Diseases of peritoneum Lect. Al Qassim University, Faculty of Medicine Phase II Year III, CMD 332 Pathology Department 31-32

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1 Diseases of peritoneum Lect Al Qassim University, Faculty of Medicine Phase II Year III, CMD 332 Pathology Department 31-32

2 Describe the etiology, pathogenesis and types of peritonitis Define ascites and list its causes

3 PERITONITIUM Extensive serous membrane that lines the entire abdominal wall of the body and is reflected over the contained viscera Divided into the parietal peritoneum and visceral peritoneum In men the peritoneum is a closed membranous sac, in women it is perforated by the free ends of the uterine tubes Course of the peritoneum (gray) in a median sagittal section of a female

4 PERITONITIUM The free surface of the peritoneum is smooth mesothelium, lubricated by serous fluid that permits the viscera to glide easily against the abdominal wall and against one another The mesentery of the peritoneum fans out from the main membrane to suspend the small intestine Other parts of the peritoneum are the transverse mesocolon, the greater omentum, and the lesser omentum

5 Peritonitis Acute inflammation of the endothelial lining of the abdominal cavity or peritoneum, life-threatening illness Peritoneal cavity contaminated by bacteria, inflammatory reaction vascular dilation capillary permeability spread inflammation peritonitis

6 PERITONITIS inflammation of the peritoneal surfaces Acute peritonitis Suppurative (septic) peritonitis Sterile peritonitis: Due to chemical irritation of the peritoneum by blood, bile or pancreatic enzymes Rheumatic peritonitis Chronic peritonitis Tuberculous peritonitis

7 Causes of peritonitis Appendicitis Diverticulitis Gangrenous gallbladder Bowel obstruction Ulcerative colitis

8 Peritonitis--pathophysiology 1. Vascular dilation continues 2. Extra blood is brought to the area of inflammation 3. Fluid is shifted from the ECF compartment into the peritoneal cavity 4. This shifting then will affect circulatory volume 5. Hypoperfusion of kidneys can result 6. Peristalsis will slow 7. Bowel lumen will become distended with gas and fluid 8. Resp. problems can ensue

9 Presentation of Peritonitis Abdominal pain and tenderness which may be referred to the chest or shoulder these are the cardinal signs Distended abdomen Nausea, vomiting and anorexia Diminished bowel sounds Rebound tenderness High fever Tachycardia Dehydration Decreased urinary output Possible respiratory compromise

10 Diagnosis Elevated WBCs with a shift to the left (bands) Possible positive blood cultures Abdominal x-ray will reveal free air or fluid and edema Peritoneal lavage will reveal more than 500 WBCs/ml of fluid, greater than 50,000 RBCs/mL or the presence of bacteria on a gram stain

11 Malignant Peritoneal Mesothelioma Doughy feeling on abdominal palpation Male:female incidence is 1.5:1 Rapidly invasive and rapidly fatal Associated with high-dose asbestos exposures Rare

12 Mesothelioma Over 50 years Diffuse encasing Histological picture: Biphasic (epithelial & mesenchymal) Monophasic (either carcinomatous or sarcomatous). Visceral peritonium Very poor prognosis

13 Ascites Derived from the Greek word askos, meaning bag or sac. Defined as the accumulation of fluid in the peritoneal cavity It is a common clinical finding, with many extraperitoneal and peritoneal causes, but most common from liver cirrhosis

14 Peritoneal cavity It is a potential space between the parietal peritoneum and visceral peritoneum, the two membranes separate the organs in the abdominal cavity from the abdominal wall Derived from the coelomic cavity of the embryo Largest serosal sac in the body and secretes approximately 50 ml of fluid per day

15 Peritoneal fluid It is a normal, lubricating fluid found in the peritoneal cavity The fluid is mostly water with electrolytes, antibodies, white blood cells, albumin, glucose and other biochemicals. Reduce the friction between the abdominal organs as they move around during digestion

16 Etiology of ascites Most Common causes(90% of cases) Portal HTN secondary to chronic liver diseases ( cirrhosis) Congestive Heart Failure Intra-abdominal malignancy

17 Other causes of ascites Hypolalbuminemia Nephrotic syndrome Protein-losing enteropathy Malnutrition Endometriosis Budd-Chiari Syndrome Myxedema Ovarian disease (e.g. Meigs' Syndrome) Pancreatic disease Chylous Ascites Sodium and water retention due to failure of the liver to inactivate aldosterone

18 Pathophysiology of Ascites Increased hydrostatic pressure - Cirrhosis - Hepatic vein occlusion (Budd-Chiari Syndrome) - Inferior vena caval obstruction - Constrictive Pericarditis - Congestive heart failure

19 Pathophysiology of ascites Decreased colloid osmotic pressure - End-stage liver disease with poor protein synthesis - Nephrotic syndrome - Malnutrition - Protein-losing enteropathy Increase permeability of peritoneal capillaries - Tuberculous peritonitis - Bacterial peritonitis - Malignant disease of the peritoneum

20 Malignant Ascites in, often linked to ovarian, gastric, pancreas, endometrial CA in, is linked to pleural mesothelioma, gastric, colon and pancreas CA