Peritonitis

General overview of Peritonitis

1. PERITONITIS Sandeep Baral
LMCTH, Final year

2. Anatomy Perietoneum : It is a serous membrane lining the abdominal cavity. Outer fibrous tissue layer, inner mesothelial cell layer. The surface area of its lining membrane is 2m.sq in an adult Closed sac in males, open at the ends of fallopian tubes in females. PARTS OF PERITONEUM Parietal peritoneum Visceral peritoneum PERITONEAL CAVITY It is the potential space between the parietal and visceral peritoneum. Normally it consists of <100ml of clear, straw colored fluid. It lubricates the viscera allowing easy movement and peristalsis.

3. Function of peritoneum IN HEALTH Visceral lubrication Fluid and particulate absorption IN DISEASE Pain perception Inflammatory and immune responses Fibrinolytic activity The peritoneum has the capacity to absorb large volumes of fluid, this ability is used during peritoneal dialysis in the treatment of renal failure

4. Peritonitis Peritonitis is defined as inflammation of the parietal and serosal layer of peritoneum either due to chemicals like gastric acids/bile or due to bacterial infection which may be localized or generalized.

5. Causes of peritoneal inflammation: Bacterial : gastrointestinal and non-gastrointestinal Chemical : eg ; bile, barium Traumatic : operative handling Ischemic : strangulated bowel, vascular occlusion

6. Types of acute peritonitis Peritonitis can be chemical or bacterial or initially chemically induced later bacterial. TYPES Primary 2. Secondary 3. Tertiary Can also be classified as: Localized Generalized

7. Primary : Common in cirrhotic patient with ascites , as spontaneous bacterial peritonitis(SBP) Common in young girls between 3 to 9 years. Results from bacterial, fungal or mycobacterial infection in absence of GI perforation. 90% of SBP infection is monomicrobial : E.coli( 40%) Commonly due to Pneumococci, ocassionly due to streptococci and hemophilus and othe gram negative( E.coli) Ascitis fluid WBC count if more than 250 cells/mm3 with more than 50% cells are polymorphonuclear cell suggestive of primary peritonitis. Total count is very high > 30,000/mm3

8. . Secondary: It occurs in GI perforation Duodenal perforation and brust appendicitis are commonest cause. E.coli is most common organism involved.

9. Tertiary: Defined as persistent/ recurrent intraabdominal infection after an adequate treatment for primary or secondary peritonitis usually after 48 hours. It occurs after any abdominal surgeries which is usually severe and patient may go in for SIRS/ MODS early. Common in immunocompromised individuals

10. Paths to peritoneal infection Gastrointestinal Perforation : e.g. perforated ulcer, appendix, diverticulum Transmural Translocation : e.g. pancreatitis, ischemic bowel, primary bacterial peritonitis Exogenous contamination : e.g. drains, open surgery, trauma, peritoneal dialysis Female genital tract infection : Pelvic inflammatory disease Hematogenous : septicemia

11. CAUSES OF PERITONEAL INFLAMMATION Gastrointestinal: Perforation of bowel Spontaneous/transmural translocation of bacteria Pancreatitis

12. Non-Gastrointestinal Female genital tract: PID, Torsion Peritoneal dialysis Surgery Perforating injury to abdomen Most common cause of peritonitis in adult male peptic ulcer perforation

13. Microorganisms in peritonitis Gastrointestinal Source Other sources E.Coli Chlamydia trachomatis Streptococci Nisseria gonorrhea Enterococci Hemolytic streptococci Bacteroides spp Staphylococci Clostridium spp Streptococcus pneumonia Klebsiella pneumoniae Mycobacterium Tuberculosis Most common bacteria During the phase of peritonitis is E.coli During abscess formation is Bacteroides fragilis

14. Pathogenesis

15. Clinical Features Abdominal pain, worse on movement, coughing and deep respiration Constitutional upset: anorexia, malaise, fever, lassitude GI upset: nausea and vomiting Pyrexia( may be absent) Raised pulse rate Tenderness: guarding/rigidity/rebound of abdominal wall Pain/tenderness on rectal/vaginal examination Absent / reduced bowel sounds Eventually leading to Hippocrates facies Septic shock, SIRS, and MODS in later satges

16. Investigations BLOOD Total Leucocyte count: increased Amylase(if 4 times normal value then significant) Lipase Urea and Creatinine Electrolytes

17. Imaging Plain x-ray abdomen Erect: gas under diaphragm Supine: ground glass appearance CT scan abdomen

18. Invasive Diagnostic laparoscopy Diagnostic peritoneal lavage

19. Differential diagnsosis Pancreatitis Intestinal Obstruction Ruptured Ectopic Pregnancy Acute mesenteric ischemia

20. Principle of therapy in peritonitis To control source of infection To eliminate bacteria and sepsis To maintain vital organ functions- Cardiac, Pulmonary and Renal Nutrition and metabolic support

21. MANAGEMENT GENERAL CARE OF THE PAIENT Correction of fluid and electrolyte loss and circulating volume Urinary catheterization and nasogastric drainage insertion Antibiotics therapy Systemic antibiotic therapy Analgesia Vital system support

22. SURGICAL TREATMENT Exploratory Laparotomy Midline vertical incision with wide exposure Suction and collection of pus for culture& sensitivity Inspect for cause Bowel perforation: perforation closure Intestinal obstruction: Resection & anastomosis Appendicitis: appendicectomy Peritoneal wash Place drain and Tension suture

23. Post operative management Proper critical care ( icu ) Ventilatory support; monitoring vitals with urine output, TLC, DLC, blood urea, serum creatinine, LFT Proper fluid and electrolyte management Prevention of DVT

24. Complications SYSTEMIC COMPLICATIONS Septic sock Systemic Inflammatory Response Syndrome Multi-organ dysfunction syndrome Death

25. ABDOMINAL COMPLICATIONS Paralytic ileus Residual or recurrent abscess Portal pyaemia Adhesional small bowel obstruction

26. REFRENCES Bailey and love’s short practice of surgery 27 th edition SRB’s manual of Surgery 5 th edition

27. THANK YOU!