1. Diseases of peritoneum & retroperitoneal space M K Alam

2. ILOs At the end of this presentation students will be able to:  Describe types and causes peritonitis.  Recognize the clinical features of localized and generalized peritonitis.  Enumerate sites of intra-abdominal collection and its clinical features.  Describe management of local& general peritonitis and intra-abdominal collections.  Describe peritoneal tumours and its management  Describe the presentation and management of retroperitoneal diseases.

3. Anatomy Peritoneal membrane: Visceral & parietal Visceral peritoneum: Poor nerve supply by autonomic, its irritation/ inflammation- poorly localized, dull and felt in midline Parietal: Rich somatic nerve, when irritated- severe, accurately localized to affected area Line by single layer mesothelial cells lying on thin layer of fibroepithelial tissue Few ml of pale yellow fluid lubricates peritoneal surface Greater and lessor sac

5. Peritoneal Inflammation Acute or chronic Causes of peritonitis: Bacterial infection: perforated appendicitis (acute) tuberculosis (chronic) Chemical peritonitis: Bile peritonitis, Acute pancreatitis Ischemic injury: Bowel strangulation, vascular occlusion Trauma: Surgery Allergic: Starch peritonitis from gloves

6. Bacterial peritonitis Usually polymicrobial Common organisms: E coli, Streptococci, Bacteroides, Klebsiela, staphylococcus Uncommon organisms: Chlamydia, pneumococcus, mycobacterium tuberculosis Routes: GI perforation (most common), exogenous (drains, trauma), transmural (ischemic bowel), fallopian tubes (PID), and haematogenous (rare ? Primary peritonitis)

7. Clinical peritonitis Localized peritonitis: Anatomical divisions ( subphrenic, pelvic, peritoneal cavity proper (supracolic, infracolic) and pathological factors (inflammatory adhesions) and slow progress. Generalized peritonitis: Free bowel perforation, peristalsis and virulent infecting organisms, improper handling of inflammatory mass, young children (small omentum)

8. Clinical features of localized peritonitis Fever, tachycardia Abdominal pain located in the area of the involved organ. Guarding, rigidity and rebound tenderness overlying the involved area. Rest of abdomen non-tender. Special features: Shoulder tip pain (subphrenic), suprapubic, both iliac fossa tenderness, anterior pelvic tenderness and fullness on DRE (pelvic collection) Investigations: CBC, u/e, AXR, u/s, CT scan (most helpful) Management: NPO, IV fluid, antibiotics (polymicrobial cover) can help resolve localized peritonitis. Percutaneous or open surgical drainage if no resolution or abscess formation

9. Subdiaphragmatic collection

10. Clinical features of generalized peritonitis Abdominal pain spreading to whole abdomen Fever, tachycardia Pain aggravated with movement Restricted abdominal wall movement, generalized tenderness, guarding, rigidity and absent bowel sounds Septic shock in late cases, silent abdomen, increasing distension anxious face

11. Management of generalized peritonitis Investigations: CBC, u/e, amylase, Upright CXR, AXR, U/S, CT scan, peritoneal aspiration (sometimes under imaging) Treatment: NPO, IV fluid (correct fluid & electrolyte imbalance) NG tube: Aspiration & drainage Broad spectrum antibiotic therapy Analgesia Operative management: Excision, repair, lavage & drainage

12. Complications of peritonitis Systemic: Septic shock, pneumonia, respiratory failure, multi-system failure Local: Adhesions, paralytic ileus, abscess formation (residual or recurrent), portal pyaemia, liver abscess

13. Tuberculous peritonitis Uncommon but still seen where tuberculosis still occurs. Infection originates from lymph nodes, ileocaecal, pyosalpinx, haematogenous Abdominal pain (90%), fever & loss of wt. (60%), ascites (60%), night sweats, abdominal mass Diagnosis: Positive tuberculin test, mycobacterium in ascitic fluid, biopsy of tubercle or caseating area (laparoscopy) Antituberculous therapy

14. Tuberculous Peritonitis

16. Spontaneous Bacterial Peritonitis (Primary peritonitis) Acute bacterial infection of ascitic fluid No source of infection is easily identifiable Affects children & adults Ominous complication in patients with cirrhosis (70% child class C) Can affect ascitics from other causes (CCF, Budd-chiari syndrome) Organism: E coli (50%), Streptococci (19%), Monomicrobial- 92% Diagnosis: Polymorphonuclear > 250 per mm 3 or a positive ascites culture. Antibiotic: 5- to 10-day of cefotaxime or a combination of amoxicillin and clavulanic acid

17. Neoplasms of peritoneum Carcinomatosis peritonei : Terminal event, studded with secondary growth, ascites (straw, blood stained). Pseudomyxoma peritonei : Rare, frequently female due to ruptured mucinous cystadenocarcinoma (appendiceal origin in most cases). Abdominal distended due to yellow jelly like fluid. U/S, CT scan help diagnosis. Treatment: Excision of primary, debulking, chemotherapy. Recur over months to years

18. Peritoneal secondaries (carcinomatosis)

19. Pseudomyxoma peritonei Scalloped indentation of the surface of the liver and spleen.

20. Retroperitoneal space The space between the posterior envelopment of the peritoneum and the posterior body wall.

21. Retroperitoneal Infections Aetiology: Extension of intraperitoneal infections- appendicitis, perforated DU, diverticulitis. Presentation: Tachycardia, pain, fever, malaise, palpable mass (sometime) CT scan – modality of choice Management: Antibiotics, treatment of primary infection, CT guided drainage for unilocular abscess, surgical drainage for multilocular abscesses.

22. Retroperitoneal Fibrosis Proliferation of fibrosis in retroperitoneum. Aetiology: Idiopathic (Ormond’s disease) ? autoimmune mechanism Secondary to malignancy- Hodgkin’s, carcinoid, or medication- methysergide. More common in men, 4-6 th decade. Fibrosis gradually involves ureter, IVC, aorta, mesenteric vessels. Presenting symptoms depends upon organ/ organs involved. Poorly localized abdominal pain, sudden sever pain (MVO), unilateral leg swelling, oliguria, dysuria, haematuria. CT scan, MRI- fibrotic process Management: Exclude drug or malignancy. For idiopathic type; Steroid therapy, surgical debulking, ureterolyis, ureteric stent.

23. Retroperitoneal Malignancies Primary malignancy: Retroperitoneal Sarcoma- the most common 15% of all soft tissue sarcomas occur in the retroperitoneum Asymptomatic abdominal mass, often after the primary tumor has reached a considerable size. Abdominal pain(50%), and less common symptoms- GI hemorrhage, early satiety, nausea and vomiting, weight loss, and lower extremity swelling. CT and MRI Treatment: Complete en bloc resection of the tumor and any involved adjacent organs. Lymph node metastases are rare Retroperitoneal malignancies from other organs: Kidney, adrenal, colon, pancreas, lymphoma, metastases from a remote primary malignancy

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