Peritonitis

Pathology

 Invasion
i off b
bacteria
i → iinflammation
fl i ((exudation
d i off
Purulent inflammations fluid) → hypovolemia (third space sequestration,
vomiting, paralytic ileus) and electrolyte
of serous cavities disbalance) → peripheral vasoconstriction → poor
perfusion → lactic acidosis → microcirculatory
disorders → SIRS and MODS
 Intoxication is caused by absorption of necrotic
materials and bacterial toxins

Etiology

 penetrating or blunt abdominal trauma with injury to

intraabdominal organs (hollow);
 inflammatory diseases of intraabdominal organs such as acute
appendicitis, cholecistitis, pancreatitis, tumor necrosis,
incarcerated hernia, etc. which may be complicated by secondary
peritonitis;
 perforation of hollow intraabdominal organs (perforated duodenal
or gastric ulcer, perforated diverticulus, due to foregin bodies,
etc ):
etc.):
 volvulus and bowel obstruction, diseases of female genital organs
(inflammatory processes in uterus, adnexitis or salpingo-
oophoritis)
 intestinal ischemia due to thrombosis of mesenterial vessels, and
some other disorders.

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 Etiology
Classification of peritonitis

1) etiology (primary, secondary, tertiary)

2) stage (initial or reactive, intermediate or toxic, and terminal or
MOD)
3) extend (local,
(local diffuse,
diffuse total)

Acute appendicitis Perforated gastric ulcer

Perforated diverticulus Major causes of intestinal obstructions. A) Hernia.

B) Volvulus. C) Intussusception. D) Cancer. E) Adhesions.

Clinical picture
Complaints: abdominal pain of different localization,
high body temperature, vomiting
History (of trauma, progression of signs, etc.)
Physical exam: signs of hypovolemia

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 Local status Local status
 Inspection: dryness of the mouth, presence of any scar, hernia,  Inspection:
wound, etc., thoracic breathing

Local status
 Auscultation: absence of sounds (paralytic ileus)
 Palpation: tenderness and muscle guarding, rebound tenderness.
 Percussion: Mendel's sign
 Rectal/vaginal examination (tenderness).

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 Free peritoneal air (arrow) under the Upright abdominal radiograph
 Laboratory changes characteristic to severe inflammation diaphragm on an upright chest showing air-fluid levels (arrows).
radiograph.
Instrumental DS

 Plane abdominal (chest) X-ray

 US, CT, MRI may detect free abdominal fluid
 Invasive tools: culdocentesis, paracentesis, diagnostic peritoneal
lavage (DPL), and video assisted laparoscopy may be done at
difficult DS cases.

Ultrasound study showing fluid in the pelvis (large arrow),

uterus (asterisk) and bladder (small arrow).

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 Culdocentesis
A peritoneal lavage catheter is inserted through the anterior
Aspiration of fluid from the cul-de-sac (rectouterine excavation)
abdominal wall. It is directed into the pelvis (cul-de-sac) where
by puncture of the vaginal vault near the midline between the
blood or intestinal contents or lavage fluid would pool.
uterosacral ligaments.

Management of hollow organ injury Principles and stages of surgery

 control of source of peritoneal soiling- requires exploration and  Correction of hypovolemia (shock) is required before
treatment of damaged part. surgery
 control of infection (AB)
 Wide midline laparotomy
 correction of hypovolemia by infusion therpy
 Exploration of intraabdominal organs
 detoxication therapy
 GIT decompression (NG)  Cleansing of purulent materials
 oxygen supplementation  Treatment of injured organ
 analgesia  Draining of the peritoneal cavity
 Closure of the surgical wound

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 Repair of the stomach injury
Irrigation ad suction of the exudate from the peritoneal cavity

a – excision of the wound’s edges; b – suturing of the wound

Billroth II or gastrojejunostomy. Billroth I or gastroduodenostomy

Bile and pancreatic enzymes
continue to pass into the duodenal
stump and make their way into the
jejunum by peristaltic action

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 Resection of the part of the intestine with reanastomosing of
Repair of the intestinal injury
both ends

Operative treatment of diverticulitis. a, Exteriorization; b, resection end

colostomy; c, resection, end colostomy, oversew rectum (Hartmann's); d, Local peritonitis may be drained through one or two drain
resection, primary anastomosis; e, resection, primary anastomosis, diverting loop
colostomy; f, resection, primary anastomosis, diverting loop ileostomy.

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 Peritoneal lavage

The zipper can be sutured into Irrigation of the viscera at

the operative wound (laparostomy) the postoperative period

Peritoneal lavage is done at the postoperative period Postoperative period

 Antibacterial therapy
 M i
Maintenance off fl
fluid
id b
balance
l b
by ii.v. fl
fluid
id
administration
 Detoxication therapy
 GIT decompression
 Correction of electrolyte disorders
 Proper postoperative wound care

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 Pleural effusion and empyema Pleural space infection (commonly secondary due to
extra-, and intrapulmonary reasons)
Etiology
 Pneumonia (56%)
 Lung abscess
 After surgery (thoracotomy,
thoracentesis, etc.)
 Infected hemothorax
 Trauma
 Esophageal perforation
 Subdiaphragmal infection
 Septicemia

Eruption of the lung abscess into the pleural space commonly

leads to pyopneumothorax
Pathophysiology of pleural effusion

Effusion (transudate)
The escape of fluid from the blood vessels or lymphatics
into the tissues or a cavity due to change of oncotic or
capillary pressure.
Reasons may include:
 Renal, cardiac, or hepatic diseases
 Malignancy
g y
 Rheumatoid arthritis
Classification
1. Acc. to etiology  Lupus erythematosis
2. Acc. to time: acute and chronic  Pancreatitis
3. Acc. to distribution: diffuse, loculated, single or multiple

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 Clinical picture

Complaints
Exudate
 Signs of pleural fluid accumulation
 Any fluid that has exuded out of a tissue or its capillaries,  Signs of uncontrolled infection, intoxication
more specifically
p y because of injury
j y or inflammation in
which case it is characteristically high in protein and Physical examination
white blood cells.  Change of vital signs
 Respiratory system
Phases of empyema formation  Inspection

 Exudative phase  Palpation

 Percussion
 Fibropurulent phase
 Auscultation
 Organizing phase

Physical examination
Respiratory system Additional diagnostic methods

 Laboratory: evidence of infection

 Instrumental:
 Plane chest
Pl h t radiograph
di h
 Ultrasound
 CT

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 Helical CT scan This shows bilateral pneumonias as well as a The arrow indicates the loculated empyema. The patient responded
multiloculated left pleural effusion. promptly to surgical decortication. All attempts at tube drainage
failed.

Bacteriologic studies of the pleural fluid

Treatment
Empyema: purulent character, pus, or high concentration
of bacteria  Frank empyema should be drained
Nonpurulent specimen is assessed for  pH
H less
l then
h 77,22
 pH  Glucose less then 40mg/dl

 Glucose  LDH at least 1000 IU/liter

 LDH activity  Positive culture

 Smear and culture  Protein level higher

g then 3,0mg/dl
, g/ and a specific
p
gravity higher then 1.018 are less specific
 Protein level and a specific gravity are less reliable

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 Treatment of empyema

 Parapneumonic effusion is treated by a thoracentesis

 Parapneumonic exudate (serous phasal fluid with
intermediate lab changes) is treated with antibiotics and
repeated thoracentesis in 12-18 hours to reassess the need
for drainage procedures
 Loculated fluid suggests a complex parapneumonic
process. It requires guided drainage
 Repeated thoracocentesis (thin and small empyema)
 Percutaneous drainage with small-bore
small bore catheter (or multiple
catheters) is more reliable (thin and small empyema)
Procedure
 Placement of the catheter can be done by direct trocar puncture
or modified Seldinger technique
 The cavity is irrigated (intermittently). Enzymatic therapy can
be added.
 Tubes can usually by withdrawn when the drainage is less then
50 ml/day and the cavity is less then 50 ml.

Treatment of the pleural empyema may require placement of

multiple chest tubes. Evacuation of a pus is achieved by different
Methods of placement of a chest drain
methods

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 Other surgical procedures
 Video assisted thoracoscopy (lysis of adhesions)
 Thoractomy and decortication
 Persistent bronchopleural fistulas may be closed by muscle flap
followed by obliteration of a cavity
cavity.

Medical therapy
 Antibiotics Bacterial pericarditis
 B-lactam are used for 2-4 weeks

 Emperical
p AB ((fluorquinolones)
q )
 Infusion therapy
 Detoxication therapy
 Mucolytics
 Improvement of ventilation, etc.

 Idiopathic (40-86%), more likely to be caused by viral infection

 Pericardial effusion due to malignancy, uremia, collagen vascular
diseases (SLE, RA, etc.)

Bacterial pericarditis
1. Spread
p from the focus within the chest ((secondaryy to pneumonia,
p
pleuropulmonary infection, esophageal perforation, mediastinitis,
trauma, after thoracic surgery, etc.)
2. Spread from the focus within the heart (bacterial endocarditis)
3. Hematogenous
4. Direct inoculation (penetrating injury, heart surgery)

Pathology
 Inflammation → secretion of fluid (effusion) and cells →
resolution or progress to fibrous thickening without or with
constriction (obliteration of the pericardial space and
calcification is followed by constrictive pericarditis).
 Rapid collection of fluid may lead to tamponade.

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 Clinical manifestation of bacterial pericarditis

 Commonly develops during the course of severe systemic

infection
 Signs of acute illness with general signs (fever, malaise,
etc.) may be attributed to the underlying disease.
 Chest pain (retrosternal with irradiation to the shoulder)
 Vital signs change (dispnea, tachicardia, etc.)
 Respiratory examination: pericardial friction rub is
possible, may be signs of underlying disorder.

 Laboratory techniques (inflammatory changes)

 Instrumental techniques: ECG, EchoCG, CT, plane chest X-ray.  Bacterial pericarditis is more likely to have serious
hemodinamic consequences.

Treatment
 Surgical drainage of the pericardium
 Periacrdiectomy is reserved for those who failed to
improve or deteriorate
 Appropriate antibacterial therapy
 T
Treatment off a main
i di
disorder
d

This scan shows an abnormal amount of fluid in the pericardial sac.

RV, right ventricle; HP, hemopericardium; LV, left ventricle.

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