The Peritoneum

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The Peritoneum
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• Definition
• The peritoneum is the largest serous membrane of
  the body lining the abdominal cavity
• Structure
• Consists of a closed sac, containing a small
  amount of serous fluid, within the abdominal
  cavity.
• Two layers
• The parietal layer - lines the abdominal wall
• Visceral layer covers the organs (viscera) in
  the abdominal and pelvic cavities

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• The oragns are invaginated into the closed sac
  from above, below and behind so that they are at
  least partly covered by the visceral layer
• Pelvic organs are covered only on their superior
  surface
• The stomach and intestines deeply invaginated
  from behind are almost completely surrounded by
  peritoneum and have a double fold ( the
  mesentery).

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• The fold of peritoneum attaches them to the
  posterior abdominal wall
• The pancreas, spleen, kidneys and adrenal glands
  are invaginated from behind - only their anterior
  surfaces are covered by the peritoneum -
  therefore retroperitoneal
• Liver completely covered - attached to the
  diaphragm
• The main blood vessels and nerves pass close to
  the posterior abdominal wall and send branches to
  the organs between the two folds of peritoneum

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• Parietal peritoneum lines the anterior abdominal
  wall
• The two layers are actually in contact - friction
  prevented by the presence of serous fluid
  secreted by the peritoneal cells
• Peritoneal cavity is only a potential cavity
• In women there is communication of the peritoneal
  cavity to the external atmosphere through the
  openings of the fallopian tubes (at fimbrial
  ends)
• In males the peritoneal cavity is completely
  closed.

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Peritonitis
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• Definition
• Inflammation of the peritoneum
• Aetiology
• Bacterial infection commonest organisms are
  Escherichia coli, aerobic and anaerobic
  streptococci, bacterioides.klebsiella pneumoniae.
  Mycobactyerium tuberculosis
• Bile irritation ? biliary peritonitis
• Biliary peritonitis following peptic ulcer
  perforation.
• Drains
• Open surgery
• Trauma
• Inflammatory bowel disease, appendicitis,
  ischaemic bowel.

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• Pelivic inflammatory disease
• Haematogenous spread ?e.g., septicaemia
• Pancreatitis inflammation of the peritoneum by
  the irritant secretions from the pancreas.
• Pathophysiology
• inflammation , exudation ? ascites, paralytic
  ileus, distension of abdomen, dehydration,
  respiratory embarassment due to the distension,
  septicaemia and death

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Clinical features -

• Loclised peritonitis
• Abdominal pain which goes on increasing
• Fever
• Vomiting
• Tenderness, rebound tenderness, Rowsings sign.
• Localised guarding, or rigidity.

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• Diffuse (generalized) peritonitis
• Severe abdominal pain
• Pain increases on moving and or breathing
• Patient lies still
• Tenderness and rigidity of the abdominal wall
• Pulse rises progressively
• The temperature may become subnormal tool
• Late features- if resolution or localisation of
  generalized peritonitis does not occur the
  abdomen remains silent and increasingly distends.
• Circlatory failure ensues
• cold and clammy extremities
• Sunken eys
• Dry tongue

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• Thready (irregular) pulse,
• Drawn and anxious face (Hippocratic facies)
• Unconsciousness
• Investigations
• Peritoneal diagnostic aspiration called
  peritoneal tapping
• Routine blood tests TC, DC, ESR etc.
• X-Ray abdomen
• Serum amylase
• Ultrasound scanning
• CT scanning

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• Treatment
• Analgesia
• Gastrointestinal deompression
• General care of the patient
• Vital system support esp. if septic shock is
  present
• Fluid balance chart
• Volume replacement
• Electrolyte imbalance correction
• Specific treatment of the cause
• Antibiotic therapy
• Peritoneal lavage when appropriate

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• Complications of peritonitis
• Systemic compications of peritonitis
• bacteraemic or endotoxic shock
• bronchopneumonia
• respiratory failure
• Renal failure
• Bone marrow suppression
• Multisystem failure

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• Abdominal complications of peritonitis
• Small bowel obstruction due to adhesions
• Paralytic ileus
• Residual or recurrent abscess
• Portal pyaemia/liver abscess
• Paralytic ileus