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Faecal Peritonitis

Faecal Peritonitis. John Hartley M62 Course March 2007. Faecal peritonitis. Definitions The clinical sequela of free contamination of the peritoneal cavity with faecal material Differs from other forms of peritonitis in magnitude and speed of systemic disturbance. Faecal peritonitis.

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Faecal Peritonitis

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  1. Faecal Peritonitis John Hartley M62 Course March 2007

  2. Faecal peritonitis Definitions • The clinical sequela of free contamination of the peritoneal cavity with faecal material • Differs from other forms of peritonitis in magnitude and speed of systemic disturbance

  3. Faecal peritonitis Causes • Perforated diverticular disease • Anastomotic failure • Stercoral perforation • Perforation of a “threatened caecum”- left sided obstruction- pseudoobstruction • Perforated toxic megacolon • Trauma

  4. The classification of perforated diverticular disease • Stage I: Localised pericolic or mesenteric abscess • Stage II: Confined pelvic abscess • Stage III: Generalised purulent peritonitis from ruptured abscess • Stage IV: Faecal peritonitis from free colonic perforationHinchey EJ et al Adv Surg 1978;12:85-109

  5. Faecal peritonitis - pathophysiology

  6. Faecal peritonitis-definitions • SIRS: 2 or more of: • Temperature > 38°C or < 36°C • Heart rate > 90 bpm • Resp rate > 20 breaths.min -1 or PaCO2 < 4.3kPa (32mmg) • WBCs > 12 or < 4 (or >10% immature forms)

  7. Faecal peritonitis-definitions • Sepsis • = SIRS with documented infection site • Severe Sepsis • Sepsis + organ dysfunction, hypoperfusion or hypotension • Septic Shock • Severe sepsis (SBP < 90mmHg) despite adequate fluid resuscitation

  8. Faecal peritonitis Clinical features • Peritonitis + some degree of the SIRS pathway: • Septic shock • Multiple organ failure

  9. Faecal peritonitis Investigations • FBC, BCP, Amylase • Erect CXR • AXR • Think before CT scan please

  10. Faecal peritonitis Principles of Management • Rapid resuscitationto enable • Source control followed by • Physiological support until recovery (or death)

  11. Faecal peritonitis Management • Vigorous resuscitation in the appropriate setting - Oxygen - Adequate volume - Monitor response - +/- inotropes - Antibiotics

  12. Faecal peritonitis The goals of resuscitation • MAP >65mmHg • CVP 8-12mmHg • Urine output >0.5ml/kg/hr • Within the first 6 hrs • What to do with non-responders?Early Goal Directed Therapy in the Treatment of Severe Sepsis. Rivers et al NEJM 2001; 345:1368-77

  13. Faecal peritonitis Operative management • Generous access • Remove particulate matter • Generous lavage • Identify source

  14. Faecal peritonitis-operative management Source control • Resect or exteriorise the perforation - Hartmann’s- TAC and end ileostomy • Avoid primary anastomosis • Occasionally - drainage, lavage, proximal diversion

  15. Faecal peritonitis – importance of source control From Christou et al 1993

  16. Faecal peritonitis-operative management • Primary anastomosis (or laparoscopic lavage) versus Hartmann’s procedure for complicated diverticular disease • Primary anastomosis in 61 of 127 pts undergoing emergency surgery, 3% mortality and 2% anastomotic leak rate Biondo S et al Br J Surg 2001;88:1419 • Probably not relevant in faecal peritonitis

  17. Faecal peritonitis – operative management Hartmann’s procedure • Excise the perforation • Intraperitoneal rectal stump vs mucous fistula vs buried stump • +/- Drainage • A viable colostomy

  18. Faecal peritonitis – operative management The difficult colostomy • Adequate mobilisation • Use the upper abdomen • Stoma through the wound • Stapled off blind end and proximal loop

  19. Faecal peritonitis Closure versus laparostomy • Consider laparostomy when - Can’t close the abdomen - Concern over source control - Concern over ischaemia • Beware abdominal compartment syndrome

  20. Faecal peritonitis – reasonable expectations? (www.riskprediction.org.uk)

  21. Faecal peritonitis Planned re-laparotomy versus laparotomy on demand? • No randomised studies • Non-significant reduction in mortality with the latter approach • Little role for scheduled re-laparotomies • Clear source at first operation

  22. Faecal peritonitis Aftercare • ICU support • Steady improvement or: • Failure to progress • +/- Signs ongoing sepsis • Progressive MOF • Usually not a surgically remediable cause - CT scan +/- percutaneous drainage - Re-laparotomy

  23. Faecal peritonitis Summary • Prompt resuscitation • Initial source control • Avoid primary anastomosis • Close abdomen where possible • ICU support • Re-laparotomy on demand • High mortality

  24. Faecal peritonitis Conclusions • Recognition of the problem, and • Primary source control by surgeons • Physiological support in a multidisciplinary setting • Outcome should be determined by the response to sepsis rather than ongoing sepsis

  25. Faecal peritonitis More definitions: • SIRS • Sepsis • Septic shock

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