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Forth stage
Surgery
Lec-2
.د
موفق مزعل
1/1/2014
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.
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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.
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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:
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".
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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
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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).