Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 1348 - файл.pdf
Peritonitis
Peritonitis: Peritonitis is inflammation of the peritoneal cavity. Most
cases are due to bacterial invasion of the peritoneal cavity, usually polymicrobial (aerobic and anaerobic), exception is the primary (spontaneous)
peritonitis (pure streptococcal, pneumococcal or haemophilis infection).
Source of contamination:
I. Gastrointestinal tract (GIT): High bacterial concentration in the colon.
Biliary and pancreatic tracts are normally free of bacteria. The
commonest bacteria are:
E coli, streptococci (aerobic and anaerobic), and bacteroids (Gram-
negative, nonsporing, anaerobic).
Less frequent: cl. welchi, staphylococci, and kl. Pneumoniae
II. Non -GIT:. Mainly from genital tract:
Chlamydia, gonococci, B H streptococci, pneumococci, mycobacterium
tuberculosis
Paths of peritoneal invasion:
A. GIT perforation: perforated DU, diverticular perforation
B. Exogenous contamination: drains, surgery, peritoneal penetration
(traumatic)
C. Transmural bacterial translocation (non perforation): IBD, bowel
ischemia (strangulated hernia), appendicitis.
181
D. Female genital tract infection: Pelvic inflammatory disease.
E. Haematogenous spread (rare): septicemia.
Many peritonitis cases are initially sterile (e.g. Perforated DU, pancreatitis,
rupture urinary bladder) and become infected via transmural spread of
bacteria from the bowel.
Mortality depends on:
a. Degree and duration of contamination
b. Age of the patient.
c. General health of the patient.
e. The nature of the underlying cause.
Localized peritonitis:
There are some favouring factors leading to local peritonitis:
1- Anatomical factor, the peritoneum is divided into subphrenic spaces,
pelvis, peritoneal cavity proper (supra- and infracolic, paracolic
gutters). Posture can assist the directing collections into the pelvis.
2- Pathological factor, formation of adhesions around inflamed organ
with inflamed red peritoneum then fibrin flakes cause loop adhesions
and outpouring of inflammatory exudates (WBCs, plasma proteins),
peristalsis retarded, and greater omentum envelope the inflamed
structures to stop spread of infection
3- Surgical factor: drains used to assist localization and drainage of
intraperitoneal collections (?? Risk of exogenous infections)
182
Severe exudative peritonitis with adhesions.
Diffuse peritonitis:
Some factors favoring development of diffuse peritonitis:
1- Speed of peritoneal contamination: if rupture occurs before localization
occur e.g. Appendicitis, perforation proximal to obstruction, sudden
anastomotic leak
2- Stimulation of peristalsis: by food,water, enemas or purgatives will
induce distribution of the infection
3- Virulence of the infecting organism
4- Young children: small omentum
5- Disruption of localised infection: appendicular mass.
6- Deficient natural resistance: AIDS, steroids, old age.
183
Diffuse peritonitis with necrotic collection.
Clinical features
1- Localized peritonitis:
· c/f of the causative condition
· Increasing pain, vomiting,temp., and pulse
· Guarding and rigidity.
· Shoulder tip pain.
· Pelvic peritonitis: minimal abdominal signs
1. Deep tenderness in lower abdomen.
2. Tender P/R and P/V examination
3. Abscess formation in 20% of cases
2- Diffuse (generalised) peritonitis:
Differing ways depending on duration of infection
184
I- Early:
· Sever pain worsening by breathing or movements
· Vomiting may occur
· Pulse rises progressively, or suddenly if peritoneum filled with
fluid
· Temperature variable: ! subnormal
· Tenderness and rigidity if anterior abdominal wall affected
· Pelvic peritonitis: urinary symptoms, tender P/R, P/V
· Bowel sounds are few or absent in paralytic ileus
Purulent peritonitis.
II- Late:
- Now rare b/o early diagnosis and management
- If resolution does not occur
185
· Silent abdomen
· Increasing abdominal distention
· Signs of shock: cold extremity, sunken eyes, dry tongue, low thread
· pulse, drawn and anxious face (Hippocratic faces).
· Finally patient becomes unconscious.
Diagnosis:
a. Careful history and repeated examinations
b. Leucocytosis
c. Peritoneal diagnostic aspiration: helpful but usually unnecessary.
Presence of WBCs, bacteria, bile, amylase
d. Plain x ray:
1. Erect chest x ray: Free gas under diaphragm
2. Abdominal x ray: Dilated gas filled loops (paralytic ileus) e. S.
amylase: Helpful in diagnosis of acute pancreatitis, but moderately
raised values are found in other abdominal emergency like
perforated PU f. Ultrasound and CT scan:
· Intraperitoneal free fluid
· Identify the cause: pancreatitis
Treatment:
1- General care of the patient:
a- correction of fluid and electrolyte imbalance:
· IV line
· TPN if recovery delayed > 7-10 days
b- Gastrointestinal decompression: Nasogastric tube (NGT)
intermittent aspiration until the paralytic ileus recovered
c- intravenous antibiotic therapy: (mixed infection)
d- fluid balance chart: input output chart Haematocrit, urea, electrolyte
e- analgesia: pre and postoperative morphine or continues epidural
analgesia allows early mobilisation and physiotherapy
186
f- vital system support especially if patient in septic shock: O2,
mechanical ventilation, diuretic,inotropic agents
2-specific treatment of the cause:
· Operative: appendicitis, perforated DU … etc
· Nonoperative: pancreatitis
3- Peritoneal lavage: in operations
· Suction of the seropurulent exudate
· Irrigation with normal saline (1-2litres)
· Some surgeon use saline with dissolved antibiotics (e.g.
Tetracycline)
Prognosis:
Generalized peritonitis carries mortality of about 10%
Complications:
1- Systemic:
· Bacteraemia and endotoxic shock
· Bronchopneumonia and respiratory failure
· Renal failure
· Bone marrow suppression
· Multisystem failure
2- Abdominal:
· Adhesional small bowel obstruction: Central abdominal pain,
vomiting, air fluid levels (proximal loop), increased bowel sounds
· Paralytic ileus: Little pain, bowel sounds absent, gas filled
loops (Small and large bowel)
3- Residual or recurrent abscess:
· Subphrenic, Pelvic, paracolic, RIF
· C/F: may be vague weakness, anorexia, failure to thrive,
187
pyrexia tachycardia, localized tenderness, leucocytosis later on
palpable mass
Treatment:
1. close monitoring of the size of the mass clinically and by US and
CTscan
2. Majority will regress with antibiotic
3. If fail to resolve or increase in size it should be drained: operative
or US or CT scan guided drainage
4- Portal pyaemia and liver abscess
Special types of peritonitis:
1- Postoperative peritonitis:
· Patient becomes ill, pulse rises, peripheral circulatory failure
· Abdominal Pain is not prominent (abdominal wound and analgesia)
· Anastomotic leakage
· Treatment: Antibiotics and operation is often indicated.
2- Peritonitis in patient on steroids:
· Pain is slight or absent. Signs are vague and misleading
3- Peritonitis in children:
· History is usually unreliable and examination is difficult.
4- Peritonitis in senile patient:
· tenderness localised, gaurding and rigidity are less mark.
5- Biliary peritonitis:
Causes: perforated cholecystitis
post cholecystectomy:
· Cystic duct stump leakage
· Accessory duct in gallbladder bed.
· Bile duct injury.
188
· T tube dislodgement following other operation.
· Leaking duodenal stump
· Leaking biliary enteric anastomosis
· Leakage around percutaneous biliary drainage
· Jaundice +++
Treatment is usually surgery with antibiotic cover.
6- Meconium peritonitis:
· Aseptic peritonitis develop in the late intrauterine life due to
intestinal
· perforation which is a result of neonatal intestinal obstruction
(50%)
· Meconium get infected 3 hrs after birth resulting in bacterial
peritonitis
· c/f: abdominal distention, vomiting, failure to pass meconium
· X rays: free air, abundant fluid, fluid levels
· Treatment: operative management is commonly indicated.
· Prognosis is usually bad because of the toxic condition.
7- Pneumococcal peritonitis:
Primary and secondary to pneumonia, is primarily more common in 36 years old girls. And usually via vagina and tubes or haematogenous:
URTI, middle ear, nephritis
C/F: sudden lower abdominal pain, pyrexia 39.8, vomiting and
profuse diarrhea, rigidity in lower abdomen
Treatment: early operation and antibiotics.
8-Tuberculous peritonitis:
A. Acute tuberculous peritonitis:
Clinically resemble acute bacterial peritonitis
189