Intraabdominal Infection, Peritonitis

8/6/2019 Intraabdominal Infection, Peritonitis

1/25

INTRAABDOMINALINTRAABDOMINAL

INFECTION,INFECTION,PERITONITISPERITONITIS


2/25

Classification of Intraabdominal InfectionsClassification of Intraabdominal InfectionsI. Primary Peritonitis

A. Spontaneous peritonitis in children

B. Spontaneous peritonitis in adults

C. Peritonitis in patients with CAPD

D. Tuberculous and other granulomatous peritonitis

E. Other forms

II. Secondary Peritonitis

A. Acute perforation peritonitis (acute suppurative peritonitis)

1. Gastrointestinal tract perforation2. Bowel wall necrosis (intestinal ischemia)

3. Pelvic peritonitis

4. Other forms

B. Postoperative peritonitis

1. Anastomotic leak

2. Leak of a simple suture3. Blind loop leak

4. Other iatrogenic leaks

C. Posttraumatic peritonitis

1. Peritonitis after blunt abdominal trauma

2. Peritonitis after penetrating abdominal trauma

3. Other forms


3/25

III. Tertiary Peritonitis

A. Peritonitis without evidence for pathogensB. Peritonitis with fungi

C. Peritonitis with low-grade pathogenic bacteria

IV. Other Forms of Peritonitis

A. Aseptic/sterile peritonitis

B. Granulomatous peritonitis

C. Drug-related peritonitis

D. Periodic peritonitis

E. Lead peritonitis

F. Hyperlipidemic peritonitis

G. Porphyric peritonitis

H. Foreign-body peritonitisI. Talc peritonitis

V. Intraabdominal Abscess

A. Associated with primary peritonitis

B. Associated with secondary peritonitis

Classification of Intraabdominal Infections (continue)


4/25

A. There are two kinds of cells, cuboidal cells (C) and flattened cells (F), on the

peritoneum of the muscular portion of the diaphragm. Stomata (S) are detected

among cuboidal cells.

B. B. There are some filamentous projections (arrow) across the stoma, which is adeep pore on the tendinous portion of the diaphragmatic peritoneum.


5/25

Diagram of a typical stoma and underlying channel linking the peritoneal

cavity with the lumen of a lymphatic lacuna. Lacunar mesothelial cells forming

the stoma and flaplike endothelial processes that bridge the channel contain

actin filaments. Where lacunar mesothelial cells and lacunar endothelial cellsmeet, their apposed plasma membranes lack junctional specializations. Both

types of cell lack a basement membrane. The connective tissue adjacent to the

channel contains abundant microfibrils. A pseudopod of a fibroblast contacts an

endothelial cell


6/25

LeftLeft sagittalsagittal drawingdrawing ofof thethe

compartmentscompartments of of thethe

retroperitonealretroperitoneal spacespace inin thisthis

areaarea andand itsits relationshiprelationship toto thethecontiguouscontiguous visceraviscera.. NoteNote thatthat

thethe anterioranterior andand posteriorposterior

layerslayers ofof thethe renalrenal fasciafascia areare

fusedfused superiorlysuperiorly butbut openopen

inferiorly,inferiorly, favoringfavoring thethe spreadspread

ofof infectionsinfections inferiorlyinferiorly..


7/25

Anterior and left and right sagittal views

of the peritoneal cavity demonstrating the

anatomic locations of various intraperitoneal

abscesses, such as right lower quadrant,

subphrenic, subhepatic, pelvic, lesser sac,interloop, Morison's pouch, right paracolic,

and left paracolic.


8/25

Foreign Bodies That May EnhanceForeign Bodies That May Enhance

Intraabdominal InfectionIntraabdominal Infection

Macroscopic Foreign

Material

Surgical drains

Suture material

Laparotomy sponges

Hemostatic pads/powders

Surgical clips

Prosthetic implants

Microscopic ForeignMaterials

Barium sulfate

Clothing fibers (can be introduced during penetrating trauma)

Fecal material

Necrotic tissue

Talcum powder or other surgical glove powders (less likely with

modern corn starch)


9/25

Adjuvant Substances for IntraabdominalAdjuvant Substances for Intraabdominal

InfectionInfection

Factor Effect

Blood Nutritive effect on bacterial growth, Hgb toxic to WBCs

Fibrin Impairs PMN chemotaxis, sequesters bacteria

Fluid Impairs phagocytosis, dilutes opsonins

Bile Lysis of host leukocytes

Urine Opsonin deficient

Chyle Opsonin deficient

Pancreatic fluid Opsonin deficient

Platelets Impair bacterial clearance, perhaps secondary to

physical obstruction of diaphragmatic lymph channels

Hgb = hemoglobin; PMN = polymorphonuclear leukocyte; WBC = white blood cell


10/25

Experimental (rat) modelExperimental (rat) modelindicating cumulativeindicating cumulative

percentage mortality withpercentage mortality with

varying inoculum size ofvarying inoculum size of

human fecal material in thehuman fecal material in the

peritoneal cavity.peritoneal cavity.


11/25

Bacterial Isolates from Intraoperative Cultures in ClinicalBacterial Isolates from Intraoperative Cultures in Clinical

intraabdominal Infectionintraabdominal Infection

Organism % of Patients with Organism

Gorbach1974 Stone1975 Solomkin1990

Mosdell1991

Gram-negative Aerobes

Escherichia coli 61 67 58 69

Enterobacter/Klebsiella sp. 37 32 39 23

Proteussp. 22 28 6 3Pseudomonas aeruginosa 17 20 15 19

Gram-positive Aerobes

Staphylococcussp. 34 6 11 11

Anaerobes

Bacteroides fragilis 26 34 23 45

OtherBacteroidessp. 58 51 21

Fusobacterium sp. 14 8 6 5

Peptostreptococcussp. 26 14 7 16

Enterococcussp. 4 23 23 11


12/25

Bacteria Commonly Encountered inBacteria Commonly Encountered in

Intraabdominal InfectionsIntraabdominal Infections

Facultative Gram-

negative Bacilli

Obligate Anaerobes Facultative Gram-positive

Cocci

Escherichia coli Bacteroides fragilis Enterococci

Klebsiella species Bacteroidesspecies Staphylococcusspecies

Proteusspecies Fusobacterium species Streptococcusspecies

Enterobacterspecies Clostridium species

Morganella morganii Peptococcusspecies

Other enteric gram-

negative bacilli

Pepostreptococcus

species

Aerobic gram-negative

bacilli

Lactobacillusspecies

Pseudomonas aeruginosa


13/25

Dermatome Origin of the Innervation ofDermatome Origin of the Innervation of

Intraabdominal StructuresIntraabdominal Structures

Organ/Structure Dermatome Innervation

Esophagus Vagus (brainstem)

Stomach T57

Small intestine T810

Colon T10L1

Liver T68

Gallbladder T68

Uterus T10L1

Kidney T10L1

Bladder S24

Diaphragm C48

C = cervical; L = lumbar; T = thoracic; S = sacral


14/25

The most obvious route of fluid andThe most obvious route of fluid and

electrolyte loss.electrolyte loss. into the bowel lumeninto the bowel lumen

into the edematous bowel wallinto the edematous bowel wall

into the free peritoneal cavityinto the free peritoneal cavity

by vomiting or nasogastric suctionby vomiting or nasogastric suction


15/25

Free gas beneath the diaphragmFree gas beneath the diaphragm


16/25

Plain film findings in hydropneumoperitoneumPlain film findings in hydropneumoperitoneum..Upright view shows fluid level too long to be within a loop of bowel.Upright view shows fluid level too long to be within a loop of bowel.


17/25

Unsuspected perforated duodenal ulcerUnsuspected perforated duodenal ulcer..AA Small amount of extraluminal gasSmall amount of extraluminal gas (arrow)(arrow) lies lateral to duodenal bulb (d). g,lies lateral to duodenal bulb (d). g,

gallbladder.gallbladder.


18/25

Unsuspected perforated duodenal ulcerUnsuspected perforated duodenal ulcer..

BBAt 3cm caudad, gasAt 3cm caudad, gas (arrow)(arrow) tracks behind the gallbladder (g) laterally.tracks behind the gallbladder (g) laterally.


19/25

Unsuspected perforated duodenal ulcerUnsuspected perforated duodenal ulcer..

CCThe airThe air--fluid levelfluid level

(arrow)(arrow)identifies the loculated extravasatedidentifies the loculated extravasated

duodenalduodenal contents. Inflammatory changes are present incontents. Inflammatory changes are present in

the surroundingthe surrounding mesentericmesenteric ffat.at.


20/25


21/25


22/25

AirAir--fluid levels in the small bowel.fluid levels in the small bowel.


23/25

AirAir--fluid levels in the smallfluid levels in the small

bowel.bowel.


24/25

AirAir--fluid levels in the smallfluid levels in the smallbowel. Absence of gas in thebowel. Absence of gas in the

colon.colon.


25/25

Visible mucosal foldsVisible mucosal folds

in the distended smallin the distended small

bowel.bowel.

Intraabdominal Infection, Peritonitis

Documents

Transcript of Intraabdominal Infection, Peritonitis