peritonitis and intra abdominal abscess.pptx

peritonitis

1. PERITONITIS AND INTRA ABDOMINAL ABSCESS PRESENTER : DR B. SNEHA JUNIOR RESIDENT MOERATOR : DR SALINI RAO ASSISTANT PROFESSOR

2. PERITONEUM Peritoneum is a single layered simple squamous epithelium of mesodermal origin termed mesothelium . Which lines the peritoneal cavity of the body . The surface area is 1.0 to 1.7 m2 approximately that of total body surface area. The mesothelial layer secretes fluid known as peritoneal fluid which gives lubricating function to the peritoneum . In males , the peritoneal cavity is normally closed In females, the peritoneal cavity is opened at fimbrial entrance of fallopian tubes .

3. Parts of peritoneum : Parietal peritoneum – it lines the inner surface of the abdominal wall , under the diaphragm and pelvic wall . It is loosely attached , can be easily stripped of , innervated by somatic nerves so pain sensitive . Visceral peritoneum – it lines the outer surface of the abdominal viscera , firmly adherent ,cannot be stripped off , innervated by autonomic nervous system , hence not pain sensitive .

4. Peritoneal cavity It is the potential space between the parietal and visceral peritoneum . Normally it contains 100ml or clear straw colored fluid secreted by mesothelial cells . Spaces in the peritoneal cavity : peritoneal cavity being the largest cavity in the body it is divided into different spaces by the ligaments and mesenteries .

5. They are 11 ligaments and mesenteries : Falciform ligament Coronary ligament Gastrohepatic ligament Hepatoduodenal ligament Phrenicolic ligament Splenorenal ligament Gastrosplenic ligament Duodenocolic ligament

6. 9. Gastrocolic ligament 10. Transverse mesocolon 11. Small bowel mesentery

7. Intra abdominal spaces are 9 in number they are : Right and left subphrenic Subhepatic Lesser sac Supra mesenteric Infra mesenteric Left and right paracolic gutters Pelvis

8. Functions of peritoneum

9. PERITONITIS Peritonitis is the inflammation of the peritoneum and the peritoneal cavity categorized as localized or diffuse , acute or chronic . Causes of peritonitis :

10. Primary peritonitis – this occurs due to bacterial , chlamydial, fungal or mycobacterial infection in the absence of perforation or inflammation of GI or GU tract . Secondary peritonitis –this occurs in settings of GI or GU tract perforation or inflammation with common causes including acute appendicitis , colonic diverticulitis and pelvic inflammatory disease. Tertiary peritonitis – it occurs after any abdominal surgeries, which are usually severe and the patient may go into SIRS or MODS early, it is defined as recurrent or persistent intra abdominal infection after an adequate treatment for primary or secondary peritonitis usually after 48 hrs.

11. Paths to peritoneal infection : Gastrointestinal perforation – perforated ulcer, appendix, diverticulum. Transmural translocation (no perforation) – pancreatitis , ischemic bowel , primary bacterial peritonitis . Exogenous contamination – drains , open surgery , trauma , peritoneal dialysis. Female genital tract infection- pelvic inflammatory disease Hematogenous spread( rare) – septicemia

12. Localised peritonitis In this peritonitis localized area of peritoneum has become inflamed . If parietal peritoneum is involved , the patient complains of pain somatic pain in the area affected . Vital signs may be normal , but tachycardia and pyrexia are common . The characteristic signs are involuntary guarding ( reflex abdominal wall contraction to reduce further peritoneal irritation) and rebound tenderness . Collectively these signs and symptoms are called as peritonism and the patient is described as peritonitic .

13. If the inflammation occurs to the peritoneum under diaphragm, there is shoulder tip pain ( phrenic pain ). If the inflammation occurs in pelvic peritoneum due to inflamed appendix, salpingitis, abdominal signs may ne limited but there is deep seated tenderness detected by doing digital rectal or vaginal examination. Diagnosis can be done by doing CT , usg , lab biomarkers. Aim of the treatment is to remove the underlying cause. During surgery in localized peritonitis , there is inflamed peritoneum which appears reddened, thickened and has velvety texture. Plaques of yellow/white fibrin may also be found , which causes the looping of intestines and mesentery to adhere to the intestines.

14. Diffuse (generalized) peritonitis It is a life threatening condition . In this not just focal regions , but the whole of the peritoneum of that region is inflamed. It arises due to pressure related perforations of the viscus( obstructed colon) , when large volumes of blood enter the peritoneal cavity ( ruptured aortic aneurysm), or due to perforated duodenal ulcer , or anastomotic leak. Patient describes acute or gradual onset pain , it may be localized initially and then becomes diffuse. The patient is gravely ill looking ( Hippocratic facies) , and usually lies still as possible to minimize the fluid movement within peritoneal cavity. The abdominal muscle undergoes reflex contraction and feels , board like rigidity on palpation.

15. Generalised ileus occurs and the abdomen becomes over distended . Vitals are deranged , patient in advance cases is hypotensive, tachycardia and pyrexia present At first patient may seem confused , drowsy but if cause not treated patient will loose consciousness. Investigations and treatment must be done rapidly , as the salvage time available is limited. An erect chest x ray is useful to identify subdiaphragmatic gas .

16. X-ray chest demonstrating air under diaphragm on right side in intraperitoneal perforation

17. clinical features of peritonitis: Abdominal pain, worse on movement , coughing and deep respiration. Constitutional upset, anorexia, malaise, fever, lassitude Gastrointestinal upset , nausea, vomiting Pyrexia may be present or absent Raised pulse rate Tenderness, guarding , rigidity Pain or tenderness in per rectal or per vaginal examination. Septic shock ,SIRS, MODS.

18. MANAGEMENT OF PERITONITIS: General care of patient Correction of fluid and electrolyte balance Insertion of nasogastric tube and urinary catheter Broad spectrum antibiotic therapy Analgesia Vital support system Surgical treatment of cause : Source control by removal or exclusion of the cause. Peritoneal lavage, with drainage.

19. Acute bacterial peritonitis It most commonly arises due to perforation of viscus of the alimentary tract. Other routes of infection can include the female genital tract and exogenous contamination Some times may include spontaneous peritonitis with streptococcal , pneumococcal or haemophilus influenza

20. Non gastrointestinal causes of acute bacterial peritonitis Pelvic infection via the fallopian tubes is most commonly responsible Most commonly affecting organism is chlamydia species and gonococci. These organisms lead to thinning of cervical mucosa and allow bacteria from vagina to pass into the uterus and oviducts, causing infection and inflammation.

21. Biliary peritonitis It is most commonly seen after cholecystectomy and arises from slippage of clip off from the cystic duct , drainage of bile from accessory cystic duct or perforation of the common bile or hepatic duct. It can also arise after hepatectomy or duodenal surgery, blunt or penetrating hepatobiliary or duodenal trauma. In severe contamination the patient will be extremely unwell and urgent intervention required. Localised collections are treated by percutaneous insertion of drain followed by ERCP to identify the source of bile leak. ERCP enables placement of stent across source of leak . If there is diffuse or high volume contamination, surgical exploration with aim being lavage and drainage.

22. Spontaneous bacterial peritonitis It is some times called as primary bacterial peritonitis. It is an acute bacterial infection of ascitic fluid , it is rare except in patient’s with cirrhosis. Clinical features as of peritonitis with worsening of liver , renal function , hepatic encephalopathy and GI bleed. Diagnosis is made by paracentesis of ascitic fluid: in which neutrophil count of ascitic fluid >250/mm . culture of ascitic fluid is negative . If culture positive most common pathogens include gram negative bacteria usually E.Coli , and gram positive cocci ( streptococci and enterococci) Treatment of SBP should be initiated immediately after diagnosis, with empirical treatment. Choice of antibiotic is third generation cephalosporins, cefotaxime and alternatively quinolones such as ciprofloxacin can be used.

23. Primary pneumococcal peritonitis The incidence is very low and now its rare It may complicate the nephrotic syndrome and cirrhosis in the children , may also affect the normal healthy children . In girls the route of infection is via the vagina and fallopian tubes , whereas blood borne secondary to respiratory or middle ear disease is also possible. It is usually sudden onset with pain in the lower abdomen , raise of temperature with frequent vomitings . After 24 -48 hrs profuse diarrhea s the characteristic feature., associated with increased frequency of micturition.

24. After starting antibiotics , we need to correct the electrolyte imbalance, dehydration , early surgery is required. Laparotomy or laparoscopy may be useful .

25. Tuberculous peritonitis Intraabdominal tuberculosis is more common in the resource poor countries , however its incidence is increasing even in the resource rich countries due to migration and immunosuppression. Mycobacterium avium intracellulare is more prevalent worldwide with widespread increase in HIV co infection. . TB can spread to the peritoneum through gastrointestinal tract via the mesenteric lymph nodes or through the blood , from pulmonary TB, and the fallopian tubes

26. Clinical features : Acute and chronic forms Abdominal pain , sweats , malaise, and weight loss are frequent Ascites common, may be loculated, abdominal distension. Caseating peritoneal nodules are seen , they distinguish from metastatic carcinoma and fat necrosis of pancreatitis .

27. Diagnosis: Abdominal ultrasonography, CT abdomen Ascitic fluid is typically straw coloured exudate with protein >25-30g/l , with white cells >500/ml, lymphocytes >40% Laparoscopy and peritoneal biopsy can be done. Gene Xpert MTB/RIF assay and interferon gamma release assay is diagnostic. Management: Supportive (nutrition, and hydration) With systemic anti TB therapy Surgery may be required for specific complication such as intestinal obstruction

28. Familial mediterranean fever Also known as familial paroxysmal polyserositis, autosomal recessive inherited inherited autoinflammatory syndrome. Associated with mutations in MEFV gene found in Arab, Armenian and Jewish people It is characterized by abdominal pain , tenderness mild pyrexia. Duration of attack is 24 hrs with complete remission but exacerbation in regular interval Peritoneum is inflamed in the splenic and gall bladder vicinity , and the treatment is colchicine during attack.

29. INTRAABDOMINAL /INTRA PERITONEAL ABSCESS Intraperitoneal abscess is the collection of pus in the peritoneal cavity, it normally arises secondary to another pathology. Inflammation of any viscus , if unresolved will lead to hypersecretion of peritoneal fluid, which later progresses to frank pus. Hence abscess formation commonly accompanies inflammation of abdominal viscus and based on location of organs.

30. Site of abscess formation : Appendicitis- pelvic abscess Infections of female genital organs- pelvic abscess Diverticulitis- left paracolic and pelvic abscess Complications of gall bladder disease- sub hepatic and right sub phrenic abscess Pancreatitis may result in lesser sac abscess Inadequately drained peritonitis , anastomotic leak and internal fistula causes intra loop abscess.

31. Clinical features of an abdominal / pelvic abscess: Symptoms: Malaise , lethargy, failure to recover from surgery as expected Anorexia and weight loss Sweats, rigors Abdominal / pelvic pain. Symptoms from local irritation , shoulder tip / hiccoughs( subphrenic), diarrhoea and mucus ( pelvic), nausea and vomiting ( any upper abdominal). Signs: Increased temperature and pulse, swinging pyrexia Localised abdominal tenderness, mass formation.

32. Investigations : Plain x-ray erect abdomen- elevation of hemidiaphragm , air fluid levels , soft tissue masses, obliteration of psoas shadow. Ultrasound of abdomen CT scan of abdomen and pelvis is the investigation of choice.

33. Treatment Adequate fluid and electrolyte management ,resuscitation and support Any abscess less than 5 cm in diameter , normally resolves with intravenous antibiotics . As the antibiotics take effect , there is decrease in the fever spikes , monitoring of CRP levels should be done serially to see the disease progression . Any abscess greater than 5cm in diameter requires percutaneous aspiration /drainage or surgical intervention

34. Prerequisites of percutaneous drainage : Anatomically safe route Done in well defined unilocular abscess cavity Needs surgical and radiological evaluation Surgical backup if technical failure Complications with percutaneous drainage : Enterocutaneous fistula formation, Bacteraemia , sepsis Vascular injury Enteric puncture

35. Surgical drainage : Done if failure of percutaneous drainage Diffuse infection Content of the abscess is too thick Access is impossible Surgical approach , it can done can be done by laparoscopically or open approach Bowel may be matted and difficult to separate to reach the abscess. all the regions of peritoneal cavity should be accessed for drainage of any residual collections. Entire small intestines along with the mesentery should be exposed to ensure that there are no residual interloop abscess.

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