PERITONITIS AND INTRAABDOMINAL ABSCESS

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Peritonitis topic standard textbook peritonitis

surgical infection

… Resident Paper

Anatomy
• Peritoneal cavity potential space diaphragm pelvis ...
2
• space subphrenic , subhepatic , paracolic pelvic space
• Peritoneum 2 parietal visceral

• Nerve supply
1. Somatic nerve T7 - T12 parietal peritoneum
abdominal muscle motor nerve spinal
reflex guarding & rigidity
2. Splanchnic nerve T7 – T12 visceral peritoneum
• visceral pain perietal
peritoneum
appendicitis

Histology
peritoneum mesothelial cell cover visceral & parietal peritoneum blood vessel
& lymphatic vessel
healing peritoneum tissue healing tissue healing heal fibroblast
peritoneal healing heal migration mesothelial cell
mature mesothelial cell peritoneal defect complete 5-8
healing time peritoneum initial defect healing time ( )
clinical & experimental studies peritoneal healing abdominal incision
peritoneum intraperitoneum adhesion

PHYSIOLOGY
• Peritoneal cavity… 100 cc. isotonic fluid
• Peritoneal absorption fluid 30 -50 cc.
• severe inflammation fluid shift 300-500 cc. … fluid loss 3rd
space severe acute pancreatitis
• Intraperitoneal blood… absorption lymphatic… absorption peritoneal
membrane ( )
• Bacterial peritonitis… uncontrol sepsis… respiratory system
• septic shock steroid
• Factors increase spreading peritonitis ( )
basic part clinical
1. polymicrobial flora
2. spillage of GI content
3. presence of large volume in peritoneal cavity clear bacteria
4. presence of blood , bile , urine , chyme… bacteria
 … wall – off infection fibrin omentum decrease spreading
peritonitis increase spreading
• Factor peritonitis…
1. Duration…
2.
3. medical comorbids
4. WBC < 5,000 > 25,000

Primary Peritonitis
• spontaneous bacterial peritonitis (SBP)
• monobacterial infection… dipplococci… E.coli overall
age group E.coli 1
• …UTI , URI pneumonia , pericarditis… bacteria hematogenous spread
peritoneal cavity
• … host defences intrahepatic shunting impaired
bactericidal activity in ascites
• bacteria transmucosal migration gut flora …
• nephrotic syndrome SLE… adult cirrhosis SLE
• …SBP
1. >
2. toxemia in pregnancy
3. 2
3.1 … < 30 Diag.SBP
3.2 4–5
• … 30 % SBP

diarrhea
• Criteria for diagnosis SBP
1. clinical presentations
2. presence of ascites
3. paracentesis neutrophil >250 / mm3
 4. no evidence of obvious intraabdominal source perforation
• Abdominal paracentesis… most useful SBP rule out secondary
peritonitis mixed organism

1. low pH high… lactate > 32 ng. / ml.

2. neutrophil count > 250 mm3 highest sensitivity and specificity
3. gram strain single organism highly specific sensitivity
• … gm. strain culture +ve
bacteria rule out SBP
• Treatment… non operative management
1. IV antibiotic aerobe anaerobe
culture 5-10
2. 48 – 72 hr.
3. PAD role ....
• SBP…
1. mortality … 50 %
2. recurrence …50 % in 6 m. 70 % in 1 yr. Quinolones long
term prophylaxis ( )… quinolones short
term prophylaxis
 Secondary Peritonitis
• septic peritonitis
• Intraabdominal source , PU perforation
• Bacteria mixed organism aerobe anaerobe B.fragilis , E.coli
Enterococcus
• Pathogenesis 1ry 2ry response Basic
• Treatment
1. source infection… PU. perforation
sigmoid diverticulitis antibiotic WBC

2. metabolic and hemodynamic support

Tertiary Peritonitis
• persistent peritonitis antibiotic
host defence
•
• Pathogenesis… poor understood
• Treatment
antibiotic cover
• Mortality… 50 %

CAPD Peritonitis

• Peritoneal dialysis catheter related infection

• Incidence… 1.3 episode
• Organism… staph. epidermidis staph. aureus … strep.
• single organism SBP… mixed infection ( )
• 1–6% sclerosing process… …
• …earliest sign turbid fluid ,
• Diagnosis
1. cloudy dialysate effluent
2. clinical sign of peritonitis
3. neutrophil > 100 / cc3
4. Gm. strain culture gm +ve bacteria
•
1. +ve blood culture
2. single organism pseudomonas 3 %... pseudo cure antibiotic
3. mixed organism anaerobe 2ry peritonitis

• Treatment
1. antibiotic heparin dialysate …
CAPD
2. Indication for catheter removal
2.1 persistence peritonitis > 4
2.2 pseudomonas , fungus TB
2.3 fecal peritonitis
2.4 severe skin infection at catheter site
• HIV indication gm –ve indication…
gm –ve pseudo.

TB Peritonitis
• case HIV
• TB peritoneal cavity 4
1. homogenous spread from pulmonary focus
2. transmural spread from bowel disease
 3. fallopian tube in TB salpingitis
4. KUB from TB nephritis
• primary … autopsy
•
1. insidious onset…
2. ascites almost always present

• Diagnosis

1. paracentesis… classic TB
1.1 +ve AFB 80 %
1.2 lymphocyte predominate
1.3 high protein content
1.4 low glucose < 30 mg./dl.
2. ascites tissue diagnosis needle biopsy ,
laparoscopy open biopsy peritoneum
• Treatment
1. anti TB
2. Indication for surgery
2.1 for diagnosis
2.2 complication gut obstruction fistula
• drain gut exteriorization
 Periodic Peritonitis
•
• peritonitis mediteranean , ,
• Familial pattern AD
• … , chest pain , abdominal pain , joint pain
• sign explore inflammed
peritoneum , ascites bacteria intraperineal pathology

Appendectomy …
• Treatment
1. NSAID
2. Colchicine gout recurrence attack Colchicine
Colchicine therapeutic diagnosis

Drug Related Peritonitis

• 3
1. INH
2. Erythromycin
3. Inderal
• sign peritoneal irritation pathogenesis

Intraabdominal Abscesses
• USA post op. pancreatic surgery
• 7-10 post op. intermittent spiking fever
• CT single best diagnostic modality
• Percutaneous abscess drainage (PAD)

Success 70 % PAD 2 success rate 82 %

Failure PAD
1. drain peripancreatic infection
2. PAD > 2
3. pus yeast
 Indication for catheter removal
1. daily drainage < 10 cc.
2. from purulent to serous drainage
3. afebrile , normal WBC count
4. radiographic criteria… cavity collapse off

Contraindication for PAD

1. coagulopathy ( )
2. vital structure
3. uncontrol ongoing GI content contamination leak

Indication for open abscess drainage

1. failure PAD
2. primary disease can’t control
3. cancer perforation
4. interloop abscess
5. fungal abscess
• Subphrenic abscess

case trauma … … sign

…CBC leucocytosis, left shift , film chest atelectasis lower lung field
…Pus somewhere…
subphrenic abscess CT
• Pelvic abscess

pus Cul de sac serious illness spontaneous drainage

rectum…
PR soft bulging tender mass ERUS drain rectum
vagina
primary disease treat

• Retroperitoneal abscess
renal infection retrocecal appendicitis , pancreatitis ,
diverticulitis
... frank , back pelvis , , WBC
.... IV antibiotic + CT guided drainage open drainage
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