What is the composition of the peritoneum?
thick mesothelium layer
on top of fibroelastic tissue
What are the divisions of the peritoneum?
- visceral peritoneum -> surrounding organs
- parietal peritoneum -> lining other surfaces of the cavity
what is the physiology of the peritoneum?
- few mls of peritoneum fluid -> pale yellow, viscid, & contains lymphocytes
- lubricates viscera -> allows easy movement & peristalsis
- irritation of parietal peritoneum -> severe localized pain (rich supply of nerves)
- irritation of visceral peritoneum -> poorly localized midline pain (poor supply of nerves)
Where does the visceral peritoneum get its innervation from?
slow C fibers running with sympathetic nerves transmit sensations
- dull crampy, poorly localized pain -> caused by ischemia, stretching, compression, traction, or chemical irritation
Where does the parietal peritoneum receive its innervation from?
A-fibers of somatic sensory nerves -> T7 - L1 anteriorly & L2 - L5 posteriorly
- sharp, well localized pain caused by irritation of parietal peritoneum
What is the function of the peritoneum?
- absorb large volume of fluids -> peritoneal dialysis in renal failure
- produce large volume of fluids -> ascites or inflammatory exudate (peritonitis)
- healing by development of new mesothelial cells
- visceral lubrication
- pain perception
- inflammatory immune responses
- fibrinolytic activity
- fluid absorption via diaphragmatic lymphatic during expiration -> abscess distant from primary disease
What is the difference between peritonitis & peritonism?
PERITONITIS
- inflammation of peritoneum (generalized or localized)
PERITONISM
- specific abdominal examination features
- irritation of peritoneum -> tenderness with guarding, rebound tenderness
What are the causes of peritoneal inflammation?
- bacterial -> GI & non-GI
- chemical -> bile & barium studies
- allergic -> starch peritonitis
- traumatic -> operative handling
- ischaemia -> strangulated bowel & vascular occlusion
- miscellaneous -> familial mediterranean fever
- primary spontaneous peritonitis -> pure streptococcal, pneumococcal, or haemophilus infection
What are the causes of acute bacterial peritonitis?
- invasion of peritoneal cavity by bacteria
- free fluid spillage -> circulation depends on attachments & gravity
What are the causes of non-bacterial peritonitis?
- acute pancreatitis
- intraperitoneal rupture of bladder
- hemoperitoneum
peritoneum will become infected by transmural spread of organisms from bowel -> systemic inflammatory response -> in a couple of hours -> bacterial peritonitis
(duodenal & gastric perforations are sterile for a couple of hours before becoming infected)
What are the routes to peritoneal infection?
- GI perforation -> perforated ulcer, appendix, diverticulum
- transmural translocation -> pancreatitis, ischemic bowel
- exogenous contamination -> drains, open surgery, trauma
- female genital tract -> pelvic inflammatory disease
- hematogenous -> septicemia (rare)
What is the cause of increased bacterial colonization in proximal bowel?
stasis & overgrowth caused by -> obstruction, chronic & acute motility disturbances
How does the biliary & pancreatic tract get infected?
gallstones
What are the organisms implicated in peritoneal infection?
2 or more bacterial strains
GRAM-NEGATIVE BACTERIA
- endotoxins -> causing release of TNF from leukocytes
- systemic absorption of endotoxin -> shock with hypotension & impaired tissue perfusion
CLOSTRIDIUM WELCHII
- exotoxins
BACTEROIDES
- gram-negative
- non-sporing
- predominant in lower intestine but escape detection because they’re anaerobic & grow slowly
- resistant to penicillin & streptomycin
- sensitive to metronidazole, clindamycin, lincomycin, & cephalosporin
What are the non-GI causes of peritonitis?
PELVIC INFECTIONS
- via the fallopian tubes
- due to chlamydia & gonococcus -> thinning of cervical mucus -> allow bacteria rom vagina into uterus & oviducts -> infection & inflammation
PERIHEPATITIS
- causes scar tissue to form on Glisson’s capsule (thin layer surrounding liver) -> Fits-Hugh-Curtis syndrome
FUNGAL PERITONITIS
- complicates severely ill patients
Summary of organisms in peritonitis?
GI source
- E. coli
- Streptococci
- Bacteroides
- Clostridium
- Klebsiella pneumoniae
Others
- staphylococcus
- streptococcis pneumoniae
- mycobacterium TB
- chlamydia trachomatis
- Neisseria gonorrhoea
- hemolytic strep
- fungal
What are the anatomical factors that cause localized peritonitis?
division of the greater sac of the peritoneum into
- subphrenic spaces
- the pelvis
- peritoneal cavity proper
peritoneal cavity proper is divided by transverse colon & mesocolon into
- supra colic compartment
- infra colic compartment
What are the anatomical factors that cause localized peritonitis?
division of the greater sac of the peritoneum into
- subphrenic spaces
- the pelvis
- peritoneal cavity proper
peritoneal cavity proper is divided by transverse colon & mesocolon into
- supra colic compartment
- infra colic compartment
when supracolic overflows (in case of peptic ulcer perforation) -> over colon -> infracolic or right paracolic gutter -> right iliac fossa
-> pelvis
What are the pathological factors leading to localized peritonitis?
- adhesions around affected organ
- retarded peristalsis
- greater omentum forms a barrier to prevent infection distribution
What are the factors that favour the development of diffuse peritonitis?
- speed of peritoneal contamination (prime factor)
- stimulation of peristalsis -> by eating or enema
- virulence of infecting organism
- young children -> small omentum
- disruption of localized collections -> by appendix mass or pericolic abscess injudicious handling
- immune deficiency -> steroid use, AIDS, old age
What are the initial symptoms of localized peritonitis?
signs of underlying condition (visceral inflammation)
- abdominal pain
- specific GI symptoms
- malaise
- anorexia
- nausea
WHEN PERITONEUM GETS INFLAMED -> abdominal pain worsens, temperature pulse rate increase
What are the pathognomonic signs of peritonitis?
- localized guarding
- rebound tenderness
- rigidity
What are the clinical features of localized peritonitis?
- inflammation under diaphragm -> shoulder tip (phrenic pain) -> C5 dermatome referred pain
- inflamed appendix in pelvic position OR salpangitis -> pelvic peritonitis -> rectal or vaginal examination reveals tenderness
What are the EARLY signs of generalized (diffuse) peritonitis?
- severe abdominal pain -> made worse by moving or breathing
- starts initially at site of lesion then spreads outward
- patient lies still
- tenderness & generalized guarding
- infrequent bowel sounds heard for a few hours -> stop with onset of paralytic ileus
- pulse & temperature rise according to degree of inflammation
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Portal Hypertension37
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Esophagus 146
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Esophagus 232
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Appendix28
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hematemesis37
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Bowel Obstruction45
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treatment of peptic ulcer32
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IBD33
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Peritonitis45
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Surgical Nutrition15
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Gallbladder diseases45
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Pancreas Anomalies21
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Benign Pancreatic Diseases27
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Acute pancreatitis21
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Chronic pancreatitis12
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Pancreatic Diseases & Malignancy23
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Liver Surgery1
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Bariatric Surgery16
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Mediastinal Masses14
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Chest wall trauma31
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Pediatrics 128
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Pediatrics 234
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Pediatrics 333
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Urology31
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urinary stones43
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Urinary congenital anomalies27
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Urological trauma25
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UTI26
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BPH25
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urological neoplasms38
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Colonic Polyps & Carcinoma35
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Rectal Prolapse13
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Rectal cancer18
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Anal canal diseases37
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Colonic Diverticula17
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Lower GI bleeding10
