4. Strangulated hernia, Special types of peritonitis, Injuries of digestive tube (stomach, small and large intestine)

What is the classification of SPECIAL TYPES OF PERITONITIS?

• local

• diffuse

• infectious

• non-infectious

What is the etiology of SPECIAL TYPES OF PERITONITIS?

• Infectious: primary, secondary, or tertiary.

• Non-infectious: leakage of sterile body fluids like blood, gastric juice, or bile into the peritoneum.

What are the risk factors of SPECIAL TYPES OF PERITONITIS?

• Ascites

• Intra-peritoneal dialysis

• systemic infections

What is the pathophysiology of SPECIAL TYPES OF PERITONITIS?

Peritonitis is an inflammation of the peritoneum. This inflammation can be caused by bacterial infection or chemical irritation from leaked sterile body fluids.

What are the signs of SPECIAL TYPES OF PERITONITIS?

• constant generalised pain worsened by movement,

• abd tenderness,

• abd guarding,

• rebound tenderness in localised peritonitis.

• absent bowel sounds.

What are the diagnostic methods of SPECIAL TYPES OF PERITONITIS?

• Physical examination

• Lab = leucocytosis, high CRP

What is the pharmacological treatment of SPECIAL TYPES OF PERITONITIS?

• ATBs

• shock management (ABCDE)

What is the surgical treatment of SPECIAL TYPES OF PERITONITIS?

1. source control,

2. cleaning of the abdominal cavity,

3. drainage.

What are the complications of SPECIAL TYPES OF PERITONITIS?

• diffuse peritonitis: hypovolaemia, toxaemia, and systemic sepsis.

• Localised peritonitis: abscess or diffuse peritonitis.

What are 3 main differential diagnoses of SPECIAL TYPES OF PERITONITIS and how do we differentiate?

• acute appendicitis (sharp localised pain in RLQ)

• acute pancreatitis (dull constant pain in epigastrium that radiates to back)

• perforated peptic ulcer (sharp epigastric pain)

*peritonitis pain is generalised / localised constant pain that worsens with movement.

What is the definition of LOCAL PERITONITIS?

localized infection of the peritoneum and peritoneal cavity

What is the etiology of LOCAL PERITONITIS?

infection, Sterile abdominal surgery

What are the risk factors of LOCAL PERITONITIS?

Sterile abdominal surgery

What is the pathophysiology of LOCAL PERITONITIS?

Localized infection affects the peritoneum and peritoneal cavity. The process is confined to a specific area.

What is the clinical presentation of LOCAL PERITONITIS?

• localized tenderness,

• guarding,

• positive sign of peritoneal irritation (BPR)

Blumberg’s = rebound tenderness = Pain upon sudden release of pressure on the abdominal wall.

Plenie’s = Pain on percussion of the abdominal wall, often in the RLQ.

Rowsing’s sign = Referred pain in the RLQ when the LLQ is palpated.

What are the signs of LOCAL PERITONITIS?

Localized tenderness and guarding are present on physical examination. Signs of peritoneal irritation like Blumberg's and Rowsing's signs may be positive.

What are the symptoms of LOCAL PERITONITIS?

Symptoms are less severe than diffuse peritonitis and localized to the site of inflammation. Pain is worsened by abdominal movement.

What are the diagnostic methods of LOCAL PERITONITIS?

Diagnosis is supported by physical examination findings such as localized tenderness. Increased CRP levels and imaging methods like USG, CT, or NMR also support the diagnosis.

What is the pharmacological treatment of LOCAL PERITONITIS?

Initial therapy is conservative with antibiotics.

What is the surgical treatment of LOCAL PERITONITIS?

Subsequent surgery is indicated in case of abscess formation or progression into diffuse peritonitis.

What are the complications of LOCAL PERITONITIS?

Localized peritonitis may resolve or progress into an abscess or diffuse peritonitis.

What is the definition of DIFFUSE PERITONITIS?

Diffuse peritonitis is defined as generalized infection of the peritoneum and abdominal cavity.

What is the classification of DIFFUSE PERITONITIS?

It may be classified as primary, secondary, or tertiary based on aetiology. Based on pathological finding, it can be purulent, stercoral, biliary, or chemical.

What are the types of DIFFUSE PERITONITIS?

Types include purulent, stercoral, biliary, and chemical based on pathological findings. Based on aetiology, types include primary, secondary, and tertiary.

What is the etiology of DIFFUSE PERITONITIS?

It can result from primary infection, spread of infection from intraabdominal organs, or surgical interventions. Examples include perforated peptic ulcer or free perforation from appendicitis.

What are the risk factors of DIFFUSE PERITONITIS?

perforated organs

What is the pathophysiology of DIFFUSE PERITONITIS?

It involves generalized infection of the peritoneum and abdominal cavity. This can be triggered by leakage of irritants like gastric acid or bile, leading to chemical then bacterial peritonitis.

What is the clinical presentation of DIFFUSE PERITONITIS?

• rapidly ill

• Patients typically lie quietly with knees drawn up and breathe shallowly to minimise abdominal motion.

What are the signs of DIFFUSE PERITONITIS?

The abdomen is rigid and tender, and bowel sounds are absent. The abdomen is rigid due to severe involuntary muscle spasm.

What are the symptoms of DIFFUSE PERITONITIS?

• hypovolaemia,

• toxaemia,

• systemic sepsis if infection is present

What are the diagnostic methods of DIFFUSE PERITONITIS?

• Physical examination

• Plain X-ray may detect free air under the diaphragm,

• abd USG can confirm free fluid.

What is the pharmacological treatment of DIFFUSE PERITONITIS?

Source control can be pharmacological. Management of shock is a key treatment principle.

What is the surgical treatment of DIFFUSE PERITONITIS?

Urgent surgical treatment is indicated. Treatment principles include surgical source control, cleaning of the abdominal cavity, and drainage.

What are the complications of DIFFUSE PERITONITIS?

• abscess

• sepsis

What are 3 main differential diagnoses of DIFFUSE PERITONITIS and how do we differentiate?

• acute pancreatitis

• myocardial infarction

What is the definition of INFECTIOUS PERITONITIS?

Infectious peritonitis involves the peritoneum being infected.

What is the classification of INFECTIOUS PERITONITIS?

It may be classified as primary, secondary, or tertiary based on aetiology. Primary results from bacterial, chlamydial, fungal or mycobacterial infection.

What are the types of INFECTIOUS PERITONITIS?

Types based on aetiology are primary, secondary, and tertiary. Types based on pathological finding, such as purulent or stercoral peritonitis, imply infection.

What is the etiology of INFECTIOUS PERITONITIS?

• primary (e.g., bacterial infection),

• secondary (spread from intraabdominal organs),

• tertiary (after surgery).

What are the risk factors of INFECTIOUS PERITONITIS?

• perforated gastrointestinal organs

• disrupted peritoneum due to trauma or surgery.

• Ascites,

• intra-peritoneal dialysis,

• systemic infections

What is the pathophysiology of INFECTIOUS PERITONITIS?

Infection causes inflammation of the peritoneum. In conditions like appendicitis, bacterial overgrowth contributes to the inflammatory process.

What is the clinical presentation of INFECTIOUS PERITONITIS?

Onset can be sudden or slow. Patients may present with signs of localized or diffuse peritonitis.

What are the signs of INFECTIOUS PERITONITIS?

Signs of localized peritonitis include tenderness and guarding. Diffuse peritonitis presents with rigid abdomen and absent bowel sounds.

What are the symptoms of INFECTIOUS PERITONITIS?

• pain,

• fever

• tachycardia in localized cases,

• hypovolaemia

• sepsis

• Nausea

• vomiting

What are the diagnostic methods of INFECTIOUS PERITONITIS?

Physical examination identifying tenderness, guarding, and rigidity is important. Laboratory tests often show leucocytosis and elevated CRP.

What is the pharmacological treatment of INFECTIOUS PERITONITIS?

ATBs

What is the surgical treatment of INFECTIOUS PERITONITIS?

Surgical interventions include source control, cleaning of the abdominal cavity, and drainage. Urgent surgery is required for diffuse peritonitis.

What are the complications of INFECTIOUS PERITONITIS?

Complications include abscess formation and sepsis. It can lead to life-threatening conditions like diffuse peritonitis.

What is the prophylactic measures against INFECTIOUS PERITONITIS?

Observance of aseptic techniques during venous catheter insertion, frequent tubing changes, and site rotation help prevent phlebitis, which can be bacterial.

What are 3 main differential diagnoses of INFECTIOUS PERITONITIS and how do we differentiate?

Differential diagnoses depend on the source but can include acute appendicitis, acute cholecystitis, and perforated peptic ulcer. Differentiation relies on pain location, specific physical exam findings, lab tests (WBC, CRP), and imaging (USG, CT, X-ray).

What is the definition of NON-INFECTIOUS PERITONITIS?

Non-infectious peritonitis results from the leakage of sterile body fluids into the peritoneum. This is also known as chemical peritonitis.

What are the types of NON-INFECTIOUS PERITONITIS?

Types include chemical peritonitis caused by substances like blood, gastric juice, bile, or pancreatic enzymes. Blood leakage can be due to conditions like endometriosis.

What is the etiology of NON-INFECTIOUS PERITONITIS?

It is caused by the leakage of sterile body fluids into the peritoneum. Examples include gastric juice from a peptic ulcer, bile from a liver biopsy, or blood from endometriosis.

What are the risk factors of NON-INFECTIOUS PERITONITIS?

• peptic ulcers,

• liver biopsy,

• endometriosis. .

What is the pathophysiology of NON-INFECTIOUS PERITONITIS?

Leakage of sterile body fluids causes chemical irritation of the peritoneum. This chemical peritonitis can later lead to bacterial peritonitis.

What is the clinical presentation of NON-INFECTIOUS PERITONITIS?

The initial symptoms from chemical irritation may temporarily improve before bacterial peritonitis develops. The presentation often evolves into signs of diffuse peritonitis.

What are the signs of NON-INFECTIOUS PERITONITIS?

Signs may include rigidity and tenderness of the abdomen, typical of diffuse peritonitis. Tympany over the liver area can occur if air escapes into the peritoneal cavity (e.g., from perforated ulcer).

What are the symptoms of NON-INFECTIOUS PERITONITIS?

Symptoms can include severe pain, such as sudden onset stabbing epigastric pain with a perforated peptic ulcer. There may be a temporary lull in symptoms initially.

What are the diagnostic methods of NON-INFECTIOUS PERITONITIS?

Physical examination revealing signs like abdominal rigidity and tenderness is important. Imaging like plain X-ray for free air or abdominal sonography for free fluid aids diagnosis.

What is the surgical treatment of NON-INFECTIOUS PERITONITIS?

Surgical treatment is necessary if diffuse peritonitis develops. This includes source control and cleaning of the abdominal cavity.

What are the complications of NON-INFECTIOUS PERITONITIS?

Non-infectious chemical peritonitis can evolve into bacterial peritonitis. This progression can lead to diffuse peritonitis or abscess formation.

What are 3 main differential diagnoses of NON-INFECTIOUS PERITONITIS and how do we differentiate?

Perforated peptic ulcer, a cause of chemical peritonitis, must be differentiated from myocardial infarction. Differentiation involves ECG to assess cardiac function. Differentiation from other causes of acute abdomen relies on history of potential sterile fluid leakage (e.g., peptic ulcer, liver biopsy, pancreatitis history), pain characteristics, and specific imaging findings (e.g., free air).

What is the definition of STRANGULATED HERNIA?

Acute, life-threatening condition in which fatty tissue or a section of the small intestines pushes through a weakened area of the abdominal muscle. The surrounding muscle then clamps down around the tissue, cutting off the blood supply to the small intestine, causing perforation and gangrene

What is the classification of STRANGULATED HERNIA?

Primary irreducible hernia where the blood supply to the content is compromised

What is the etiology of STRANGULATED HERNIA?

It occurs when the blood supply to the content of an irreducible hernia becomes compromised. Delaying the surgical treatment of an abdominal hernia increases the risk of this complication.

What are the risk factors of STRANGULATED HERNIA?

delaying the surgical treatment of an abdominal hernia

What is the pathophysiology of STRANGULATED HERNIA?

1. The blood supply to the tissue or organ trapped within the hernia sac is cut off.

2. ischemia and potential necrosis of the incarcerated content.

What is the clinical presentation of STRANGULATED HERNIA?

• severe, sudden onset, ischemic abdominal pain

• nausea and vomiting (due to irritation of the vagal nerve)

What are the signs of STRANGULATED HERNIA?

• External strangulated hernias = painful irreducible bulging.

• intestinal obstruction or ischemia = abd USG or X-ray.

What are the symptoms of STRANGULATED HERNIA?

• severe, sudden onset abdominal pain,

• nausea,

• omiting

• intestinal obstruction

• ischemia

What are the diagnostic methods of STRANGULATED HERNIA?

• history

• physical examination

• abd USG

• X-ray,

• CT

What is the surgical treatment of STRANGULATED HERNIA?

• Open hernia repair: incision in groin & push back into abdomen. Reinforce with hernioplasty (mesh) & close by stiches/staples.

• Laparoscopic hernia repair use: inserted through a small incision at the umbilicus (belly button).

What is the prophylactic measures against STRANGULATED HERNIA?

Elective surgical repair of abdominal hernias

What are the complications of STRANGULATED HERNIA?

• bowel necrosis

• peritonitis

• Sepsis

What are 3 main differential diagnoses of STRANGULATED HERNIA and how do we differentiate?

• lymphadenopathy,

• tumor,

• arterial aneurysms.

What is the surgical treatment of GASTRIC INJURY?

1. local tissue debridement.

2. Gastrotomy / Primary closure of injury

What are the etiologies of SMALL BOWEL INJURY?

• volvulus,

• gallstone ileus,

• lymphoma,

• jejunoileal atresia,

• meconium ileus

What are the clinical presentations of SMALL BOWEL INJURY?

melena

What are the signs of SMALL BOWEL INJURY?

• Volvulus: inverted superior mesenteric artery/vein, hyperpulsatile superior mesenteric artery, thickened small-bowel wall

• gallstone ileus: calcified gallstone in an ectopic position, gas in the biliary tree, and small-bowel obstruction may be demonstrated.

• Small-bowel lymphoma: eccentric mural thickening, aneurysmal dilatation of the bowel lumen, and mesenteric lymphadenopathy.

• Jejunoileal atresia and meconium ileus: dilated loops of bowel, gas, and fluid with reduced or increased peristalsis.

What are the symptoms of SMALL BOWEL INJURY?

Melena

What are the diagnostic methods of SMALL BOWEL INJURY?

• Abd USG

• small bowel endoscopy

• video capsule endoscopy.

• Tagged red blood cells scan or mesenteric angiography

• CT angiography or MRI angiography (chronic mesenteric ischemia)

What is the surgical treatment of SMALL BOWEL INJURY?

1. debridement and closed with suturing.

2. Resection.

3. Stoma formation / restoration of continuity.

What are the clinical presentations of COLONIC INJURY?

Lower-GI bleeding typically presents with hematochezia.

What are the signs of COLONIC INJURY?

Hematochezia, bright red bleeding from the rectum, is typical for rectal and distal colonic sources and should be confirmed by rectal examination.

What are the symptoms of COLONIC INJURY?

Hematochezia, bright red bleeding from the rectum that may or may not be mixed with stool, is typical for a rectal and distal colonic source. It can range from bright red blood to old dark clots.

What are the diagnostic methods of COLONIC INJURY?

• CT

• X-ray

• colonoscopy

• mesenteric angiography

What is the surgical treatment of COLONIC INJURY?

1. primary repair (without stoma preferred),

2. resection & anastomosis,

3. repair w/ proximal diversion,

4. exteriorization.

5. Colostomy.

6. Right hemicolectomy (Severe injury to right colon)

What are 3 main differential diagnoses of COLONIC INJURY and how do we differentiate?

colorectal cancer

What are the etiologies of RECTAL INJURY?

blunt / penetrating injury to the abdomen, pelvis / thighs.

What are the risk factors of RECTAL INJURY?

Rapid insertion of foreign bodies without prior sphincter dilation increases the likelihood of injury. Associated pelvic fractures can lead to bone fragments piercing the rectum.

What is the pathophysiology of RECTAL INJURY?

Injury can involve disruption of the rectal wall and injury to the sphincters. A broken spiculated piece of bone from an associated pelvic fracture can pierce the rectum.

What are the clinical presentations of RECTAL INJURY?

• Hematochezia,

• bright red bleeding from the rectum

What are the diagnostic methods of RECTAL INJURY?

• Digital rectal examination

• Proctoscopy

• Sigmoidoscopy

• CT

• Colonoscopy

What are the complications of RECTAL INJURY?

• Injury to the sphincters

• Peritonitis

What are 3 main differential diagnoses of RECTAL INJURY and how do we differentiate?

colorectal cancer