Complication of Acute Peritonitis & Tuberculous Peritonitis

1. Complications of acute peritonitis &
its management
TB peritonitis
Meconium Ileus
Dr. Kalpesh Patel

2. COMPLICATIONS OF PERITONITIS
• SYSTEMIC COMPLICATIONS
• ABDOMINAL COMPLICATIONS

3. SYSTEMIC COMPLICATIONS
• BACTERAEMIC/ENDOTOXIC SHOCK
• BRONCHOPNEUMONIA/RESPIRATORY
FAILURE
• RENAL FAILURE
• BONE MARROW SUPRESSION
• MULTISYSTEM FAILURE

4. ABDOMINAL COMPLICATIONS
• Adhesional small bowel obstruction
• Paralytic ileus
• Residual or recurrent abscesses
• Portal pyemia/liver abscess

5. Acute intestinal obstruction due to
peritoneal adhesions
• Central colicky abdominal pain
• On X-ray small bowel gas/fluid levels confined
to proximal intestine
• Peristalsis increased
• More common with localized peritonitis
• Essential to distinguish from paralytic ileus

6. Paralytic ileus
• Peristalsis reduced or completely absent
• Very little pain
• Gas filled loops with fluid levels are seen
distributed throughout the samll and large
intestine on X-ray

7. Abscesses

8. Signs and symptoms
• Vague and consist of nothing more than
lassitude, anorexia and failure to thrive
• Pyrexia (often low-grade), tachycardia,
leucocytosis and localised tenderness common
• Later on, a palpable mass may develop
• When palpable an intraperitoneal abscess should
be monitored by marking out its limitations on
the abdominal wall, and meticulous daily
examination

9. • Monitoring with repeated ultrasound / CT Scan
• In majority of cases with aid of antibiotic
treatment the abscess or mass becomes smaller
and smaller and finally undetectable.
• In others the abscess fails to resolve and
becomes larger, in that case it has to be drained.
• In many cases, by waiting for a few days the
abscess becomes adherent to the abdominal wall
so that it can be drained without opening the
general peritoneal cavity

10. • If facilities available USG or CT guided
drainage my avoid further operation
• Open drainage of an intraperitoneal collection
should be carried out by cautious blunt finger
exploration to minimise the risk of an
intestinal fistula.

11. PELVIC ABSCESS
• Commonest site of intraperitoneal abscess because
appendix is often pelvic in position and also the
fallopian tube are frequent sites of infection
• It can also occur as a sequel to any case of diffuse
peritonitis and is a common sequel of anastomotic
leakage following large bowel and rectal surgery.
• Pus can accumulate in this area without serious
constitutional disturbances and unless the patient is
examined carefully from day to day such abscesses
may attain considerable proportions before diagnosed.

12. • Charasteristic symptoms /signs
– Diarrhoea
– Passage of mucus in the stool
– (Passage of mucus, occuring for the first time in a
patient who has or is recovering from peritonitis is
pathognomic of pelvic abscess)
– Rectal examination reveals a bulging of the
anterior rectal wall which when the abscess is
ripe, becomes soft / cystic

13. • If left untreated theses abscesses bursts into
the rectum after which the patient nearly
always recovers rapidly
• Abscess should be drained deliberately
• In women vaginal drainage through the
posterior fornix is possible
• In other cases where the abscess is definitely
pointing in to the rectum, rectal drainage
done

14. • If diagnosis not confirmed, USG / CT scan or
aspirating needle inserted through rectum or
abdominal wall into the swelling to confirm
diagnosis
• Laparotomy is almost never necessary
• Rectal drainage is preferable to suprapubic
drainage (risk of exposing the general peritoneal
cavity to infection)
• Drainage tube can also be inserted through
rectum/vagina under radiological guidance

19. TUBERCULOUS PERITONITIS
• Acute
• Chronic
• Varieties of tuberculous peritonitis
– Ascitic form
– Encysted form
– Fibrous form
– Purulent form

20. Acute tuberculous peritonitis
• Acute onset, resembles acute peritonitis
leading to urgent laparotomy
• Straw colour fluid escapes and tubercules are
seen scattered over the peritoneum and
greater omentum
• Early tubercles are greyish and transluscent
eventually undergo caseation and appear
white or yellow and are then less difficult to
distinguish from malignancy

21. • Occasionally appear like patchy fat necrosis
• On opening the abdomen and finding
tuberculous peritonitis the fluid is evacuated and
some being retained for bacteriological studies
• A portion of diseases omentum is removed for
histological confirmation of the diagnosis and the
wound closed without drainage
• Sometimes even if acute abdominal symptoms
arise, presence of ascites make diagnosis evident

22. Chronic tuberculous peritonitis
• Presents with
– abdominal pain
– Fever
– Loss of weight
– Ascites
– Night sweats
– Abdominal mass

23. Origin of the infection
• Tuberculous mesentric lymph nodes
• Tuberculosis of the ileocaecal region
• A tuberculous pyosalpinx
• Blood-borne infection from pulmonary
tuberculosis usually the “miliary” but
occasionally the “cavitating” form

24. Ascitic form
• Peritoneum is studded with tubercules and the
pritoneal cavity becomes filled with pale, straw
coloured fluid.
• Insidious onset
• Loss of energy
• Facial pallor
• Loss of weight
• Enlargement of abdomen
• Usually NO PAIN

25. • Abdominal discomfort associated with alternate
diarrhoea/constipation
• Dilated veins along side lower abdominal wall
• Shifting dullness
• In male child congenital hydrocele appear
sometime
• Umbilical hernia occur due to increased
intraabdominal pressure
• On palpation, transverse solid mass may
occasionally demonstrated (rolled-up abdomen)

26. • Diagnosis is seldom difficult when it occurs in
acute form or when it first appears in an adult
in which case it has to be differentiated from
other forms of ascites especially from
malignant secondary deposits
• In child positive mantoux test with ascites
strongly suggests and negative test is good
evidance against tuberculosis (in adults this
test has little value)

27. • Laparoscopy is useful by allowing inspection of
the peritoneal cavity, where the appearance is
diagnositic, areas of caseation can be biopsied for
histology and microbiological studies
• Also look at the tuberculous disease elsewhere
especially tuberculous salpingitis in females
• Chest x ray is must before
laparoscopy/laparotomy

28. Ascitic fluid
• Pale yellow
• Usually clear
• Rich in lymphocytes
• Specific gravity usually high 1.020 or higher
• Even after centrifugation, rarely M.
tuberculosis found, but its presence can be
demonstrated by culture or by guinea-pig
inoculation

29. • Start AKT
• Patient can return home if general condition
good

30. Encysted form
• Encysted = loculated
• Similar to ascitic form but one part of the abdominal
cavity along is involved
• Localised intraabdominal swelling, so gives rise to
difficulty in diagnosis
• D/D in female is ovarian cyst, in child mesentric cyst
• Laparotomy is performed and if an encapsulated
collection found then it is evacuated and the abdomen
is closed
• AKT
• Complication – late intestinal obstruction

31. Fibrous form
• Fibrous = plastic
• Characterised by production of widespread
adhesions, which cause coils of intestine,
especially ileum, to become matted together
and distended
• These distended coils act as a “blind loop” and
give rise to steatorrhoea, wasting and attacks
of abdominal pain

32. • On examination, adherent intestine with
omentum attached together with the thickened
mesentry may give rise to a palpable
swelling/swellings
• Subacute/ acute intestinal obstruction
• Division of bands to relieve obstruction
• If the adhesions are accompanied by fibrous
strictures of the ileum as well it is best to excise
the affected bowel, provided not too much of the
small intestine needs to be sacrificed
• AKT after surgery for rapid cure

33. Purulant form
• Rare
• When secondary to tuberculous salpingitis
• Amidst a mass of adherent intestines and
omentum, tuberculous pus is present
• Sizeable cold abscesses often form and point on
the surface commonly near umbilicus, or burst
into bowel
• Surgical treatment is necessary for the
evacuation of cold abscesses and possibly for
intestinal obstruction

34. • If faecal fistula forms then it may persists
because of distal intestinal obstruction
• Closure of the fistula must therefore be
combined with some form of anastomosis
between the segment of intestine above the
fistula and an unobstructed area below.
• Prognosis of this variety of tuberculous
peritonitis is relatively poor

35. MECONIUM ILEUS
• This is neonatal manifestation of cystic fibrosis
• Meconium is normally kept fluid by action of
pancreatic enzymes.
• The terminal ileum becomes filled with
meconium and viscid mucus resulting in
progressive inspissation in utero and neonatal
obstruction.
• Inspissated meconium may be palpated as
rubbery swelling

36. • X ray may reveal a distended small intestine with
mottling. Fluid levels are usually not seen no
abrupt cut-off like ileal atresia
• Autosomal recessive genetic defect- family
history may be present
• Absence of trypsin from stool or bile
• Concentration of sodium chloride in sweat
greater than 80 mmol/lit
• Negative immunoreactive blood trypsin
estimation

37. • 40% cases associated with volvulus neonatorium,
atresia or meconium peritonitis (Dickson)
• If acute then immediate laparotomy
• Else gastrograffin or mypaque enema may be given to
confirm diagnosis
• The radioopaque fluid will pass easily to the ileum
where it may disperse the obstructing meconium and
relieve the condition owing to its high osmolarity and
detergent action
• As the instilled solution is hypertonic, rapid loss of fluid
in bowel lumen must be corrected by iv fluids

38. • If conservative management fails, laparotomy done
• May be confused with hirschprung’s disease affecting
whole colon
• Standart treatment is resection of the most dilated
segment with an end to side anastomosis of the colon
to the ileum.
• The distal opening is formed into an ileostomy through
which the meconium may be irrigated post-operatively
(Bishop-koop operation)
• The ileostomy becomes a mucus fistula which usually
requires subsequent closure.