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Surgery M4 part 2 > Peritonitis > Flashcards

Peritonitis Flashcards

1
Q

What is the composition of the peritoneum?

A

thick mesothelium layer

on top of fibroelastic tissue

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2
Q

What are the divisions of the peritoneum?

A
  • visceral peritoneum -> surrounding organs

- parietal peritoneum -> lining other surfaces of the cavity

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3
Q

what is the physiology of the peritoneum?

A
  • few mls of peritoneum fluid -> pale yellow, viscid, & contains lymphocytes
  • lubricates viscera -> allows easy movement & peristalsis
  • irritation of parietal peritoneum -> severe localized pain (rich supply of nerves)
  • irritation of visceral peritoneum -> poorly localized midline pain (poor supply of nerves)
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4
Q

Where does the visceral peritoneum get its innervation from?

A

slow C fibers running with sympathetic nerves transmit sensations
- dull crampy, poorly localized pain -> caused by ischemia, stretching, compression, traction, or chemical irritation

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5
Q

Where does the parietal peritoneum receive its innervation from?

A

A-fibers of somatic sensory nerves -> T7 - L1 anteriorly & L2 - L5 posteriorly
- sharp, well localized pain caused by irritation of parietal peritoneum

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6
Q

What is the function of the peritoneum?

A
  • absorb large volume of fluids -> peritoneal dialysis in renal failure
  • produce large volume of fluids -> ascites or inflammatory exudate (peritonitis)
  • healing by development of new mesothelial cells
  • visceral lubrication
  • pain perception
  • inflammatory immune responses
  • fibrinolytic activity
  • fluid absorption via diaphragmatic lymphatic during expiration -> abscess distant from primary disease
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7
Q

What is the difference between peritonitis & peritonism?

A

PERITONITIS
- inflammation of peritoneum (generalized or localized)

PERITONISM

  • specific abdominal examination features
  • irritation of peritoneum -> tenderness with guarding, rebound tenderness
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8
Q

What are the causes of peritoneal inflammation?

A
  • bacterial -> GI & non-GI
  • chemical -> bile & barium studies
  • allergic -> starch peritonitis
  • traumatic -> operative handling
  • ischaemia -> strangulated bowel & vascular occlusion
  • miscellaneous -> familial mediterranean fever
  • primary spontaneous peritonitis -> pure streptococcal, pneumococcal, or haemophilus infection
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9
Q

What are the causes of acute bacterial peritonitis?

A
  • invasion of peritoneal cavity by bacteria

- free fluid spillage -> circulation depends on attachments & gravity

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10
Q

What are the causes of non-bacterial peritonitis?

A
  • acute pancreatitis
  • intraperitoneal rupture of bladder
  • hemoperitoneum

peritoneum will become infected by transmural spread of organisms from bowel -> systemic inflammatory response -> in a couple of hours -> bacterial peritonitis
(duodenal & gastric perforations are sterile for a couple of hours before becoming infected)

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11
Q

What are the routes to peritoneal infection?

A
  • GI perforation -> perforated ulcer, appendix, diverticulum
  • transmural translocation -> pancreatitis, ischemic bowel
  • exogenous contamination -> drains, open surgery, trauma
  • female genital tract -> pelvic inflammatory disease
  • hematogenous -> septicemia (rare)
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12
Q

What is the cause of increased bacterial colonization in proximal bowel?

A

stasis & overgrowth caused by -> obstruction, chronic & acute motility disturbances

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13
Q

How does the biliary & pancreatic tract get infected?

A

gallstones

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14
Q

What are the organisms implicated in peritoneal infection?

A

2 or more bacterial strains

GRAM-NEGATIVE BACTERIA

  • endotoxins -> causing release of TNF from leukocytes
  • systemic absorption of endotoxin -> shock with hypotension & impaired tissue perfusion

CLOSTRIDIUM WELCHII
- exotoxins

BACTEROIDES

  • gram-negative
  • non-sporing
  • predominant in lower intestine but escape detection because they’re anaerobic & grow slowly
  • resistant to penicillin & streptomycin
  • sensitive to metronidazole, clindamycin, lincomycin, & cephalosporin
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15
Q

What are the non-GI causes of peritonitis?

A

PELVIC INFECTIONS

  • via the fallopian tubes
  • due to chlamydia & gonococcus -> thinning of cervical mucus -> allow bacteria rom vagina into uterus & oviducts -> infection & inflammation

PERIHEPATITIS
- causes scar tissue to form on Glisson’s capsule (thin layer surrounding liver) -> Fits-Hugh-Curtis syndrome

FUNGAL PERITONITIS
- complicates severely ill patients

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16
Q

Summary of organisms in peritonitis?

A

GI source

  • E. coli
  • Streptococci
  • Bacteroides
  • Clostridium
  • Klebsiella pneumoniae

Others

  • staphylococcus
  • streptococcis pneumoniae
  • mycobacterium TB
  • chlamydia trachomatis
  • Neisseria gonorrhoea
  • hemolytic strep
  • fungal
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17
Q

What are the anatomical factors that cause localized peritonitis?

A

division of the greater sac of the peritoneum into

  • subphrenic spaces
  • the pelvis
  • peritoneal cavity proper

peritoneal cavity proper is divided by transverse colon & mesocolon into

  • supra colic compartment
  • infra colic compartment
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17
Q

What are the anatomical factors that cause localized peritonitis?

A

division of the greater sac of the peritoneum into

  • subphrenic spaces
  • the pelvis
  • peritoneal cavity proper

peritoneal cavity proper is divided by transverse colon & mesocolon into

  • supra colic compartment
  • infra colic compartment

when supracolic overflows (in case of peptic ulcer perforation) -> over colon -> infracolic or right paracolic gutter -> right iliac fossa
-> pelvis

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18
Q

What are the pathological factors leading to localized peritonitis?

A
  • adhesions around affected organ
  • retarded peristalsis
  • greater omentum forms a barrier to prevent infection distribution
19
Q

What are the factors that favour the development of diffuse peritonitis?

A
  • speed of peritoneal contamination (prime factor)
  • stimulation of peristalsis -> by eating or enema
  • virulence of infecting organism
  • young children -> small omentum
  • disruption of localized collections -> by appendix mass or pericolic abscess injudicious handling
  • immune deficiency -> steroid use, AIDS, old age
20
Q

What are the initial symptoms of localized peritonitis?

A

signs of underlying condition (visceral inflammation)

  • abdominal pain
  • specific GI symptoms
  • malaise
  • anorexia
  • nausea

WHEN PERITONEUM GETS INFLAMED -> abdominal pain worsens, temperature pulse rate increase

21
Q

What are the pathognomonic signs of peritonitis?

A
  • localized guarding
  • rebound tenderness
  • rigidity
22
Q

What are the clinical features of localized peritonitis?

A
  • inflammation under diaphragm -> shoulder tip (phrenic pain) -> C5 dermatome referred pain
  • inflamed appendix in pelvic position OR salpangitis -> pelvic peritonitis -> rectal or vaginal examination reveals tenderness
23
Q

What are the EARLY signs of generalized (diffuse) peritonitis?

A
  • severe abdominal pain -> made worse by moving or breathing
  • starts initially at site of lesion then spreads outward
  • patient lies still
  • tenderness & generalized guarding
  • infrequent bowel sounds heard for a few hours -> stop with onset of paralytic ileus
  • pulse & temperature rise according to degree of inflammation
24
Q

what are the LATE features of generalized peritonitis?

A
  • generalized rigidity
  • distention
  • absent bowel sounds
  • circulatory failure -> cold, clammy extremities, sunken eyes, dry tongue, thready pulse, drawn anxious face (Hippocratic facies)
  • unconsciousness
25
Q

What are the diagnostic aids that should be preformed?

A

BEDSIDE

  • urine dipstick -> urinary tract infection
  • ECG

BLOOD

  • baseline U&E for treatment
  • full WBC count
  • serum amylase -> diagnosis of acute pancreatitis (also in perforated duodenal ulcer, mesenteric ischemia)
26
Q

What imaging modalities are used to diagnose peritonitis?

A
  • Erect chest x-ray -> free sub diaphragmatic gas
  • Supine abdominal -ray -> presence of dilated gas-filled loops of bowel (paralytic ileus)
  • ultrasound
  • CT

if patient is too ill for erect film -> lateral decubitus film shows gas beneath abdominal wall

27
Q

When is the use of ultrasound of value?

A
  • pelvis peritonitis in females

- localized right upper quadrant peritonism

28
Q

What does CT demonstrate?

A
  • the cause of peritonitis

- influences management decisions

29
Q

How should a patient with peritonitis be managed?

A

GENERAL CARE

  • care of critically ill
  • nutritional support
  • anesthesia & pain relief

PRINCIPLES OF SURGERY

  • correction of fluid loss & circulating volume
  • urinary catheterization +- GI decompression (NGT allows drainage till ileus resolves)

ANTIBIOTIC THERAPY
- parenteral broad-spectrum antibiotics

30
Q

What is the importance of analgesia?

A
  • pain relief is mandatory pre & post op (epidural) -> ALLOWS early mobilization & adequate physiotherapy post op
  • helps prevent -> basal pulmonary collapse, DVT, & pulmonary embolism

taken in nursing position (sitting up)

31
Q

when is early surgical intervention preferred over conservative?

A
  • if patient is fit for anesthesia
  • satisfactory resuscitation & return to normal physiology

MORE CAUTION IN PATIENTS WITH

  • comorbidity
  • old
32
Q

When is non-operative treatment preferred?

A

in pancreatitis or salpingitis
primary peritonitis of streptococcal or pneumococcal origin
IF DIAGNOSIS IS MADE WITH CONFIDENCE

33
Q

What is the approach in surgery in case of peritonitis?

A
  • removing the cause & adequate peritoneal lavage +- drainage
  • exploration + suction + mop drying
  • saline lavage -> 3L containing antiseptic or antibiotic
34
Q

What is the specific surgical approach in case of peritonitis caused by a perforated duodenal ulcer?

A
  • exploratory laparotomy
  • Graham’s patch
  • thorough lavage
35
Q

What is the specific surgical approach in case of peritonitis caused by a perforated appendix?

A
  • exploration
  • base of appendix & stump closure
  • wash thoroughly
  • close abdomen but leave skin open
36
Q

What is the specific surgical approach in case of peritonitis caused by an intestinal perforation?

A
  • exploratory laparotomy
  • identify the viability status of the gut
  • resection anastomosis/primary repair
  • thorough lavage
37
Q

What affects the prognosis & risk of complication in peritonitis?

A
  • degree & duration of peritoneal contamination
  • age & fitness of patient
  • nature of underlying cause
38
Q

What are the causes of biliary peritonitis?

A
  • perforated cholecystitis
  • postcholecystectomy -> cystic stump leakage
    - > leakage from accessory duct in gallbladder bed
    - > bile duct injury
    - > T-tube drainage dislodgement
  • following other operations -> leaking duodenal stump postgastrectomy
    - > leaking biliary-enteric anastomosis
    - > leakage around percutaneous placed biliary drains
  • following liver trauma
39
Q

What is the clinical presentation of biliary peritonitis?

A
  • secondary to biliary tract damage
  • patient has proven acute cholecystitis
  • diffuse peritonitis
  • jaundice occurs after a few hours
40
Q

How should biliary peritonitis be managed?

A

laparoscopic -> evacuation of bile & peritoneal lavage
-> treat source of bile leakage (infected bile is more lethal)
-> exclude or relieve obstruction to a major bile duct
if duodenal stump is blown -> drain
-> cover by jejunal patch

41
Q

How should a bile leak be managed after cholecystectomy or liver trauma?

A
  • percutaneous ultrasound guided drainage
  • endoscopic biliary stenting to reduce bile duct pressure
  • drain removal when dry
  • stent removal at 4-6 weeks
42
Q

What are the clinical features of primary peritonitis?

A
  • sudden onset of pain localized to lower half of abdomen
  • temperature raised to 39C
  • frequent vomiting
  • severe profuse diarrhea after 24-48 hours (CHARACTERISTIC)
  • increased micturition frequency
  • diffuse peritonism
43
Q

Who does primary peritonitis mostly affect?

A
  • healthy girls -> vagina & fallopian tubes
  • in males -> blood-borne & secondary to respiratory tract or middle ear infection
  • in children -> may complicate nephrotic syndrome or cirrhosis
44
Q

What are the investigations that should be performed & the treatment of primary peritonitis?

A
  • leukocytosis > 30 000uL with 90% polymorphs
  • start antibiotic therapy & correct dehydration & electrolyte imbalances -> THEN early surgery
  • if spontaneous infection of pre-existing ascites -> peritoneal tap is diagnostic

Surgery M4 part 2 (36 decks)

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