Summary

• Peritoneum


  Single layer of flat mesothelial cells resting on a bed of loose connective tissue rich with capillary and lymphatic channels
• Parts of the peritoneum


  • Parietal peritoneum (lining the abdominal cavity and pelvis)
  • Visceral peritoneum (covering the viscera and mesentery)
• Parietal peritoneum


  Richly supplied with somatic nerve innervation
• Visceral peritoneum


  Has autonomic innervation
• Functions of the peritoneum


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


  Inflammation of the peritoneum
• Types of peritonitis


  • Generalized peritonitis
  • Localized peritonitis
• Causes of peritonitis


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


  Caused by pyogenic organisms (E. coli, aerobic, anaerobic, streptococci, bacteroids, and pneumococcal bacteria)
• Sources of generalized septic peritonitis


  • Gastrointestinal tract perforation
  • Exogenous (surgery, penetrating trauma, drains)
  • Transmural bacterial translocation
  • Female genital tract infection
  • Hematogenous spread
  • Spontaneous primary peritonitis (SPP)
• Pathology of generalized septic peritonitis


  • Inflammation
  • Fibrinous adhesions (bowel, omentum)
  • Inflammatory exudates, purulent, pus collection
  • Paralytic ileus
• Clinical features of generalized septic peritonitis


  • Abdominal pain (worsened by movement)
  • Abdominal distention
  • Absolute constipation
  • Vomiting
  • Toxic appearance (sunken eyes, dry tongue)
  • Tender abdomen, guarding, or rigidity
  • Absent bowel sounds
  • Septic shock (cold, clammy extremities, thready pulse, anxiety)
• Investigations for generalized septic peritonitis


  • Complete blood count (CBC)
  • Plain abdominal X-ray
  • Abdominal ultrasound
  • Abdominal CT scan
  • Peritoneal diagnostic aspiration
• Complications of generalized septic peritonitis


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


  • Operative intervention
  • Fluid and electrolyte correction
  • Nasogastric tube
  • Urinary catheter
  • Broad-spectrum antibiotics
  • Analgesics
  • Vital system support
• Localized septic peritonitis (intra-abdominal abscess)


  Collection of pus in a localized area of the abdomen
• Types of localized septic peritonitis


  • Iliac abscess
  • Pelvic abscess
  • Subphrenic abscess
• Iliac abscess


  Pus collection in the iliac region, caused by perforated appendix, duodenal ulcer, diverticulitis, PID, or primary peritonitis
• Iliac abscess


  • Pain, swelling, vomiting, constipation, fever, tenderness, and rigidity over the site of collection
• Pelvic abscess


  Collection of pus in the recto-vaginal or recto-vesical pouch, caused by acute appendicitis, generalized peritonitis, or PID
• Pelvic abscess


  • Fever, pelvic pain, diarrhea (mucous diarrhea), tender rectum on digital rectal examination
• Subphrenic abscess


  Residual pus collection from generalized peritonitis, spread from chest infection, or post-operative
• Subphrenic abscess


  • Swinging fever, upper abdominal discomfort, shoulder pain, tachycardia, anorexia, persistent hiccough, tenderness, swelling, rigidity at the affected site, downward displacement of the liver
• Investigations for localized septic peritonitis


  • CBC
  • Ultrasound
  • CT scan
• Treatment for localized septic peritonitis


  • Drainage of pus
  • Controlling the cause
  • Effective antibiotics
• Tuberculous peritonitis


  Inflammation of the peritoneum due to tuberculosis infection
• Causes of tuberculous peritonitis


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


  • Acute form (pyogenic-like presentation, straw-colored fluid, caseating tubercles)
  • Chronic ascitic form (copious straw-colored fluid, thickened peritoneum)
  • Chronic encysted form (localized ascitic type)
  • Chronic purulent form (multiple cold abscesses, sinuses/fistulae)
  • Chronic fibrous form (extensive adhesions, intestinal obstruction)
• General clinical features of tuberculous peritonitis


  • Age (young adults, children)
  • Recurrent abdominal pain, distension, vomiting
  • Night fever, night sweating, anorexia, wasting
  • Doughy abdomen, multiple masses
  • Ascites
  • Tender, guarding abdomen
• Investigations for tuberculous peritonitis


  • Erythrocyte sedimentation rate (ESR - very high)
  • Tuberculin test (significant if positive, especially in children)
  • Quantiferon test
  • Plain chest X-ray
  • Abdominal ultrasound
  • Aspiration for Ziehl-Neelsen stain and culture
  • Diagnostic laparoscopy
• Treatment for tuberculous peritonitis


  • Anti-tuberculosis therapy for one year
  • Surgery for complications
• Ascites


  Abnormal accumulation of fluid in the peritoneal cavity
• Classification of ascites


  • Transudate (protein < 25g/l)
  • Exudate (protein > 25g/l)
• General causes of ascites (transudate)


  • Liver disease
  • Heart disease
  • Renal disease
  • Hypoalbuminemia
• Local causes of ascites (exudate)


  • Tuberculous ascites
  • Malignant ascites
  • Budd-Chiari syndrome
  • Chylous ascites
  • Pancreatic ascites
• Carcinoma peritonei


  Terminal event for advanced cancer (stomach, colon, breast, etc.) due to secondary implantation
• Carcinoma peritonei


  • Discrete nodules, plaques of different sizes, adhesions
• Pseudomyxoma peritonei


  Abdomen filled with yellow, jelly-like material and adhesions, caused by rupture of a pseudomucinous ovarian cyst or mucocele/mucoid carcinoma of the appendix
• Pseudomyxoma peritonei


  • Distended abdomen, multiple firm masses
• Mesothelioma


  Primary tumor of the peritoneum, associated with exposure to asbestos