PERITONITIS.pptx

PERITONITIS

1. PERITONITIS

2. Peritonitis is inflammation of the peritoneum either a portion or all of the parietal and visceral, surfaces of the peritoneal cavity.

3. Peritonitis may be either Septic or aseptic, Bacterial or viral, Primary or secondary, Acute or chronic.

4. Most surgical peritonitis is secondary to bacterial contamination from the gastrointestinal tract.

5. Primary peritonitis refers to inflammation of the peritoneal cavity without a documented source of contamination.

6. ROUTES OF BACTERIAL INVASION 1. Direct invasion either due to ( i ) penetrating injury of the abdomen or (ii) due to perforation of some part of the gastrointestinal tract or (iii) due to insertion of foreign material, drain, dialysis tube etc.

7. 2. Local extension from ( i ) a neighbourhood inflamed organ e.g. cholecystitis , appendicitis etc. or (ii) migration through the devitalised gut wall e.g. strangulated hemia or (iii) via the fallopian tubes. 3. Through blood stream e.g. general septicaemia.

8. CAUSING ORGANISMS A mixed or polymicrobial bacterial flora usually is present in patients suffering from suppurative peritonitis. The most common offending organisms are E. coli, Anaerobic bacteroides , Anaerobic and aerobic streptococci, Enterococci and ciostridia . Less frequently staphylococci and Klebsiella pneumoniae may be seen.

9. CLINICAL FEATURES. Localised peritonitis The signs and symptoms of the causative lesion are the main features. There will be complaint of pain at or near the causative lesion. As the pain increases, vomiting is often complained of.

10. CLINICAL FEATURES. On examination The most important feature is localised tenderness. As soon as the local peritoneum is involved there will be guarding and rigidity of the abdominal wall with rebound tenderness. The pulse rate will rise along with the body temperature.

11. CLINICAL FEATURES. If the pelvic peritoneum is involved due to salpingitis or inflamed appendix in the pelvic position, abdominal signs will be minimal, but tenderness will be elicited in rectal and vaginal examinations. With conservative treatment majority of the localised peritonitis cases resolve. Very occasionally localised peritonitis may become diffuse peritonitis mainly in untreated cases.

12. CLINICAL FEATURES DIFFUSE OR GENERALISED PERITONITIS The clinical feature of this condition can be conveniently described under 3 stages. 1. The FIRST STAGE is known as peritonism . 2. The SECOND STAGE is known as the stage of reaction. 3. The THIRD STAGE is the stage of diffuse peritonitis.

13. FIRST STAGE The first stage is known as peritonism i.e. irritation of the peritoneum. This is due to irritation of the peritoneum caused by perforation or inflamed viscus near about little pain is severe and is made worse by breathing and movement . It is first experienced at the site of the lesion and gradually spreads all over the abdomen. The patient may or may not vomit

14. On examination, the patient usually lies still. There is little change in the pulse and temperature. Tenderness, rigidity and muscle guard are constantly present over the site of the lesion. It must be remembered, in this context, that in case of pelvic peritonitis or peritonitis of the lesser sac there is hardly any tenderness or rigidity of the anterior abdominal wall.

15. So rectal and vaginal examination along with palpation of the flanks are highly important. Infrequent bowel sounds will be heard as the paralytic ileus has not set in. Diagnosis should be made at this stage, as if the condition is allowed to continue the chance of survival of the patient will be minimised. Two features are important for diagnosis at this stage viz. onset of pain with dramatic suddenness and presence of muscle guard and rebound tenderness.

16. SECOND STAGE SECOND STAGE is known as the stage of reaction. At this stage the irritant fluid becomes diluted with the peritoneal exudate . The intensity of the symptoms dwindles, although the fire is still burning under the ashes. The patient feels comfortable and nothing is more diplorable than the attending doctor sharing the patient’s comfort.

17. On examination muscle rigidity continues to be present though it may be softer the other two new features at this stage are obliteration of liver dullness and appearance of shifting dullness. Paralytic ileus sets in with silent abdomen on auscultation. Rectal examination will still elicit tenderness in case of pelvic peritonitis in the rectovesical or rectouterine pouch.

18. At this stage straight X-ray in sitting posture will reveal gas under the diaphragm in 70% of cases.

19. THIRD STAGE THIRD STAGE is the stage of diffuse peritonitis. At this stage the patient has gone a step further towards the grave. The pinched and anxious face, shunken eyes and hollow cheeks — the so called facies hippocratica is quite characteristic of this condition.

20. FACIES HIPPOCRATICA

21. On examination the pulse rate rises and becomes low in volume . There is persistent vomiting . The abdomen becomes silent and increasingly distended. There is board-like rigidity of the abdomen. The patient finally collapses into unconsciousness.

22. SPECIAL INVESTIGATIONS 1. Serum amylase estimation may show raised level in case of peritonitis due to perforated duodenal ulcer, acute pancreatitis etc. There will be high leucocyte count.

23. SPECIAL INVESTIGATIONS 2. Examination of peritoneal aspirate is not always necessary, though it may be helpful in certain cases of peritonitis. Presence of pus indicates bacterial peritonitis. Bile stained fluid indicates perforated duodenal cancer. Blood in the aspirate indicates intraperitoneal bleeding or acute pancreatitis. In latter case there will be high amylase level.

24. SPECIAL INVESTIGATIONS 70% of cases. If the patient is too ill to be seated, a lateral decubitus film is also useful. In late cases there may be dilated gas-filled loop of bowel with multiple fluid levels in third stage, which indicates paralytic ileus .

25. MANAGEMENT The management includes both therapeutic and diagnostic efforts. While therapeutic efforts are directed to resuscitate the patient. Diagnostic efforts should be continued to find out the exact cause of peritonitis.

26. Conservative treatment This in fact is the preoperative preparation which includes (1) fluid resuscitation and correction of electrolyte imbalance. (2) Nasogastric intubation for decompression. (3) Antibiotics. (4) Ventilatory support.

27. 1. FLUID RESUSCITATION The patients are usually hypovolaemic with disturbed electrolytes. Large volumes of fluid may be needed very rapidly till blood volume and urine output are restored. Till the central venous pressure (CVP) reaches the level of 10 cm of water, fluid administration should be at a rapid rate. The most frequent mistake made is that the rate of initial fluid administration is too slow.

28. 1. FLUID RESUSCITATION The slow rate is undertaken for fear of precipitating congestive cardiac failure. If CVP is monitored, there is no chance of occurrence of congestive cardiac failure. A central venous catheter should be placed through the subclavian or internal jugular vein to assess intravenous replacement. Fluid administered must include crystalloid to replace water and electrolytes.

29. 1. FLUID RESUSCITATION Colloids (albumin or plasma) should also be given to restore an effective volume quickly. Plasma protein depletion needs correction as inflamed peritoneum leaks protein continuously. Whole blood or packed red blood cells are administered, if needed, to correct anaemia and to maintain an adequate red cell mass.

30. 2. NASOGASTRIC INTUBATION Decompression is performed by nasogastric intubation to evacuate the stomach and reduce accumulation of additional air in the paralysed bowel. Urinary catheterisation is also important to monitor urinary output. Oral feeding is absolutely prohibited till the bowel sounds return, tenderness disappears and the abdomen becomes soft following resolution of peritonitis.

31. 2. NASOGASTRIC INTUBATION Vital signs such as temperature, blood pressure, pulse and respiration rate are recorded every 4 hours or more often if needed. Biochemical evaluation which includes measurements of serum electrolytes, glucose, creatinine and alkaline phosphatase and a urinalysis should be performed as required.

32. 3. ANTIBIOTICS Antibiotics that are known to be effective against the full spectrum of aerobic and anaerobic gastrointestinal bacteria should started as soon as possible, as the acutal organism may not be known. Antibiotics that are effective against E. coli are mostly used. These are cephalosporins , aminoglycosides , cefainycin and chloramphenicol.T etracyclineand ampicillin are also active against many coliforms . The drugs effective against bacteroids are clindamycin , chloramphenicol , metronidazole and the newer cephalosporins

33. 4. VENTILATORY SUPPORT Oxygen is administered to help the response to the increased metabolic demands of peritonitis which are so often associated with impairment of pulmonary ventilatory function mild hypoxia. A nasal catheter supplying oxygen at about 5 litres per minute is sufficient prior to induction of anaesthesia. Assessment of respiratory function should be made clinically noting the work of breathing and apparent tidal volume.

34. STEROIDS ANALGESICS should not be administered to patients until diagnosis is made.

35. OPERATIVE MANAGEMENT Operation is mainly aimed at to correct the underlying cause. Every attempt should be made to perform the operation as soon as possible . PERITONEAL TOILET DRAINAGE CLOSURE

36. Complications 1 . Paralytic ileus 2 . Intestinal obstructions due to peritoneal adhesion. 3 . Residual abscesses

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