PERITONITIS
THEJAL R
PERITONEUM
• It is a serous membrane lining the abdominal cavity
outer fibrous tissue layer
( which gives strength )
inner mesothelial cell layer
( secretes fluid giving lubricating function
to the peritoneum)
PARTS OF PERITONEUM
Parietal peritoneum –
¤ it lines the inner surface of the abdominal wall ,
under surface of diaphragm and pelvic wall
¤ loosely attached to the overlying walls and can be
easily stripped off
¤ innervation by somatic nerves , so pain sensitive
Visceral peritoneum-
¤ it lines the outer surface of the abdominal viscera
¤ firmly adherent , cannot be stripped off
¤ it is innervated by autonomic nervous system , hence not pain
sensitive
PERITONEAL CAVITY
▪︎ it is the potential space between the parietal and visceral
peritoneum.
▪︎ Normally it contains 100mL of clear , straw coloured fluid
secretion by the mesothelial cells
FUNCTION OF PERITONEUM
1. Fluid secretion – peritoneal lining secretes fluid which is having
specific gravity of < 1016 ; protein <3 gram/ dL ; total count < 3000
cells/L
2. Fluid absorption
3. Keeping peritoneal surface lubricated
4. localisation of inflammation and infection
5. Pain perception
6. Inflammatory response and immune activity
ACUTE PERITONITIS
• Peritonitis is defined as inflammation of the parietal and serosal
layer of the peritoneum either due to chemicals like acid (gastric)
or bile or due to bacterial infection
- localised/ generalized
- chemical / bacterial or initially chemical induced but later
becoming bacterial. Chemical peritonitis is caused by acid , bile ,
blood , barium and other substances
• Localised peritonitis ( contained infection)–
- based on the anatomical factors like supracolic / infracolic
compartments ; greater omentum ; paracolic gutters ; dilated small
bowel , etc...
- pathological factors are thickened peritoneum, fibrin
deposition , omental adhesions , reduced bowel peristalsis.
- it may form abscess – pelvic / subphrenic
• Generalized peritonitis ( diffuse infection- mortality 10% )
- poor localisation
- rapid peritoneal contamination
- violent peristalsis
- virulent organism
- immunodeficiency status
TYPES:
PRIMARY PERITONITIS
• 1% of all peritonitis
• Without any secondary causes like bowel perforation or pelvic infection;
it is commonly seen in young girls ( 3-9 years ) where infection occurs
through.
Fallopian tube
Respiratory tract
Middle ear infection in males
• It is commonly due to pneumococci , and occasionally due to
streptococci , haemophilus , gonococcus and gram negative ( E.coli )
organism
• Primary streptococcal peritonitis is seen in infants and children
below 4 years of age with cloudy fibrin flakes in the peritoneal
cavity having source of tonsillitis and pharyngitis , presents with
gastroenteritis often greenish watery stool
• It is also common in cirrhotic patients with ascites , as SBP due to
Translocation of gut bacteria
Through mesenteric lymphatics
Blood spread
Ascitic fluid protein content = <1 g / dL
Ascitic fluid WBC count = > 250 cells mm³ with >50% cells are
polymorphonuclear cells
• Above two are suggestive of primary peritonitis ( SBP )
SECONDARY PERITONITIS
• It is secondary to any bowel or other visceral pathology,
• Eg : perforation, appendicitis
• E.coli (70%) is the most common organism involved
• others – aerobic and anaerobic streptococci , clostridium
welchii ,bacterioides , staphylococci
• Duodenal perforation and burst appendicitis- m/c
TERTIARY PERITONITIS
• It occurs after any abdominal surgeries , which is usually severe and
the patient may go for SIRS or MODS early
• Tertiary peritonitis is defined as persistent or recurrent intra-
abdominal infection after an adequate treatment for primary or
secondary peritonitis – usually after 48 hours
• M/c – immunosuppressed individual
• Common infection- E. Faecalis, E.faecium , S.epidermidis ,P.aeuginosa
• complications – DIC , septicemia, uraemia , haemorrhage,
pneumonia, ARDS
BACTERIA CAUSING PERITONITIS
BACTERIA FROM GIT BACTERIA NOT FROM GIT
•E.coli •gonococcus
•aerobic and anaerobic •pneumococcus
streptococci •chlamydia
•streptococcus faecalis •beta – haemolytic streptococci
•Staphylococcus •mycobacterium
•bacteroids
•Klebsiella
•cl.welchii
MODE OF INFECTION
• Perforation- duodenal / gastric / enteric / colonic ulcers , meckels
diverticulitis Perforation
• Penetrating or blunt trauma
• Surgery, dialysis
• Foreign body
• Appendicitis
• Via fallopian tube
• Blood spread
• Transmural spread
• Abortion / termination of pregnancy
FACTORS AFFECTING THE SPREAD
OF INFECTION IN PERITONITIS
• Burst appendix , perforation
• Amount of peristalsis ( more the peristalsis, more the spread )
• Virulence of the organism
• Localising action of the omentum
• Immunosuppression – HIV , steroids
• Age , associated disease like malignancy, malnutrition, anaemia
PATHOGENESIS
CLINICAL FEATURES
• Sudden onset of pain which is severe
• Fever , vomiting
• Tenderness- which is initially localised later becomes diffused
• Rebound tenderness- blumberg sign
• Guarding and rigidity , dull flanks on percussion
• Tachycardia, tachypnoea
• Hippocratic facies –[ severe end stage disease ]
• Bowel sounds are absent
SCORING SYSTEMS
APACHE II [ ACUTE PHYSIOLOGY
AND CHRONIC HEALTH EVALUATION] MANNHEIM PERITONITIS
• AaDO2 ( alveoloarterial oxygen partial • Presence of organ failure
pressure difference)
• Temperature ( rectal )
• Time more than 24 hours
• Mean arterial pressure • Presence of malignancy
• pH arterial
• Respiratory rate
• Origin of sepsis
• Sodium • Faecal peritonitis
• Potassium
• Generalised peritonitis
• Creatinine
• Hematocrit
• White blood cell count
• Glasgow coma scale
INVESTIGATIONS
1. Chest x – ray in standing position with abdomen ( erect )
Ground glass appearance with gas under diaphragm
suggest hollow viscous perforation
2. TC is increased
3. US abdomen- shows fluid in the abdominal cavity
4. CT scan
5. MRI
6. Electrolyte study , blood culture
7. Blood urea and Serum creatinine
8. Serum amylase if four times the normal value
9. LFT also done
10. Platelet count , bleeding time , clotting time , prothrombin time – to assess
severe peritonitis
11. Four quadrant abdominal tap – reveals pus or infected fluid
12. Diagnostic peritoneal lavage
13. Diagnostic laparoscopy – duodenal ulcer perforation, primary peritonitis
DIFFERENTIAL DIAGNOSIS
• Pancreatitis
• Intestinal obstruction
• Acute pyelonephritis
• Acute mesenteric ischaemia
• Diabetic Acute abdomen
• Acute myocardial infarction
TREATMENT
• Airway
• Breathing
• Circulation
• IV fluids for resuscitation ( NS , RL are usually used ; 2 mL /
kg / hour
• Nasogastric tube aspiration
• TPN , CVP line
• Blood transfusion, FFP , platelet transfusion
• Catheterisation with maintenance of adequate urine output ( 30
mL/ hr ) ( 0.5 mL / hour/ kg
• Antibiotics- ampicillin , gentamicin , metronidazole, ceftazidime ,
cefoperazone , cefotaxime , tazobactum, piperacillin etc...
• Analgesics
• Sitting propped up position , early mobilisation, exercise,
respiratory physiotherapy, prevention of DVT using heparin / low
molecular heparin
• Surgical correction of underlying cause
• Use of dopamine , steroids , and management of shock
• ICU and ventilator support is required during postoperative period
• Monitoring the patient using po2 , pco2 , electrolytes, and pulse
oximeter
LAPAROTOMY
• On laparotomy , the cause for peritonitis is identified and
corrected .
1) In bowel perforation- perforation closure
2) in intestinal obstruction- resection and anastomosis
3) In appendicitis- appendicectomy
proper peritoneal toilet ( wash with 10 litres of warm
saline ) is given
A drain is placed ( tube)
pus should be sent for culture and sensitivity
tension sutures are placed when required to prevent burst
abdomen
LAPAROSTOMY
• Open and closed method
• Open method( ettapan’s lavage ) – abdominal wall / fascia and
peritoneum are not sutured but kept open
Advantages -1) reduce the chances of abdominal compartment
syndrome
2) easier and faster drainage
Disadvantages- 1) fluid loss
2) electrolyte imbalance
3) allow infection to get into the peritoneal
cavity
• In closed method ,
1) abdominal fascia wound is closed using a zip
2) it facilitates the regular washing of the peritoneal
cavity with normal saline without contamination the cavity from
outside and reduces the unnecessary fluid loss
Disadvantages- abdominal compartment syndrome
TECHNIQUE OF EMERGENCY
LAPAROTOMY
• Abdomen is opened with midline incision, often extending both
above and below the umbilicus , with incision inclined towards
the left side of umbilicus
• Once peritoneum is opened gushing pus is removed using suction
• Pus is collected for culture
• Abdominal cavity is inspected thoroughly for site of origin of
sepsis – appendicitis/ perforation/ gangrene, etc .
• Proper wash is given using warm normal saline (10 litres)
• Drain should be placed
• Wound is closed with tension sutures using nonabsorbable
monofilament sutures
POSTOPERATIVE MANAGEMENT
• Proper critical care ( ICU ) postoperatively
• Ventilatory support ; pulse rate, blood pressure, neutrophil
count , platelet count , prothrombin time , blood urea and Serum
creatinine, ,liver function test
• Proper fluid and electrolyte management
• Total parenteral nutrition
• Prevention of DVT by leg exercise , LMWH
• Prevention of ARDS
• Prevention of bedsore
COMPLICATION
Systemic complications Abdominal complications
• Septicemia • Portal pyaemia
• ARDS • Paralytic ileus
• SIRS • Surgical site infection
• MODS • ACS
SPONTANEOUS BACTERIAL
PERITONITIS
• It is defined as bacterial infection of ascitic fluid in the
absence of an intra – abdominal surgically treatable source
of infection
• Seen in
infants and children commonly
In nephritic syndrome
Cirrhosis
SCLEROSING PERITONITIS
• It is usually practolol ( beta – blocker) induced
peritonitis.
• It is fibrinous peritonitis causing thickening of bowel and
other contents of abdomen
• It leads to intestinal obstruction and malnutrition
BILIARY PERITONITIS
• Causes :
1) trauma ; idiopathic
2) post – operative leak after surgery for gall bladder , CBD ,
duodenum , ERCP , pyloroplasty
3) Perforation of gallbladder or CBD
4) Gangrenous cholecytitis and rupture
POSTOPERATIVE PERITONITIS
• It is the development of peritonitis in post – operative period, either due to
anastomotic leak , or biliary leak and there is collection of pus in the peritoneal
cavity including interloop areas
• In all abdominal surgeries patient initially develops paralytic ileus which last for 3-
5 days .
• If it persists or progresses one should suspect post – operative peritonitis.
• Other features –
persisting toxaemia
Oliguria
Pyrexia
OTHER FORMS OF PERITONITIS
1. Meconium peritonitis
2. Chronic bacterial peritonitis – tuberculous
3. Chronic non bacterial peritonitis- granulomatous peritonitis due
to talc or starch ( from surgical gloves) – starch peritonitis
4. Gonococcal peritonitis with perihepatitis
5. Familial periodic peritonitis
6. Parturition / abortion peritonitis
