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PERITONEUM

»The peritoneum is single layered simple squamous epithelium of

mesodermal origin lying on thin connective tissue stroma.

»The surface area is 1.0 to 1.7 m? approximately that of total body

surface area.

»In male peritoneal cavity is sealed whereas in female it 1s open to

the ostia of fallopian tube.

» Consist of two part:

1.Parietal layer : covers anterior ,lateral and posterior

abdominal wall surface and inferior of diaphragm

2.Visceral layer : covers most of surfaces of

intraperitoneal organ and anterior aspect of retroperitoneal organ .
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PERITONEAL CAVITY

* The peritoneal cavity is subdivided into interconnected

compartments by 11 ligaments and mesenteries.

* The peritoneal ligaments includes:

. Coronary ligaments
. Gastrohepatic ligaments

1
2
3. Hepatoduodenal ligament
4, Falciform ligament

. Gastrocolic ligament
6. Duodenalcolic ligament
7. Gastrosplenic ligament
8. Splenorenal ligament

9. Phrenicocolic ligament
10. Transverse mesocolon

11.Small bowel mesentry

* These structures partition the peritoneal cavity into nine
potential spaces which are :

“Right & left subphrenic

“+ Subhepatic

“*Supramesentric & inframesentric

“Right & left paracolic

+» Lesser sac

+ Pelvis

These spaces , ligaments and mesenteries direct the

circulation of fluid in peritoneal cavity and thus useful in
predicting the route of spread of infection and malignancies.
Gefaial arrangemedl of the penlofhewm

= amen Fig. BLY ©

PHYSIOLOGY

* The peritoneum is bidirectional semipermeable membrane

that control the amount of fluid in peritoneal cavity .

« Normally it contain only less than 100 ml of sterile serous

fluid.

» Microvilli are present on the apical surface of peritoneal

membrane which markedly increases the surface area and
promotes the rapid absorption of fluid from cavity to
lymphatics and portal and systemic circulation.

* The circulation of fluid in peritoneal cavity driven in part by

movement of diaphragm .
* There are intracellular pores in peritoneum called
STOMATA present in inferior surface of diaphragm,
communicating with lymphatics pool of diaphragm .

* Lymph flows from diaphragmatic lymph channel through

subpleural to regional to thoracic duct.

» Relaxation of diaphragm during expiration opens the

stomata and negative intra thoracic pressure draws fluids
and particles like bacteria .

* Contraction of diaphragm during inspiration propel the

lymph through channels into thoracic duct. These
mechanism is so called diaphragmatic pump drive .
* The circulatory pattern of peritoneal fluid toward
diaphragm and into central lymphatic is consistent with
rapid appearance of sepsis in patients with generalized
intra-abdominal infection and occurrence of abscesses
distant from primary disease.

* When parietal peritoneum defects are created , healing

occurs not from the edges but by the development of new
mesothelial cells throughout the defect , so large defect
heals as rapidly as small defect.
Functions of the peritoneum
In health

+ Visceral lubrication
* Fluid and particulate absorption

In disease

* Pain perception (mainly parietal)

* Inflammatory and immune responses

* Fibrinolytic activity
* Peritonitis is inflammation of peritoneum and peritoneal
cavity caused by generalized or localized infection.

» Cause of peritonitis:

Causes of partoneaal iInNfammation

Bacterial, gastrointestinal and non-gastrointestinal

Chemical, e.g. bile, barium

Allergic, e.g. starch pentonitis

Traumatic, e.g. operative handling

Ischaemia, e.g. strangulated bowel, vascular occlusion

Miscellaneous, e.g. familial Madteranean fever
* Primary peritonitis: it results from bacterial , chlamydial ,
fungi or mycobacterium infection in absence of perforation
of GI tract.

* Secondary peritonitis - it occur in gastro intestinal

perforations.

» Spontaneous bacterial peritonitis: is defined as bacterial

infection of ascitic fluid in the absence of any intra-
abdominal source of infection and is monomicrobial. Usually
associated with cirrhosis , nephrotic syndrome . In adult
most common pathogen is E.coli or Klebsiella pneumonae.
In child age group nephrogenic or hepatogenic ascites group
A streptococci ,Staphylococei or Streptococci pneumonae .
PATHS OF PERITONEAL INFECTION

» (Gastrointestinal perforation, e.g. perforated ulcer, appendix,

diverticulum
Transmural translocation (no perforation), 8.g. pancreatitis,
ischaemic bowel, primary bacterial peritonitis
Exogenous contamination, &.g. drains, open surgery, trauma
peritoneal dialysis

* Female genital tract infection, e.g. pelvic inflammatory disease

* Haematogenous spread (rare), e

BACTERIA FROM GASTROINTESTINAL TRACT

* The number of bacteria in gut lumen is normally low until

distal small bowel is reached. The bilary and pancreatic
tract is also normally free from bacteria.

* In case of diseased condition there is stasis and overgrowth

of bacteria (obstruction, chronic and acute motility
disturbances ).

* Gram negative bacteria contain endotoxins

(lipopolysaccharides)in their cell wall that have multiple
toxic effect on host like release of TNF from leukocytes ,
systemic absorption may leads to endotoxic shock
NON GASTROINTESTINAL CAUSE OF PERITONITIS

Pelvic infection via fallopian tube 1s responsible for high

proportion of non gastrointestinal infection . Most common
organism 1s Chlamydia spp and Gonococci . These
organisms leads to thinning of mucous cervical plug and
allow bacteria from vagina causing infection and
infalmamtion.
MICROBILOGY

Gastrosrtestimal source
Escherichia coli
Streplococc
Ermterococci
Bacteroides spp
Clostridium spp
Milabsialla pnaurmonias

Uther sources
Chiarmydia trachomatis
Neisseria gonormhoeas
Haamolytic streplococci
Staphwvilococc
StreplocoCcClUls Dneuiimoniiae
Mycobactenum fubsrculiosis and other species

Fungal infections
LOCALIZED PERITONITIS

« Anatomical and pathological factors responsible for

localization of peritonitis:

1. The potential spaces , ligaments and mesenteries.

2. Clinical course of localized peritonitis is determined in

part by the manner in which adhesions form , around the
affected part. Glistening appearance of peritoneum
become red velvety , flakes of fibrin appears and loop of
intestine adherent to each other , there is outpouring of
exudates rich in leukocytes and plasma proteins which
soon become turbid then frank pus.
3. Peristalsis retarded in affected bowel which prevent
further distribution of infection.

4. The grater omentum by enveloping and become adherent

to inflamed structure further reducing the spread of
infection.
DIFFUSE (GENERALIZED) PERITONITIS

* Factors favoring development of diffuse peritonitis:

1,

SLE A

Speed of peritoneal contamination. Eg . If an inflamed

appendix perforates before localization there is efflux of
content in the whole cavity.

Stimulation of peristalsis by ingestion of food or enema

hinders localization.

The virulence of infective organism

Young age due to small omentum
Disruption of localised collection by injudicious handling

Immune deficiencies like AIDS or steroids .

CLINICAL FEATURES

1. Localised peritonitis:

* Initial sign and symptom depends on underlying condition

« visceral inflammation leads to pain , specific GI symptom

like malaise anorexia and nausea

* Peritoneal inflammation : pathognomic sign 1s guarding ,

rebound tenderness and rigidity for protecting viscus

* Increase temperature

* Tachycardia
2. Diffuse peritonitis:
+ EARLY :
* Severe abdominal pain worsen on movement or breathing

* Patient lie still

* Tenderness and generalised guarding on palpation when

peritonitis affects ant abdominal wall

* Infrequent bowel sound still be heard for few hours but

ceases with onset of paralytic ileus
* LATE : If localisastion or resolution doesn’t occur
» Abdomen becomes rigid (generalised )
* Distention with no bowel sound

* Circulatory failure cold clammy extremities , sunken eyes,

dry tongue, irregular pulse , anxious face

* Finally unconscious
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DIAGNOSTIC AIDS

» Bedside :

1. Urine dipstix for UTI

2. ECG (If diagnosis in doubt for cause abdominal or

cardiac )

Blood investigations :

3. Baseline urea & creatinine

4. CBC TLC

5. SERUM AMYLASE & LIPASE

6. BLOOD GROUPING
* IMAGING:

1.

ERECT CHEST Xray for free subdiaphragmatic

gases

2. SUPINE ABDOMINAI Xray for dilated bowel loops

> on

In patients who are too ill for erect radioimaging a

lateral decubitus film is required

MULTIPLANAR CT for cause of peritonitis

USG

INVASIVE : PERITONEAL DIGNOSTIC

ASPIRATION has little value in era of high quality
CT imaging.
(Gas under
diaphragm
MANAGEMENT

* General care of patient

* Correction of fluid loss and circulating volume

« Patient are frequently hypovolemic with electrolyte

disturbance . Plasma volume must be restored and
monitored for ongoing losses

» Special measure for cardiac , pulmonary , renal support (If

septic shock present)including CVP monitoring.

Urinary cathterisation and gastrointestinal decompression

through nasogastric tube until paralytic ileus has resolved.
+ Antibiotic therapy : Parenteral broad spectrum (aerobic and
anaerobic)

* Analgesia ® patient must be nursed in sitting up position and

must be relieved of pain before and after operation . Epidural
infusion is an excellent approach if possible

« Specific treatment of cause :

+ Patients in whom specific treatment not guided by CT scanning

, early surgical approach is preferred to wait & watch policy.

* In peritonitis caused by pancreatitis or salpengitis or in case of

primary peritonitis of streptococcal or pneumococcal origin non
surgical treatment is preferred.
General care of patient

» Corraction of fluid and slectrolyte imbalance

* [nsertion of nasogastric drainage tube and urinary catheter

» Broad-spectrum antibiotic therapy

» Analgesia

» Vital system support

Surgical treatment of cause when appropnate

* Remove or divert ¢

* Peritoneal lavage +
PROGNOSIS AND COMPLICATION

* Several scoring systems have been developed in the past

two decades, like APACHE-II SCORE by Kanus et al,
SEPSIS SEVERITY SCORE by STEVENS, BIONOMIAL
CLASSIFICATIONS by MEAKINS , MULTIPLE ORGAN
FAILURE SCORE by GORIS et al & MANNHEIM
PERITONITIS INDEX by BILLING et al. These scoring
systems scientifically compare the effectiveness of different
treatment regimens, health facilities and to inform patient’s
relatives with greater objectivity. They may also indicate
individual patients who may require a more aggressive
surgical approach.

» Diffuse peritonitis carries mortality rate of 10 percent in

J et =
» Complication -

Systemic comphcations of peritorwtis

Saptic shock
Systemic inflammatory response syndrome
Multi-organ dysfunction syndrome

Noa
Ueatl

Abdominal comphcations of peritonitis

Paralytic
Hasidual or recurrant abs: inflammatory mass
Portal pyaemia/liver absc
Adhesional small owe
hed

peritonitis : cause

sauses of Dile paritonitis

Parforated gall bladder secondary to inflammation or

obstruction [especially empyema)
Post-cholecystectomy

Cystic duct stump leakage

Leakage from an accessory duct in the gall-biadder bed

Bile duct injury

T-tube drain dislodgement (or tract rupture on removal)

Following other operations/procedures:

Duodenal injury

Leaking duodenal stump post gastrectomy

Leaking biliary—anteric anastomosis

Leakage around percutanaously placed biliary drains

Bilurmt or penetrating hepatobiliary or duodanal trauma
SPONTANEOUS BACTERIAL PERITONITIS

* Acute bacterial infection of ascitic fluid ,its rare except in

patient with cirrhosis affecting 1.5-3.5 percent.

* Clinical features as of peritonitis with worsening liver and

renal function hepatic encephalopathy and GI bleed.

* Diagnosis ‘made by paracentesis

» neutrophil count of aseitic fluid > 250/mm*
# ascitic culture is negative in 60 percent

# 40 percent culture positive most common organism is E.coli ,

Streptococci or enterococci
* Treatment is third generation cephalosporin cefotaxim,
alternative is amoxicillin or quinolones .

» Complication of SBP is septic shock , GI bleed ,

hypoalbuminia .

+ PRIMARY PNEUMOCOCCAL PERITONITIS

* In healthy children , girl aged 3 to 9 yrs route of infection is

via vaginal and fallopian tube and in boy the infection is
blood borne secondary to respiratory infection .

* Clinical onset is sudden with pain lower abdomen and

temperature raise . After 24-48 hours profuse diarrhoea is
characteristics and increase in frequency of urination.
* Leukocyte count > 30000 /ul , 90 percent polymorph
suggestive of pneumococcal peritonitis rather than
appendicitis.

* Management : Antibiotics and correction of dehydration and

electrolyte imbalance

* Early laparotomy odourless sticky exudates confirm

diagnosis

* The prevalence has declined greatly and now its rare .

TUBERCULAR PERITONITIS

* Intra abdominal tuberculosis is very common in resource

poor country but also rising in resource rich country due to
migration and immunosuppression where mycobacterium
avium-intracellulare is prevalent with widespread
increasing HIV virus co infection.

« Abdomen is involved in 11 percent of patients with extra

pulmonary TB. [leocaecal involvement is most common.

* Tuberculosis can spread to peritoneum through GI tract via

mesenteric lymph node or directly through blood (milliary)
* Clinically ascites is the presenting complaint , multiple
tubercular deposits present in both the layer of peritoneum

* Diagnosis : USG/ CT to detect ascites + lymphadenopathy +

diffuse thickening of peritoneum ,mesentery or omentum .

» Ascitic fluid : Straw color

Exudate (protein >25g/1)
WBC > 500 mm?®
Lymphocyte > 40 percent

» Management is supportive (nutrition ,hydration )with

systemic antituberculous drugs.
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PERIODIC PERITONITIS
* Familial Mediterrean fever (periodic peritonitis) characterized
by abdominal pain and tenderness ,mild pyrexia
;polymorphonuclear leukocytosis , pain in thorax and joint.

* Duration of attack is 24 hrs with compete remission but

exacerbation in regular interval.

* Most patient had undergone appendectomy in childhood and is

familial disease .

* This disease is limited to Arab, Armenia and cause is mutation

in MEFV(Mediterrean fever)gene.

* Peritoneum is inflamed in splenic and gall bladder vicinity ,

treatment 1s COLCHICINE during attack.
PERITONITIS ASSOCIATED WITH CHRONIC
AMBULATORY PERITONEAL DIALYSIS

* 6 percent of patient with chronic renal failure undergo

peritoneal dialysis

* Refractory or recurrent peritonitis is most common cause of

technical failure

« Patient presents with pain abdomen , fever , leucocyte count of

fluid >100 with 40 percent neutrophils.

« 70 percent caused by staph. Epidermidis and fungi are also

important cause .

* Treatment is antibiotics and removal of catheter and resumption

of hemodialysis.
CARCINOMA OF PERITONEUM
« PRIMARY TUMORS is rare and in most cases their origin

is not from the layers but adjacent structures.eg lipoma of

appendices epiploicea. Asbestos is recognized cause.

+ SECONDARY TUMORS: Common terminal event in many

cases of carcinoma of abdominal organ , both the layers of

peritoneum studded with secondaries.

» Three main form 1.) descrete nodules 2.) plaque 3.) diffuse
adhesions late stage of disease which give rise to frozen
pelvis.

* Gravity determines the distribution of malignant cells

+ Differential diagnosis is abdominal tuberculosis

* Cytoreductive surgery with hyperthermic intraperitoneal

chemotherapy is treatment of choice.

« PSEUDOMYXOMA PERITONEI * Rare condition occur

frequently in women

* Abdomen is filled with yellow jelly which are encysted .

+ Associated with mucinous cystic tumor of ovary and appendix

* Treatment 1s laparotomy and scooping out jelly mass and

complete cytoreduction (right hemicoloectomy ,spleen ,
gallbladder, greater and lesser omentum along with stripping of
peritoneum ovary and uterus in female) and HIPEC with
mitomyocin C.
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