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Peritonitis Dr.S.Easwaramoorthy MS FRCS (Edinburgh) FRCS (Eng) FRCS (Glasgow) HOD, Dept of Gastroenterology Lotus hospital Erode

Classification of Peritonitis:

Classification of Peritonitis Primary, Secondary and Tertiary Localised, Generalised According to the causes: Traumatic Chemical Allergic Ischemic Infective: Bacterial

Types of Peritonitis:

Types of Peritonitis Primary Secondary Tertiary ( Persistent) Cause Source outside abdomen Blood spread Genital tract Dialysis catheter GI origin Perforation Infection Ischemia Complicated Secondary peritonitis Organism Monomicrobial Str Pneumo H Influenza Polymicrobial E.coli Klebsiella Bacteroides Str Unusual polymicrobial Candida Enterococci Staph

Pathogeneis of Peritonitis:

Pathogeneis of Peritonitis Localised by Anatomical reason Compartments Omentum Pathological Adhesion Peristalsis low Spread by Speed of contamination Virulence of organism Immuno compromise Drugs Disease

Clinical Presentation:

Clinical Presentation Symptoms Abdominal pain Fever Anorexia Nausea/vomit Signs General Fever Signs of shock Hypovolumic/Septic Abdominal Guarding Rebound Tenderness Rigidity Absent Bowel sounds


Investigations Haemotological FBC Biochemical Urea,sugar, Creatinine, Electrolytes, Amylase Radiological X ray chest and abdomen US abdomen CT abdomen rarely


Management Shock/Sepsis Control Adequate fluids Antibiotics Analgesia Aspiration Source Control Laparotomy

Source Control:

Source Control Surgery Close : DU perf Excise : Appendicitis/Cholecystitis Resect/Anas : Ischemic bowel Colostomy : Diverticulitis Peritoneal lavage Drainage Others Planned relaparotomy/Second look laparotomy Laparostomy Eg: Necrotic pancreatitis

Source Control/Laparoscopy:

Source Control/Laparoscopy

Complications of Peritonitis:

Complications of Peritonitis Local Paralytic I leus Adhesions Abscess Subphrenic Pelvic Inter loop Portal Pyemia Systemic Shock Bronchopneumonia Renal failure MOF

Subphrenic Spaces:

Subphrenic Spaces Left Subphrenic Left Subhepatic Right Subphrenic Right Subhepatic

Subphrenic Abscess Types and Causes:

Subphrenic Abscess Types and Causes Type Causes 1 Left Subphrenic Splenectomy/Gastrectomy 2 Left Subhepatic (Lesser Sac) Pancreatic surgery 3 Right Subphrenic Hepatectomy 4 Right Subhepatic (Morison’s Pouch) Cholecystecomy, DU perf Appendicectomy

Subphrenic Abscess:

Subphrenic Abscess Presentation Failure to Improve Fever Pus somewhere, pus no where else, pus under diaphragm Investigations Haemotological Biochemical: CRP Radiological X ray chest/Abdomen US abdomen/CT scan Nuclear scan Treatment Antibiotics Guided aspiration/Open drainage

Pelvic Abscess:

Pelvic Abscess

Pelvic Abscess:

Pelvic Abscess Presentation Mucus diarrhea, Pain abdomen, fever Investigation Haemotological Biochemical: CRP Imaging: US abdomen/CT Treatment Antibiotics Guided drainage

TB abdomen:

TB abdomen 1/6 of TB cases are extra pulmonary and out of them 10 % TB is confined to abdomen. In HIV infected individuals 50% of extra pulmonary TB is abdominal. 20% of ATB patients had concomitant pulmonary TB.


Types GI tract (Enteric) 50% Peritoneum 43% Lymph nodes 6-8% Solid viscera like liver spleen, kidney and pancreas or in any combination.

Enteric TB Distribution: :

Enteric TB Distribution: Esophageal TB 0.3 % Mid esophageal ulcer Gastric TB 0.2 % Gastric outlet obstruction Duodenal TB 2 % Jejunum/Ileum 35 % Ulcerative/Stricture Ileocaecal 42 % Hyperplastic/stricture Appendix 1 % Colon 12 % Bleeding PR AnoRectal 7% Perianal fistula


Pathogenesis Primary Secondary Swallowing of infected sputum. Hematogenous spread from active pulmonary or miliary TB. Ingestion of contaminated milk or food. Contiguous spread from adjacent organs.

Macroscopic Appearance of Enteric TB:

Macroscopic Appearance of Enteric TB Ulcerative 60 % Hypertrophic 10 % Ulcero-hypertrophic / Stricture 30 %

Clinical Manifestations:

Clinical Manifestations Nonspecific chronic abdominal pain 80-90 %. Weight loss 66 % Palpable mass 25-50 % Fever 35 % Altered bowel habit 20 % Anorexia, fatigue, night sweats or bleeding P/R


Investigation Laboratory Tests: Mild anemia and increased ESR seen 50-80 % WBC count is usually normal. PPD positive in the > 70% of patients but has limitations Radiology: Barium enema and small bowel follow-through: May show mucosal ulcerations and strictures, deformed cecum, and a gaping and incompetent ileocecal valve.

UC & Crohn’s disease:

UC & Crohn’s disease Lead pipe sign String sign of Kantor

Hyperplastic TB/Ca colon:

Hyperplastic TB/Ca colon Pulled up Caecum Distended ileum Apple core sign


Investigations CT Scan of abdomen: Ileo caecal mass Nodes Ascites Colonoscopy: ulcers, strictures, nodules, deformed ileocecal valve are seen.

DD for RIF mass:

DD for RIF mass Appendicular mass Amebiasis, Adenocarcinoma. Crohn's disease, Lymphoma, Actinomycosis


Management Standard ATT as per pulmonary TB. Surgery is usually reserved for patients who have developed complications. Stricture Strictureplasty Resection and anastomosis Limited right hemicolectomy

TB Peritonitis:

TB Peritonitis Wet type: Ascitic form Loculated or Encysted form Fibrous adhesive form

Pathology and risk factors:

Pathology and risk factors As the disease progresses, the visceral and parietal peritoneum become studded with tubercles. Ascites develops secondary to "exudation" of proteinaceous fluid from the tubercles. More than 90 percent of patients with TB peritonitis have ascites at the time of presentation, while the remainder present with a more advanced "dry" phase, representing a fibroadhesive form of the disease The risk is increased in patients with cirrhosis, HIV , diabetes mellitus, malignancy, and in patients with peritoneal dialysis (CAPD).

Symptoms and Signs:

Symptoms and Signs Symptoms Abdominal pain, fever, and weight loss. Signs: A diffusely distended tender abdomen. The classic doughy abdomen is associated with the fibroadhesive form and is rarely seen. Omental mass


Investigation Haemotological FBC/ESR Immunological: Mantoux ELISA Biochemical: Ascitic fluid Adenosine Deaminase: >36u/l CA 125 SAAG : <1.1 Culture: PCR Radiology X ray chest CT abdomen Special: Biopsy Laparoscopy Mini laparotomy

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