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الدكتور حسن عبد هللا العاقولي 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 الدكتور حسن عبد هللا العاقولي 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 . الدكتور حسن عبد هللا العاقولي 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: الدكتور حسن عبد هللا العاقولي 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 الدكتور حسن عبد هللا العاقولي 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.