peritoneum, mesentery omentum, rp
TRANSCRIPT
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Peritoneum, mesentery,
omentum and retroperitoneum
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PeritoneumPeritoneum is a membrane located within the
abdominopelvic cavity that covers the surface of both the organs that lie in the abdominal cavity and the inner surface of the abdominal cavity itself.
• Serosa, or visceral peritoneum:
covers organs within peritoneal cavity, pain insensitive
• Parietal peritoneum:
lines inner surfaces of body wall, very pain sensitive
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Peritoneal Fluid
• Is produced by serous membrane lining
• Provides essential lubrication
• Separates parietal and visceral surfaces
• Allows sliding without friction or irritation
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Mesentery
• Tissue between mesothelial surfaces:
– Provides an access route to and from the digestive tract for passage of blood vessels, nerves, and lymphatic vessels
– Stabilize positions of attached organs
– Prevents entanglement
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• Is a thick mesenterial sheet
• Provides stability
• Permits some independent movement
• Suspends all but first 25 cm of small intestine
• Initial portion of small intestine (duodenum) and pancreas fused with posterior abdominal wall, locking structures in position
The Mesentery Proper
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Omentum• Greater and lesser omenta are peritoneal
folds that pass from stomach to the liver, transverse colon, spleen, bile duct, pancreas and diaphragm.
• They are separated via the foramen of Winslow and Epiploic foramen
• Originates from dorsal and ventral midline mesenteries of embryonic gut.
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Bacterial Peritonitis
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Intra-abdominal infections result in 2 major clinical manifestations
• Early or diffuse infection results in localized or generalized peritonitis.
• Late and localized infections produces an intra-abdominal abscess.
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2 Major Types
• Primary: Caused by the spread of an infection from the blood & lymph nodes to the peritoneum. Very rare < 1%
• Usually occurs in people who have an accumulation of fluid in their abdomen (ascites).
• Also seen in septicemia.
• The fluid that accumulates creates a good environment for the growth of bacteria.
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• Secondary: 1. Direct Infection
• Caused by the entry of bacteria or enzymes into the peritoneum from the gastrointestinal or biliary tract.
• This can be caused due to an ulcer eroding through stomach wall or intestine when there is a rupture of the appendix or a ruptured diverticulum.
• Also, it can occur due to a burst intestine or injury to an internal organ which bleeds into the internal cavity.
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2. Local Extension
• From an inflamed organ
• Migration through gut wall
• Via Fallopian tubes
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Both cases are very serious &
can be life threatening if not
treated properly!!!
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• Post op Peritonitis
• Steroid Induced Peritonitis
• Biliary Peritonitis
• Meconium Peritonitis
• Pneumococcal Peritonitis
• Post Abortion
• Starch Peritonitis
Special variants
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Meconium Peritonitis
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Histopathology of typical flask-shaped ulcer of intestine
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Complications of Peritonitis
• Acute intestinal obstruction due to adhesions.
• Paralytic Ileus
• Residual Abscess 1. Pelvic
2. Sub Phrenic
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Intestinal Obstruction
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Signs & Symptoms
• Swelling & tenderness in the abdomen
• Fever & Chills
• Loss of Appetite
• Nausea & Vomiting
• Breathing & Heart Rates
• Shallow Breaths
• Hypotension
• Oliguria and renal shutdown
• Inability to pass gas or feces
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Contd…
• An acutely ill patient of peritonitis tends to lie “very” still because any movement causes excruciating pain.
• They will lie with there knees bent to decrease strain on the tender peritoneum.
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Examination & Evaluation
• Check vitals of patient first. Check for difficulty breathing, low blood pressure & signs of dehydration.
• Feel & press the abdomen to detect any swelling & tenderness in the area as well as signs of fluid has collected in the area.
• Listen to the bowel sounds.
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• The abdomen may be rigid and boardlike.
• Accumulations of fluid will be notable in primary due to ascites
• The usual bowel sounds made by the active intestine will be absent on auscultation, because the intestine usually stops functioning.
Evaluation cont:
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Exams cont..:• Blood Tests
• Erect or lateral decubitus X-rays of chest and abdomen.
• USG abdomen
• CT Scan
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Plain erect x-ray showing Gas DIAPHRAGM
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Perforated Gastric Ulcer
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• Antibiotics are prescribed to control the infection & intravenous therapy (IV) is used to restore hydration.
• Morphine for pain.
• Mainstay is surgery…an exploratory laparotomy is often necessary to remove the source of infection and to treat underlying cause.
Treatment
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Tubercular Peritonitis
• Acute• Mimics acute bacterial peritonitis• Tubercles studded all over.
• Chronic• Origin
– Tubercular mesenteric nodes– Ileocecal TB– TB PYOSALPINX– PULMONARY/ MILIARY
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Presentations
• Ascitic
• Encysted/ Loculated
• Plastered
• Purulent
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Treatment
• Antitubercular drugs are mainstay.
• Surgical intervention in cases of tense ascites, perforations, adhesions leading to bowel obstruction.
• Nutritional support
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Peritoneal Tumors• Carcinoma Peritonei:
– due to metastases from GI Tumors, ovarian, breast, bronchus.• Discrete Nodules, Plaques, Diffuse Adhesions(Plastered
abdomen)
• Pseudomyxoma Peritonei– Ruptured mucinous cyst of ovary,mucocoele of appendix
– Locally malignant, no metastases
• Mesothelioma– Highly malignant, mimics prostatic carcinoma, ??asbestos
– cytoreduction, chemotherapy (pemetrexed and cisplatin)
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Peritoneal Calcifications
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Pseudomyxoma Peritonei
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Pseudomyxoma Peritonei
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Mesenteric Cysts• 3 major types
– Chylolymphatic
– Enterogenous (arises from diverticula on mesenteric border)
– Dermoid/ Teratoma
• Symptoms– Usually painless; sometimes Chr. Intermittent pain, can
become acute excruciating when there is torsion/ hemorrhage
• “Tillauxs” sign- lateral mobility of cyst• CT scan is investigation of choice• Rx- surgical resection is sufficient but enterogenous
type requires resection and anastomosis.
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Chylogenous Mesenteric Cyst
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Dermoid Cyst Enterogenous Cyst
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USG CT Scan
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Retroperitoneal Fibrosis• Primary
– Ormonds d/s• Due to antibodies to CEROID( lipoprotein)
• Men> Female, involves retroperitoneum below renal arteries first and then spreads all over.
• Secondary– Drugs (methysergide, hydrazaline, B blockers)
– Malignancies( Ca Prostate, NHL,
– Autoimmune disorders( SLE, AS)
• Presents with features of the organ involved.• CT scan is Investigation of choice.• Surgical debulking and corticosteroids, cyclosporine,
azathioprione and tamoxifen chemotherapy.
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Retroperitoneal Fibrosis
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