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GIS-K-24
Peritonitis Mesenteric Lymphadenitis
Syahbuddin Harahap
Division of Digestive Surgery
Department of SurgeryDepartment of Surgery
Faculty of Medicine
University of North Sumatera
Adam Malik Hospital
Peritoneum•Serous membrane•Lining abdominal cavity•Covers the intra-abdominal organs.
Layers Peritoneum•The outer layer
-parietal peritoneum-parietal peritoneum
•The inner layer -visceral peritoneum.
•The term mesentery-double layer of visceral peritoneum
Subdivisions :•The greater sac
•The lesser sac (or omental )two "omenta":
1. The lesser omentum(or gastrohepatic)
2. The greater omentum2. The greater omentum(or gastrocolic) like an apron, protective layer.
•Greater sac and lesser sacConnected by the epiploic foramen
PeritonitisInflammation of the serosal membrane that lines the abdominal cavity and the organs contained therein often as a result of infection.
Peritonitis are classified as :1. Primary peritonitis2. Secondary peritonitis3. Tertiary peritonitis3. Tertiary peritonitis
Peritonitis are usually divided into1. Generalized peritonitis2. Localized peritonitis
Peritonitis is often caused by:
- Perforation hollow viscus
- Chemically irritating material
Etiology
- Chemically irritating material(blood,pancreatic/gastic juice)
- Infected / Inflammation
Primary peritonitis
No pathologic process in a visceral organ
�Via hematogenous Children
�Translocation of bacteria across the gut wall AscitesIntestinal obstructionIntestinal obstruction
�Ascending infection in femaleGonorrhea Chlamydial infectionspreads into the abdominal cavity.
�Systemic infections tuberculosis
Secondary peritonitis
Related to a pathologic process in a visceral organ
hollow viscus- Perforation - Infected
most common cause of peritonitis, perforations of :most common cause of peritonitis, perforations of :
- the stomach
- intestine
- gallbladder
- appendix
Tertiary peritonitis
Persistent or recurrent infection after adequate initial therapy
• Anastomotic leakage
• Abscess with or without fistulization.
Diagnosis and investigations
• Based primarily on clinical grounds
• No further investigation should delay surgery
Clinical:
The diagnosis of peritonitis is usually clinical.
1. Chief complaint ����Acute abdominal pain
2. Peritoneal irritation � Anorexia and nausea ,vomiting.
3. Fever exceed 38°C 3. Fever exceed 38°C
4. Hypovolemia � Hypotensive
5. Hypothermia � severe sepsis � Septic shock
Peritonitis generally represents a surgical emergency.
On abdominal examination of Peritonitis
1. Position/lighting/draping 2. Inspection�Abd. Distended � Ileus paralyticus
�Keep their hips flexed to relieve the abdominal wall tension.
3. Palpation all four quadrantsTenderness
Rebound tendernessRebound tenderness
Diffuse Abdominal rigidity ("washboard abdomen")
Abdominal Guarding voluntary in response of the abdominal
Inflammatory mass.
4.PercussionTenderness all four quadrants Percuss the liver span � free air5. AuscultationParalytic Ileus � Hypoactive-to-absent bowel sounds.
6 . Digital rectal exam .
Generalized peritonitisTenderness in all direction
Appendicitis Tenderness in the right diection
�Female patients vaginal and bimanual examination �Female patients vaginal and bimanual examination Pelvic inflammatory disease
Mimic certain signs and symptoms of peritonitis.
1. Thoracic processes with diaphragmatic irritation (eg, empyema)
2. Extraperitoneal processes (eg, pyelonephritis, cystitis, acute urinary retention)
3. Abdominal wall processes (eg, rectus hematoma)
WORKUP
Lab Studies:
• Blood test
– leukocytosis (>11,000 cells/mL)
– Blood chemistry may reveal dehydration and acidosis.
• Liver function tests if clinically indicated
• Serum electrolytes
• Renal function
• Amylase and lipase if pancreatitis is suspected
• Urinalysis (UA) is essential to rule out urinary tract diseases (eg,
pyelonephritis, renal stone disease
• Aerobic and anaerobic blood cultures
Complications
• Hypovolaemia shock
-Sequestration of fluid and electrolytes
-Decreased central venous pressure
• Electrolyte disturbances
• Acute renal failure
• Peritoneal abscess
• Abdominal Sepsis may develop � Septic shock
RadiographsPlain films of the abdomen :
•supine •upright � Free air•lateral decubitus positions
Imaging Studies
•lateral decubitus positionsComputed tomography scan
•Diagnosis cannot be established on clinical grounds
•Cannot be findings on abdominal plain films.
Treatment
INFORMED CONSENTGeneral supportive measures :
- Intravenous rehydration- Correction of electrolye disturbances.
Antibiotics- broad-spectrum antibiotics
The exception is spontaneous bacterial peritonitis, which does not The exception is spontaneous bacterial peritonitis, which does not benefit from surgery.
Surgery� Exl .laparotomy � full exploration � Lavage of the peritoneum
Abscess in Pouch of Douglas (Cul de sac abscess )(Pelvic abscesses) DRT : often are palpable as tenderAnterior fullness and fluctuation Male � Rectovesical pouchFemale � Recto-uterine pouch
TreatmentTreatmentDraining these abscesses transvaginally or transrectally is best to avoid the transabdominal approach.
Mesenteric Lymphadenitis
1. Inflammation of the mesenteric lymph nodes. 2. Acute or chronic, depending on the causative agent. 3. Often difficult to differentiate from acute appendicitis.
PathophysiologyMicrobial agents are thought to gain access to the lymph nodes via the intestinal lymphatics.
ClinicalClinical features of associated organ involvement, such as enterocolitis or ileitisAbdominal pain - Often right lower quadrant (RLQ) but may be more diffuse Fever Diarrhea Malaise Malaise Anorexia Upper respiratory tract infection Nausea and vomiting
Physical
Fever (38-38.5°C)
RLQ tenderness - Mild, with or without rebound
tenderness
Rectal tenderness
Rhinorrhea
Hyperemic pharynx Hyperemic pharynx
Associated peripheral lymphadenopathy (usually
cervical) in 20% of cases
CausesStreptococcus beta-hemolytic, Staphylococcus species, Escherichia coli
Streptococcus viridans,
Mycobacterium tuberculosis,
Viruses, such as coxsackieviruses, rubeola virus, and adenovirus
Children with upper respiratory tract infection, has popularized a theory that swallowed pathogen-laden sputum may be the primary source of infection.
Lab StudiesCBC countLeucocytosis exceeding 10,000/µL
Urinalysis � exclude urinary tract infection.
Stool cultures � Diarrheal symptoms
Blood culture � Septicemia
Imaging Studies
CT scanningIn mesenteric adenitis:� lymph nodes to be larger� greater in number� greater in number
CT scanning is also important to exclude other differential diagnoses, especially acute appendicitis.
�Medical Care
Hemodinamic support
Broad-spectrum antibiotics
To quickly identify patients who require surgical interventionTo quickly identify patients who require surgical intervention
�Surgical Care
Signs of peritonitisAppendectomy