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Peritoneal diseases and ascites

The document discusses diseases of the peritoneum and ascites, describing the peritoneum's structure, functions, and clinical implications of conditions like peritonitis and ascites. It outlines causes, symptoms, diagnostics, management strategies, and complications associated with these conditions, emphasizing the role of ascites in liver disease. Key treatments include diuretics, paracentesis, and liver transplantation for severe cases.

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Diseases of the Peritoneum and ascites Dr. Tumaini, BB MD Resident in Internal Medicine For MD students year 3 14 December 2016 Peritoneal diseases and ascites_MD3 From: peri “around” - tonos “to stretch”
Outline • Introduction • Peritonitis • Ascites 14 December 2016 Peritoneal diseases and ascites_MD3
14 December 2016 Peritoneal diseases and ascites_MD3
14 December 2016 Peritoneal diseases and ascites_MD3
Introduction • Peritoneum is a continuous transparent serous membrane which lines the abdominal cavity and covers the viscera • Peritoneal cavity is lined by visceral and parietal layers. • Visceral-poorly innervated; vague pain. • Parietal: richly innervated; very painful; pain precisely localized. • In visceral perforation contents flow inferiorly directed by anatomical landmarks; e.g., into the pelvis via paracolic gutters. 14 December 2016 Peritoneal diseases and ascites_MD3
Functions of the peritoneum • Pain perception • Visceral lubrication: • Fluid and particulate absorption • Inflammatory and immune response • Fibrinolytic activity 14 December 2016 Peritoneal diseases and ascites_MD3
Peritoneal inflammation: Causes • Bacterial infection eg. Appendicitis; TB • Chemical injury eg bile peritonitis • Ischaemic injury eg strangulated bowel • Direct trauma eg surgery • Allergic reaction eg starch peritonitis. 14 December 2016 Peritoneal diseases and ascites_MD3
Acute peritonitis • Due to invasion of peritoneal cavity by bacteria • Polymicrobial: aerobic, anaerobic (exception: Primary peritonitis due to streptococcal, pneumococcal or H. Influenza spp.) 14 December 2016 Peritoneal diseases and ascites_MD3
Bacteriology: • Bacteria from GI tract – E. coli, – Aerobic and anaerobic streptococci – Bacteroides • Non-GI causes: – PID – Chlamydia, gonococcus, – Mycobacteria e.g., Mycobacterium bovis 14 December 2016 Peritoneal diseases and ascites_MD3
Paths to peritoneal infection • Gastrointestinal perforation – E.g., Perforated peptic ulcer • Exogenous contamination – E.g., drains, trauma • Transmural bacterial translocation – E.g., Appendicitis, ischemic bowel • PID • Hematogenous infection - septicaemia 14 December 2016 Peritoneal diseases and ascites_MD3
Clinical features • Localized peritonitis – Symptoms and signs are those of the causative disease – Abdominal pain – Guarding and rigidity of the abdominal wall 14 December 2016 Peritoneal diseases and ascites_MD3
Clinical features • Generalized peritonitis – Abdominal pain – Vomiting – Abdominal rigidity with guarding and rebound tenderness – Absence of bowel sounds – Fast pulse and high temperature 14 December 2016 Peritoneal diseases and ascites_MD3
Diagnosis Mainly clinical • CBC • X-rays-chest, erect -abdominal plain • Serum amylase and lipase, creatinine, electrolytes 14 December 2016 Peritoneal diseases and ascites_MD3
Management • General – Correction of fluid and electrolyte imbalance + fluid balance charts – Gastrointestinal decompression: NGT – Antibiotic therapy: IV – Analgesia 14 December 2016 Peritoneal diseases and ascites_MD3
Management • Specific – Surgery e.g., perforated DU, appendicitis gangrenous cholecystitis – Peritoneal lavage – Non-surgical: pancreatitis, salpingitis 14 December 2016 Peritoneal diseases and ascites_MD3
Complications: systemic • Bacteremia/endotoxic shock • Bronchopneumonia/respiratory failure • Renal failure • Bone marrow suppression • Multisystem failure 14 December 2016 Peritoneal diseases and ascites_MD3
Complications-abdominal • Small bowel obstruction • Paralytic ileus • Residual/recurrent abscess • Portal pyaemia • Liver abscess 14 December 2016 Peritoneal diseases and ascites_MD3
Abscesses • Subphrenic • Subhepatic • Pelvic • Paracolic gutters • In-between bowel loops 14 December 2016 Peritoneal diseases and ascites_MD3
Tuberculous peritonitis • Acute – Resembles acute pyogenic peritonitis – Straw coloured fluid escapes at laparotomy – Tubercles are seen over peritoneum and greater omentum – Take specimen for macroscopic (caseous necrosis) and histological examination 14 December 2016 Peritoneal diseases and ascites_MD3
Tuberculous peritonitis-chronic • Origin – Tb of mesenteric lymph nodes – Ileocaecal TB – TB pyosalphinx – Blood borne TB usually milliary TB 14 December 2016 Peritoneal diseases and ascites_MD3
TB peritonitis-chronic • Types: • Ascitic form – Peritoneum seeded with TB tubercles – Ascites is preset – No pain – Diagnosis: • Exclude other causes of ascites • Ascitic fluid – exudate (protein content > 30gm/L) • Histology from other lesions e.g., tubercles 14 December 2016 Peritoneal diseases and ascites_MD3
TB peritonitis chronic • Encysted form – Similar to ascitic type but localizedto one part of abdominal cavity. – May be difficult to differentiate from a mesenteric cyst – Laparotomy needed for diagnosis 14 December 2016 Peritoneal diseases and ascites_MD3
TB peritonitis chronic • Fibrous (dry, plastic) form – There is no ascites – There are a lot of adhesions – Bowel walls are matted together – Present as bowel obstruction • Treatment – Surgery – adhesiolysis; excision of stenosed bowel – Anti-TB medications 14 December 2016 Peritoneal diseases and ascites_MD3
Ascites • The accumulation of fluid in the peritoneal cavity • Has many extraperitoneal and peritoneal causes • Commonest cause: cirrhosis 14 December 2016 Peritoneal diseases and ascites_MD3
Peritoneal fluid • It is a normal, lubricating fluid found in the peritoneal cavity • Peritoneum secretes about 50 ml of fluid per day • The fluid is mostly water with electrolytes, antibodies, WBCs, albumin, glucose and other biochemicals. • Reduces the friction between the abdominal organs as they move around during digestion. 14 December 2016 Peritoneal diseases and ascites_MD3
Patient with Ascites 14 December 2016 Peritoneal diseases and ascites_MD3
Etiology of ascites: commonest causes • Portal HTN secondary to chronic liver diseases (cirrhosis) • Congestive Heart Failure • Mycobacterium tuberculosis • Intra-abdominal malignancy 14 December 2016 Peritoneal diseases and ascites_MD3
Portal Hypertension • It is a high blood pressure in the portal vein and its tributaries(portal venous system). • It is defined as a portal pressure gradient (the difference in pressure between the portal vein and the hepatic veins) of 5 mm Hg or greater. 14 December 2016 Peritoneal diseases and ascites_MD3
Causes of portal hypertension • Intrahepatic causes: liver cirrhosis and hepatic fibrosis (e.g. due to Wilson's disease, hemochromatosis, or congenital fibrosis). • Prehepatic causes : portal vein thrombosis or congenital atresia. • Posthepatic obstruction occur at any level between liver and right heart, including hepatic vein thrombosis, IVC thrombosis, IVC congenital malformation, and constrictive pericarditis. 14 December 2016 Peritoneal diseases and ascites_MD3
Cirrhosis Commonest causes of cirrhosis: • Alcoholic liver disease or alcoholic hepatitis • viral hepatitis (B or C) • fatty liver disease 14 December 2016 Peritoneal diseases and ascites_MD3
14 December 2016 Peritoneal diseases and ascites_MD3
14 December 2016 Peritoneal diseases and ascites_MD3
Other causes of ascites Hypoalbuminemia • Nephrotic syndrome • Protein-losing enteropathy • Malnutrition 14 December 2016 Peritoneal diseases and ascites_MD3
Other causes of ascites • Bacterial, fungal or parasitic disease • Vasculitis • Whipple's Disease • Familial Mediterranean fever • Endometriosis • Starch peritonitis • Budd-Chiari Syndrome • Myxedema • Ovarian disease (e.g. Meigs Syndrome) • Pancreatic disease • Chylous Ascites 14 December 2016 Peritoneal diseases and ascites_MD3
Pathophysiology 1. Increased hydrostatic pressure • Cirrhosis • Hepatic vein occlusion (Budd-Chiari Syndrome) • IVC obstruction • Constrictive Pericarditis • Congestive heart failure 14 December 2016 Peritoneal diseases and ascites_MD3
Pathophysiology 2. Decreased colloid osmotic pressure • End-stage liver disease with poor protein synthesis • Nephrotic syndrome • Malnutrition • Protein-losing enteropathy 3. Increased permeability of peritoneal capillaries • Tuberculous peritonitis • Bacterial peritonitis • Malignant disease of the peritoneum 14 December 2016 Peritoneal diseases and ascites_MD3
Pathophysiology 4. Leakage of fluid into the peritoneal cavity • Bile ascites • Pancreatic ascites • Chylous ascites • Urine ascites 5. Miscellaneous causes • Myxedema • Ovarian disease (Meigs syndrome) • Chronic hemodialysis 14 December 2016 Peritoneal diseases and ascites_MD3
Morbidity and Mortality • Ambulatory patients with an episode of cirrhotic ascites have a 3-year mortality rate of 50%. The development of refractory ascites carries a poor prognosis, with a 1-year survival rate of less than 50%. 14 December 2016 Peritoneal diseases and ascites_MD3
Diagnosis: history Pts should be questioned about: • Liver diseases • Risk factors for viral hepatitis: IDU, needle sharing, blood transfusion, etc • Pts with obesity, diabetes, hyperlipidemia - Nonalcoholic steatohepatitis (NASH) 14 December 2016 Peritoneal diseases and ascites_MD3
• Pts with ascites who lack risk factors for cirrhosis should be questioned about to rule out cancer, heart failure, TB, dialysis, and pancreatitis • Operative injury to the ureter or bladder can lead to leakage of urine into peritoneal cavity. • HIV pts may have infections leading to ascites 14 December 2016 Peritoneal diseases and ascites_MD3
Diagnosis 2-clinical Features A - Asymptomatic (fluid <100 - 400ml): Mild ascites B - symptomatic (fluid >400ml): Increased abdominal girth, presence of abdominal pain or discomfort, early satiety, pedal edema, weight gain and respiratory distress depending on the amount of fluid accumulated in the abdomen. 14 December 2016 Peritoneal diseases and ascites_MD3
Physical examination findings: • Umbilicus Eversion (often with umbilical herniation) • Tympany at the top of the abdomen • Fluid wave • Peripheral edema • Shifting dullness (> 500ml fluid) • Bulging flanks (>500ml fluid) 14 December 2016 Peritoneal diseases and ascites_MD3
Bulging Flanks and Umbilical Hernia 14 December 2016 Peritoneal diseases and ascites_MD3
Diagnosis 3 - paracentesis • It is a diagnostic procedure to establish the etiology of new-onset ascites or to rule out spontaneous bacterial peritonitis in patients with preexisting ascites. Large volume paracentesis is performed in hemodynamically stable patients with tense or refractory ascites to alleviate discomfort or respiratory compromise. • For diagnostic purposes, a small amount (20cc) may be enough for adequate testing. 14 December 2016 Peritoneal diseases and ascites_MD3
Ascitic fluid analysis Cell count: • A white blood cell count is the most important. • A neutrophil > 250 cells/mL  spontaneous bacterial peritonitis • An elevated lymphocyte  tuberculosis or peritoneal carcinomatosis • Gram stain and culture: for bacteria and acid fast bacilli 14 December 2016 Peritoneal diseases and ascites_MD3
• RBCs Seen in hemorrhagic ascites, which usually is due to malignancy, tuberculosis or trauma. 14 December 2016 Peritoneal diseases and ascites_MD3
Serum-Ascites Albumin Gradient [SAAG] • Best single test for classifying ascites into portal hypertensive and non-portal hypertensive causes. • Calculated by: Serum albumin – Ascites albumin= SAAG SAAG >1.1 g/dL= Portal HTN SAAG < 1.1 g/dL= Non-Portal hypertensive cause 14 December 2016 Peritoneal diseases and ascites_MD3
SAAG SAAG >1.1 1. Liver Disease 2. Hepatic Congestion 3. CHF 4. Tricuspid Insufficiency 5. Massive Hepatic Metastasis SAAG <1.1 1. Peritoneal carcinomatosis 2. Peritoneal Infection (TB, Fungal, CMV) 3. Nephrotic syndrome 4. Pancreatic ascites 14 December 2016 Peritoneal diseases and ascites_MD3
• Total protein: Helpful in diagnosing spontaneous bacterial peritonitis Pts with a value<1 g/dl protein and glucose of <50mg/dl have high risk of SBP • Cytology: for malignant cells • Amylase: to exclude pancreatic ascites 14 December 2016 Peritoneal diseases and ascites_MD3
Imaging Studies Ultrasound • Easiest and most sensitive technique for detection of ascitic fluid. • Volume as small as 5-10ml can be seen. 14 December 2016 Peritoneal diseases and ascites_MD3
14 December 2016 Peritoneal diseases and ascites_MD3
diagnosis Imaging Studies Chest and Plain Abdominal Films - 14 December 2016 Peritoneal diseases and ascites_MD3
bilateral pleural effusions in a patient with ascites 14 December 2016 Peritoneal diseases and ascites_MD3
Imaging Studies CT scan • Well visualized • Fluid may be visualized in the: • Right perihepatic space • Posterior subhepatic space (Morison pouch) • Pouch of Douglas 14 December 2016 Peritoneal diseases and ascites_MD3
Large ascites displacing bowel posteriorly 14 December 2016 Peritoneal diseases and ascites_MD3
Management of Ascites The goal is to prevent Na loading and increase renal excretion of Na and H2O and produce a net re-absorption of fluid from the ascites back into the circulating volume. • Dietary Na restriction Diet of 2g sodium per day • Fluid Restriction: Only done when serum Na is <128mmol/L • Check Labs Ck serum electrolytes and creatinine every other day. Weigh the patient and measure urinary output daily. 14 December 2016 Peritoneal diseases and ascites_MD3
Management of ascites • Management of underlying disease • Dietary sodium restriction • Fluid restriction • Diuretic therapy • Large-volume paracentesis • Liver transplantation and shunts 14 December 2016 Peritoneal diseases and ascites_MD3
Management of Ascites Diuretic therapy • Spironolactone: diuretic of choice • Others: furosemide etc Paracentesis 14 December 2016 Peritoneal diseases and ascites_MD3
Paracentesis Contraindications: • Acute abdomen (absolute) • Severe bowel distention • Previous abdominal surgery (if necessary perform open procedure) • Pregnancy (if necessary perform after first trimester using an open technique above the umbilicus) • Distended bladder that cannot be relieved by foley catheder • Infection at site of insertion (cellulitis or abscess) • Thrombocytopenia (relative) • Coagulopathy (relative) 14 December 2016 Peritoneal diseases and ascites_MD3
Paracentesis Complications: • Bladder perforation • Small or large bowel perforation • Stomach perforation • Laceration of major vessels ( mesenteric, iliac, aorta) • Laceration of catheter or guide wire and loss in peritoneal cavity (requires laparotomy) • Abdominal wall hematoma • Incisional hernia • Wound infection • Wound dehiscence 14 December 2016 Peritoneal diseases and ascites_MD3
Management of Ascites Transjugular Intrahepatic Portasystemic Shunt: The TIPS procedure is an interventional radiologic technique that reduces portal pressure and may be the most effective treatment for diuretic resistant ascites. Risks: • Hepatic Encephalopathy (30% of pts) • Thrombosis and shunt stenosis. 14 December 2016 Peritoneal diseases and ascites_MD3
Management of Ascites liver transplantation: • Tx of choice • Corrects portal hypertension • Changes the natural course of progressive liver failure due to cirrhosis • Not all pts are candidates for transplant, and those who are may wait for years for a donor • Many die from complications of ascites while waiting for transplant donor 14 December 2016 Peritoneal diseases and ascites_MD3
Complications from Ascites Refractory Ascites • Fluid overload that is unresponsive to Na- restricted diet and high dose anti-diuretic treatment. • Usually in the setting of chronic or acute liver diseases with associated portal hypertension. 14 December 2016 Peritoneal diseases and ascites_MD3
Treatment of Refractory Ascites: Liver transplantation is treatment of choice. If unsuitable, treatment with: • Serial paracentesis • TIPS 14 December 2016 Peritoneal diseases and ascites_MD3
Complications of Ascites • Hepatorenal syndrome • Spontaneous bacterial peritonitis 14 December 2016 Peritoneal diseases and ascites_MD3