Peritonitis MeSentEric by dr.S.H..

7/31/2019 Peritonitis MeSentEric by dr.S.H..

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GIS-K-24

PeritonitisMesenteric Lymphadenitis

Syahbuddin Harahap

Division of Digestive Surgery

r ur ryFaculty of Medicine

University of North Sumatera

Adam Malik Hospital


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Subdivisions :

The greater sac

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

1. The lesser omentum(orgastrohepatic)

.

o

(orgastrocolic)

like an apron, protective

layer.

Greater sac and lesser sacConnected by the epiploic foramen


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PeritonitisInflammation of the serosal membrane that lines theabdominal cavity and the organs contained thereinoften as a result of infection.

Peritonitis are classified as :1. Primary peritonitis2. Secondary peritonitis

3. Tertiary peritonitis

Peritonitis are usually divided into

1. Generalized peritonitis2. Localized peritonitis


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Peritonitis is often caused by:

- Perforation hollow viscus

Etiology

- (blood,pancreatic/gastic juice)

- Infected / Inflammation


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Primary peritonitis

No pathologic process in a visceral organ

Via hematogenous

ChildrenTranslocation of bacteria across the gut wall

Ascites

n es n o s ruc onAscending infection in female

Gonorrhea

Chlamydial infection

spreads into the abdominal cavity.

Systemic infections tuberculosis


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Secondary peritonitis

Related to a pathologic process in a visceral organ

hollow viscus- Perforation- Infected

most common cause of eritonitis erforations of :

- the stomach

- intestine

- gallbladder

- appendix


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Tertiary peritonitis

Persistent or recurrent infection after adequate initial therapy

Anastomotic leakage

Abscess with or without fistulization.


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Diagnosis and investigations

Based primarily on clinical grounds

No further investigation should delay surgery


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Clinical:

The diagnosis of peritonitis is usually clinical.

1. Chief complaintAcute abdominal pain

2. Peritoneal irritation Anorexia and nausea ,vomiting.

.

4. Hypovolemia Hypotensive

5. Hypothermia severe sepsis Septic shock

Peritonitis generally represents a surgical emergency.


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On abdominal examination of Peritonitis

1. Position/lighting/draping

2. InspectionAbd. Distended Ileus paralyticusKeep their hips flexed to relieve the abdominal wall tension.

3. Palpation all four quadrantsTenderness

e oun en erness

Diffuse Abdominal rigidity ("washboard abdomen")Abdominal Guarding voluntary in response of the abdominalInflammatory mass.

4.Percussion

Tenderness all four quadrantsPercuss the liver span free air

5. AuscultationParalytic Ileus Hypoactive-to-absent bowel sounds.


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6 . Digital rectal exam .Generalized peritonitis

Tenderness in all direction

AppendicitisTenderness in the right diection

Female patients vaginal and bimanual examinationPelvic inflammatory disease


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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)


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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


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Complications

Hypovolaemia shock-Sequestration offluid and electrolytes

-Decreased central venous pressure

Electrolyte disturbances

Acute renal failure

Peritoneal abscess

Abdominal Sepsis may develop Septic shock


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Radiographs

Plain films of the abdomen :

supineupright Free air

Imaging Studies

Computed tomography scanDiagnosis cannot be established on clinical grounds

Cannot be findings on abdominal plain films.


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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 lymphnodes via the intestinal lymphatics.


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Clinical

Clinical features of associated organ involvement, such asenterocolitis or ileitisAbdominal pain - Often right lower quadrant (RLQ) but may

be more diffuseFeverDiarrheaMalaise

AnorexiaUpper respiratory tract infectionNausea and vomiting


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Physical

Fever (38-38.5C)RLQ tenderness - Mild, with or without rebound

tendernessRectal tendernessRhinorrhea

Hyperemic pharynxAssociated peripheral lymphadenopathy (usuallycervical) in 20% of cases


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Causes

Streptococcus beta-hemolytic,Staphylococcusspecies,Escherichia coliStreptococcus viridans,

Mycobacterium tuberculosis,Viruses, such as coxsackieviruses, rubeola virus, andadenovirus

Children with upper respiratory tract infection, haspopularized a theory that swallowed pathogen-laden sputummay be the primary source of infection.


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Lab StudiesCBC countLeucocytosis exceeding 10,000/L

Urinalysis exclude urinary tract infection.

Stool cultures Diarrheal symptoms

Blood culture Septicemia


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Imaging Studies

CT scanning

In mesenteric adenitis: lymph nodes to be larger

CT scanning is also important to excludeother differential diagnoses, especially acuteappendicitis.


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Medical Care

Hemodinamic support

Broad-spectrum antibiotics

Surgical Care

Signs of peritonitis

Appendectomy

Peritonitis MeSentEric by dr.S.H..

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