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P E R I T O N I T I SFAISALGHANISIDDIQUIMBBS; FCPS; PGDIP-BIOETHICS; MCPS-HPE
PROFESSOR OF SURGERY &DIRECTOR, PROFESSIONAL DEVELOPMENT CENTREJ I N N A H S I N D H M E D I C A L U N I V E R S I T Y
LEARNING OBJECTIVES
• Nature and functions of the peritoneal membrane
• Causes of peritonitis• Clinical features of peritonitis• Investigations • Management• Complications of peritonitis
LEARNING OBJECTIVES
• Nature and functions of the peritoneal membrane
• Causes of peritonitis• Clinical features of peritonitis• Investigations• Management• Complications of peritonitis
STRUCTURE OF PERITONEAL MEMBRANE
• Lined by mesothelium (flattened polyhedral cells)• Mesothelium rests on a thin layer of fibroelastic tissue• FE tissue is supported by areolar tissue rich in
lymphatics and capillaries
PARTS OF PERITONEAL MEMBRANE
• Visceral peritoneum• Parietal peritoneum
FUNCTIONS OF PERITONEAL MEMBRANE
• Visceral lubrication• Pain perception• Inflammatory and immune response• Bacteria and particulate absorption
LEARNING OBJECTIVES
• Nature and functions of the peritoneal membrane
• Causes of peritonitis• Clinical features of peritonitis• Investigations• Management• Complications of peritonitis
DEFINITION OF PERITONITIS Inflammation of the peritoneal membrane
CAUSES OF PERITONITIS
Bacteria: gastrointestinal and non-gastrointestinalChemicals: bile, barium, urine, bloodAllergy: cornstarch Trauma: operations, traumaIschaemia: strangulated bowel
SOURCES OF BACTERIA
GASTROINTESTINALGastrointestinal perforation: perforated ulcer, appendix, diverticulumTransmural translocation: pancreatitis, ischaemic bowel
NON-GASTROINTESTINALExogenous: trauma, surgery, drainsFemale genital tract: pelvic inflammatory diseaseHaematogenous: sepeticemia
MICROORGANISM IN PERITONITIS
GASTROINTESTINALE. ColiKlebsiella pneumoniaestreptococciClostridiumBacteroides BLOOD
StaphylococciHemolytic streptococciStreptococcuspneumoniae
FEMALE GENITAL TRACTChlamydia trachomatisNeisseria gonorrheae
OTHERMycobacterium tuberculosisFungus
CAUSES OF BILE PERITONITIS
Perforated acute cholecystitisPostcholecystectomy• Cystic duct stump leak• Accessory duct in gall bladder bed• Bile duct injury• T-tube drain dislodgement
Other operations• Leaking duodenal stump• Leaking biliary-enteric anastomosis
LEARNING OBJECTIVES
• Nature and functions of the peritoneal membrane
• Causes of peritonitis• Clinical features of peritonitis• Investigations• Management• Complications of peritonitis
CLINICAL FEATURES -SYMPTOMS
• Abdominal pain• Nausea, vomiting• Lassitude• Fever• Constipation
CLINICAL FEATURES -SIGNS
• Fever• Tachycardia• Abdominal distension• Rebound tenderness• Tenderness• Guarding and rigidity• Sluggish or absent bowel
sounds
Hippocratic Facies-Sunken eyes-Drawn and anxious face-Cold, clammy skin-Dry tongue
LEARNING OBJECTIVES
• Nature and functions of the peritoneal membrane
• Causes of peritonitis• Clinical features of peritonitis• Investigations• Management• Complications of peritonitis
LAB INVESTIGATIONS
• Blood CP• Urea & electrolytes• Serum amylase• Blood grouping and cross-
match
X-RAYS
• Erect Chest X-ray• Lateral decubitus• Supine X-ray abdomen
CT SCAN ABDOMEN
Helps identify the cause of peritonitis
LEARNING OBJECTIVES
• Nature and functions of the peritoneal membrane
• Causes of peritonitis• Clinical features of peritonitis• Investigations• Management• Complications of peritonitis
MANAGEMENT OF PERITONITIS
General management of the patient
Specific treatment of the cause
GENERAL MANAGEMENT OF THE PATIENT
• Correction of fluid / electrolyte imbalance• Urinary catheterization• NG intubation• Antibiotics• Analgesia• Position of patient
SPECIFIC TREATMENT OF THE CAUSE
• If the cause of peritonitis is amenable to surgery, operation must be carried out as soon as the patient is fit
• Remove the cause• Peritoneal lavage and drainage to remove all
seropurulent exudate
LEARNING OBJECTIVES
• Nature and functions of the peritoneal membrane
• Causes of peritonitis• Clinical features of peritonitis• Investigations• Management• Complications of peritonitis
COMPLICATIONS OF PERITONITIS
• Systemic complications• Bacteraemic / endotoxic shock• SIRS / MODS• Death
• Local complications• Residual abscess• Portal pyaemia / liver abscess• Adhesions / intestinal obstruction