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Acute peritonitis

Class for undergrad med students

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Acute peritonitis

  1. 1. Acute Peritonitis Yuvaraj Karthick R
  2. 2. Peritnoeum  Made of mesothelium.  Largest cavity in the body  Composed of flattened polyhedral cells, resting on fibro-elastic membrane.  Beneath the peritoneum lies loos areolar tissue which has rich supply of capillaries and lymphatics.
  3. 3.  Visceral Peritoneum: Poorly supplied by blood vessels hence cannot localize pain properly.  Parietal Peritoneum: Richly supplied by blood vessels  can localize pain better
  4. 4. Peritonitis  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 the gut.
  5. 5. Causes of Peritonitis:  Bacterial  Gastrointestinal & non- gastrointestinal  Chemical Bile, Barium  Allergic  Starch  Traumatic  Operative Handling  Ischaemic  Strangulated bowel, vascular occlusion  Miscellaneous  Familial Mediterranean fever.
  6. 6. Route of spread:  Bowel perforation   Transmural Translocation   Exogenous contamination   Female genital tract   Hematogenous spread 
  7. 7. Microbiology: (Those from GI tract)  Peritoneal infection is usually caused by more than 2 strains of bacteria.  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 cephalosporins
  8. 8. 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 Immunocompramised patients.
  9. 9. MICROORGANISMS  GASTRO INTESTINAL SOURCE: E.coli Streptococci Bacteroids K.pneumonia  NON GASTROINTESTINAL SOURCE: Chlamydia Neisseria gonorrheoa Streptococci Mycobacterium & Fungal
  10. 10. Localized Peritonitis  Anatomical and pathological factors help confining infection to localized areas.  Greater sac is divided into  Subphrenic space  The pelvis  Peritoneal cavity proper. Supracolic and infracolic (division by transverse colon and transverse mesocolon)  When supracolic compartment overflows, it does so over to infracolic region/paracolic gutters/pelvis.
  11. 11. Pathological Peritoneum • Inflammed peritoneum loses sheen Fibrin • Flakes of fibrin appear  loops of intestine become adherent to each other Leukocytes • Outpouring of serous fluid rich in leukocytes which later becomes frank pus  Ileus  Prevents spread of infection  Greater omentum seals the area.
  12. 12. Diffuse peritonitis  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  Immune deficiency  With appropriate treatment localized disease will resolve  About 20% progress to abscess.
  13. 13. 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  Pain worsens,  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 P/V
  14. 14. Diffuse peritonitis  Early  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
  15. 15. Late peritonitis  Abdomen becomes rigid.  Distension +  Bowel sounds –ve  Shock  Cold clammy extremities  Sunken eyes, dry tongue  Rapid thread pulse  Anxious facies.
  16. 16. Diagnostic aides:  Bedside:  Urine dipstick  ECG  Bloods:  Baseline U&E  CBC  S. amylase
  17. 17. Imaging  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.
  18. 18. Management  General Care for the patient  Correction of fluid loss and circulating volume.  Urinary catheterization and output monitoring.  Antibiotic therapy.  Analgesia  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 non-operative treatment.
  19. 19. Surgery:
  20. 20. Prognosis and complications:  Mortality is 10% with modern treatment.  Factors responsible for prognosis  Load  Age  Onset of treatment
  21. 21. Complications:  Systemic complications:  Bacterimic or endotoxic shock  SIRS  MODS  Abdominal Complications:  Paralytic ileus  Residual/recurrent abscess/ Inflammatory mass  Portal pyemia/ Liver abscess  Adhesions  Small bowel obstruction
  22. 22. Bile peritonitis:  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 CBD.
  23. 23. Primary peritonitis or Spontaneous bacterial peritonitis:  D/t Pneumococci  occurs in Cirrhosis or Nephrotic syndrome. Rarely in Female children (3-9 yrs)  Sudden onset with pain over lower abdomen  Raised temp  Vomiting but after 24-48 hrs  Profuse diarrhea  Peritonism + but less than perforation peritonitis.  Investigations:  Leukocytes >30k with > 90 % polymorphs  If peritoneal fluid is odourless and sticky then almost certain diagnosis  Peritoneal fluid can be sent for evaluation

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