631 Postgrad Med J: first published as 10.1136/pgmj.28.326.631 on 1 December 1952. Downloaded from THE MANAGEMENT OF ACUTE GENERAL PERITONITIS By C. R. SAVAGE Resident Assistant Surgeon, St. Thomas's Hospital, London Introduction intestinal tract, a diffuse and often fatal peritonitis Inflammation of the peritoneal cavity is usually may ensue. Considerable efforts on the part of due to bacterial infection which may be preceded the body may be made in an attempt to seal off in certain instances by an initial chemical peri- the area of such perforations and these are on tonitis. Infection most often commences locally in occasion successful. Diversion of the intestinal some part of the peritoneal cavity and particularly contents from the site of the perforation will with early and efficient treatment frequently re- certainly assist in this process. It may take the mains confined to that area. It may, however, form of gastric aspiration in cases of perforated become widespread and it is to this condition that peptic ulcer or of proximal colostomy above the the term acute general peritonitis is applied. In site of a colonic perforation. It is seldom wise, many cases when the cause of this infection is however, to rely on this measure alone to control removed at an early stage, inflammation although continued peritoneal contamination, for in the Protected by copyright. widespread, never becomes established in the former instance it may not be possible to keep the peritoneum. This distinction between a general stomach completely empty and even if this is peritonitis which has, and one which has not, successful, duodenal reflux may still occur, while become established, although largely a matter of in the latter intestinal contents below the level of degree is one of great importance as regards the colostomy may still continue to discharge treatment. In the former -case such measures as through the perforation. Good results have, the parenteral administration of fluids and the use however, been obtained in the conservative treat- of gastrointestinal aspiration may well be essential, ment of perforated gastric and duodenal ulcers by while in the latter, in the majority of cases, they gastric aspiration (Hermon Taylor), but it is con- are quite unnecessary. The causes of general sidered that early surgical closure is still the treat- peritonitis are many and varied, but the most ment of choice except in those cases in which the common are acute appendicitis and perforations operative risks are considered to be unduly high. of the stomach and duodenum; a not inconsider- Diversion of the stream of intestinal contents re- able number of instances occur after elective mains a valuable adjuvant measure. http://pmj.bmj.com/ surgery on the gastrointestinal tract and these carry Removal of infected material which has already a very high mortality. There are a number of accumulated in the peritoneal cavity should be principles underlying efficient management and carried out at operation with suction and the these will now be considered. gentle use of gauze swabs. All methods of irrigation have long since been abandoned because Early Elimination of the Source of Infection of their disastrous effect of spreading infection and In the majority of instances organisms gain because of the severe shock that they produced. on September 29, 2021 by guest. access to the peritoneal cavity through perfora- It has long been realized also that attempts to tions in the walls of hollow viscera. Where the drain the general peritoneal cavity are quite futile source of infection can be dealt with at an early owing to the rapid sealing off of the drain track. stage either by closure of a perforation, as in In addition there are certain positive dangers and perforated peptic ulcer or. by removal of the in- disadvantages associated with the use of drainage fected organ as in acute appendicitis, the peri- tubes, such as the formation of adhesions, the toneum is usually well able to overcome any in- erosion of surrounding structures (if the tube is fection which remains. Where, however, a too rigid), the giving of unnecessary pain, and the persistent leakage of infected material occurs into possible formation of an avenue of infection to the the peritoneal cavity either as a result of delay in peritoneal cavity from without. Used, however, treatment of an acute abdominal condition or with certain definite objectives in mind, drainage occasionally following an operation on the gastro- may be of very great value. Such is the case when 632 POSTGRADUATE MEDICAL JOURNAL December 1952 Postgrad Med J: first published as 10.1136/pgmj.28.326.631 on 1 December 1952. Downloaded from doubt is felt about the integrity of a suture line, may closely resemble distended segments of bowel. when it is not possible to remove an infected organ Fig. i shows the X-rays of such a case. An opera- or infected material which forms part of an in- tion for the relief of intestinal obstruction had been flammatory mass or the wall of an abscess cavity, performed three weeks previously and had been or when adequate haemostasis cannot be ensured. followed by general peritonitis and paralytic ileus. In these cases the presence of a drainage tube to Three days after the abdomen had returned to the site rapidly forms an exit for infected dis- normal size following resumption of bowel activity, charges which might otherwise form a local it again became grossly distended, but this time abscess or spread elsewhere within the peritoneal with gas and fluid outside the lumen of the bowel. cavity. Further operation confirmed these X-ray findings. The process of localization of infection within The Assistance ofthe Natural Processes ofthe the peritoneal cavity is brought about by the Body in the Resolution and Localization of the Infection FIG. i.-X-ravs in erect and horizontal lateral positions Widespread infection of the peritoneal cavity showing encysted intraperitoneal collections of may terminate in one of the following ways. It fluid and gas followina acute general peritonitis. may undergo resolution with complete absorption (The dense shadows in the horizontal film are due to of the inflammatory exudate with or without the mercury in the bowel lumen following rupture of formation of adhesions. It may result in the death the balloon of a Miller Abbott tube.) of the patient usually by causing a general toxaemia with peripheral circulatory failure due to a com- bination of factors amongst which continued sepsis, interference with the water, electrolyte and protein balances of the body and paralytic ileus are the most important. It may localize into one or Protected by copyright. more areas with the formation of abscesses which may in their turn either be absorbed, extend in various directions and discharge either spon- taneously or with surgical aid into the lumen of the intestine, externally or, on rare occasions, into the general peritoneal cavity. It cannot be emphasized too strongly that a most important part of the management of these cases consists in repeated clinical examination to ascertain the presence and site of these residual abscesses and in their efficient treatment. Where the bowel forms part of the wall of the abscess FIG. Ia.-Horizontal lateral X-ray. Spontaneous cavity, discharge frequently occurs into the pneumoperitoneumn. lumen, but when this process is delayed, with http://pmj.bmj.com/ deterioration in the general condition of the ............... patient, when the abscess points externally or where anatomical factors preclude this termination (e.g. subphrenic abscess) surgical evacuation is necessary. If for any reason such treatment is delayed for too long, sepsis may spread either in the with locally or widely peritoneal cavity on September 29, 2021 by guest. disastrous results. On rare occasions due either to the effect of antibiotics, to high resistance on the part of the individual or to low resistance of the organisms concerned, a chronic septic peritonitis may ensue with multiple plastic adhesions and scattered collections of pus and fibrin between the loops of intestine. In such cases either as the result of leakage of air from the bowel at some un- known site or due to the presence of gas-forming organisms, a form of spontaneous pneumo- peritoneum may occur with multiple encysted FIG. Ib.-X-ray in erect position. From the same collections of gas and fluid which on radiography patient as in Fig. ia. December I95 SAVAGE: The Management of .4cuite General Peritonitis 633 Postgrad Med J: first published as 10.1136/pgmj.28.326.631 on 1 December 1952. Downloaded from k/I V Protected by copyright. I I FIG. Z.-Spreading peritonitis: Directions of spread of intraperitoneal fluids following perforations in the region of the pylorus. (I) According to Livingstone, and (II) according to Mitchell. Intraperitoneal spaces are numbered as follows: (i) Subhepatic Space, (2) Lesser Sac, (3) Right Supracolic Space, (4) Right Paracolic Gutter, (5) Right Subphrenic Space, (6) Pelvic Space, (7) Left Supracolic Space, (8) Left Paracolic Gutter, (g) Left Subphrenic Space. adhesion ofthe inflamed surfaces ofthe peritoneum in infant cadavers in which radio-opaque fluid had to one another, the omentum playing a con- been introduced through artificial perforations in spicuous part, the reflex inhibition of intestinal the stomach and intestines, has shown that some of movements and the reflex rigidity of the-abdominal the previously accepted avenues of spread of http://pmj.bmj.com/ wall. Iffollows, therefore, that any measure which fluids are in fact inaccurate. The accompanying tends to interfere with this process of localization diagrams (Fig. 2) shows both the older views of must be strictly avoided. Manipulations at the the directions of spread and those indicated by his time of operation should be confined as far as experimental work in cases of perforations near the possible to the area of the source of infection and pylorus.