Faecal Peritonitis

John Hartley M62 Course March 2007

Faecal peritonitis

Definitions  The clinical sequela of free contamination of the peritoneal cavity with faecal material  Differs from other forms of peritonitis in magnitude and speed of systemic disturbance

Faecal peritonitis

Causes  Perforated diverticular disease      Anastomotic failure Stercoral perforation Perforation of a “threatened caecum” - left sided obstruction - pseudoobstruction Perforated toxic megacolon Trauma

The classification of perforated diverticular disease     Stage I: Stage II: Stage III: Stage IV: Localised pericolic or mesenteric abscess Confined pelvic abscess Generalised purulent peritonitis from ruptured abscess

Faecal peritonitis from free colonic perforation

Hinchey EJ et al Adv Surg 1978;12:85-109

Faecal peritonitis - pathophysiology

Faecal peritonitis-definitions

 SIRS: 2 or more of:     Temperature > 38°C or < 36°C Heart rate > 90 bpm Resp rate > 20 breaths.min PaCO2 < 4.3kPa (32mmg) -1 WBCs > 12 or < 4 (or >10% immature forms) or

Faecal peritonitis-definitions

   Sepsis  = SIRS with documented infection site Severe Sepsis  Sepsis + organ dysfunction, hypoperfusion or hypotension Septic Shock  Severe sepsis (SBP < 90mmHg) despite adequate fluid resuscitation

Faecal peritonitis

Clinical features  Peritonitis + some degree of the SIRS

pathway:

  Septic shock Multiple organ failure

Faecal peritonitis

Investigations    FBC, BCP, Amylase Erect CXR AXR 

Think before CT scan please

Faecal peritonitis

Principles of Management  Rapid resuscitation

to enable

  Source control

followed by

Physiological support until recovery (or death)

Faecal peritonitis

Management  Vigorous resuscitation in the

appropriate setting - Oxygen - Adequate volume - Monitor response - +/- inotropes - Antibiotics

Faecal peritonitis

The goals of resuscitation   MAP CVP >65mmHg 8-12mmHg    Urine output >0.5ml/kg/hr Within the first 6 hrs

What to do with non-responders?

Early Goal Directed Therapy in the Treatment of Severe Sepsis. Rivers et al NEJM 2001; 345:1368 77

Faecal peritonitis

Operative management   Generous access Remove particulate matter   Generous lavage Identify source

Faecal peritonitis-operative management Source control    Resect or exteriorise the perforation - Hartmann’s - TAC and end ileostomy

Avoid primary anastomosis

Occasionally - drainage, lavage, proximal diversion

Faecal peritonitis – importance of source control No. of reops 0 1 2 3 4 5 N 156 46 15 10 5 7 From Christou et al 1993 6 5 7 Planned reops 0 25 7 Mortality (%) 27 43 40 30 40 57

Faecal peritonitis-operative management   Primary anastomosis (or laparoscopic lavage) versus Hartmann’s procedure for complicated diverticular disease Primary anastomosis in 61 of 127 pts undergoing emergency surgery, 3% mortality and 2% anastomotic leak rate

Biondo S et al Br J Surg 2001;88:1419



Probably not relevant in faecal peritonitis

Faecal peritonitis – operative management Hartmann’s procedure    

Excise the perforation

Intraperitoneal rectal stump vs mucous fistula vs buried stump +/- Drainage

A viable colostomy

Faecal peritonitis – operative management The difficult colostomy   Adequate mobilisation Use the upper abdomen   Stoma through the wound Stapled off blind end and proximal loop

Faecal peritonitis

Closure versus laparostomy  Consider laparostomy when - Can’t close the abdomen  - Concern over source control - Concern over ischaemia

Beware abdominal compartment syndrome

Faecal peritonitis – reasonable expectations? (www.riskprediction.org.uk) Physiological parameters Age <61

>80 >80

Cardiac failure No/mild

Moderate Moderate

Systolic BP Pulse rate 100-170 101-120 100-170 101-120

<90mmHg >120

Operative parameters Hb Urea CEPOD

Predicted mortality

13-16 <10 Operation type Major Peritoneal contamination Malignancy Free bowel content No cancer Emergency

13%

13-16 <10 Major Free bowel content No cancer Emergency

70%

13-16

>15

Major Free bowel content No cancer Emergency

92%

Faecal peritonitis

Planned re-laparotomy versus laparotomy on demand?

    No randomised studies Non-significant reduction in mortality with the latter approach Little role for scheduled re-laparotomies Clear source at first operation

Faecal peritonitis

Aftercare  ICU support  Steady improvement or:     Failure to progress +/- Signs ongoing sepsis Progressive MOF

Usually not a surgically remediable cause

- CT scan +/- percutaneous drainage - Re-laparotomy

Faecal peritonitis

Summary   Prompt resuscitation Initial source control      Avoid primary anastomosis Close abdomen where possible ICU support Re-laparotomy on demand High mortality

Faecal peritonitis

Conclusions   Recognition of the problem, and Primary source control by surgeons   Physiological support in a multidisciplinary setting Outcome should be determined by the response to sepsis rather than ongoing sepsis

Faecal peritonitis

More definitions:  SIRS  Sepsis  Septic shock