Download Peritoneum

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Peritoneum
peritoneum
 Types: visceral,parietal –pain ,nerve amount
 Function:pain,lubrication,absorption,immune,
 ,fibrinolytic
 Peritoneal cavity largest cavity in body =skin
 Peritoneal fluid few ml pale yellow
 Upwad movement of peritoneal fluid responsible for occurrence of many
subphrenic abscess
 Large absorption capacity used in peritoneal dialysis
 Parietal peritoneum defects heal not from edges but by develop of new
mesothelial cells so large defects heal as rapidly as small defects
Causes of peritoneal inflammation
 Bacterial,chemical,ischemic,trauma,allergic
Peritonitis
Acute peritonitis:
 Mostly bacterial
 Usually polymicrobial both aerobic and anaerobic,commonest are E.
coli,anaerobic
strept,and
bacteroides.Less
frequently
cl.welchi,staph.,klebsiella pneumoniae
 Exception
is
primary
spontaneous
peritonitis=pure
streptococcal,pneumococcal,or hemophilus bacteria.
Non-GI causes of peritonitis:
 Chlamydia,gonococcus,beta-hemolytic strep.,pneumococcus,.M.tuberculosis
 Immunodeficient-M. avium intracellulare MAI
Paths to peritoneal infection
 GI perforation
 Exogenous contamination
 Transmural bacterial translocation
 Female genital tract infection
 Hematogenous-rare
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Bacteriology:
 NO. of bacteria within GIT increase from above downward,and in case of
obstruction,achlorhydria,diverticulua increase proximal colonisation.
 Biliary and pancreatic tract normally free from bacteria
 Even with nonbacterial peritonitis.often amatter of hours transmural spread of
organisms often develop bacterial peritonitis.
 Most duodenal and many gastric perforations are initially sterile at first.while
intestinal perforation usually infected from start.
 Proportion of anaerobic to aerobic organisms increase with passage of time.
Localised peritonitis:
factors favour localisation of peritonitis.
 Anatomical : Abdominal compartment ,paracolic gutter ,posture
 Pathological: Adhesion ,decrease peristalsis ,greater omentum .
 surgical :Drains.
Diffuse peritonitis
Factors may favour diffuse peritonitis
 Speed of peritoneal contamination .
 Perforation proximal to obstruction or from sudden anastamotic seperation –
sever.
 Stimulation of peristalsis : food ,purgative, enema.
 Virulence of MO .
 Young children / small omentum .
 Distrubtion of localised collection /rough handling .
 Immuno deficency.
Clinical feature:
Localised peritonitis :that of initial condition , temperature,pulse rate ,abdominal
pain, vomiting
 Most important sign is guarding & rigidity with posative release sign .
 Shoulder tip pain.
 In pelvic peritonitis abdominal sign often slight , deep tenderness but rectal or
vaginal examination reveal marked tenderness .
Fate of localised peritonitis:
 With appropriate treatment usually resolve.
 20% abscess .
 Infrequently localised peritonitis become diffuse .
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Diffuse peritonitis:
 Early:pain,vomiting,tenderness,rigidity
 Tenderness and rigidity are diminished or absent in pelvic peritonitis or
peritonitis in lesser sac.
 Pelvic peritonitis may complain urinary symptoms.
 Bowel sounds ,pulse rate,temperature.
 Late: fate of diffuse peritonitis:
 Resolution
 Localisation
 Deterioration:abdomen silent,distend
 Circulatory failure,hypocratic facies,unconciousness but these rarely seen
today because early DX and TX.
Diagnosis:
 Leucocytosis is usual but often delayed
 Peritoneal diagnostic aspiration:helpful but usually unnecessary.
 Plain X-RAY of abdomen:paralytic ileus,free gas on erect CXR or lateral
decubitus.
 S. amylase
 US.and CT scan
Treatment:
A-General care of patient:
 Fluid and electrolyte correction .plasma protein,IV feeding.
 GI decompression.
 Antibiotic therapy.
 Fluid balance chart,PCV,s,electrolyte,urea check.
 Analgesia ,sitting up position.
 Vital system support
B-Specific treatment of cause:
 Surgery,nonoperative.
 C-peritoneal lavage.
 Prognosis:mortality rate of diffuse peritonitis is 10%
 Complication of peritonitis:
 A-systemic:endotoxic
shock,bronchopneumonia,respiratory
failure,renal
failure,bone marrow suppression,MOFS.
 B-abdominal:adhesional
S.B.obstruction,paralytic
ileuse,abscess,portal
pyemia-liver abscess.
 Intraperitoneal abscess:
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Intraperitoneal abscess:
Common sites: subphrenic,paracolic,RIF,pelvic.
Pelvic abscess:
 Commonest site of intraperitoneal abscess.?
 Causes:appendicitis,salpingitis,diffuse peritonitis,anastomotic leak.
 May attain considerable proportion before being recognized and without
serious constitutional disturbance.
 Most characteristic symptoms are diarrhia and pass mucus in stool.it is even
pathognomonic sign.
 Rectal exam reveal bulging of anterior rectal wall .
Treatment:
 Left to nature a proportion bursts into rectum with nearly always rapid
recovery.
 If this not occur it should be drained.in women vaginal drainage through
posterior vaginal fornex is often chosen ,in other cases rectal drainage.
 In uncertain cases pus can be confirmed by US or CT scan or by needle
aspiration through rectum or abdominal wall into swelling.
 Laparotomy almost never necessary,rectal drainage is preferable to
suprapubic ?
 Drainage can also done percutanously or via rectum or vagina under US or
CT scan guide.
Subphrenic abscess:
 Anatomy:4 peritoneal and 3 extraperitoneal spaces.Rt subhepatic is deepest
and commonest space.bare area ?
 Clinical feature:
 Nonspecific,pus somewhere pus no where else pus under diaphragm .
 Common history
 Sometime there is epigastric fullness and pain,shoulder tip pain.
 Persistent hiccup may presenting symptom.
 Swinging pyrexia usually present.
 Abdominal exam,chest exam is important because in majority of cases
collapse of lung or evidence of basal effusion or empyema is found.
Investigation:
 wbc count,
 Plain XRAY:gas or pleural effusion,on screening:often
diaphragm(tented diaphragm)and its movements impaired.
 US or CT scan is IX of choice ,permit early detection.
 Radiolabelled white cell scaning:when other image failed.
elevated
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 DDX:pylonephritis,amebic abscess,pulmonry collapse and pleural empyema.
Treatment:
 Percutaneous drainage tube under US or CT guide.with instillation of antibiotic
and irrigation via tube.
 Aspirating needle through pleura and diaphragm should be avoided.
 If operation is necessary incision is made over site of maximum tenderness or
odema or redness over site of swelling.
 If no swelling is apparent,subphrenic space should be explored via anterior
subcostal or posterior after removal of outer part of 12th rib but pleura must not
be opened.
 Aim of all techniques of drainage is to avoid dissemination of pus into
peritoneal or pleural cavities.
 All loculi broken and tube drain inserted with antibiotic cover.