Diseases of peritoneum & retroperitoneal space

M K Alam

ILOs

• At the end of this presentation students will be able to:  Describe types and causes peritonitis. Recognize features of localized and generalized peritonitis. Enumerate sites of intra-abdominal collection and its clinical

features. Describe management of local& general peritonitis and intra-

abdominal collections. Describe peritoneal tumours and its management Describe the presentation and management of

retroperitoneal diseases.

Anatomy

• Line by single layer mesothelial cells lying on thin layer of

fibroepithelial tissue

• Few ml of pale yellow fluid lubricates peritoneal surface

• Greater and lessor sac

• Peritoneal membrane: Visceral & parietal

• Visceral peritoneum: Poor nerve supply by autonomic, its

irritation/ inflammation- poorly localized, dull and felt in midline

• Parietal: Rich somatic nerve, when irritated- severe & accurately

localized to affected area

Peritoneal Inflammation

• Acute or chronic

• Secondary, primary (uncommon)

Causes of peritonitis:• Bacterial infection: perforated appendicitis (acute) tuberculosis

(chronic)

• Chemical peritonitis: Bile peritonitis, Acute pancreatitis

• Ischemic injury: Bowel strangulation, vascular occlusion

• Trauma: Surgery

• Allergic: Starch peritonitis from gloves

Bacterial peritonitis

• Usually polymicrobial

• Common organisms: E coli, Streptococci,

Bacteroides, Klebsiela, staphylococcus

• Uncommon organisms: Chlamydia,

pneumococcus, mycobacterium tuberculosis

Routes of infection

• GI perforation: Most common

• Exogenous: Drains, trauma

• Transmural: Ischemic bowel, fallopian tubes (PID)

• Haematogenous: Rare ? Primary peritonitis

Clinical types of peritonitis

Localized peritonitis

• Anatomical divisions: Subphrenic, pelvic,

peritoneal cavity proper (supracolic, infracolic)

• Pathological factors: Inflammatory adhesions,

slow progress.

Clinical features- Localized peritonitis

• Fever, tachycardia

• Abdominal pain located in the area of the involved organ.

• Guarding, rigidity and rebound tenderness overlying the involved

area. Rest of the abdomen non-tender.

• Special features: Shoulder tip pain (subphrenic),

Suprapubic/both iliac fossa tenderness,

DRE: Anterior pelvic tenderness and fullness on (pelvic collection)

Management

• Investigations: CBC, u/e, AXR, Ultrasound, CT scan (most helpful)

• Treatment: NPO, IV fluid,

• Antibiotics (polymicrobial cover) can help resolve localized peritonitis.

• Percutaneous/ open surgical drainage if no resolution or abscess formation

Subdiaphragmatic collection

Generalized peritonitis

• Free bowel perforation

• Peristalsis

• Virulent infecting organisms

• Improper handling of inflammatory mass

• Young children (small omentum)

Clinical features of generalized peritonitis

• Abdominal pain: spreading to whole abdomen, aggravated with movement

• Fever, tachycardia

• Restricted abdominal wall movement,

• Generalized tenderness, guarding, rigidity

• Absent bowel sounds

• Late cases: Septic shock, silent abdomen,

increasing distension, anxious face

Management of generalized peritonitis

• Investigations: CBC, u/e, amylase, upright CXR, AXR, U/S , CT scan, peritoneal aspiration (sometimes under imaging)

• Treatment: • NPO, IV fluid (correct fluid & electrolyte imbalance)

• NG tube: Aspiration & drainage

• Broad spectrum antibiotic therapy• Analgesia• Operative management: Excision, repair, lavage & drainage

Complications of peritonitis

• Systemic: Septic shock, pneumonia,

respiratory failure, multi-system failure

• Local: Adhesions, paralytic ileus, abscess

formation (residual or recurrent), portal

pyaemia, liver abscess

Tuberculous peritonitis• Uncommon but still seen where tuberculosis still occurs.

• Infection originates from lymph nodes, ileo-caecal, pyosalpinx,

haematogenous

• Abdominal pain (90%), fever & loss of wt. (60%), ascites (60%), night

sweats, abdominal mass

• Diagnosis: Positive tuberculin test, mycobacterium in ascitic fluid,

biopsy of tubercle or caseating area (laparoscopy)

• Treatment: Antituberculous therapy.

Surgery: Diagnosis/ complications

Tuberculous Peritonitis

Tuberculous Peritonitis

Spontaneous Bacterial Peritonitis (Primary peritonitis)

• Acute bacterial infection of ascitic fluid

• No source of infection is easily identifiable

• Affects children & adults

• Risk group: Cirrhosis (70% child class C), CCF, Budd-Chiari syndrome

• Organism: Monomicrobial- 92%, E coli (50%), Streptococci (19%)

• Diagnosis by paracentesis of ascitic fluid:

• Polymorphonuclear > 250 per mm3 or a positive ascites culture,

• Total protein > 1gm/dl, LDH > serum LDH, Glucose < 50 mg/dl- all suggest 2° peritonitis

• Treatment: 5- to 10-day of cefotaxime or a combination of amoxicillin and clavulanic acid.

Neoplasms of peritoneum

• Carcinomatosis peritonei: Terminal event, studded with

secondary growth, ascites (straw, blood stained).

• Pseudomyxoma peritonei: Rare, frequently female due to

ruptured mucinous cystadenocarcinoma (appendiceal origin in most cases).

Abdominal distended due to yellow jelly like fluid.

U/S, CT scan help diagnosis.

Treatment: Excision of primary, debulking, chemotherapy.

Recur over months to years

• Mesothelioma

Peritoneal secondaries (carcinomatosis)

Pseudomyxoma peritoneiScalloped indentation of the surface of the liver and spleen.

Mesothelioma

Retroperitoneal space

The space between the posterior envelopment of the peritoneum and the posterior body wall.

Retroperitoneal Infections

• Aetiology: Extension of intraperitoneal infections-

appendicitis, perforated DU, diverticulitis.

• Presentation: Tachycardia, pain , fever, malaise,

Palpable mass (sometime)

• CT scan – modality of choice

• Management: Antibiotics, treatment of primary infection,

CT guided drainage for unilocular abscess,

Surgical drainage for multilocular abscesses.

Retroperitoneal Fibrosis

• Proliferation of fibrosis in retroperitoneum.

• Aetiology: Idiopathic (Ormond’s disease) ? autoimmune

Secondary to malignancy- Hodgkin’s, carcinoid, medication- methysergide.

• More common in men, 4-6th decade.

• Fibrosis gradually involves ureter, IVC, aorta, mesenteric vessels.

Retroperitoneal Fibrosis

• Presenting symptoms depends upon organ/ organs involved.

• Poorly localized abdominal pain, sudden sever pain (MVO),

unilateral leg swelling, oliguria, dysuria, haematuria.

• CT scan, MRI- fibrotic process

• Management: Exclude drug or malignancy.

For idiopathic type: Steroid therapy,

Surgical debulking, ureterolyis, ureteric stent.

Retroperitoneal MalignanciesPrimary malignancy

• Retroperitoneal Sarcoma- the most common

• 15% of all soft tissue sarcomas occur in the retroperitoneum

• Asymptomatic abdominal mass, often tumor has reached a considerable size.

• Abdominal pain(50%),

• Less common symptoms- GI hemorrhage, early satiety, nausea and vomiting,

weight loss, and lower extremity swelling.

• CT and MRI

• Treatment: Complete en bloc resection of the tumor and any involved

adjacent organs. Lymph node metastases are rare

Retroperitoneal MalignanciesRetroperitoneal malignancies from other organs:

• Kidney,

• Adrenal,

• Colon,

• Pancreas,

• lymphoma,

• Metastases from a remote primary malignancy

Thank you!