PERITONITIS
Perietoneum:
Anatomy
It is a serous membrane lining the abdominal cavity. Outer fibrous tissue layer, inner
mesothelial cell layer.
The surface area of its lining membrane is 2m.sq in an adult Closed sac in males, open at
the ends of fallopian tubes in females
Parts of Peritoneum
1. Parietal peritoneum
2. Visceral peritoneum
Peritoneal cavity
It is the potential space between the parietal and visceral
peritoneum. Normally it consists of <100ml of clear, straw
colored fluid. It lubricates the viscera allowing easy movement
and peristalsis.
Function of peritoneum
IN HEALTH
Visceral lubrication
Fluid and particulate absorption
IN DISEASE
Pain perception
Inflammatory
immune responses
Fibrinolytic activity
The peritoneum has the capacity to absorb large volumes of fluid,
this ability is used during dialysis in the treatment of renal failure
Peritonitis
Inflammation of parietal and serosal layer of
peritoneum either due to chemicals like gastric
acid/bile or due to bacterial infection which
may be localized or generalized
Causes of
peritoneal
inflammation:
Bacterial: gastrointestinal and non-gastrointestinal
Chemical: eg; bile, barium
Traumatic: operative handling
Ischemic: strangulated bowel, vascular occlusion
Types of acute peritonitis
Peritonitis can be chemical or bacterial or initially chemically
induced later bacterial.
TYPES
1. Primary
2. Secondary
3. Tertiary
Can also be classified as:
1. Localized
2. Generalized
Primary
Common in cirrhotic patient with ascites, as spontaneous bacterial
peritonitis(SBP)
Common in young girls between 3 to 9 years.
Results from bacterial, fungal or mycobacterial infection in
absence of Gl perforation.
90% of SBP infection is monomicrobial: E.coli(40%)
Commonly due to Pneumococci, ocassionly due to streptococci
and hemophilus and other gram negative( E.coli)
Ascitis fluid WBC count if more than 250 cells/mm3 with more
than 50% cells are polymorphonuclear cell suggestive of primary
peritonitis.
Secondary:
It occurs in Gl perforation
Duodenal perforation and brust appendicitis are
commonest cause.
E.coli is most common organism involved
Tertiary
Defined as persistent/ recurrent intraabdominal infection
after an adequate treatment for primary or secondary
peritonitis usually after 48 hours.
It occurs after any abdominal surgeries which is usually severe and
patient may go in for SIRS/ MODS early.
Common in immunocompromised individuals
Modes of infection
Gastrointestinal Perforation: e.g. perforated ulcer, appendix, diverticulum
Transmural Translocation: e.g. pancreatitis, ischemic bowel,
primary bacterial peritonitis
Exogenous contamination: e.g. drains, open surgery, trauma,
peritoneal dialysis
Female genital tract infection: Pelvic inflammatory disease
Hematogenous: septicemia
CAUSES OF PERITONEAL INFLAMMATION
Gastrointestinal:
Perforation of bowel
Spontaneous/transmural translocation of bacteria
Pancreatitis
Non-Gastrointestinal
Female genital tract: PID, Torsion
Peritoneal dialysis Surgery
Perforating injury to abdomen
Most common cause of peritonitis in adult
male peptic ulcer perforation
PATHOPHYSIOLOGY
Leakage:- peritonitis is caused by leakage of contents from abdominal
cavity
Proliferation :- Bacterial proliferation occur
Edema :- occurs and exudation of fluid develops in a short time
Invasion:- Fluid in the peritoneal cavity becomes turbid with increasing amounts of
protein, WBC, cellular debris and blood.
Response :- the immediate response of the intestinal tract is hypermotality. Soon
followed by paralytic ilius with an accumulation of air and fluid in the bowel.
CLINICAL FEATURES
* Sudden onset of pain which is severe.
Fever, vomiting.
Tenderness-initially localised later becomes diffused
Rebound tenderness-Blumberg sign.
Guarding and rigidity, dull flanks on percussion.
Tachycardia, tachypnoea.
Eventually leading to Hippocrates facies, septicaemic shock and loss of
consciousness.
Bowel sounds are absent due to paralytic ileus.
Fever may be absent in severe peritonitis due to pyrogenic reaction.
INVESTIGATIO
N
BLOOD
*Total Leucocyte count: increased
Amylase (if 4 times normal value then
significant) Lipase
Urea and Creatinine Electrolytes
IMAGING
Plain x-ray abdomen
Erect: gas under diaphragm
Supine: ground glass
appearance CT scan abdomen
INVASIVE
Diagnostic laparoscopy
Diagnostic peritoneal
lavage
Principle of therapy in
peritonitis
1. To control source of infection
2. To eliminate bacteria and sepsis
3. To maintain vital organ functions- Cardiac, Pulmonary and
Renal 4.Nutrition and metabolic support
MANAGEMEN
T
General care of the patient
Correction of fluid and electrolyte loss and
circulating
volume
Urinary catheterization and nasogastric drainage
insertion
Antibiotics therapy Systemic antibiotic therapy
Analgesia
Vital system support
SURGICAL TREATMENT
Exploratory Laparotomy
Midline vertical incision with wide exposure Suction
and collection of pus for culture& sensitivity Inspect
for cause
Bowel perforation: perforation closure Intestinal
obstruction: Resection & anastomosis Appendicitis:
appendicectomy
Peritoneal wash
Place drain and Tension suture
POST OPERATIVE MANAGEMENT
1. Proper critical care (icu)
2. Ventilatory support; monitoring vitals with urine output, TLC, DLC, blood
urea, serum creatinine, LFT
3. Proper fluid and electrolyte management
4. Prevention of DVT
COMPLICATIONS
1. Septic sock
2. Systemic Inflammatory Response
Syndrome 3.Multi-organ dysfunction
syndrome
4.Death
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