ACUTEABSCESSEPERITONITIS

AnatomyandPhysiologyofthePeritonealCavityTheperitonealcavityiscoveredbyasinglelayerofmesothelialcellsonconnectivetissue,includingcollagen,elasticfibers,macrophages,andfatcells.AnatomyandPhysiologyofthePeritonealCavityTheparietalperitoneum,whichcoverstheabdominalcavity,includingtheanteriorabdominalwall,diaphragm,andpelvis,isimmediatelyadjacenttoandreinforcedbythetransversalisfascia.Thevisceralperitoneumcoversalltheintraperitonealviscera,creatingacompletelyenclosedcavityexceptfortheopenendsofthefallopiantubes.Theparietalperitoneumisinnervatedbybothsomaticandvisceralafferentnerves.Theperitoneumoftheanteriorabdominalwallistheareamostsensitivetostimuli,andthepelvicperitoneumisthearealeastsensitive.AnatomyandPhysiologyofthePeritonealCavityPatientswithabdominalpainmayshowtendernesstopalpationoftheabdomen;andifperitonealirritationexists,theyhavereboundtenderness.Localizedinflammationoftheanteriorparietalperitoneummayleadtovoluntarymuscleguarding.Thevisceralperitoneumisrelativelyinsensitiveandreceivesafferentinnervationonlyfromtheautonomicnervoussystem.Stimulifromthevisceralperitoneumareoftenpoorlylocalizedandareperceivedasdullorintermittentcramping.

AcuteGeneralizedPeritonitis

1.Definition:Acuteabscessperitonitispervadedallperitonealcavityiscalledacutegeneralizedperitonitis(AGP).Peritonitis,classifiedasprimaryorspontaneousperitonitisandsecondaryperitonitis.

2.Etiology

Secondarydefuseperitonitis(themostcommon)①Acuteperforationofgastricandduodenalulcer②Gallbladderperforationfollowingacutecholecystitis③Traumaticruptureofintestineandbladder④Severeacuteappendicitisandpancreatitis⑤Anastomoticleakagefollowingoperation

Primarydefuseperitonitis1.Throughbloodroute2.Upwardinfectionfromfemaleoviduct3.Directspreadingfromurinarytractinfection4.Conditionalbacteriainfectionwhenthefunctionofintestinalmembranebarrierdecrease.OutcomeofacutedefuseperitonitisTwofactorsdecidetheoutcomeofacutedefuseperitonitis:Oneistheabilityofbody’sdefensesystemAnotherisbacteria’squality,numberandduration.Ifthebody’sdefensesystem>bacteria’sinvasionability-------absorbedorlocalizedIfthedefensesystem<bacteria’sinvasionability-------infectiveshock,MOF,death

3.FeverandtachycardiaTheresultofreactiontobothinfectiveandnon-infectiveinflammation.Sometimeslowertemperaturemeansthatpatient’sconditionsispoorortheinfectionhasbecomeworse.

4.InfectiveshockmanifestationPalecomplexion,coolextremities,weakpulse,lowerbloodpressure,andlossofconsciousness.

AccessoryExaminationX-ray:Air-fluidlevelindilatedloopsofsmallbowelcanbefound.Freeairunderthediaphragmindicateperforationofgastro-intestinaltract.Ultrasound:Usedtofindfluidinsideabdominalcavity,andhelptolocalizepositionofaspiration.CT:Usedtofindlesionsofpancreas.Abdominalaspiration:samewiththeprevious.Rectumfingerexamination:Tofindabscessinpelviccavity.

Treatment

3)CorrecttheunbalanceofwaterandelectrolytesGastricsuctionandexudationoffluidinsidetheintestinemaycausethelossofbodyfluidandelectrolytes4)Applicationofantibiotics:Trytouseappropriateandsensitiveantibiotics5)Nutritionsupport6)Useofsedativedrugandoxygen

2.Operationtreatment

Indications:1)Localsignsgetworseafterconservativetherapy2)Severeperforationofstomachorgallbladder,orstrangulatedintestinalobstruction3)Largeamountofintra-abdominalfluidandobvioustoxicsymptoms4)CauseisnotclearandnolocalizingtendencyMethodsofoperation1)managementofprimarylesion2)cleaningoftheabdominalcavity3)drainageRERITONEALABSCESSESIntraperitonealabscessesarecommoncomplicationsofperitonitisandmayalsofollowmajorabdominaloperationswithoutestablishedperitonitis.Increatesurgery,smallsbclinicalleakagefollowingbilliardorpancreaticsurgery,smallsubclinicalleaksfromintestinalanastomoses,collectionsofblood,andcontaminatedperitonealfluidalltendtosettleindependentpartsoftheabdomen,andabscessformationmaybeasequel.Detritus,foreignmaterial,andnecrotictissuearemoreimportantfactorsInabscessformationthanbacteriaalone.Thecommonsitesareunderthediaphragm,alongtheundersurfaceoftherightlobeoftheliver,alongthelateralgutters,andinthepelvis.Inabout15%ofcases,multipleabscessesarepresent.Persistentfeveristheclassicsignofadevelopingintraperitonelabscess.Asthefeverfollowingamajorperitonealinsultsubsides,insteadofreturningtonormalitpersistsandgraduallyrisesinastepwisefashion.Aprogressivelyrisingtemperaturethatdoesnotreturntonormaloveraperiodofseveraldaysistypicalofabscessformation.Withthreatenedperforationofextensionintoadjacentstructures,chills,fever,andhypertensionmaydevelop.30subhepaticabscessesGeneralconsiderationsSubphrenicandsubhepaticabscessesposespecialproblemsindiagnosisandtreatment.Almosthalfofallintroabdominalabscessesoccurinthesesites.Althoughthereismuchargumentabouttheanatomicnatureofthesubphrenicspaces,fromapracticalpointofviewabscessesmayoccurinanyoneof6areas.ClinicalFindingsandDiagnosisTherecognitionofsubphrenicabscessanditspreciselocalizationrequireacombinationofrepeatedphysicalandx-rayexaminationsandscanning.Unexplainedfeverafterperitonealinfectionofanytype-withoutevidentwoundinfectionorperitonealabscessesshouldimmediatelyarousesuspicionofasubphrenicabscess.Alltoooftensubphrenicabscessesdevelopinsidiously,butonoccasintheremaybepainandtendernessanteriorlyorposterorlyontheaffectedside.Motionofthediaphragmontheaffectedsideisrestricted,andineffusion.Inadvancedcases,theremaybewideningoftheintercostalspaces,withfull-nessandpalpableedema.TreatmentThetreatmentofsubphrenicabscessisdrainage,eitherbypercutaneousaspirationorsurgically.Posteriorabscessesmaybedrainedthroughthebedofthe12thribontheaffectedside.Theincisionmustbetransverseandnotparalleltothebedoftheribtoavoidenteringthepleura.Somesurgeonsconsideralateralextraperitonealapproachtobesimplerandmoredirectthantheposteriorroute.Anteriorly,asubcostalincisionismadeandcarriedthroughthetransversalisfascia.Theabscesscavityislocatedbybluntdissectionanddrainedwithoutenteringtheperitonealcavity.MidabdominalAbscessTheseabscessesmayoccuranywherewithintheabdominalcavityfromjustbelowthetransversecolontothepelvis.Therightandleftguttersarethemostcommonsites,butandabscessmayformwhereveracollectionofforeignmaterialorbloodhasoccurred.Midabdominalabscessesareparticularlydifficulttoidentify.Knowingthecauseoftheoriginalperitonealdiseaseisofconsiderablehelpinidentifyingthepresenceofanabscess-divertculitisbeingmorelikelyofanabscess-diverticulitisbeingmorelikelytoinvolvetheleftgutterandappendicitistherightgutter.Perforationsfromregionalenteritisorulcerativecolitismayresultincentrallyplacedabscesses.Aprogressivelyenlargingabdominalmassisanindicationfordrainage.Frequentlythiswillbedelayedfor2-3daysuntilthemassappearstobewelllocalizedandinclosecontactwiththeabdominalwall.Onotheroccasions,withdeep-seatedmidabdominalabscesses,thepatientmaybecomesoill,withhighfever,chills,andhypotension,thatlaparotomybecomesessentialandhypotension,thatlaparotomybecomesessentialevenwithoutdeinitivelocalizationoftheabscess.Opentransabdominaldrainageofanintraperitonealabscesscanbesafelydoneundercoverofantibioticsandperitonealirrigation.Itisabsolutelyessential.PelvicAbscessApelvicabscess