Peritoneum chapter 61 short practice 18 ed.

Functions of the peritoneum

In health
1● Visceral lubrication
2● Fluid and particulate absorption
In disease
1● Pain perception (mainly parietal)
2● Inflammatory and immune responses
3● Fibrinolytic activity
Paths to peritoneal infection
1● Gastrointestinal perforation, e.g. perforated ulcer,
appendix, diverticulum
2● Transmural translocation (no perforation), e.g.
pancreatitis, ischaemic bowel, primary bacterial peritonitis
3● Exogenous contamination, e.g. drains, open surgery,
trauma, peritoneal dialysis
4● Female genital tract infection, e.g. pelvic inflammatory
disease
5● Haematogenous spread (rare), e.g. septicaemia.
Non-gastrointestinal causes of peritonitis
Pelvic infection via the fallopian tubes is responsible for a high
proportion of ‘non-gastrointestinal’ infections.
The most common offending organisms are Chlamydia spp.
and gonococci.
 PERITONITIS
Peritonitis is simply defined as inflammation of the peritoneum and
may be localised or generalised. Most cases of peritonitis are
caused by an invasion of the peritoneal cavity by bacteria, so that,
when the term ‘peritonitis’ is used without qualification, acute
bacterial peritonitis is often implied.
Causes of peritoneal inflammation
1● Bacterial, gastrointestinal and non-gastrointestinal
2● Chemical, e.g. bile, barium. 3● Allergic, e.g. starch peritonitis
4● Traumatic, e.g. operative handling
5● Ischaemia, e.g. strangulated bowel, vascular occlusion
6● Miscellaneous, e.g. familial Mediterranean fever .
Although acute bacterial peritonitis most commonly arises from a perforation of
a viscus of the alimentary tract, other routes of infection can include the female
genital tract and exogenous contamination. There are also less common forms in
which the aetiology is a primary ‘spontaneous’ peritonitis, in which a pure
infection with streptococcal, pneumococcal or haemophilus bacteria occurs.
Localized peritonitis
Anatomical and pathological factors may favour the localisation of
peritonitis.
Anatomical-The greater sac of the peritoneum is divided into ;-
(1) the subphrenic spaces, (2) the pelvis and (3) the peritoneal
cavity proper.
The last is divided into a supracolic and an infracolic compartment by
the transverse colon and transverse mesocolon, which deters the
spread of infection from one to the other.
When the supracolic compartment overflows, as is often the case
when a peptic ulcer perforates, it does so over the colon into the
infracolic compartment or by way of the right paracolic gutter to
the right iliac fossa and hence to the pelvis.
Pathological-The clinical course is determined in part
by the manner in which adhesions form around the
affected organ.
1*Inflamed peritoneum loses its glistening appearance
and becomes reddened and velvety.
2*Flakes of fibrin appear and cause loops of intestine
to become adherent to each other and to the parietes.
3*There is an outpouring of serous inflammatory
exudate rich in leukocytes and plasma proteins that
soon becomes turbid; if localisation occurs, the turbid
fluid becomes frank pus.
4*Peristalsis is retarded in affected bowel and this
helps to prevent distribution of the infection.
5*The greater omentum, by enveloping and becoming
adherent to inflamed structures, often forms a
substantial barrier to the spread of infection.
Diffuse (generalised) peritonitis –
factors may favour the development of diffuse peritonitis:
1● Speed of peritoneal contamination is a prime factor. If an inflamed appendix or
other hollow viscus perforates before localisation has taken place, there will be
an efflux of contents into the peritoneal cavity, which may spread over a large
area almost instantaneously.
Perforation proximal to an obstruction or from sudden anastomotic separation is
associated with severe generalised peritonitis and a high mortality rate.
2● Stimulation of peristalsis by the ingestion of food or even water hinders
localisation. Violent peristalsis occasioned by the administration of a purgative
or an enema may cause the widespread distribution of an infection that would
otherwise have remained localised.
3● The virulence of the infecting organism may be so great as to render the
localisation of infection difficult or impossible.
Young children have a small omentum, which is less effective in localising infection.
4● Disruption of localised collections may occur with injudicious handling, e.g.
appendix mass or pericolic abscess.
5● Deficient natural resistance (‘immune deficiency’) may result from use of drugs
(e.g. steroids), disease [e.g. acquired immune deficiency syndrome or old age.
Clinical features
Localised peritonitis-The initial symptoms and signs of localised
peritonitis are those of the underlying condition – usually visceral
inflammation ;-
1- abdominal pain, GI symptoms , malaise, anorexia and nausea). When
the peritoneum becomes inflamed, abdominal pain will worsen and in
general temperature and pulse rate will rise.
2-The pathognomonic signs are localised guarding (involuntary
abdominal wall contraction to protect the viscus from the examining
hand), a positive ‘release’ sign (rebound tenderness) and sometimes
rigidity.
3-If inflammation arises under the diaphragm, shoulder-tip (‘phrenic’)
pain may be felt as the pain is referred to the C5 dermatome.
4-In cases of pelvic peritonitis arising from an inflamed appendix in the
pelvic position or from salpingitis, the abdominal signs are often slight;
there may be deep tenderness of one or both lower quadrants alone,
but a rectal or vaginal examination reveals marked tenderness of the
pelvic peritoneum.
Clinical features of Diffuse (generalised) peritonitis
Early
1-Abdominal pain is severe and made worse by moving or breathing.
2-The patient usually lies still.
3-Tenderness and generalised guarding are found on palpation, when the
peritonitis affects the anterior abdominal wall.
4-Infrequent bowel sounds may still be heard for a few hours but they cease
with the onset of paralytic ileus.
5- Pulse and temperature rise in accord with degree of inflammation and
infection.
Late
1-If resolution or localisation of generalised peritonitis does not occur, the
abdomen will become rigid (generalised rigidity).
2-Distension is common and bowel sounds are absent.
3-Circulatory failure ensues, with cold, clammy extremities, sunken eyes, dry
tongue, thready (irregular) pulse, and drawn and anxious face (Hippocratic
facies ).
4-The patient finally lapses into unconsciousness.
5-Septic shock’ (systemic inflammatory response syndrome [SIRS] and
multi-organ dysfunction syndrome [MODS]) in later stages.
 Diagnostic aids in peritonitis
Investigations may elucidate a doubtful diagnosis, but the importance of
a careful history and repeated examination must not be forgotten.
Bedside-● GUE for urinary tract infection.
● ECG if diagnostic doubt (as to cause of abdominal pain)o r cardiac history.
Bloods● Baseline urea and electrolytes . ● Full blood count.
● Serum amylase estimation may establish the diagnosis of acute
pancreatitis
●Blood Group,Rh and blood preparation.
Imaging ● Erect CXR to demonstrate free subdiaphragmatic gas.
● A supine radiograph of the abdomen may show ( presence of dilated gas-
filled loops of bowel ( paralytic ileus), and other gasfilled structures that
may aid diagnosis, e.g. biliary tree; In the patient who is too ill for an ‘erect’
film, a lateral decubitus film can show gas beneath the abdominal wall .
● computed tomography (CT) ● Ultrasonography .
Invasive-● peritoneal diagnostic aspiration.
Management of peritonitis
General care of patient
1● Correction of fluid and electrolyte imbalance
2● Insertion of nasogastric drainage tube and urinary
catheter
3● Broad-spectrum antibiotic therapy
4● Analgesia
5● Vital system support
Surgical treatment of cause when appropriate
1● Remove or divert cause
2● Peritoneal lavage ± drainage
1-correction of fluid and circulatory volume.
Patients are frequently hypovolaemic with electrolyte disturbances.
The plasma volume must be restored and electrolyte concentrations
corrected.
Fluid balance should be monitored and pre-existent and ongoing losses
corrected.
Special measures may be needed for cardiac, pulmonary and renal support,
especially if septic shock is present , including central venous pressure
monitoring in patients with concurrent disease.
2-Urinary catheterization + Gastrointestinal decompression.
A urinary catheter will give a guide to central perfusion and will be required
if abdominal surgery is to proceed. A nasogastric tube is commonly passed
to allow drainage ± aspiration until paralytic ileus has resolved.
3-Antibiotic therapy-Administration of parenteral broad-spectrum (aerobic
and anaerobic) antibiotics prevents the multiplication of bacteria and the
release of endotoxins.
4-Analgesia-The patient should be nursed in the sitting-up position and
must be relieved of pain before and after the operation.
Freedom from pain allows early mobilisation and adequate physiotherapy in
the postoperative period, which helps to prevent basal pulmonary collapse,
deep vein thrombosis and pulmonary embolism.
Specific treatment of the cause
1- early surgical intervention is to be preferred to a ‘wait and see’ policy,
assuming that the patient is fit for anaesthesia and that resuscitation has
resulted in a satisfactory restitution of normal body physiology.
This rule is particularly true for previously healthy patients and those with
postoperative peritonitis.
More caution is of course required in patients at high operative risk because
of comorbidity or advanced age.
2-In those patients with a preoperative diagnosis, if the cause of peritonitis
is amenable to surgery, an operation must be carried out as soon as the
patient is fit. This is usually within a few hours.
*In peritonitis caused by pancreatitis or salpingitis, or in cases of primary
peritonitis of streptococcal or pneumococcal origin, non-surgical treatment
is preferred, provided that the diagnosis can be made with confidence.
*However, in general, surgery is directed to removing (or diverting) the
cause and subsequent adequate peritoneal lavage ± drainage.
3-In operations for generalised peritonitis it is essential that, after the cause
has been dealt with, the whole peritoneal cavity be explored with the
sucker and, if necessary, mopped dry until all seropurulent exudate has
been removed.
4-The use of a large volume of saline (typically 3 litres) containing dissolved
antiseptic or antibiotic.
complications of peritonitis
1-Systemic
● Septic shock
●Systemic inflammatory response syndrome
● Multi-organ dysfunction syndrome
● Death
2-Abdominal
● Paralytic ileus
● Residual or recurrent abscess/inflammatory mass
● Portal pyaemia/liver abscess
● Adhesional small bowel obstruction
 Duodenal ulcer Ileal perforation
On table finding in
perforation with severe
a case of
causing peritonitis.
peritonitis, where
peritonitis.
the
peritoneal cavity is
filled with pus.
 Perforation in the
fundus of the
Plain X-ray abdomen
uterus due to
showing gas under
Severe peritonitis showing attempted
diaphragm.
pus in the peritoneal abortion. It caused
Perforation is the
cavity. severe peritonitis.
most common cause
of peritonitis.
 SPECIAL FORMS OF PERITONITIS
Bile peritonitis -Causes of bile peritonitis
1● Perforated gall bladder secondary to inflammation or obstruction (especially
empyema)
2● Post-cholecystectomy:
A-Cystic duct stump leakage.
B-Leakage from an accessory duct in the gall-bladder bed.
C-Bile duct injury
D-T-tube drain dislodgement (or tract rupture on removal)
3● Following other operations/procedures:
A-Duodenal injury
B-Leaking duodenal stump post gastrectomy
C-Leaking biliary–enteric anastomosis
D-Leakage around percutaneously placed biliary drains
4● Blunt or penetrating hepatobiliary or duodenal trauma.
Clinical presentation ;- the bile has extravasated slowly and the collection
becomes shut off from the general peritoneal cavity, there are symptoms
(often severe pain) and signs of diffuse peritonitis.
After a few hours a tinge of jaundice is not unusual.
Laparotomy (or laparoscopy) should be undertaken with evacuation of the
bile and peritoneal lavage.
The source of bile leakage should be identified and treated accordingly.
Infected bile is more lethal than sterile bile.
A ‘blown’ duodenal stump should be drained because it is too oedematous
to repair, but sometimes it can be covered by a jejunal patch.
Treatment ;-
Bile leaks after cholecystectomy or liver trauma may be dealt with by
percutaneous (ultrasound-guided) drainage and endoscopic biliary stenting
to reduce bile duct pressure.
The drain is removed when dry and the stent at 4–6 weeks.
Spontaneous bacterial peritonitis-(SBP-primary bacterial peritonitis)
it is an acute bacterial infection of ascitic fluid.
It can occur in children and adults and can occur as a complication of
any disease state that produces the clinical syndrome of ascites.
Clinical features usually include local symptoms and/or signs of
peritonitis, GI upset (secondary to ileus, e.g. nausea and vomiting),
signs of systemic inflammation (hyper- or hypothermia, chills,
tachycardia and tachypnoea + signs of septic shock), worsening liver
and renal function, hepatic encephalopathy and GI bleeding.
It should, however, be noted that evolving infection may be
asymptomatic, especially in outpatients.
diagnosis is made by paracentesis.
Empirical treatment of SBP must be initiated immediately after
diagnosis before the results of culture have been received.
Complications of SBP, e.g. septic shock, GI bleeding and
hypoalbuminaemia, should be managed accordingly.
Primary pneumococcal peritonitis
This may complicate nephrotic syndrome or cirrhosis in children.
In girls it is likely that the route of infection is sometimes via the vagina
and fallopian tubes. in boys always, the infection is blood borne and
secondary to respiratory tract or middle- ear disease.
clinical features ;-onset is sudden, wit h pain usually localised to the
lower half of the abdomen.
The temperature is raised to 39°C or more and there is usually frequent
vomiting.
After 24–48 hours, profuse diarrhoea is characteristic.
There is usually increased frequency of micturition.
The last two symptoms are caused by severe pelvic peritonitis.
On examination, peritonism is usually diffuse but less prominent than in
most cases of a perforated viscus, leading to peritonitis.
A leukocytosis of ≥30 000/μL, with approximately 90% polymorphs,
suggests pneumococcal peritonitis rather than another cause, e.g.
appendicitis.
Treatment ;- After starting antibiotic therapy and correcting
dehydration and electrolyte imbalance.
1-early surgery is required unless spontaneous infection of pre-
existing ascites is strongly suspected, in which case a diagnostic
peritoneal tap is useful. Laparotomy or laparoscopy may be used.
2-the exudate is aspirated and sent to the laboratory for
microscopy, culture and sensitivity tests.
3-Thorough peritoneal lavage is carried out and the incision closed.
4-Antibiotics and fluid replacement therapy are continued and
recovery is usual.
Other organisms are now known to cause some cases of primary
peritonitis in children, including Haemophilus spp., group A
streptococci and a few gram-negative bacteria.
5-Underlying pathology (including an intravaginal foreign body
in girls) must always be excluded before primary peritonitis
can be diagnosed with certainty.
*Idiopathic streptococcal and staphylococcal peritonitis can also
occur in adults.
Tuberculous peritonitis
*Intra-abdominal tuberculosis (TB) is very common in poor countries .
* Mycobacterium avium-intracellulare is becoming increasingly prevalent
with the widespread increase in (HIV) co-infection.
*ileocaecal is the most common site of involvement.
* TB peritonitis is often diagnosed late in the course of the disease, resulting
in undue patient morbidity and mortality.
*Tuberculosis can spread to the peritoneum through the GI tract (typically
the ileocaecal region) via mesenteric lymph nodes or directly from the
blood, usually from the ‘miliary’, but occasionally from the ‘cavitating’ form
of pulmonary TB, lymph and the fallopian tubes.
*Clinical or subclinical ascites is reported in virtually all patients with TB
peritonitis and is frequently a presenting feature. In the most common form
of the disease, ascites may be localised or generalised throughout the
peritoneal cavity.
*Multiple tubercle deposits appear on both layers of the peritoneum.
Diagnosis ;-
1- abdominal US or CT to detect ascites and
lymphadenopathy + diffuse thickening of the
peritoneum, mesentery and/or omentum .
2-Ascitic fluid is typically a straw-coloured exudate
(protein >25–30 g/L) with white cells >500 mm3 and
lymphocytes >40%.
***** (diagnostic smears for acid-fast bacilli) .
3-Laparoscopy and peritoneal biopsy may thus be
helpful to couple typical appearances with histology.
TB management-1-supportive (nutrition and hydration)
2- medical (systemic antituberculous therapy.
3- surgery may be required for specific complications
such as intestinal obstruction.
Familial Mediterranean fever-FMF-(periodic peritonitis)
*It is characterised by abdominal pain and tenderness, mild pyrexia,
polymorphonuclear leukocytosis and, occasionally, pain in the thorax
and joints. The duration of an attack is 24–72 hours, when it is
followed by complete remission, but exacerbations recur at regular
intervals.
*Most of the patients have undergone appendicectomy in childhood.
*This disease, often familial, is limited principally to Arab, Armenian
and Jewish populations; other races are occasionally affected.
*Usually, children are affected but it is not rare for the disease to
make its first appearance in early adult life, with cases in women
outnumbering those in men by two to one.
*At surgery, which may be necessary to exclude other causes (but
should be avoided if possible), the peritoneum is inflamed,
particularly in the vicinity of the spleen and the gall bladder.
*Colchicine therapy is used during attacks and to prevent recurrent
attacks.
Intraperitoneal abscess
Following intraperitoneal sepsis (usually manifest first as local or
diffuse peritonitis), the anatomy of the peritoneal cavity is such that
with the influence of gravity (depending on patient position – sitting
or supine), abscess development usually occupies one of a number of
specific abdominal or pelvic sites.
In general, the symptoms and signs of a purulent collection may be
vague and consist of nothing more than lassitude, anorexia and
malaise, pyrexia (often low grade), mild tachycardia and localised
tenderness.
Certain sites have more specific clinical features.
Larger abscesses will give rise to the picture of swinging pyrexia and
pulse and a palpable mass.
Blood tests will reveal elevated inflammatory markers.
The complicated arrangement of the peritoneum results in the
formation of four intraperitoneal spaces in which pus may
commonly collect
Left Subphrenic space-The common cause of an abscess here is an
operation on the stomach, the tail of the pancreas, the spleen or the
splenic flexure of the colon.
Left Subhepatic space \lesser sac-The most common cause of
infection here is complicated acute pancreatitis and rarely a
perforated gastric ulcer .
Right Subphrenic space-Common causes of abscess here are
perforating cholecystitis, a perforated duodenal ulcer and a duodenal
cap ‘blow-out’ following gastrectomy and appendicitis.
Right Subhepatic space -It is arises from appendicitis, cholecystitis, a
perforated duodenal ulcer or following upper abdominal surgery.
Clinical features-1-A common history is that, when some infective
focus in the abdominal cavity has been dealt with, the condition of
the patient improves temporarily but, after an interval of a few days
or weeks, symptoms of toxaemia reappear.
2-The condition of the patient steadily, and often rapidly,
deteriorates. Sweating, wasting and anorexia are present.
3-There is sometimes epigastric fullness and pain, or pain in the
shoulder on the affected side, because of irritation of sensory fibres
in the phrenic nerve, referred along the descending branches of the
cervical plexus.
4-Persistent hiccoughs may be a presenting symptom.
5-A swinging pyrexia is usually present.
6-If the abscess is anterior, abdominal examination will reveal some
tenderness, rigidity or even a palpable swelling.
7-Sometimes the liver is displaced downwards but more often it is
fixed by adhesions.
Investigation and management
1-Examination of the chest and plain radiograph are important
because, in most cases, collapse of the lung or evidence of basal
effusion or even an empyema is evident.
2-The modern management of an abscess is by radiological
diagnosis using US or CT guidance , followed by drainage.
The same tube can be used to instil antibiotic solutions or irrigate
the abscess cavity if necessary.
*repeat ultrasonography or CT scanning will be required.
Radiolabelled white cells canning may occasionally prove helpful.
* Open drainage of an intraperitoneal collection is thus now
uncommon but may be necessary.
*If a swelling can be detected in the subcostal region or in the
loin, an incision is made over the site of maximum tenderness or
over any area where oedema or redness is discovered.
*Appropriate antibiotics are also given.
 Pelvic abscess-
The pelvis is the most common site of abscess formation
because the vermiform appendix is often pelvic in position
and the fallopian tubes are also frequent sites of infection.
A pelvic abscess can also occur as a sequel to any case of
diffuse peritonitis.
It is common after anastomotic leakage following
colorectal surgery.
Clinical features-The most characteristic symptoms are of
pelvic pain, diarrhoea and the passage of mucus in the
stools.
Rectal examination reveals a bulging of the anterior rectal
wall, which, when the abscess is ripe, becomes softly cystic.
Investigation and management of pelvic abscess
1- A proportion of these abscesses burst into the rectum, after
which the patient almost always recovers rapidly.
2-If this does not occur, the abscess should be drained
deliberately.
3-In women, vaginal drainage through the posterior fornix is
often chosen.
4-In other cases, when the abscess is definitely pointing into
the rectum, rectal drainage is employed.
5-If any uncertainty exists, the presence of pus should be
confirmed by US or CT scanning .
6-Laparotomy is almost never necessary and rectal drainage
of a pelvic abscess is far preferable to suprapubic drainage,
which risks exposing the general peritoneal cavity to infection.
It is, however, increasingly common to insert drainage tubes
percutaneously, e.g. via the buttock or via the vagina or
rectum under CT guidance.
In male, pelvic abscess
is drained through an
incision over the
anterior aspect of the
rectum. In female, it is
drained through
posterior colpotomy.
Chylous ascites
*In some patients the ascitic fluid appears milky
because of an excess of chylomicrons (triglycerides).
*Most cases are associated with malignancy, usually
lymphomas; other causes are cirrhosis, TB, filariasis,
nephrotic syndrome, abdominal trauma (including
surgery), constrictive pericarditis, sarcoidosis
and congenital lymphatic abnormality.
*The prognosis is poor unless the underlying
condition can be cured. In addition to other
measures used to treat ascites, patients should be
placed on a fat-free diet with medium-chain
triglyceride supplements.
TUMOURS OF THE PERITONEUM
Primary tumours
*Primary tumours of the peritoneum are rare and in most cases take
their origin not from the serous layer but from some adjacent
structure, e.g. lipoma from appendices epiploicae, fibroma from
connective tissue.
*Mesothelioma of the peritoneum is less frequent than in the
pleural cavity but equally lethal.
*Asbestos is a recognised cause.
*It has a predilection for the pelvic peritoneum.
*Chemocytotoxic agents are the mainstay of treatment.
*Desmoid tumours which have a relationship to the peritoneum are
considered under familial adenomatous polyposis .
Secondary tumours\Carcinomatosis peritonei
This is a common terminal event in many cases of carcinoma of the
stomach, colon, ovary or other abdominal organs, and also of the breast
and bronchus.
The peritoneum, both parietal and visceral, is studded with secondary
growths and the peritoneal cavity becomes filled with clear, straw-coloured
or blood-stained ascitic fluid. The main forms of peritoneal metastases are:
1● discrete nodules – the most common variety;
2● plaques varying in size and colour;
3● diffuse adhesions – this form occurs at a late stage of the disease and
gives rise, sometimes, to a ‘frozen pelvis’.
Implantation occurs also on the greater omentum, the appendices
epiploicae and the inferior surface of the diaphragm.
The main differential diagnosis is from tuberculous peritonitis .
Investigation and treatment are as for underlying malignancy;such as
*cytoreductive surgery, *intraperitoneal chemotherapy and *hyperthermic
intraperitoneal chemotherapy.
Pseudomyxoma peritonei
1-This rare condition occurs more frequently in women.
2-The abdomen is filled with a yellow jelly, large quantities of which are often
encysted.
3-It is associated with mucinous cystic tumours of the ovary and appendix.
4-It is often painless and there is frequently no impairment of general health.
5-It does not give rise to extraperitoneal metastases but causes symptoms and
complications due to tumour bulk.
6-Although an abdomen distended with what seems to be fluid that cannot be
made to shift should raise the possibility, the diagnosis is more often suggested by
ultrasonography and CT scanning, or made at operation.
7-At laparotomy, masses of jelly are scooped out. The appendix, if present, should
be excised together with any ovarian tumour.
8-More definitive treatment can be achieved by ‘complete cytoreduction’ in which
the right hemicolon, spleen, gall bladder, and greater and lesser omentum are
excised, along with stripping of the peritoneum from the pelvis and diaphragm, and
stripping of the tumour from the surface of the liver (the uterus and ovaries are
also removed in women).
9-Intraoperative heated chemotherapy (using mitomycin C) .
Peritoneal inclusion cysts
These are usually caused by accumulation of ovarian fluid that is contained by
peritoneal adhesions. The development of a peritoneal inclusion cyst thus depends
on the presence of an active ovary and peritoneal adhesions.
The normal peritoneum absorbs fluid easily. However, the absorptive capacity of
the peritoneum is greatly diminished in the presence of mechanical injury,
inflammation and peritoneal adhesions.
Peritoneal inclusion cysts occur only in premenopausal women with a history of
pelvic or abdominal surgery. They range in size from several millimetres in
diameter to bulky masses that may fill the entire pelvis and abdomen.
Pathologically, the cyst results from non-neoplastic, reactive mesothelial
proliferation.
Investigation includes the exclusion of ovarian tumour by blood tests and
appropriate imaging (US and [MRI]).
Treatment -Cysts may be managed expectantly or by hormonal modulation, e.g.
oral contraceptives.
Radiological drainage will give transient relief and may help diagnosis using
cytology.
Surgery can be performed to remove adhesions but the risk of recurrence is 30–
50%.
ADHESIONS---Adhesions are strands of fibrous tissue that form,
usually as a result of surgery, between surgically injured tissues.
After injury, there is bleeding and an increase in vascular permeability
with extravasation of fibrinogen-rich fluid from the injured surfaces
forming a temporary fibrin matrix.
An inflammatory response ensues with cell migration, release of
cytokines and activation of the coagulation cascade.
The activation of the coagulation system results in thrombin
formation, which is necessary for the conversion of fibrinogen to
fibrin. In the absence of fibrinolysis, adhesions will form within 5–7
days as the matrix gradually becomes more organised with collagen
secretion by fibroblasts.
Fibrinolysis is therefore the key factor in determining whether an
adhesion persists.
Ischaemic tissue loses its ability to break down fibrin and inhibits
fibrinolysis in adjacent tissues.
Complications
1-The most common adhesion-related problem is small bowel obstruction.
2-Adhesions are also implicated as a major cause of secondary infertility .
3- chronic abdominal and pelvic pain.
Prevention
1-Minimising the production of ischaemic tissue by careful surgical
technique, including meticulous control of bleeding, remain, however, the
most critical concepts.
2-The evolution of laparoscopic bowel surgery result in reduced adhesion-
related readmissions for a number of abdominal and pelvic procedures, e.g.
cholecystectomy, hysterectomy and colectomy.
3-The effect of a number of drugs including anti-inflammatory drugs such as
aspirin and steroids, some hormones, anticlotting agents, antibiotics,
vitamin E and even methylene blue have been investigated in adhesion
prevention but have not achieved widespread use, because of either side
effects or lack of consistent evidence of effectiveness.
4-Many barrier methods of reducing adhesions .
THE OMENTUM-( greater omentum ‘the abdominal policeman’).
The greater omentum attempts, often
successfully, to limit intraperitoneal infective
and other noxious processes . e,g;-
* an acutely inflamed appendix is often found
wrapped in omentum, and this saves many
patients from developing diffuse peritonitis.
Some sufferers of herniae are also greatly indebted to this structure,
because it often plugs the neck of a hernial sac and prevents a coil of
intestine from entering and becoming strangulated.
It can of course also be a cause of obstruction (acting as a large
adhesion).
The omentum is usually involved in tuberculous peritonitis and
carcinomatosis of the peritoneum.
Torsion of the omentum
*It is a rare emergency and consequently is seldom
diagnosed correctly.
*It is usually mistaken for appendicitis with somewhat
abnormal signs.
*It may be primary or secondary to adhesion of the
omentum to an old focus of infection or hernia.
*The patient is most frequently a middle-aged, obese
man.
*A tender lump may be present in the abdomen.
*The blood supply having been jeopardised, the twisted
mass sometimes becomes gangrenous, in which case
bacterial peritonitis may follow.
*Treatment is surgical; the pedicle above the twist is
ligated securely and the mass removed.
THE MESENTERY
Mesenteric injury
A wound of the mesentery can follow severe abdominal
contusion and is a cause of haemoperitoneum.
More commonly, it is injured by a torsional force, so-called
seatbelt syndrome.
This occurs during a vehicular collision when a seatbelt is
being worn with sudden deceleration resulting in a torn
mesentery.
This possibility should be borne in mind, particularly as
multiple injuries may distract attention from this injury.
Aside from control of any ongoing haemorrhage, associated
ischaemic or ruptured gut will require resection.
Embolism and thrombosis of mesenteric vessels leading to
intestinal ischaemia.
Acute non-specific ileocaecal mesenteric adenitis
The aetiology often remains unknown, although some cases are associated with
Yersinia infection of the ileum. In other cases, an unidentified virus is blamed.
In about 25% of cases, a respiratory infection precedes an attack of non-specific
mesenteric adenitis.
This self-limiting disease is never fatal but may be recurrent. Its significance thus
mainly lies in its differential diagnosis with appendicitis in children.
Diagnosis
During childhood, acute, non-specific mesenteric adenitis is a common condition.
The typical history is one of short attacks of central abdominal pain lasting from 10
min to 30 min, commonly associated with vomiting.
The patient seldom looks ill.
In more than half the cases the temperature is elevated.
Abdominal tenderness is poorly localised and, when present, shifting tenderness is
a valuable sign for differentiating the condition from appendicitis.
The neck, axillae and groins should be palpated for enlarged lymph nodes.
There is often a leukocytosis of 10 000–12 000/μL (10–12 × 109/L) or more on the
first day of the attack, but this falls on the second day.
TREATMENT
1-When the diagnosis can be made with assurance, bed rest and simple analgesia
are the only treatment necessary.
2-If, at a second examination a few hours later, acute appendicitis cannot be
excluded, it is safer to perform either appendicectomy or diagnostic laparoscopy.
3-If surgery is mistakenly undertaken, there is a small increase in the amount of
peritoneal fluid.
4-The ileocaecal mesenteric lymph nodes are enlarged, and can be seen and felt
between the leaves of the mesentery.
5- In very acute cases they are distinctly red, and many of them are the size of a
walnut.
6-The nodes nearest the attachment of the mesentery are the largest.
They are not adherent to their peritoneal coats and, if a small incision is made
through the overlying peritoneum, a node is extruded easily.
Tuberculosis of the mesenteric lymph nodes
It is considerably less common than acute non-specific
lymphadenitis.
Tubercle bacilli, usually, but not necessarily, bovine, are
ingested and enter the mesenteric lymph nodes by way of
Peyer’s patches.
The presentation may be with abdominal pain (a rare
differential for appendicitis) or with general constitutional
symptoms (pyrexia, weight loss, etc.).
Calcified lymph nodes may be demonstrated on a plain
radiograph of the abdomen where they must be
distinguished from other calcified lesions, e.g. renal or
ureteric stones.
Mesenteric cysts
Cysts may occur in the mesentery of either the small intestine
(60%) or the colon (40%) and can be classified as the
following: 1● Chylolymphatic 2● Enterogenous
3● Urogenital remnant (actually retroperitoneal but project
into peritoneum) 4● Dermoid.
chylolymphatic cyst *It is the most common variety.
*It is most frequently in the mesentery of the ileum.
*The thin wall of the cyst, which is composed of connective
tissue lined by flat endothelium, is filled with clear lymph or,
less frequently, with chyle, varying in consistency from
watered milk to cream. *Occasionally, the cyst attains a great
size. *A chylolymphatic cyst has a blood supply that is
independent from that of the adjacent intestine and, thus,
enucleation is possible without the need for resection of gut.
enterogenous cyst
These are believed to be derived either from a diverticulum of the mesenteric
border of the intestine that has become sequestrated from the intestinal canal
during embryonic life, or from a duplication of the intestine .
An enterogenous cyst has a thicker wall than a chylolymphatic cyst and it is lined by
mucous membrane, which is sometimes ciliated.
The content is mucinous and either colourless or yellowish brown as a result of past
haemorrhage. The muscle in the wall of an enteric duplication cyst and the bowel
with which it is in contact have a common blood supply; consequently, removal of
the cyst always entails resection of the related portion of intestine.
Urogenital remnant
A cyst developing in the retroperitoneal space often attains very large dimensions
and has first to be distinguished from a large hydronephrosis.
Even after the latter condition has been eliminated by scanning or urography, a
retroperitoneal cyst can seldom be distinguished with certainty from a
retroperitoneal tumour until displayed at operation.
The cyst may be unilocular or multilocular.
Many of these cysts are believed to be derived from a remnant of the wolffian duct,
in which case they are filled with clear fluid.
clinical features of mesenteric cysts
1● Cysts occur most commonly in adults with a mean age of 45 years
2● Twice as common in women as in me
3● Rare: incidence around 1 per 140 000
4● Approximately a third of cases occur in children younger than 15 years
5● The mean age of children affected is 4.9 years
6● The most common presentation is of a painless abdominal swelling with
characteristic physical signs there is a fluctuant swelling near the umbilicus
the swelling moves freely in a plane at right angles to the attachment of the
mesentery (Tillaux’s sign) there is a zone of resonance around the cyst
7● Other presentations are with recurrent attacks of abdominal pain with or
without vomiting (pain resulting from recurring temporary impaction of a food
bolus in a segment of bowel narrowed by the cyst or possibly from torsion of the
mesentery) and acute abdominal catastrophe, due to:
1-torsion of that portion of the mesentery containing the cyst
2-rupture of the cyst, often as a result of a comparatively trivial accident
3-haemorrhage into the cyst
4-infection
Investigation and treatment
US and CT scanning will demonstrate the lesion and may allow diagnosis of
cyst type . There are no suitable medical therapies.
The goal of surgical therapy is complete excision of the mass.
The preferred treatment of mesenteric cysts is enucleation, although bowel
resection is frequently required to ensure that the remaining bowel is
viable.
Bowel resection may be required in children with mesenteric cysts, whereas
resection is necessary in about a third of adults .
Differential diagnosis
The following, although not being mesenteric cysts in the true meaning of
the term, give rise to the same physical signs:
1● peritoneal inclusion cyst .
2● serosanguineous cyst, probably traumatic in origin although a history of
an accident is seldom obtained.
3● tuberculous abscess of the mesentery.
4● hydatid cyst of the mesentery.
Neoplasms of the mesentery
The mesentery is necessarily affected by local lymphatic spread of carcinoma
arising from the peritoneal viscera. Other benign and malignant tumours are
less common.
Diagnosis
(a) ultrasound findings; (b) computed tomography findings; and
(c) intraoperative findings requiring en masse small bowel resection .
Types
Benign 1● Lipoma 2● Fibroma 3● Fibromyxoma.
Malignant 1● Lymphoma 2● Secondary carcinoma
Tumours situated in the mesentery give rise to physical signs that are similar
to those of a mesenteric cyst, the sole exception being that they sometimes
feel solid.
If indicated, a benign tumour of the mesentery is excised in the same way as
an enterogenous mesenteric cyst, i.e. with resection of the adjacent intestine.
A malignant tumour of the mesentery requires biopsy confirmation and
specific, usually non-surgical, treatment, e.g. chemotherapy for lymphoma.
THE RETROPERITONEAL SPACE
Retroperitoneal fibrosis
This is a relatively rare diagnosis characterised by the development of a flat
grey/white plaque of tissue, which is found first in the low lumbar region
but then spreads laterally and upwards to encase the common iliac vessels,
ureters and aorta.
Its aetiology is obscure in most cases (idiopathic) being allied to other
fibromatoses (others being Dupuytren’s contracture and Peyronie’s disease).
In other patients the cause is known.
Causes of retroperitoneal fibrosis
Benign-1● Idiopathic (Ormond’s disease) 2● Chronic inflammation
3● Extravasation of urine 4● Retroperitoneal irritation by leakage of blood
or intestinal content. 5● Aortic aneurysm (inflammatory type)
6● Trauma 7● Drugs (chemotherapeutic agents and methysergide)
Malignant
1● Lymphoma 2● Carcinoid tumours 3● Secondary deposits (especially from
carcinoma of stomach, colon, breast and prostate
clinical presentation may be one of ill-defined
chronic backache or occur as a result of compromise
to involved structures, e.g. lower limb or scrotal
oedema secondary to venous occlusion, or chronic
renal failure secondary to ureteric obstruction.
Treatment will be directed to the cause, the
modification of disease activity when appropriate,
e.g. immunomodulation with steroids, tamoxifen
and restoration of flow in affected structures, e.g.
ureteric stenting
Retroperitoneal (psoas) abscess
Psoas abscess is a relatively uncommon diagnosis. At the start of the
20th century, psoas abscess was mainly caused by TB of the spine
(Pott’s disease).* psoas abscess was mostly found secondary to direct
spread of infection from the inflamed ± perforated digestive or
urinary tract.
*primary psoas abscess due to haematogenous spread from an occult
source is more common, especially in immunocompromised and
older patients, as well as in association with intravenous drug misuse.
Clinical presentation is with back pain, lassitude and fever.
A swelling may point to the groin as it tracks along iliopsoas.
Pain may be elicited by passive extension of the hip or a fixed flexion
of the hip evident on inspection.
Radiological investigation is via CT scanning.
treatment usually by percutaneous CT-guided drainage and
appropriate antibiotic therapy.
Retroperitoneal tumours
A retroperitoneal tumour is usually confined to primary tumours arising in
other tissues in this region e.g. muscles, fat, lymph nodes and nerves.
Retroperitoneal lipoma
The patient may seek advice on account of a swelling or because of
indefinite abdominal pain. Women are more often affected.
These swellings sometimes reach an immense size.
Diagnosis is usually by ultrasonography and CT scanning.
A retroperitoneal lipoma sometimes undergoes myxomatous degeneration,
a complication that does not occur in a lipoma in any other part of the body.
Moreover, a retroperitoneal lipoma is often malignant (liposarcoma)and
may increase rapidly in size.
Retroperitoneal sarcoma -They are rare tumours .
The peak incidence is in the fifth decade of life, although they can occur at
almost any age. The most common types of retroperitoneal soft-tissue
sarcomas in adults vary from study to study. However, in most studies, the
most frequently encountered cell types are:1● liposarcoma;
2● leiomyosarcoma;3● malignant fibrous histiocytoma.
Clinical features
Patients with sarcomas present late, because these tumours arise in
the large potential spaces of the retroperitoneum and can grow very
large without producing symptoms. Moreover, when symptoms do
occur, they are non-specific, such as abdominal pain and fullness, and
are easily dismissed as being caused by other less serious processes.
Retroperitoneal sarcomas are, therefore, usually very large at the
time of presentation.
Investigations *(CT + MRI) for tumour detection, staging and surgical
planning, but also for guiding percutaneous or surgical biopsy of these
tumours. Such biopsies have a greater role than for other sarcomas.
Treatment
The definitive treatment of primary retroperitoneal sarcomas is
surgical resection.
Chemotherapy and radiotherapy without surgical debulking have
rarely been beneficial, when used alone or in combination .