Acute peritonitis.

Nearly all varieties of peritonitis are due to an invasion

of peritoneal cavity by bacteria.
Bacteriology. Bacteria from the alimentary canal.
Usually the infection is caused by two ore more strains. The
commonest invaders are E.coli, aerobic and anaerobic
streptococci.
bacteroides, clostridium Welchii, Klebsiella pneumonia.
E.coli, bacteroides, and Cl. Welchii produce toxins that
cause severe illness or death when they invade a large
absorptive area (entotoxin shock).
Bacteria not from the alimentary canal: gonococcus, and
mycobacterium tuberculosis.
The inflammatory response of the peritoneum may
involve the entire intra abdominal cavity or only a portion of
either the visceral or parietal peritoneum.
1 Generalized peritonitis.
2 Diffuse peritonitis.
3 Localized peritonitis : free or loculated fluid
collection (abscess).

Peritonitis may be primary peritonitis (or spontaneous)

and secondary peritonitis.
Primary p. is when a diffuse bacterial infection without an
apparent intraabdominal source of infection

(1%). The

organisms are most commonly those of pneumococcus and

hemolytic

streptococcus

and

occur

more

commonly

in

children than in adults.

Secondary peritonitis (99%) implies that it is the result
of bacterial contamination from a known source, usually from
within the abdomen and often from a perforation of the
gastrointestinal tract.
Chemical

peritonitis

refers

to

the

peritoneal

inflammation from substances other than bacteria: gastric

juice, pancreatic juice, bile, blood, urine, meconium, and
chyle.
Bile peritonitis may occur as a result of perforation of
gallbladder, with acute gangrenous cholecystitis.
Hemoperitoneum is the result of a ruptured abdominal
aneurysm, a ruptured Graafian follicle or splenic injury.
Abdominal pain secondary to inflammatory lesions
of the gastrointestinal subsystem.
1- Stomach: Perforation of Gastric ulcer, or Duodenal
ulcer, 2- Biliary tract: Acute cholecystitis with or without
choledocholithiasis. 3- Pancreas: Acute recurrent or chronic
pancreatitis.4- Small intestine: Crohns disease,
Meckels diverticulum.5- Large intestine: Appendicitis,
Diverticulitis.
Abdominal pain secondary to lesions of the
gynecologic subsystem.
1- Ovary (Ruptured Graafian follicle, torsion of ovary).
2- Fallopian tube: ruptured Ectopic pregnancy, acute
salpingitis, pyosalpinx.

3- Uterus: Uterine rupture, endometrit

Causes of Hemoperitoneum.
Gastrointestinal: Traumatic laceration of liver, spleen,
pancreas, mesentery, bowel.
Gynecologic: Ruptured ectopic pregnancy, Ruptured
Graafian follicle, and ruptured uterus.
Vascular: Ruptured aneurysm aortoiliac, hepatic, renal
and splenic artery.
Urologic ruptured bladder.
Hematologic ruptured spleen.
Abdominal pain secondary to obstructing lesions of
the gastrointestinal tract.
1- Jejunum. Malignancy. Volvulus. Adhesions
Intussusceptions. 2- Ileum. Malignancy. Volvulus. Adhesions.
Intussusceptions.
3- Colon: Malignancy. Volvulus caecal or sigmoid.
Diverticulitis.
Paths of bacterial invasion of peritoneal
space.
Direct infection via perforation of some part of
gastrointestinal canal. Operative e.g.: drains, dialysis tubes,
foreign material.
Local extension: from an inflamed organ, e.g.
appendicitis, cholecystitis, migration of bacteria through gut
wall, e. g. strangulated hernia.
From or via the fallopian tubes.

Blood stream - part of general septicemia.

Natural factors which favor localization of
peritonitis.
These factors are anatomical, pathological and surgical.
Anatomical : 1) the pelvis, 2) the peritoneal cavity
proper: a)a supra colic compartment, b) a infra colic
compartment.
The transverse colon and transverse mesocolon, deter the
spread of infection from one to the other compartment.
The right and left paracolic gutter.
Pathological. Inflamed peritoneum loses its glistening
appearance and becomes reddened and velvety. Flakes of
fibrin appear and cause coils of intestine to become adherent
to one another and to the parietes. Adhesions form around
the affected organ. There is an outpouring of serous fluid rich
in leukocytes and antibodies that soon becomes turbid, if
localization occurs, the turbid fluid becomes franc pus.
Peristalsis is retarded in affected coils, and this helps in
preventing distribution of the infection to other coils.
The greater omentum, by enveloping and becoming
adherent to inflamed structures, often forms a substantial
barrier to the spread of infection.
Surgical. Drains are frequently used postoperatively to
assist localization (and exit) of intraabdominal collections.
Natural factors which tend to cause diffusion of
peritonitis.

A primary factor in the spread of peritonitis is whether it

develops rapidly or slowly. The ingestion of food or even water
hinders localization by stimulating peristaltic action.
When the virulence of the infecting organism is so great
as to render the localization of the infection difficult or
impossible.
In children the omentum is small.
In judicious and rough handling of localized collections
of puss, e. g. appendix mass or pericolic abscess.
Deficient natural resistance (immune deficiency). This can
result from drugs, disease (e. g. A I D S) or infancy and old age.
(Aids = acquired immune deficiency syndrome).
Open Abdomen and Staged Abdominal Repair.
Classically, the goal of operative management has been to
solve the problem with a single operation and to conclude the
operation with definitive primary closure of the abdomen.
Edema

of

the

peritoneal

cavity,

however,

precludes

approximation of the abdominal wall fascia in some cases

without enormous tension on suture lines. Furthermore, closure
in such circumstances leads to increased intraabdominal
pressure. elevates the diaphragm, and restricts ventilation,
thereby promoting

development of basal atelactasis and

increasing the risk of pneumonia. Elevated intraabdominal

pressure also negatively influences cardiovascular and renal
function. In other patients, particularly those with necrotizing
pancreatitis or intestinal gangrene, a need for early re-exploration is apparent at the initial operation. And, in patients with
mid-abdominal. interloop abscesses, multiple re-explorations

are often required to drain pus.

One response to the predictable need to re-explore was to
pack the abdominal cavity open. The drawbacks of this method
are the development of spontaneous small bowel fistulae and
large incisional hernias. Attempts were then made to close the
abdomen temporarily. Initially, prosthetic mesh was used; later,
zipper de-vices helped in quickly approximating the fascia
between operations performed at intervals of 24 h. This
concept of planned relaparotomies later fused with the openabdomen technique when the requirement for tension-free
abdominal wound closure became evident. The new concept.
termed staged abdominal repair, uses new devices for closure
such as a zipper with larger seams (Ethizip). Marlex mesh with
a zipper, or an artificial burr device.
Relaparotomies are performed at 24-h intervals in the
operating room. Only if the patient is in a very deteriorated
state may the temporary abdominal closure be reopened at the
bedside for diagnostic purposes. If a problem that was
recognized at the first operation persists or if new problems are
encountered,
problems

are

further

relaparotomy

solved,

the

is

indicated.

abdominal

cavity

Once
is

all

closed

definitively.
Staged abdominal repair. then, implies a commitment
before or during the first operation for multiple laparotomies
done at 24-h intervals. The average number of operations
performed is depicted in Fig. 32-17.
As a result of our experience with this procedure since
1980.

the

indications

for

staged

crystallized and are listed in Table .

abdominal

repair

have

Table. Indications for Staged Abdominal Repair

1.

Mortality predicted above 30% (APACHE-II greater

than 15)
2.

Poor patient condition precludes definitive closure

3.

Source of infection not eliminated or controlled

4.

Debridement incomplete

5.

Uncontrolled hemorrhage managed by packing

6.

Excessive peritoneal edema

7.

Bowel ischemia in which tissue survival is uncertain