DISEASES OF THE PERITONEUM

Dr. Abdelkhalig Elhilu

Assistant professor of surgery

Definition, Anatomy & Function:

 It is a double layer of serous membrane that lines the peritoneal

cavity from inside.
I. Parietal : lines the wall of the abdomen and pelvis and folds
back on its self forming the mesentery.
II. Visceral : covers the internal organs.
 Peritoneal cavity is divided into greater and lesser sac.
 Provides support to the intestine ( small & large ).
 Prevents intestinal twisting.
 Visceral lubrication.
 Stores fat and water and absorbs fluids.
 Act as a pathway for blood vessels.
 Defensive role – policeman of the abdomen.
 Fibrinolytic activity.
 Peritoneal ligaments

 Mesentery : connects the small intestine and parts of the

colon to the posterior abdominal wall.
 Greater omentum : hangs from the transverse colon
between the anterior abdominal wall and the small
bowel.
 Lesser omentum : passes from the lesser curve of the
stomach and 1st part of the duodenum to the inferior
surface of the liver.
 Other ligaments : Falciform, Triangular, coronary, Gastro-
phrenic, Gastro-splenic, Ligament of Trietz.
Etiology of peritoneal Diseases

Congenital

Traumatic

Inflammatory

Neoplastic

Miscellaneous
CONGENITAL
Congenital bands:
 present with a picture of intestinal obstruction e.g.
intestinal malrotation.
Congenital diaphragmatic hernia :
 Present with ARDS.

Mesenteric cyst:
 Chylolymphatic, Enterogenous, Urogenital remnants,
Dermoids
 They may present in young adults as painless mass,
recurrent abd pain, torsion, rupture, haemorhage,
intestinal obstruction or infection
Other cysts:
 Omental cyst, mesocolon cyst

Mesenteric
enterogenous cyst
TRAUMA

 Mesenteric tears:
Associated with other organ injury, signs of shock, seat
belt use
 Avulsion of ligaments:

leads to viscus injury

Inflammation (peritonitis)

Non
infective
peritonitis
Primary
pnemococcal ( Peritonism)
peritonitis

Spontaneous Tuberculous
bacterial
peritonitis peritonitis

Acute Acute
secondary secondary
diffuse localised
bacterial bacterial
perotonitis peritonitis
1- Primary pneumococcal peritonitis

Definition:
Bacterial infection of the peritoneal cavity in the absence of any
intra-abdominal source of infection.
Organisms:
.(
(route of infection is the vagina And Fallopian tube or blood born)
 Affects mainly children 3-9 yrs. (esp. girls- related to intra-vaginal
FB). , cirrhotic pts., nephrotic Syndrome pts.
Clinical picture :
 Sudden onset, lower abd. pain, fever (39º) , vomiting, profuse
diarrhea ( blood stained), frequent micturition, abd rigidity , high
WBC (30000/µl).
Differential diagnosis:
 Acute appendicitis, Basal pneumonia.

Treatment:
 Antibiotics, Rehydration, Correction of electrolyte imbalance, Early
operation.

2-Generalized diffuse secondary peritonitis

Aetiology :
 Usually secondary to a localized intra-peritoneal
inflammation e.g. acute appendicitis, perforated
viscus, diverticulitis, ruptured tubo-ovarian abscess etc.
Organisms :
 Usually polymicrobial (aerobic and anaerobic organisms).

 Bacteria comes from GIT, Fallopian tube, exogenous

source ( drains),translocation, haematogenous
 E.coli, Streptococci, Bacteroides, Clostridium,
Klebsiella,staphylococci, Chlamedia,
Gonococci,pneumococci
  Presentation:
 Early : Severe abd pain, vomiting, urinary
symptoms, abd tenderness and rigidity,
tacchycardia, fever !, paralytic ileus, abd distension
.
 Late : coma, circulatory failure and shock
(Hippocratic facies)
 Investigations:
 wbc, plain x-ray abdomen, US, CT, serum amylase

The X-ray can

give a clue to
the cause of
peritonitis
 Treatment:

 General care: Correction of dehydration & electrolytes,

support of vital systems, naso-gastric tube suction
 Antibiotics.

 Specific treatment of the cause: surgical intervention for the

specific cause.
 Peritoneal lavage.

Complications:
 Bacteremia and endotoxic shock.

 Bronchopneumonia & respiratory failure.

 Multi-organ failure.

 Ileus.

 Intra-abdominal abscesses.

 Peritoneal adhesions.

3-Localized peritonitis (intraperitneal abscesses)

 Secondary to local peritonitis, diffuse peritonitis, abdominal

surgery.
 Pus collects in certain areas:-
I. Left sub phrenic space(lesser sac – complications of pancreatitis).
II. Right sub phrenic space (between liver & diaphragm- perforated DU, gall
bladder and appendix).
III. Right sub hepatic space (Morrison pouch- cholecystitis, appendicitis,
perforated DU, upper abdominal surgery).
IV. Para colic space.
V. Right iliac fossa.
VI. Pelvis (commonest site – appendicitis, peritonitis, anastomotic leak, colo-
rectal surgery)
 Clinical features:

 Symptoms include: Persistent fever, sweating,

malaise, epigastric fullness and pain ( radiates to
the shoulder in sub phrenic abscess) .Diarrhea and
passage of mucous (pelvic abscess).
 Progressive deterioration in the general condition.

 Signs include: swinging pyrexia, palpable mass in

subphrenic abscess, pulging of anterior rectal wall
in PR examination in pelvic abscess.
Investigations:
 Blood test – wbc, c-reactive protein.

 Plain radiographs.

 Ultrasound .

 CT scan.

2 4
1.Lt inferior
subphrenic
space 1
2.Rt
subphrenic
space. 3

3.Subhepatic
space.

4. Lt superior
Subphrenic
space
Treatment :

 For extra pelvic abdominal abscess:-

o Ultrasound or CT guided percutaneous drainage.
o Open drainage – especially for pointing abscesses.
o Exploration and drainage.
o Appropriate antibiotics.
 For pelvic abscess:-
o Trans-vaginal drainage (females).
o Trans-rectal drainage (preferable).
o Ultrasound or CT guided supra-pubic drainage.
o Laparotomy should not be necessary.
o Appropriate antibiotics.

Pelvic abscess in CT scan Trans-rectal drainage

 4-Spontaneous bacterial peritonitis

 Acute infection of ascitic fluid.

 Affects children and adults.

 Affects patients with liver cirrhosis ( Child’s C)

 High mortality rate.

Organisms:
 E.coli, Streptococci, other Gram +ve. organisms.

Clinical picture:
 Abdominal pain, fever, diarrhea, worsening encephalopathy , ileus
or asymptomatic , mild – severe tenderness
Treatment:
 Conservative – antibiotics 3rd generation cephalosporin plus,
supportive therapy.

5-Tuberculous peritonitis
Clinical features:

 Two types, Acute and chronic form.

Acute form:
 Can simulate acute bacterial peritonitis ( straw colored exudate plus tubercles)
Chronic forms:
 Present with abdominal pain, fever, loss of wt, ascites, night sweats and
abdominal mass.
 Originates from TB lymph nodes,ileocaecal TB, pyosalpinx, or blood

 Types include:
I. Ascitic form- generalized ascites and tubercles (abd distension, transverse
abd mass).
II. Encysted form- localized ascites
III. Fibrous (plastic) – adhesions (blind loop , mass , intestinal obs.).
IV. Purulent – rare (secondary to TB salpingitis, forms cold abscesses point to
umbilicus or burst into the bowel, Intestinal obs).
Treatment:
 Anti tuberculous drugs, ( Surgery: int. Obstruction, Rt. Iliac fossa mass,
salpingitis, cold abscess)
6-Other types of peritonitis

 Idiopathic strept & staph peritonitis of adults:-

rare.
 Peritonitis following abortion and delivery.
 Periodic peritonitis ( Familial Mediterranean
fever) – Arabs, Jews & Arminians.
 Starch peritonitis.
 Post-operative peritonitis
 Biliary peritonitis.

Peritoneal neoplasms

 Either primary or secondary.

 Secondary neoplasms are far more common.
 Primary malignancies:
o Mesothelioma:
 Highly malignant.
 Caused by asbestos.
 May respond to chemotherapy.
o Pseudo myxoma peritonei:
 More in women.
 Associated with mucinous tumours of the ovary and appendix.
 Abdomen is filled with a jelly like substance.
 Occasionally respond to radio isotopes or chemotherapy.
o Mesenteric Neoplasms:
 Benign include lipoma, fibroma, fibromyxoma
 Malignant include lymphoma.
 Secondary tumours:
o Carcinoma peritonei:
 Due to metastasis from primaries (stomach,
colon, ovaries etc.).
 Terminal event.
 Discrete nodules , plaques, diffuse adhesions,
frozen pelvis , ascites.
 Treated by chemotherapeutic agents (systemic
or intraperitoneal).