Made of mesothelium.
Largest cavity in the body
Composed of flattened polyhedral cells, resting on fibro-elastic
Beneath the peritoneum lies loos areolar tissue which has rich
supply of capillaries and lymphatics.
Visceral Peritoneum: Poorly supplied by blood vessels hence
cannot localize pain properly.
Parietal Peritoneum: Richly supplied by blood vessels can
localize pain better
Defined as inflammation of the peritoneum.
May be localized or generalized.
In most cases there is bacterial invasion hence when it is said that
there is peritonitis Bacterial peritonitis.
Even in patients with non bacterial peritonitis like those d/t
Pancreatitis Eventually gets infected d/t transmural spread from
Microbiology: (Those from GI tract)
Peritoneal infection is usually caused by more than 2 strains of
Gram negative endotoxins (lipopolysaccharides) TNF
Endotoxic shock Tissue perfusion
These organisms are present in the lower GI tract and do respond
to Penicillins rather to metronidazole and clindamycin and
Non gastrointestinal causes of Peritonitis
Pelvic infection via fallopian tubes are one of the major causes of
Non GI cause of peritonitis.
The most common organisms being Chlamydia or gonococcus.
Chlamydia Fitz Hugh Curtis Syndrome (perihepatitis)
Fungal Peritonitis In severely ill patients or
Anatomical and pathological factors help confining infection to
Greater sac is divided into
Peritoneal cavity proper.
Supracolic and infracolic (division by transverse colon and transverse
When supracolic compartment overflows, it does so over to
infracolic region/paracolic gutters/pelvis.
• Inflammed peritoneum loses sheen
• Flakes of fibrin appear loops of intestine become adherent to each other
• Outpouring of serous fluid rich in leukocytes which later becomes frank pus
Ileus Prevents spread of infection Greater omentum seals the area.
Factors favoring spread of peritonitis.
Speed of peritoneal contamination
Ingestion of food.
Virulence of infecting organism
Young children with small omentum.
Disruption of localized collection
With appropriate treatment localized disease will resolve
About 20% progress to abscess.
Clinical features of localized peritonitis
Symptoms and signs are those of the affected organ.
Abdominal pain, specific GI symptoms, malaise, anorexia & nausea.
Then peritoneum gets inflamed
Increased temp and pulse rate.
Localized guarding ++
Rebound tenderness ++
If inflammation under the diaphragm Shoulder tip Pain+
Pelvic inflammation: Abdominal signs but severe tenderness of P/R or
Pain Worsened by movement
Initially at the site of lesion then followed by spread elsewhere.
Tenderness and generalized guarding
Decreased bowel sounds as Paralytic ileus sets in
Increased temperature and pulse
Erect X-ray abdomen – Air under the diaphragm
Supine X-ray – Distended bowel loops
CECT – To localize the condition.
USG abdomen – To localize the condition.
General Care for the patient
Correction of fluid loss and circulating volume.
Urinary catheterization and output monitoring.
Specific treatment for the condition.
Early surgery following localization of the lesion
In case of causes relating to non GI like Salpingitis or Pancreatitis then
Usually occurs following Lap. Cholecystectomy on damaging the
biliary tract or a duodenal stump blow out.
Extravasated bile gets collected and causes local chemical
peritonitis laparotomy and evaluation
Source of bile leak should be identified and treated.
Laparotomy wound is not closed unless the leak is dealt with.
Usually dealt with placement of drain and ERCP and stenting of the
Primary peritonitis or Spontaneous bacterial
D/t Pneumococci occurs in Cirrhosis or Nephrotic syndrome.
Rarely in Female children (3-9 yrs)
Sudden onset with pain over lower abdomen
Vomiting but after 24-48 hrs Profuse diarrhea
Peritonism + but less than perforation peritonitis.
Leukocytes >30k with > 90 % polymorphs
If peritoneal fluid is odourless and sticky then almost certain diagnosis
Peritoneal fluid can be sent for evaluation