International Journal of Surgery: Elroy Patrick Weledji, Marcelin Ngowe Ngowe
International Journal of Surgery: Elroy Patrick Weledji, Marcelin Ngowe Ngowe
International Journal of Surgery: Elroy Patrick Weledji, Marcelin Ngowe Ngowe
Review
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 28 January 2013
Accepted 18 February 2013
Available online 6 March 2013
An overview of intra-abdominal sepsis is necessary at this time with new experimental studies, scoring
systems and audits on management outcomes. The understanding of the pathophysiology of the peritoneum in the manifestation of surgical sepsis and the knowledge of the source of pathogenic organisms
which reach the peritoneal cavity are crucial in the prevention of intra-abdominal infection. Interindividual variation in the pattern of mediator release and of end-organ responsiveness may play a
signicant role in determining the initial physiological response to major sepsis and this in turn may be a
key determinant of outcome. The ability to identify the presence of peritoneal inammation probably has
the greatest inuence on the nal surgical decision. The prevention of the progression of sepsis is by
early goal-directed therapy and source control. Recent advances in interventional techniques for peritonitis have signicantly reduced the morbidity and mortality of physiologically severe complicated
abdominal infection. In the critically ill patients there is some evidence that the prevention of gut
mucosal acidosis improves outcome.
The aim of this review is to ascertain why intra-abdominal sepsis remains a major clinical challenge
and how a better understanding of the pathophysiology may enable its prevention and better
management.
Method: Electronic searches of the medline (PubMed) database, Cochrane library, and science citation
index were performed to identify original published studies on intra-abdominal sepsis and the current
management. Relevant articles were searched from relevant chapters in specialized texts and all
included.
2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords:
Peritoneum
Localized peritonitis
Generalized peritonitis
Intra-abdominal abscess
Mannheim peritonitis index (MPI)
Early goal-directed therapy
Source control
Gut tonometry
1. Introduction
Intra-abdominal sepsis is one of the most challenging situations
in surgery and usually presents as peritonitis.1e5 Gastrointestinal
perforation, with leakage of alimentary contents into the peritoneal
cavity, is a common surgical emergency and may have lifethreatening sequelae. The mortality of perforated viscus increases
with delay in diagnosis and management.1e3,9e12 The recently reported 12-fold variation in the 30-day mortality rate following
emergency abdominal surgery in Britain ranged from 3.6% in the
best performing hospital to 41.7% in the worst.5 This would be
alarming in the developing world where an overall mortality rate of
less than 17% is reported.12 This shows that surgical outcome depends on a complex interaction of many factors and the success
obtained with the early onset of specic therapeutic procedures.
* Corresponding author. Department of Clinical Sciences, Faculty of Health Sciences, University of Buea & Department of Surgery, Regional Hospital, Buea, S.W.
Region, Cameroon. Tel: 237 99 92 21 44.
E-mail address: [email protected] (E.P. Weledji).
1743-9191/$ e see front matter 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijsu.2013.02.021
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where resuscitation with crystalloid will likely lead to an abdominal compartment syndrome may benet from a laparostomy.34,35
Source control dened as any procedure, or series of procedures that eliminates infectious foci, controls factors that promote on-going infection and corrects or controls anatomic
derangements to restore normal physiologic function.21,22 Source
control failure is more likely in patients with delayed (>24 h)
procedural intervention, higher severity of illness (Acute physiology and chronic health evaluation score or APACHE > 15),
advanced age (>70 years), co-morbidity, poor nutritional status,
and a higher degree of peritoneal involvement (i.e. a high MPI
score), and is heralded by persistent or recurrent intra-abdominal
infection, anastomotic failure, or stula formation.12,13,16,21,22 Untreated, colonic perforation with faecal peritonitis is rapidly fatal e
death results from septicaemia and multiple organ failure caused
by the absorption of pathogenic bacteria load and their toxins from
the peritoneal cavity.3,5
3.1. Implications on surgical management
Localised peritonitis occurs because peritoneal resistance to
infection relies upon localization rather than dispersal of a
contaminant.28,29 The inhibition of peritoneal brinolysis permits
stabilization of brinous exudates and limits the spread of infection. The omentum abdominal policeman and the intraperitoneal
viscera also have a remarkable ability to conne infection as seen
for example in acute appendicitis, perforated duodenal ulcer/
diverticular disease.29e31 Thus, localised peritonitis implies either
contained or early perforation of a viscus or inammation of an
organ in contact with anterior parietal peritoneum. For instance, a
palpable mass in the right iliac fossa represents either an inamed
mass of adherent omentum, appendix and adjacent viscera, or an
abscess. Conservative treatment with later drainage of any abscess
had been the standard and diffuse peritonitis was usually fatal.30,31
Surgery for appendicitis evolved when the mortality associated
with perforated appendicitis was high. Although only a few patients progressed to the potentially lethal complications, early
surgery for all patients with suspected appendicitis became the
denitive method of preventing severe peritoneal sepsis.10 The
prognosis after appendicectomy is excellent.30 An appendix mass is
often detected only after the patient has been anaesthesized and
paralysed. Thus, the differentiation of a phlegmonous mass from an
abscess is not a practical problem because surgery is the correct
management for both. Such a policy renders any debate on interval
appendicectomy redundant. Operation during the rst admission is
expeditious and safe, provided steps are taken to minimize postoperative sepsis. The consequences of missing a carcinoma in the
elderly patient or other pathology including ileoecaecal TB, lymphoma etc are also abolished.10
Generalised peritonitis will occur when there is failure of
localization. Failure of localization may arise for the following reasons: a) a rapid contamination that does not permit localization as in
a perforated colon/anastomotic leak, b) persistent or repeated
contamination that overwhelms an attempt to overcome it, c) a
localized abscess that continues to expand and ruptures into the
peritoneal cavity (e.g. appendix, diverticular abscess).26,30,31 The
peritoneal cavity becomes acutely inamed with production of an
inammatory exudate which spreads through the peritoneum
leading to intestinal dilatation and paralytic ileus. Early denitive
primary or re-operative surgery leading to the removal of necrotic
tissue, the drainage of abscesses, and the control of peritoneal
soilage (source control) may be effective in the intra-abdominally
septic patient.12,21,49 Ongoing intestinal ischaemia with doubt
about intestinal viability is best managed by exteriorizing the bowel
ends after resection of the ischaemic bowel and a second-look
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Ethical approval
No ethical approval was required as it is a simple review article.
Funding
A quarterly research allowance to university lecturers from the
Ministry of Higher Education, Cameroon.
Author contribution
Dr Elroy Patrick Weledji (FRCS) e Senior Lecturer, Anatomy &
Surgery in the Department of Clinical Sciences is the main Author
and Researcher.
Prof Marcelin Ngowe Ngowe e Professor of Surgery and Dean of
the Faculty provided facilities and contributed ideas to the
manuscript.
Conict of interest
There is no conict of interest.
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