Peritonitis priorities
1 / 35

Peritonitis Priorities - PowerPoint PPT Presentation

  • Uploaded on

Peritonitis Priorities. Paul Finan Department of Colorectal Surgery Leeds General Infirmary. Peritonitis Classification. Primary - often spontaneous and single organism Secondary - multiple organisms, perforations, leaks, ischaemia etc

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Peritonitis Priorities' - blair-barlow

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Peritonitis priorities

Peritonitis Priorities

Paul Finan

Department of Colorectal Surgery

Leeds General Infirmary

Peritonitis classification

  • Primary - often spontaneous and single organism

  • Secondary - multiple organisms, perforations, leaks, ischaemia etc

  • Tertiary - no organisms, disturbance in host immune response

Priorities in peritonitis early recognition
Priorities in PeritonitisEarly Recognition

  • Often classical clinical picture but….

  • Beware of immuno-suppressed patients

  • Elderly patients

  • Post-operative patients with cardiac problems

  • Unexplained failure to progress clinically

Peritonitis priorities radiological support
Peritonitis PrioritiesRadiological Support

  • Plain films e.g. free gas or unexplained ileus

  • Abdominal ultrasound – simple collections

  • CT scanning – of particular value in the post-operative patient

  • Labelled white cell scans

  • MR imaging – no experience

Peritonitis priorities1
Peritonitis Priorities

Wound Care Specialists



Nutritional Team

Nursing Staff


Surgical Staff

Scoring systems1
Scoring Systems

An effort to quantify case mix and so estimate outcome

  • APACHE – initially 34 variables

  • APACHE II – reduced to 12 variables

  • Sepsis Score (SS)

  • Sepsis Severity Score (SSS)

Prognostic scoring systems in peritonitis
Prognostic Scoring Systems in Peritonitis

Comparison of APACHE II, APS, SSS, MOF and MPI, in 50 patients with peritonitis

  • All scoring systems predicted outcome in univariate analysis

  • APACHE II and MPI contributed independently in a multivariate analysis

  • All patients with an APACHE II of >20 or MPI >27 died in hospital

Bosscha et al 1997

Peritonitis priorities2
Peritonitis Priorities

Source Control

Source Control

Damage Limitation

Source control
Source Control

  • Drainage of abscesses

  • Debridement of devitalised tissue

  • Diversion, repair or excision of focus of infection from a hollow viscus

Source control drainage of abscesses
Source ControlDrainage of abscesses

Surgical or non-surgical drainage governed by..

  • Clinical state of patient

  • Site of collection

  • Extent of collection

  • Underlying aetiology

Non surgical drainage of intra abdominal abscesses
Non-surgical Drainage of Intra-abdominal Abscesses

A study of PCD in 96 patients with 137 abscesses accumulated over a 3-year period

  • Successful resolution in 70% after a single procedure and 82% with a second drainage

  • More often successful in post-operative abscesses.

  • Poorer results with pancreatic abscesses and those containing yeasts

Cinat et al 2002

Non surgical drainage of intra abdominal abscesses1
Non-surgical drainage of Intra-abdominal Abscesses

A study of 75 patients undergoing PCD of intra-abdominal abscess

  • Successful treatment in 62/75 patients (83%)

  • Success associated with unilocular collections, <200 mls., APACHE score <30 and accessible regions

Betsch et al 2002

Source control debridement of devascularised tissue
Source ControlDebridement of Devascularised Tissue

  • Most commonly encountered in necrotic pancreatitis

  • Removal of dead bowel

  • Debridement of other necrotic intra-abdominal tissue

Source control management of the source of contamination
Source ControlManagement of the Source of Contamination

  • Excision – appendicitis, cholecystitis

  • Repair – perforated ulcer, early iatrogenic injury

  • Diversion +/- excision – leaking anastamosis

    NB These are the decisions that require experience

Damage limitation
Damage Limitation

  • Procedures at the time of surgery

  • Decisions in the post-operative period

Damage limitation decisions at the time of surgery
Damage LimitationDecisions at the time of Surgery

  • Management of the infective source

  • Peritoneal toilet and removal of particulate matter

  • Peritoneal lavage

  • Drains

  • Wound closure

Damage limitation post operative decisions
Damage LimitationPost-operative Decisions

  • Re-laparotomy

  • Laparostomy

  • Interval imaging

  • Duration of antibiotic therapy

Re laparotomy in peritonitis
Re-laparotomy in Peritonitis

  • Failure to progress clinically

  • Prompted by radiological imaging

  • Where viability is in doubt

  • Failure to control source of infection

Relaparotomy for secondary peritonitis
Relaparotomy for Secondary Peritonitis

Meta-analysis comparing planned relaparotomy and laparotomy on demand

  • No randomised studies

  • Non-significant reduction in mortality with the latter approach

  • Evidence based on eight heterogeneous studies

Lamme et al 2002


Abdominal wall cannot or should not be closed

  • Major loss of the abdominal wall

  • Visceral or retroperitoneal oedema

  • If decision has already been taken to perform a re-laparotomy

  • Likelihood of creating abdominalcompartment syndrome

Peritonitis priorities3
Peritonitis Priorities

Wound Care Specialists



Nutritional Team

Nursing Staff


Surgical Staff

Antibiotics in peritonitis
Antibiotics in Peritonitis

  • Consideration to source of infection and likely bacteria

  • Fewer drugs for shorter periods of time

  • A policy of reculture and change if necessary

  • No clear benefit of a particular regimen in the Cochrane review (Wong et al 2005)

Peritonitis priorities conclusions
Peritonitis PrioritiesConclusions

  • Multi-disciplinary approach

  • Increasing role of the radiologist

  • Emphasis on source control

  • Need for correct decision at time of laparotomy

  • Lack of trial evidence