PERITONITIS (TYPES AND MANAGEMENT)

1. PERITONITIS(TYPES AND MANAGEMENT) By SUMAYYA.P MBBS-2002 Batch

2. PERITONEUM • VISCERAL • PARIETAL • FUNCTIONS • VISCERAL LUBRICATION • FLUID AND PARTICULATE ABSORPTION • PAIN PERCEPTION-[PARIETAL] • INFLAMMATORY AND IMMUNE RESPONSES • FIBRINOLYTIC ACTIVITY

3. ANATOMY

4. PERITONEAL RELATIONS

5. PERITONITIS

6. DEFINITION “INFLAMMATION OF THE PERITONEAL CAVITY,WHERE THE PERITONEAL FLUID INCREASES IN VOLUME WITH THE PASSAGE OF A TRANSUDATE RICH IN LEUCOCYTE POLYMORPHS &FIBRIN”.

7. CLASSIFICATION A.PRIMARY PERITONITIS: • Spont.peritonitis in children • Spont. Peritonitis in adult • Peritonitis in patients with CAPD • Tuberculous &other granulomatous peritonitis

8. B . Secondary peritonitis. a/c suppurative peritonitis 2. Post-op peritonitis 3.Post traumatic - peritonitis

9. Perforation of appendix

10. C.Other forms of peritonitis • Bile peritonitis • Meconium peritonitis • Peritonitis following abortion/parturition • Periodic peritonitis • Talc peritonitis • Drug-related peritonitis • Lead peritonitis • Porphyric peritonitis • Hyperlipemic peritonitis.

11. CHILDREN Neonate & at age 4-5 With NS &SLE hemolytic strept. & pneumococci hematogenous Short duration of symptom Abdominal pain, Vomiting,diarrhoea, lethargy,fever. ADULT With ascites-cirrhosis E.coli Hematogenous Insidious onset Abdominal pain &distention PRIMARY PERITONITIS

12. Investigations • Paracentesis - fluid taken • Cell count, pH, Gram stain & culture Treatment • Antibiotics - Cephalosporins or -ampicillin-sulbactam

13. PERITONITIS RELATED TO CAPD • Dominant complication of CAPD in patients with end-stage renal disease • Most comm. Mechanism - Catheter related infection • Single organism • Commonest -staph.aureus, -staph.epidermidis, • fungus

14. Diagnosis-when any of following is present…….. • a cloudy dialysate effluent • +ve culture from peritoneal fluid • clinical signs of peritonitis Treatment: • adminstratn of antibiotics &heparin in dialysate &increase in the dwell time of dialysate fluid Prevention: Sclerosing peritonitis:

15. TUBERCULOUS PERITONITIS • Acute • chronic Origin of infection: • TB of the ileocaecal region • tuberculous mesentric lymph node • Tuberculous pyosalpinx • Blood born infection from pulmonary TB

16. TUBERCULOUS PERITONITIS

17. Clinical features: Abdominal pain, fever, loss of wt ., Ascites, night sweats, abdominal mass, malaise • Caseating peritoneal nodules-distinguish from metastatic carcinoma &fat necrosis of pancreatitis 4 TYPES • Ascitic form • Encysted form • Fibrous form • Purulent form

18. 1.ASCITIC FORM • peritoneum studded with tubercules • peritoneal cavity filled with pale straw- coloured fluid • Abdomen distended,shifting- dullness,cong.hydroceles,umbilical hernia. • On palpatn:transverse solid mass-rolled-up greater omentum infiltrated with tubercles. DIAGNOSIS • A +ve mantoux test in a child with ascites • In adult this test is of negligible value • Chest x-ray • CT-scan CONTD…..

19. TB peritonitis showing granulomas

20. TUBERCULOUS PERITONITIS

22. Peritoneal fluid tap:ascitic fluid -pale yellow, lymphocyticpleocytosis, glucose<30mg/dl, increased protein, sp.gravity>1.020,mycobacteria demonstrated by culture. • Peritoneoscopy &direct biopsy • Laparoscopy-open (Hassan) technique. • Percutaneous needle biopsy • Exploratory laparotomy-peritoneal biopsy TREATMENT • Anti-tuberculous therapy

24. 2.ENCYSTED FORM(LOCULATED FORM) • Localised intra abdominal swelling-difficult to diagnose • Laparotomy-ATT • Complicatn-late intestinal obstruction. 3.FIBROUS FORM(PLASTIC FORM) • Widespread adhesion • Distended coils of intestine-blind loop formation, abdominal pain, steatorrhoea, wasting. TREATMENT • Usually ATT only needed without surgery • If adhesion+fibrous stricture present-excise the affected bowel • If only adhesion present-plication may be performed

25. HISTOLOGY

26. 4.PURULENT FORM (Rare) • secondary to tuberculous salpingitis • Formation of cold abscess commonly near umbilicus TREATMENT • ATT & Operative treatment • evacuation of cold abscess • Removal of intestinal- obstruction • closure of faecal fistula. • Prognosis - relatively poor.

27. ACUTE BACTERIAL/SUPPURATIVE PERITONITIS • Bacteria in peritonitis • E.coli • Streptococci • Bacteroides • Clostridium • Klebsiella • Staphylococcus • Other sources • Chlamydia,gonococcus,β-hemolytic strep.,pneumococcus

28. Routes of infection • GI Route • Exogenous contamination • Transmural bacteria-translocation • Female genital tract • Hematogenous (rare)

29. ACUTE PERITONITIS

30. Bacterial peritonitis may be localised or diffuse • Localised peritonitis • Anatomical: supracolic infracloic • Pathological: • Surgical:

31. CLINICAL FEATURES A.LOCALISED PERITONITIS • ↑ temperature ,PR • Abd.pain worse on movmnt • Guarding,board like rigidity • +ve release sign/blumberg’s sign/rebound tenderness • Kehr’s sign may be +ve • Tenderness on PR/ PV(pelvic peritonitis)

32. B.DIFFUSE PERITONITIS • Factors favouring • Speed of peritoneal contamination • Stimulation of peristalsis • Virulence of infecting organism • Young Children • Disruption of localised collection • Immune compromised people

33. DIFFUSE / GENERALISED PERITONITIS • Depends on presentation • EARLY PRESENTATION • Severe abdominal pain • Vomiting • PR rise progressively • Temp.variable-may be subnormal • Patient lies still • Tenderness & rigidity on palpation • Urinary symptoms+pain on PV/PR (PELVIC PERITONITIS)

34. LATE PRESENTATION • Silent abdomen • Abdominal distension • Cold clammy extremities • Sunken eyes • Dry tongue • Anxious face (HIPPOCRATIC FACIES) • Thready-irregular pulse • Unconsiousness

36. DIAGNOSIS • CAREFUL HISTORY • REPEATED EXAMINATION • RAISED WHITE CELL COUNT • SERUM AMYLASE >4 times normal • CXR-ERECT • X-RAY ABDOMEN • USG / CT • PERITONEAL ASPIRATE

37. X-RAY

38. TREATMENT • General care of the patient • Specific treatment for the cause • Peritoneal lavage when needed

39. 1.GENERAL CARE • Correction of fluid and electrolyte • I / O chart maintained • CVP monitoring • Correction of plasma protein depletion • TPN if hospitalised >7-10 days • GI decompression • Broad spectrum antibiotics • Analgesics • Vital system support

40. 2.SPECIFIC TREATMENT OF THE CAUSE • SURGERY FOR…. • Perforated appendicitis, • Colonic diverticulitis, • Peptic ulcer, • Gangrenous cholecystitis • Small bowel perforation **patient should be fit for anaesthesia to do surgery

41. 3.PERITONEAL LAVAGE • PROGNOSIS: • DIFFUSE PERITONITIS-MORTALITY-10%

42. SYSTEMIC Bacteraemia and endotoxic shock Bronchopneumoni-a/resp.failure Renal failure Bone marrow suppression Multisystem failure ABDOMINAL Adhesional small bowel obstruction Paralytic ileus Residual / recurrent abscess Portal pyaemia , liver abscess COMPLICATIONS

43. Adhesional small bowel obstruction: • Bowel sound increased • Colicky abd.pain • Paralytic ileus: • Bowel sounds reduced/absent • Usually little pain • Abd.x-ray.

45. ABSCESS FORMATION • SUB-PHRENIC • PARACOLIC • RIGHT ILIAC FOSSA • PELVIC CLINICAL FEATURES • Anorexia ,wt.loss ,swinging pyrexia, tachycardia ,localised tenderness, palpable mass(late),sympt.of local- irritation.

46. SITES OF ABSCESS FORMATION

47. SUBPHRENIC ABSCESS:

48. PELVIC PERITONITIS& ABSCESS

49. CT

50. POST-OPERATIVE PERITONITIS • FREQUENT • COMMONEST CAUSE- ANASATOMOTIC LEAK. CLINICAL FEATURES • Ill looking patient • PR ↑ • Peripheral circulation failure • Local sympt.&signs are non-specific • Abd. Pain is not prominent