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- 3. + PERITONEUM Visceral Parietal Location Onorgans Abdominal wall Innervation Autonomic Somatic Sensation Poorly localised Well localised Foregut Midgut Hindgut Anatomical limits Lower oesophagus to D2 D2 to 2/3 across Transverse colon Transverse colon to upper rectum Site of autonomic pain Epigastric Periumbilical Suprapubic
- 4. + INTRAPERITONEAL SPACE • Theperitoneum can hold >5L of fluid/pus/blood • Large absorptive area
- 5. + CAUSES OF PERITONITIS TypeCausative agent Possible cause Bacterial Gram negative (E.coli) Gram positive (Staphylococcus) Perforated viscus Spontaneous bacterial peritonitis Chemical Bile. urine, pancreatic juice, gastric content, blood, barium Bile leak (post-op), trauma, pancreatitis, imaging Allergic Starch Operative intervention Traumatic Operative intervention Ischaemia strangulated bowel, vascular occlusion Complicated hernia Miscellaneous familial Mediterranean fever Genetic
- 6. + CLASSIFICATION OF BACTERIAL PERITONITIS ◼Primarymicrobial peritonitis :occurs when microbes invade the normally sterile peritoneal cavity via hematogenous dissemination as infected ascites –peritoneal dialysis ◼ Secondarymicrobial peritonitis : occurs subsequenttocontaminationoftheperitonealcavityduetoperforation orsevereinflammationandinfectionofanintra-abdominalorgan. Examplesincludeappendicitis,perforationofanyportionofthe gastrointestinaltract,ordiverticulitis. ◼ Tertiary (persistent) peritonitis: is more common in immunosuppressed patients (causes see later)
- 7. + PATHOGENESIS ◼ Release ofhistamine and vasoactive substances ◼ Creation of inflammatory exudate and fibrinous adhesions ◼ Release of toxins and consequent toxic shock ◼ Paralytic ileus complicate the condition
- 9. + PATHOLOGICAL TYPES ◼ Localisedperitonitis ◼ Anatomical ◼ Pathological ◼ Diffuse (generalised) peritonitis ◼ Speed of peritoneal contamination(failure of localization) ◼ Stimulation of peristalsis(food or even water) ◼ The virulence of the infecting organism ◼ Youngchildren havea small omentum ◼ Disruption of localised collections(appendix mass or pericolic abscess) ◼ Deficient naturalresistance
- 10. + CLINICAL FEATURES Localised peritonitis ◼Localised guarding ◼ Rebound tenderness ◼ Rigidity ◼ The pain is referred to the C5 dermatome(sub phernic) ◼ Pelvic peritonitis; rectal or vaginal examination marked tenderness
- 11. + DIFFUSE (GENERALISED) PERITONITIS EARLY ◼ Abdominalpain is severe and made worse by moving or breathing; experienced at the site of the spreads outwards from this original lesion and point. ◼ The patient usually lies still. Tenderness and generalised guarding are found on palpation. ◼ Infrequent bowel sounds may still be heard but they cease with the onset of paralytic ileus. ◼ Pulse and temperature rise in accord with degree of inflammation and infection.
- 12. + DIFFUSE (GENERALISED) PERITONITIS LATE ◼ Generalisedrigidity ◼ Distension and absent bowel sounds ◼ Circulatory failure ensues, with cold, clammy extremities ◼ Sunken eyes, dry tongue, thready (irregular) pulse, and drawn and anxious face (hippocratic facies) ◼ The patient finally lapses into unconsciousness
- 13. The hippocratic faciesin terminal diffuse peritonitis
- 14. + INVESTIGATIONS Blood ◼ Urea andelectrolytes ◼ Full blood count for white cell count (WCC) ◼ Serum amylase ◼ Group and compatibility
- 15. + INVESTIGATIONS Imaging ◼Erect chest radiograph ◼CT ◼Ultrasonography ◼Peritonealdiagnostic aspiration
- 16. Gas under thediaphragm in a patient with free perforation and peritonitis
- 17. + MANAGEMENT General care ofthe patient ◼ Correction of fluid loss and circulating volume ◼ Urinary catheterisation ± gastro- intestinal decompression(NG tube) ◼ Antibiotic therapy ◼ Analgesia
- 18. + MANAGEMENT • Specific treatmentof the cause ◼Non-surgical treatment is preferred ◼Surgery is directed to removing (or diverting) the cause and subsequent adequate peritoneal lavage ± drainage ◼The whole peritoneal cavity be explored and mopped. The use of a large volume of saline (typically 3 litres) containing dissolved antiseptic or antibiotic
- 19. + COMPLICATIONS complications of Systemic peritonitis ◼Septic shock ◼Systemicinflammatory response syndrome ◼Multi-organ dysfunction syndrome ◼Death
- 20. + ABDOMINAL COMPLICATIONS OF PERITONITIS ◼Paralytic ileus ◼ Residual or recurrent abscess/inflammatory mass ◼ Portal pyaemia/liver abscess ◼ Adhesional small bowel obstruction
- 21. + SPECIAL FORMSOF PERITONITIS operations/ Bile peritonitis ◼ Perforated gall bladder ◼ Post-cholecystectomy ◼ Following other procedures: ◼Blunt or penetrating hepatobiliary or duodenal trauma
- 22. + SPECIAL FORMSOF PERITONITIS Tuberculous peritonitis ◼ Acute (may be clinically indistinguishable from acute bacterial peritonitis) and chronic forms ◼ Abdominal pain, sweats, malaise and weight loss ◼ Ascites common, may be loculated ◼ Caseating peritoneal nodules – distinguish from metastatic carcinoma and fat necrosis of pancreatitis ◼ Intestinal obstruction may respond to anti- tuberculous treatment without surgery
- 23. + SPECIAL FORMSOF PERITONITIS Familial Mediterranean fever (periodic peritonitis) ◼ Comes in attacks ◼ Recurrentwith remissions and exacerbations ◼ Plus pain in the thorax and joints ◼ Familial Female more,children more ◼ +ve appendectomy ◼ Colchicine therapy
- 24. + SPECIAL FORMSOF PERITONITIS INTRAPERITONEAL ABSCESS Symptoms ◼ Malaise, lethargy – failure to recover from surgery as expected ◼ Anorexia and weight loss ◼ Sweats ± rigors ◼ Abdominal/pelvic pain ◼ Symptomsfrom local irritation
- 25. + SPECIAL FORMSOF PERITONITIS Signs ◼Increased temperatureand pulse ± swinging pyrexia ◼Localised abdominal tenderness ± mass (including on pelvic exam)
- 26. + TERTIARY PERITONITIS ISMAINLY: A. Postoperative complication of delayed diagnosis of secondary peritonitis poly B. Residual intraperitoneal abscess C. Wrong management of traumatized patient D. Usually occurred in ascetic patents with hepatorenal impairment
- 27. + IN SUMMARY ❑Peritonitis is avery common serious surgical emergency ❑Early effective Treatment is the cornerstone ❑Treatment underlying cause and complications