Peritonitis

By;Abrar Hussain Zaidi

Anatomy of peritoneum

Parietal peritoneum

Visceral peritoneum

Male close peritoneum

Female open peritoneum

Abdominal wall peritoneum

Peritonitis is an inflammation (irritation) of the peritoneum, the membrane that lines the wall of the abdomen and covers the abdominal organs.

DefinitionDefinition

Etiology

Causes of peritonitis

Perforation of bowelChemically irritating

material

Types

Types of peritonitis

Primary peritonitis

Secondaryperitonitis

Dialysis-associated peritonitis

Trauma/

Types

Types of peritonitis

Generlizedvs

locolized

Chemical vs

septic

Acute vs

chronic

Diffuse bacterial infection without loss of integrity of GI tract

E-coli commonest organism involved

Primary peritonitisPrimary peritonitis

Risk factors

-*Liver diseases

-*Chronic renal failure

-*Compromised immune system

-*Pelvic inflammatory diseases

0

10

20

30

40

50

60

70

80

90

100

Gram -ve bacteria

E-coli

K pneumoniae

Pseudomonas species

Proteus species

Streptococcusspecies

Staphylococcusspecies

Anaerobic species

Comman organisms leading to primary pertonitis

•Acute peritoneal infection

secondary to/resulting from

GI perforation /Trauma/other causes [appendicitis]

Sources-intra-abdominal /extra-abdominal

Secondary Secondary peritonitisperitonitis-:-:

SourceCauses

Esophagus Boerhaave syndromeMalignancyTrauma (mostly penetrating) Iatrogenic*

StomachPeptic ulcer perforationMalignancy (eg, adenocarcinoma, lymphoma, gastrointestinal stromal tumor) Trauma (mostly penetratingIatrogenic*

Duodenum Peptic ulcer perforationTrauma (blunt and penetrating) Iatrogenic*

Biliary tract CholecystitisStone perforation from gallbladder (ie, gallstone ileus) or common ductMalignancyCholedochal cyst (rare) Trauma (mostly penetrating) Iatrogenic*

Common Causes of Secondary Peritonitis

SourceCauses

Small Bowel

Ischemic bowelIncarcerated hernia (internal and external) Closed loop obstructionCrohn diseaseMalignancy (rare) Meckel diverticulumTrauma (mostly penetrating

Larg bowelIschemic bowelDiverticulitisMalignancyUlcerative colitis and Crohn diseaseAppendicitisColonic volvulusTrauma (mostly penetrating) Iatrogenic

Causes of Secondary Peritonitis

SourceCauses

Pancreas PancreatitisTrauma (blunt and penetrating) Iatrogenic*

Uterus, salpinx, and ovaries

Pelvic inflammatory disease (eg, salpingo-oophoritis, tuboovarian abscess, ovarian cyst) Malignancy (rare) Trauma (uncommon)

Common Causes of Secondary Peritonitis

Chronic peritonitis

TuberculosisNon-specificDiverticulitisPID

This is an acute or chronic inflammation (irritation and swelling)

of the peritoneum (lining of the abdominal cavity) that occurs in people receiving trauma/post-op/

peritoneal dialysis.

Post traumaticPost traumatic

Treatment typically involves;

Surgery and antibiotics.

In cases associated with peritoneal dialysis, antibiotics may be infused through the dialysis catheter

TreatmentTreatment

Intra abdominal abscess

localized peritonitisDefinition :- collection of pus walled-off from rest of peritoneal cavity by inflammatory adhesions and viscera

Number of bacteria exceed host’s ability to terminate infection

complication --may lead to diffuse bacterial peritonitis

Classification of intra abdominal abscess

Pelvicabscess

Sub phrenic abscess

Mid abdominalabscess

Intra abdominalIntra abdominal abscessabscess

Sub phrenic abscess35% are right sided abscess

25% are left sided abscess

20% are multiple abscess

EtiologyEtiology-: -:

Direct contamination after surgery . Local diseases Direct contamination after surgery . Local diseases or injuryor injury. .

Mortality rate is 25% to 40%Mortality rate is 25% to 40%

Causes of deathCauses of death-: -:

Uncontrolled infectionUncontrolled infection

MalnutritionMalnutrition

Prolong hospitalizationProlong hospitalization

pulmonary embli pulmonary embli nasocomial infectionnasocomial infection

Mid abdominal abscess

Between transverse colon and pelvis

Right lower quadrant abscess

Left lower quadrant abscess

Pelvic abscessusually complication of :-

acute appendicitispelvic inflammatory disease

colonic diverticulitis

Symptoms

abdominal pain dull aching sharp fever chills

loss of appetite nausea vomitinginability to pass gas or feces

Signs

toxic ill lookingtachypnea tachacardia hypotension

abdomengenerlized gaurding rigidity

tenderness all over positive reboundabsent peristalsis

Pancreatitis

Splenic rupture &infarc

Splenic aneurysm

Gastritis

Mi

Pneumonia

Intestinal obstruction

Diverticulitis

Psoas abscess

Ectopic pregnancy

Ovarian cyst

Salpingitis

Ureteral calculi

endometriosis

Gallbladder

Hepatitis hepatic abscess

Peptic ulcer

Pancreatitis

Mi

pneumonia

Appendicitis

Intestinal obstruction

DiverticulitisEctopic pregnancy

Ovarian cyst Salpingitis

Ureteral calculiendometriosis

Investigation

1:-CBC :- leukocytosis2:-RFT3:-Septic work up 4:-Peritoneal fluid sample for chemistry5:-Plain film of abdomen6:-Ultrasonography7:-Computed tomography

Treatment -Principles1:-Control of infection2:- Remove the source/ decontaminate/ Wash toxins/drain3:- Maintain organ system function4:- Control inflammatory process

Medical treatment

1:- systemic antibiotic therapy2:- intensive care with hemodynamic, pulmonary and renal replacement

NPO, IVF, Foley catheter3:-nutrition and metabolic support 4:-inflammatory response modulation therapy

TreatmentEarly control of septic source

Achieved by; Operative treatment Non operative treatment Percutanous drainage Endoscopy/laparoscopy

Systemic treatment Antibiotics Fluids/electrolytes Nutrition

Treatmentoperative management

principles :-1:- Early and definitive source control

2:- Minimize the load of bacteria and toxin from abdominal cavity

second look operation = sever sepsis

Abdominal closure-provisional

LaparoscopyInitial laparoscopic examination of abdomen can assist in elimination of etiology

diagnostic, therapeutic

Prognosis -Primary peritonitis

The overall mortality rate of patients with SBP may exceed 30% if diagnosis and treatment are delayedless than 10% in fairly-well compensated patients with early therapy

Recurrent episodes within 1 year represent 70% of patients the mortality rate approaches 50% long-term antibiotic prophylaxis decreased to less than 20%

Prognosis -Secondary peritonitis Mortality rate less than 5% in simple abscess and uncomplicated SP

More than 30-50% in sever infection

Greater than 90% with quadruple organ failure

Thank you