Peritonium

Complications of peritonitis

General complications: MODS Local complications: paralytic ileus. Residual intra-peritoneal abscesses. Portal pyaemia/liver abscess Adhesions.

Residual intra-peritoneal abscesses:

Clinically:
Suggestive story: Main complain: General symptoms of abscess: Symptoms of local irritation:

Pelvic abscess:

The pelvis is the commonest site of intraperitoneal abscess. Causes : The appendix and fallopian tubes are frequent sites of infection. Also, it could be a sequel to any diffuse peritonitis. Anastomotic leakage in colo-rectal surgery.

Clinically:

Pus accumulate in the pelvis without serious constitutional disturbance and may attain considerable proportion before being recognized. The most characteristic symptom is diarrhea and passage of mucus in the stool. Abdominal exam: tenderness or mass Rectal examination reveals bulging of the anterior wall of the rectum.

Investigations:

Blood tests Any doubt about the diagnosis it can be confirmed by U/S scan or CT scan.


US and/or CT Scan

Course of the disease

when the abscess ripe it become soft and cystic and may burst into the rectum after which the patient recovers rapidly. The abscess must be drained through the rectum and in female it could be drained via the posterior fornix of vagina. A drainage tube can be inserted percutaneously or through the rectum under US/ CT scan guide. Laparotomy is usually unnecessary.

Subphrenic Abscess:

Anatomy:
The subphrenic region lie between diaphragm above and the transverse colon below and further subdivided by the liver and the falciform ligament into:

Anatomy

left subphrenic, left subhepatic spaces, right subphrenic, right subhepatic.

Morrison pouch

It is a common site for abscess collection following: cholecystitis, perforated ulcer, upper abdominal surgery.



Clinically:"Pus somewhere, pus nowhere = pus under Diaphragm".

Clinically:

Suggestive story: Main complain: General symptoms of abscess: Symptoms of local irritation:

Symptoms:

History of an infected focus in the peritoneal cavity dealt with by surgery or without surgery and the condition improve temporarily. after days to weeks toxemia reappear with sweating, fever, weight loss. Epigastric pain and fullness with pain referred to the shoulder Persistent hiccough.

Exam

Swinging pyrexia, Tenderness, rigidity or a mass, Hepatomegaly !!? Also chest might be involved and atelectasis, pleural effusion and empyema.

Investigations:

Blood tests: WBC = leucocytosis. CRP

Imaging: A plain X ray.

Plain X ray findings

US/ CT scan

Treatment:

It depends on the availability of facilities. Supportive measures are necessary: Fluid resuscitation, Correction of any electrolyte disturbance, Analgesic, Antibiotics coverage.

Treatment: Interventional Radiology

Percut. drainage tube inserted under US or CT scan. The same tube can be used to instill antibiotics solution or for irrigation.

Operative Intervention = Surgery

Swelling which can be detected in the sub-costal or in the loin region= (extra-peritoneal approach).

If no swelling is detected then the subphrenic spaces are explored by anterior approach (intraperitoneal).

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