The peritoneal membrane lines the abdominal cavity and divides it into two parts. It has several functions including pain perception, lubrication, and immune responses. Peritonitis is inflammation of the peritoneum which can be caused by infection, chemicals, ischemia or other factors. It can be localized or diffuse. Tuberculosis is a common cause of chronic peritonitis. Cancer can also spread to the peritoneum causing carcinomatosis. Mesenteric cysts occur in the mesentery and have several classifications including chylolymphatic and enterogenous cysts. Clinical features of mesenteric cysts include a painless abdominal swelling or acute symptoms from torsion or rupture.

1. peritonium
The peritoneal membrane is conveniently
divided into two parts
– the visceral peritoneum surrounding the viscera and
--the parietal peritoneum lining the other surfaces of the
cavity.

14. Functions of the peritoneum
■
Pain perception (parietal peritoneum)
■
Visceral lubrication
■
Fluid and particulate absorption
■
Inflammatory and immune responses
■
Fibrinolytic activity

15. The peritoneal cavity is the largest cavity in the body, the
surface area of its lining membrane (2 sq meter in an
adult) being nearly equal to that of the skin. The
peritoneal membrane is composed of flattened
polyhedral cells (mesothelium), one layer thick, resting
upon a thin layer of fibroelastic tissue.

16. Scope of disease
Intraperitoneal disease
• Peritonitis
Primary
Secondary
Causes of peritoneal inflammation
• Bacterial, gastrointestinal and non-
gastrointestinal
• Chemical, e.g. bile, barium
• Allergic, e.g. starch peritonitis
• Traumatic, e.g. operative handling

17. • Ischaemia, e.g. strangulated bowel,
vascular occlusion
• Miscellaneous, e.g. familial Mediterranean
fever
• Abscess
• Ascites
Transudate
Exudate
• Tumours
Primary
Secondary
• Adhesions

18. Omental disease
• Hernia
• Adhesions
• Torsion
• Neoplasia
Mesenteric disease
• Trauma
• Ischaemia
• Inflammation
• Cysts
• Neoplasm
Paths to peritoneal infection
• Gastrointestinal perforation, e.g. perforated ulcer,
appendix,
diverticulum
• Transmural translocation (no perforation), e.g.
pancreatitis,ischaemic disease

19. • Exogenous contamination, e.g. drains, open surgery, trauma,
peritoneal dialysis
• Female genital tract infection, e.g. pelvic inflammatory
disease
• Haematogenous spread (rare), e.g. septicaemia
Retroperitoneal disease
• Chronic inflammation/fibrosis
• Abscess
• Tumours

20. Although acute bacterial peritonitis most commonly arises
from a perforation of a viscus of the alimentary tract, other
routes of infection can include the female genital tract and
exogenous contamination. There are also less common forms
in which the aetiology is a primary ‘spontaneous’ peritonitis,

21. Beneath the peritoneum, supported by a small amount of
areolar tissue, lies a network of lymphatic vessels and rich
plexuses of capillary blood vessels from which all absorption
and exudation must occur. In health, only a few millilitres of
peritoneal fluid is found in the peritoneal cavity. The fluid is
pale yellow, somewhat viscid and contains lymphocytes and
other leucocytes; it lubricates the viscera, allowing easy move-
ment and peristalsis.

22. When a visceral perforation occurs, the free fluid that spills in
the peritoneal cavity runs downwards, largely directed by the
normal peritoneal attachments. For example, spillage from a
perforated duodenal ulcer may run down the right paracolic
gutter.

23. Acute peritonitis
Causes of a peritoneal inflammatory exudate
■
Bacterial infection, e.g. appendicitis,
■
Chemical injury, e.g. bile peritonitis
■
Ischaemic injury, e.g. strangulated bowel, vascular
Occlusion
Most cases of peritonitis are caused by an invasion of the
peritoneal cavity by bacteria, so that when the term
‘peritonitis’ is used without qualification, bacterial
peritonitis is implied.

24. Gas under diaphragm

25. Acute pancreatitis seen on computerised
tomography scanning with swelling of the gland and
surrounding inflammatory changes.

26. The Hippocratic facies in terminal diffuse peritonitis

28. Bacteria in peritonitis
Gastrointestinal source
Escherichia coli
Streptococci (aerobic and anaerobic)
Bacteroides
Clostridium
Klebsiella pneumoniae
Staphylococcus
Other sources
Chlamydia
Gonococcus
b-Haemolytic streptococci
Pneumococcus
Mycobacterium tuberculosis

29. Paths to peritoneal infection
■
Gastrointestinal perforation, e.g. perforated ulcer,
diverticular perforation
■
Exogenous contamination, e.g. drains, open surgery,
trauma
■
Transmural bacterial translocation (no perforation), e.g.
inflammatory bowel disease, appendicitis, ischaemic bowel
■
Female genital tract infection, e.g. pelvic inflammatory
disease
■
Haematogenous spread (rare), e.g. septicaemia

30. Localised peritonitis
Anatomical, pathological and surgical factors may favor the
localization of peritonitis.
The greater sac of the peritoneum is divided into (1) the
subphrenic spaces, (2) the pelvis and (3) the peritoneal
cavity proper. The last is divided into a supracolic and an
infracolic compartment by the transverse colon and
transverse mesocolon,which deters the spread of infection
from one to the other.

31. Intraperitoneal abscesses
(1) Left subphrenic;
(2) left subhepatic/lesser sac;
(3) right subphrenic;
(4) Right subhepatic.

32. Diffuse peritonitis
A number of factors may favour the development of diffuse
peritonitis:
• Speed of peritoneal contamination is a prime factor. If an
inflamed appendix or other hollow viscus perforates before
localisation has taken place, there is a gush of
contents into the peritoneal cavity, which may spread over a
large area almost instantaneously. Perforation proximal to an
obstruction or from sudden anastomotic separation is asso-
ciated with severe generalised peritonitis and a high mortality
rate.

33. Stimulation of peristalsis by the ingestion of food or even water
hinders localisation. Violent peristalsis occasioned by the
administration of a purgative or an enema may cause the
widespread distribution of an infection that would otherwise
have remained localised.

34. • The virulence of the infecting organism may be so great as to
render the localisation of infection difficult or impossible.
• Young children have a small omentum, which is less effective in
localising infection.
• Disruption of localised collections may occur with injudicious
handling, e.g. appendix mass or pericolic abscess.
• Deficient natural resistance (‘immune deficiency’) may result
from use of drugs (e.g. steroids), disease [e.g. acquired immune
deficiency syndrome (AIDS)] or old age.

35. Investigations in peritonitis
■ Raised white cell count and C-reactive protein are usual
■ Serum amylase > 4× normal indicates acute pancreatitis
■ Abdominal radiographs are occasionally helpful
■ Erect chest radiographs may show free peritoneal gas
(perforated viscus)
■ Ultrasound/CT scanning often diagnostic
■ Peritoneal fluid aspiration (with or without ultrasound
guidance) may be helpful

36. Systemic complications of peritonitis
■ Bacteraemic/endotoxic shock
■ Bronchopneumonia/respiratory failure
■ Renal failure
■ Bone marrow suppression
■ Multisystem failure

37. treatment
• general care of the patient;
• specific treatment of the cause;
• peritoneal lavage when appropriate.

38. General care of patient:
■ Correction of fluid and electrolyte imbalance
■ Insertion of nasogastric drainage tube
■ Broad-spectrum antibiotic therapy
■ Analgesia
■ Vital system support
Operative treatment of cause when appropriate with
peritoneal debridement/lavage

39. Abdominal complications of peritonitis
■ Adhesional small bowel obstruction
■ Paralytic ileus
■ Residual or recurrent abscess
■ Portal pyaemia/liver abscess

48. BILE PERITONITIS
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

49. Tubercular peritonitis
Acute tuberculous peritonitis
Chronic tuberculous peritonitis

54. Ileocaecal region is common site due to;
Stasis
Abundant Peyer’s patches-organism get trapped in peyer’s patches.
Bacteria contact time with mucosa is more
M cells in peyer’s patches phagocytose bacilli & transfer to host cells.
Liquid content in the region
Increased rate of fluid & electrolyte absorption
Minimal digestive activity

57. Origin of the infection
• 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.

58. Varieties of tuberculous peritonitis
There are four varieties of tuberculous peritonitis:
1.ascitic,
2.encysted,
3.fibrous and
4.purulent.

59. Ascitic form
The peritoneum is studded with tubercles and the peritoneal
cavity becomes filled with pale, straw-coloured fluid. The onset is
insidious. There is loss of energy, facial pallor and some loss of
weight. The patient is usually brought for advice because of
distension of the abdomen. Pain is often absent; in other cases
there is considerable abdominal discomfort, which may be
associated with constipation or diarrhoea.

60. Fibrous form
The fibrous (synonym: plastic) form is characterized by the production
of widespread adhesions, which cause coils of intestine,
especially the ileum, to become matted together and distended.
These distended coils act as a ‘blind loop’ and give rise to
steatorrhoea, wasting and attacks of abdominal pain.

61. On examination, the adherent intestine with omentum attached,
together with the thickened mesentery, may give rise to a palpable
swelling or swellings. The first intimation of the disease may be
subacute or acute intestinal obstruction. Sometimes the cause of the
obstruction can be remedied easily by the division of bands. Small
bowel bypass should be avoided to prevent development of a
‘blind loop’ syndrome.

62. Encysted form
The encysted (loculated) form is similar to the ascitic form except
that one part of the abdominal cavity alone is involved. Thus, a
localised intra-abdominal swelling is produced, which may give
rise to difficulty in diagnosis. In a woman above the age of
puberty, when the swelling is in the pelvis, an ovarian cyst will
probably be diagnosed.

63. In the case of a child it is sometimes difficult to
distinguish the swelling from a mesenteric cyst.
For these reasons, operation is often performed
and, if an encapsulated collection of fluid is
found, it is evacuated and sent for microscopy
and culture.Late intestinal obstruction is a
possible complication.

64. Purulent form
The purulent form is rare. When it occurs, usually it is
secondary to tuberculous salpingitis. Amidst a mass of
adherent intestine and omentum, tuberculous pus is present..

65. Sizeable cold abscesses often form and point on
the surface, commonly near the umbilicus, or
burst into the bowel. In addition to prolonged
general treatment, operative treatment may be
necessary for the evacuation of cold abscesses
and possibly for intestinal obstruction

66. If a faecal fistula forms, it usually persists because of distal
intestinal obstruction. Closure of the fistula must therefore be
combined with some form of anastomosis between the
segment of intestine above the fistula and an unobstructed
area below. Prognosis in this variety is very poor.

70. Barium study shows
Pulled up caecum,conical caecum,pulled down hepatic flexure
Obtuse ileocaecal angle
Narrow ileum with thickened valve-Fleischner sign
Calcifications
Ulcers & Strictures in terminal ileum & caecum-Napkin lesions

74. CB-NAAT/Genexpert test
Cartridge-Based Nucleic Acid
Amplification test.

75. PCR
Polimerase chain reaction
CB- NAAT
Cartridge based nucleic acid amplification test
Gene xpert test
Molecular test for TB

82. Carcinoma peritonei
This is a common terminal event in many cases of carcinoma of
the stomach, colon, ovary or other abdominal organs and also of
the breast and bronchus. The peritoneum, both parietal and
visceral, is studded with secondary growths and the peritoneal
cavity becomes filled with clear, straw-coloured or blood-stained
ascitic fluid.

83. The main forms of peritoneal metastases are:
• discrete nodules – by far the most common variety;
• plaques varying in size and colour;
• diffuse adhesions – this form occurs at a late stage of the
disease and gives rise, sometimes, to a ‘frozen pelvis’.

84. Treatment
Ascites caused by carcinomatosis of the
peritoneum may respond
to systemic or intraperitoneal chemotherapy
or to endocrine therapy in the case of
hormone receptor-positive tumours.

85. Pseudomyxoma peritonei
This rare condition occurs more frequently in
women. The abdomen is filled with a yellow
jelly, large quantities of which are
often encysted. The condition is associated
with mucinous cystic tumours of the ovary
and appendix.

86. Mesentery:
I. Anatomy
- a reflection of the posterior peritoneum
- connects the intestines to the posterior
abdominal wall and carries blood vessel and nerves
- root of the mesentery extends from the
ligament of Treitz at the level of L2 to ileo-cecal
junction and is approximately 6 inches long.

88. Mesenteric cysts
Mesenteric cysts are classified as:
• chylolymphatic;
• simple (mesothelial)
• enterogenous;
• urogenital remnant;
• dermoid (teratomatous cyst)

89. Chylolymphatic cyst: the commonest variety, probably arises in
congenitally misplaced lymphatic tissue that has no efferent
communication with the lymphatic system; it arises most
frequently in the mesentery of the ileum. The thin wall of the cyst,
which is composed of connective tissue lined by flat endothelium,
is filled with clear lymph or, less frequently, with chyle varying in
consistency from watered milk to cream. Occasionally, the cyst
attains a great size. More often unilocular than multilocular, a
chylolymphatic cyst is almost invariably solitary, although there is
an extremely rare variety in which myriads of cysts are found in
the various mesenteries of the abdomen. A chylolymphatic cyst
has a blood supply that is independent from that of the adjacent
intestine and, thus, enucleation is possible without the need for
resection of gut.

90. Enterogenous cysts : are believed to be derived either from a
diverticulum of the mesenteric border of the intestine that has
become sequestrated from the intestinal canal during embryonic
life or from a duplication of the intestine. An enterogenous cyst
has a thicker wall than a chylolymphatic cyst and it is lined by
mucous membrane, sometimes ciliated. The content is mucinous
and is either colourless or yellowish brown as a result of past
haemorrhage. The muscle in the wall of an enteric duplication
cyst and the bowel with which it is in contact have a common
blood supply; consequently, removal of the cyst always
entails resection of the related portion of intestine.
.

91. Clinical features of a mesenteric cyst
A mesenteric cyst is encountered most frequently
in the second decade of life, less often between
the ages of 1 and 10 years and, exceptionally, in
infants under 1 year.
Tillaux triad:

92. CLINICAL FEATURES :
1. A painless abdominal swelling
2. Recurrent attacks of abdominal pain
3. An acute abdominal catastrophe
--due to torsion of that portion of the mesentery
containing the cyst;
– rupture of the cyst
– haemorrhage into the cyst;
– infection.

93. investigations
Ultrasound
CT scan
Ba meal follow-through.

102. Retroperitoneum
Haematoma due to injuries
Acute and chronic infections
Retroperitoneal fibrosis
tumours

103. Acute infections:
Perinephric abscess
Retrocaecal appendicular abscess

104. Chronic infection
Tubercular abscess (psoas abscess)

105. Retroperitoneal haematoma
Retroperitoneal haematoma may be
caused by a fractured spine or pelvis, a leaking abdominal
aneurysm, acute pancreatitis or a ruptured kidney.

106. Retroperitoneal cyst
A cyst developing in the retroperitoneal space often attains
very large dimensions and has first to be distinguished from a
hydronephrosis and retroperitoneal tumour
until displayed at operation. The cyst may be unilocular or
multilocular.
Many of these cysts are believed to be derived from a
remnant of the wolffian duct

107. Retroperitoneal tumours arising from connective
tissues
Retroperitoneal lipoma
Retroperitoneal sarcoma

108. Retroperitoneal Tumours arising from specific
organs
• lymph nodes
• adrenal gland
• kidney and ureter
• nervous tissue.

114. Retroperitoneal lipoma
The patient may seek advice on account of a swelling or
because of indefinite abdominal pain . Women are more often
affected . These swellings sometimes reach an immense size.
Diagnosis is usually by ultrasonography and CT scanning.
A retroperitoneal lipoma sometimes undergoes myxomatous
degeneration, a complication that does not occur in a lipoma
in any other part of the body. Moreover, a retroperitoneal
lipoma is often malignant ( liposarcoma ) (see below) and may
increase rapidly in size.

115. Retroperitoneal sarcoma
Retroperitoneal sarcomas are rare tumours accounting for
only l-2 % of all solid malignancies ( 10-20% of all sarcomas
are retroperitoneal ). The peak incidence is in the fifth
decade of life, although they can occur at almost any age. The
most common types of retroperitoneal soft- tissue sarcomas in
adults vary from study to study. However, in most studies, the
most frequently encountered cell types are:

116. • liposarcoma ;
• leiomyosarcoma ;
• malignant fibrous histiocytoma ( MFH ) .

118. Plastic stent
in CBD
Enlarged
retro
peritoneal
lymph
node

119. CLINICAL FEATURES
Patients with sarcomas present late, because these tumours
arise in the large potential spaces of the retroperitoneum
and can grow very large without producing symptoms. More-
over, when symptoms do occur, they are non-specific, such
as abdominal pain and fullness, and are easily dismissed as
being caused by other less serious processes. Retroperitoneal
sarcomas are, therefore, usually very large at the time of
presentation.

120. INVESTIGATION
Detailed multiplanar imaging (CT + MRI ) with reconstructions
is required not only for tumour detection, staging and
surgical planning, but also for guiding percutaneous or surgi- cal
biopsy of these tumours. Such biopsies have a greater role
than for other sarcomas

121. TREATMENT
The definitive treatment of primary retroperitoneal sarcomas
is surgical resection. Chemotherapy and radiotherapy
without surgical dehulking have rarely been beneficial, when
used alone or in combination A multidisciplinary treatment
approach with imaging review will be required when assessing
operability ( based on adjacency or involvement of vital struc-
tures) and approach. Up to 75% of retroperitoneal sarcoma
resections involve resection of at least one adjoining intra-
abdominal visceral organ.

122. PROGNOSIS
In the vast majority of sarcomas, cell type has no impact on
treatment and long-term survival. Survival rates are in general
poor, even after complete resection, being in the order of 35 to
50%.

123. Idiopathic retroperitoneal fibrosis
This is one of a group of fibromatoses (others being
Dupuytren’s contracture and Peyronie’s disease). Most
cases are idiopathic but in other patients the cause is
known .

124. Causes of retroperitoneal fibrosis
Benign
■ Idiopathic (Ormond’s disease)
■ Chronic inflammation
■ Extravasation of urine
■ Retroperitoneal irritation by leakage of blood or intestinal
content
■ Aortic aneurysm (‘inflammatory type’)
■ Trauma
■ Drugs:
Chemotherapeutic agents
Methysergide
β-Adrenoceptor antagonists
Malignant
■ Lymphoma
■ Carcinoid tumours
■ Secondary deposits (especially from carcinoma of
stomach, colon, breast and prostate, testis.

125. Pericardial effusion
There is a continuous production and
resorption of pericardial fluid. If a disease
process disturbs this balance, a pericardial
effusion may develop. If the pressure
exceeds the pressure in the atria,
compression will occur, venous return will
fall and the circulation will be compromised.
This state of affairs is called ‘tamponade’

126. A gradual build up of fluid (e.g. malignant
infiltration) may be well tolerated for a long
period before tamponade occurs, and the
pericardial cavity may contain 2 litres of fluid.
Acute tamponade (from penetrating trauma,
during coronary angiography or
postoperatively) may occur in minutes with
small volumes of blood.

127. The clinical features are low blood
pressure with a raised jugular venous
pressure and paradoxical pulse.
Kussmaul’s sign is a characteristic pattern
that is seen when the jugular venous
pressure rises with inspiration as a result
of the impaired venous return to the
heart.

128. Emergency treatment of pericardial tamponade is
aspiration of the pericardial space. A wide-bore
needle is inserted under local anaesthesia to the
left of the xiphisternum, between the angle of the
xiphisternum and the ribcage. The needle is
advanced towards the tip of the scapula into the
pericardial space. An ECG electrode attached to
the needle will indicate when the heart has been
touched.

129. pneumothorax
Pneumothorax is the presence of air outside the lung,
within the pleural space. It must be distinguished
from bullae or air cysts within the lung. Bullae can be
the cause of an air leak from the lung and can
therefore coexist with pneumothorax

130. Tension pneumothorax is when (independent
of aetiology) there is a build up of positive
pressure within the hemithorax, to the extent
that the lung is completely collapsed, the
diaphragm is flattened and the mediastinum is
distorted and, eventually, the venous return to
the heart is compromised

131. A pleural breach is inherently valve-like
because air will find its way out through the
alveoli but cannot be drawn back in because
the lung tissue collapses around the hole in
the pleura. Patients being mechanically
ventilated following trauma are at particular
risk.

132. Primary spontaneous pneumothorax
This is a common disease characteristically
seen in young people from their mid-teens to
late twenties. About 75 per cent of cases are in
young men, who tend to be tall, and the
condition runs in families. It is due to leaks
from small blebs, vesicles or bullae, which may
become pedunculated, typically at the apex of
the upper lobe or on the upper border of the
lower or middle lobes.

133. Secondary spontaneous pneumothorax
This occurs when the visceral pleura leaks
as part of an underlying lung disease; any
disease that involves the pleura may cause
pneumothorax, including tuberculosis, any
degenerative or cavitating lung disease and
necrosing tumours

134. Usually, pneumothorax presents with sharp
pleuritic pain and breathlessness. The pleura is
exquisitely sensitive and the movement of the
lung on and off the parietal pleura causes
severe discomfort. As a result, it is mild cases
that are more painful, whereas complete
collapse is usually painless but causes more
breathlessness.

135. If the patient is not in respiratory distress
or hypoxic, there is no urgency. Tension
pneumothorax should be immediately
relieved by inserting a cannula into the
hemithorax in as safe a position as possible.

136. The safest site for insertion of a drain
is in the triangle that lies:
• anterior to the mid-axillary line;
• above the level of the nipple;
• below and lateral to the
pectoralis major muscle.
This will ideally find the fifth space.

137. The technique includes the following:
• Meticulous attention to sterility
throughout.
• Adequate local anaesthesia to include the
pleura.
• Sharp dissection only to cut the skin. •
Blunt dissection with artery forceps down
through the muscle layers; these should only be
the serratus anterior and the intercostals.
• An oblique tract, so that the skin incision
and the hole in parietal pleura does not overly
each other.

138. A drain for pneumothorax and haemothorax
should aim towards the apex of the lung. A
drain for pleural effusion or empyema should
be nearer the base. The drain should pass
over the upper edge of the rib to avoid the
neurovascular bundle that lies beneath the
rib.

139. Pleurectomy and pleurodesis
Surgery for pneumothorax can be
performed by video-assisted
thoracoscopic surgery (VATS) or as an
open procedure (thoracotomy).

140. • to deal with any leaks from the
lung;
• to search for and obliterate any
blebs and bullae (Bullectomy);
• to make the visceral pleura
adherent to the parietal pleura so that
any subsequent leaks are contained
and the lung cannot completely
collapse.

141. • Pleurectomy: systematically
strip the parietal pleura from the
chest wall.
• Pleural abrasion: a scourer is
used to scrape off the slick surface of
the parietal pleura.
• Chemical pleurodesis: usually
talc is used and is insufflated into the
chest cavity.