Complications of acute peritonitis & its management

TB peritonitisMeconium Ileus

Dr. Kalpesh Patel

COMPLICATIONS OF PERITONITIS

• SYSTEMIC COMPLICATIONS• ABDOMINAL COMPLICATIONS

SYSTEMIC COMPLICATIONS

• BACTERAEMIC/ENDOTOXIC SHOCK• BRONCHOPNEUMONIA/RESPIRATORY

FAILURE• RENAL FAILURE• BONE MARROW SUPRESSION• MULTISYSTEM FAILURE

ABDOMINAL COMPLICATIONS

• Adhesional small bowel obstruction• Paralytic ileus• Residual or recurrent abscesses• Portal pyemia/liver abscess

Acute intestinal obstruction due to peritoneal adhesions

• Central colicky abdominal pain• On X-ray small bowel gas/fluid levels confined

to proximal intestine• Peristalsis increased• More common with localized peritonitis• Essential to distinguish from paralytic ileus

Paralytic ileus

• Peristalsis reduced or completely absent• Very little pain• Gas filled loops with fluid levels are seen

distributed throughout the samll and large intestine on X-ray

Abscesses

Signs and symptoms

• Vague and consist of nothing more than lassitude, anorexia and failure to thrive

• Pyrexia (often low-grade), tachycardia, leucocytosis and localised tenderness common

• Later on, a palpable mass may develop• When palpable an intraperitoneal abscess should

be monitored by marking out its limitations on the abdominal wall, and meticulous daily examination

• Monitoring with repeated ultrasound / CT Scan• In majority of cases with aid of antibiotic

treatment the abscess or mass becomes smaller and smaller and finally undetectable.

• In others the abscess fails to resolve and becomes larger, in that case it has to be drained.

• In many cases, by waiting for a few days the abscess becomes adherent to the abdominal wall so that it can be drained without opening the general peritoneal cavity

• If facilities available USG or CT guided drainage my avoid further operation

• Open drainage of an intraperitoneal collection should be carried out by cautious blunt finger exploration to minimise the risk of an intestinal fistula.

PELVIC ABSCESS• Commonest site of intraperitoneal abscess because

appendix is often pelvic in position and also the fallopian tube are frequent sites of infection

• It can also occur as a sequel to any case of diffuse peritonitis and is a common sequel of anastomotic leakage following large bowel and rectal surgery.

• Pus can accumulate in this area without serious constitutional disturbances and unless the patient is examined carefully from day to day such abscesses may attain considerable proportions before diagnosed.

• Charasteristic symptoms /signs– Diarrhoea – Passage of mucus in the stool– (Passage of mucus, occuring for the first time in a

patient who has or is recovering from peritonitis is pathognomic of pelvic abscess)

– Rectal examination reveals a bulging of the anterior rectal wall which when the abscess is ripe, becomes soft / cystic

• If left untreated theses abscesses bursts into the rectum after which the patient nearly always recovers rapidly

• Abscess should be drained deliberately• In women vaginal drainage through the

posterior fornix is possible• In other cases where the abscess is definitely

pointing in to the rectum, rectal drainage done

• If diagnosis not confirmed, USG / CT scan or aspirating needle inserted through rectum or abdominal wall into the swelling to confirm diagnosis

• Laparotomy is almost never necessary• Rectal drainage is preferable to suprapubic

drainage (risk of exposing the general peritoneal cavity to infection)

• Drainage tube can also be inserted through rectum/vagina under radiological guidance

TUBERCULOUS PERITONITIS

• Acute• Chronic• Varieties of tuberculous peritonitis– Ascitic form– Encysted form– Fibrous form– Purulent form

Acute tuberculous peritonitis

• Acute onset, resembles acute peritonitis leading to urgent laparotomy

• Straw colour fluid escapes and tubercules are seen scattered over the peritoneum and greater omentum

• Early tubercles are greyish and transluscent eventually undergo caseation and appear white or yellow and are then less difficult to distinguish from malignancy

• Occasionally appear like patchy fat necrosis• On opening the abdomen and finding

tuberculous peritonitis the fluid is evacuated and some being retained for bacteriological studies

• A portion of diseases omentum is removed for histological confirmation of the diagnosis and the wound closed without drainage

• Sometimes even if acute abdominal symptoms arise, presence of ascites make diagnosis evident

Chronic tuberculous peritonitis

• Presents with – abdominal pain– Fever– Loss of weight– Ascites– Night sweats– Abdominal mass

Origin of the infection

• Tuberculous mesentric lymph nodes• Tuberculosis of the ileocaecal region• A tuberculous pyosalpinx• Blood-borne infection from pulmonary

tuberculosis usually the “miliary” but occasionally the “cavitating” form

Ascitic form

• Peritoneum is studded with tubercules and the pritoneal cavity becomes filled with pale, straw coloured fluid.

• Insidious onset• Loss of energy• Facial pallor• Loss of weight• Enlargement of abdomen• Usually NO PAIN

• Abdominal discomfort associated with alternate diarrhoea/constipation

• Dilated veins along side lower abdominal wall• Shifting dullness• In male child congenital hydrocele appear

sometime• Umbilical hernia occur due to increased

intraabdominal pressure• On palpation, transverse solid mass may

occasionally demonstrated (rolled-up abdomen)

• Diagnosis is seldom difficult when it occurs in acute form or when it first appears in an adult in which case it has to be differentiated from other forms of ascites especially from malignant secondary deposits

• In child positive mantoux test with ascites strongly suggests and negative test is good evidance against tuberculosis (in adults this test has little value)

• Laparoscopy is useful by allowing inspection of the peritoneal cavity, where the appearance is diagnositic, areas of caseation can be biopsied for histology and microbiological studies

• Also look at the tuberculous disease elsewhere especially tuberculous salpingitis in females

• Chest x ray is must before laparoscopy/laparotomy

Ascitic fluid

• Pale yellow• Usually clear• Rich in lymphocytes• Specific gravity usually high 1.020 or higher• Even after centrifugation, rarely M.

tuberculosis found, but its presence can be demonstrated by culture or by guinea-pig inoculation

• Start AKT• Patient can return home if general condition

good

Encysted form• Encysted = loculated• Similar to ascitic form but one part of the abdominal

cavity along is involved• Localised intraabdominal swelling, so gives rise to

difficulty in diagnosis• D/D in female is ovarian cyst, in child mesentric cyst• Laparotomy is performed and if an encapsulated

collection found then it is evacuated and the abdomen is closed

• AKT• Complication – late intestinal obstruction

Fibrous form

• Fibrous = plastic• Characterised by production of widespread

adhesions, which cause coils of intestine, especially ileum, to become matted together and distended

• These distended coils act as a “blind loop” and give rise to steatorrhoea, wasting and attacks of abdominal pain

• On examination, adherent intestine with omentum attached together with the thickened mesentry may give rise to a palpable swelling/swellings

• Subacute/ acute intestinal obstruction• Division of bands to relieve obstruction• If the adhesions are accompanied by fibrous

strictures of the ileum as well it is best to excise the affected bowel, provided not too much of the small intestine needs to be sacrificed

• AKT after surgery for rapid cure

Purulant form• Rare• When secondary to tuberculous salpingitis• Amidst a mass of adherent intestines and

omentum, tuberculous pus is present• Sizeable cold abscesses often form and point on

the surface commonly near umbilicus, or burst into bowel

• Surgical treatment is necessary for the evacuation of cold abscesses and possibly for intestinal obstruction

• If faecal fistula forms then it may persists because of distal intestinal obstruction

• Closure of the fistula must therefore be combined with some form of anastomosis between the segment of intestine above the fistula and an unobstructed area below.

• Prognosis of this variety of tuberculous peritonitis is relatively poor

MECONIUM ILEUS

• This is neonatal manifestation of cystic fibrosis• Meconium is normally kept fluid by action of

pancreatic enzymes.• The terminal ileum becomes filled with

meconium and viscid mucus resulting in progressive inspissation in utero and neonatal obstruction.

• Inspissated meconium may be palpated as rubbery swelling

• X ray may reveal a distended small intestine with mottling. Fluid levels are usually not seen no abrupt cut-off like ileal atresia

• Autosomal recessive genetic defect- family history may be present

• Absence of trypsin from stool or bile• Concentration of sodium chloride in sweat

greater than 80 mmol/lit• Negative immunoreactive blood trypsin

estimation

• 40% cases associated with volvulus neonatorium, atresia or meconium peritonitis (Dickson)

• If acute then immediate laparotomy• Else gastrograffin or mypaque enema may be given to

confirm diagnosis• The radioopaque fluid will pass easily to the ileum

where it may disperse the obstructing meconium and relieve the condition owing to its high osmolarity and detergent action

• As the instilled solution is hypertonic, rapid loss of fluid in bowel lumen must be corrected by iv fluids

• If conservative management fails, laparotomy done• May be confused with hirschprung’s disease affecting

whole colon• Standart treatment is resection of the most dilated

segment with an end to side anastomosis of the colon to the ileum.

• The distal opening is formed into an ileostomy through which the meconium may be irrigated post-operatively (Bishop-koop operation)

• The ileostomy becomes a mucus fistula which usually requires subsequent closure.