THE PERITONEUM

The peritoneal cavity is a closed sac lined by mesothelial cells, which produce surfactant
that acts as a lubricant within the peritoneal cavity. The cavity contains <100 mL of serous
fluid containing <30 g/L of protein.

The mesothelial cells lining the diaphragm have gaps that allow communication between the
peritoneum and the diaphragmatic lymphatics. Approximately one-third of fluid drains through
these lymphatics, the remainder through the parietal peritoneum. These mechanisms allow
particulate matter to be removed rapidly from the peritoneal cavity.

Complement activation is an early defence mechanism followed rapidly by upregulation of

the peritoneal mesothelial cells and migration of polymorphonuclear neutrophils and
macrophages into the peritoneum.

Mast cells release potent mediators of inflammation and interact with T cells to generate an
immune response.

The peritoneal-associated lymphoid tissue includes:

 The omental milky spots.
 The lymphocytes within the peritoneal cavity.
 The draining lymph nodes.
B cells with a unique CD5+ are common. This defence system plays a major role in
localizing peritoneal infection.

Peritonitis can be acute or chronic, as seen in T.B. Most cases of infective peritonitis are
secondary to gastrointestinal disease, but it occurs occasionally without intra-abdominal
sepsis in ascites due to liver disease. Very rarely, fungal and parasitic infections can also
cause primary peritonitis (e.g. amoebiasis, candidiasis).
The peritoneum can be involved by secondary malignant deposits.
The most common cause of ascites in a young to middle-aged woman is an ovarian
carcinoma.
Disease of the peritoneum
1. Infective (bacterial) peritonitis
 Secondary to gut disease, e.g. appendicitis
 perforation of any organ
 Chronic peritoneal dialysis
 Spontaneous, usually in ascites with liver disease
 Tuberculosis
2. Neoplasia
 Secondary deposits (e.g. from ovary, stomach)
3. Primary mesothelioma
4. Vasculitis
 Rheumatic autoimmune disease
 Polyserositis (e.g. familial Mediterranean fever)

A subphrenic abscess 
Is usually 2nd to infection in the abdomen and is characterized by fever, malaise, pain in the
right or left hypochondrium and shoulder-tip pain. An erect chest X-ray shows gas under the
diaphragm, impaired movement of the diaphragm and a pleural effusion. Ultrasound is
usually diagnostic.
Percutaneous catheter drainage inserted under CT or ultrasound guidance and antibiotics
is highly successful therapy.

Ascites is associated with all diseases of the peritoneum. The fluid that collects is an
exudate with high protein content. It is also seen in liver disease.
Retroperitoneal fibrosis (periaortitis)
A rare condition, there is a marked fibrosis over the post. abdominal wall and retroperitoneum.

Tuberculous peritonitis
This is the second most common form of abdominal TB.

Three subgroups can be identified: wet, dry and fibrous.

1. The wet type. Ascitic fluid should be examined for

protein concentration (> 20 g/L) and
tubercle bacilli (rarely found).
2. The dry form. Present with subacute intestinal
obstruction due to adhesions.
3. The fibrous form. Present with abdominal pain, distension and
ill-defined irregular tender abdominal
masses.

The diagnosis is by ultrasound or CT screening (mesenteric thickening and lymph node

enlargement). A histological diagnosis is not always required before instituting treatment.

Treatment is similar to that for pulmonary TB.