Académique Documents
Professionnel Documents
Culture Documents
BY
PROF: DR. NAHEED SULTAN
LOCALIZED PERRITONITIS
• Inflammation confined to part of the
peritoneum.
• Inflamed appendix, appendicular abscess,
Pelvic abscess, Subphrenic abscess etc are
the examples of localized peritonitis.
• Localized peritonitis may end up in diffuse
peritonitis if left untreated.
ABDOMINAL ABSCESS
• Caused by localized or generalized
peritonitis.
• Presenting features lassitude, anorexea
and failure to thrive; low grade fever,
tachycardia, leucocytoses and localized
tenderness.
• Later a palpable mass.
ABDOMINAL ABSCESS
Subphrenic
Parcolic
Right iliac Fossa
Pelvic
ABDOMINAL ABSCESS
• In palpable Mass meticulous daily
examintion to monitor change in size.
• CT/ Ultrasound to look for size and exact
location.
• Antibiotic Treatment abscess may
become smaller and smaller and finally
undetectable.
ABDOMINAL ABSCESS
• In refractory cases drainage
• Ultrasound/ CT guided drainage
• Open Surgical drainage.
Pelvic Abscess
• Commonest site of abscess due to appendix
(if pelvic) and fallopian tubes.
• As a sequel to diffuse peritonitis or
anastomotic leakage following gut surgery.
• Some times they attain a considerable size
to be detected.
Clinical features of pelvic abscess
• Diarrhoea and passage of mucus in stool.
• Passage of mucus for the first time in a patient
who is recovering from peritonitis
pathognomonic of pelvic abscess.
• Fever, lassitude, anorexia, tachycardia,
leucocytosis.
• Pelvic or rectal tenderness, bogginess or bulging
of anterior rectal wall.
• Can be confirmed by Ultrasound or CT scan if
uncertain.
TREATMENT OF PELVIC
ABSCESS
• Abscess may rupture to release pus in rectum if
left untreated and patient may recover.
• Surgical drainage per rectally with the help of
hemostat.
• In women surgical drainage per vagina through
posterior fornix.
• Placement of drainage tubes percutaneously/ via
the vagina/ rectum under radiological guidance.
OPENING PELVIC ABSCESS IN
RECTUM
Culdocentesis/ colpotomy
Percutaneous drainage of pelvic
abscess with drainage tube.
SUBPHRENIC ABSCESS.
Right
Superior Ieft inferior
space
Space
(lesser sac)
Subphrenic Abscess
Left
subphrenic
Right
abscess
subphrenic
abscess
• Sweating, wasting.
• Epigastric fullness.
Subphrenic Abscess
• Non-productive cough due to an atelectasis in the
lung of the affected side or a pleural effusion on
that side.
• Abdominal pain on the affected side in the upper
abdomen is common, which is severe on deep
palpation by the physician with rigidity and
palpable swelling.
• Dyspnea, chest and shoulder pain and dullness or
rales over the lung base may be noted.
Subphrenic Abscess
• CBC leucocytosis,
• Plain abdominal X-ray films may show the abscess cavity
with gas in it from gas producing bacteria.
• Chest X-rays atelectases, lower lobe pneumonia and
pleural effusions as well as an immobile diaphragm.
• Ultrasound Abdomen.
• CT scan.
• Radiolabelled white cell scanning when other imaging
technique are not helpful.
TYPICAL
RADIOGRAPHIC
PRESENTATION OF
RIGHT
Elevated Rt: SUBPHRENIC
Hemidiapragm ABSCESS
Ultrasound showing subphrenic
abscess.
TREATMENT
• Use of broad spectrum antibiotics.
• Ultrasound of CT guided percutaneous
drainage with placement of drainage tube.
• Irrigation with antibiotic solutions through
the drainage tube.
• Open surgical drainage.
TUBERCULOUS PERITONITIS
• Ascitic form
• Encysted form
• Fibrous form
• Purulent form
Ascitic Form
• Peritoneum is studded with tubercles and
peritoneal cavity becomes filled with pale,
straw colored fluid.
Ascitic Form
• The onset is insidious.
• Loss of energy.
• Facial pallor and loss of weight.
• Night sweats
• Abdominal distension
• Abdominal discomfort.
• Dilated veins can be seen in the abdominal
wall.
Ascitic Form
• Shifting dullness
• Congenital hydrocelle can be some time
seen in male child due to PPV.
• Umblical hernia secondary to long standing
abdominal distension.
• Transverse abdominal mass due to rolled up
greater omentum infiltrated with tubercles.
Encysted Form
• Also known as loculated.
• One part of abdominal cavity alone is
involoved with resultant localized intra-
abdominal swelling.
• Poses diagnostic difficulties.
• Is difficult to differentiate from ovarian
cysts.
Fibrous Form/ Plastic form
• Characterized by widespread adhesions coils of
small intestine become matted together and
distended.
• Distended boil act as a blind loop and give rise to
steatorrhea, wasting and attacks of abdominal
pain.
• Palpable mass composed of intestine adherent to
omentum along with thickened Mesentry.
• Patient may present with sub acute or acute
intestinal obstruction
Purulent form
• This is rare.
• Secondary to tuberculous salpingitis.
• In between the mass of adherent intestine and
omentum, tuberculous pus is present.
• Cold abscess often form and point on to the
surface, commonly near the umblicus, or, burst
into the bowel.
• It may complicate into the fecal fistula formation
DIAGNOSIS
• Routine laboratory tests Normocytic normochromic
anemia in 50 %
• Mantoux test/ Tuberculin skin testing
OTHER TESTS
• Extremely rare.
• Frequent on women.
• Ultrasound Abdomen.
• CT Scan Abdomen.
TREATMENT
Sugarbaker Protocol
• Radical debulking of tumor load:
– appendix, peritoneum, omentum;
– additional viscera as indicated
– Curative therapy = all nodules > 2.5 mm
• Intraoperative heated mitomycin
• Post-operative 5-FU
• Reports of 80% 10 yr survival
Rationale for Radical Surgery
• Low aggressiveness of tumor; rare LN or liver
involvement
• Peritoneal dissemination occurs early
• Areas of spread are treatable by peritonectomy/
omentectomy
• Redistribution phenomenon: small bowel is
largely spared (2nd motility?)
• Regional chemotherapy can attack all surfaces
exposed to tumor
THANKS