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DISEASES OF PERITONEUM

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.

• The formation of pus in the subphrenic


space.
• Subphrenic abscess formation is usually an
insidious process. The manifestations may
be nonexistent, are usually non-specific and
may be misleading. The findings are
commonly those of an intra-thoracic rather
than an intra-abdominal condition.
ANATOMY OF SUBPHRENIC
SPACE
• Right superior subphrenic space b/w right lobe of liver
and the diaphragm.
• Right inferior subphrenic space transversely beneath the
right lobe of liver in Rutherford Morrison’s pouch.
• Left subphrenic space bounded above by the diaphragm
and behind by the left triangular ligament and the left lobe
of liver, the gastrohepatic ligament and the left lobe of
liver.
• Left inferior or left sub hepatic space lesser sac.
• In about 50% of the cases there is a right-sided, in 25% a
left-sided and in 25% a bilateral subphrenic abscess.
Anatomy of subphrenic space
Left superior space

Right
Superior Ieft inferior
space
Space
(lesser sac)
Subphrenic Abscess

Left
subphrenic
Right
abscess
subphrenic
abscess

Right sub- Left


hepatic subhepatic
abscess abscess
CAUSES
• Develops 3 to 6 weeks following Biliary Surgery,
Appendicectomy, surgery on the stomach,
duodenum pancreas, spleen or splenic flexure of
colon.
• Perforated duodenal and gastric ulcer.
• Perforated gall bladder
• Aastomosis leakage or other wound contamination
tends to lead to a subphrenic abscess.
PATHOGENESIS
• The pressures from the diaphragmatic
movements with respirations are such that
there is a movement of the ascitic fluid of
the abdomen into the subphrenic space and
with it travel any bacteria that might be
present, which facilitates abscess formation.
Subphrenic Abscess
• Patients are often elderly.

• Fever and a loss of appetite.

• 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

Tuberculous peritonitis is a chronic infection.


The great majority of infections are caused by
M. tuberculosis.
Tuberculous peritonitis can also be caused by M.
bovis, which is acquired by drinking
unpasteurised milk from infected cows.
PATHOLOGY
• Abdominal tuberculosis can present either as a
tuberculous peritonitis or gastrointestinal
tuberculosis.
• Occasionally, both presentations may be seen in
the same patient.
• As the disease progresses, the visceral and parietal
peritoneum become increasingly studded with
tubercles.
• Ascites develops secondary to "exudation" of
proteinaceous fluid from the tubercles.
Pathology
• More than 90 percent of patients with
Tuberculous peritonitis have ascites at the
time of presentation,
• While the remainder present with a more
advanced "dry" phase, representing a
fibroadhesive form of the disease.
Tuberculous Peritonitis
• Presentation may be:
»Acute Tuberculous Peritonitis
&
»Chronic Tuberculous
Peritonitis
Acute tuberculous Peritonitis
• Presents with symptoms and signs of acute
peritonitis usually ends in surgery.
• Peroperative findings straw colored fluid,
tubercles scattered on peritoneum and
omentum.
• If this happens evacuate the fluid and
send for C/S, send piece of omentum of
histopathology.
Chronic tuberculous Peritonitis
• Patient may present with:
» Abdominal pain
» Fever (low grade) evening rise of
Temperature.
» Loss of weight
» Ascites
» Night sweats
» Abdominal Mass.
Mode Of Infection
• Tuberculous mesenteric lymph nodes
rupture Peritonitis
• Tuberculosis of iliocaecal region.
• Hematogenous spread from active
Pulmonary or Miliary TB.
• Or contiguously from tuberculous
salpingitis.
Varieties Of Chronic 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

• Mantoux test is of value in children but is of


negligible value in adults.

• Lymphocyte rich Ascitic fluid


DIAGNOSIS
• The gold-standard for diagnosis is
culture growth of Mycobacterium on
ascetic fluid or a peritoneal biopsy.
DIAGNOSIS

OTHER TESTS

Chest x-ray Old tuberculosis in 20 to 30 %

Peritoneal thickening, omental caking and /or


US & CT ascites with fine mobile septations. Enlarged
L.N
DIAGNOSIS
• Diagnostic laparoscopy full inspection of
the peritoneal cavity and biopsies of the
tubercles most accurate and minimum
morbidity.
Treatment
• Ascitic form if the general condition is
good start Anti tuberculous therapy.
• Encysted form conservative management.
Treatment of Fibrous form
• Sub-acute intestinal obstruction.
• keep the patient NPO
• Pass N.G tube.
• Pass foley’s cath: to calculate out put
• Maintain I.V line to correct fluid and electrolyte
imbalance.
• Antibiotics to prevent infection from bacterial
translocation
• Input/ out charting.
• Monitor abdominal girth to look whether the
obstruction is relieving or not.
Treatment of Fibrous form
• Acute Intestinal Obstruction
• Initial Resuscitation to built the patient for surgery
i.e. correction of dehydration and electrolyte
imbalance.
• Exploratory laparotomy to relieve the obstruction
Treatment of Purulent form
• Prolong treatment with ATT.
• Surgical evacuation of cold abscess.
• Surgical management for intestinal
obstruction.
• Management of fecal fistula
» Conservative or
» Surgical
Complications
• Blind loop syndrome in fibrous form.
• Fecal fistula.
PSEUDOMYXOMA PERITONEI

• Extremely rare.
• Frequent on women.

• Diffuse, Intraperitoneal collection of gelatinous fluid large


part of which is encysted
• Associated with mucinous and cystic tumors implants on
peritoneal surfaces and omentum

• Strictly, etiology is secondary to grade I mucinous


cystadenocarcinoma of the appendix.

• Ovarian, pancreatic cancer  similar picture


Pathophysiology
• Mucocele rupture  dissemination of mucin-
producing tumor cells throughout peritoneal cavity

• Characteristic and predictable pattern of tumor


progression:

– Gravity  dependent collection of tumor


(pelvis, retrohepatic space, paracolic gutters, )

2) Resorption of peritoneal fluid  accumulation of


tumor cells to distinct sites:
Deposit Sites Secondary To Fluid
Resorption

• Locally Malignant does not metastasize to


extraperitoneal structures.
• It usually Metastasizes to:
» Between liver, Rt: hemi diaphragm
through lymphatic within undersurface of
hemi diaphragm.
» Greater, lesser omentum
lymphatics draw fluid, attracting tumor
cells to their surface  Omental caking
Clinical features.
• Painless
• No impairment of general health.
• Abdominal distension.
• Negative shifting dullness.
Diagnosis
• Abdominal distension with negative shifting
dullness.

• 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