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 features of localized & generalized peritonitis.
Enumerate sites & features of intra-abdominal collection.
Describe management of local& general peritonitis.
Describe types & management of peritoneal tumours.
Describe retroperitoneal diseases.

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

5. Peritoneal Inflammation
Acute or chronic
Secondary, primary (uncommon)
Causes of peritonitis:
Bacterial infection: perforated bowel- 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

7. Routes of infection GI perforation: Most common
Exogenous: Drains, trauma
Transmural: Ischemic bowel, fallopian tubes (PID)
Haematogenous: Rare ? Primary peritonitis

8. Clinical types of peritonitis Localized peritonitis
Factors for localization:
Anatomical divisions: Subphrenic, peritoneal cavity proper (supracolic, infracolic), pelvic
Pathological factors: Inflammatory adhesions, slow progress.

9. Clinical features- 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 the abdomen non-tender.
Special features: Shoulder tip pain (subphrenic), Suprapubic/both iliac fossa tenderness, DRE: Anterior pelvic tenderness and fullness (pelvic collection)

10. Management
Investigations: CBC, u/e, AXR, Ultrasound, CT scan (most helpful)
Treatment: NPO, IV fluid,
Antibiotics (polymicrobial cover) can help resolve localized peritonitis.
Percutaneous/ open surgical drainage if no resolution or abscess formation

11. Subdiaphragmatic collection

13. Generalized peritonitis
Free bowel perforation
Peristalsis
Virulent infecting organisms
Improper handling of inflammatory mass
Young children (small omentum)

14. Clinical features of generalized peritonitis
Abdominal pain: spreading to whole abdomen, aggravated with movement
Fever, tachycardia
Restricted abdominal wall movement,
Generalized tenderness, guarding, rigidity
Absent bowel sounds
Late cases: Septic shock, silent abdomen, increasing distension, anxious face

16. 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

17. 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

18. Tuberculous peritonitis
Uncommon but still seen where tuberculosis still occurs.
Infection originates from lymph nodes, ileo-caecal, 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)
Treatment: Antituberculous therapy Surgery: Diagnosis/ complications

19. Tuberculous Peritonitis

20. Tuberculous Peritonitis

21. Spontaneous Bacterial Peritonitis (Primary peritonitis)
Acute bacterial infection of ascitic fluid
No source of infection is easily identifiable
Affects children & adults
Risk group: Cirrhosis (70% child class C), CCF, Budd-Chiari syndrome
Organism: Monomicrobial- 92%, E coli (50%), Streptococci (19%)
Diagnosis by paracentesis of ascitic fluid:
Polymorphonuclear > 250 per mm3 or a positive ascites culture,
Total protein > 1gm/dl, LDH > serum LDH, Glucose < 50 mg/dl- all suggest 2° peritonitis
Treatment: 5- to 10-day of cefotaxime or a combination of amoxicillin and clavulanic acid.

22. Spontaneous Bacterial Peritonitis

23. 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
Mesothelioma

24. Peritoneal secondaries (carcinomatosis)

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

26. Mesothelioma

27. Retroperitoneal space

28. 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.

29. Retroperitoneal Fibrosis
Proliferation of fibrosis in retroperitoneum.
Aetiology: Idiopathic (Ormond’s disease) ? autoimmune Secondary to malignancy- Hodgkin’s, carcinoid, medication- methysergide.
More common in men, 4-6th decade.
Fibrosis gradually involves ureter, IVC, aorta, mesenteric vessels.

30. Retroperitoneal Fibrosis
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.

31. Retroperitoneal Malignancies Primary malignancy
Retroperitoneal Sarcoma- the most common
15% of all soft tissue sarcomas occur in the retroperitoneum
Asymptomatic abdominal mass, often tumor has reached a considerable size.
Abdominal pain(50%),
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

32. Retroperitoneal Mass- CT scan

33. Retroperitoneal Malignancies
Retroperitoneal malignancies from other organs:
Kidney,
Adrenal,
Colon,
Pancreas,
lymphoma,
Metastases from a remote primary malignancy

34. Thank you!