PERITONITIS

M. IQBAL RIVAI

PERITONEUM
Function of peritoneum

Pain perception
Visceral lubrication
Fluid and particulate absorption
Inflammatory and immune response
Fibrinolytic activity
ABDOMINAL POLICEMAN

PERITONEUM
Causes of peritoneal inflammatory exudate:

Bacterial infection appendicitis

Chemical injury bile peritonitis
Ischaemic injury strangulated bowel, vasc.
Occlusion

Direct trauma operation

Allergic reaction starch peritonitis

ACUTE PERITONITIS
Bacteria in peritonitis

Gastrointestinal source
Eschericia coli
Streptococci (aerobic and anaerobic)
Bacteroides
Clostridium
Klebsiella pneumoniae
Staphylococcus

Other sources
Chlamydia
Pneumococcus

ROUTE OF INFECTION
Paths to peritoneal infection

Gastrointestinal perforation perforated ulcer

Exogenous contamination drains, open
surgery

Transmural bacterial translocation (no

perforation) inflammatory bowel disease,
appendicitis, ischaemic bowel

Haematogenous spread septicemia

PERITONITIS
Mortality in peritonitis reflects:

The degree and duration of peritoneal

contamination

The age of the patient

The general health of the patient
The nature of the underlying cause

ABDOMINAL REGION

DIFFUSE PERITONITIS
Factors of the development of diffuse
peritonitis:

Speed of peritoneal contamination

Stimulation of peristalsis by ingestion of food or
even water hinders localisation

Virulence of the infecting organism

Young children have a small omentum
Disruption of localised collections
Immune deficiency

CLINICAL FEATURES IN
PERITONITIS
Abdominal pain, worse on movement
Guarding/ rigidity of abdominal wall
Pain/ tenderness on rectal/ vaginal examination
(pelvic peritonitis)

Pyrexia (may be absent)

Raised pulsed rate
Absent or reduced bowel sound
Septic shock (SIRS) in later stages

Free
air

Hippocratic facies in terminal diffuse peritonits

Acute pancreatitis on CT
Scan

DIAGNOSTIC AIDS
Raised white cell count and C-reactive protein are usual
Radiographic of the abdomen
Gas-filled loop of bowels (paralytic ileus)
Free gas

Serum amylase estimation

For acute pancreatitis (serum amylase >4x normal)

Ultrasound and CT Scan

Used to identify the cause of peritonitis

Peritoneal diagnostic aspiration

TREATMENT
General care of patient
Correction of fluid and electrolyte imbalance
Insertion of nasogastric tube
Broad-spectrum antibiotics
Analgesia (if diagnosis is confirmed as
peritonitis)

Operative treatment

SURGERY
To eliminate the source of
contamination

To reduce the bacterial contamination

To prevent further complications and
sepsis

SYSTEMIC COMPLICATIONS OF
PERITONITIS
Bacteraemic/endotoxic shock
Bronchopneumonia/respiratory failure
Renal failure
Bone marrow suppression
Multisystem failure

ABDOMINAL COMPLICATIONS
OF PERITONITIS
Adhesional small bowel obstruction
Paralytic ileus
Residual or recurrent abscess
Portal pyaemia/live abscess

PROGNOSIS
Untreated peritonitis is poor, usually
resulting in death.

With therapy, prognosis is variable,

dependent on the underlying causes.

PREVENTIVE CARE
There is NO WAY to prevent peritonitis,
since the diseases it accompanies are
usually not under the voluntary control of
an individual.

However, the best way to prevent

serious complications is to seek medical
attention as soon as symptoms
appear.

SPECIAL FORMS OF
PERITONITIS
Postoperative
Leakage post anastomosis
Anastomosis dehisence
Antibiotic therapu alone is inadequate

In patient on treatment with steroids

Pain is frequently slight or absent

In children
Diagnosis more difficult
Gentle, patient and sympathetic approach is needed

In patients with dementia

Unable to give reliable history
Abdominal tenderness is well localised
Guarding and rigidity are less because abdominal
muscles are often thin and weak

SPECIAL FORMS OF
PERITONITIS
Bile peritonitis

Causes of bile peritonitis

Perforated cholecystitis

Post cholecystectomy
Cystic duct stump leakage
Leakage from an accesory duct in the gallbladder bed
Bile duct injury
T-tube drain dislodgement (or tract rupture on removal)

Following other operations/procedures

Leaking duodenal stump post gastrectomy
Leaking biliary-enteric anastomosis
Leakage around percutaneous placed biliary drains

Following liver trauma

SPECIAL FORMS OF
PERITONITIS
Starch peritonitis

Found disfavour as a surgical glove lubricant

In sensitive patients, it causes a painful ascites
Laparotomy small granulomas may be found
that contain statch particles

TUBERCULOUS
PERITONITIS
Acute and chronic forms
Abdominal pain, sweats, malaise and weight
loss are frequent

Caseating peritoneal nodules are common

distinguish from metastatic carcinoma and fat

necrosis of pancreatitis

Ascites common, may be loculated

Intestinal obstruction may respond to antituberculous treatment without surgery

TUBERCULOUS
PERITONITIS
Origin of infection:

Tuberculous mesentric lymph nodes

Tuberculosis of the ileocaecal region
A tuberculous pyosalpinx
Blood-borne infection from pulmonary
tuberculosis

TUBERCULOUS
PERITONITIS
Varieties of tuberculous peritonitis

Ascitic form
Encysted form
Fibrous form
Purulent form (rare)

PNEUMOCOCCAL
PERITONITIS
Primary pneumococcal peritonitis may complicate nephrotic
syndrome or cirrhosis in children

Particularly girls between 3 and 9 years of age route of

infection: vagina and fallopian tubes

Route of infection in males blood-borne and secondary to

respiratory tract or middle ear disease

Onset is sudden, pain localised to the lower half of the

abdomen

Temperature raise to 39C

Frequent vomiting
Profuse diarrhea is characteristic after 24-48 hours
Increased frequency of micturation

PNEUMOCOCCAL
PERITONITIS
Treatment:
Antibiotic therapy
Correction of imbalance electrolye and
dehydration
Early surgery

TERIMA KASIH