Peritonitis
Definition
Inflammation of the peritoneum
Aetiology
Bacterial infection - commonest organisms are Escherichia coli, aerobic and anaerobic
streptococci, enterobacteriaceae, staphylococcus spp., clostridia and the bacterioides, .klebsiella pneumoniae. Mycobacterium tuberculosis
Bile irritation → biliary peritonitis
Biliary peritonitis may follow peptic ulcer perforation.
Trauma, open surgery, drains
Inflammatory bowel disease, appendicitis, ischaemic bowel.
Pelivic inflammatory disease
Haematogenous spread 'e.g., septicaemia
Pancreatitis - inflammation of the peritoneum by the irritant secretions from the pancreas.
Pathophysiology: -
inflammation ,
exudation ' ascites,
paralytic ileus,
distension of abdomen,
dehydration,
respiratory embarassment due to the distension,
septicemia
death
Clinical features: -
Localised peritonitis
o Abdominal pain which goes on increasing
o Fever
o Vomiting
o Tenderness, rebound tenderness, Rowsing's sign.
o Localised guarding, or rigidity.
Generalized peritonitis
o Severe abdominal pain
o Pain increases on moving and or breathing
o Patient lies still
o Tenderness and rigidity of the abdominal wall
o Pulse rises progressively
o The temperature may become subnormal
o Late features:- if resolution or localisation of generalized peritonitis does not occur the
abdomen remains silent and increasingly distends.
o Circulatory failure ensues
o cold and clammy extremities
o Sunken eys
o Dry tongue
o Thready (irregular) pulse,
o Drawn and anxious face (Hippocratic facies)
o Unconsciousness
Investigations
Peritoneal diagnostic aspiration - called peritoneal tapping
Routine blood tests - TC, DC, ESR etc.
X-Ray abdomen
Serum amylase
Ultrasound scanning
CT scanning
Treatment
o General care of the patient
o Specific treatment for the cause
o Peritoneal lavage when appropriate
General Care of the Patient
o Volume replacement
o Electrolyte imbalance correction
o Gastrointestinal deompression
o Antibiotic therapy
o Fluid balance chart
o Analgesia
o Vital system support esp. if septic shock is present
Complications of peritonitis
Systemic complications of peritonitis
o bacteraemic or endotoxic shock
o bronchopneumonia/respiratory failure
o Renal failure
o Bone marrow suppression
o Multisystem failure
Abdominal complications of peritonitis
o Adhesional small bowel obstruction
o Paralytic ileus
o Residual or recurrent abscess
o Portal pyaemia/liver abscess
o Paralytic ileus
Jejunal diverticulitis with peritonitis
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Anatomy of The Peritoneum
Definition
o The peritoneum is the largest serous membrane of the body lining the abdominal cavity
Structure
o Consists of a closed sac, containing a small amount of serous fluid, within the abdominal cavity.
o Two layers
o The parietal layer - lines the abdominal wall
o Visceral layer - covers the organs (viscera) in the abdominal and pelvic cavities
o The oragns are invaginated into the closed sac from above, below and behind so that they are at least partly covered by the visceral layer
o Pelvic organs are covered only on their superior surface
o The stomach and intestines deeply invaginated from behind are almost completely surrounded by peritoneum and have a double fold ( the mesentery).
o The fold of peritoneum attaches them to the posterior abdominal wall
o The pancreas, spleen, kidneys and adrenal glands are invaginated from behind - only their anterior surfaces are covered by the peritoneum - therefore retroperitoneal
o Liver completely covered - attached to the diaphragm
o The main blood vessels and nerves pass close to the posterior abdominal wall and send branches to the organs between the two folds of peritoneum
o Parietal peritoneum lines the anterior abdominal wall
o The two layers are actually in contact - friction prevented by the presence of serous fluid secreted by the peritoneal cells
o Peritoneal cavity is only a potential cavity
o In women there is communication of the peritoneal cavity to the external atmosphere through the openings of the fallopian tubes (at fimbrial ends)
o In males the peritoneal cavity is completely closed.
