INTRAABDOMINAL INFECTION, PERITONITIS

Classification of Intraabdominal Infections

I. Primary Peritonitis A. Spontaneous peritonitis in children B. Spontaneous peritonitis in adults C. Peritonitis in patients with CAPD D. Tuberculous and other granulomatous peritonitis E. Other forms II. Secondary Peritonitis A. Acute perforation peritonitis (acute suppurative peritonitis) 1. Gastrointestinal tract perforation 2. Bowel wall necrosis (intestinal ischemia) 3. Pelvic peritonitis 4. Other forms B. Postoperative peritonitis 1. Anastomotic leak 2. Leak of a simple suture 3. Blind loop leak 4. Other iatrogenic leaks C. Posttraumatic peritonitis 1. Peritonitis after blunt abdominal trauma 2. Peritonitis after penetrating abdominal trauma 3. Other forms

Classification of Intraabdominal Infections (continue)

III. Tertiary Peritonitis A. Peritonitis without evidence for pathogens B. Peritonitis with fungi C. Peritonitis with low-grade pathogenic bacteria IV. Other Forms of Peritonitis A. Aseptic/sterile peritonitis B. Granulomatous peritonitis C. Drug-related peritonitis D. Periodic peritonitis E. Lead peritonitis F. Hyperlipidemic peritonitis G. Porphyric peritonitis H. Foreign-body peritonitis I. Talc peritonitis V. Intraabdominal Abscess A. Associated with primary peritonitis B. Associated with secondary peritonitis

A. There are two kinds of cells, cuboidal cells (C) and flattened cells (F), on the peritoneum of the muscular portion of the diaphragm. Stomata (S) are detected among cuboidal cells. B. B. There are some filamentous projections (arrow) across the stoma, which is a deep pore on the tendinous portion of the diaphragmatic peritoneum.

Diagram of a typical stoma and underlying channel linking the peritoneal cavity with the lumen of a lymphatic lacuna. Lacunar mesothelial cells forming the stoma and flaplike endothelial processes that bridge the channel contain actin filaments. Where lacunar mesothelial cells and lacunar endothelial cells meet, their apposed plasma membranes lack junctional specializations. Both types of cell lack a basement membrane. The connective tissue adjacent to the channel contains abundant microfibrils. A pseudopod of a fibroblast contacts an endothelial cell

Left sagittal drawing of the compartments of the retroperitoneal space in this area and its relationship to the contiguous viscera. Note that viscera. the anterior and posterior layers of the renal fascia are fused superiorly but open inferiorly, favoring the spread of infections inferiorly. inferiorly.

Anterior and left and right sagittal views of the peritoneal cavity demonstrating the anatomic locations of various intraperitoneal abscesses, such as right lower quadrant, subphrenic, subhepatic, pelvic, lesser sac, interloop, Morison's pouch, right paracolic, and left paracolic.

Foreign Bodies That May Enhance Intraabdominal Infection

Macroscopic Foreign Material Surgical drains Suture material Laparotomy sponges Hemostatic pads/powders Surgical clips Prosthetic implants Microscopic Foreign Materials Barium sulfate Clothing fibers (can be introduced during penetrating trauma) Fecal material Necrotic tissue Talcum powder or other surgical glove powders (less likely with modern corn starch)

Adjuvant Substances for Intraabdominal Infection

Factor Blood Fibrin Fluid Bile Urine Chyle Pancreatic fluid Platelets Effect Nutritive effect on bacterial growth, Hgb toxic to WBCs Impairs PMN chemotaxis, sequesters bacteria Impairs phagocytosis, dilutes opsonins Lysis of host leukocytes Opsonin deficient Opsonin deficient Opsonin deficient Impair bacterial clearance, perhaps secondary to physical obstruction of diaphragmatic lymph channels

Hgb = hemoglobin; PMN = polymorphonuclear leukocyte; WBC = white blood cell

Experimental (rat) model indicating cumulative percentage mortality with varying inoculum size of human fecal material in the peritoneal cavity.

Bacterial Isolates from Intraoperative Cultures in Clinical intraabdominal Infection

Organism % of Patients with Organism Gorbach 1974 Escherichia coli Enterobacter/Klebsiella sp. Proteus sp. Pseudomonas aeruginosa Staphylococcus sp. Bacteroides fragilis Other Bacteroides sp. Fusobacterium sp. Peptostreptococcus sp. Enterococcus sp. 61 37 22 17 34 Anaerobes 26 58 14 26 4 34 51 8 14 23 23 21 6 7 23 5 16 11 45 Stone 1975 67 32 28 20 6 Solomkin 1990 58 39 6 15 11 Mosdell 1991 69 23 3 19 11

Gram-negative Aerobes

Gram-positive Aerobes

Bacteria Commonly Encountered in Intraabdominal Infections

Facultative Gramnegative Bacilli Escherichia coli Klebsiella species Proteus species Enterobacter species Morganella morganii Other enteric gramnegative bacilli Aerobic gram-negative bacilli Pseudomonas aeruginosa Obligate Anaerobes Bacteroides fragilis Bacteroides species Fusobacterium species Clostridium species Peptococcus species Pepostreptococcus species Lactobacillus species Facultative Gram-positive Cocci Enterococci Staphylococcus species Streptococcus species

Dermatome Origin of the Innervation of Intraabdominal Structures

Organ/Structure
Esophagus Stomach Small intestine Colon Liver Gallbladder Uterus Kidney Bladder Diaphragm

Dermatome Innervation
Vagus (brainstem) T57 T810 T10L1 T68 T68 T10L1 T10L1 S24 C48

C = cervical; L = lumbar; T = thoracic; S = sacral

The most obvious route of fluid and electrolyte loss.

   

into the bowel lumen into the edematous bowel wall into the free peritoneal cavity by vomiting or nasogastric suction

Free gas beneath the diaphragm

Plain film findings in hydropneumoperitoneum. hydropneumoperitoneum.

Upright view shows fluid level too long to be within a loop of bowel.

Unsuspected perforated duodenal ulcer. ulcer.

A Small amount of extraluminal gas (arrow) lies lateral to duodenal bulb (d). g, gallbladder.

Unsuspected perforated duodenal ulcer. ulcer.

B At 3cm caudad, gas (arrow) tracks behind the gallbladder (g) laterally.

Unsuspected perforated duodenal ulcer. ulcer.

C The air-fluid level (arrow) identifies the loculated extravasated airduodenal contents. Inflammatory changes are present in the surrounding mesenteric fat.

AirAir-fluid levels in the small bowel.

AirAir-fluid levels in the small bowel.

AirAir-fluid levels in the small bowel. Absence of gas in the colon.

Visible mucosal folds in the distended small bowel.