1- Postoperative peritonitis:
· Aetiology:Missed lesion or anastomotic leakage.
· Diagnosis:Difficult diagnosis as pain is usually masked by that of the surgical wound and general deterioration is usually diagnosed as postoperative cardiopulmonary complication.
· Treatment: No antibiotic can replace surgey in such condition.
2- Patients under steroid therapy:Pain is usually slight or absent and signs are vague and misleading.
3- In children and senile patient: History is vague and guarding and rigidity are less marked.
4- Bile peritonitis:
· Aetiology:
ü Perforated cholecystitis.
ü Postcholecystectomy.
ü Post, gastric, duodenal, or jejunal surgery.
· Diagnosis: Diffuse peritonitis with tinge of jundice. Infected bile is more lethal than sterile bile.
· Treatment: Exploration , bile evacuation and dealing with the cause. Postcholecystectomy bile leak may be dealt with by percutaneous (Ultrasound guide) drains and endoscopic biliary stenting.
5- Meconium Peritonitis:
· Aetiology: Meconium leakage from intestinal perforation on top of neonatal intestinal obstruction.
· Pathology: Aseptic peritonitis with exudation. Exudate will organize causing matting of the intestine. In many cases the meconium become calcified within weeks.
· Clinical picture: Baby born with tense abdomen and fluid thrill is often present. Vomiting and failure to pass meconium. Associated mucoviscidosis in 5:10 % of cases causing damage to the pancreas, lungs, liver and small intestine. Bronchial obstruction by viscid meconium can cause fatal pneumonia.
· Investigations: Sonar abdomen can detect fluid and plain x ray can detect calcified meconium.
· Treatment: Unless operated rapidly the prognosis is bad. Peritoneal lavage, closure of the perforation, intestinal evacuation may cure cases without mucoviscidosis. Supplements of pancreatic exocrine enzymes are often necessary throughout life.
6- Primary Pneumococcal, Streptococcal or Staphylococcal Peritonitis:
· Aetiology: Usually infection is either ascending from fallopian tubes (in female) or blood born (in male).
· Diagnosis: It is usually made when after exploration no definite cause is found. In females intravaginal forign body should always be looked for.
· Treatment: Peritoneal lavage, drans, antibiotic therapy. Recovery is usual.
7- Periodic peritonitis (Famililial Mediterranean fever):
· Aetiology: Unknown.
· Clinical picture: Periodic peritonitis with pain in thorax and joints. It is limited to Arabs, Americans, and Jews. If laparotomy is done to exclude other causes the peritoneum is found inflamed near the gall bladder and spleen.
· Treatment: Colchicine may prevent recurrent attacks.
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