GIS-K-24

Peritonitis
Syahbudin Harahap
Peritoneum
•Lining abdominal cavity
•Covers the intra-abdominal organs.
•Serous membrane
•Mesothelium

Layers Peritoneum
•The outer layer
-Parietal peritoneum
•The inner layer
-Visceral peritoneum.
•The term mesentery
-double layer of visceral peritoneum
Region Peritoneum
•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 lay
er.

• Greater sac and lesser sac C

onnected by the epiploic foramen
Peritonitis
denotes Inflammation of the serosal membrane/peritoneum t
hat lines the abdominal cavity and the organs contained ther
ein often as a result of infection.

Peritonitis are usually divided into

1.Localized peritonitis
2.Generalized peritonitis

Peritonitis are classified as :

1.Primary peritonitis
2.Secondary peritonitis
3.Tertiary peritonitis
Etiology
Peritonitis is often caused by:

- Perforation hollow viscus

- Chemically irritating material

(blood,pancreatic/gastic juice)

- Infected / Inflammation
 Primary peritonitis
No pathologic process in a visceral organ
Via hematogenous most commonly caused by Pneumo
coccus or hemolytic Streptococcus
Children
Translocation of bacteria across the gut wall Escherichia coli
and Klebsiella
Ascites
Intestinal obstruction
Ascending infection in female
Gonorrhea
Chlamydial infection
spreads into the abdominal cavity.
Systemic infections tuberculosis
 Secondary peritonitis
Related to a pathologic process in a visceral organ
hollow viscus
- Perforation
- Infected
most common cause of peritonitis, perforations of :

- appendix

- the stomach

- intestine

- gallbladder
Secondary peritonitis
 Tertiary peritonitis
Persistent or recurrent infection after adequate initial therapy

• Anastomotic leakage

• Abscess with or without fistulization.

Clinical features in peritonitis:
The diagnosis of peritonitis is usually clinical.

1.The main manifestation of peritonitis are

- Acute abdominal pain
- Tenderness
- Rebound tenderness
- Guarding
2.Diffuse abdominal rigidity especially in Generalises peritonitis
3.Fever
4.Sinus tachycardia
5.Nausea and vomiting
6. Absent or reduced bowel sounds

Peritonitis is an example of ACUTE ABDOMEN and generally represents a su

rgical emergency.
Based primarily on clinical grounds No further investigation shoul
d delay surgery
 Complications
• Sequestration of fluid and electrolytes
-Hypovolaemia shock
-Decreased central venous pressure
-Electrolyte disturbances
-Acute renal failure

• Peritoneal abscess

• Abdominal Sepsis ( SIRS + INFEKSI ) may develop  Sep

tic shock
 Diagnosis and investigations

• HISTORY-TAKING
• EXAMINATION OF THE ABDOMEN
• Investigations in peritonitis
- Imaging Studies
- Lab Studies
 Abdominal examination

1.POSITION
2.INSPECTION
3.PALPATION
4.PERCUSSION
5.AUSCULTATION
6.DIGITAL RECTAL EXAMINATION
 Imaging Studies
Chest x ray  Free air

Plain films of the abdomen :

•supine
•upright
•lateral decubitus positions

Computed tomography scan

•Diagnosis cannot be established on clinical grounds

•Cannot be findings on abdominal plain films.

 WORKUP
Lab Studies:
• CBC
• Liver function tests if clinically indicated
• Serum electrolytes
• Renal function
• Amylase and lipase if pancreatitis is suspected
• Urinalysis is essential to rule out urinary tract diseases (eg, pyel
onephritis, renal stone disease)
• Aerobic and anaerobic blood cultures
Mimic certain signs and symptoms of peritonitis.

1. Thoracic processes with diaphragmatic irritation

(eg, empyema)

2. Extraperitoneal processes
(eg, pyelonephritis, cystitis, acute urinary retention)

3. Abdominal wall processes

(eg, rectus hematoma)
Management of peritonitis

INFORMED CONSENT
Insertion of nasogastric drainage tube
General supportive measures :
- Intravenous rehydration
- Correction of electrolye disturbances.
Antibiotics
- broad-spectrum antibiotics

Surgery
 Exl .laparotomy  full exploration
 Lavage of the peritoneum
Source control temporary Abdominal Closure with BOGOT
A BAG
 BOGOTA BAG