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GIS-K-24
PeritonitisMesenteric Lymphadenitis
Syahbuddin Harahap
Division of Digestive Surgery
r ur ryFaculty of Medicine
University of North Sumatera
Adam Malik Hospital
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Subdivisions :
The greater sac
The lesser sac (or omental )two "omenta":
1. The lesser omentum(orgastrohepatic)
.
o
(orgastrocolic)
like an apron, protective
layer.
Greater sac and lesser sacConnected by the epiploic foramen
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PeritonitisInflammation of the serosal membrane that lines theabdominal cavity and the organs contained thereinoften as a result of infection.
Peritonitis are classified as :1. Primary peritonitis2. Secondary peritonitis
3. Tertiary peritonitis
Peritonitis are usually divided into
1. Generalized peritonitis2. Localized peritonitis
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Peritonitis is often caused by:
- Perforation hollow viscus
Etiology
- (blood,pancreatic/gastic juice)
- Infected / Inflammation
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Primary peritonitis
No pathologic process in a visceral organ
Via hematogenous
ChildrenTranslocation of bacteria across the gut wall
Ascites
n es n o s ruc onAscending infection in female
Gonorrhea
Chlamydial infection
spreads into the abdominal cavity.
Systemic infections tuberculosis
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Secondary peritonitis
Related to a pathologic process in a visceral organ
hollow viscus- Perforation- Infected
most common cause of eritonitis erforations of :
- the stomach
- intestine
- gallbladder
- appendix
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Tertiary peritonitis
Persistent or recurrent infection after adequate initial therapy
Anastomotic leakage
Abscess with or without fistulization.
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Diagnosis and investigations
Based primarily on clinical grounds
No further investigation should delay surgery
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Clinical:
The diagnosis of peritonitis is usually clinical.
1. Chief complaintAcute abdominal pain
2. Peritoneal irritation Anorexia and nausea ,vomiting.
.
4. Hypovolemia Hypotensive
5. Hypothermia severe sepsis Septic shock
Peritonitis generally represents a surgical emergency.
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On abdominal examination of Peritonitis
1. Position/lighting/draping
2. InspectionAbd. Distended Ileus paralyticusKeep their hips flexed to relieve the abdominal wall tension.
3. Palpation all four quadrantsTenderness
e oun en erness
Diffuse Abdominal rigidity ("washboard abdomen")Abdominal Guarding voluntary in response of the abdominalInflammatory mass.
4.Percussion
Tenderness all four quadrantsPercuss the liver span free air
5. AuscultationParalytic Ileus Hypoactive-to-absent bowel sounds.
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6 . Digital rectal exam .Generalized peritonitis
Tenderness in all direction
AppendicitisTenderness in the right diection
Female patients vaginal and bimanual examinationPelvic inflammatory disease
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Mimic certain signs and symptoms of peritonitis.
1. Thoracic processes with diaphragmatic irritation(eg, empyema)
2. Extraperitoneal processes(eg, pyelonephritis, cystitis, acute urinary retention)
3. Abdominal wall processes(eg, rectus hematoma)
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WORKUP
Lab Studies:
Blood test
leukocytosis (>11,000 cells/mL)
Blood chemistry may reveal dehydration and acidosis.
Liver function tests if clinically indicated
Serum electrolytes
Renal function Amylase and lipase if pancreatitis is suspected
Urinalysis (UA) is essential to rule out urinary tract diseases (eg,
pyelonephritis, renal stone disease Aerobic and anaerobic blood cultures
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Complications
Hypovolaemia shock-Sequestration offluid and electrolytes
-Decreased central venous pressure
Electrolyte disturbances
Acute renal failure
Peritoneal abscess
Abdominal Sepsis may develop Septic shock
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Radiographs
Plain films of the abdomen :
supineupright Free air
Imaging Studies
Computed tomography scanDiagnosis cannot be established on clinical grounds
Cannot be findings on abdominal plain films.
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Mesenteric Lymphadenitis
1. Inflammation of the mesenteric lymph nodes.2. Acute or chronic, depending on the causative agent.3. Often difficult to differentiate from acute appendicitis.
PathophysiologyMicrobial agents are thought to gain access to the lymphnodes via the intestinal lymphatics.
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Clinical
Clinical features of associated organ involvement, such asenterocolitis or ileitisAbdominal pain - Often right lower quadrant (RLQ) but may
be more diffuseFeverDiarrheaMalaise
AnorexiaUpper respiratory tract infectionNausea and vomiting
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Physical
Fever (38-38.5C)RLQ tenderness - Mild, with or without rebound
tendernessRectal tendernessRhinorrhea
Hyperemic pharynxAssociated peripheral lymphadenopathy (usuallycervical) in 20% of cases
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Causes
Streptococcus beta-hemolytic,Staphylococcusspecies,Escherichia coliStreptococcus viridans,
Mycobacterium tuberculosis,Viruses, such as coxsackieviruses, rubeola virus, andadenovirus
Children with upper respiratory tract infection, haspopularized a theory that swallowed pathogen-laden sputummay be the primary source of infection.
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Lab StudiesCBC countLeucocytosis exceeding 10,000/L
Urinalysis exclude urinary tract infection.
Stool cultures Diarrheal symptoms
Blood culture Septicemia
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Imaging Studies
CT scanning
In mesenteric adenitis: lymph nodes to be larger
CT scanning is also important to excludeother differential diagnoses, especially acuteappendicitis.
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Medical Care
Hemodinamic support
Broad-spectrum antibiotics
Surgical Care
Signs of peritonitis
Appendectomy