Peritonitis  

Anatomy and physiology

 

Peritoneum

The peritoneum is a thin membrane which has many folds and covers the outer surface of the intestines and lines the abdominal cavity.

Parietal

Visceral

Serous fluid

 

Omentun

Double fold of peritoneum

Variable amounts of fat

Lesser - connects liver to stomach

Greater - stomach to colon

"Walls of"

 

Peritonitis  

Acute or chronic

Septic or aseptic

Primary or secondary

Localised or diffuse

 

Causes

Inflammatory disease of the abdominal viscera

Female genital tract infections

Penetrating injury

Rupture of intra-abdominal abscess

Ischaemia of the bowel

Tuberculous

Granulomatous

Postoperative

 

Perforation

Acute inflammation of the appendix

Acute inflammation of the gall bladder

Perforating peptic ulceration

Crohn`s disease

Ulcerative colitis

Diverticulitis

Ulcerating carcinomas

Acute intestinal obstruction

Salphingitis

 

 

Pathophysiology

An acute inflammatory process

 

Purulent exudate

 

Intestine becomes flaccid and dilated

 

If any part of the intestine is perforated bacteria may enter this cavity and cause widespread inflammation.

 

Infection may be localised resulting in abscess formation

 

A similar clinical picture may be produced by the presence of blood, bile, gastric secretions or pancreatic enzymes in the peritoneum

 

E. coli or Bacteroides usually involved

 

Inflammatory exudate collects in the peritoneal cavity, (up to 5 l per day)

 

Systemic septicaemia may develop

 

Clinical features of Peritonitis

Often sudden onset

Visceral pain may reduce with time

Rebound tenderness

Patient lies still and is afraid to move

Knees usually flexed

Maximum tenderness is over the inflamed site

Shallow respirations

Silent abdomen Paralytic ileus, (after a time)

Abdominal distension develops over time

Nausea and vomiting increasing over time

Possible vomiting of bile and small bowel contents

Board like abdomen decreasing as toxicity increases

Free gas in the peritoneum

Accumulation of fluid in the peritoneum

Pyrexia

Leucocytosis                                                             Tachycardia

Shock                                                                         Dry tongue

Anorexia                                                                    Possible shoulder pain

 

Treatment

Diagnose

Stabilise

Analgesia

I/V infusion and nasogastric drainage

Flatus tube may be passed to decompress abdominal volume

Pre op care

Full Blood Count

Measurement of abdominal girth

Correction of cause - eg. repaire of perforation, resection of infarcted bowel, drainage and removal of infective focus

Peritoneal lavage

IV antibiotics

IV/IM analgesia

Central venous pressure measurement