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The peritoneum
 PERITONEAL TUBERCULOSIS:

Pathology in Peritoneal Tuberculosis

 Enormous thickening of the parietal peritoneum with multiple tiny yellowish

tubercles.
 Dense adhesions in peritoneum and omentum with content inside as small bowel
looking like abdominal cocoon. It may precipitate intestinal obstruction.
 Multiple dense adhesions between bowel loops and between bowel and peritoneum
and omentum.
 Thickening of bowel wall with adhesions.

Types

1. Acute Type—Mimics Acute Abdomen Exploratory laparotomy reveals straw-coloured fluid

with tubercles in the peritoneum, greater omentum and bowel wall. It is an on-table
diagnosis. Fluid is evacuated and collected for AFB study and culture. Omental biopsy is
taken. Abdomen is closed (without a drain) with tension sutures to prevent burst abdomen.
ATD is started.

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2. Chronic Tuberculous Peritonitis

 Present as abdominal pain, fever, ascites, loss of weight and appetite, abdominal mass,
doughy abdomen (10%).
 Peritoneum is thickened with multiple tubercles. Omentum is thick, fibrosed, rolled
up.
 Infection is usually from mesenteric lymph nodes, ileocaecal tuberculosis, from
fallopian tubes rarely blood born (from lungs).
 Laparoscopy is very useful in this type to diagnose.

Chronic TB peritonitis can present it self in four pathological forms:

1. Ascitic form
 Ascitic form shows enormous distension of abdomen with dilated veins. It presents
with congenital hydrocele in male with patent processus vaginalis, umbilical hernia,
rolled up omentum, shifting dullness, fluid thrill, and mass abdomen.
 Ascitic tap reveals straw coloured fluid from which AFB can be isolated. Fluid is pale
yellow, clear, rich in lymphocytes, with high specific gravity.
 Chest X-ray, Mantoux test are other required investigations.
 ATDs for one year are required. Repeat tapping may be required initially as part of
the treatment.

2. Encysted (Loculated) ascites

 Ascites gets Loculated because of the fibrinous deposition.
 Dullness, which is not shifting, is the typical feature.
 They may present as intra-abdominal mass, which may mimic ovarian cyst,
retroperitoneal cyst or mesenteric cyst.
 Treatment is U/S guided aspiration along with ATD‘s.

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3. Plastic type
 Here there are wide spread adhesions between the coils of the intestine (ileum
commonly), abdominal wall, omentum, with distension of the small bowel, leading to
blind loop, ileus, intestinal obstruction (sub-acute, acute), thickened parietal
peritoneum.
 They get recurrent colicky abdominal pain, diarrhoea, wasting, and loss of weight,
mass abdomen, and doughy abdomen.
 Differential diagnosis: Peritoneal carcinomatosis. Open/ laparoscopic peritoneal
biopsy is very useful tool to diagnose.
 They respond well for drug treatment. Surgery is indicated if obstruction occurs.

Laparoscopy shows plastic type of abdominal tuberculosis and multiple tubercles over parietal and
visceral surfaces of the peritoneum.

4. Purulent form
 It is invariably due to tuberculous salpingitis, presenting as a mass in the lower
abdomen containing pus, omentum, fallopian tubes, small and large bowel.
 Cold abscess gets adherent to the abdominal wall, umbilicus and may form an
umbilical fistula.
 Patient commonly has got genitourinary tuberculosis.
 U/S, discharge study, X-ray abdomen and other investigations are useful.
 Treatment: ATD’s are started exploration of umbilicus, exploration of fistula and
bowel by pass is done.
 Prognosis is poor in this type.

SUBPHRENIC SPACES AND SUBPHRENIC ABSCESS

Surgical Anatomy (By Boyd)

There are four intraperitoneal and three extraperitoneal spaces.

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1. Intraperitoneal Spaces

 Right anterior intraperitoneal space (Right subphrenic space): It is bounded by

right lobe of the liver and diaphragm, posteriorly by anterior layer of coronary and
right triangular ligament, and to the left by falciform ligament. Causes: Abscess here
occurs due to cholecystitis, perforated duodenal ulcer, postoperative, appendicitis,
duodenal cap blow out.
 Right posterior intraperitoneal space (Right subhepatic space): (Rutherford
Morison’s kidney pouch) is bounded in front by the liver and gallbladder, above by
the liver, behind by the right kidney and diaphragm, below by the transverse colon and
hepatic flexure, to the left by foramen of Winslow and duodenum. It is large and
deepest space of all. It is the most common site of subphrenic abscess. Causes:
Appendicitis, cholecystitis, postoperative, perforated duodenal ulcer, intestinal
obstruction.
 Left anterior intraperitoneal space (Left subphrenic space): It is bounded above by
the diaphragm, behind by left lobe of liver and left triangular ligament, gastrohepatic
ligament and anterior surface of the stomach, to the right is the falciform ligament.
Causes for abscess here are surgeries of the stomach, tail of the pancreas, spleen,
colon (splenic flexure), and diverticulitis.
 Left posterior intraperitoneal space: It is bounded by stomach, pancreas, greater
omentum, liver, transverse colon (Lesser sac). Most common cause here is
pseudocyst of pancreas. Rarely perforated gastric ulcer.

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2. Extraperitoneal Spaces

Right extraperitoneal space is right perinephric space and left extraperitoneal space is
left perinephric space. Causes: Abscess here is due to tuberculosis, trauma, and haematoma.

Midline extraperitoneal is bare area of the liver. Pus collects here commonly due to
ruptured amoebic liver abscess and pyogenic abscess of the liver.

Pathology of Subphrenic Abscess:

During expiration, intra-abdominal pressure (especially in subphrenic area) is reduced and so

this with capillary action and upward movement of the diaphragm make the peritoneal fluid
to move upwards towards the diaphragm. This is the reason why there is higher incidence of
subphrenic abscess and subphrenic abscess is the second most common type of intra-
abdominal abscess, first one being the pelvic abscess.

Subphrenic abscess is more common on the right side than on left (left anterior) because
infective conditions are more common on the right side (like appendicitis/perforation/liver
abscess/cholecystitis); and right paracolic gutter is wide and deep without any barrier (unlike
left side paracolic gutter which is narrow and limited above by colophrenic ligament).

Clinical Features:

Barnard’s aphorism (Harold Barnard):

“Pus somewhere, pus nowhere else, pus under diaphragm”.

History relevant of the specific causes; history of any previous surgery:

_ Fever with chills and rigors.

_ Pain in right hypochondrium, epigastrium or lower thorax.

_ Tenderness in right hypochondrium.

_ Sympathetic right sided pleural effusion due to congestion and hyperaemia of the
diaphragm.

_ Collapse of the lung/basal atelectasis—right side may be evident. Tachypnoea and

respiratory distress can be observed.

_ Pain in the right shoulder due to irritation of phrenic nerve.

_ Hiccough, tachycardia.

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_ Hoover’s sign: Scoliosis towards same side in subphrenic abscess.

_ Wasting and anorexia is common.

_ Occasionally tender mass in the right hypochondrium may be palpable.

_ Tenderness over 11th intercostal space may be evident in right subhepatic space abscess.

Bacteria causing:

_ E. coli.

_ Klebsiella.

_ Streptococci.

_ Anaerobic organisms.

Investigations:

_ Plain X-ray chest and abdomen shows soft tissue shadow, pleural effusion, tenting of
diaphragm, collapse of the lung. Fluoroscopy shows elevated right diaphragm with reduced
right sided diaphragmatic movement.

_ U/S abdomen confirms the diagnosis.

_ TC is high. There is raise in ‘C’ reactive protein.

_ CT scan is very useful to find out the extent and relation. CT shows ‘rind’ sharp outer
margin; septations; size, shape, extent, diaphragmatic position, pleural changes, displaced
bowel and other organs and communications.

_ Gallium 67 or iridium 111 isotope imaging.

Treatment:

 Antibiotics: Ampicillin, metronidazole, gentamicin, cephalosporins.

 Percutaneous drainage: Initially ultrasound guided aspiration is useful. Here, under
ultrasound or CT guidance, a catheter is placed and pus is drained. Catheters used are

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Pigtail catheter, 16 French trocar catheters or sump catheter. 90% of subphrenic abscess are
drained percutaneously.

Note: Aspiration alone is not done in subphrenic abscess.

 Open drainage is indicated (Required in 10-20% of cases) in:

 Good nutritional supplement and respiratory physiotherapy are additional support

required.

Complications:

Empyema, Respiratory arrest, Septicaemia, Sinus formation, Recurrence& Peritonitis.

PELVIC ABSCESS

_ It is the most common intraperitoneal abscess (50-60%).

_ It is the collection of pus in rectovesical or recto uterine pouch (pouch of Douglas).

Causes

_ Appendicitis.

_ Pelvic infections.

_ Sequelae of diffuse peritonitis.

_ Postoperative and other abdominal causes.

Bacteria: Bacteroides fragilis, E. coli, anaerobic streptococci.

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Clinical Features:

_ Diarrhoea.

_ Mucus discharge per rectum.

_ High temperature with chills and rigors.

_ Lower abdominal pain and distension.

_ Frequency and burning micturition.

_ P/R shows a soft, boggy, and tender swelling in the anterior wall of the rectum.

Investigations:

_ TC is raised.

_ U/S is diagnostic—shows pus in rectovesical or pouch of Douglas.

_ CT scan to find out the size and extent.

Treatment:

_ After starting antibiotics, under G/A, abscess is drained per rectally, through the boggy
area. Catheter is passed to the bladder before draining the pus.

_ In females, posterior colpotomy is done to drain the pus.

_ occasionally spontaneous rupture of the abscess into the rectum occurs leading to natural
regression.

_ When abscess is very large, when it is progressing into the general peritoneal cavity or
when in doubt, laparotomy through lower abdomen incision is done to drain the pus and to
correct the cause. Often in such cases, drainage tube can be placed through the abdomen
under U/S guidance.

_ CT or US guided insertion of drainage tube into the abscess cavity per rectally or per
vaginally or percutaneously.

_ But most often laparotomy is not necessary.