GIS-K-24 Peritonitis

Mesenteric Lymphadenitis
Syahbuddin Harahap Division of Digestive Surgery Department of Surgery Faculty of Medicine University of North Sumatera Adam Malik Hospital

Peritoneum Serous membrane Lining abdominal cavity Covers the intra-abdominal organs. Layers Peritoneum The outer layer -parietal peritoneum The inner layer -visceral peritoneum. The term mesentery -double layer of visceral peritoneum

Subdivisions : The greater sac The lesser sac (or omental ) two "omenta": 1. The lesser omentum (or gastrohepatic) 2. The greater omentum (or gastrocolic) like an apron, protective layer. Greater sac and lesser sac Connected by the epiploic foramen

Peritonitis
Inflammation of the serosal membrane that lines the abdominal cavity and the organs contained therein often as a result of infection. Peritonitis are classified as : 1. Primary peritonitis 2. Secondary peritonitis 3. Tertiary peritonitis

Peritonitis are usually divided into 1. Generalized peritonitis 2. Localized peritonitis

Etiology Peritonitis is often caused by: - Perforation hollow viscus - Chemically irritating material
(blood,pancreatic/gastic juice)

- Infected / Inflammation

Primary peritonitis
No pathologic process in a visceral organ Via hematogenous Children Translocation of bacteria across the gut wall Ascites Intestinal obstruction Ascending infection in female Gonorrhea Chlamydial infection spreads into the abdominal cavity. Systemic infections tuberculosis

Secondary peritonitis
Related to a pathologic process in a visceral organ hollow viscus - Perforation - Infected most common cause of peritonitis, perforations of : - the stomach - intestine - gallbladder - appendix

Tertiary peritonitis
Persistent or recurrent infection after adequate initial therapy Anastomotic leakage Abscess with or without fistulization.

Diagnosis and investigations

Based primarily on clinical grounds

No further investigation should delay surgery

Clinical:
The diagnosis of peritonitis is usually clinical. 1. Chief complaint 2. Peritoneal irritation
3.

Acute abdominal pain Anorexia and nausea ,vomiting.

Fever exceed 38 C Hypotensive severe sepsis Septic shock

4. Hypovolemia 5. Hypothermia

Peritonitis generally represents a surgical emergency.

On abdominal examination of Peritonitis

1. Position/lighting/draping 2. Inspection
Abd. Distended Ileus paralyticus Keep their hips flexed to relieve the abdominal wall tension.

3. Palpation all four quadrants

Tenderness Rebound tenderness Diffuse Abdominal rigidity ("washboard abdomen") Abdominal Guarding voluntary in response of the abdominal Inflammatory mass. 4.Percussion

Tenderness all four quadrants Percuss the liver span free air 5. Auscultation
Paralytic Ileus Hypoactive-to-absent bowel sounds.

6 . Digital rectal exam .

Generalized peritonitis Tenderness in all direction Appendicitis Tenderness in the right diection Female patients vaginal and bimanual examination Pelvic inflammatory disease

Mimic certain signs and symptoms of peritonitis.

1. Thoracic processes with diaphragmatic irritation (eg, empyema) 2. Extraperitoneal processes (eg, pyelonephritis, cystitis, acute urinary retention) 3. Abdominal wall processes (eg, rectus hematoma)

WORKUP
Lab Studies: Blood test leukocytosis (>11,000 cells/mL) Blood chemistry may reveal dehydration and acidosis. Liver function tests if clinically indicated Serum electrolytes Renal function Amylase and lipase if pancreatitis is suspected Urinalysis (UA) is essential to rule out urinary tract diseases (eg, pyelonephritis, renal stone disease Aerobic and anaerobic blood cultures

Complications
Hypovolaemia shock -Sequestration of fluid and electrolytes -Decreased central venous pressure Electrolyte disturbances Acute renal failure Peritoneal abscess Abdominal Sepsis may develop Septic shock

Imaging Studies

Radiographs Plain films of the abdomen : supine upright Free air lateral decubitus positions Computed tomography scan
Diagnosis cannot be established on clinical grounds Cannot be findings on abdominal plain films.

Treatment INFORMED CONSENT General supportive measures : - Intravenous rehydration - Correction of electrolye disturbances. Antibiotics - broad-spectrum antibiotics The exception is spontaneous bacterial peritonitis, which does not benefit from surgery. Surgery Exl .laparotomy full exploration Lavage of the peritoneum

Abscess in Pouch of Douglas (Cul de sac abscess ) (Pelvic abscesses)

DRT : often are palpable as tender Anterior fullness and fluctuation Male Rectovesical pouch Female Recto-uterine pouch Treatment Draining these abscesses transvaginally or transrectally is best to avoid the transabdominal approach.

Mesenteric Lymphadenitis
1. Inflammation of the mesenteric lymph nodes. 2. Acute or chronic, depending on the causative agent. 3. Often difficult to differentiate from acute appendicitis.

Pathophysiology Microbial agents are thought to gain access to the lymph nodes via the intestinal lymphatics.

Clinical Clinical features of associated organ involvement, such as enterocolitis or ileitis Abdominal pain - Often right lower quadrant (RLQ) but may be more diffuse Fever Diarrhea Malaise Anorexia Upper respiratory tract infection Nausea and vomiting

Physical Fever (38-38.5 C) RLQ tenderness - Mild, with or without rebound tenderness Rectal tenderness Rhinorrhea Hyperemic pharynx Associated peripheral lymphadenopathy (usually cervical) in 20% of cases

Causes Streptococcus beta-hemolytic, Staphylococcus species, Escherichia coli Streptococcus viridans, Mycobacterium tuberculosis, Viruses, such as coxsackieviruses, rubeola virus, and adenovirus Children with upper respiratory tract infection, has popularized a theory that swallowed pathogen-laden sputum may be the primary source of infection.

Lab Studies CBC count Leucocytosis exceeding 10,000/L Urinalysis exclude urinary tract infection. Diarrheal symptoms Septicemia

Stool cultures Blood culture

Imaging Studies CT scanning In mesenteric adenitis: lymph nodes to be larger greater in number CT scanning is also important to exclude other differential diagnoses, especially acute appendicitis.

Medical Care Hemodinamic support Broad-spectrum antibiotics To quickly identify patients who require surgical intervention Surgical Care Signs of peritonitis Appendectomy