Diseases of the Peritoneum

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The peritoneum is an extensive membrane which lines the whole of the inside of the abdomen, enveloping all of the contained organs, and extending downwards in front of them as a double fold, or apron, known as the omentum. The whole peritoneal surface is almost equal in area to the skin surface of the body.

Acute Peritonitis

Causes
Acute peritonitis is due to bacterial infection, usually from the alimentary canal. The most common seat of the primary condition is an inflamed appendix. The infection passes through the damaged walls of the appendix, leading to the formation of peritoneal adhesions and possibly of an appendix abscess.

When the infection is particularly virulent, or the patient's resistance is unusually low, a spreading infection of the whole peritoneal cavity occurs, causing the coils of intestine to become glued together with a sticky exudate, and leading to acute general peritonitis. As well as infection due to a ruptured appendix, peritonitis may follow infection caused by perforation of stomach or duodenal ulcers, an infected gall-bladder, or perforating wounds of the abdomen, intestinal surgery, or septic abortions.

Primary pneumococcal peritonitis may occur in children, especially girls between the age of six and ten, from infection through the genital passages.

Other cases of primary peritonitis are seen in which there is no apparent infection of any abdominal organ. In such cases the organisms presumably reach the peritoneum by the bloodstream from an infected focus elsewhere in the body.

Abdominal pain is the earliest and most constant symptom, usually central and in front; vomiting follows and generally the pain becomes more local, with tenderness and fever. If the infected organ is near the abdominal wall, the central pain may be absent, and local pain occurs at the outset. The patient lies immobile.

The pulse increases up to 100 or 120 per minute, and diminishes in volume, giving rise to the `wiry' pulse of late peritonitis. The temperature begins to rise and the tongue becomes dry and furred. In the early stages, and especially in young and vigorous patients, the abdomen has an immovable board-like rigidity, and is extremely tender on pressure. The patient lies with his knees drawn up to relieve the abdominal tension and the movements of respiration are confined to the chest. Unless the condition is relieved by surgical operation, the paralysed intestine gradually becomes dilated and the abdomen distended. Vomiting then becomes frequent, the vomited matter being exceedingly foul. The breath is offensive and the urine scanty.

Throughout the whole course of the disease the outstanding feature is the pain, which may at first be intermittent and colicky but soon becomes constant and agonising, and is increased by the smallest movements. In old, fat, or feeble persons, whose muscles are poorly developed, pain and rigidity may be slight or absent, though the other features remain.

Treatment
The condition is always dangerous and must be diagnosed as soon as possible. Treatment must be directed at removing the cause, e.g. surgical removal of an infected appendix, or surgical treatment of a perforated peptic ulcer.

Until a definite diagnosis has been made and operation agreed to, no morphine or opium should be given in any form, since it masks the symptoms.

It is important also that at no time previous to operation should any fluid or food be given by mouth, as it will tend to leak away through any existing perforation in the abdomen, and thus cause a further spread of infection. The most that should be allowed is an occasional moistening of the tongue with a few drops of water. Above all, no purgatives (castor oil, etc.) should be given, as these have often caused the rupture of an already inflamed appendix. An enema, however, may be required to clear the lower bowel before operation is undertaken, and saline solution (1 level teaspoonful of salt to the pint of warm water) may be given by this route to combat the collapse and relieve thirst.

The intestines meanwhile are rested by passing a Ryle's tube and aspirating the contents of the stomach at frequent intervals. In severely collapsed patients, fluid may be given intravenously.

Operation is followed by drainage of the peritoneal cavity with a tube. Both before and after operation the patient should be propped up in bed in a sitting position to allow the infective material to gravitate downwards to the lower abdomen and pelvic cavity, where the peritoneum has a diminished absorptive surface and from where it can be removed more easily.

The outlook in acute peritonitis has been greatly improved by the use of antibiotics. They are commonly used both for prevention and for treatment, as the infection in these cases is usually a mixed one.

Tubereulous Peritonitis
Chronic tuberculous peritonitis is often associated with tuberculosis in other parts of the body, especially of the lungs. Most cases occur between the ages of 3 and 20 years. In children (who do not often have tuberculosis of the lungs) the drinking of tuberculous milk may lead to infection of the abdominal lymph glands, which in turn gives rise to infection of the peritoneum. The condition is now relatively rare in Great Britain.

Symptoms
The onset is gradual. The general symptoms of ill health which are common to all types of tuberculosis are the first to appear. The patient loses weight and strength, the appetite is poor, and the temperature tends to become slightly raised at night.

After a time there are symptoms of general abdominal discomfort, which are especially marked after exercise or hard work. Attacks of colic, together with either constipation or diarrhcea may occur in the later stages.

Treatment
The most important prophylactic measures are the provision of a pure milk supply, the removal of children from contact with adults suffering from active pulmonary tuberculosis, and inoculation with the B.C.G. vaccine.

Open Am. When the disease has actually developed, the patient should be kept in bed completely at rest so long as his temperature is raised. Complete rest in bed may be necessary for several months and, whenever possible, the child should be nursed in an open-air hospital or sanatorium.

Diet
The diet should be as liberal and as nourishing as possible, with extra milk, cream, butter and eggs. Cod-liver oil or halibut-liver oil should also be given together with ascorbic acid (Vitamin C).

Medication
Diarrhoea should be treated with a non-irritating fluid or semi-fluid diet, and by an intestinal sedative medicine containing kaolin. The standard treatment today is to combine streptomycin and isoniazid. The dosage of streptomycin is 20 milligrammes per pound of body weight per day for at least three months, while isoniazid is given in a dosage of 5 milligrammes per pound of body weight per day, also for at least. three months.

Operation is only rarely indicated, though fluid may require to be withdrawn from a distended abdomen.

Cancer of the Peritoneum Cancer of the peritoneum is nearly always secondary to cancer of one of the abdominal organs, especially the stomach or the ovary. The disease may also follow cancer of the breast. Malignant peritonitis generally leads to ascites and may cause extensive peritoneal adhesions with possible obstruction of the intestine. The navel is often infiltrated with growth.

Treatment
This is purely palliative, and it is rare for a patient to survive for more than six months after the peritoneum becomes involved. Considerable relief may follow tapping of the abdomen for fluid.

Additional Resource:
Peritoneum in Wikipedia

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