2. The peritoneum is the serous membrane that forms the lining of the abdominal cavity. It covers most of the intra-abdominal organs, and is composed of a layer of mesothelium supported by a thin layer of connective tissue. This peritoneal lining of the cavity supports many of the abdominal organs and serves as a conduit for their blood vessels, lymphatic vessels, and nerves.

3. Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs.

4. Peritonitis may be localized or generalized. It may result from infection (often due to perforation of the intestinal tract as may occur in abdominal trauma or inflamed appendix) or from a non- infectious process. Generally has an acute course, & may depend on either infectious or non-infectious process. Peritonitis represents a surgical emergency.

5. Infections in the blood. liver disease(Fluid accumulates in the abdomen, creating an environment for growth of microorganisms.) Secondary peritonitis is caused by the spillage of bacteria, enzymes, or bile into the peritonium from a hole or tear in the GI or biliary tract. Tears can occur as a result of an infected organ, such as ruptured appendix or any surgical complication.

6. 1. Generalized Infected peritonitis: Perforation of part of the gastrointestinal tract is the most common cause of peritonitis. This includes: Perforation of the distal oesophagus (Boerhaave syndrome). perforation of the stomach as peptic ulcer, gastric carcinoma perforation of the duodenum (peptic ulcer) perforation of the remaining intestine (e.g., appendicitis, inflammatory bowel disease, intestinal infarction, intestinal strangulation, colorectal carcinoma.

7. Or perforation of the gall bladder (cholesystitis) Other possible reasons for perforation include abdominal trauma, ingestion of a sharp forgin body, perforation by an endoscope or catheter.

8. Disruption of the peritoneum, even in the absence of perforation of a hollow viscus, may also cause infection by letting micro-organism into the peritoneal cavity. Examples include trauma, surgical wound, continuous ambulatory peritoneal dialysis, and intra-peritoneal chemotherapy. Direct entry through an operative or traumatic wound. Intra-peritoneal dialysis predisposes to peritoneal infection Though blood spread in cases of septicemia and pyaemia but is rare. Systemic or localized infections(eg. TB)

9. pyogenic bacteria - E-coli Aerobic and anaerobic streptococci staphylococci

10. II-Non-infected peritonitis Leakage of sterile body fluids into the peritoneum, such as blood, gastric juice (e.g., peptic ulcer, gastric carcinoma), bile (e.g., liver), urine (pelvic trauma), pancreatic juice (pancreatitis). Sterile abdominal surgery under normal circumstances, causes localized or minimal generalized peritonitis through a foreign body reaction and/or fibrotic adhesions.

11. Risk factors for Primary Peritonitis:  Liver disease (cirrhosis)  Kidney damage  Fluid in the abdomen  Weakened immune system  Pelvic inflammatory disease

12.  Appendicitis (inflammation of the appendix)  Stomach ulcers  Twisted intestine  Pancreatitis  Inflammatory bowel disease  Inflamed gall bladder  Damage to pancrease  Injury caused by an operation.  Peritoneal dialysis,  Trauma.

13. In normal conditions, the peritoneum appears greyish and glistening. It becomes dull 2–4 hours after the onset of peritonitis, initially with serous or slightly turbid fluid. Inflammation, infection, ischemia, trauma, or tumor perforation leakage of contents from abdominal organs into the abdominal cavity Bacterial proliferation occurs Edema of the tissues & exudation of fluid develops in a short time.

14. Fluid in the peritoneal cavity becomes turbid (with increasing amounts of protein, white blood cells, cellular debris, and blood). The immediate response of the intestinal tract is hypermotility, followed by paralytic ileus with an accumulation of air and fluid in the bowel. Later on, the exudate becomes creamy and suppurative. It may spread to the whole peritoneum.

15. Symptoms will vary depending on the underlying cause of your infection. Common symptoms of peritonitis include: tenderness in your abdomen pain in your abdomen that gets more intense with motion or touch abdominal bloating or distension nausea and vomiting diarrhoea

16. constipation or the inability to pass gas minimal urine output anorexia, or loss of appetite excessive thirst fatigue fever and chills

17. A diagnosis of peritonitis is based on the clinical manifestations. Blood picture for identification of microorganism causing the condition & for leukocytosis. Culture of the peritoneal fluid can determine the microorganism responsible and determine their sensibility to antimicrobial agents.

18.  Computed tomography (CT or CAT scanning) may be useful in differentiating causes of abdominal pain & identify fluid in abdomen, accumulation of pus or infected organ.  Chest X-ray detects air in the abdomen, indicates the presence of a tear or perforated organ.

19. General supportive measures such as intravenous rehydration and correction of electrolyte disturbances. Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. Eg:- cefotaxim Analgesics for pain. Eg:- morphine If peritonitis is caused by peritoneal dialysis, dialysis catheter should be removed.

20. IV Fluid administration to replace body fluids. Anti-emetics are to be given to control vomiting. Bed rest, NPO status, respiratory support, if needed. Possibly rectal tube to facilitate passage of gas. Blood transfusion if appropriate. Oral feeding after return of bowel sounds and passage of flatus.

21. NPO status to be maintained 6-12 hrs before surgery. IV fluids should be replaced. Antibiotic therapy should be provided. NG suctioning should be done. Analgesics like morphine is to be given. Provide Oxygen. Preparation of the surgery by giving pre medications and monitoring the vitals.

22. Objectives include removing the infected material & correcting the cause. Appendectomy:- for an inflamed appendix that causes peritonitis. Colon resection:- for tumor formation in colon. Incision and drainage:- to drain out fluid and abscess from the abdomen. Laparotomy:- is needed to perform a full exploration and lavage of the peritoneum, as well as to correct any gross anatomical damage that may have caused peritonitis.

23. Monitor vitals. Semi fowler’s position. NPO till bowel sounds returns. NG tube to low intermittent suctioning. IV fluids and electrolyte replacement. Parenteral nutrition as needed. Antibiotic therapy. Blood transfusion if required. Sedatives and opioids to be prescribed.

24. Intra abdominal abscess formation. Septicemia Hypovolemic problems Renal or liver failure Respiratory insufficiency.

25. ASSESSMENT:- Thorough history of the patient. Assess for pain including location. Assess for abdominal distension and tenderness, guarding, rebound, hypoactive or absent bowel sounds to determine bowel function. Observe for signs of shock- tachycardia and hypotension. Monitor vital signs ABG levels, CBC, electrolytes, and central venous pressure to monitor hemodynamic status and assess for complications.

26. Acute pain related to inflammation of the peritoneum and abdominal distension. Risk for fluid deficient fluid volume related to fluid shifts into the peritoneal cavity. Imbalanced nutrition less than body requirements related to anorexia, nausea and vomiting. Anxiety related to uncertainty of cause or outcome of condition and pain.

27. INTERVENTIONS :- Place the patient in semi-fowler’s position before surgery to enable less painful breathing. After surgery place the patient in fowler’s position to promote drainage by gravity and thus reduce the pain. Provide analgesics as prescribed. Provide calm environment to the patient.

28. Keep patient NPO to reduce peristalsis. Provide IV fluids to establish adequate fluid intake and to promote adequate urine output as prescribed. Record accurately intake output, including the measurement to vomitus and NG drainage. Minimize nausea, vomiting and distension by using NG suctioning. Prescribe antiemetics. Monitor for signs of hypovolemia: dry mucous membrane, oligruria, postural hypotension, tachycardia, diminished skin turgor.

29. Administer TPN, as ordered, to maintain positive nitrogen balance until patient can resume oral diet. Reduce parentral fluids and give oral food and fluids per order when the following occurs:-  Temperature and pulse returns to normal.  Abdomen becomes soft.  Peristalsis sounds returns (auscultate it)  Flatus is passesd and patient has bowel movements.