1. Peritonitis BY PROF/ GOUDA ELLABBAN EGYPT 2. Topics peritonitis Intra-abdominal abscess 3. Anatomy of peritoneum Parital peritoneum Visceral peritoneum Male close peritoneum Female open peritoneum Abdominal wall peritoneum 4. Peritonitis is an inflammation (irritation) of the peritoneum, the membrane that lines the wall of the abdomen and covers the abdominal organs. Definition :- 5. Etiology Causes of peritonitis Perforation of bowel Chemically irritating material 6. Types Types of peritonitis Primary peritonitis Secondary peritonitis Dialysis-associated peritonitis 7. Types Types of peritonitis Generlized vs locolized Chemical vs septic Acute vs chronic 8. Diffuse bacterial infection without loss of integrity of GI tract E-coli commonest organism involved Primary peritonitis 9. Risk factors Liver diseases Chronic renal failure Comrised immune system Plevic inflammatory diseases 10. 0 25 50 75 100 Gram -ve bacteria E-coli K pneumoniae Pseudomonas species Proteus species Streptococcus species Staphylococcus species Anaerobic species Comman organisms leading to primary pertonitis 11. Acute peritoneal infection resulting GI perforation Secondary peritonitis:- 12. Source Causes Esophagus Boerhaave syndrome Malignancy Trauma (mostly penetrating) Iatrogenic* Stomach Peptic ulcer perforation Malignancy (eg, adenocarcinoma, lymphoma, gastrointestinal stromal tumor) Trauma (mostly penetrating Iatrogenic* Duodenum Peptic ulcer perforation Trauma (blunt and penetrating) Iatrogenic* Biliary tract Cholecystitis Stone perforation from gallbladder (ie, gallstone ileus) or common duct Malignancy Choledochal cyst (rare) Trauma (mostly penetrating) Iatrogenic* Common Causes of Secondary Peritonitis 13. Source Causes Small Bowel Ischemic bowel Incarcerated hernia (internal and external) Closed loop obstruction Crohn disease Malignancy (rare) Meckel diverticulum Trauma (mostly penetrating Larg bowel Ischemic bowel Diverticulitis Malignancy Ulcerative colitis and Crohn disease Appendicitis Colonic volvulus Trauma (mostly penetrating) Iatrogenic Common Causes of Secondary Peritonitis 14. Source Causes Pancreas Pancreatitis Trauma (blunt and penetrating) Iatrogenic* Uterus, salpinx, and ovaries Pelvic inflammatory disease (eg, salpingo-oophoritis, tuboovarian abscess, ovarian cyst) Malignancy (rare) Trauma (uncommon) Common Causes of Secondary Peritonitis 15. This is an acute or chronic inflammation (irritation and swelling) of the peritoneum (lining of the abdomenal cavity) that occurs in people receiving peritoneal dialysis. associated - Dialysis peritonitis 16. The cause of dialysis-associated peritonitis may be the introduction of bacteria into the peritoneum by the dialysis procedure. Skin bacteria are the most common organisms causing infection. Incidence is about one infection for every 15 months of peritoneal dialysis. 17. Treatment typically involves surgery and antibiotics. In cases associated with peritoneal dialysis, antibiotics may be infused through the dialysis catheter, but if the infection is severe, the catheter itself must often be removed. Treatment 18. Intra abdominal abscess localized peritonitis Definition :- collection of pus walled-off from rest of peritoneal cavity by inflammatory adhesions and viscera 19. Number of bacteria exceed hosts ability to terminate infection complication may perforate leading to diffuse bacterial peritonitis 20. Classification of intra abdominal abscess Pelvic abscess Sub phrenic abscess Mid abdominal abscess Intra abdominal abscess 21. Sub phrenic abscess 35% are right sided abscess 25% are left sided abscess 20% are multiple abscess Etiology :- Direct contamination after surgery . Local diseases or injary . Mortality rate is 25% to 40% Causes of death :- Uncontrolled infection Malnutrition Prolong hospitalization pulmonary embli nasocomal infection 22. Mid abdominal abscess Between transverse colon and pelvis Right lower quadrant abscess Left lower quadrant abscess 23. Pelvic abscess usually complication of :- acute appendicitis pelvic inflammatory disease colonic diverticulitis 24. Syptoms abdominal pain dull aching sharp fever chilles loss of appetite nausea vomiting inability to pass gas or feces 25. Signs toxic ill looking tachypnea tachacardia hypotension abdomen generlized gaurding rigidity tenderness all over positive rebound absent peristalsis 26. Pancreatitis Splenic rupture &infarc Splenic aneurysm Gastritis Mi Pneumonia Intestinal obstruction Diverticulitis Psoas abscess Ectopic pregnancy Ovarian cyst Salpingitis Ureteral calculi endometriosis Gallbladder Hepatitis hepatic abscess Peptic ulcer Pancreatitis Mi pneumonia Appendicitis Intestinal obstruction Diverticulitis Ectopic pregnancy Ovarian cyst Salpingitis Ureteral calculi endometriosis 27. Investigation 1:-CBC :- leukocytosis 2:-RFT 3:-septic work up 4:-peritoneal fluid sample for chemistry 5:-plain film of abdomen 6:-ultrasonography 7:-computed tomography 28. Treatment 1:- control infection 2:- purge bacteria and toxin 3:- maintain organ system function 4:- control inflammatory process 29. Medical treatment 1:- systemic antibiotic therapy 2:- intensive care with hemodynamic, pulmonary and renal replacement NPO, IVF, Foly catheter 3:-nutrition and metabolic support 4:-inflammatory response modulation therapy 30. Treatment early control of septic source is mandatory and can be achieved by operative and non opreative means including percutanous drainage of abscess and percutanous and endoscopic stent placement 31. Treatment operative mangment 2 principles :- 1:- early and definitive source control 2:- purging of bacteria and toxin from abdominal cavity second look operation = sever sepesis 32. Laparoscopy initial laparoscopic examination of abdomen can assist in elemination of etiology peritonitis diagnostic, therapeutic 33. Primary peritonitis prognosis the overall mortality rate of pateints with SBP may exceed 30% if diagnosis and treatment are delayed less than 10% in fairly-well compensated patients with early therapy recurrant episodes eithin 1 year represent 70% of patients the mortality rate approaches 50% long-term antibiotc prophlaxi decresed to less than 20% 34. Secondary peritonitis prognosis mortality rate less than 5% in simple abscess and uncomplicated SP more than 30-50% in sever infection greater than 90% with quadruple organ failure 35. Thank you