ACUTE PERITONITIS

ANATOMY

• The abdominal cavity and viscera are lined by the peritoneum which is lubricated by small amount of pale yellow fluid
• It is completely closed in the male but communicates with the exterior in the female through the genital tract
• The peritoneum has a vast surface area and is semipermeable
• It may be used for dialysis
• It can absorb massive amounts of toxins and bacteria in peritoneal infections and strangulation of bowel.
• The peritoneum loses excessive sero-fibrinous fluid when inflamed
• The parietal peritoneum has somatic innervation and its irritation causes pain
• The visceral peritoneum has autonomic innervation and pain is diffuse and poorly localized.
• The peritoneal cavity is divided into the greater and lesser sacs
• The peritoneal cavity has a number of potential spaces and recesses in which pus may collect or bowel may herniate and strangulate

 

 

ACUTE PERITONITIS

• Two types of acute peritonitis
• Primary Peritonitis
• Secondary peritonitis

PRIMARY PERITONITIS

• There are 2 types
• One type affects young girls between 3 and 10 years and occasionally boys
• It is caused by Strept. pneumonia and Strept. pyogenes.
• ii. The second type affects cirrhotic patients with ascites or those with nephrotic syndrome and is caused by E. coli and Strept. faecalis or anaerobic organisms.

SECONDARY PERITONITIS

• May be localized or generalized

Causes

• Acute inflammation of viscus
• Acute appendicitis
• Acute salpingitis
• acute cholecystitis
• Amoebic colitis
•  Puerperal + postabortal sepsis
• Penetrating abdominal injury
• Septicaemia caused by staphyloccocus or pneumococcus

• Commonest causes in males in West Africa:
• Acute appendicitis
• Typhoid perforation
• Perforated duodenal ulcer
• Traumatic perforation of a viscus

• Commonest causes in females in West Africa:
• Acute salpingitis
• Acute appendicitis

• Causative organisms
• Usually a mixed infection

E. coli Strept. faecalis Klebsiella Enterococci Proteus	Pseudomonas Staphylococcus Bacteroides Gonococcus Chlamydia trachomatis

FACTORS AFFECTING PERITONITIS

• Size of the infecting inoculum
• Virulence of the infecting organisms
• Synergism between the bacteria
• Underlying disease causing the peritonitis

CAUSES OF DEATH IN PERITONITIS

• Shock –hypovolaemic/septic
• Dehydration and electrolyte imbalances
• Septicaemia
• Respiratory failure/ARDS
• Acidosis – Metabolic/Respiratory
• Acute renal failure-pre-renal or ATN
• Liver failure
• Paralytic ileus
• Intraperitoneal abscess
• Multiple Organ Dysfunction Syndrome (MODS)

CLINICAL FEATURES

• Generalized abdominal pain
• Anorexia and nausea and vomiting
• Constipation
• Scanty concentrated urine
• The tongue is dry and furred
• Dry inelastic skin + sunken eyes
• Hypotension + shock
• Pyrexia of 38 oC or over 
• Abdomen may or may not be distended
• Shallow, rapid, grunting respirations
• Generalized tenderness, rebound tenderness & rigidity
• Acid peritonitis causes board-like rigidity
• Bowel sounds are few, infrequent or absent
• Free fluid in the abdomen may be detected

INVESTIGATIONS

• Four quadrant peritoneal tap
• Erect chest X’ray – Gas under the diaphragm
• Ultrasound scan
• Vaginal or urethral smear and culture
• Blood culture & widal test
• FBC & sickling
• Urea & electrolytes & creatinine
• Urine R/E

DIFFERENTIAL DIAGNOSIS

• Differential diagnosis of causes of peritonitis
• Acute intestinal obstruction
• Acute pancreatitis
• Haemoperitoneum
• Acute dysentery
• Ureteric colic
• Biliary colic
• Ruptured or dissecting aortic aneurysm
• Basal pleurisy

TREATMENT

• The principle of treatment are:
• Restoration of fluid and electrolyte balance
• Decompression of the bowel
• Administration of appropriate antibiotics
• Relief of pain
• Timed surgical intervention

• Conservative Treatment - Indications
• Peritonitis of pelvic origin
• Localization of infection – App. Abscess
• Moribund patient
• Residual abscesses following conservative treatment should be drained

PROGNOSIS

• Prognosis depends on the following factors
• Duration of peritoneal soiling
• Age of the patient
• Pre-existing illness
• Level of perforation
• Multiple Organ Failure

BILE PERITONITIS

• Uncommon
• Mortality 50%

BILE PERITONITIS CAUSES

• Traumatic rupture of gall bladder
• Injury to liver or bile ducts
• Leakage from gallbladder bed after cholecystectomy
• Perforated acute cholecystitis
• Transudation of bile from gangrenous gallbladder

CLINICAL FEATURES

• Are those of generalized peritonitis
• Jaundiced may be present

TREATMENT

• Laparotomy
• Cholecystectomy
• Tube cholecystostomy
• Repair of injury