SPECIAL FORM OF PERITONITIS

NAVINKUMAR SUBRAMANIAM
SPECIAL FORMS OF
PERITONITIS
• BILE PERITONITIS
• SPONTANEOUS BACTERIAL PERITONITIS
• PRIMARY PNEUMOCOCCAL PERITONITIS
• TUBERCULOUS PERITONITIS
• FAMILIAL MEDITERRANEAN FEVER (PERIODIC PERITONITIS)
 BILE PERITONITIS
DAMAGED BILIARY TRACT DURING SURGERY / ACUTE CHOLECYSTITIS , IMPROBABLE TO THINK BILE IS A CAUSE
UNTIL EXPLORATION
UNLESS THE BILE IS EXTRAVASATED SLOWLY AND THE COLLECTION BECOME SHUT OFF FROM THE GENERAL
PERITONEAL CAVITY.
TINGE OF JAUNDICE IS UNUSUAL (ABSORPTION OF PERITONEAL BILE). INFECTED BILE > LETHAL THAN
NONINFECTED
LAPRASCOPY - EVACUATION OF BILE AND PERITONEAL LAVAGE.
SOURCE OF BILE LEAKAGE -IDENTIFIED AND TREATED
'BLOWN' DUODENAL STUMP SHOULD BE DRAINED BECAUSE ITS TOO EDEMATOUS BUT SOMETIMES ITS COVRED
BY JEJUNAL PATCH.
BILE LEAKS AFTER CHOLECYSTECTOMY AND LIVER TRAUMA - PERCUTANEOUS DRAINAGE AND ENDOSCOPIC
BILIARY STENTING TO REDUCE BILE DUCT PRESSURE. DRAIN IS REMOVED WHEN DRY AND STENT AT 4-6 WKS.
SPONTANEOUS BACTERIAL
PERITONITIS
SOMETIMES CALLED PRIMARY BACTERIAL PERITONITIS.
RARE EXCEPT IN PATIENT WITH CIRRHOSIS AND ASCITES, 1.5-3.5 OF OUTPATIENTS AND 1.5 OF
INPATIENTS .
C/F :PERITONISM , GI UPSET , SIGN OF SYSTEMIC INFLAMMATION , WORSENING LIVER AND RENAL
FUNCTION , HEPATIC ENCEPHALOPATHY AND GI BLEEDING.
DX BY ASPIRATION (PARACENTESIS). NEUTROPHILS COUNT >250/MM3.
MOST COMMON PATHOGEN IS E.COLI AND GRAM POSITIVE COCCI.(MAINLY STREPTOCOCCI AND
ENTEROCOCCI)
 THIRD GEN CEPHALOSPORIN - CEFOTAXIME
COMPLICATIONS : SEPTIC SHOCK , GI BLEEDING , HYPOALBUMINEMIA.
MORTALITY RATE : 90% IF LATE DX AND IF EARLY DX AND MANAGEMENT REDUCED TO 20%.
 PRIMARY PNEUMOCOCCAL
PERITONITIS
MAY COMPLICATE NEPHROTIC SYNDROME OR CIRRHOSIS IN CHILDREN.
AGE 3-9 YEARS , ROUTE OF IFXN : VAGINA AND FALLOPIAN TUBE (GIRLS) AND FOR BOYS : BLOOD BORNE AND
SECONDARY TO RESPIRATORY TRACT INFXN OR MIDDLE-EAR DISEASE.
CONDITION IS NOW RARE. CLINICAL ONSET IS SUDDEN , PAIN USUALLY LOCALISED TO THE LOWER HALF OF
THE ABDOMEN.
TEMPERATURE RAISED TO 39 C OR MORE AND FREQUENT VOMITING. AFTER 24-48H PROFUSE DIARRHEA AND
POLYURIA.
 LEUCOCYTOSIS >30000 /UL , 90% POLYMORPHS.
RX: ANTIBIOTIC , CORRECT DEHYDRATION AND ELECTROLYTE IMBALANCE ; EARLY SURGERY IS REQUIRED.
LAPARATOMY OR LAPAROSCOPY IS REQUIRED. EXUDATE IS ODOURLESS AND STICKY ; DIAGNOSIS IS CERTAIN.
AB AND FLUID REPLACEMENT CONTINUED AFTER THE SURGERY.
OTHER ORGANISM : HAEMOPHILUS SP. , GROUP A STREPTOCOCCI , GRAM-VE BACT.
TUBERCULOUS PERITONITIS
 MYCOBACTERIUM AVIUM, WITH THE WIDESPREAD IN HIV CO-INFECTION.
 11% OF EXTRAPULMONARY TB INFECTS PERITONEUM.ILEOCECAL IS THE MOST COMMON SITE OF
PRESENTATION.
 TB PERITONITIS ALWAYS DIAGNOSED LATE RESULTING IN UNDUE PATIENT MORBIDITY AND
MORTALITY.
 SPREAD VIA MESENTRIC LYMPH NODES OR DIRECTLY FROM THE BLOOD , MILIARY , CAVITATING
FORM OF PULMONARY TB , LYMPHS AND THE FALLOPIAN TUBES .
 ASCITIC FLUID ; STRAW-COLORED EXUDATE (PROTEIN>25G/L) WHITE CELLS >500MM3 ,
LYMPHOCYTE >40% , AFB DX IN 3% OF PATIENTS , CULTURE TAKES 4-6 WEEKS. LAPAROSCOPY AND
PERITONEAL BIOPSY IS HELPFUL.
 TB MANAGEMENT IS SUPPORTIVE AND MEDICAL. SURGERY REQUIRED IN IO.
 PROBLEM : MDR HIGHER IN ABDOMINAL TB THAN PULMONARY TB.
• CASEATING PERITONEAL NODULES ARE COMMON - DISTINGUISH FROM METASTATIC
CARCINOMA AND FAT NECROSIS OF PANCREATITIS.
• INTESTINAL OBSTRUCTION MAY RESPOND TO ANTI-TB TREATMENT WITHOUT SURGERY.
 FAMILIAL MEDITERRANEAN FEVER
(PERIODIC PERITONITIS)
 ABDOMINAL PAIN , TENDERNESS , MILD PYREXIA , POLYMORPHONUCLEAR LEUCOCYTOSIS AND
OCCASIONALLY PAIN IN THE THORAX AND JOINTS.
 DURATION OF ATTACK ; 24-72H FOLLOWED BY COMPLETE REMISSION BUT EXACERBATIONS OCCURS
REGULARLY. MAY HAVE DONE APPENDICECTOMY IN THE CHILDHOOD.
 LIMITED TO ARAB , ARMENIAN , AND JEWISH POPULATION, OTHER RACES OCCASIONALLY AFFECTED.
 MUTATION IN THE GENE MEFV (MEDITERRANEAN FEVER), GENE PRODUCE A PROTEIN CALLED PYRIN
WHICH IS EXPRESSED MOSTLY IN NEUTROPHILS ; THE EXACT FUNCTION OF PYRIN IS UNKNOWN.
 CHILDREN >ADULT AND FEMALE > MALE 2:1 . EXACERBATION IN PATIENT AGE >40
 SURGERY: PERITONEUM IS INFLAMED MOSTLY AT THE VICINITY OF THE SPLEEN AND THE GALL
BLADDER BUT NO EVIDENCE OF ABNORMALITY IN THE INTERNAL ORGAN.
 RX : COLCHICINE THERAPY.
 References
• Bailey and Love’s short practise of surgery, 27th edition