Chapter 5: Acute Suppurative Peritonitis Anatomy and Physiology of Peritoneum: serosal membrane, which is composed of a single layer of flat

flat mesothelial cells supported by submesothelial connective tissue In this subserosal tissue there are fat cells, lymphatics, blood vessels and inflammatory cells like lymphocytes and plasma cells. bidirectional, semipermeable membrane that controls the amount of fluid within the peritoneal cavity, promotes the sequestration and removal of bacteria from the peritoneal cavity, and facilitates the migration of inflammatory cells from the microvasculature into the peritoneal cavity. Normally, the peritoneal cavity contains less than 100 mL of sterile serous fluid.

Acute abdomen: Acute peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the peritoneal cavity and viscera. Peritonitis -localized or generalized, results from infection or non-infectious process. Classification: Primary or secondary (pathogenesis) Bacterial or non bacterial( cause) Diffused or local (area) *Acute, subacute or chronic (clinic duration) *Acute diffused peritonitis : common causes: Perforation, Inflammation, Rupture Cause: Secondary peritonitis ,Primary peritonitis Primary Peritonitis: an infection that occurs as a complication of ascites. Most cases of bacterial peritonitis occur as a result of ascites due to chronic liver disease, or kidney failure patients undergoing peritoneal dialysis. Ways of bacteria come into abdominal cavity : Hematogenous dissemination: Pathogens from focus of infection in respiratory or urinary tract, spread through the blood arriving to the peritoneum. Upward infection: Bacteria from the female reproductive tract, spread through the fallopian tubes upward to the abdominal cavity directly Direct dissemination: Such as urinary tract infection Transmural infection: the bacteria in intestine would arrive at the peritoneal cavity

The outcome of peritonitis:

Death Local peritonitis Local abscess Adherence

Clinical Features-Symptoms: Abdominal Pain Swelling & tenderness in the abdomen Fever & Chills Loss of Appetite Nausea & Vomiting Toxicity symptom ^ Breathing & Heart Rates Shallow Breaths Low BP Limited Urine Production Inability to pass gas or feces An acutely ill patient tends to lie very still because any movement causes excruciating pain. They will lie with their knees bent to decrease strain on the tender peritoneum. Sign:

Abdominal distension Abdominal tenderness, rebound tenderness, muscle rigidity Bowel sounds decreasing Rectal examination

Lab Studies: CBC: WBC Blood chemistry- May reveal dehydration and acidosis Urinalysis (UA) - To rule out urinary tract diseases Amylase and lipase - If pancreatitis is suspected Peritoneal fluid: Abdominal acupuncture- @ right & left McBurneys point Imaging Studies: Abdomen erect film B-ultrasound CT Diagnosis: History Sign Auxiliary test

Treatment:

The general principles to control the infectious source to eliminate bacteria and toxins to maintain organ system function to control the inflammatory process.

Treatment2: Nonoperative management: Position: semi-reclining position Prohibiting oral intake and Nasogastric Aspiration Correct fluid and electrolyte imbalance Systemic antibiotic therapy : empiric broad-spectrum parenteral antibiotic coverage Nutrition and metabolic support Sedative, Analgesia and Oxygen inhalation Intensive care with hemodynamic, renal, and pulmonary support for severe cases Surgery: *Principle Dealing with primary disease Thorough clean abdominal cavity Full drainage Postoperative management * A full exploration and lavage of the peritoneum , as well as to correct any gross anatomical damage which may have caused peritonitis. Intra-abdominal Abscess: Subphrenic abscess: Clinical Manifestation: Obvious Systemic symptom Unclear Local symptom Diagnosis and Differential Diagnosis Fever and abdominal pain after treatment of any history of intra-abdominal infectious processes , or any abdominal post operation. A CT-scan of the abdomen will usually reveal an intra-abdominal abscess. Liver function tests, abdominal x-ray, and sonogram may also be helpful. Treatment: Surgery drainage: Percutaneous drainage and percutaneous and endoscopic stent placements Pelvic Abscess: Clinical Manifestation: Obvious Local symptom Mild Systemic symptom Treatment :

Surgery and non-operation

Interloop abscess: Treatment: Surgery and non-operation