Peritoneal

• Peritoneal cavity


  The Peritoneum, mesentery, omentum and retroperitoneum
• Peritoneum


  • Single layer of flat mesothelial cells resting on bed of loose connective tissue riches with capillary & lymphatic channels
  • Parietal
  • Visceral
• Peritoneal cavity


  Largest cavity in the body, equaled to body surface in adult 2 M2
• Peritoneal cavity


  Semipermeable, can exchange fluid with extracellular fluid space in rate of 500 ml/hr or more
• Normally, there is less than 50 ml free peritoneal fluid
• Peritoneal fluid


  With criteria of transudate: Gravity <1.016, protein <3g/dl, WBC <3000
• Parietal peritoneum


  • Lining the abdominal cavity and pelvis
  • Richly supplied with nerves (somatic innervations)
  • Its irritation lead to severe localized pain, reflex muscle spasm (guarding, rigidity)
• Visceral peritoneum


  • Covering the viscera and mesentery
  • Poorly supplied with nerves (autonomic innervations)
  • Its irritation cause vague abdominal pain, localized to midline
• Functions of peritoneum


  • Pain perception
  • Visceral lubrication
  • Fluid and particulate absorption
  • Inflammatory & immune response
  • Fibrinolytic activity
• Peritonitis


  Inflammation of peritoneal cavity
• Types of peritonitis


  • Generalized peritonitis
  • Localized peritonitis
• Causes of peritonitis


  • Bacterial infection (pyogenic, tuberculosis)
  • Chemical peritonitis (bile, gastric acid, pancreatic enzyme)
  • Ischemic injury
  • Direct trauma (operation)
  • Allergic reaction (starch peritonitis)
• Generalized septic peritonitis


  Inflammation of the peritoneal cavity by pyogenic organism (E-coli, aerobic, anaerobic, streptococci, bacteroids and pneumococcal bacteria)
• Sources of infection in peritonitis

  • GIT perforation
  • Exogenous (surgery, penetrated trauma, drain)
  • Transmural bacterial translocation
  • Female genital tract infection
  • Haematogenous spread
  • Spontaneous primary peritonitis (SPP)
• Pathology of peritonitis


  • Inflammation
  • Fibrinous adhesion (bowel, omentum)
  • Inflammatory exudates, purulent, pus collection
  • Paralytic ileus
• Fate of peritonitis


  • Resolution
  • Localization
  • Flare up
  • Septicemia, multi-organ failure, death
• Clinical features of peritonitis


  • Abdominal pain (worse by movement)
  • Abdominal distention
  • Absolute constipation
  • Vomiting
  • Toxic look (sunken eyes, dry tongue)
  • Tender abdomen, guarding or rigid
  • Absent bowel sound
  • Septic shock (cold clammy extremities, thready pulse, anxious)
• Investigations for peritonitis


  • CBC
  • Plain abdominal X-ray
  • Abdominal US
  • Abdominal CT scan
  • Peritoneal diagnostic aspiration
• Complications of peritonitis


  • Adhesive intestinal obstruction
  • Paralytic ileus
  • Intra-abdominal abscess
  • Portal pyema / liver abscess
  • Renal impairment
  • Bacteremia /septicemia / septic shock / multi-organ failure
  • Death
• Treatment of peritonitis


  • Correction of fluid and electrolytes
  • Nasogastric tube and urine catheter
  • Broad-spectrum antibiotic
  • Analgesic
  • Vital system support
  • Operative intervention
• Iliac abscess


  Collection of pus in the iliac fossa
• Causes of iliac abscess


  • Perforated appendix
  • Perforated DU
  • Perforated diverticulitis
  • PID
  • Secondary to primary peritonitis
• Iliac abscess


  • Pain, swelling, vomiting, constipation, fever
  • Tenderness and rigidity over the site of collection
• Investigations for iliac abscess


  • CBC
  • US
• Treatment of iliac abscess


  • Drainage of pus
  • Controlling the cause
  • Effective antibiotics
• Pelvic abscess


  Collection of pus in the recto-vaginal pouch (Douglas pouch) or recto-vesical pouch
• Causes of pelvic abscess


  • Acute appendicitis
  • Secondary to generalized peritonitis
  • PID in female
• Pelvic abscess


  • Fever
  • Pelvic pain
  • Diarrhea (mucous diarrhea)
  • PR tender rectum
• Investigations for pelvic abscess


  • CBC
  • US
  • CT scan
• Treatment of pelvic abscess


  • Drainage through the rectum, vagina or laparotomy
• Subphrenic abscess


  Collection of pus under the diaphragm
• Causes of subphrenic abscess


  • Residual pus collection for generalized peritonitis
  • Spread from chest infection
  • Post operative
• Subphrenic abscess


  • Swinging fever
  • Upper abdomen discomfort, shoulder pain
  • Tachycardia, anorexia
  • Persistent hiccough
  • Tenderness, swelling, rigidity at affected site
  • Downward displacement of the liver
• Investigations for subphrenic abscess


  • CBC (leukocytosis)
  • CXR (tented hemi diaphragm, associated pleural effusion)
  • US
  • CT scan
• Treatment of subphrenic abscess


  • Drainage
• Causes of tuberculous peritonitis


  • Direct spread (enteritis, salpingitis, TB lymphadenitis)
  • Blood stream (pulmonary TB)
  • Lymphatic spread
• Clinical varieties of tuberculous peritonitis


  • Acute form
  • Chronic form: Ascitic, Encysted, Fibrous, Purulent
• Acute tuberculous peritonitis


  • Presented like pyogenic peritonitis, straw coloured fluid, caseating tubercles over all the peritoneal cavity
• Ascitic form of tuberculous peritonitis


  • Commonest type, copious amount of straw colored fluid, the peritoneum studded with tubercles, the peritoneum is thicked & rolled up (masses)
• Encysted form of tuberculous peritonitis


  • Localized form of ascitic type