PERTONITIS Investigations

INVESTIGATIONS

The  minimum  investigations required to  establish  an  accurate

diagnosis are:

*  Plain X-ray abdomen to detect

   -  Air under the diaphragm (perforation)

   -  Air fluid levels (intestinal obstruction)

   -  Gallbladder or urinary stones

   -  Evidence of fluid in peritoneal cavity

*  Blood examination

   -  Raised total leucocytes

   -  Raised ESR

   -  Electrolytes examination

*  Urine  examination for R.B.C. and pus cells in case  of  renal

   origin of pain

*  Peritoneal tap in doubtful cases.

3.4 NEW IMAGING

CT  Scanning and ultrasound scan provide information  on  changes

related to the diseased organ causing the acute abdomen  syndrome

and  also the changes related to peritonitis and the  sequlae  of

abdominal   abcess   and  its   location   (parateolic,   pelvic,

subdiaphragmatic). Fig. 21.4

Colour  Doppler ultrasonography can give accurate information  on

the  state  of  the  blood vessals  of  the  abdomen,  aneurysms,

thrombism arterio-venous fistulas can be detected.

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Peritonitis Causes

-  Acute  peritoneal  inflammation is most often secondary  to  a

   disease condition of the abdominal viscera or contamination of

   the peritoneal cavity through a penetrating wound.

-  Many conditions can lead to peritonitis and are:

   *  Perforation of peptic ulcer

   *  Acute inflammation of the vermiform appendix

   *  Gangrene of the bowel

   *  Acute inflammation of the gallbladder

   *  Post-operative intestinal leak into the peritoneal cavity

   *  Infection along the fallopian tubes in a young female

   *  Septicaemia

3.2 CLINICAL PICTURE

The most prominent feature of peritonitis is:

-  Pain in abdomen.  It starts from the time of contamination and

   it  is  a diffuse generalised continued burning  pain  in  the

   abdomen.

-  Intestinal  activity comes to a stand still and distension  of

   the abdomen is observed.

-  Patient also shows signs of dehydration due to starvation  the

   intestines, vomiting fluid loss into the peritoneal cavity and

   submesothelial oedema.

-  The  inflammatory response is very severe in cases of  colonic

   perforation  when  compared  with  small  bowel's  perforation

   because of high bacterial content in the colon.

-  The patient gives the appearance of toxaemia.

Local  examination  of the abdomen shows a tense  tender  abdomen

with  a  certain degree of guadrding and later  rigidity  of  the

abdominal muscles.

Respiratory movement is rapid and the abdomen is held immobile.

Loss  of  fluid  and  electrolytes  into  the  peritoneal  cavity

produces  hypovolaemia and shock.  There may also be evidence  of

septicaemia.

If  untreated, the shock like state can produce renal  shut  down

Fig.FC.1.

Other  signs  consist of raised temperature 40-42oC and  a  rapid

thready pulse.

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PERITONITIS Pathology

ACUTE PERITONITIS

3.1 PATHOLOGY

Contamination of the peritoneum with intestinal content  produces

both chemical and becterial peritonitis.

The  inflammatory response consistes of dilatation of  the  small

vessels   of   the   peritoneum  and   an   increased   capillary

permeability.

-  There  is increased fluid exudation both into  the  peritoneal

   cavity and in the submesothelial space (third space) producing

   oedema and thickening of the peritoneum.

-  The exudate contain phagocytes and fibrin

  

-  This fibrin content tends to cause adhesion between  adjoining

   inflammed peritoneal surfaces.

-  The  peritoneum loses its shine and may even be  roughened  on

   the surface.

-  The sequestration of fluid in the third space causes a  series

   of body changes that can threaten the life of the patient.

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Pain Acute Abdomen

PAIN

Most  abdominal pains originate in stretch receptors  present  in

the  wall of hollow organs (intestine, ureter and biliary  tract)

or  in  the  capsules  of solid organs  like  liver,  spleen  and

kidney.   Pain  in  a hollow system is usually  colicky  with  an

accompanying vomitting.

Pain in solid organs is usually of a dull aching nature.

There  is a third variety of pain originating from the  receptors

present in the inflammed peritoneium.

This pain is very vague, of a general distribution and burning in

nature  and on involvement of the parietal peritoneum it  becomes

more accurately localised.

2.5 ISCHAEMIA AND PAIN

Thrombosis or embolism of the main blood vessels of the intestine

produce pain of the corresponding portion of the bowel.

This  may  occur along the distribution of  a  superior  mesentry

artery  or  inferior  mesenteric artery producing  a  picture  of

severe pain of the small or large bowel and a profound shock like

state.

Ischaemia  of  the  bowel  can  also  be  produced  in  cases  of

obstructions  of the bowel left untreated for long period and  in

stragulated hernia

2.6 DIAGNOSIS

With  experience  and modern imaging techniques (see 3.4)  it  is

possible  to arrive at an early accurate diagnosis and to plan  a

surgical intervention in most cases.

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Peritonitis Acute Abdomen

ACUTE ABDOMEN

2.1  Presentation

In cases of severe pain in the abdomen and the presence of  signs

of shock, it may not be possible to come to an accurate diagnosis

on  presentation  at  times  the  abdominal  conditions   produce

symptoms  and  signs  which  suggest  a  catastrophy  inside  the

abdomen.

*  The coexistence of severe abdominal signs and symptoms in  the

   absence  of  an  accurate diagnosis is referred  to  as  acute

   abdomen. Fig. 21.2

An acute abdomen can be caused by a number of disorders.

2.2 Pathology

The  prominant symptoms are of pain, vomiting and  altered  bowel

functions and can be because of

-  either inflammatory peritonitis

-  obstructive  (obstruction  of  any hollow  tubes  of  the  GIT

   urinary and bile tracts)

-  they  can also be of vascular origin  leading  to ischaemia of

   the  bowel wall

Prominent causes of peritonitis are inflammatory disorders of the

appendix, gall bladder and perforation of a peptic ulcer.

2.3 Clinical

The  clinical  conditions wihich can produce a picture  of  acute

abdomen are listed below and sites indicated in Fig. 21.3.

*  Peptic perforation

*  Perforation of the bowel (Enteric Fever)

*  Intestinal obstruction

*  Obstructions and inflammation of the biliary tract

*  Pancreatitis

*  Inflammations of the female genital tract

*  Obstructions  and  inflammation  of the  upper  urinary  tract

   (Renal/Colic)

*  Mesenteric Vascular Thrombosis and Embolism

Obstructions  of  a hollow system can produce severe pain  and  a

picture  of  acute  abdomen,  and are met with  in  the  case  of

obstructions of the intestinal and upper urinary tract or biliary

tracts, the pain in these conditions however tends to be  colicky

in nature with periods free from pain in-between attacks.

All  these  conditions  are kept in mind  when  investigating  an

"acute abdomen" in the abdomen.

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