THE MANAGEMENT of ACUTE GENERAL PERITONITIS by C

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. Certain other factors such as respiratory great care should be taken that naturally formed and peristaltic movements, movement of the

barriers against the spread of infectibn are not patient as a whole, particularly if violent (e.g. on September 29, 2021 by guest. broken down. Only that which is strictly necessary vomiting) and the deflecting action ofthe naturally- for the immediate welfare of the patient should be formed barriers against infection may somewhat undertaken at the emergency operation. No modify this picture in the living subject. attempt should be made to obtain intestinal move- The influence of gravity on the disposition of ment either by purgation by enemas or by the free intraperitoneal fluids has been appreciated for use of the cholinergic drugs. many years and was the underlying principle in Much attention has been directed to the path- the treatment of peritonitis by the adoption of ways of spread of free intraperitoneal fluids and Fowler's position. It was claimed that the position also to the influence of the position of the patient definitely reduced the incidence of subphrenic in relation to the location of intraperitoneal abscess and that it encouraged any possible abscesses following acute peritonitis. Mitchell, in abscess formation to occur in the pelvis, where it a valuable contribution based on work carried out was thought peritoneal absorption of toxic sub- F 634 POSTGRADUATE MEDICAL JOURNAL December I952 Postgrad Med J: first published as 10.1136/pgmj.28.326.631 on 1 December 1952. Downloaded from stances was less active than in the subdiaphrag- come the infection may be due to the presence of matic area. Whereas large collections of fluid will insensitive organisms, to persistent reinfection of certainly be influenced in this way, it is not the peritoneal cavity, to failure of the drugs to necessarily true of smaller ones. Spalding has penetrate into infected and necrotic tissue whose maintained that the Fowler position so far from blood supply has been impaired and occasionally discouraging may, in fact, predispose to subphrenic to failure of the patient's normal resources against abscess formation. He has emphasized the part infection to play their necessary part. In rare played 'by respiratory movement in promoting a instances it may be due to inadequate dosage. constant flow of a thin film of peritoneal fluid in Parenteral administration of antibiotics is an upward direction towards the subdiaphragmatic normally'relied upon and is in most cases satis- area under normal conditions, where it is absorbed factory. Attempts to control infection by oral together with any. small, particles w7hich may be administration' in cases of persistent reinfection present into the diaphragmatic lymphatics. When from the" alimentary tract are likely to be un- air is present within the peritoneal cavity (e.g. successfui owing to the'loss of peristaltic activity after laparotomy) this mechanism ceases to of the intestine and the frequent necessity of function so efficiently. Un&er' these' conditions he gastrointestinal aspiration. Local use 'within the considers that, in the sitting position, a pocket of peritoneal cavity is unwise in view of the formation air forms beneath the diaphragm which under the of foreign body granulomas and adhesions. Owing influence of respiratory movement may aspirate to their wide range of activity, antibiotics have infected fluid from the subhepatic pouch (which almost entirely superseded the sulphonamides in does not empty in)'that position) into the sub- the treatment of peritonitis. It seems doubtful if phrenic spaces. toxins produced by infecting bacteria themselves It is certainly quite evident that a number of are of much importance in contributing to the

factors are involved in the localization of infection general toxaemia and circulatory failure that mayProtected by copyright. within the subphrenic area and very difficult to be present. It is more likely that other substances assess which will, in fact, be predominant in any formed as a result of inflammatory destruction of particular instance. In practice, moreover, factors tissue (perhaps of the nature of toxic amino- other than the location of residual abscesses will acids) may be responsible by exerting a direct modify opinion as to the correct position for action on the bowel wall and on the medullary the patient with general peritonitis. The, im- centres. The enormous area of peritoneal. surface portance of rest, both general and local, has long available for absorption is obviously of importance been realized in the treatment of acute inflam- but it seems doubtful whether this absorbtive matory conditions, but only more recently has it capacity differs significantly in the various parts of been appreciated that rest is not synonymous with the peritomeal cavity. immobility and that the latter may have certain very serious consequences. Important amongst Correction of the Disturbed Water, Electro- these are the liability to chest comnplications and lyte and Protein Balance of the Body the tendency to peripheral vein thrombosis and There is no doubt that a large part of the circu- pulmonary embolism. These dangers far out- latory collapse which is so marked a feature in the http://pmj.bmj.com/ weight the doubtful possibilities of influencing the later stages of peritonitis, especially if complicated site of abscesses. It is now considered that move- by paralytic ileus, is dependent upon the losses of iment and frequent change of position are of the water, electrolytes and protein that occur and to greatest importance to the patient, and that there an alteration of their distribution within the is no such thing as a correct or an incorrect cellular, extracellular and vascular compartments position. Constant attention must be -paid to of the body. These losses may in fact be of improvement of the pulmonary ventila'tion, to the enormous dimensions and occur by vomiting or on September 29, 2021 by guest. expectoration of bronchial secretions and to the suction from the upper intestinal tract, in some prevention of circulatory stasis. cases by diarrhoea from the lower, from the lungs, from the' kidneys and by sweating. In addition Destruction of Infecting Organisms large quantities which cannot be, in fact, accurately The introduction first of all of the sulphonamide measured, are lost to the body in the formation of group of drugs and later of the antibiotics has been inflammatory exudates and into the lumen of one of the most important advances in the treat- distended bowel. The normal intake of fluid may ment of peritonitis in recent years. Most cases of in addition be grossly reduced. peritonitis are due to the combined activities of a The aim in management in peritonitis must number of different types of organisms and many therefore be to' restore the normal balance of of these organisms are sensitive to one or other of water, electrolytes and protein in the body and to the antibiotics. Failure of the antibiotics to over- maintain it once this has been achieved. In many December 1952 SAVAGE: The -Management of Acute General Peritonitis 635 Postgrad Med J: first published as 10.1136/pgmj.28.326.631 on 1 December 1952. Downloaded from early cases where peritonitis has not become vomiting and a rapid pulse rate. In most cases established, this may be accomplished by oral there is no bowel movement and no flatus is intake alone or supplemented by' the rectal route. passed per rectum. It is important, however, to Where, ho'wever, infectioTi has advanced beyond realize that nausea and vomiting may on occasions this stage as indicated by operative findings, by be entirely absent, that distension may pass un- nausea, or vomiting (excluding post anaesthetic), noticed in the lax abdomen (e.g. after parturition by abdominal distension and terrderness and by a or in the obese) and that the only warning signs rising or sustained high pulse' rate, dehydration is may then be an otherwise unexplained rising pulse likely to be more severe and other measures will rate in an anxious ill-looking patient. Symptoms be necessary. The main method' of administra- of peripheral circulatory failure may follow rapidly. tion of fluid'must now be the intravenous route, Paralytic ileus may affect either the whole or only and large amounts may be required to begin with. a part of the gastro-intestinal tract and diarrhoea Careful records of the intake and output of fluid may occur in the presence of gross distension must be kept in all cases. Estimation of the exact particularly in cases where infection is most marked requirements is not alw*ys easy as allthe relevant in the pelvis. When in these cases the diarrhoea is information necessary is never- available. In accompanied by a gradually rising pulse rate, it practice, guidance should be obtained from careful appears to. be of very ominous significance. The clinical examination of the patient for evidence of most important causative factors appear to be the under- or over-hydration, from study of the fluid failure of the normal gas and fluid balancing balance charts with special reference to the urinary mechanisms of the bowel, the disorganization of output and by daily' estimation of the urinary the propulsive element of peristaltic activity, chlorides. Progress may be checked periodically toxic paralysis of the bowel wall, circulatory stasis by appropriate blood examinations. It is most and hypoproteinemia. The fluid'in the distended important to realize that' at all times the findings of bowel is. derived from intake by mouth, gastric, Protected by copyright. clinical examination are of primary importance and intestinal, biliary and pancreatic secretions, and information gained by other means interpreted fluid diffused from the blood through the oedema- strictly in relation-to these. tous inflamed and ill-nourished bowel' wall. The importance of protein deficiency which may According to Wangensteen the gas is derived result from loss into inflammatory exudates, into largely from swallowed air, the normal absorptive the lumen of the distended intestine, into the mechanism having broken down and, to a much intestinal wall and from diminished intake has lesser extent, from diffusion from the blood and -been emphasized by Rob, who recommended the from digestive processes. administration of plIsna, sometimes in large Mgaiagemrnt.should be directed to the relief of quantities, for the prevention and treatment of distension and to the maintenance of a satisfactory -peripheral circulatory failure in 'all cases of circulation to the distended bowel as only if this peritonitis of sufficient severity to require intra- is ensured can there be hope of resumption of -venous fluids. normal activity. Gastrointestinal aspiration has Recent work suggests that potassium loss is also been of the greatest value in achieving these important and any defiiciency must be rectified objects. Introduced originally for diagnostic http://pmj.bmj.com/ with due regard to the dangers of over-dosage. purposes its therapeutic possibilities were 'soon realized. The Miller Abbott double lumen tube, Control of Gastrointestinal Distension acting as a progressing internal enterostomy, was Reflex depression of gastrointestinal activity of an additional advance on this principle. Difficulty varying degree follows every laparotomy and may, in introduction of the end of this tube into the in fact, be initiated reflexly on rare occasions by duodenum despite careful attention to detail is not trauma to more distant parts of the body. The infrequent, particularly in those cases in which it on September 29, 2021 by guest. depression of activity is accompanied by a dis- might be expected to be of; most benefit. Once organization of the gas and fluid balancing past the pylorous, however, its progress is4usually mechanisms of the intestine. In the majority of most satisfactory. It is fortunate that' in the cases it is of a temporary nature only, but in certain majority of cases gastric intubation appears to be instances a self-perpetuating vicious circle of efficient in preventing vomiting and in ensuring events is set up and paralytic ileus becomes adequate decompression. It is certainly seldom established. This is particularly likely to occur advisable to persist in repeated attempts to pass in diffuse peritonitis. Careful and repeated clinical the Miller Abbott tube into the duodenum in a examination is necessary if the early symptoms and 'serioisly ill patient. Even when' this ttibe, 'has signs of the onset of the condition are to be recog- passed into the small intestine it may on occa3ion nized. These are increasing abdominal distension, fail to function satisfactorily even when its patencv absent or altered bowel sounds, nausea and is undoubted. It scems probable that this may be 636 POSTGRADUATE NIEDICAL JOURNAL. December 1952 Postgrad Med J: first published as 10.1136/pgmj.28.326.631 on 1 December 1952. Downloaded from due either to the necessarily small caljbre of the mission of the intestinal contents. They may, in- tube in relation to thick intestinal contents some- fact, stimulate further secretion from the bowel times encountered, to further distention occurring wall and where the mechanical obstructive element in the bowel above the level of the end of the has supervened there are other possible dangers. tube, as suggested by the increased aspirate which Certain other factors which have already been may be obtained on withdrawing the tube to a dealt with, such as the control of infection and of higher level or to the arrest of the tube above an the water, electrolyte and protein balance of the angulated distended loop of bowel. This additional body will have a direct effect on improving the factor of mechanical superimposed upon functional circulation of the bowel wall and maintaining it obstruction, caused by angulation of distended in such a condition that its normal function may bowel is very important and arises in all cases in return. They constitute an essential part of which distension becomes severe. Multiple points treatment. of obstruction are produced and attempted surgical relief is never indicated as these angulations Provision of Rest and Relief of Pain rapidly become reduced once normal peristaltic The importance of ensuring adequate rest in activity is resumed. Obstruction by adhesions at the form of sleep and relief of pain and anxiety in a single site certainly occurs following peritonitis, general peritonitis has already been mentioned, but it is seldom seen in the early post-operative and this is even more true when paralytic ileus has period. At one time it was considered that, in ensued. Many conflicting accounts have been some cases, obstruction might be due to a localized given of the effects of morphine on the motility of loop of small intestine becoming paralyzed by the alimentary tract. Even if it were proved con- immersion in a collection of pus in the pelvis (the clusively, however, that it had inhibitory effects on ileus duplex of Sampson Handley), but it seems the intestinal muscle, its enormously valuable doubtful if this is ever really so although the relief general effects would continue to justify its use. of obstruction which may follow the drainage of an Protected by copyright. intraperitoneal abscess tends to support it. It may Conclusion be, in fact, that the inteptine has become angulated Improvement in the prognosis of general and oedematous by becoming involved in the peritonitis has been very marked in recent years. forma,tion of the wall ofNthe abscess and that this The most important factors responsible are the is relieved when the pus has been evacuated. introduction of the antibiotics, the fuller under- Prolonged inhalation of oxygen in high con- standing of the fluid, electrolyte and protein centrations has been advocated in an attempt to balances of the body, the use of gastrointestinal reduce distension by displacing the nitrogen in the decompression and the earlier diagnosis and treat- bowel. It is very difficult to judge clinically of its ment of the acute abdomen. More powerful anti- efficacy, but this does not seem to be very great, biotics with an increased range of activity may certainly not sufficient to justify the additional become available in the future, but in the absence discomfort and manipulation that it entails. of the most careful pre- and post-operative Stimulation of the bowel by various methods has management, attention to general surgical prin- also been advised on many occasions in the treat- ciples and to the details of surgical technique, it is http://pmj.bmj.com/ ment of paralytic ileus, but as far as that com- doubtful if the outlook in this condition can be plicating peritonitis is concerned it is contra- further improved to any great extent. indicated. There is no convincing evidence that enemas can induce reflex peristalsis in the small BIBLIOGRAPHY TAYLOR, HERMON (I946), Lancet, ii, 44i. intestine and they may, in fact, add to distension ROB, C. G. ('947), Proc. Roy. Soc. Med., 40, 123. by being retained and fail to relieve even large SPALDING, J. E. (1946), Lancet, 1, 643. MITCHELL, G. A. G. (I94I), B.J.S., 28, 291. bowel ileus when this is present. Cholinergic on September 29, 2021 by guest. WANGENSTEEN, 0. H. (1942), Int. Obs. Springfield: Charles drugs may cause contraction of the bowel but this C. Thomas. 2nd Edition. contraction does not seem to be ofthe co-ordinated LIVINGSTONE, E. M. (1932), 'A Clinical Study of Abdominal Cavity and Peritoneum ' (Hoeber's Surgical Monographs No. x), propulsive type necessary for the forward trans- New York: Paul B. Hoeber, Inc.

CORRECTION We Mmust apologise for the Printer's error which appears on p. 583 of the November issue, this acknowledgment should read (Figs. 2, 3, 5 and 6 reproduced by kind permission of The Medical Press).