A CLINICAL STUDY OF PERFORATIVE PERITONITIS

A CLINICAL  STUDY  OF   PERFORATIVE  PERITONITIS

INTRODUCTION

Peritonitis  is  the  inflammation  of  the  serosal  membrane  that  lines  the abdominal cavity and the organs contained therein.   Peritonitis is often secondary to  an infection into the otherwise sterile peritoneal environment through perforation of gastrointestinal tract  or  a    chemically  irritating  material,  such  as  gastric  acid  from  a  perforated  ulcer.¹ Frequent  causes  of secondary bacterial  peritonitis  include  perforation  due  to  peptic  ulcer  disease , acute  appendicitis ,  ileal  perforation  due  to typhoid & tuberculosis  ,  jejunal  perforation  most  often  due  to blunt trauma ,  colonic  perforations  secondary  to closed loop  obstruction or malignancy.²

The  purpose  of  operative  protocol  is  to  correct  the pathology while  avoiding any serious  accidents  and to  adopt  a  surgical procedure which  is  associated  with  minimal  complications.  Initial  resuscitation  with  large  volume  of  crystalloids , administration  of  broad  spectrum antibiotics  against    gram  negative  bacteria  and  anaerobes   are   usually followed  by  laparotomy  and  closure  of  peforation.

Despite  a  better  understanding  of  pathophysiology , advances in diagnosis , surgery , antimicrobial therapy and  intensive care support  peritonitis  remains potentially fatal.

 Peritonitis  secondary  to   hollow  viscus  perforation  is  a common occurrence  in this country  and  the  spectrum  of  etiology  in  tropical  countries  continues  to  differ  from  western  counterpart.   

“ In peritonitis  -  source  control  is  above  all

 The  mechanical  control of  the source of  infection , which itself  non biologic , determines the extent of the host biologic response to infection.”

-         Ronald V .Maier ³

OBJECTIVES

                                

1. To  analyse   the age / sex incidence of perforative  peritonitis         

                2. To estimate   the relative frequency of anatomical site of perforation..

                3. To enlist  the  mode of   presentation  of  perforation  cases

 4.   To  know the  usefulness  of   investigative  procedures  in diagnosis

  5.   To  study  the   outcome   of  surgical  management  for  perforative    peritonitis  

      

LIMITATIONS   OF  STUDY

1)     This  study   does not include  the   cases  of    traumatic  perforative

Peritonitis.

 2)      This  study  does not include  patients  with  previous  history  of

Comorbid  illness.

 3)      Cases  with  previous  history  of   abdominal  surgeries  were not included. 

REVIEW OF LITERATURE

Anatomy:

The peritoneum is the largest and the most complex serous membrane in the body.  It  forms  a  closed  sac  (i.e.  coelom)  by  lining  the  interior  surfaces  of  the abdominal wall (anterior and lateral), by forming the boundary to the retro peritoneum (posterior), by covering the extra peritoneal structures in the pelvis (inferior), and by covering the undersurface of the diaphragm (superior).⁴ This parietal layer of the peritoneum  reflects  onto  the  abdominal  visceral  organs  to  form  the  visceral peritoneum. Hence creating a potential space between the two layers.

The peritoneum consists of a single layer of flattened mesothelial cells over a loose areolar tissue. The loose connective tissue layer contains a rich network of vascular and lymphatic capillary channels, nerve endings, and immune – competent cells, particularly lymphocytes and macrophages. The peritoneal surface cells are joined  by functional complexes, thus forming a  dialyzing membrane  that  allows passage of fluid and certain small solutes.⁵

Peritoneal Cavity:

This is the potential space between the parietal and visceral layers of peritoneum. This consists of –

- The greater sac or general peritoneal cavity.

- The lesser sac or the small omental bursa which is a diverticulum of the peritoneal cavity behind the stomach and adjoining structures.

It opens into the greater sac through a slit like aperture the epiploic foramen.

Greater Omentum:⁵

The greater omentum hangs down like a vascular apron from the  greater curvature of the stomach, overlying coils of intestine. It is the most vascular part of the peritoneum, and is often called the ‘policeman’ of the abdomen, since it can move to a site of infection and become adherent to it, bringing protective leucocytes to the area of pathology and ‘walling off’ the inflammatory region.

The greater omentum consists of four closely applied layers of peritoneum enclosing blood vessels and lymphatics. The greater omentum has a continuous attachment from abdominal oesophagus to duodenum, along the greater curvature of stomach. The part of the greater  omentum  immediately  below  the  stomach  overlies  and  fuses  with  the transverse mesocolon .

 Lesser omentum:

The two layers of peritoneum that extend from the liver onto the lesser curvature of stomach and the first inch of duodenum constitute the lesser omentum.

Peritoneal Compartments:

The peritoneum by virtue of its attachments to the posterior abdominal wall and to various viscera, divides the peritoneal cavity into compartments called

    - Supracolic

- Infracolic and

- Pelvic

The Supracolic compartment is subdivided into four compartments

- Right upper or right subphernic (sub diaphragmatic) compartment

- Right lower or hepatorenal pouch (of Morrison)

- Left upper or left Subphrenic (subdiaphargmatic) compartment

- Left lower or left subhepatic compartment.

The dividing line between the supracolic and infracolic compartments is the attachment of the transverse mesocolon to the posterior abdominal wall.

Parietal peritoneum is supplied segmentally by the spinal nerves that innervate the overlying  muscles.  Thus  the  diaphragmatic  peritoneum  is  supplied  centrally  by phrenic nerve (C4) and peripherally by intercostal nerves.  The remainder of the parietal peritoneum is supplied segmentally by intercostal and lumbar nerves. The visceral peritoneum has no afferent supply and pain form diseased viscera is due to muscle spasm, tension on mesenteric folds or involvement of the parietal peritoneum.

Stomach:

The stomach is the most dilated part of the alimentary tract, interposed between the oesophagus and duodenum in the upper part of abdominal cavity and lying mainly in the left hypochondriac , epigastric and umbilical region. Its mean capacity varies from 30 ml at birth, but in the adult it may accommodate upto1500 ml or more.

The junction of stomach with the oesophagus is the cardia and lies under the diaphragm, to the left of the midline at the level of T-11 vertebrae. The distal opening is the pyloric opening, at the gastroduodenal junction. It is about 1.2 cm to the right of the midline in the transpyloric plane, when the body supine and the stomach empty. The main parts of the stomach are the fundus, body and pyloric part, with the greater and lower curvatures forming the upper and lower borders and joining the anterior and posterior surfaces.   Fundus is the part which projects upwards above the level of the cardia. The body extends from the fundus to the angular notch (incisura angularis) of the lower part of the lesser curvature. The  pyloric  part  extends  from  the  angular  notch  to  the  gastroduodenal junction, and consists of the proximal pyloric antrum which narrows distally as the pyloric canal. The circular muscle of the distal end of the canal is   thickened to form the pyloric sphincter, whose position is indicated on the anterior surface by the prepyloric vein.