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| Year : 1987 | Volume
: 33
| Issue : 2 | Page : 61-4 |
Post-operative irrigation in the management of amoebic peritonitis.
Dalvi AN, Gondhalekar RA, Upadhye AS
How to cite this article:
Dalvi A N, Gondhalekar R A, Upadhye A S. Post-operative irrigation in the management of amoebic peritonitis. J Postgrad Med 1987;33:61 |
Acute peritonitis, secondary to intra abdominal rupture of amoebic liver abscess, is an infrequent but serious complication of invasive amoebiasis. It is associated with a high morbidity and mortality. In the present study, we tried to test the use of post-operative irrigation to see if it can help in reducing the mortality and morbidity following this complication.
During a period of about 4 years from March 1982 to January 1986, from among the patients hospitalized with signs and symptoms of peritonitis, 24 cases were found to have amoebic peritonitis, the diagnosis of which was established by identification of E. histolytica in the peritoneal fluid in 10 patients and in the rest 14, by operative findings characteristic of amoebic liver abscess. Their ages varied from 20 to 70 years. Twenty two subjects were males and two, females. Abdominal tenderness with rigidity was the most common clinical presentation. Five of these cases were admitted in a state of shock, 10 showed elevation of the right dome of diaphragm and 3 showed pleural effusion. Abdominal paracentesis was positive in all cases.
At operation, all cases were found to have peritonitis of diffuse nature with necrotic material scattered all over the peritoneal cavity. The right lobe was seen to have ruptured in 19 cases. The control group of 14 cases received conventional treatment in the form of supportive fluid and electrolyte replacement along with antibiotics, metronidazole, supportive drugs and laparotomy. Removal of necrotic material, peritoneal toilet and drainage were also accomplished. In the group of 10 patients with irrigation, management was essentially the same in all respects but at the conclusion of laparotomy, canula and drains were inserted and lavage instituted. The infusion canula was inserted by a stab wound in the right upper quadrant and placed near the site of rupture. Two large tube drains were inserted through separate stab incisions and placed in the right paracolic gutter and pelvis respectively. The drains were connected to a slow suction by means of a Y connection. Normal saline solution was infused through the canula at a rate of 2000 ml per 24 hours. This was continued till the perfusate was clear.
Morbidity and mortality were compared in these two groups.
Patients in both the groups were comparable with respect to their age, site of rupture, general condition and the amount of peritonitis.
Six out of 14 patients expired in the control group giving a mortality rate of about 43% whereas only 2 out of 10 patients in the irrigation group succumbed resulting in 20% mortality. The morbidity as seen in both the groups is shown in [Table 1].
Dramatic improvement in the clinical condition with rapid restoration of the intestinal activity was noted in all patients of group II.
Rupture of amoebic liver abscess into the free peritoneal cavity results in peritonitis with high morbidity and/or mortality rates. Reported figures vary between 2.5 and 17%.[6] Morbidity of peritonitis is readily appreciated when one realises that diffuse peritonitis involves a mesothelial surfaced 22000 sq cm and is equivalent to 75-100 of body surface burns. Just as debridement plays a major role in the management of surface wounds and burns, so also mechanical cleansing by continuous peritoneal lavage may be expected to benefit the large inflammed, peritoneal surface.
Role of surgery in the treatment of amoebic peritonitis is controversial. The condition, in previous years, was thought to be fatal if surgically intervened.[3] De-Bakey and Ochsner,[5] in 1951, reported no survivors in their 12 cases. However, removal of the necrotic material, peritoneal toilet and drainage of the peritoneal cavity are practised by many surgeons.[9],[12],[14],[15] Lamont and Pooler[9] had no mortality in their 5 cases. Paul[12] reported 50% survival in 16 cases. Singh et al[14] reported a decrease in mortality from 80% in the conservative treatment group to 14% in a group of 21 cases treated surgically Wallace,[15] reviewing the literature reported a mortality of 49%.
Peritoneal lavage as a method of treating; peritoneal sepsis was first described by Price (as quoted by McKenna et al[10]), Burnett et al[4] and Artz et al[1] reported a decrease in mortality using peritoneal lavage. It is recognised that diffuse peritonitis may follow a fulminant course. A profound toxicity usually ensues with extensive inflammation of the peritoneum. Debris removal in the host would require massive expenditure of energy derived from protein and fat catabolism. A protracted recovery period and a significant nutritional depletion are prevented by lavage of this debritus from the recesses of the peritoneal cavity. Kelley and Vast[8] have shown that lavage of the peritoneum with balanced salt solution rapidly restores the metabolic derangement to normal. In case of peritonitis, Filler and Sleeman[7] have demonstrated that the elimination of small molecules from the peritoneal cavity is highly effective but the peritoneal emptying of cellular debris, particles and microbes is slow. Residual infection in peritonitis and its association with haemoglobin derivatives are often refractory to antibiotics given by conventional parenteral routes. Towards the end of the operative procedures for patients with generalized peritonitis, several authors have recommended irrigation of the peritoneal cavity with antibiotic solution. Continuous peritoneal lavage was advocated by Aune and Norman,[2] McKenna et al,[10] and Pickard.[13]
It has been shown by peritoneography[10] that there is a rapid dispersion of fluid into all the recesses of the peritoneal cavity. In some controlled studies,[2],[10] safety and efficacy of continuous peritoneal lavage has been demonstrated. Both series of patients had a significant decrease in morbidity and mortality. Moukhtar and Romney,[11] in managing purulent sepsis of the pelvis, have used peritoneal lavage with good results.
The principle of peritoneal irrigation, was studied in cases of amoebic peritonitis which in the conventional way, has high morbidity and mortality rates. In our experience, as suggested by the results, there is a significant reduction in mortality and morbidity, and a faster recovery in patients subjected to post-operative irrigation.
We thank Dr. G. B. Parulkar, the Dean, Seth G. S. Medical College and K. E. M. Hospital, Bombay, for allowing us to publish the hospital data.
| 1. | Artz, C. P., Barnett, W. O. and Grogan, J. B.; Further studies concerning the pathogenesis and the treatment of peritonitis. Ann. Surg., 155: 756-767, 1962.  |
| 2. | Aune, S. and Normann, E.: Diffuse peritonitis treated with continuous peritoneal lavage. Acta Chir: Scand., 136: 401-404, 1970. |
| 3. | Biggam, R. G.: Rupture of amoebic liver abscess into the peritoneal cavity, Certain points concerning its diagnosis and treatment. J, Trap. Med, Hyg., 17: 285- 287, 1931. |
| 4. | Burnett, W. E., Brown, R. G., Rosemond, G. P., Caswell, H. T., Buchor, E. B. and Tyson, R. R.: The treatment of peritonitis using peritoneal lavage. Ann. Surg., 145: 675-682, 1957. |
| 5. | DeBakey, M. E. and Ochsner, A.: Hepatic amoebiasis. A 20 year experience and analysis of 263 cases. Int. Abstr. Surg., 92: 209-231, 1951. In, Surg. Gynaecol. & Obstet., March 1951. |
| 6. | Eggleston, F. C., Handa, A. K. and Verghese, M.: Amoebic peritonitis secondary to amoebic liver abscess. Surgery, 91: 46-48, 1982. |
| 7. | Filler, R. and Sleeman, H. K.: Pathogenesis of peritonitis; I-The effect of E. coli and hemoglobin on peritoneal absorption, Surgery, 61: 385-392, 1967. |
| 8. | Kelley, R. A. and Vast, S. A.: The potentiality of peritoneum as a dialyzing membrane. J. Urol, 68: 539-545, 1952 |
| 9. | Lamont, N. M. E. and Pooler, N. R.: Hepatic amoebiasis. Quart. J. Med., 27:389-412, 1958. |
| 10. | McKenna, J. P., MacDonald, J. A. Mahoney, L. J. and Lanskaill, J. C.: The use of continuous post-operative peritoneal lavage in management of diffuse peritonitis. Surg. Gynaecol. & Obstet., 130: 254-258, 1970. |
| 11. | Moukhtar, M. and Romney, S.: Continuous intraperitoneal antibiotic lavage in the management of purulent sepsis of the pelvis. Surg. Gynaecol. & Obstet., 150: 548-550, 1980. |
| 12. | Paul; M.: New concepts on amoebic abscess of the liver. Brit. J. Surg., 47: 502-514, 1960. |
| 13. | Pickard, R. G.: Treatment of peritonitis with pre- and post-operative irrigation of peritoneal cavity with noxythiolin solution, Brit. J. Surg., 59: 642-648, 1972. |
| 14. | Singh, K. P., Sreemannarayana, J. and Mehdiratta, K. S.: Intra-peritoneal rupture of amoebic liver abscess. Int. Surg., 62: 432-434, 1977. |
| 15. | Wallace, R. J. (Jr.), Greenberg, S. B., Lau, J. M., Kalchoff, W. P., Mangold, D. E. and Martin, R.: Amoebic peritonitis following rupture of an amoebic liver abscess, successful treatment of two patients. Arch. Surg., 113: 322-325, 1978, |
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