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Peritonitis

The document provides an overview of peritonitis, including its anatomy, types (primary, secondary, and tertiary), causes, symptoms, and treatment options. It details the structure of the peritoneum, the peritoneal cavity, and the various spaces within it, as well as the pathogens responsible for peritonitis and the complications that may arise. Treatment strategies include antibiotics, surgical interventions, and supportive care, with a focus on the challenges posed by multidrug-resistant infections.

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prer1205
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2 views31 pages

Peritonitis

The document provides an overview of peritonitis, including its anatomy, types (primary, secondary, and tertiary), causes, symptoms, and treatment options. It details the structure of the peritoneum, the peritoneal cavity, and the various spaces within it, as well as the pathogens responsible for peritonitis and the complications that may arise. Treatment strategies include antibiotics, surgical interventions, and supportive care, with a focus on the challenges posed by multidrug-resistant infections.

Uploaded by

prer1205
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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PERITONITI

S
PRESENTED BY:82-91
ANATOMY OF PERITONEUM
• THE PERITONEUM IS A LARGE THIN SEROUS MEMBRANE, WHICH LINES THE
INTERIOR OF THE ABDOMINOPELVIC CAVITY.
• IT IS MADE UP OF A TOUGH LAYER OF ELASTIC TISSUE LINED WITH THE SIMPLE
SQUAMOUS EPITHELIUM AND FORMS THE LARGEST SEROUS SAC OF THE BODY
• THESE LAYERS ARE SEPARATED FROM EACH OTHER BY A POTENTIAL SPACE
CALLED PERITONEAL CAVITY, WHICH IS FILLED WITH A THIN CAPILLARY FILM OF
FLUID
LAYERS:
• OUTER PARIETAL LAYER AND
• AN INNER VISCERAL LAYER
PARIETAL PERITONEUM:
• IT LINES THE INNER SURFACE OF THE ABDOMINAL WALL, UNDER
SURFACE OF DIAPHRAGM AND PELVIC WALL.
• IT IS LOOSELY ATTACHED TO THE OVERLYING WALLS AND CAN BE EASILY

STRIPPED
• OFF.
• IT IS INNERVATED BY THE SOMATIC NERVES, SO PAIN SENSITIVE.
•
• ANTERIOR PERITONEUM IS MOST SENSITIVE WHEN COMPARED TO PELVIC

PERITONEUM.
VISCERAL PERITONEUM:
• IT LINES THE OUTER SURFACE OT THE ABDOMINAL VISCERA, FIRMLY

ADHERENT, CANNOT BE STRIPPED OFF


• IT IS INNERVATED BY AUTONOMIC NERVOUS SYSTEM; HENCE NOT PAIN

SENSITIVE
PERITONEAL CAVITY
:
• IT IS THE POTENTIAL SPACE BETWEEN THE PARIETAL AND VISCERAL
PERITONEUM
• NORMALLY IT CONTAINS 100ML OF CLEAR, STRAW COLOURED FLUID
SECRETED BY THE MESOTHELIOMA CELLS
• IT'S QUANTITY AND QUALITY VARIES IN PATHOLOGICAL CONDITIONS
• IT GOT LUBRICATING FUNCTION , ALLOWING FRICTIONLESS MOVEMENTS OF
ADJACENT PERITONEAL SURFACES
SPACES IN THE PERITONEAL CAVITY:
• PERITONEAL CAVITY BEING LARGEST CAVITY IN THE BODY IS DIVIDED
INTO DIFFERENT SPACES BY LIGAMENTS AND MESENTERIC.

SPACES OF ABDOMEN ARE -


• RIGHT AND LEFT SUBPHRENIC
• SUBHEPATIC
• LESSER SAC
• SUPRAMESENTERIC
• INFRAMESENTERIC
• RIGHT AND LEFT PARA COLIC GUTTERS
• PELVIC
Subphrenic
spaces
LESSER SAC
• THE LESSER SAC (ALSO CALLED OMENTAL BURSA) IS A DIVERTICULUM
OF THE PERITONEAL CAVITY BEHIND THE STOMACH.
• IT COMMUNICATES WITH THE GREATER SAC THROUGH A SLIT-LIKE
APERTURE CALLED EPIPLOIC FORAMEN (OR FORAMEN OF WINSLOW
BOUNDARIES
• ANTERIOR WALL: FROM ABOVE DOWNWARD, IT
IS FORMED BY:
1. (A) CAUDATE LOBE OF THE LIVER,
2. (B) LESSER OMENTUM,
3. (C) POSTEROINFERIOR SURFACE OF THE
STOMACH,
4. D) ANTERIOR TWO LAYERS OF THE GREATER
OMENTUM.
• POSTERIOR WALL: FROM BELOW UPWARD, IT
IS FORMED BY:
1. (A) POSTERIOR TWO LAYERS OF THE GREATER
OMENTUM,
2. (B) STRUCTURES FORMING THE STOMACH BED
EXCEPT SPLEEN ARE:– TRANSVERSE COLON.–
FORAMEN EPIPLOCIUM

• COMMUNICATES WITH THE GREATER


SAC THROUGH A SLIT-LIKE APERTURE
CALLED EPIPLOIC FORAMEN
Control of hemorrhage during
cholecystectomy: If the cystic artery is torn
during cholecystectomy, the surgeon can stop
hemorrhage by compressing the hepatic
pedicle (formed by the right free margin of
lesser omentum), containing portal vein,
hepatic artery and bile duct, between the
index finger and thumb. This is achieved by
inserting the index finger in the foramen of
Winslow and compressing the hepatic pedicle
against it by the thumb
PERITONITI
S
• INFLAMMATION OF THE SEROSAL AND PARIETAL LAYER OF PERITONEUM
DUE TO ACID/BILE/BACTERIAL INFECTION.
• LOCALISED OR GENERALISED.
PRIMARY
PERITONITIS
• IT IS COMMONLY DUE TO PNEUMOCOCCI, AND CAN OCCASIONALLY BE DUE

TO STREPTOCOCCI, HAEMOPHILUS, GONOCOCCUS AND OTHER GRAM-

NEGATIVE ORGANISMS.

• IT IS COMMON IN WOMEN

• IT IS COMMON IN YOUNG GIRLS------3-9 YEARS


• INFECTION USUALLY SPREADS FROM LOWER GENITALS THROUGH

FALLOPIAN TUBES, FROM UPPER RESPIRATORY TRACT INFECTION OR FROM

MIDDLE EAR IN MALES.

• COMMON IN CIRRHOTIC PATIENTS WITH ASCITES AND IS DUE TO

TRANSLOCATION OF GUT BACTERIA OR THROUGH MESENTERIC LYMPHATICS

OR OCCASIONALLY AS BLOOD SPREAD

• 30% OF PATIENTS WITH ASCITES IN CIRRHOSIS WILL DEVELOP SBP


• 90% OF SBP IS MONOMICROBIAL INFECTION DUE TO E. COLI , KLEB SIELLA,

PSEUDOMONAS, PROTEUS ,STREPTOCOCCUS PNEUMONIAE AND

STAPHYLOCOCCUS AND ANAEROBIC MICROORGANIS


• CAN OCCUR IN CHILDREN WITH NEPHROTIC SYNDROME OR SYSTEMIC LUPUS

ERYTHEMATOSUS
• ASCITIC FLUID PROTEIN CONTENT --< 1 G/DL INCREASES THE RISK OF PRIMARY

PERITONITIS
• ASCITIC FLUID WBC COUNT -- >250 CELLS MM3 WITH > 50% CELLS ARE

POLYMORPHONUL CLEAR CELLS SUGGESTIVE OF PRIMARY PERITONITIS


• IT IS UNCOMMON AFTER 10 YEARS OF AGE.

• IT IS COMMON IN MALNOURISHED CHILD AND CHILD WITH NEPHRITIS.

• IT IS ALSO SEEN IN ASCITES, PATIENT WITH INDWELLING CATHETER

FOR PERITONEAL DIALYSIS, PATIENTS WITH PERITONEOVENOUS

SHUNT.

• IT CAN ALSO BE DUE TO CHLAMYDIA, FUNGAL OR MYCOBACTERIAL

INFECTION.

• TC IS VERY HIGH >30,000/MM3 .


TREATMEN
T
• DIAGNOSTIC TAPPING, TUBE PERITONEAL DRAINAGE AND LAPAROSCOPIC

DRAINAGE AND WASH ARE USEFUL METHODS.


• LAPAROTOMY AND PERITONEAL TOILET.
• BROAD SPECTRUM ANTIBIOTICS INCLUDING COMBINATION OF AMINO

GLYCOSIDES, CEPHALOSPORINS AND METRONIDAZOLE.


• LOCAL INSTILLATION OF ANTIBIOTICS, INTO THE PERITONEAL CAVITY TO

ACHIEVE QUICK AND EFFECTIVE RESULTS.


SECONDARY
PERITONITIS
• SECONDARY TO BOWEL INJURY OR VISCERAL PATHOLOGY.
• MC ORGANISM: E.COLI
• DUODENAL PERFORATION AND BURST APPENDICITIS
BACTERIA CAUSING
PERITONITIS
• FROM GIT: E. coli, aerobic Streptococci, Streptococcus faecalis, Staph species.,
anaerobic Streptococci, Klebsiella, Cl.welchii.
• NOT FROM GIT: Gonococcous , Pneumococcous , Chlamydia.
PATHOGENESI
S
LOCALISED
PERITONITIS
• IT IS BASED ON ANATOMICAL COMPARTMENTS.

• THICKENED PERITONEUM, FIBRIN DEPOSITION, OMENTAL

ADHESIONS, REDUCED BOWEL PERISTALSIS.


• RESOLVES BY PROPER THERAPT

• IT MAY FORM ABSCESS: SUBPHRENIC/PELVIC.

• PROGRESSES TO FORM GENERALISED PERITONITIS.


DIFFUSE
PERITONITIS
• IS SEEN DUE TO POOR LOCALISATION

• RAPID PERITONEAL CONTAMINATION.

• VIOLENT PERISTALSIS.

• IMMUNODEFICIENCY STATUS.

• SMALL OMENTUM IN CHILDREN.


TERTIARY
PERITONITIS
TERTIARY PERITONITIS IS DEFINED AS PERSISTENT OR RECURRENT INTRA-
ABDOMINAL 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 THE PATIENT MAY GO IN FOR SYSTEMIC INFLAMMATORY RESPONSE
SYNDROME (SIRS) OR MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS).
• COMMON IN IMMUNOSUPPRESSED INDIVIDUALS.
• INFECTIONS DUE TO E. CAECUM, E. FAECIUM, S. EPIDERMIDIS, P. AERUGINOSA,
C. ALBICANS ARE COMMON IN SUCH PATIENTS.

IT IS DIFFICULT TO DIAGNOSE CLINICALLY CAUSING DELAY IN THERAPY.


INVESTIGATION
S
• CT ABDOMEN

• PLATELET COUNT

• LIVER FUNCTION TEST

• MONITORING OF RENAL FUNCTIONS

• HOURLY URINE OUTPUT ASSESSMENT

• CHEST X-RAY
TREATMENT
• AGGRESSIVE ANTIBIOTIC THERAPY
• ANTIFUNGAL THERAPY
• TPN
• MAINTAINING OF HAEMODYNAMIC STABILITY
• EXPLORATION OF ABDOMEN, THOROUGH WASH
• COLOSTOMY/ILEOSTOMY OR EXTERIORISATION OF BOWEL SEGMENT
• FFP, PACKED CELLS, PLATELETS TRANSFUSIONS MAY BE REQUIRED
• VENTILATOR AND ICU CARE IS OFTEN NEEDED
IT IS DIFFICULT TO MANAGE PATIENT WITH INFECTIONS LIKE CANDIDA,
STAPHYLOCOCCUS EPIDERMIDIS, ENTEROBACTER, PSEUDOMONAS AS THEY
SHOW MULTIDRUG RESISTANT.
COMPLICATION
S
• DIC
• SEPTICAEMIA
• URAEMIA
• HAEMORRHAGE
• PNEUMONIA
• ARDS
THANK YOU

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