Peritonitis is among the most common surgical cases. getting familiarized with it for early proper diagnostic and management is the key to reduce morbidity and mortality. In this power point i have analysed important anatomy, causes, investigation and how to manage it as medical personal covers all the necessary things you will require to know about peritonitis Kindly like, save and share if you find the material useful

1. PERITONITIS
Dr. STEVEN VALLERY MLOSA. MD

2. Anatomy of the peritoneum
• The peritoneum is the continuous membrane which lines the
abdominal cavity and covers the abdominal organs
• The peritoneum consists of two layers that are continuous with each
other: the parietal peritoneum and visceral peritoneum and they are
both made of mesothelial cells
• Mesothelial cells produced serous fluid (peritoneal fluid) which
lubricates parietal and visceral peritoneum
• Any alteration which cause the increase in fluid production will result
into ascites

3. Peritonitis
• Peritonitis is the inflammation of the peritoneum and maybe localized
or generalized.
• Localized peritonitis can be seen in places like subphrenic spaces
secondary to perforated appendecitis and pelvic region

4. Etiology
Bacterial peritonitis
Can be classified as primary or secondary
Primary peritonitis is diffuse bacterial infection without loss of
gastrointestinal tract integrity. Its rare but streptococcus pneumoniae a
usual causative organism.
Secondary peritonitis is an acute peritoneal infection caused by loss of
integrity of gastrointestinal or infected pancreatic necrosis, or from
reproductive tract in female

5. • Bacterial may enter the peritoneum via the following routes:
a) Direct invasion from external environment eg. Through abdominal
wound and during laparotomy
b) Translocation from damaged intra abdominal visceral eg.
Perforated viscus (perforated PUD) gangrenous viscus
(appendecitis) trauma, iatrogenic (anastomotic leak)
c) Via female genital tract eg. Acute salpingitis, ruptured ectopic
pregnancy

6. Spontaneous bacterial peritonitis
• An infection of ascitic fluid without an evident intra-abdominal
surgically treatable source.
• It should be suspected in patient with advanced cirrhosis and children
with nephrotic syndrome

7. Chemical peritonitis (aseptic peritonitis)
• Accounts for 20% of all cases of peritonitis and usually it is secondary
to perforated duodenal or gastric ulcer.
• Sterile peritonitis will progress to bacterial peritonitis usually in few
hours due to bacterial trans-migration (eg. From bowel)
• Biliary peritonitis is relatively rare form of sterile peritonitis and can
result due to acute cholecystitis, trauma, iatrogenic (eg slippage of
cystic duct ligature following cholecystectomy) or idiopathic

8. • Other form of sterile peritonitis including
a) Pancreatic juices- due to acute pancreatitis, trauma.
b) Blood e.g ruptured ovarian cysts leakage of aortic aneurysm
c) Urine e.g intraperitoneal rupture of bladder

9. Tuberculous peritonitis
• Can be seen in immunocompromised patients and spread to the
peritoneum occurs through the following way:-
a) Directly from mesenteric lymphnodes
b) Via blood borne on infection originating from pulmonary
tuberculosis

10. Clinical presentation
• Pain is the major complain and maybe localized or diffuse. It is usually
constant and of sharp, pricking character.
• In visceral perforation pain is usually at the site of perforation but
maybe become more generalized as peritoneum contaminataion
spreads.
• Aneroxia, malaise nausea and vomiting usually are the associated
features.

11. Examination
• General examination:
Usually they are pale, sunken eyes due to dehydration, restlessness and
disoriented
• Per abdomen examination
Palpation will exacerbate the pain and therefore should be done very
gently and carefully. It will reveals tenderness, guarding and rebound
tenderness, the site of maximum pain usually it is related to the site of
pathology
Auscultation will confirm increasing ileus as bowel sound will be
diminished or and eventually ceased.

12. Investigations.
• Peritonitis mainly is clinical diagnosis and urgent laparotomy should
be performed without unnecessary investigations
• Investigations includes:
Full blood picture- will demonstrate a leukocytosis
Grouping and cross matching- laparotomy may be indicated and
therefore its essentially to know the group if may require transfusion
Urea and Electrolytes- will confirm dehydration and acute renal failure
and will guide you in replacement of fluid and electrolytes
Serum amylase and lipase- elevations may confirm acute pancreatitis
as the cause of peritonitis

13. Imaging
• Erect radiograph will show pneumoperitoneum in 70-80% of cases
with visceral perforations a lateral decubitus position is alternative
position in those who can not stand supine position is less
informative but will reveal ground glass appearance in diffuse
peritoneum
• Ultrasound may play role in confirming or excluding specific diagnosis
(eg subphrenic abscess, appendicitis)
• CT scan abdomen

14. Management
• Conservative management
Medical management is indicated if the:
a) Infection has localized (eg appendix mass)
b) cause of peritonitis doesn’t require surgical management (eg acute
appendicitis)
c) patient is not fit for general anesthesia (elederly, patient with
severe comorbid)
d) Medical facility are unable to support surgical management

15. Principal Management of medical treatment
• High flow oxygen- is vital for all shocked patients, hypoxia maybe
monitored using pulse oximetry or arterial blood glass.
• Fluid resuscitation- intravenous crystalloids volume depending on the
degree of shock and dehydration, electrolyte replacement especially
potassium may be required. Patient maybe catheterized to monitor
input and output of urine
• Analgesia- opiate analgesia such as morphine maybe used
• Antibiotics- broad spectrum antibiotics covering anaerobes and
aerobes are given intravenously. 3rd generation cephalosporin and
metronidazole are used commonly.

16. • Nasogastric tube- reduces risk of aspiration pneumonia
Early initiation of antibiotic is the key for mortality reduction in patient
with septic shock associated with peritonitis.

17. Surgical management
• Laparotomy- usually performed through an upper or lower midline
incision depending suspected site of pathology
• The objective of laparotomy includes:
a) Establish the cause of peritonitis
b) Control origin of the sepsis by removal of the inflamed or ischemic
organ (or closure of perforated viscus)
c) Performing effective peritoneal toilet or lavage

18. • Re-laparotomy has an important role in the treatment of patient with
severe secondary peritonitis who after primary laparotomy have on
going or worsening features of sepsis.
• Planned strategy like re laparotomy, leaving abdominal wall open with
a sheet of synthetic mesh in situ to prevent evisceration, then staged
abdominal repair and closure. However obtaining effective control of
sepsis at first option is vitally important because each operation has
subsequent risk of morbidity and mortality.
• Drains- maybe effective to drain localized space of the peritoneal
cavity.

19. Complications
• Septic shock
• Paralytic ileus
• Adhesions
• Intra abdominal abscess
• Deep wound surgical site infection

20. summary

21. THANK YOU