Intraperitoneal abscess
Special types of peritonitis
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Peritoneal neoplasms
Dept. of Surgery
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Surgical AnatomyPeritoneum is the largest serous membrane in the body
Surface area: approx. 22,000 cm2.
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Divided into parietal and visceral portionsParietal layer lines the abdominal and pelvic cavities and the
abdominal surface of the diaphragm.
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loosely connected with the body wall, separated from it by anadipose layer, tela subserosa
Visceral layer covers the abdominal and pelvic viscera and
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includes the mesenteries.
visceral peritoneum is usually tightly attached to the organs it
covers.
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It does not line the entirety of the abdominopelvic cavity.
It is lifted from the body wall, especially posteriorly, by organs
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located against the wall during embryologic development.This chain of events causes the formation of a retroperitoneal
space between the peritoneum and the body wall, with organs
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situated within the space.
An organ that is covered only in part by the peritoneum is
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referred to as a retroperitoneal organ.An organ that is covered by peritoneum essentially everywhere
except for the site of entrance of vessels is referred to as an
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intraperitoneal organ.
Innervation of peritoneum
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Parietal peritoneum is
Visceral peritoneum is sensitive
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to stretch & tearing.sensitive to pain, pressure,
temperature & touch
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It is supplied by autonomicParietal peritoneum is
afferent nerves which supply the
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viscera.
supplied by:
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T7-- T12,L1 nerveNB. Parietal peritoneum of the
pelvis is supplied by Obturator
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phrenic nerve.
nerve.
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Functions of peritoneumIt suspend the organs within the peritoneal cavity.
It fixes some organs within the abdominal cavity.
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Storage of large amount of fat in the peritoneal ligaments (e.g..
Greater omentum)
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Peritoneal covering of intestine tends to stick together in infectionGreater omentum is cal ed the policeman of abdomen to prevent
spread of infection
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It secretes the peritoneal fluid
Peritoneal fluid
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Peritoneal fluid is pale yellow fluid rich in leukocytes
Mobile viscera glide easily on one another.
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Peritoneal fluid moves upward towards subphrenic spaces-whatever the position of the body by:
Movements of diaphragm.
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Movements of abdominal musclesPeristaltic movements.
Peritoneum is extensive in the region of diaphragm.
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PeritonitisPeritonitis ? inflammation of the peritoneum which
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maybe localised or generalisedPeritonism ? refers to specific features found on
abdominal examination in those with peritonitis
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Characterised by tenderness with guarding
Rebound /percussion tenderness on examination
Eased by lying still and exacerbated by any movement
Maybe localised or generalised
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Generalised peritonitis is a surgical emergency ?
requires resuscitation and immediate surgery
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TypesPrimary:
Not related to intraabdominal abnormality
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Also cal ed spontaneous bacterial peritonitis
Secondary:
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Due to spil age of GI or GU organisms into peritonealspace due to breach of mucosal barrier
Tertiary:
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clinical peritonitis and systemic signs of peritonitis persist
after treatment of secondary peritonitis
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No/low virulence organism isolatedCauses
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Infective ?bacteria cause peritonitis
most common cause of peritonitis
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Non-infective ?leakage of certain sterile body fluids into the peritoneum
can cause peritonitis.
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Note: although sterile at first these fluids often become
infected within 24-48 hrs of leakage from the affected
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organ resulting in a bacterial peritonitisClinical features
Pain
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Constant and severe
Worse on movement
Eased by lying stil
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Signs of ileus (generalised peritonitis > localisedperitonitis)
Distension
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VomitingTympanic abdomen with reduced bowel sounds
Signs of systemic shock
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Tachycardia, tachypnoea, hypotension, low urine outputMore prominent with generalised than localised peritonitis
Investigations
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Diagnosis most often made on history and examination
If localised peritonitis
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Bloods testsChest X Ray
ECG
Complex investigations are requested depending on suspected
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diagnosisIf generalised peritonitis
Surgical emergency ? wil require emergency operation
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Following investigations should be performed:Bloods: FBC, U&E, LFT, Amylase!! CRP, clotting, G&S, ABG
Chest X ray
CT scan
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Management
ABC
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OxygenFluid resuscitation
IV antibiotics
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Analgesia
Surgery
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Pelvic Abscess
? Rare but the most serious late postop complication
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? Involve one or both residual adnexa (tubo-ovarianabscess)
? occur almost exclusively in premenopausal women
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occur despite prophylactic AB? often have a latent period of many between surgery
and onset of symptoms
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Clinical features
? fever (high spike late in the afternoon or
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early evening)
? palpable mass high in the pelvis
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? WBC: around 20,000/mm? ESR
Ultrasonography and CT scan
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? confirm the presence of a mass
? help to determine whether it is
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Loculatedrelated to an intraperitoneal structure
drainable percutaneously
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? Immediate drainage is not mandatory if it is
inaccessible AB therapy alone may be successful
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? isolation of -lactamase?producing Prevotella
species use of clindamycin, metronidazole, or
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other agents against gram-negative anaerobesClindamycin + gentamicin fails to respond
drainage
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Necrosis+infections surgical exploration in some
cases
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Aerobic and anaerobic culture of purulent materialor tissue
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Primary peritoneal tumoursDefined As Tumors With Primary Manifestation In
The Peritoneum In The Absence Of A Visceral Site
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Of Origin
Arise From Mesothelial Cel s, Sub Mesothelial
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Classification
Differential diagnosis
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Peritoneal Malignant Mesothelioma
Uncommon Malignant Neoplasm
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Arises From Mesothelial Cells Or Multipotential Subserosal
Mesenchymal Cells
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Account for 6%?10% of malignant mesotheliomasDiffuse: highly aggressive, are incurable
Localized: good prognosis following complete surgical
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excision
Etiology
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Exposure To Higher Levels Of Asbestos, ErioniteTherapeutic Irradiation
Exposure To Simian Virus 40
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Chronic pleural or peritoneal irritation
Majority in males
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Median age: 60 yearsClinical presentation
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Abdominal Pain Or DiscomfortAbdominal Distension
Increasing Abdominal Girth
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Nausea, Anorexia
Weight Loss
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Bowel ObstructionPalpable Abdominal or pelvic mass
A:innumerable tumor nodules
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B: macrolobulated mass with foci of
(arrows) scattered over the
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intratumoral degeneration andomental surfaces
hemorrhage
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Imaging Features
Nodular Thickening Of The Peritoneum
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Omental Caking: Fine, Nodular, Soft-tissue
Studding
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Ascites: diffuse to focal,small, loculated collectionsBarium examination shows separation of small bowel segments
and irregular fold thickening of small bowel segments
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A: Axial CT scans: show ascites
B: large, heterogeneously enhancing
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and omental nodule
mass in the greater omentum
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TreatmentThe most effective treatment for peritoneal
mesothelioma is:
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Cytoreductive Surgery
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Hyper thermic IntraperitonealChemotherapy (HIPEC)
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Primary Peritoneal Serous CarcinomaEpithelial tumor that arises from the peritoneum
Almost always occurs in women (mean age, 56?62 years)
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Clinical features:
abdominal distension
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Pain, nausea and vomitingIncreasing abdominal girth
ascites
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elevated serum levels of cancer antigen CA-125
Multiple nodules on omentum
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Omental cakingPsammoma bodies are commonly present
So reffered as psammomacarcinoma
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The fol owing criteria have been established to make
the diagnosis of primary peritoneal serous carcinoma:
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Both ovaries are normalInvolvement of extra ovarian sites must be greater than the
involvement on the surface of either ovary
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Ovarian involvement is limited to ovarian surface epithelium,
either without stromal invasion or involving the cortical
stroma with tumor size less than 5 x5 mm
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Imaging Features
Ascites
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Peritoneal nodules and thickeningOmental nodules and masses
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CT scan: showing calcified nodules and soft-tissue caking of thegreater omentum (arrowheads)
Treatment
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Cytoreductive Surgery
(optimal < 1 cm residual disease)
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Chemotherapy(Cisplatin,Taxol based)
Primary Peritoneal Serous Borderline Tumor
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Rare lesion of low malignant potential
Tumor cells do not invade into the submesothelial layers of
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the peritoneum or omental fatFemale patients,16- 67 years of age (mean:33 years)
Treated by surgical resection (omentectomy,
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hysterectomy, and oophorectomy)
Have a good long-term prognosis
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Leiomyomatosis Peritonealis Disseminata(diffuse peritoneal leiomyomatosis)
Rare, benign entity
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Innumerable smooth muscle nodules throughout the
peritoneal cavity
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Associated with high estrogen states, caused by pregnancyand oral contraceptive use
Spontaneous regression of the leiomyomas or regression
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following withdrawal of ovarian hormones or oophorectomy