GIS-K-24

Peritonitis
Mesenteric Lymphadenitis
Syahbuddin Harahap
Division of Digestive Surgery
Department of Surgery
Faculty of Medicine
University of North Sumatera
Adam Malik Hospital

Peritoneum
Serous membrane
Lining abdominal cavity
Covers the intra-abdominal organs.
Layers Peritoneum
The outer layer
-parietal peritoneum
The inner layer
-visceral peritoneum.
The term mesentery
-double layer of visceral peritoneum

Subdivisions :
The greater sac
The lesser sac (or omental )
two "omenta":
1. The lesser omentum
(or gastrohepatic)
2. The greater omentum
(or gastrocolic)
like an apron, protective
layer.
Greater sac and lesser sac
Connected by the epiploic
foramen

Peritonitis
Inflammation of the serosal membrane that lines the
abdominal cavity and the organs contained therein
often as a result of infection.
Peritonitis are classified as :
1. Primary peritonitis
2. Secondary peritonitis
3. Tertiary peritonitis

Peritonitis are usually divided into

1. Generalized peritonitis
2. Localized peritonitis

Etiology
Peritonitis is often caused by:
- Perforation hollow viscus
- Chemically irritating material
(blood,pancreatic/gastic juice)

- Infected / Inflammation

Primary peritonitis
No pathologic process in a visceral organ
Via hematogenous
Children
Translocation of bacteria across the gut wall
Ascites
Intestinal obstruction
Ascending infection in female
Gonorrhea
Chlamydial infection
spreads into the abdominal cavity.
Systemic infections tuberculosis

Secondary peritonitis
Related to a pathologic process in a visceral organ

hollow viscus
- Perforation
- Infected
most common cause of peritonitis, perforations of :
- the stomach
- intestine
- gallbladder
- appendix

Tertiary peritonitis
Persistent or recurrent infection after adequate initial therapy
Anastomotic leakage

Abscess with or without fistulization.

Diagnosis and investigations

Based primarily on clinical grounds

No further investigation should delay surgery

Clinical:
The diagnosis of peritonitis is usually clinical.
1. Chief complaint Acute abdominal pain
2. Peritoneal irritation Anorexia and nausea ,vomiting.
3.

Fever exceed 38C

4. Hypovolemia Hypotensive

5. Hypothermia severe sepsis Septic shock

Peritonitis generally represents a surgical emergency.

On abdominal examination of Peritonitis

1. Position/lighting/draping
2. Inspection
Abd. Distended Ileus paralyticus
Keep their hips flexed to relieve the abdominal wall tension.

3. Palpation all four quadrants

Tenderness
Rebound tenderness
Diffuse Abdominal rigidity ("washboard abdomen")
Abdominal Guarding voluntary in response of the abdominal
Inflammatory mass.
4.Percussion

Tenderness all four quadrants

Percuss the liver span free air
5. Auscultation
Paralytic Ileus Hypoactive-to-absent bowel sounds.

6 . Digital rectal exam .

Generalized peritonitis
Tenderness in all direction
Appendicitis
Tenderness in the right direction

Female patients vaginal and bimanual examination

Pelvic inflammatory disease

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)

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

Complications
Hypovolaemia shock
-Sequestration of fluid and electrolytes
-Decreased central venous pressure
Electrolyte disturbances
Acute renal failure
Peritoneal abscess
Abdominal Sepsis may develop Septic shock

Imaging Studies

Radiographs
Plain films of the abdomen :
supine
upright Free air
lateral decubitus positions
Computed tomography scan
Diagnosis cannot be established on clinical
grounds
Cannot be findings on abdominal plain films.

Treatment
INFORMED CONSENT
General supportive measures :
- Intravenous rehydration
- Correction of electrolye disturbances.
Antibiotics
- broad-spectrum antibiotics
The exception is spontaneous bacterial peritonitis, which does not
benefit from surgery.
Surgery

Exl .laparotomy full exploration

Lavage of the peritoneum

Abscess in Pouch of Douglas (Cul de sac abscess )

(Pelvic abscesses)
DRE: often are palpable as tender
Anterior fullness and fluctuation
Male Rectovesical pouch
Female Recto-uterine pouch

Treatment
Draining these abscesses transvaginally or transrectally is
best to avoid the transabdominal approach.

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.

Pathophysiology
Microbial agents are thought to gain access to the lymph
nodes via the intestinal lymphatics.

Clinical
Clinical features of associated organ involvement, such as
enterocolitis or ileitis
Abdominal pain - Often right lower quadrant (RLQ) but may
be more diffuse
Fever
Diarrhea
Malaise
Anorexia
Upper respiratory tract infection
Nausea and vomiting

Physical
Fever (38-38.5C)
RLQ tenderness - Mild, with or without rebound
tenderness
Rectal tenderness
Rhinorrhea
Hyperemic pharynx
Associated peripheral lymphadenopathy (usually
cervical) in 20% of cases

Causes
Streptococcus beta-hemolytic,
Staphylococcus species,
Escherichia coli
Streptococcus viridans,
Mycobacterium tuberculosis,
Viruses, such as coxsackieviruses, rubeola virus, and
adenovirus

Children with upper respiratory tract infection, has

popularized a theory that swallowed pathogen-laden sputum
may be the primary source of infection.

Lab Studies
CBC count
Leucocytosis exceeding 10,000/L
Urinalysis exclude urinary tract infection.
Stool cultures Diarrheal symptoms
Blood culture Septicemia

Imaging Studies
CT scanning
In mesenteric adenitis:
lymph nodes to be larger
greater in number
CT scanning is also important to exclude
other differential diagnoses, especially acute
appendicitis.

Medical Care
Hemodinamic support
Broad-spectrum antibiotics
To quickly identify patients who require surgical intervention
Surgical Care
Signs of peritonitis
Appendectomy