Functions of the peritoneum Causes of peritoneal inflammation

In health ●● Bacterial, gastrointestinal and non-

●● Visceral lubrication
●● Fluid and particulate absorption
In disease
●● Pain perception (mainly parietal)
●● Inflammatory and immune responses
●● Fibrinolytic activity
gastrointestinal
●● Chemical, e.g. bile, barium
●● Allergic, e.g. starch peritonitis
●● Traumatic, e.g. operative handling
●● Ischaemia, e.g. strangulated bowel,
vascular occlusion
●● Miscellaneous, e.g. familial Mediterranean
fever

Mesenteric tumours Causes of peritoneal inflammation

Benign ●● Bacterial, gastrointestinal and non-
●● Lipoma gastrointestinal
●● Fibroma ●● Chemical, e.g. bile, barium
●● Fibromyxoma ●● Allergic, e.g. starch peritonitis
Malignant ●● Traumatic, e.g. operative handling
●● Lymphoma ●● Ischaemia, e.g. strangulated bowel,
●● Secondary carcinoma vascular occlusion
●● Miscellaneous, e.g. familial Mediterranean
fever

Clinical features of an abdominal/pelvic abscess Mesenteric cysts: clinical features

Symptoms ●● Cysts occur most commonly in adults with a mean age of 45
●● Malaise, lethargy – failure to recover from years
surgery as expected ●● Twice as common in women as in me
●● Anorexia and weight loss ●● Rare: incidence around 1 per 140 000
●● Sweats ± rigors ●● Approximately a third of cases occur in children younger
●● Abdominal/pelvic pain than
●● Symptoms from local irritation, e.g. shoulder 15 years
tip/hiccoughs ●● The mean age of children affected is 4.9 years
(subphrenic), diarrhoea and mucus (pelvic), nausea ●● The most common presentation is of a painless abdominal
and swelling with characteristic physical signs
vomiting (any upper abdominal) there is a fluctuant swelling near the umbilicus
Signs the swelling moves freely in a plane at right angles to the
●● Increased temperature and pulse ± swinging attachment of the mesentery (Tillaux’s sign) (Figure 61.12)
pyrexia there is a zone of resonance around the cyst
●● Localised abdominal tenderness ± mass ●● Other presentations are with recurrent attacks of abdominal
(including on pelvic pain with or without vomiting (pain resulting from recurring
exam) temporary impaction of a food bolus in a segment of
bowel narrowed by the cyst or possibly from torsion of the
mesentery) and acute abdominal catastrophe, due to:
torsion of that portion of the mesentery containing the cyst
rupture of the cyst, often as a result of a comparatively
trivial accident
haemorrhage into the cyst
infection
Causes of retroperitoneal fibrosis Achalasia
Benign ●● Is uncommon
●● Idiopathic (Ormond’s disease) ●● Is due to selective loss of inhibitory
●● Chronic inflammation neurons in the lower
●● Extravasation of urine oesophagus
●● Retroperitoneal irritation by leakage of blood or intestinal ●● The causes dysphagia and carcinoma
content must be excluded
●● Aortic aneurysm (inflammatory type) ●● Treatment is by either endoscopic
●● Trauma dilatation, or endoscopic or
●● Drugs (chemotherapeutic agents and previously surgical myotomy
methysergide)
Malignant
●● Lymphoma
●● Carcinoid tumours
●● Secondary deposits (especially

Stimulate secretion Factors associated with pseudo-obstruction

Gastrin
Histamine ●● Metabolic
Acetylcholine Diabetes
Gastrin-releasing peptide Hypokalaemia
Cholecystokinin (CCK) Uraemia
Myxodoema
Inhibit secretion Intermittent porphyria
Somatostatin ●● Severe trauma (especially to the lumbar spine and pelvis)
Secretin ●● Shock
Enteroglucagon Burns
Prostaglandins Myocardial infarction
Neurotensin Stroke
GIP ●● Idiopathic
PYY ●● Septicaemia
●● Postoperative (for example fractured neck of femur)
Stimulate motility ●● Retroperitoneal irritation
Acetylcholine Blood
5-HT Urine
Histamine Enzymes (pancreatitis)
Substance P Tumour
Substance K ●● Drugs
Motilin Tricyclic antidepressants
Gastrin Phenothiazines
Angiotensin Laxatives
●● Secondary gastrointestinal involvement
Inhibit motility Scleroderma
Somatostatin Chagas’ disease
VIP
Nitric oxide
Noradrenaline
Encephalin
Dopamine
GORD
●● Is due to loss of competence of the LOS and is extremely
common
●● May be associated with a hiatus hernia, which may be sliding
or, less commonly, rolling (paraoesophageal)
●● The most common symptoms are heartburn, epigastric
discomfort and regurgitation, often made worse by stooping
and lying
●● Achalasia and GORD are diagnostically easily confused
Dysphagia may occur, but a neoplasm must be excluded
Diagnosis and treatment can be instituted on clinical
grounds
●● Endoscopy may be required and 24-hour pH is the ‘gold
standard’
Management is primarily medical (PPIs being the most
effective), but surgery may be required; laparoscopic
fundoplication is the most popular technique
Stricture may develop in time

Peptic ulceration
●● Most peptic ulcers are caused by H. pylori or NSAIDs and
changes in epidemiology mirror changes in these principal
aetiological factors
●● Duodenal ulcers are more common than gastric ulcers, but
the symptoms are indistinguishable
●● Gastric ulcers may become malignant and an ulcerated
gastric cancer may mimic a benign ulcer
●● Gastric antisecretory agents and H. pylori eradication therapy
are the mainstay of treatment, and elective surgery is very
rarely performed
●● The long-term complications of peptic ulcer surgery may be
difficult to treat
●● The common complications of peptic ulcers are perforation,
bleeding and stenosis
●● The treatment of the perforated peptic ulcer is primarily
surgical, although some patients may be managed
conservatively

CF of peptic ulcer
Pain
Periodicity
Vomiting
Alteration in weight
Bleeding

Causes of acute liver failure

●● Viral hepatitis (hepatitis A, B, C, D, E)
●● Drug reactions (halothane, isoniazid–rifampicin,
antidepressants, non-steroidal anti-inflammatory drugs,
valproic acid)
●● Paracetamol overdose
●● Mushroom poisoning
●● Shock and multiorgan failure
●● Acute Budd–Chiari syndrome
●● Wilson’s disease
●● Fatty liver of pregnancy
Risk factors for perforation of the appendix Polyps in the rectum
●● Extremes of age ●● Adenomas are the most frequent histological type
●● Immunosuppression ●● Villous adenomas may be extensive and undergo
●● Diabetes mellitus malignant
●● Faecolith obstruction change more commonly than tubular adenomas
●● Pelvic appendix ●● All adenomas must be removed to avoid malignant
●● Previous abdominal surgery change
●● All patients must undergo colonoscopy to determine
Early symptoms of rectal whether
cancer further polyps are present
●● Bleeding per rectum ●● Most polyps can be removed by endoscopic
●● Tenesmus techniques, but
●● Early morning diarrhoea sometimes major surgery is required

Congenital/childhood Causes of anal

incontinence Anal fissure
●● Anorectal anomalies ●● Acute or chronic
●● Ischaemic ulcer in the midline of the anal canal
●● Spina bifida
●● Hirschsprung’s disease ●● Ectopic site suggests a more sinister cause
Symptoms:
●● Behavioural
●● Pain on defaecation
●● Bright-red bleeding
●● Mucus discharge
●● Constipation