Peritonitis

By;
Abrar Hussain Zaidi
Anatomy of peritoneum
Parietal peritoneum
Visceral peritoneum
Male close peritoneum
Female open peritoneum

Abdominal
wall peritoneum
 Definition

Peri toni tis is an inf lamma ti on

(ir ri ta ti on ) of the per it oneum, the
membr ane t ha t lines the w al l of the
abdom en and co ver s the abdomi nal
or gans.
 Etiology

Causes of peritonitis

Chemically irritating
Perforation of bowel
material
 Types

Types of peritonitis

Trauma/
Primary Secondary Dialysis- associated
peritonitis peritonitis peritonitis
 Types

Types of peritonitis

Generlized
Chemical Acute
vs
vs vs
locolized
septic chronic
 Primary peritonitis

Diffuse bacterial infection without loss

of integrity of GI tract

E-coli commonest organism involved

 Risk factors
Liver diseases-*
Chronic renal failure-*
Compromised immune system-*
Pelvic inflammatory diseases-*
100

90
E-coli
80
K pneumoniae
70

60 Pseudomonas species

50 Proteus species
40
Streptococcus
30 species
Staphylococcus
20 species
10 Anaerobic species

0
Gram -ve bacteria
Comman organisms leading to primary pertonitis
 Secondary
-:peritonitis
•
Acute peritoneal infection
secondary to/resulting from

GI perforation /Trauma
/other causes [appendicitis]

Sources-
intra-abdominal /extra-abdominal
 Common Causes of Secondary
Peritonitis
Source Causes
Boerhaave syndrome
Esophagus Malignancy
Trauma (mostly penetrating)
Iatrogenic*
Peptic ulcer perforation
Stomach Malignancy (eg, adenocarcinoma, lymphoma,
gastrointestinal stromal tumor)
Trauma (mostly penetrating
Iatrogenic*
Peptic ulcer perforation
Duodenum Trauma (blunt and penetrating)
Iatrogenic*
Cholecystitis
Biliary tract Stone perforation from gallbladder (ie, gallstone ileus) or
common duct
Malignancy
Choledochal cyst (rare)
Trauma (mostly penetrating)
Iatrogenic*
 Causes of Secondary Peritonitis

Source Causes
Ischemic bowel
Small Incarcerated hernia (internal and external)
Bowel Closed loop obstruction
Crohn disease
Malignancy (rare)
Meckel diverticulum
Trauma (mostly penetrating

Ischemic bowel
Larg bowel Diverticulitis
Malignancy
Ulcerative colitis and Crohn disease
Appendicitis
Colonic volvulus
Trauma (mostly penetrating)
Iatrogenic
 Common Causes of Secondary
Peritonitis
Source Causes

Pancreas Pancreatitis
Trauma (blunt and penetrating)
Iatrogenic*

Uterus, Pelvic inflammatory disease (eg,

salpinx, and salpingo-oophoritis, tuboovarian
ovaries abscess, ovarian cyst)
Malignancy (rare)
Trauma (uncommon)
 Chronic peritonitis

Tuberculosis
Non-specific
Diverticulitis
PID
 Post traumatic

This is an acute or chronic

inflammation (irritation and
swelling) of the peritoneum (lining
of the abdominal cavity) that
occurs in people receiving
trauma/post-op/ peritoneal
dialysis.
 Treatment

Treat ment typi call y involves;

Surger y and anti bi oti cs .

In cases associated with peritoneal dialysis, antibiotics

may be infused through the dialysis catheter
 Intra abdominal
abscess
localized peritonitis
Definition :- collection of pus
walled-off from rest of peritoneal
cavity by inflammatory adhesions
and viscera
Number of bacteria exceed
host’s ability to terminate
infection
complication --may lead to
diffuse bacterial peritonitis
Classification of intra
abdominal abscess
Mid abdominal
abscess

Intra abdominal
abscess

Pelvic Sub phrenic

abscess abscess
 Sub phrenic abscess
are right sided abscess 35%
are left sided abscess 25%
are multiple abscess 20%
-: Etiology
Direct contamination after surgery . Local diseases
. or injury
Mortality rate is 25% to 40%

-: Causes of death
Uncontrolled infection
Malnutrition
Prolong hospitalization
pulmonary embli
nasocomial infection
Mid abdominal abscess
Between transverse colon and pelvis

Right lower quadrant abscess

Left lower quadrant abscess
 Pelvic abscess
usually complication of :-

acute appendicitis
pelvic inflammatory disease
colonic diverticulitis
 Symptoms

abdominal pain dull aching sharp

fever chills
loss of appetite nausea vomiting
inability to pass gas or feces
 Signs

toxic ill looking

tachypnea tachacardia hypotension
abdomen
generlized gaurding rigidity
tenderness all over positive
rebound
absent peristalsis
 Pancreatitis
Splenic rupture &infarc

Gallbladder Splenic aneurysm

Hepatitis hepatic abscess Gastritis

Peptic ulcer Mi

Pancreatitis Pneumonia

Mi
pneumonia

Intestinal obstruction
Appendicitis
Diverticulitis
Intestinal obstruction
Psoas abscess
Diverticulitis
Ectopic pregnancy Ectopic pregnancy
Ovarian cyst Ovarian cyst
Salpingitis
Ureteral calculi Salpingitis
endometriosis Ureteral calculi
endometriosis
Investigation

1:-CBC :- leukocytosis
2:-RFT
3:-Septic work up
4:-Peritoneal fluid sample for
chemistry
5:-Plain film of abdomen
6:-Ultrasonography
7:-Computed tomography
Treatment -Principles
1:-Control of infection
2:- Remove the source/
decontaminate/ Wash toxins/drain
3:- Maintain organ system
function
4:- Control inflammatory
process
Medical treatment

1:- systemic antibiotic therapy

2:- intensive care with hemodynamic, pulmonary
and renal replacement

NPO, IVF, Foley catheter

3:-nutrition and metabolic support
4:-inflammatory response modulation therapy
Treatment
Early control of septic source
Achieved by;
Operative treatment
Non operative treatment
Percutanous drainage
Endoscopy/laparoscopy

Systemic treatment
Antibiotics
Fluids/electrolytes
Nutrition
Treatment
operative management

principles :-
1:- Early and definitive source control
2:- Minimize the load of bacteria and toxin from
abdominal cavity

second look operation = sever sepsis

Abdominal closure-provisional
Laparoscopy
Initial laparoscopic examination of
abdomen can assist in elimination of
etiology

diagnostic, therapeutic
Prognosis -Primary
peritonitis

The overall mortality rate of patients with SBP

may exceed 30% if diagnosis and treatment are
delayed
less than 10% in fairly-well compensated
patients with early therapy

Recurrent episodes within 1 year represent 70%

of patients the mortality rate approaches 50%
long-term antibiotic prophylaxis decreased to
less than 20%
Prognosis -Secondary
peritonitis
Mortality rate less than 5% in simple abscess and
uncomplicated SP

More than 30-50% in sever infection

Greater than 90% with quadruple organ failure

Thank you