أ.د. عبد المنعم الخطيب

THE PERITONEUM ,OMENTUM ,

MESENTERY& RETROPERITONEAL SPACE

THE PERITONEUM is divided into 2parts --VISCERAL&PARIETAL The parietal peritoneum is richly supplied with nerves when irritated produce severe PAIN &accuraely localised to the affected area The visceral peritoneum is poorly supplied with nerves,pain arising is vague & badly localised

FUNCTIONS OF THE PERITONEUM

PAIN PERCEPTION(PARIETAL) VISCERAL LUBRICATION FLUID &PARTICULATE ABSORPTION INFLAMMTORY &IMMUNE RESPONCES FIBRINOLYTIC ACTIVITY

•Surgical physiology:- It is the largest cavity in the body, the surface area (2m2) - It composed of flattened polyhedral cells (mesothelium), one layer thick, resting upon athin layer of fibroelastic tissue.The peritoneum is supported by a small amount of areolar tissue with network of lymphatics & rich in capillaries.- In health, afew free peritoneal fluid (50ml) is found. The fluid is pale yellow & contains lymphocytes & leucocytes- intraperitoneal fluids travel in an upward direction towards the diaphragm aided by – ve pressure during expiration.

-particulate matter & bacteria are absorbed within a few minutes into the lymphatic network through a number of “pores” within the diaphragmatic peritoneum.- This upward movement is resposible for the occurrence of many subphrenic abscesses. The peritoneum has the capacity to absorb large volumes of fluid: this ability is used during peritoneal dialysis in the treatment of renal failure.* The peritoneum can also produce an inflammatory exudate when injured

Causes of a peritonealInflammatory exudate:1- Bacterial infection, ---appendicitis, tuberculosis2- chemical injury, ------ bile peritonitis.3- Ischaemis injury, ---- strangulated bowel, vascular occlusion.4- Direct trauma -------- operation.5- Allergic reaction -------- strach peritonitis* defects in the parietal peritoneum heal very rapid not from edge but by development of new mesothelial cells throughout the surface of the defect. So the large defects heal as rapidly as small defects.

ACUTE PERITONITISACUTE PERITONITIS

Invation ofInvation of

the peritoneum by pyogenic organismsthe peritoneum by pyogenic organisms.

There are 3 main types * secondary peritonitis

* primary peritonitis

* tertiary peritonitis

BACTERIOLOGYBACTERIOLOGY From the alimentary canal :two or more strains: E.coli,aerobic &anaerobic streptococci ,bacteroides,klebsiella,staphylococci&clostridium

Not from the alimentary canal: gonococci, beta –haemolytic streptococci, pneumococci,&M.Tuberculosis

PATHS to peritoneal infection

Gastrointestinal perforation:----perforated ulcer,diverticular perforation

Exogenous contamination ----drains ,open surgery,trauma

Transmural bacterial translocation ---inflammatory bowel disease,appendicitis,ischaemic bowel .

Female genital tract infection :--pelvic inflammatory diseases.

Haematogenous spread :---septicaemia

PATHOLOGY -------- Localised Diffuse

1-LOCALISED PERITONITIS Occurs when the inflammatory process becomes circumscribed &walled of

FACTORS FAVOUR FACTORS FAVOUR LCALISATIONLCALISATION

1- Anatomical :the peritoneal cavity is divided into subphr enic spaces &the greater sac. The greater sac is divided into the pelvis & the peritroneal cavity proper .the cavity is divided into supracolic & infracolic compartments by the transverse colon &mesocolon. When supracolic compartment overflows as in gastric ulcer perforation it does so over the colon-----to infracolic by the way of paracolic gutter.

Posture can assist in directing collections into the pelvis as in ( Sherren,s regime)

2-Pathological :-- Adhesions from around the affected organ .---Inflammed peritoneum loses its glistening appearances & becomes reddend & velvety .----Flakes of fibrin appear & cause coils of intestine to become adherent .---Serous fluid rich in leucocytes &antibodies accumelates & becomes turbid --- changes to frank pus.Peristalsis is retarded in the affected part helps in preventing distribution of the infection.*The omentum envelops becoming adherent to inflammed area (policeman of the abdomen).

3-Surgical:

Drains—red- rubber are known to be a cause of increased exudates & a route of bact. Infection.

Factors that tend to cause DIFFUSE Peritonitis

1-Sudden perforation of hollow viscus so that the defence mechanisms have no time to come into action.

2-Ingestion of food, or even water by stimulating prestaltic action ,hinders localisation ,also purgatives &enema .

3-Suppression of reflex rigidity by strong sedatives.4—The virulence of the infecting organism is so great.5---In children ,the omentum is small.6---Deficient natural resistant (immune deficiency)from drugs (steroids), disease (AIDS) or infancy &old age7---Injudicious &rough handling of localised collections (app.mass,or pericolic abscess).

CLINICAL FEATURES Localised peritonitis:--

symptoms---↑↑temperature ↑,pulse rate,&pain associated

with vomiting

Signs:guarding, & rigidity over the area of the abdomen.-- shoulder pain in case of sub phrenic inflammation.

Diffuse peritonitis:*INITIAL phase: server pain made worse by moving or breathing --- vomiting ---tenderness & rigidity --- paralytic ileus.

INTERMEDIATE phase: Peritonitis may resolve , the pulse slows, pain & tenderness diminish leaving silent abdomen, it may be localized --- producing one or more abscesses with over lying swelling & tenderness.

TERMINAL phase: resolution or localization have not occurred --- the abdomen remains silent.

-- Abdomen distension.- Circulatory failure: cold clammy extremities, sunken eyes , dry tongue, thready pulse, anxious face (HIPPOCRATIC facies), unconsiousness.* DIAGNOSIS: Blood picture, -- peritoneal aspiration (DPL) – plain X-rays, -- ultrasonography –serum amylase estimation, an isotope scan.

* Treatment: early surgical intervention is to be preferred to a “wait & see” policy.General care of patient: I.v. fluids --- nasogastric tube --- antibiotics – analgesics --- oxygen. --- Exploratory laparotomy. – peritoneal lavage.

CONSERVATIVE TREATMENT:

     1. Primary peritonitis

     2. localised

     3.Moribund patient

PROGNOSIS :diffuse peritonitis carries a mortality about 10% .

The lethal factors are:1-Bacterial toxaemia 2-paralytic ileus 3-brochpneumonia 4-electrolyte imbalanc 5-renal failure 6-undrained collection 7-bone marrow suppression 8-MOF.* Postoperative peritonitis has a mortality 50% .* Faecal peritonitis---- 75%

PERITONEAL ABSCESSPERITONEAL ABSCESS

Failure of resolution after successful localisation of acute peritonitis leads to formation of intraperitoneal abscess.

II- Iliac abscess:- Iliac abscess:1- One the right side: from acute appendicitis, & perforated duodenal ulcer

2- On the left side: diverticulitis &ulcerative colitis.3-On either sides :-- iliac adenitis –perinephric,&osteomylitis of iliac bone CLINICAL PICTURECLINICAL PICTURE---Deep pain ,tenderness swelling &rigidity in the iliac fosa, fever ,vomiting, constipation .pointing through abd. Wall----red&oedematous.TREATMENT :1-Conservative if fail-----2—Drain

II-PELVIC ABSCESS:--Collection of pus in rectovesical pouch in male& in Douglas pouch in female.Aetiology :1-pelvic appendicitis 2-localization of diffuse peritonitis3- lesions of pelvic organs .4-osteomyelitis of pelvic bones.

Clinical picture:History of primary infection –deep pain –fever---diarrhaea ---mucus in stool --“the passage of mucus ,occuring for the first time in a patient who has or recovering from peritonitis is pathognomonic of pelvic abscess

Rectal examination:Rectal examination:PR.—PR.—tense,tender,cystic swelling.tense,tender,cystic swelling.

TREATMENT:

1-Suprapubic extraperitoneal incision

2-posterior colpotomy---if pointing in the vagina

3- through the anus.

III-SUBPHRENIC ABSCESSES1-RT.ant. intraperitoneal space above: diaphragm below:liver post.:coronary lig. Ant.:abd.wall Left:falciform lig.

Infected from: Gall bladder,liver.stomach,or

duodenum. 

2-RT.post. intraperitoneal space: (Morison,s pouch) ant.: liver post.:kidney &diaphragm sup.:coronary lig. Infected by: Appendix,colon,duodenum

3-RT.EXTRA PERITONEAL SPACEBounded by:above &

Below} 2 layers of coronary lig. Ant.: bare area of the liver Post.:the diaphragm Left: I.V.C. Infected by: liver, kidney ,or pleura.

4- LEFT ANT. INTRAPERITONEAL SPACE : Above :diaphragm Post.:lt.triangular lig.,liver,lesser Om.,stomach. Ant.:abd. Wall MediallyMedially: falciform lig. Infected by : Splenectomy---gastrectomy.

5-left POST.intra peritoneal space (lesser sac)Ant.: caudate lobe of liver,lesser om.

&stomach. Post.:diaphragm,pancreas,&t.colon MediallyMedially: I.V.C.,foramen of Winslow

LaterallyLaterally:gastrosplenic ligament6-LEFT EXTRAPERITONEAL SPACE lies around the upper pole of the kidney -----left perinephric space.AETIOLOGY:Occurs as residual abscess after diffuse peritonitis. --75% located on the Rt. Side as acomplications of: appendicitis ,perforated duodenal ulcer or cholecystitis

---left sided abscess ,may result from ; pancreatitis, perforated gastric ulcer, leakage from gastrectomy,&inf.haematoma

CLINICAL PICTURECLINICAL PICTURE Aphorism “Pus somewhere ,pus nowhere else,pus under diaphragm”Subphrenic abscess should be suspected whenever a hectic pyrexia develops or persists after the treatment of any inflammatory lesions.Inspection impaired movement of chestPalpation Tenderness over lower ribs

Upper abdominal swellingPercussion :dullness over the base of the lung ,if the abscess contains gas---4 percussion zones 1-normal lung resonance 2-dullness of effusion 3-resonance of gas 4-liver dullness Auscultation: impaired air entery with crepitations.

Diagnosis:Diagnosis: 1- Blood exam. ---leucoytosis2- Plain x-ray ----elevateddiaphragm, obliterated costophrenic angle & gas under diaphragm3- Ultrasonography

TREATMENTTREATMENT

Surgical drainage 1-post.subpleural approach. 2-ant. Extraperitoneal approach.D.D. pyelophlebitis ,tropical abscess, Pulmonary collapse & empyema

Special forms of peritonitis:Special forms of peritonitis: 1-Post operative peritonitis 2- Bile-peritonitis. 3- Tuberculous peritonitis:

Acute tuberculous peritonitis chronic tuberculous peritonitis

Abdominal pain, fever, Night sweat, abd.Mass

Origin of infectionOrigin of infection 1-Tuberculous mesentric lymph nodes 2- T.B. of ileo caecal region. 3- A tuberculous pyosalpinx. 4- Blood-borne from pulmonary T.B. (Miliary type)

4- Clinical varieties 1- Ascitic form: Pale straw –coloured fluid--onset is insidious.Loss of energy --- facial pallor--pain is absent---abdominal discomfort, constipation or diarrhea

Inspection: Dilated veins, shifting dullness, cong. Hydrocele in children, & umbilical h. Palpation Transverse solid mass can be detected (rolled – up greater omentum)

2- Encysted (loculated)formD.D. Ovarian cyst in female mesentric cyst in children TTT.. Evacuation.

3- FIBROUS (plastic) form: Widespread adhesions, act as blind loop-steatorrhea, wasting, &abd. Pain TTT.: excision,plication, & chemotherapy.4- PURULENT form:Multiple abscesses, fistulae formation* SCLEROSING peritonitis: practolol, B blockers* Peritoneal bands & adhesions.* Granulomatous peritonitis: starch, talc & silicate.

(II)(II)THE PERITONIUM, THE PERITONIUM,

OMENTUM,MESENTERY& OMENTUM,MESENTERY& RETROPERITONEAL SPACERETROPERITONEAL SPACE

ASCITES :An excess of serous fluid within

the peritoneal cavity.it can be recognised clinically when the

amount exceeds 1500 ml

MECHANISM OF ASCITES:The balanced effects of colloid osmotic

pressure & hydrostatic pressures control the exchange of fluid b\w the peritoneal

fluid &capillaries*Protein- rich fluid enters the peritoneal

cavity when capillary permeability to protein is increased, as in peritonitis

&carcinomatosis peritonei

***Capillary pressure may increased due to generalised water retention

cardiac failure, constrictive pericarditis ,or vena caval

obstruction .**Capillary pressure is raised selectively in the portal venous system as in portal cirrhosis or

extrahepatic venous obstruction

***Plasma colloid osmotic pressure may be decreased in patients with

reduced intake, diminished absorption, abnormal losses or defective protein synthesis as in

cirrhosis.

CLINICAL FEATURES := The abdomen is distended with fullness

of the flanks.= Dullness to percussion.

= Shifting dullness is present ---- absent in a very large accumulation of fluid .

=Fluid thrill is transmitted from one side to the other. Fluid aspiration is useful.

D.D . enormous ovarian cyst.

TYPES: 1--- Due to congestive heart failure The commonest

cause--- due to chronic Venous stasis,--- with engorged

neck vv. --light yellow serum of low sp. G.(1010)

2—Due to hepatic or biliary disease:-In cirrhosis there is obstruction to

-Venous out flow of the liver.-Lymph flow may be increased

-In the Budd—Chiari syndrome—thrombosis or obst. Of hepatic vv.

3—Tuberculous ascites: -The fluid is clear & pale yellow, -High sp.G.(1020) ,rich in lymphocyte -Culture or animal inoculation—TB. 4—Malignant ascites: -Dark yellow,blood stained fluid with -high sp.G. –CANCER cells may be detected by microscopic ex.

5- Chylous ascites: -Milky fluid due to excess chylomicrons. -Most cases are due to malignancy, usually lymphoma. Other causes, cirrhosis, T.B., filtariasis nephrotic syndrome, abdominal trauma, const. Pericarditis, sarcoidosis & cong. Lymphatic abnormality.The condition is rare – the prognosis is poor The patient should put on a fat – free diet.

6- Nutritional ascites:

-- Due to starvation & hypoproteinemia7- Renal ascites: -- Due to albuminuria & alteration in the pressure.8- Chronic constrictive pericarditis: (Pick’s dis.) Peritoneal & pleural effusions due to engorgement of the venae cavae --- due to diminished capacity of the RT. Side of the heart.

9-Meig’s syndrome: Ascites & pleural effusion associated with solid fibroma of the ovary.Treatment --- treatment of the underlying cause --- paracentesis abdominis - Dietary sodium restriction to 200mg \ day --- DIURETICS. --- Permanent drainage of ascitic fluid --- Peritoeovenous shunts (Lee-Veen shunts) or (Denevers shunt)

NEOPLASMS OF THE PERITONIUM

1-   Carcinoma peritonei :

-Common terminal event in many cases of carcinoma of the stomach, colon , ovary, breast,& bronchus.

The peritoneum is studded with secondary growths. Peritoneal cavity becomes filled with blood- stained ascitic fluid.

-Peritoneal metastases ( discrete nodules, plaques,diffuse adhesions--- frozen pelvis)

D.D. T.B. tubercles- peritoneal hydatidsTTT.--- instillations of radioactive Gold &chemocytotoxic agents( methotrexate)-- Tamoxifen can dramatically ameliorate ascites due to breast cancer.

2—Pseudomyxoma peritonei :*More frequent in females. – the abdomen is filled with yellow jelly ,due to rupture of a pseudomucinous cyst of the ovary or due to rupture of mucocele of the appendix.- It is painless -- it is locally malignant-there is no impairment of general health for a long time -The mass is localized when arises from the appendix.TTT.--- laparotomy—scooping of the jelly &removal of the primary focus.In recurrent cases –radioactive isotopes& interferon.

3-Mesothelioma:-As in the pleural cavity – it is highly malignant--Asbestos is a recognized cause.-- clinically – may mimic puboprostatic carcinoma-- It is not radiosensitive & alkylating agents – remission.--Recent multiple regimes of chemo cytotoxic agents have been reported as curative for early forms of malignant mesothelioma.

THE GREATER OMENTUMTHE GREATER OMENTUMRutherford morisonRutherford morison called it “ the called it “ the

abdominalabdominal PolicemanPoliceman””

Torsion of the omentum :

-Arare emergency ---acute abdomen.--It is usually mistaken for appendicitis--It occur due to adhesion to a hernia or old focus of infection.—rarely to fatty infilteration ,cysts or tumours

C\P : ---middle –aged ,obese male. -tender lump may be present -the abdomen is rigid -sudden onset of acute abd. Pain &severe shock.TTT Excision of the strangulated omentum..

Acute non specific mesenteric adenitisAE. –remains unknown. -may be viral infection.in 25% respiratory infection precedes the attack-- It is self –limiting disease.--Removal of the appendix reduce the incidence of further attack.

PATHOLOGY:

-Small increase in the amount of peritoneal fluid.-ileocaecal mesenteric lymph nodes are enlarged.& mesentery are congested &oedematous.

Clinical features:

--childhood 3—10 years -Sometimes in teenage girles (nurses syndrome) -- central abdominal pain associated with circumoral pallor.-- vomiting is common –no alteration of bowel habits.

EXAMINATION --abdominal tenderness along the mesentery--- increased temp. 38.5 c-shifting tenderness + Ve---- PR. Tender.--leucocytic count > 10-12000\mmD.D. : -acute appendicitis.- Brucellosis—enlarged lymph nodes of the neck ,axillary, &groin TTT. Conservative , but it is safer to remove the appendix.

TUBERCULOUS MESENTERIC LYMPHADENITIS:”tabes mesentrica”-- Affects young children –tubercle bacilli reach the mesentric glands by way of Peyers patches—the diseased glands heal spontaneously &may become calcified--primary tuberculous complex)--Sometimes thedisease remains active and give rise to pain & wasting---hence the name.

C\F: Fever ----- wasting ---TB. Toxaemia --recurrent attacks of abdominal pain -vomiting &constipation or diarrheaEXAM. Deep tenderness & slight rigidity in the RT. Iliac fossa.--- palpable glands.X-RAYS--- calcified glands as irregular mottled radio-opaque shadows which may be mistaken for urinary calculi

COMPLICATIONS :1—T.B. peritonitis 2- Intestinal obst. due to adhesions3-Pseudo—mesenteric cyst due to collection of caseous material.TTT. Surgical drainage & chemotherapy.

MESENTERIC CYSTS

Pathology --TRUE: 1-lymphatic

2—Enterogenous

3—Dermoid (teratoma)

4-Hydatid

5-Urogenital remnant.

FALSE :Encysted haematoma --Cold abscess. -- Degenerating t. --Gas –cyst.

Chylolymphatic cyst : The commonest ,arises in congenitally misplaced lymphatic tissues .More frequently in the mesentery of the ileum -- filled with clear lymph or chyle-- unilocular

Enterogenous cyst : --Arises from a diverticulum of the mesenteric border or from duplication of the intestine.--Has a thicker wall & it is lined by m.m.---The content is mucinous.C\P: In the second decade of life ----A painless abdominal swelling

Tillaux’s traid :1- a fluctuating swelling is palpable near the umbilicus.2- It moves freely in a plane at right angle to the attachment of the mesentery.3- There is a zone of resonance around and band of resonance across the swelling.- Recurrent attacks of abdominal pain with or without vomiting.--- An acute abdominal catastrophe arises as a result of:

1- torsion of that portion of the mesentery containing cyst.

2- Repture of the cyst, often due to a comparatively trivial accident

3- Haemorrhage into the cyst.

4- InfectionRadiology ----- Ultrasonogrophy

TTT. Enucleation -- Excision of the cyst with part of intestine

NEOPLASM OF THE MESENTERYBenign: -- Lipoma --- fibroma --- fibromyxomaMalignant : --- Lymphoma

--- Secondary carcinoma

The Retroperitoneal spaceThe Retroperitoneal space- Pus or blood in the retroperitoneal space tends to track to the corresponding iliac fossa.-- Pus frequently develops from a renal or spinal source & is sometimes tuberculous “cold abscess”* Retroperitoneal haematoma:* Retroperitoneal haematoma:-- May be caused by: fractured spine, leaking abd. Aneurysm, acute peritonitis or a ruptured kidney.

** Retroperitoneal cyst :--Unilocular or multilocular -- Derived from a remnant of the Wolfian duct.--- filled with clear fluid--- teratomatous cyst--- sebaceous materialD.D.---- Hydronephrosis------ tumours.TTT.------ EXCISION

Idiopathic retroperitoneal fibrosis-Idiopathic ( Ormonds disease)--- chronic inflammation-- extravasation of urine-- blood or intestinal contents --- trauma--- aortic aneurysm ---- drugs ( beta blockers,chemotherapy)--- malignancy- carcinoids, metastases

---Familial cases are involving – mediastinal fibrosis ,sclerosing cholangitis, Riedle’s thyroiditis & orbital pseudotumourC\P:ureteric obstruction, renal failure .TTT.--- treat the cause with poor prognosis

Retroperitoneal neoplasms

Ret.lipoma---sarcomaFrom lymph nodes—adrenals---

kidneys-nervous tissues.