P E R I T O N I T I SFAISALGHANISIDDIQUIMBBS; FCPS; PGDIP-BIOETHICS; MCPS-HPE

PROFESSOR OF SURGERY &DIRECTOR, PROFESSIONAL DEVELOPMENT CENTREJ I N N A H S I N D H M E D I C A L U N I V E R S I T Y

LEARNING OBJECTIVES

• Nature and functions of the peritoneal membrane

• Causes of peritonitis• Clinical features of peritonitis• Investigations • Management• Complications of peritonitis

LEARNING OBJECTIVES

• Nature and functions of the peritoneal membrane

• Causes of peritonitis• Clinical features of peritonitis• Investigations• Management• Complications of peritonitis

STRUCTURE OF PERITONEAL MEMBRANE

• Lined by mesothelium (flattened polyhedral cells)• Mesothelium rests on a thin layer of fibroelastic tissue• FE tissue is supported by areolar tissue rich in

lymphatics and capillaries

PARTS OF PERITONEAL MEMBRANE

• Visceral peritoneum• Parietal peritoneum

FUNCTIONS OF PERITONEAL MEMBRANE

• Visceral lubrication• Pain perception• Inflammatory and immune response• Bacteria and particulate absorption

LEARNING OBJECTIVES

• Nature and functions of the peritoneal membrane

• Causes of peritonitis• Clinical features of peritonitis• Investigations• Management• Complications of peritonitis

DEFINITION OF PERITONITIS Inflammation of the peritoneal membrane

CAUSES OF PERITONITIS

Bacteria: gastrointestinal and non-gastrointestinalChemicals: bile, barium, urine, bloodAllergy: cornstarch Trauma: operations, traumaIschaemia: strangulated bowel

SOURCES OF BACTERIA

GASTROINTESTINALGastrointestinal perforation: perforated ulcer, appendix, diverticulumTransmural translocation: pancreatitis, ischaemic bowel

NON-GASTROINTESTINALExogenous: trauma, surgery, drainsFemale genital tract: pelvic inflammatory diseaseHaematogenous: sepeticemia

MICROORGANISM IN PERITONITIS

GASTROINTESTINALE. ColiKlebsiella pneumoniaestreptococciClostridiumBacteroides BLOOD

StaphylococciHemolytic streptococciStreptococcuspneumoniae

FEMALE GENITAL TRACTChlamydia trachomatisNeisseria gonorrheae

OTHERMycobacterium tuberculosisFungus

CAUSES OF BILE PERITONITIS

Perforated acute cholecystitisPostcholecystectomy• Cystic duct stump leak• Accessory duct in gall bladder bed• Bile duct injury• T-tube drain dislodgement

Other operations• Leaking duodenal stump• Leaking biliary-enteric anastomosis

LEARNING OBJECTIVES

• Nature and functions of the peritoneal membrane

• Causes of peritonitis• Clinical features of peritonitis• Investigations• Management• Complications of peritonitis

CLINICAL FEATURES -SYMPTOMS

• Abdominal pain• Nausea, vomiting• Lassitude• Fever• Constipation

CLINICAL FEATURES -SIGNS

• Fever• Tachycardia• Abdominal distension• Rebound tenderness• Tenderness• Guarding and rigidity• Sluggish or absent bowel

sounds

Hippocratic Facies-Sunken eyes-Drawn and anxious face-Cold, clammy skin-Dry tongue

LEARNING OBJECTIVES

• Nature and functions of the peritoneal membrane

• Causes of peritonitis• Clinical features of peritonitis• Investigations• Management• Complications of peritonitis

LAB INVESTIGATIONS

• Blood CP• Urea & electrolytes• Serum amylase• Blood grouping and cross-

match

X-RAYS

• Erect Chest X-ray• Lateral decubitus• Supine X-ray abdomen

CT SCAN ABDOMEN

Helps identify the cause of peritonitis

LEARNING OBJECTIVES

• Nature and functions of the peritoneal membrane

• Causes of peritonitis• Clinical features of peritonitis• Investigations• Management• Complications of peritonitis

MANAGEMENT OF PERITONITIS

General management of the patient

Specific treatment of the cause

GENERAL MANAGEMENT OF THE PATIENT

• Correction of fluid / electrolyte imbalance• Urinary catheterization• NG intubation• Antibiotics• Analgesia• Position of patient

SPECIFIC TREATMENT OF THE CAUSE

• If the cause of peritonitis is amenable to surgery, operation must be carried out as soon as the patient is fit

• Remove the cause• Peritoneal lavage and drainage to remove all

seropurulent exudate

LEARNING OBJECTIVES

• Nature and functions of the peritoneal membrane

• Causes of peritonitis• Clinical features of peritonitis• Investigations• Management• Complications of peritonitis

COMPLICATIONS OF PERITONITIS

• Systemic complications• Bacteraemic / endotoxic shock• SIRS / MODS• Death

• Local complications• Residual abscess• Portal pyaemia / liver abscess• Adhesions / intestinal obstruction