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Peritonitis

  • Intra-abdominal infections results in two major clinical manifestations
    • Early or diffuse infection results in localised or generalised peritonitis
    • Late and localised infections produces an intra-abdominal abscess
  • Pathophysiology depend on competing factors of bacterial virulence and host defences
  • Bacterial peritonitis is classified as primary or secondary

Primary peritonitis

  • Diffuse bacterial infection without loss of integrity of GI tract
  • Often occurs in adolescent girls
  • Streptococcus pneumonia commonest organism involved

Secondary peritonitis

  • Acute peritoneal infection resulting
    • GI perforation
    • Anastomotic dehiscence
    • Infected pancreatic necrosis
  • Often involves multiple organisms - both aerobes and anaerobes
  • Commonest organisms are E. coli and Bacteroides fragilis

Surgical management

  • The management of secondary peritonitis involves
    • Elimination of the source of infection
    • Reduction of bacterial contamination of the peritoneal cavity
    • Prevention of persistent or recurrent intra-abdominal infections
  • Could be combined with fluid resuscitation, antibiotics and ITU / HDU management 
  • Source control achieved by closure or exteriorisation of perforation
  • Bacterial contamination reduced by aspiration of faecal matter and pus
  • Recurrent infection prevented by the used of:
    • Drains
    • Planned re-operations
    • Leaving the wound open / laparostomy

Peritoneal lavage

  • Peritoneal lavage often used but benefit is unproven
  • Simple swabbing of pus from peritoneal cavity may be of same value
  • Has been suggested that lavage may spread infection or damage peritoneal surface
  • No benefit of adding antibiotics to lavage fluid
  • No benefit of adding Chlorhexidine or Betadine to lavage fluid
  • If used, lavage with large volume of crystalloid solution probably has best outcome

Intra-abdominal abscesses

  • An intra-abdominal abscess may arise following:
    • Localisation of peritonitis
    • Gastrointestinal perforation
    • Anastomotic leak
    • Haematogenous spread
  • They develop in sites of gravitational drainage
    • Pelvis
    • Subhepatic spaces
    • Subphrenic spaces
    • Paracolic gutters

Clinical features

  • Postoperative abscesses usually present at between 5 and 10 days after surgery
  • Suspect if unexplained persistent or swinging pyrexia
  • May also cause abdominal pain and diarrhoea
  • A mass may be present with overlying erythema and tenderness
  • A pelvic abscess may be palpable only on rectal examination

Management

  • Ultrasound scanning may reveal the diagnosis
  • Contrast-enhanced CT is probably the investigation of choice
  • May delineate a gastrointestinal or anastomotic leak
  • Identifies collection and often allows percutaneous drainage
  • Operative drainage may be required if:
    • Multi-locular abscess
    • No safe route for per cutaneous drainage
    • Recollection after percutaneous drainage
  • Patients should receive antibiotic therapy guided by organism sensitivities

Bibliography

Bausch K, van Vroonhoven Th J M, van der Werken Ch. Surgical management of severe secondary peritonitis. Br J Surg 1999; 86: 1371-1377.

Mens M,  Akhan O, Koroglu M.  Percutaneous drainage of abdominal abscess.  Eur J Radiol 2002;  43:  204-218.

Platell C,  Papadimitiriou J M,  Hall J C.  The influence of lavage fluid on peritonitis.  J Am Coll Surg 2000; 191: 672-680.

vanSonnenberg E,  Wittich G R,  Goodacre B W et al.  Percutaneous abscess drainage:  update.  World J Surg 2001;  25:  362-369.

 

 
 

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