PERITONITIS

Descriptive Definition Of Peritonitis

·      Peritonitis simply is the inflammation of the serous membrane that lines the abdominal cavity and its viscera

·         The peritoneum is a continuous thin, shiny avascular membrane which lines the abdominal cavity

·         The portion behind the muscles of the anterior abdominal wall and infront of those on the posterior abdominal wall is known as the parietal peritoneum and is richly endowed with nerve endings.  Irritation of this portion of the peritoneum gives rise to pain at the site at which it is stimulated.

·         The visceral peritoneum is the portion which is reflected to envelop most of the abdominal organs.

·         It forms the outer or serous coat of organs like the stomach and intestines and it has few nerve endings and is almost insensitive.

·         The peritoneal cavity which is the space between the parietal and visceral layers contains a film of sterile fluid. 

·         Infection or inflammation of this cavity is known as peritonitis

·         Peritonitis may affect part or the entire peritoneal cavity. 

·         Therefore peritonitis can be local or general.

·         When the infection is caused by infection of the abdominal cavity without obvious organ rupture it is said to be primary peritonitis

·         When it is from a ruptured or perforated organ it is said to be secondary peritonitis

Pathophysiology of Peritonitis and causes

·         Any break in the continuity of abdominal organs can cause spillage of chemical contents and bacteria throughout the peritoneum.

·         The presence of the irritating material leads to localized abscess formation or generalized inflammation

·         When generalized peritonitis occurs vascular fluid shifts to the abdomen, lowering blood pressure and producing hypovolemic shock.

·         If the condition is not promptly or adequately treated, death may follow.

·         The general causes of peritonitis are:

• Blood borne (rare)
• Penetrating wounds
• Closed abdominal injury causing rupture of an organ (e.g. spleen, liver, gut)
• Inflammation of an organ local peritonitis (e.g. appendicitis, cholecystitis)
• Escape of gastrointestinal contents of another organ- general peritonitis for example perforated peptic ulcer, perforated ectopic pregnancy, ruptured gall bladder, ruptured ovarian cyst)

·         General peritonitis is the most frequent

• If a portion of the gastrointestinal organs become diseased and their walls infected this infection may spread to the serous covering coat which becomes inflamed.
• The serous covering coat is part of the visceral peritoneum.  If this is inflamed it irritates the adjoining parietal peritoneum and pain is felt at the spot where this is inflamed, this is known as a local peritonitis
• If the disease progresses and the organ rupture the infected contents leak into the peritoneal cavity and a general peritonitis has developed

·         If the toxic material from the gastrointestinal tract is not sealed off the result is:

• Widespread absorption of toxins
• Paralysis of the intestines.  Nature tries to limit the outpouring of septic contents by rest.

Specific causes

·         The specific causes of general peritonitis are:

• Perforated acute appendicitis
• Perforated gastric or duodenal ulcer
• Perforated diverticulitis
• Acute pancreatitis
• Rupture of the intestine, rectum, or the bladder secondary to inflammation, trauma, obstruction, neoplasm
• Ruptured ovarian cyst, uterus or fallopian tubes
• Ruptured spleen or liver-closed abdominal trauma
• Abdominal wounds penetrating the peritoneal cavity
• Haematogenous (blood- borne) infection

Signs and Symptoms and diagnostic findings

·         Severe abdominal pain and tenderness

·         Nausea and vomiting

·         Fever as infection becomes established

·         Client avoids movement of the abdomen when breathingbecause such movement increases pain

·         Lack of bowel motility

·         Abdomen feels rigid and boardlike as it distends with gas and contents that cannot normally pass through the gastrointestinal tract.

·         Bowels sounds absent

·         Pulse rate  elevated

·         Respiration rapid and shallow

·         If peritonitis is unresolved severe weakness, hypotension and a drop in body temperature as the client nears death

Diagnostic findings

·         Leucocytosis

·         Presence of free air and fluid within the peritoneum as seen in radiographs

·         A CT scan may identify structural changes within abdominal organs

Management of a Patient with Peritonitis

The principles of treatment are:

·         To terminate if possible lesion which threaten to cause general peritonitis

·         To treat shock

·         To rest the gastrointestinal tract-food and purgatives are forbidden and aspiration of the stomach contents is undertaken

·         To counteract infection. Treatment with gentamycin and intravenous metronidazole should be commenced before operation

·         To cut off the source of irritant or infection e.g. suture of a perforation or removal of a perforated appendix

·         To cleanse or drain the peritoneum of septic contents and pus.  This involves not only sucking out pus at operation but also intraperitoneal lavage with saline so that all pus, fecal material, and fibrin are removed.

·         A long vertical incision may be necessary to do so.

Nursing management

• Monitor the acutely ill patient
• Prepare for diagnostic tests and surgery
• Control pain by giving analgesics using good judgment when administering narcotics
• Give I.V fluids which should be uninterrupted
• Adminster antibiotics
• A Nasogastric tube is passed and connected to suction
• Insert urinary retention catheter
• Take frequent vital signs
• Provide frequent mouth care
• Place the patient in a fowlers position to promote the collection of fluid below the diaphragm
• Encourage slow but deep breathing on a regular basis.
• Give oxygen therapy if needed
• Plan hygiene during periods when clients discomfort is reduced
• Support the incision when the client deep beathes and coughs.
• To relive fear stay with the client as much as possible
• Permit a supportive family member to stay with the patient
• If client asks to see a member of the clergy facilitate it and provide chance for praying and spiritual counseling.

Complications Following Peritonitis

·         Wound evisceration

·         Abscess formation

·         Wound dehiscence