Peritonitis

this presentation includes anatomy physiology function of peritoneum ,also includes cause of peritonitis its severity ,various scoring system investigation and treatment.It includes the recent advancement and latest articles from latest books of surgery.

1. peritonitis By Dr. Abhishek Kumar 2 nd year resident, Dept. of Surgery National Institute of Medical Sciences and Hospital

2. The peritoneum is single layered simple squamous epithelium of mesodermal origin lying on thin connective tissue stroma. The surface area is 1.0 to 1.7 m 2 approximately that of total body surface area. In male peritoneal cavity is sealed whereas in female it is open to the ostia of fallopian tube. Consist of two part: 1.Parietal layer : covers anterior ,lateral and posterior abdominal wall surface and inferior of diaphragm 2.Visceral layer : covers most of surfaces of intraperitoneal organ and anterior aspect of retroperitoneal organ . peritoneum

3. Peritoneal cavity The peritoneal cavity is subdivided into interconnected compartments by 11 ligaments and mesenteries. The peritoneal ligaments includes: Coronary ligaments Gastrohepatic ligaments Hepatoduodenal ligament Falciform ligament Gastrocolic ligament

4. 6. Duodenalcolic ligament 7. Gastrosplenic ligament 8. Splenorenal ligament 9. Phrenicocolic ligament 10. Transverse mesocolon Small bowel mesentry

5. Anatomy

6. These structures partition the peritoneal cavity into nine potential spaces which are : Right & left subphrenic Subhepatic Supramesentric & inframesentric Right & left paracolic Lesser sac Pelvis These spaces , ligaments and mesenteries direct the circulation of fluid in peritoneal cavity and thus useful in predicting the route of spread of infection and malignancies.

7. The peritoneum is bidirectional semipermeable membrane that control the amount of fluid in peritoneal cavity . Normally it contain only less than 100 ml of sterile serous fluid. Microvilli are present on the apical surface of peritoneal membrane which markedly increases the surface area and promotes the rapid absorption of fluid from cavity to lymphatics and portal and systemic circulation. The circulation of fluid in peritoneal cavity driven in part by movement of diaphragm . physiology

8. There are intracellular pores in peritoneum called STOMATA present in inferior surface of diaphragm, communicating with lymphatics pool of diaphragm . Lymph flows from diaphragmatic lymph channel through subpleural to regional to thoracic duct. Relaxation of diaphragm during expiration opens the stomata and negative intra thoracic pressure draws fluids and particles like bacteria . Contraction of diaphragm during inspiration propel the lymph through channels into thoracic duct. These mechanism is so called diaphragmatic pump drive .

9. The circulatory pattern of peritoneal fluid toward diaphragm and into central lymphatic is consistent with rapid appearance of sepsis in patients with generalized intra-abdominal infection and occurrence of abscesses distant from primary disease. When parietal peritoneum defects are created , healing occurs not from the edges but by the development of new mesothelial cells throughout the defect , so large defect heals as rapidly as small defect.

10. Function of peritoneum

11. peritonitis Peritonitis is inflammation of peritoneum and peritoneal cavity caused by generalized or localized infection. Cause of peritonitis:

12. Primary peritonitis : it results from bacterial , chlamydial , fungi or mycobacterium infection in absence of perforation of GI tract. Secondary peritonitis : it occur in gastro intestinal perforations. Spontaneous bacterial peritonitis : is defined as bacterial infection of ascitic fluid in the absence of any intra-abdominal source of infection and is monomicrobial . Usually associated with cirrhosis , nephrotic syndrome . In adult most common pathogen is E.coli or Klebsiella pneumonae. In child age group nephrogenic or hepatogenic ascites group A streptococci ,Staphylococci or Streptococci pneumonae .

13. Paths of peritoneal infection

14. Bacteria from gastrointestinal tract The number of bacteria in gut lumen is normally low until distal small bowel is reached. The bilary and pancreatic tract is also normally free from bacteria. In case of diseased condition there is stasis and overgrowth of bacteria (obstruction, chronic and acute motility disturbances ). Gram negative bacteria contain endotoxins (lipopolysaccharides)in their cell wall that have multiple toxic effect on host like release of TNF from leukocytes , systemic absorption may leads to endotoxic shock

15. Non gastrointestinal cause of peritonitis Pelvic infection via fallopian tube is responsible for high proportion of non gastrointestinal infection . Most common organism is Chlamydia spp and Gonococci . These organisms leads to thinning of mucous cervical plug and allow bacteria from vagina causing infection and infalmamtion .

16. Microbilogy

17. Localized peritonitis Anatomical and pathological factors responsible for localization of peritonitis: The potential spaces , ligaments and mesenteries. Clinical course of localized peritonitis is determined in part by the manner in which adhesions form , around the affected part. Glistening appearance of peritoneum become red velvety , flakes of fibrin appears and loop of intestine adherent to each other , there is outpouring of exudates rich in leukocytes and plasma proteins which soon become turbid then frank pus.

18. Peristalsis retarded in affected bowel which prevent further distribution of infection. The grater omentum by enveloping and become adherent to inflamed structure further reducing the spread of infection.

19. Diffuse (generalized) peritonitis Factors favoring development of diffuse peritonitis: Speed of peritoneal contamination. Eg . If an inflamed appendix perforates before localization there is efflux of content in the whole cavity. Stimulation of peristalsis by ingestion of food or enema hinders localization. The virulence of infective organism Young age due to small omentum Disruption of localised collection by injudicious handling Immune deficiencies like AIDS or steroids .

20. Clinical features Localised peritonitis : Initial sign and symptom depends on underlying condition visceral inflammation leads to pain , specific GI symptom like malaise anorexia and nausea Peritoneal inflammation : pathognomic sign is guarding , rebound tenderness and rigidity for protecting viscus Increase temperature Tachycardia

21. 2. Diffuse peritonitis : EARLY : Severe abdominal pain worsen on movement or breathing Patient lie still Tenderness and generalised guarding on palpation when peritonitis affects ant abdominal wall Infrequent bowel sound still be heard for few hours but ceases with onset of paralytic ileus

22. LATE : If localisastion or resolution doesn’t occur Abdomen becomes rigid (generalised ) Distention with no bowel sound Circulatory failure cold clammy extremities , sunken eyes, dry tongue, irregular pulse , anxious face Finally unconscious

23. Diagnostic aids Bedside : Urine dipstix for UTI ECG (If diagnosis in doubt for cause abdominal or cardiac ) Blood investigations : 3. Baseline urea & creatinine 4. CBC TLC 5. SERUM AMYLASE & LIPASE 6. BLOOD GROUPING

24. IMAGING : ERECT CHEST Xray for free subdiaphragmatic gases SUPINE ABDOMINAl Xray for dilated bowel loops In patients who are too ill for erect radioimaging a lateral decubitus film is required MULTIPLANAR CT for cause of peritonitis USG INVASIVE : PERITONEAL DIGNOSTIC ASPIRATION has little value in era of high quality CT imaging.

25. Gas under diaphragm

26. Management General care of patient Correction of fluid loss and circulating volume Patient are frequently hypovolemic with electrolyte disturbance . Plasma volume must be restored and monitored for ongoing losses Special measure for cardiac , pulmonary , renal support (If septic shock present)including CVP monitoring. Urinary cathterisation and gastrointestinal decompression through nasogastric tube until paralytic ileus has resolved.

27. Antibiotic therapy : Parenteral broad spectrum (aerobic and anaerobic) Analgesia : patient must be nursed in sitting up position and must be relieved of pain before and after operation . Epidural infusion is an excellent approach if possible Specific treatment of cause : Patients in whom specific treatment not guided by CT scanning , early surgical approach is preferred to wait & watch policy. In peritonitis caused by pancreatitis or salpengitis or in case of primary peritonitis of streptococcal or pneumococcal origin non surgical treatment is preferred.

28. Prognosis and complication Several scoring systems have been developed in the past two decades, like APACHE-II SCORE by Kanus et al, SEPSIS SEVERITY SCORE by STEVENS , BIONOMIAL CLASSIFICATIONS by MEAKINS , MULTIPLE ORGAN FAILURE SCORE by GORIS et al . & MANNHEIM PERITONITIS INDEX by BILLING et al. These scoring systems scientifically compare the effectiveness of different treatment regimens, health facilities and to inform patient’s relatives with greater objectivity. They may also indicate individual patients who may require a more aggressive surgical approach . Diffuse peritonitis carries mortality rate of 10 percent in modern era.

29. Complication :

30. Special forms of peritonitis Bile peritonitis : cause

31. Spontaneous bacterial peritonitis Acute bacterial infection of ascitic fluid ,its rare except in patient with cirrhosis affecting 1.5-3.5 percent. Clinical features as of peritonitis with worsening liver and renal function ,hepatic encephalopathy and GI bleed. Diagnosis :made by paracentesis neutrophil count of ascitic fluid > 250/mm 3 ascitic culture is negative in 60 percent 40 percent culture positive most common organism is E.coli , Streptococci or enterococci

32. Treatment is third generation cephalosporin cefotaxim , alternative is amoxicillin or quinolones . Complication of SBP is septic shock , GI bleed , hypoalbuminia . PRIMARY PNEUMOCOCCAL PERITONITIS In healthy children , girl aged 3 to 9 yrs route of infection is via vaginal and fallopian tube and in boy the infection is blood borne secondary to respiratory infection . Clinical onset is sudden with pain lower abdomen and temperature raise . After 24-48 hours profuse diarrhoea is characteristics and increase in frequency of urination.

33. Leukocyte count > 30000 /ul , 90 percent polymorph suggestive of pneumococcal peritonitis rather than appendicitis. Management : Antibiotics and correction of dehydration and electrolyte imbalance Early laparotomy odourless sticky exudates confirm diagnosis The prevalence has declined greatly and now its rare .

34. Tubercular peritonitis Intra abdominal tuberculosis is very common in resource poor country but also rising in resource rich country due to migration and immunosuppression where mycobacterium avium-intracellulare is prevalent with widespread increasing HIV virus co infection. Abdomen is involved in 11 percent of patients with extra pulmonary TB. Ileocaecal involvement is most common. Tuberculosis can spread to peritoneum through GI tract via mesenteric lymph node or directly through blood ( milliary )

35. Clinically ascites is the presenting complaint , multiple tubercular deposits present in both the layer of peritoneum Diagnosis : USG/ CT to detect ascites + lymphadenopathy + diffuse thickening of peritoneum ,mesentery or omentum . Ascitic fluid : Straw color Exudate (protein >25g/l) WBC > 500 mm 3 Lymphocyte > 40 percent Management is supportive (nutrition ,hydration )with systemic antituberculous drugs.

36. Periodic peritonitis Familial Mediterrean fever (periodic peritonitis) characterized by abdominal pain and tenderness ,mild pyrexia , polymorphonuclear leukocytosis , pain in thorax and joint. Duration of attack is 24 hrs with compete remission but exacerbation in regular interval. Most patient had undergone appendectomy in childhood and is familial disease . This disease is limited to Arab, Armenia and cause is mutation in MEFV(Mediterrean fever)gene. Peritoneum is inflamed in splenic and gall bladder vicinity , treatment is COLCHICINE during attack.

37. Peritonitis associated with chronic ambulatory peritoneal dialysis 6 percent of patient with chronic renal failure undergo peritoneal dialysis Refractory or recurrent peritonitis is most common cause of technical failure Patient presents with pain abdomen , fever , leucocyte count of fluid >100 with 40 percent neutrophils. 70 percent caused by staph. Epidermidis and fungi are also important cause . Treatment is antibiotics and removal of catheter and resumption of hemodialysis.

38. Carcinoma of peritoneum PRIMARY TUMORS is rare and in most cases their origin is not from the layers but adjacent structures.eg lipoma of appendices epiploicea . Asbestos is recognized cause. SECONDARY TUMORS : Common terminal event in many cases of carcinoma of abdominal organ , both the layers of peritoneum studded with secondaries . Three main form 1.) descrete nodules 2.) plaque 3.) diffuse adhesions late stage of disease which give rise to frozen pelvis. Gravity determines the distribution of malignant cells

39. Differential diagnosis is abdominal tuberculosis Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is treatment of choice. PSEUDOMYXOMA PERITONEI : Rare condition occur frequently in women Abdomen is filled with yellow jelly which are encysted . Associated with mucinous cystic tumor of ovary and appendix Treatment is laparotomy and scooping out jelly mass and complete cytoreduction (right hemicoloectomy ,spleen , gallbladder, greater and lesser omentum along with stripping of peritoneum ovary and uterus in female) and HIPEC with mitomyocin C.

40. Thank you