Peritonitis

Peritonitis By; Abrar Hussain Zaidi

Anatomy of peritoneum Parietal peritoneum Visceral peritoneum Male

close peritoneum

Female

open peritoneum

Abdominal wall

peritoneum

Definition

Peri toni tis is an inf lamma ti on (ir ri ta ti on ) of the per it oneum, the membr ane t ha t lines the w al l of the abdom en and co ver s the abdomi nal or gans.

Etiology Causes of peritonitis

Perforation of bowel

Chemically irritating material

Types Types of peritonitis

Primary peritonitis

Secondary peritonitis

Trauma/

Dialysis- associated peritonitis

Types Types of peritonitis

Generlized vs locolized

Chemical vs septic

Acute vs chronic

Primary peritonitis

Diffuse bacterial infection without loss of integrity of GI tract E-coli commonest organism involved

Risk factors Liver diseases-* Chronic renal failure-* Compromised immune system-* Pelvic inflammatory diseases-*

100 90

E-coli

80 K pneumoniae

70 60

Pseudomonas species

50

Proteus species

40

Streptococcus species Staphylococcus species Anaerobic species

30 20 10 0 Gram -ve bacteria

Comman organisms leading to primary pertonitis

Secondary -:peritonitis •

Acute peritoneal infection secondary to/resulting from GI perforation /Trauma /other causes [appendicitis] Sourcesintra-abdominal /extra-abdominal

Common Causes of Secondary Peritonitis

Source

Causes

Esophagus

Boerhaave syndrome Malignancy Trauma (mostly penetrating) Iatrogenic*

Stomach

Peptic ulcer perforation Malignancy (eg, adenocarcinoma, lymphoma, gastrointestinal stromal tumor) Trauma (mostly penetrating Iatrogenic*

Duodenum

Peptic ulcer perforation Trauma (blunt and penetrating) Iatrogenic*

Biliary tract

Cholecystitis Stone perforation from gallbladder (ie, gallstone ileus) or common duct Malignancy Choledochal cyst (rare) Trauma (mostly penetrating) Iatrogenic*

Causes of Secondary Peritonitis

Source

Causes

Small Bowel

Ischemic bowel Incarcerated hernia (internal and external) Closed loop obstruction Crohn disease Malignancy (rare) Meckel diverticulum Trauma (mostly penetrating

Larg bowel

Ischemic bowel Diverticulitis Malignancy Ulcerative colitis and Crohn disease Appendicitis Colonic volvulus Trauma (mostly penetrating) Iatrogenic

Common Causes of Secondary Peritonitis

Source

Causes

Pancreas

Pancreatitis Trauma (blunt and penetrating) Iatrogenic*

Uterus, salpinx, and ovaries

Pelvic inflammatory disease (eg, salpingo-oophoritis, tuboovarian abscess, ovarian cyst) Malignancy (rare) Trauma (uncommon)

Chronic peritonitis Tuberculosis Non-specific Diverticulitis PID

Post traumatic This is an acute or chronic inflammation (irritation and swelling) of the peritoneum (lining of the abdominal cavity) that occurs in people receiving trauma/post-op/ peritoneal dialysis.

Treatment Treat ment typi call y involves; Surger y and anti bi oti cs . In cases associated with peritoneal dialysis, antibiotics may be infused through the dialysis catheter

Intra abdominal abscess localized peritonitis Definition :- collection of pus walled-off from rest of peritoneal cavity by inflammatory adhesions and viscera

Number of bacteria exceed host’s ability to terminate infection complication --may lead to diffuse bacterial peritonitis

Classification of intra abdominal abscess Mid abdominal abscess

Intra abdominal abscess

Pelvic abscess

Sub phrenic abscess

Sub phrenic abscess are right sided abscess 35% are left sided abscess 25% are multiple abscess 20% -: Etiology Direct contamination after surgery . Local diseases . or injury Mortality rate is 25% to 40%

-: Causes of death Uncontrolled infection Malnutrition Prolong hospitalization nasocomial infection

pulmonary embli

Mid abdominal abscess Between transverse colon and pelvis

Right lower quadrant abscess Left lower quadrant abscess

Pelvic abscess

usually complication of :acute appendicitis pelvic inflammatory disease colonic diverticulitis

Symptoms abdominal pain dull aching sharp fever chills loss of appetite nausea vomiting inability to pass gas or feces

Signs toxic ill looking tachypnea tachacardia hypotension abdomen generlized gaurding rigidity tenderness all over positive rebound absent peristalsis

Pancreatitis Splenic rupture &infarc Gallbladder Hepatitis hepatic abscess

Splenic aneurysm Gastritis

Peptic ulcer

Mi

Pancreatitis

Pneumonia

Mi pneumonia

Appendicitis Intestinal obstruction Diverticulitis Ectopic pregnancy Ovarian cyst Salpingitis Ureteral calculi endometriosis

Intestinal obstruction Diverticulitis Psoas abscess Ectopic pregnancy Ovarian cyst Salpingitis Ureteral calculi endometriosis

Investigation 1:-CBC :- leukocytosis 2:-RFT 3:-Septic work up 4:-Peritoneal fluid sample for chemistry 5:-Plain film of abdomen 6:-Ultrasonography 7:-Computed tomography

Treatment -Principles 1:-Control of infection

2:- Remove the source/ decontaminate/ Wash toxins/drain 3:- Maintain organ system function 4:- Control inflammatory process

Medical treatment 1:- systemic antibiotic therapy 2:- intensive care with hemodynamic, pulmonary and renal replacement NPO, IVF, Foley catheter 3:-nutrition and metabolic support 4:-inflammatory response modulation therapy

Treatment Early control of septic source Achieved by; Operative treatment Non operative treatment Percutanous drainage Endoscopy/laparoscopy Systemic treatment Antibiotics Fluids/electrolytes Nutrition

Treatment

operative management principles :1:- Early and definitive source control 2:- Minimize the load of bacteria and toxin from abdominal cavity second look operation = sever sepsis Abdominal closure-provisional

Laparoscopy Initial laparoscopic examination of

abdomen can assist in elimination of etiology diagnostic, therapeutic

Prognosis -Primary peritonitis The overall mortality rate of patients with SBP

may exceed 30% if diagnosis and treatment are delayed less than 10% in fairly-well compensated patients with early therapy Recurrent episodes within 1 year represent 70% of patients the mortality rate approaches 50% long-term antibiotic prophylaxis decreased to less than 20%

Prognosis -Secondary peritonitis Mortality rate less than 5% in simple abscess and uncomplicated SP

More than 30-50% in sever infection Greater than 90% with quadruple organ failure

Thank you