PERITONITIS

DEFINITION
Acute Peritonitis is a localised or
generalised inflammatory process of
the peritoneum.
Peritonitis refers to inflammation of
the peritoneal lining or cavity, as
may occur with either a perforation
or by spread of infection through the
wall of one of the abdominal organs.
This too is a serious condition, and
often requires emergency surgery.
Anatomy
Visualize the abdomen
as a completely empty
shell.
Let's then imagine
pouring a rubber
substance that creates a
continuous lining of this
cavity. We will define
this thin rubber liner as
the peritoneum (see
Figure).
In reality, it is a
membrane just a few
millimeters thick that
has the ability to absorb
fluids in the abdomen.
Anatomy
Now let's imagine
pushing this flexible
lining inward, like
pushing your finger into
a balloon (Figure).
This causes an
indentation that is
surrounded by the
peritoneum, and the
resulting double-layer
structure is known as
the mesentery, that
encases and suspends
the small intestine.
Anatomy
In between these peritoneal
sides of the mesentery, we
find fatty tissue, blood vessels
and lymphatics that support
the intestines (Figure).
This is important in providing
a healthy blood supply to the
intestine and the return of
nutrients absorbed by the gut
to the circulation and lymph
system. This in turn reaches
your main circulation so the
nutrients can be used to keep
the person nourished. The
mesentery also acts to anchor
the bowel to the body. In this
case the gut where the
mesentery connects the bowel
to the posterior muscular
attachments.
Anatomy
We can now see the
intraperitoneal and
retroperitoneal regions. The
area within the peritoneum is
referred to as
intraperitoneal. Before we begin
to place organs within the
abdomen, we need to clarify the
boundaries of the abdominal
cavity.
Superior (closest to the head) is
defined by the breathing muscle
- the diaphragm,
Posterior (back) is defined by
the muscles of the body wall
and the spine,
Lateral/anterior (sides/front)-
are formed by the muscles of
the abdomen, and
Inferior (closest to the feet)
boundary is formed by the
muscles of the pelvic floor.
Anatomy
Organs contained within the peritoneal
cavity are called intraperitoneal and
include the stomach, liver, gallbladder,
most of the small intestine and a portion
of the colon (transverse and sigmoid
colon).
Organs that lie behind these structures
are referred to as retroperitoneal. These
included the aorta (artery that carries
blood from the heart to the body),
inferior vena cava (vein that returns most
of the blood from the body back to the
heart), first portion of the small intestine
(duodenum), pancreas, adrenal glands,
the ascending and descending colon,
kidneys, ureters (tubes that carry urine
from the kidneys to the bladder),
multiple sensory nerves to the abdominal
walls (extending to the groin and upper
legs), and nerves that regulate bowel
control and sexual function (both found
in the pelvic portion of the
retroperitoneum).
Anatomy
Layers
Do not confuse the abdominal cavity (the
space bounded by the vertebrae, abdominal
muscles, diaphragm and pelvic floor) with
the intraperitoneal space (located within the
abdominal cavity, but wrapped in
peritoneum). For example, a kidney is inside
the abdominal cavity, but is retroperitoneal.
Although they ultimately form one
continuous sheet, two types or layers of
peritoneum and a potential space between
them are referenced:
The outer layer, called the parietal
peritoneum, is attached to the abdominal
wall.
The inner layer, the visceral peritoneum,
is wrapped around the internal organs that
are located inside the intraperitoneal cavity.
The potential space between these two
layers is the peritoneal cavity; it is filled
with a small amount (about 50 ml) of
slippery serous fluid that allows the two
layers to slide freely over each other.
The term mesentery is often used to refer to
a double layer of visceral peritoneum. There
are often blood vessels, nerves, and other
structures between these layers.
Anatomy
Subdivisions
There are two main regions of the
peritoneum, connected by the
epiploic foramen:
the greater sac (or general cavity
of the abdomen), represented in
red in the diagrams above.
the lesser sac (or omental bursa),
represented in blue. The lesser
sac is divided into two "omenta":
– The lesser omentum (or
gastrohepatic) is attached to the
lesser curvature of the stomach
and the liver.
– The greater omentum (or
gastrocolic) hangs from the
greater curve of the stomach and
loops down in front of the
intestines before curving back
upwards to attach to the
transverse colon. In effect it is
draped in front of the intestines
like an apron and may serve as an
insulating or protective layer.
 Development
The peritoneum develops ultimately from the
mesoderm of the trilaminar embryo. As the
mesoderm differentiates, one region known as
the lateral plate mesoderm splits to form two
layers separated by an intraembryonic coelom.
These two layers develop later into the visceral
and parietal layers found in all serous cavities,
including the peritoneum.
As an embryo develops, the various abdominal
organs grow into the abdominal cavity from
structures in the abdominal wall. In this process
they become enveloped in a layer of peritoneum.
The growing organs "take their blood vessels with
them" from the abdominal wall, and these blood
vessels become covered by peritoneum, forming
a mesentery.
 Causes
Infected peritonitis
Perforation of a hollow viscus is the most common
cause of peritonitis. Examples include perforation of the
distal oesophagus, of the stomach (peptic ulcer, gastric
carcinoma, of the duodenum (peptic ulcer), of the
remaining intestine (e.g. appendicitis, diverticulitis,
Meckel diverticulum, intestinal infarction, intestinal
strangulation, colorectal carcinoma, meconium
peritonitis), or of the gallbladder (cholecystitis). Other
possible reasons for perforation include trauma,
ingestion of sharp foreign body (such as a fish bone),
perforation by an endoscope or catheter, and
anastomotic leakage. The latter occurrence is
particularly difficult to diagnose early, as abdominal
pain and ileus paralyticus are considered normal in
patients who just underwent abdominal surgery. In
most cases of perforation of a hollow viscus, mixed
bacteria are isolated; the most common agents include
Gram-negative bacilli (e.g. Escherichia coli) and
anaerobic bacteria (e.g. Bacteroides fragilis).
 Causes
Infected peritonitis
Disruption of the peritoneum, even in the absence of
perforation of a hollow viscus, may also cause infection
simply by letting microorganisms into the peritoneal
cavity. Examples include trauma, surgical wound,
continuous ambulatory peritoneal dialysis, intraperitoneal
chemotherapy. Again, in most cases mixed bacteria are
isolated; the most common agents include cutaneous
species such as Staphylococcus aureus, and coagulase-
negative staphylococci, but many others are possible,
including fungi such as Candida.
Spontaneous bacterial peritonitis (SBP) is a peculiar form
of peritonitis occurring in the absence of an obvious
source of contamination. It occurs either in children, or
in patients with ascites. See the article on spontaneous
bacterial peritonitis for more information.
Systemic infections (such as tuberculosis) may rarely
have a peritoneal localisation.
 Infected peritonitis
Bacteroidesare commonly found in peritonitis.
These Gram-negative, nonsporing organisms,
although predominant in the lower intestine,
often escape detection because they are
strictly anaerobic, and slow to grow on culture
media unless there is an adequate carbon
dioxide tension in the anaerobic apparatus
(Gillespie). In many laboratories, the culture is
discarded if there is no growth in 48 hours.
These organisms are resistant to penicillin and
streptomycin but sensitive to metronidazole,
clindamycin, lincomycin and cephalosporin
compounds. Since the widespread use of
metronidazole (‘Flagyl’) bacteroides infections
have diminished greatly.
 Non-infected peritonitis
Leakage of sterile body fluids into the
peritoneum, such as:
blood (e.g. endometriosis, blunt abdominal
trauma),
gastric juice (e.g. peptic ulcer, gastric
carcinoma),
bile (e.g. liver biopsy),
urine (pelvic trauma),
menstruum (e.g. salpingitis),
pancreatic juice (pancreatitis), or even the
contents of a ruptured dermoid cyst.
It is important to note that, while these body
fluids are sterile at first, they frequently become
infected once they leak out of their organ,
leading to infectious peritonitis within 24-48h.
 Non-infected peritonitis
Sterile abdominal surgery normally causes
localised or minimal generalised
peritonitis, which may leave behind a
foreign body reaction and/or fibrotic
adhesions. Obviously, peritonitis may also
be caused by the rare, unfortunate case of
a sterile foreign body inadvertently left in
the abdomen after surgery (e.g. gauze,
sponge).
Much rarer non-infectious causes may
include familial Mediterranean fever,
porphyria, and systemic lupus
erythematosus.
 Pathology
The peritoneum normally appears greyish
and glistening; it becomes dull 2-4 hours
after the onset of peritonitis, initially with
scarce serous or slightly turbid fluid.
Later on, the exudate becomes creamy
and evidently suppurative; in dehydrated
patients, it also becomes very inspissated.
The quantity of accumulated exudate
varies widely. It may be spread to the
whole peritoneum, or be walled off by the
omentum and viscera.
Inflammation features infiltration by
neutrophils with fibrino-purulent
exudation.
 Classification
Peritonitis are classified according to:
- character of microbial contamination: primary
or secundary;
- the clinical course: acute and chronic;
- etiological agents: peritonotis, caused by
bacteria of digestive tract (E.coli, staphylococci,
streptococci, proteus, anaerobes, etc.) Also
distingueshed aseptic (nonbacterial) peritonitis,
resulting from irritation by blood, bile,
pancreatic juice or urine;
- the character of exudate: serous, fibrinous,
purulent, hemorrhagic, “peritonitis sicca”;
- the extension of inflammatory process: local,
diffuse, generelized (common).
The extension of inflammatory
process

If has been affected:

Only 1 area – local
peritonitis;
From 2-5 arae’s – diffuse;
>5 area’s - total
 The Stages
1. Reactive (first 24 hours) – maximal
manifestation of local signs of the disease.
2. Toxic (24-72 hours) - gradual reducing
of local signs and increasing general
intoxication.
3. Terminal (after 72 hours) – severe,
often unreversable intoxication on the
background of sharply expressed local
manifestation of peritoneal inflammation.
Abdominal pain & tenderness
The main manifestations of peritonitis are acute
abdominal pain, tenderness, and guarding,
which are exacerbated by moving the
peritoneum, e.g. coughing, flexing the hips, or
eliciting the Blumberg sign (rebound tenderness),
meaning that pressing a hand on the abdomen
elicits pain, but releasing the hand abruptly will
aggravate the pain, as the peritoneum snaps
back into place).
The localisation of these manifestations depends
on whether peritonitis is localised (e.g.
appendicitis or diverticulitis before perforation),
or generalised to the whole abdomen; even in the
latter case, pain typically starts at the site of the
causing disease.
Peritonitis is an example of acute abdomen.
 Collateral manifestations
Diffuse abdominal rigidity
("washboard abdomen") is often
present, especially in generalised
peritonitis;
Fever;
Sinus tachycardia;
Development of ileus paralyticus (i.e.
intestinal paralysis), which also
causes nausea and vomiting;
 Complications
Sequestration of fluid and electrolytes, as
revealed by decreased central venous
pressure, may cause electrolyte
disturbances, as well as significant
hypovolaemia, possibly leading to shock
and acute renal failure.
A peritoneal abscess may form (e.g.
above or below the liver, or in the lesser
omentum).
Sepsis may develop, so blood cultures
should be obtained.
the fluid may push on the diaphragm and
cause breathing difficulties
Diagnosis and investigations
A diagnosis of peritonitis is based primarily on
clinical grounds, that is on the clinical
manifestations described above; if they support a
strong suspicion of peritonitis, no further
investigation should delay surgery.
Leukocytosis and acidosis may be present, but
they are not specific findings.
Plain abdominal X-rays may reveal dilated,
oedematous intestines, although it is mainly
useful to look for pneumoperitoneum (free air in
the peritoneal cavity), which may also be visible
on chest X-rays.
If reasonable doubt still persists, an exploratory
peritoneal lavage may be performed (e.g. in
cause of trauma, in order to look for white blood
cells, red blood cells, or bacteria).
Diagnosis and investigations
Clinical examination
Postoperative peritonitis
 Treatment
Depending on the severity of the patient's state, the
management of peritonitis may include:

General supportive measures such as vigorous

intravenous rehydration and correction of electrolyte
disturbances.
Antibiotics are usually administered intravenously, but
they may also be infused directly into the peritoneum. The
empiric choice of broad-spectrum antibiotics
(carvbopenems) often consist of multiple drugs, and should
be targeted against the most likely agents, depending on
the cause of peritonitis (see above); once one or more
agents are actually isolated, therapy will of course be
targeted on them.
Surgery (laparotomy) is needed to perform a full
exploration and lavage of the peritoneum, as well as to
correct any gross anatomical damage which may have
caused peritonitis.
The exception is spontaneous bacterial peritonitis, which
does not benefit from surgery.
 Surgery
Analgesia The patient should be nursed
in the sitting-up position and must be
relieved of pain before and after
operation. Once the diagnosis has been
made morphine may be given, and
continued as necessary. If appropriate
expertise is available epidural infusion
may provide excellent analgesia. Freedom
from pain allows early mobilisation and
adequate physiotherapy in the
postoperative period which help to prevent
basal pulmonary collapse, deep-vein
thrombosis and pulmonary embolism.
Specific treatment of the cause
If the cause of peritonitis is amenable to
surgery, such as in perforated
appendicitis, diverticulitis, peptic ulcer,
gangrenous cholecystitis or in rare cases
of perforation of the small bowel,
operation must be carried out as soon as
the patient is fit for anaesthesia. This is
usually within a few hours.

In peritonitis due to pancreatitis or

salpingitis, or in cases of primary
peritonitis of streptococcal or
pneumococcal origin, nonoperative
treatment is preferred (if the diagnosis
can be made with certainty)
 Peritoneal lavage
In operations for general peritonitis
itis essential that after the cause has
been dealt with the whole penitoneal
cavity should be explored with the
sucker and mopped dry, if necessary
until all seropurulent exudate is
removed. The use of a large volume
of saline (1—2 litres) containing
dissolved antibiotic (e.g.
tetracycline) has been shown to be
very effective (Matheson).
Peritoneal lavage
Laparostomy
Laparostomy
Laparostomy
 Specific complication
Subphrenic
abscess (1-2)
Subhepatic
abscess (3)
Appendicular
abscess (4)
Interintestinal
abscess (6)
Pelvic abscess(5)
 Definition
An intra-abdominal abscess is a
pocket of infected fluid and pus
located inside abdominal cavity.
There may be more than one
abscess.
 Causes, incidence, and risk
factors
An intra-abdominal abscess can be caused
by a ruptured appendix, ruptured
intestinal diverticulum, inflammatory
bowel disease, parasite infection in the
intestines (Entamoeba histolytica), or
other condition.
Risk factors include a history of
appendicitis, diverticulitis, perforated ulcer
disease, or any surgery that may have
infected the abdominal cavity.
• Symptoms

Depending on the location, symptoms may

include:
Abdominal pain and distention
Chills
Diarrhea
Fever
Lack of appetite
Nausea
Rectal tenderness and fullness
Vomiting
Weakness
 Signs and tests

A complete blood count may show a higher than

normal white blood count. A comprehensive
metabolic panel may show liver, kidney, or blood
chemistry problems.
A CT scan of the abdomen will usually reveal an
intra-abdominal abscess. After the CT scan is
done, a needle may be placed through the skin
into the abscess cavity to confirm the diagnosis
and treat the abscess.
Other tests may include:

Sometimes surgery called a laparotomy may be

needed to diagnose this condition.
 Treatment

Treatment of an intra-abdominal abscess requires

antibiotics (given by an IV) and drainage. Drainage involves
placing a needle through the skin in the abscess, usually
under x-ray guidance. The drain is then left in place for
days or weeks until the abscess goes away.
Occasionally, abscesses cannot be safely drained this way.
In such cases, surgery must be done while the patient is
under general anesthesia (unconscious and pain-free). A
cut is made in the belly area (abdomen), and the abscess is
drained and cleaned. A drain is left in the abscess cavity,
and remains in place until the infection goes away.
It is always important to identify and treat the cause of the
abscess.
 Expectations (prognosis)

The outlook depends on the original

cause of the abscess and how bad
the infection is. Generally, drainage
is successful in treating intra-
abdominal abscesses that have not
spread.
 Result’s
Prognosis

With modern treatment diffuse

peritonitis carries a mortality of
about 10 per cent.
• Complications

Complications include:
Rupture of an abscess
Return of the abscess
Spread of the infection to the
bloodstream
Widespread infection in the abdomen