1、Anatomy and Physiology of the Peritoneal CavityThe peritoneal cavity is covered by a single layer of mesothelial cells on connective tissue,including collagen,elastic fibers,macrophages,and fat cells.1Anatomy and Physiology of the Peritoneal Cavity The parietal peritoneum,which covers the abdominal
2、cavity,including the anterior abdominal wall,diaphragm,and pelvis,is immediately adjacent to and reinforced by the transversalis fascia.The visceral peritoneum covers all the intraperitoneal viscera,creating a completely enclosed cavity except for the open ends of the fallopian tubes.The parietal pe
3、ritoneum is innervated by both somatic and visceral afferent nerves.The peritoneum of the anterior abdominal wall is the area most sensitive to stimuli,and the pelvic peritoneum is the area least sensitive.2Anatomy and Physiology of the Peritoneal Cavity Patients with abdominal pain may show tendern
4、ess to palpation of the abdomen;and if peritoneal irritation exists,they have rebound tenderness.Localized inflammation of the anterior parietal peritoneum may lead to voluntary muscle guarding.The visceral peritoneum is relatively insensitive and receives afferent innervation only from the autonomi
5、c nervous system.Stimuli from the visceral peritoneum are often poorly localized and are perceived as dull or intermittent cramping.3Anatomy and Physiology of the Peritoneal Cavity The visceral afferent nerves have no receptors to mediate pain and temperature but do respond to distention,traction,an
6、d pressure.The biliary tract and mesentery have greater innervation than the small intestine.Thus,pain from the gallbladder and common duct is more accurately localized than that from the small intestine.4 Acute Generalized Peritonitis 1.Definition:Acute abscess peritonitis pervaded all peritoneal c
7、avity is called acute generalized peritonitis(AGP).Peritonitis,classified as primary or spontaneous peritonitis and secondary peritonitis.2.Etiology Secondary defuse peritonitis(the most common)Acute perforation of gastric and duodenal ulcer Gall bladder perforation following acute cholecystitis Tra
8、umatic rupture of intestine and bladder Severe acute appendicitis and pancreatitis Anastomotic leakage following operation 5Primary defuse peritonitis1.Through blood route2.Upward infection from female oviduct3.Direct spreading from urinary tract infection4.Conditional bacteria infection when the fu
9、nction of intestinal membrane barrier decrease.67 Outcome of acute defuse peritonitis Two factors decide the outcome of acute defuse peritonitis:One is the ability of bodys defense system Another is bacterias quality,number and duration.If the bodys defense systembacterias invasion ability-absorbed
10、or localized If the defense systembacterias invasion ability-infective shock,MOF,death8 Clinical findings 1.Abdominal pain The main complaint is abdominal,which is severe and consistent,generally spreading from the lesion point to the whole abdomen.Patients breath can be obviously limited.2.Nausea a
11、nd vomiting Because stimulation to peritoneum,the content inside the stomach and intestine may be vomited out reflectively.9 3.Fever and tachycardia The result of reaction to both infective and non-infective inflammation.Sometimes lower temperature means that patients conditions is poor or the infec
12、tion has become worse.4.Infective shock manifestation Pale complexion,cool extremities,weak pulse,lower blood pressure,and loss of consciousness.10 5.Abdominal signs Obvious distension and disappearance of abdominal respiration can be noticed.Tenderness,muscular spasm,and rebound pain are typical si
13、gns of acute defuse peritonitis,If the peritonitis is caused by gastric or gallbladder perforation,muscular rigidity and absence of peristalsis can be found.11 Accessory Examination X-ray:Air-fluid level in dilated loops of small bowel can be found.Free air under the diaphragm indicate perforation o
14、f gastro-intestinal tract.Ultrasound:Used to find fluid inside abdominal cavity,and help to localize position of aspiration.CT:Used to find lesions of pancreas.Abdominal aspiration:same with the previous.Rectum finger examination:To find abscess in pelvic cavity.12 Diagnosis Based on clinical findin
15、gs and accessory examinations Treatment 1.Non-operative Indication:1)slight peritonitis 2)local signs have got better conservative treatment Methods 1)Half lying position:to let the inflammatory fluid inside abdominal 2)Fasting and gastro-intestinal suction:To avoid the content inside the digestive
16、tract flowing into abdominal cavity,and alleviate abdominal distension13 Treatment 3)Correct the unbalance of water and electrolytes Gastric suction and exudation of fluid inside the intestine may cause the loss of body fluid and electrolytes4)Application of antibiotics:Try to use appropriate and se
17、nsitive antibiotics5)Nutrition support6)Use of sedative drug and oxygen14 2.Operation treatment Indications:1)Local signs get worse after conservative therapy2)Severe perforation of stomach or gall bladder,or strangulated intestinal obstruction3)Large amount of intra-abdominal fluid and obvious toxi
18、c symptoms4)Cause is not clear and no localizing tendency Methods of operation1)management of primary lesion2)cleaning of the abdominal cavity3)drainage15RERITONEAL ABSCESSES Intraperitoneal abscesses are common complications of peritonitis and may also follow major abdominal operations without esta
19、blished peritonitis.Increate surgery,small sbclinical leakage following billiard or pancreatic surgery,small subclinical leaks from intestinal anastomoses,collections of blood,and contaminated peritoneal fluid all tend to settle in dependent parts of the abdomen,and abscess formation may be a sequel
20、.Detritus,foreign material,and necrotic tissue are more important factors In abscess formation than bacteria alone.16 The common sites are under the diaphragm,along the undersurface of the right lobe of the liver,along the lateral gutters,and in the pelvis.In about 15%of cases,multiple abscesses are
21、 present.Persistent fever is the classic sign of a developing intraperitonel abscess.As the fever following a major peritoneal insult subsides,instead of returning to normal it persists and gradually rises in a stepwise fashion.A progressively rising temperature that does not return to normal over a
22、 period of several days is typical of abscess formation.With threatened perforation of extension into adjacent structures,chills,fever,and hypertension may develop.3017subhepatic abscessesGeneral considerations Subphrenic and subhepatic abscesses pose special problems in diagnosis and treatment.Almo
23、st half of all introabdominal abscesses occur in these sites.Although there is much argument about the anatomic nature of the subphrenic spaces,from a practical point of view abscesses may occur in any one of 6 areas.1819Clinical Findings and Diagnosis The recognition of subphrenic abscess and its p
24、recise localization require a combination of repeated physical and x-ray examinations and scanning.Unexplained fever after peritoneal infection of any type-without evident wound infection or peritoneal abscesses should immediately arouse suspicion of a subphrenic abscess.20 All too often subphrenic
25、abscesses develop insidiously,but on occasin there may be pain and tenderness anteriorly or posterorly on the affected side.Motion of the diaphragm on the affected side is restricted,and in effusion.In advanced cases,there may be widening of the intercostal spaces,with full-ness and palpable edema.2
26、1 X-ray examination is of the greatest importance.Demonstration of an air-fluid level below the diaphragm with a pleural effusion above it is diagnostic.Unfortunately,this represents an advanced abscess and more commonly the only findings on plain films are fixation and elevation of the diaphragm an
27、d a pleural effusion on the involved side.Lateral films may be of great help in localizing the abscess to an anterior or posterior position.In most cases,CT or ultrasound scans are diagnostic.22Treatment The treatment of subphrenic abscess is drainage,either by percutaneous aspiration or surgically.
28、Posterior abscesses may be drained through the bed of the 12th rib on the affected side.The incision must be transverse and not parallel to the bed of the rib to avoid entering the pleura.Some surgeons consider a lateral extraperitoneal approach to be simpler and more direct than the posterior route
29、.Anteriorly,a subcostal incision is made and carried through the transversalis fascia.The abscess cavity is located by blunt dissection and drained without entering the peritoneal cavity.23Midabdominal Abscess These abscesses may occur anywhere within the abdominal cavity from just below the transve
30、rse colon to the pelvis.The right and left gutters are the most common sites,but and abscess may form wherever a collection of foreign material or blood has occurred.Midabdominal abscesses are particularly difficult to identify.Knowing the cause of the original peritoneal disease is of considerable
31、help in identifying the presence of an abscess-divertculitis being more likely of an abscess-diverticulitis being more likely to involve the left gutter and appendicitis the right gutter.Perforations from regional enteritis or ulcerative colitis may result in centrally placed abscesses.24 Abscesses
32、develop at the root of the mesentery between loops of bowel and are protected from the anterior abdominal wall by the mesentery of the small intestine.Repeated careful and gentle examination of the abdomen,feeling for a developing mass,may be the first clue to a midabdominal abscess.Plain x-ray film
33、s of the abdomen may be helpful:A mass shadow may be identified,collections of gas or air may be seen,or persistently dilated irregular loops of bowel may indicate the preformed based on the degree of clinical suspicion.25 A progressively enlarging abdominal mass is an indication for drainage.Freque
34、ntly this will be delayed for 2-3 days until the mass appears to be well localized and in close contact with the abdominal wall.On other occasions,with deep-seated midabdominal abscesses,the patient may become so ill,with high fever,chills,and hypotension,that laparotomy becomes essential and hypote
35、nsion,that laparotomy becomes essential even without deinitive localization of the abscess.Open transabdominal drainage of an intraperitoneal abscess can be safely done under cover of antibiotics and peritoneal irrigation.It is absolutely essential.26Pelvic Abscess A pelvic abscess is usually readil
36、y recognized.In addition to fever,there may be lower abdominal discomfort tenderness and a fullness in the pouch of Douglas.With a very high pelivc abscess,rectal examination may initially be negative,so that repeated daily examinations become necessary.This is essential if the patient appears serio
37、usly ill,with high fever and pulse rate.27Pelvic Abscess Pelvic abscesses may subside spontaneously or progress to a large,tense slightly fluctuant mass protruding into the anterior rectal wall or vagina.Diarrhea is an indication that the abscess is mature.Pelvic abscesses may be drained through the
38、 rectum or vagina.Needle aspiration before introducing scissors or a clamp is a wise precaution in most cases.Drains should be left in the cavity but may be removed in several days if the clinical response is good.In general,drainage of pelvic abscess provides a very gratifying result with rapid recovery.28
