shock’ [systemic inflammatory response syndrome
(SIRS)] in later stages.
10. Diffuse abdominal pain is felt.The pain tends to become
constant, localized, and more intense near the site of the
inflammation.
Movement usually aggravates pain.
The affected area becomes extremely tender and
distended, and the muscles become rigid.
Pain/tenderness on rectal/vaginal examination (pelvic
peritonitis)
Usually, nausea and vomiting occur and peristalsis is
diminished.
Fever, tachycardia, and leukocytosis.
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11. Diagnosis most often made on history and physical Examination
If localised peritonitis
Investigations are those listed on “investigations for acute
abdomen” slide
All patients get simple investigations..
Complex investigations are requested depending on
suspected diagnosis (remember that some diagnoses do
not require complex investigations and are entirely based
on history and examination e.g. Appendicitis)
12. Simple Investigations:
Bloods tests (FBC, U&E, LFT, amylase, clotting,CRP, G&S/ Xmatch, ABG)
BM
Urine dipstick
Pregnancy test (all women of child bearing age with lower abdominal pain)
AXR/E-CXR
ECG
More complex investigations:
USS
Contrast studies
Endoscopy (OGD/colonoscopy/ERCP)
CT
MRI
urea and electrolytes
Ultrasound scan
13. Diagnosis most often made on history and physical Examination
If generalised peritonitis
Surgical emergency – will require emergency operation
Following investigations should be performed:
Bloods: FBC, U&E, LFT, Amylase!! (acute pancreatitis can present with
generalised peritonitis and does not require emergency surgery), CRP, clotting,
G&S, ABG
AXR and Erect CXR
CT scan
Only if this can be performed urgently and patient is stable
If this can not be performed urgently or patient is unstable then for surgery
without delay
Does not change management (i.e. Patients will need emergency surgery
regardless) but useful as will identify cause of peritonitis therefore helping to
plan surgical procedure
OtherTime consuming complex investigations should not be performed as they
will only delay definitive treatment (emergency surgery) and add very little
14. Leukocytosis.
The hemoglobin and hematocrit levels may be low if blood
loss has occurred.
An abdominal x-ray shows air, fluid levels, and distended
bowel loops.
An abdominal ComputerizedTomography (CT) scan may
show abscess formation.
Peritoneal aspiration and culture and sensitivity studies of
the aspirated.
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15.
16.
17. Fluid Replacement:
Colloid (blood, plasma).
Electrolyte replacement.
Hypo volemia occurs because of massive loss of fluid and
electrolytes.
Analgesics for pain.
Anti emetics for nausea and vomiting.
Intestinal Intubation and suction to relieve abdominal
distention.
Fluids in the abdominal cavity can affect lung expansion and
causes respiratory distress.
Oxygen therapy is indicated with or without airway
intubation and ventilator assistance.
Massive antibiotic therapy.
Broad spectrum antibiotics.(triple therapy)
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18. A - Secure airway
B – Oxygen 15L
C - Fluid Balance: large bore, IVF, catheter, bloods, X
match
C - BloodTransfusion
D - Analgesia
E – IV Antibiotics
E –Thrombus prophylaxis?
Anti-emetics/ NG aspiration
Supportive nutrition/ NBM
Re-assess
Therapeutic procedures: ERCP
19. Emergency Laparotomy orWatch+Wait?
Monitor Pain
Serial CTs
Unstable patient ?
Surgical objectives include removing the infected material and
correcting the cause.
Surgical treatment is directed toward:
excision (ie, appendix),
resection with or without anastomosis (ie, intestine),
repair (ie, perforation),
and drainage (ie, abscess).
Also...
Appendicectomy.
Cholecystectomy.
Defunctioning Ileostomy.
Abscess drainage/ Necrosectomy.
20. Despite modern treatment, diffuse peritonitis carries a
mortality rate of about 10%.
Generalized Sepsis, frequently, affects the whole abdominal
cavity. Sepsis is the major cause of death from peritonitis.
Shock may result from septicemia or hypovolemia.The
inflammatory process may cause intestinal obstruction,
primarily from the development of bowel adhesions.
The two most common postoperative complications are
wound evisceration and abscess formation.
Any suggestion from the patient that an area of the
abdomen is tender or painful must be reported.
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22. :
Abdominal complications of peritonitis
■ Adhesional small bowel obstruction
■ Paralytic ileus
■ Residual or recurrent abscess
■ Portal pyaemia/liver abscess
widespread abscesses of a metastatic nature
23. ■ Malaise.
■ Sweats with or without rigors.
■ Abdominal/pelvic (with or without shoulder tip)
pain.
■ Anorexia and weight loss.
■ Symptoms from local irritation, e.g. hiccoughs
(subphrenic), diarrhoea and mucus (pelvic).
■ Swinging pyrexia.
■ Localised abdominal tenderness/mass.
26. ➢ Postoperative.
➢ In patients on treatment with steroids.
➢ In children.
➢ In patients with dementia.
➢ Pneumococcal peritonitis.
➢ Idiopathic streptococcal and staphylococcal
peritonitis in adults.
➢ Familial Mediterranean fever (periodic
peritonitis).
27. :
Causes of bile peritonitis
■ Perforated cholecystitis.
■ Post cholecystectomy:
Cystic duct stump leakage
Leakage from an accessory duct in the gall bladder bed
Bile duct injury
T-tube drain dislodgement (or tract rupture on removal)
■ Following other operations/procedures:
Leaking duodenal stump post gastrectomy
Leaking biliary–enteric anastomosis
Leakage around percutaneous placed biliary drains
■ Following liver trauma
28. ■ Acute and chronic forms
■ Abdominal pain, sweats, malaise and weight
loss are frequent.
■ Caseating peritoneal nodules are common –
distinguish from metastatic carcinoma and fat
necrosis of pancreatitis.
■ Ascites common, may be loculated
■ Intestinal obstruction may respond to anti-
tuberculous treatment without surgery.
29. Infection originates from:
• tuberculous mesenteric lymph nodes;
• tuberculosis of the ileocaecal region;
• a tuberculous pyosalpinx;
• blood-borne infection from pulmonary tuberculosis,
usually the ‘miliary’ but occasionally the ‘cavitating’
form.
:
Chronic tuberculous peritonitis
The condition presents with abdominal pain (90% of
cases), fever(60%), loss of weight (60%), ascites (60%),
night sweats (37%)and abdominal mass (26%) .
