PERITONITIS
M. IQBAL RIVAI
PERITONEUM
Function of peritoneum
Pain perception
Visceral lubrication
Fluid and particulate absorption
Inflammatory and immune response
Fibrinolytic activity
‘ABDOMINAL POLICEMAN’
PERITONEUM
Causes of peritoneal inflammatory exudate:
Bacterial infection appendicitis
Chemical injury bile peritonitis
Ischaemic injury strangulated bowel, vasc. Occlusion
Direct trauma operation
Allergic reaction starch peritonitis
ACUTE PERITONITIS
Bacteria in peritonitis
Gastrointestinal source
Eschericia coli
Streptococci (aerobic and anaerobic)
Bacteroides
Clostridium
Klebsiella pneumoniae
Staphylococcus
Other sources
Chlamydia
Pneumococcus
ROUTE OF INFECTION
Paths to peritoneal infection
Gastrointestinal perforation perforated ulcer
Exogenous contamination drains, open surgery
Transmural bacterial translocation (no perforation)
inflammatory bowel disease, appendicitis, ischaemic
bowel
Haematogenous spread septicemia
PERITONITIS
Mortality in peritonitis reflects:
The degree and duration of peritoneal contamination
The age of the patient
The general health of the patient
The nature of the underlying cause
ABDOMINAL REGION
DIFFUSE PERITONITIS
Factors of the development of diffuse peritonitis:
Speed of peritoneal contamination
Stimulation of peristalsis by ingestion of food or even
water hinders localisation
Virulence of the infecting organism
Young children have a small omentum
Disruption of localised collections
Immune deficiency
CLINICAL FEATURES IN PERITONITIS
Abdominal pain, worse on movement
Guarding/ rigidity of abdominal wall
Pain/ tenderness on rectal/ vaginal examination (pelvic
peritonitis)
Pyrexia (may be absent)
Raised pulsed rate
Absent or reduced bowel sound
‘Septic shock’ (SIRS) in later stages
Free
air
Hippocratic facies in terminal diffuse peritonits
Acute pancreatitis on CT
Scan
DIAGNOSTIC AIDS
Raised white cell count and C-reactive protein are usual
Radiographic of the abdomen
Gas-filled loop of bowels (paralytic ileus)
Free gas
Serum amylase estimation
For acute pancreatitis (serum amylase >4x normal)
Ultrasound and CT Scan
Used to identify the cause of peritonitis
Peritoneal diagnostic aspiration
TREATMENT
General care of patient
Correction of fluid and electrolyte imbalance
Insertion of nasogastric tube
Broad-spectrum antibiotics
Analgesia (if diagnosis is confirmed as peritonitis)
Operative treatment
SURGERY
To eliminate the source of contamination
To reduce the bacterial contamination
To prevent further complications and sepsis
SYSTEMIC COMPLICATIONS OF PERITONITIS
Bacteraemic/endotoxic shock
Bronchopneumonia/respiratory failure
Renal failure
Bone marrow suppression
Multisystem failure
ABDOMINAL COMPLICATIONS OF
PERITONITIS
Adhesional small bowel obstruction
Paralytic ileus
Residual or recurrent abscess
Portal pyaemia/live abscess
PROGNOSIS
Untreated peritonitis is poor, usually resulting in
death.
With therapy, prognosis is variable, dependent
on the underlying causes.
PREVENTIVE CARE
There is “NO WAY” to prevent peritonitis, since
the diseases it accompanies are usually not
under the voluntary control of an individual.
However, the best way to prevent serious
complications is to seek medical attention as
soon as symptoms appear.
SPECIAL FORMS OF PERITONITIS
Postoperative
Leakage post anastomosis
Anastomosis dehisence
Antibiotic therapu alone is inadequate
In patient on treatment with steroids
Pain is frequently slight or absent
In children
Diagnosis more difficult
Gentle, patient and sympathetic approach is needed
In patients with dementia
Unable to give reliable history
Abdominal tenderness is well localised
Guarding and rigidity are less because abdominal muscles are
often thin and weak
SPECIAL FORMS OF PERITONITIS
Bile peritonitis
Causes of bile peritonitis
Perforated cholecystitis
Post cholecystectomy
Cystic duct stump leakage
Leakage from an accesory duct in the gallbladder 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
SPECIAL FORMS OF PERITONITIS
Starch peritonitis
Found disfavour as a surgical glove lubricant
In sensitive patients, it causes a painful ascites
Laparotomy small granulomas may be found that
contain statch particles
TUBERCULOUS PERITONITIS
Acute and chronic forms
Abdominal pain, sweats, malaise and weight loss are
frequent
Caseating peritoneal nodules are common –
distinguish from metastatic carcinoma and fat necrosis
of pancreatitis
Ascites common, may be loculated
Intestinal obstruction may respond to anti-tuberculous
treatment without surgery
TUBERCULOUS PERITONITIS
Origin of infection:
Tuberculous mesentric lymph nodes
Tuberculosis of the ileocaecal region
A tuberculous pyosalpinx
Blood-borne infection from pulmonary tuberculosis
TUBERCULOUS PERITONITIS
Varieties of tuberculous peritonitis
Ascitic form
Encysted form
Fibrous form
Purulent form (rare)
PNEUMOCOCCAL PERITONITIS
Primary pneumococcal peritonitis may complicate nephrotic
syndrome or cirrhosis in children
Particularly girls between 3 and 9 years of age route of infection:
vagina and fallopian tubes
Route of infection in males blood-borne and secondary to
respiratory tract or middle ear disease
Onset is sudden, pain localised to the lower half of the abdomen
Temperature raise to 39°C
Frequent vomiting
Profuse diarrhea is characteristic after 24-48 hours
Increased frequency of micturation
PNEUMOCOCCAL PERITONITIS
Treatment:
Antibiotic therapy
Correction of imbalance electrolye and dehydration
Early surgery
