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Peritoneum

•Serous membrane 

•

Lining abdominal cavity •Covers the intra-abdominal organs. 

Layers Peritoneum

•The outer layer

-parietal peritoneum 

•The inner layer

-visceral peritoneum.

•The term mesentery 

-double layer of visceral peritoneum 

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Subdivisions :

•The greater sac 

•The lesser sac (or omental )two "omenta":

1. The lesser omentum 

(or gastrohepatic)

2. The greater omentum 

(or gastrocolic)

like an apron, protective

layer.

•Greater sac and lesser sac 

Connected by the epiploic

foramen 

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PeritonitisInflammation of the serosal membrane that lines the

abdominal cavity and the organs contained therein

often as a result of infection.

Peritonitis are classified as :

1. Primary peritonitis

2. Secondary peritonitis3. Tertiary peritonitis

Peritonitis are usually divided into1. Generalized peritonitis

2. Localized peritonitis

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Primary peritonitis

No pathologic process in a visceral organ

Via hematogenous

Children 

Translocation of bacteria across the gut wall

Ascites Intestinal obstruction

 Ascending infection in female

Gonorrhea

Chlamydial infectionspreads into the abdominal cavity.

Systemic infections tuberculosis 

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Secondary peritonitis

Related to a pathologic process in a visceral organ

hollow viscus 

- Perforation

- Infected

most common cause of peritonitis, perforations of :

- the stomach

- intestine

- gallbladder

- appendix

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Tertiary peritonitis

Persistent or recurrent infection after adequate initial therapy

• Anastomotic leakage

• Abscess with or without fistulization.

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On abdominal examination of Peritonitis

1. Position/lighting/draping

2. Inspection  Abd. Distended  Ileus paralyticus 

Keep their hips flexed to relieve the abdominal wall tension.

3. Palpation  all four quadrants

Tenderness Rebound tenderness 

Diffuse Abdominal rigidity ("washboard abdomen")

 Abdominal Guarding voluntary in response of the abdominal

Inflammatory mass.

4.Percussion 

Tenderness all four quadrantsPercuss the liver span free air

5. Auscultation Paralytic Ileus Hypoactive-to-absent bowel sounds.

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6 . Digital rectal exam .

Generalized peritonitisTenderness in all direction

Appendicitis

Tenderness in the right direction 

Female patients vaginal and bimanual examination

Pelvic inflammatory disease

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WORKUP 

Lab Studies:

•

Blood test – leukocytosis (>11,000 cells/mL)

 – Blood chemistry may reveal dehydration and acidosis.

• Liver function tests if clinically indicated

• Serum electrolytes• Renal function

• Amylase and lipase if pancreatitis is suspected

• Urinalysis (UA) is essential to rule out urinary tract diseases (eg,

pyelonephritis, renal stone disease

• Aerobic and anaerobic blood cultures

l

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Complications

• Hypovolaemia shock 

-Sequestration of fluid and electrolytes 

-Decreased central venous pressure 

• Electrolyte disturbances 

• Acute renal failure 

• Peritoneal abscess 

• Abdominal Sepsis may develop Septic shock

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Radiographs

Plain films of the abdomen :•supine

•upright Free air

•lateral decubitus positions

Computed tomography scan•Diagnosis cannot be established on clinical

grounds

•Cannot be findings on abdominal plain films.

Imaging Studies 

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Treatment

INFORMED CONSENT

General supportive measures :

- Intravenous rehydration - Correction of electrolye disturbances.

Antibiotics 

- broad-spectrum antibiotics 

The exception is spontaneous bacterial peritonitis, which does not

benefit from surgery.

Surgery 

 Exl .laparotomy  full exploration

 Lavage of the peritoneum 

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Abscess in Pouch of Douglas (Cul de sac abscess ) 

(Pelvic abscesses)DRE: often are palpable as tender  

Anterior fullness and fluctuation

Male  Rectovesical pouch

Female Recto-uterine pouch

Treatment

Draining these abscesses transvaginally or transrectally is

best to avoid the transabdominal approach.

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Mesenteric Lymphadenitis

1. Inflammation of the mesenteric lymph nodes.

2. Acute or chronic, depending on the causative agent.

3. Often difficult to differentiate from acute appendicitis.

Pathophysiology

Microbial agents are thought to gain access to the lymph

nodes via the intestinal lymphatics.

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Clinical

Clinical features of associated organ involvement, such as

enterocolitis or ileitis 

 Abdominal pain - Often right lower quadrant (RLQ) but may

be more diffuse

Fever

Diarrhea

Malaise Anorexia

Upper respiratory tract infection

Nausea and vomiting

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Physical

Fever (38-38.5°C)

RLQ tenderness - Mild, with or without rebound

tenderness

Rectal tenderness

RhinorrheaHyperemic pharynx

 Associated peripheral lymphadenopathy (usually

cervical) in 20% of cases

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Causes

Streptococcus beta-hemolytic,

Staphylococcus species,

Escherichia coliStreptococcus viridans,

Mycobacterium tuberculosis,

Viruses, such as coxsackieviruses, rubeola virus, and

adenovirus

Children with upper respiratory tract infection, has

popularized a theory that swallowed pathogen-laden sputum

may be the primary source of infection.

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Lab Studies

CBC count

Leucocytosis exceeding 10,000/µL

Urinalysis  exclude urinary tract infection.

Stool cultures

  Diarrheal symptoms

Blood culture   Septicemia

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Imaging Studies

CT scanning 

In mesenteric adenitis:

  lymph nodes to be larger

  greater in number

CT scanning is also important to exclude

other differential diagnoses, especially acuteappendicitis.

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Medical Care

Hemodinamic support

Broad-spectrum antibiotics

To quickly identify patients who require surgical intervention

Surgical Care

Signs of peritonitis Appendectomy