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Peritonitis

We can define it as inflammation of the peritoneum. Anatomically we can divide peritoneum into two parts: the parietal layer which covers the intrinsic walls of the abdominal cavity and visceral layer which covers the walls of the organs. According to the distribution of the peritoneum we can define organs as:

Intraperitoneal organs which are covered with the peritoneum from all sides e.g. stomach, gall bladder , small intestine, superior horizontal branch of the duodenum, transverse colon, appendix, spleen etc. all organs which have their own mesentery are known as intraperitoneal organs.
Mesoperitoneal organs which are covered with peritoneum from three sides e.g. ascending and descending colon, descending part f the duodenum, liver etc.
Retroperitoneal organs are covered by the peritoneum from only one side. They are also called as extraperitoneal organs e.g. pancreas, aorta, inferior vena cava, ureter, urinary bladder, uterus, kidneys etc.

Classification of peritonitis:
Septic: when the inflammation is caused by bacteria e.g. staphylococcus, streptococcus, H. pneumonia etc.
Aseptic: When intrinsic or non-bacterial fluid such as bile, blood, non-infectious urine is present in the peritoneal cavity. The specific form of aseptic peritonitis is caused by talk (from the surgical gloves, aluminum).

Division of peritonitis is also considered on the basis of the type of exudation such as serosal exudates, septic (purulent exudates), fibrinose, haemorrhagic exudates and their mixed forms.

While considering the source of peritonitis, there are primary and secondary forms of peritonitis. Spreading of infection via blood stream from other parts of the organ is considered as primary peritonitis, but if the infection spreads due to contact with the lumen of various organs then it should be considered as secondary peritonitis e.g. after acute perforative appendicitis, gastric and duodenal ulcer perforation, small and large bowel wall perforation after malignant process, gall bladder disease etc.

Idiopathic, periodic, spontaneous peritonitis and peritonitis in children should be considered as primary peritonitis. Idiopathic peritonitis: for which the reason is unknown.
Periodic peritonitis: in contrast to other forms of peritonitis, the periodic form of peritonitis should not b treated surgically. It is strange type of peritonitis which is specifically characteristic for some groups of population like little Asia, Cost Line, Mediterranean sea etc. its only treatment is Colchicines.

Division of peritonitis according to its localization:
Local: when the process doesn’t spread over more than two anatomical segments.
Diffused: when the process spreads beyond these borders, more than 5cm etc.

Clinical divisions:
There are acute and chronic forms of peritonitis. We call chronic peritonitis as specific peritonitis because of being caused by specific type of infections such as tuberculosis, syphilis, gonorrhoea etc. gynaecological peritonitis should also be considered in this group (gonococci).

Clinical manifestations:
There are three stages:
  • Stage one corresponds to the shock phase and lasts for about 24 hours. It is manifested by severe pain, high temperature, tachycardia, dry mouth, positive Blumberg’s sign (reflux rebound), good expressed muscular rigidity (Guardening) and leucocytosis with or without left shift
  • It corresponds to the phase of intoxication and is represented by the tachycardia, dry mouth and pain becomes more severe. Leucocytosis is shifted more to the left. This is the beginning of multiorgan insufficiency especially kidneys and cardiovascular system. It lasts for 72 hours
  • in this stage we can confirm the insufficiency of organs. The number of leucocytes comes to normal or hyponormal but the left shift is dramatic. Blumberg’s sign and muscular guardening become negative due to the necrotic changes in the fibers of the nervous system. Oligoanuria is stated frequently. Feeble (thready) pulse is stated. Bilirubinemia as well as the level of nitric compounds increase in blood which is the markers of hepatic and renal failure. Hippocratic face is seen. Hippocratic face includes tipping (sharpening) of nose, chin and endophthalmus
Treatment:
  • Surgical liquidation of the source of peritonitis is done e.g. appendectomy, partial gastric resection, ulcerography, cholecystectomy etc.
  • Thorough complete cleaning of the abdominal cavity is done by removing the liquid, blood, exudates etc.
  • Prevention of the bowel adhesion is done by the removal of the fibrinotic precipitatives from the walls of the bowels and local anaesthesia is injected to avoid paralytic destruction
  • Adequate drainage and peritoneal lavage is performed with the help of antiseptics and antibiotic fluids
  • Drainage tube must be inserted in several places such as left and right subcostal regions, left and right hypogastric regions, ileocecal region, left sigmoid region and in the Doughla’s pouch
  • Administration of the superiorly positioned tube is performed to administer the antiseptics and for the removal of the fluid from inferiorly placed drainage tube
  • After closing the abdominal cavity, broad spectrum antibiotics and fluids (crystalloid and fluid for the parental feeding) should be administered intravenously
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This article has been written by Dr. M. Javed Abbas.
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12:53 06/02/2003