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8/10/2019 K24 Peritonitis
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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
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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
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PeritonitisInflammation 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 peritonitis3. Tertiary peritonitis
Peritonitis are usually divided into1. Generalized peritonitis
2. Localized peritonitis
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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 infectionspreads into the abdominal cavity.
Systemic infections tuberculosis
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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
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Tertiary peritonitis
Persistent or recurrent infection after adequate initial therapy
• Anastomotic leakage
• Abscess with or without fistulization.
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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 quadrantsPercuss the liver span free air
5. Auscultation Paralytic Ileus Hypoactive-to-absent bowel sounds.
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6 . Digital rectal exam .
Generalized peritonitisTenderness in all direction
Appendicitis
Tenderness in the right direction
Female patients vaginal and bimanual examination
Pelvic inflammatory disease
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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
l
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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
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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.
Imaging Studies
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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
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Abscess in Pouch of Douglas (Cul de sac abscess )
(Pelvic abscesses)DRE: 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.
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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.
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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
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Physical
Fever (38-38.5°C)
RLQ tenderness - Mild, with or without rebound
tenderness
Rectal tenderness
RhinorrheaHyperemic pharynx
Associated peripheral lymphadenopathy (usually
cervical) in 20% of cases
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Causes
Streptococcus beta-hemolytic,
Staphylococcus species,
Escherichia coliStreptococcus 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.
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Lab Studies
CBC count
Leucocytosis exceeding 10,000/µL
Urinalysis exclude urinary tract infection.
Stool cultures
Diarrheal symptoms
Blood culture Septicemia
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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 acuteappendicitis.
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Medical Care
Hemodinamic support
Broad-spectrum antibiotics
To quickly identify patients who require surgical intervention
Surgical Care
Signs of peritonitis Appendectomy