GIS-K-24

Peritonitis Mesenteric Lymphadenitis

Syahbuddin Harahap

Division of Digestive Surgery

Department of SurgeryDepartment of Surgery

Faculty of Medicine

University of North Sumatera

Adam Malik Hospital

Peritoneum•Serous membrane•Lining abdominal cavity•Covers the intra-abdominal organs.

Layers Peritoneum•The outer layer

-parietal peritoneum-parietal peritoneum

•The inner layer -visceral peritoneum.

•The term mesentery-double layer of visceral peritoneum

Subdivisions :•The greater sac

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

1. The lesser omentum(or gastrohepatic)

2. The greater omentum2. The greater omentum(or gastrocolic) like an apron, protective layer.

•Greater sac and lesser sacConnected by the epiploic foramen

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 peritonitis2. Secondary peritonitis3. Tertiary peritonitis3. Tertiary peritonitis

Peritonitis are usually divided into1. Generalized peritonitis2. Localized peritonitis

Peritonitis is often caused by:

- Perforation hollow viscus

- Chemically irritating material

Etiology

- Chemically irritating material(blood,pancreatic/gastic juice)

- Infected / Inflammation

Primary peritonitis

No pathologic process in a visceral organ

�Via hematogenous Children

�Translocation of bacteria across the gut wall AscitesIntestinal obstructionIntestinal obstruction

�Ascending infection in femaleGonorrhea Chlamydial infectionspreads 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 :most common cause of peritonitis, perforations of :

- the stomach

- intestine

- gallbladder

- appendix

Tertiary peritonitis

Persistent or recurrent infection after adequate initial therapy

• Anastomotic leakage

• Abscess with or without fistulization.

Diagnosis and investigations

• Based primarily on clinical grounds

• No further investigation should delay surgery

Clinical:

The diagnosis of peritonitis is usually clinical.

1. Chief complaint ����Acute abdominal pain

2. Peritoneal irritation � Anorexia and nausea ,vomiting.

3. Fever exceed 38°C 3. Fever exceed 38°C

4. Hypovolemia � Hypotensive

5. Hypothermia � severe sepsis � Septic shock

Peritonitis generally represents a surgical emergency.

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 quadrantsTenderness

Rebound tendernessRebound tenderness

Diffuse Abdominal rigidity ("washboard abdomen")

Abdominal Guarding voluntary in response of the abdominal

Inflammatory mass.

4.PercussionTenderness all four quadrants Percuss the liver span � free air5. AuscultationParalytic Ileus � Hypoactive-to-absent bowel sounds.

6 . Digital rectal exam .

Generalized peritonitisTenderness in all direction

Appendicitis Tenderness in the right diection

�Female patients vaginal and bimanual examination �Female patients vaginal and bimanual examination Pelvic inflammatory disease

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)

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

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

RadiographsPlain films of the abdomen :

•supine •upright � Free air•lateral decubitus positions

Imaging Studies

•lateral decubitus positionsComputed tomography scan

•Diagnosis cannot be established on clinical grounds

•Cannot be findings on abdominal plain films.

Treatment

INFORMED CONSENTGeneral supportive measures :

- Intravenous rehydration- Correction of electrolye disturbances.

Antibiotics- broad-spectrum antibiotics

The exception is spontaneous bacterial peritonitis, which does not The exception is spontaneous bacterial peritonitis, which does not benefit from surgery.

Surgery� Exl .laparotomy � full exploration � Lavage of the peritoneum

Abscess in Pouch of Douglas (Cul de sac abscess )(Pelvic abscesses) DRT : often are palpable as tenderAnterior fullness and fluctuation Male � Rectovesical pouchFemale � Recto-uterine pouch

TreatmentTreatmentDraining these abscesses transvaginally or transrectally is best to avoid the transabdominal approach.

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.

PathophysiologyMicrobial agents are thought to gain access to the lymph nodes via the intestinal lymphatics.

ClinicalClinical features of associated organ involvement, such as enterocolitis or ileitisAbdominal pain - Often right lower quadrant (RLQ) but may be more diffuse Fever Diarrhea Malaise Malaise Anorexia Upper respiratory tract infection Nausea and vomiting

Physical

Fever (38-38.5°C)

RLQ tenderness - Mild, with or without rebound

tenderness

Rectal tenderness

Rhinorrhea

Hyperemic pharynx Hyperemic pharynx

Associated peripheral lymphadenopathy (usually

cervical) in 20% of cases

CausesStreptococcus beta-hemolytic, Staphylococcus species, Escherichia coli

Streptococcus 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.

Lab StudiesCBC countLeucocytosis exceeding 10,000/µL

Urinalysis � exclude urinary tract infection.

Stool cultures � Diarrheal symptoms

Blood culture � Septicemia

Imaging Studies

CT scanningIn mesenteric adenitis:� lymph nodes to be larger� greater in number� greater in number

CT scanning is also important to exclude other differential diagnoses, especially acute appendicitis.

�Medical Care

Hemodinamic support

Broad-spectrum antibiotics

To quickly identify patients who require surgical interventionTo quickly identify patients who require surgical intervention

�Surgical Care

Signs of peritonitisAppendectomy