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Ministry of Healthcare of Ukraine Danylo Halytsky Lviv National Medical University MINISTRY OF HEALTHCARE OF UKRAINE DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY DEPARTMENT OF SURGERY #1 ACUTE PERETONITIS. ETIOLOGY AND PATHOGENESIS. CLASSIFICATION. CLINICAL PRESENTATION. TREATMENT Guidelines for Medical Students LVIV – 2019 Approved at the meeting of the surgical methodological commission of Danylo Halytsky Lviv National Medical University (Meeting report № 56 on May 16, 2019) Guidelines prepared: GERYCH Igor Dyonizovych – PhD, professor, head of Department of Surgery #1 at Danylo Halytsky Lviv National Medical University VARYVODA Eugene Stepanovych – PhD, associate professor of Department of Surgery #1 at Danylo Halytsky Lviv National Medical University STOYANOVSKY Igor Volodymyrovych – PhD, assistant professor of Department of Surgery #1 at Danylo Halytsky Lviv National Medical University CHEMERYS Orest Myroslavovych – PhD, assistant professor of Department of Surgery #1 at Danylo Halytsky Lviv National Medical University Referees: ANDRYUSHCHENKO Viktor Petrovych – PhD, professor of Department of General Surgery at Danylo Halytsky Lviv National Medical University OREL Yuriy Glibovych - PhD, professor of Department of General Surgery at Danylo Halytsky Lviv National Medical University Responsible for the issue first vice-rector on educational and pedagogical affairs at Danylo Halytsky Lviv National Medical University, corresponding member of National Academy of Medical Sciences of Ukraine, PhD, professor M.R. Gzegotsky I. Background Peritonitis is defined as inflammation of the serosa membrane that lines the abdominal cavity and the organs contained therein. The peritoneum, which is an otherwise sterile environment, reacts to a variety of pathologic stimuli with a fairly uniform inflammatory response. Depending on the underlying pathology, the resultant peritonitis may be infectious or sterile (i.e., chemical or mechanical). Peritonitis is most often caused by introduction of an infection into the otherwise sterile peritoneal environment through organ perforation, but it may also result from other irritants, such as foreign bodies, bile from a perforated gall bladder or a lacerated liver, or gastric acid from a perforated ulcer. Women also experience localized peritonitis from an infected fallopian tube or a ruptured ovarian cyst. Patients may present with an acute or insidious onset of symptoms, limited and mild disease or systemic and severe disease with septic shock. Peritoneal infections are classified as primary (i.e., from haematogenous dissemination, usually in the setting of immunocompromise), secondary (i.e., related to a pathologic process in a visceral organ, such as perforation, trauma, or postoperative), or tertiary (i.e., persistent or recurrent infection after adequate initial therapy). Infections in the peritoneum are further divided into generalized (peritonitis) and localized (intra-abdominal abscess). This article focuses on the diagnosis and management of infectious peritonitis and abdominal abscesses. An abdominal abscess is seen in the images below. II. Learning Objectives 1. To study the etiological factors of disease, classification of acute peritonitis, clinical signs, diagnostic methods, treatment and complications (α = I). 2. To know the main causes of the disease, typical clinical course and complications, diagnostic value of laboratory and instrumental methods of examination and the principles of the modern conservative and surgical treatment (α = II). 3. To be able to collect and analyse the complaints and disease history, thoroughly perform physical examination, determine the order of the most informative examination methods and perform their interpretation, establish clinical diagnosis, justify the indications for surgery, choose adequate method of surgical intervention (α = III). 4. To develop creativity in solving complicated clinical tasks in patients with atypical clinical course or complications of acute peritonitis (α = ІV). III. Purpose of personality development Development of professional skills of the future specialist, study of ethical and deontological aspects of physicians job, regarding communication with patients and colleagues, development of a sense of responsibility for independent decision making. To know modern methods of treatment of patients with acute peritonitis and its complications. IV. Interdisciplinary integration Subject To know To be able Previous subjects 1. Anatomy and Anatomy of the abdominal Determine the topographic Physiology cavity features of the abdominal cavity 2. Pathomorphology Theory of inflammation Describe macroscopic and Pathophysiology and its morphological changes of inflamed signs, etiological factors peritoneum of disease 3. Propedeutics of Sequence of patient’s Determine the patients internal diseases survey and physical complaints, medical history examination of the of the disease, perform abdominal cavity superficial and deep palpation of the abdomen 4. Pharmacology Groups and Prescribe conservative representatives of treatment of patient with antibiotics, spasmolytics, acute peritonitis analgesics, anti- inflammatory drugs, colloid and crystalloid solutions 5. Radiology Efficiency of radiological Indications and description of investigation in patients x-ray, ultrasound, computed with acute appendicitis tomography examination Future subjects Anaesthesiology and Clinical signs urgent Determine the symptoms of Critical Care conditions that occur in urgent conditions, differential Medicine patients with diagnosis and treatment complications of acute peritonitis, methods of diagnosis and pharmacotherapy Interdisciplinary integration 1. Acute pancreatitis Clinical picture of acute Check Mondor’s, Grey- pancreatitis Turner’s, Cullen’s, Mayo- Robson’s signs 2. Acute cholecystitis Clinical picture of acute Check Ortner’s, Kehr’s, cholecystitis Merphy’s, Mussy’s signs 3. Peptic ulcer of Clinical picture of peptic Check Blumberg’s sign, stomach and ulcer of stomach and describe plain abdominal film duodenum duodenum in patient with peptic ulcer perforation 4. Acute bowel Clinical picture of acute Describe x-ray signs of acute obstruction bowel obstruction bowel obstruction 5. Renal colic Clinical signs of renal Check Pasternacky’s sign colic V. Content of the topic and its structuring Anatomy of the Peritoneal Cavity The peritoneum is composed of a layer of polyhedral-shaped squamous cells approximately 3 mm thick and may be viewed anatomically as a closed sac that allows for the free movement of abdominal viscera. Adherent to the anterior and lateral abdominal walls, the peritoneum invests the intraabdominal viscera in such a way as to form the mesentery for the small and large bowel, a peritoneal diverticulum posterior to the stomach (the lesser sac) and a number of spaces or recesses in which blood, fluid, or pus can localize in response to various disease processes Fluid can therefore collect in the right and left subphrenic spaces (left more commonly than right), the subhepatic space (posterior to the left lobe of the liver), Morrison’s pouch the lesser sac (usually in response to pancreatitis or pancreatic injury), the left and right gutters (lateral to the left and right colon respectively), the pelvis, and the interloop spaces (between the loops of intestine). The Omentum The omentum is a membranous adipose tissue within the peritoneal cavity forming the roof of the lesser sac between the greater curvature of the stomach and the transverse colon (lesser omentum) and a veil-like structure suspended from the transverse colon covering the small intestine (the greater omentum). Surgeons have referred to the omentum as “the policeman of the abdomen” because of its role in walling off intraabdominal abscesses and preventing free peritonitis. However, there is no evidence that there is any intrinsic omental movement. The precise mechanism by which the intraabdominal viscera and the omentum wall off collections of pus is not known. The omentum also contains areas with high concentrations of macrophages called “milky spots” which play a major role in the immune response to peritoneal infection. The Retroperitoneum The liver, duodenum, and the right and left colon are all partially invested by the peritoneal membrane so that portions of these structures are actually located in the retroperitoneum. The pancreas, kidneys, ureters, and bladder are located entirely in the retroperitoneum. A long retrocecal appendix may be considered as a retroperitoneal structure. These anatomical considerations are important because injuries, diseases, or perforations of these structures in their retroperitoneal location usually produce subtle early symptoms and signs that are often more difficult to diagnose than intraperitoneal infections owing to delay in the onset of peritoneal irritation. Physiology of the Peritoneum The major function of the peritoneal membrane is the maintenance of peritoneal fluid balance. The bidirectional semipermeable membrane has an exchange surface area of 1 m2. Normally the peritoneal cavity contains less than 100 ml of serous fluid. Although the parietal peritoneum of the anterolateral abdominal wall behaves as a passive semipermeable membrane, the diaphragmatic peritoneum is capable of absorbing bacteria. Von Recklinghausen in 1863 described intercellular gaps called stomata in the diaphragmatic peritoneum that serve as portals to the diaphragmatic lymphatic pools, called lacunae. Lymph flows from the lacunae via subpleural lymphatics to the regional lymph nodes and then to the thoracic duct. As the diaphragm
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