1. GIS-K-24 Peritonitis Mesenteric Lymphadenitis Syahbuddin Harahap Division of Digestive Surgery Department of Surgery Faculty of Medicine University of North Sumatera Adam Malik Hospital

2. Peritoneum Serous membrane Lining abdominal cavityabdominal cavity Covers the intra-abdominal organs. Layers Peritoneum The outer layer -parietal peritoneum The inner layer -visceral peritoneum. The term mesenterymesentery -double layer of visceral peritoneum

3. Subdivisions : The greater sacgreater sac The lesser sac (or omental )lesser sac two "omenta": 1.The lesser omentumlesser omentum (or gastrohepatic) 2.The greater omentumgreater omentum (or gastrocolic) like an apron, protective layer. Greater sac and lesser sac Connected by the epiploic foramen Greater sac lesser sacepiploic foramen

4. Peritonitis Inflammation of the serosal membrane that lines the abdominal cavity and the organs contained therein often as a result of infection. Peritonitis are classified as : 1.Primary peritonitis 2.Secondary peritonitis 3.Tertiary peritonitis Peritonitis are usually divided into 1.Generalized peritonitis 2.Localized peritonitis

5. Peritonitis is often caused by: - Perforation hollow viscus - Chemically irritating material (blood,pancreatic/gastic juice) - Infected / Inflammation Etiology

6. Primary peritonitis No pathologic process in a visceral organ  Via hematogenous Children  Translocation of bacteria across the gut wall Ascitesscites Intestinal obstruction  Ascending infection in female Gonorrhea Chlamydial infection spreads into the abdominal cavity.  Systemic infections tuberculosistuberculosis

7. Secondary peritonitis Related to a pathologic process in a visceral organ hollow viscus - Perforation - Infected most common cause of peritonitis, perforations of : - the stomach - intestine - gallbladder - appendix

8. Tertiary peritonitis Persistent or recurrent infection after adequate initial therapy Anastomotic leakage Abscess with or without fistulization.

9. Diagnosis and investigations Based primarily on clinical grounds No further investigation should delay surgerysurgery

10. Clinical: The diagnosis of peritonitis is usually clinical. 1.Chief complaint  Acute abdominal painpain 2.Peritoneal irritation  Anorexia and nausea,vomiting. 3. Fever exceed 38°C 4.Hypovolemia  Hypotensive 5.Hypothermia  severe sepsis  Septic shock Peritonitis generally represents a surgical emergency.surgical emergency

11. On abdominal examination of Peritonitis 1.Position/lighting/draping 2.InspectionInspection  Abd. Distended  Ileus paralyticus Abd. Distended  Ileus paralyticus  Keep their hips flexed to relieve the abdominal wall tension. 3.Palpation all four quadrantsPalpation Tenderness Rebound tendernessebound tenderness Diffuse Abdominal rigidity ("washboard abdomen")washboard abdomen Abdominal Guarding voluntary in response of the abdominaluarding Inflammatory mass. 4. Percussion Tenderness all four quadrants Percuss the liver span  free air 5.AuscultationAuscultation Paralytic Ileus  Hypoactive-to-absent bowel sounds.

12. 6. Digital rectal exam6. Digital rectal exam. Generalized peritonitis Tenderness in all direction Appendicitis Tenderness in the right diection  Female patients vaginal and bimanual examination Pelvic inflammatory disease

13. Mimic certain signs and symptoms of peritonitis. 1. Thoracic processes with diaphragmatic irritation (eg, empyema) 2. Extraperitoneal processes (eg, pyelonephritis, cystitis, acute urinary retention) 3. Abdominal wall processes (eg, rectus hematoma)

14. WORKUP Lab Studies: Blood test – leukocytosis (>11,000 cells/mL) – Blood chemistry may reveal dehydration and acidosis. Liver function tests if clinically indicated Serum electrolytes Renal function Amylase and lipase if pancreatitis is suspected Urinalysis (UA) is essential to rule out urinary tract diseases (eg, pyelonephritis, renal stone disease Aerobic and anaerobic blood cultures

15. Complications Hypovolaemia shock Hypovolaemia shock -Sequestration of fluid and electrolytesfluidelectrolytes -Decreased central venous pressurecentral venous pressure Electrolyte disturbances Acute renal failure Peritoneal abscess Abdominal Sepsis may develop  Septic shock Abdominal Sepsis

16. Radiographs Plain films of the abdomen : supine upright  Free air lateral decubitus positions Computed tomography scan Diagnosis cannot be established on clinical grounds Cannot be findings on abdominal plain films. Imaging Studies

17. Treatment INFORMED CONSENT General supportive measures : - Intravenous rehydrationntravenousrehydration - Correction of electrolye disturbances.electrolye disturbances Antibiotics - broad-spectrum antibioticsbroad-spectrum antibiotics The exception is spontaneous bacterial peritonitis, which does not benefit from surgery.spontaneous bacterial peritonitissurgery Surgery  Exl.laparotomy  full explorationlaparotomy  Lavage of the peritoneumperitoneum

18. Abscess in Pouch of Douglas (Cul de sac abscess ) (Pelvic abscesses) DRT : often are palpable as tender Anterior fullness and fluctuation Male  Rectovesical pouch Female  Recto-uterine pouch Treatment Draining these abscesses transvaginally or transrectally is best to avoid the transabdominal approach.

19. Mesenteric Lymphadenitis 1.Inflammation of the mesenteric lymph nodes. 2.Acute or chronic, depending on the causative agent. 3.Often difficult to differentiate from acute appendicitis. Pathophysiology Microbial agents are thought to gain access to the lymph nodes via the intestinal lymphatics.

20. Clinical Clinical features of associated organ involvement, such as enterocolitis or ileitis Abdominal pain - Often right lower quadrant (RLQ) but may be more diffuse Fever Diarrhea Malaise Anorexia Upper respiratory tract infection Nausea and vomiting

21. Physical Fever (38-38.5°C) RLQ tenderness - Mild, with or without rebound tenderness Rectal tenderness Rhinorrhea Hyperemic pharynx Associated peripheral lymphadenopathy (usually cervical) in 20% of cases

22. Causes Streptococcus beta-hemolytic, Staphylococcus species, Escherichia coli Streptococcus viridans, Mycobacterium tuberculosis, Viruses, such as coxsackieviruses, rubeola virus, and adenovirus Children with upper respiratory tract infection, has popularized a theory that swallowed pathogen-laden sputum may be the primary source of infection.

23. Lab Studies CBC count Leucocytosis exceeding 10,000/µL Urinalysis  exclude urinary tract infection. Stool cultures  Diarrheal symptoms Blood culture  Septicemia

24. Imaging Studies CT scanning In mesenteric adenitis:  lymph nodes to be larger  greater in number CT scanning is also important to exclude other differential diagnoses, especially acute appendicitis.

25.  Medical Care Hemodinamic support Broad-spectrum antibiotics To quickly identify patients who require surgical intervention  Surgical Care Signs of peritonitis Appendectomy