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The production of pancreatic enzymes is suppressed by restricting the patient's oral intake of food patient in conjunction with the use of long-acting somatostatin analogues. The patient's nutrition is maintained by total parenteral nutrition.
This treatment is continued for 2–3 weeks, and the patient is observed for improvement. If no improvement is seen, the patient may receive endoscopic or surgical treatment. If surgical treatment is followed, an ERCP is needed to identify the site of the leak.
Fistulectomy is done in which the involved part of the pancreas is also removed.
A pancreatic fistula is an abnormal communication between the pancreas and other organs due to leakage of pancreatic secretions from damaged pancreatic ducts. An "external" pancreatic fistula is one that communicates with the skin, and is also known as a pancreaticocutaneous fistula, whereas an internal pancreatic fistula communicates with other internal organs or spaces. Pancreatic fistulas can be caused by pancreatic disease, trauma, or surgery.
Depending on the severity of the patient's state, the management of peritonitis may include:
- General supportive measures such as vigorous intravenous rehydration and correction of electrolyte disturbances.
- Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. The empiric choice of broad-spectrum antibiotics often consist of multiple drugs, and should be targeted against the most likely agents, depending on the cause of peritonitis (see above); once one or more agents are actually isolated, therapy will of course be target on them.
- Gram positive and gram negative organisms must be covered. Out of the cephalosporins, cefoxitin and cefotetan can be used to cover gram positive bacteria, gram negative bacteria, and anaerobic bacteria. Beta-lactams with beta lactamase inhibitors can also be used, examples include ampicillin/sulbactam, piperacillin/tazobactam, and ticarcillin/clavulanate. Carbapenems are also an option when treating primary peritonitis as all of the carbapenems cover gram positives, gram negatives, and anaerobes except for ertapenem. The only fluoroquinolone that can be used is moxifloxacin because this is the only fluoroquinolone that covers anaerobes. Finally, tigecycline is a tetracycline that can be used due to its coverage of gram positives and gram negatives. Empiric therapy will often require multiple drugs from different classes.
- Surgery (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. The exception is spontaneous bacterial peritonitis, which does not always benefit from surgery and may be treated with antibiotics in the first instance.
If properly treated, typical cases of surgically correctable peritonitis (e.g., perforated peptic ulcer, appendicitis, and diverticulitis) have a mortality rate of about <10% in otherwise healthy patients. The mortality rate rises to about 40% in the elderly, or in those with significant underlying illness, as well as cases that present late (after 48 hours).
Without being treated, generalised peritonitis almost always causes death. The stage magician Harry Houdini died this way, having contracted streptococcus peritonitis after his appendix ruptured and was removed too late to prevent spread of the infection.
Ascites is generally treated while an underlying cause is sought, in order to prevent complications, relieve symptoms, and prevent further progression. In patients with mild ascites, therapy is usually as an outpatient. The goal is weight loss of no more than 1.0 kg/day for patients with both ascites and peripheral edema and no more than 0.5 kg/day for patients with ascites alone. In those with severe ascites causing a tense abdomen, hospitalization is generally necessary for paracentesis.
Treatments in high SAAG ("transudate") are:
Salt restriction is the initial treatment, which allows (production of urine) since the patient now has more fluid than salt concentration. Salt restriction is effective in about 15% of patients. Water restriction is needed if serum sodium levels drop below 130 mmol L.
Since the mechanism behind chylothorax is not well understood, treatment options are limited. Drainage of the fluid out of the pleural space is essential to obviate damage to organs, especially the inhibition of lung function by the counter pressure of the chyle. Another treatment option is pleuroperitoneal shunting (creating a communication channel between pleural space and peritoneal cavity). By this surgical technique loss of essential triglycerides that escape the thoracic duct can be prevented. Omitting fat (in particular FFA) from the diet is essential. Either surgical or chemical pleurodesis are options: the leaking of lymphatic fluids is stopped by irritating the lungs and chest wall, resulting in a sterile inflammation. This causes the lung and the chest wall to be fused together which prevents the leaking of lymphatic fluids into the pleural space. The medication octreotide has been shown to be beneficial and in some cases will stop the chylothorax after a few weeks.
In animals, the most effective form of treatment until recently has been surgical ligation of the thoracic duct combined with partial pericardectomy. There is at least one case report (in a cat) of clinical response to treatment with rutin.
Treatment is directed at the underlying condition and usually surgical.
Treatment of Meigs' syndrome consists of thoracentesis and paracentesis to drain off the excess fluid (exudate), and unilateral salpingo-oophorectomy or wedge resection to correct the underlying cause.
The management of lipodermatosclerosis may include treating venous insufficiency with leg elevation and elastic compression stockings; in some difficult cases, the condition may be improved with the additional use of the fibrinolytic agent, stanozol. Fibrinolytic agents use an enzymatic action to help dissolve blood clots.
Stanozol is injected directly into the affected area, Venous Ablation has also been known to help circulation in patients.
Surgical decompression can be achieved by opening the abdominal wall and abdominal fascia anterior in order to physically create more space for the abdominal viscera. Once opened, the fascia can be bridged for support and to prevent loss of domain by a variety of medical devices (Bogota bag, artificial bur, and vacuum devices using negative pressure wound therapy ).
Treatment is variable, both due to its rarity and to its frequently slow-growing nature. Treatment ranges from watchful waiting to debulking and hyperthermic intraperitoneal chemotherapy (HIPEC, also called intraperitoneal hyperthermic chemotherapy, IPHC) with cytoreductive surgery.
Given its rarity, there are no established guidelines for the treatment of peritoneal mesothelioma. The modern approach to malignant peritoneal mesothelioma includes cytoreductive surgery, hyperthermic intraperitoneal chemotherapy (HIPEC), intraperitoneal chemotherapy, and intravenous chemotherapy. These are often used in conjunction and in a complementary fashion, and this multifaceted approach has significantly improved outcomes when compared to intravenous chemotherapy alone. For instance, the reported median survival time for patients with stage IV mesothelioma as reported by the American Cancer Society is 12 months; however, with adequate cytoreduction, intraperitoneal, and intravenous chemotherapy combined, some authors report 10-year survival rates projected at nearly 75%.
Multiple factors have been shown to be significant in predicting the outcome and overall survival. Age greater than 60 at surgery, more overall disease burden (defined as a PCI greater than 15), complete cytoreduction (no visible disease), and epitheliod subtype pathology have all been shown to be predictors of both mortality and disease progression. These known predictors notwithstanding, many patients with advanced peritoneal mesothelioma are still surgical candidates, and even patients with the highest possible score on the peritoneal carcinomatosis index (39) can be completely reduced to a PCI of 0 with adequate surgery.
A peritoneal inclusion cyst is a cyst-like structure that appears in the pelvis due to non neoplastic reactive mesothelial proliferation, often as a consequence of prior episodes of pelvic inflammation, as can occur in pelvic inflammatory disease. It has the potential to mimic ovarian cysts, hydrosalpinx or even malignancy, due to its nonspecific anechoic appearance.
Surgical intervention is nearly always required in form of exploratory laparotomy and closure of perforation with peritoneal wash. Occasionally they may be managed laparoscopically.
Conservative treatment including intravenous fluids, antibiotics, nasogastric aspiration and bowel rest is indicated only if the person is nontoxic and clinically stable.
Pneumoperitoneum is (abnormal presence of air or other gas) in the peritoneal cavity, a potential space within the abdominal cavity. The most common cause is a perforated abdominal viscus, generally a perforated peptic ulcer, although any part of the bowel may perforate from a benign ulcer, tumor or abdominal trauma. A perforated appendix seldom causes a pneumoperitoneum.
In the mid-twentieth century, an "artificial" pneumoperitoneum was sometimes intentionally administered as a treatment for a hiatal hernia. This was achieved by insufflating the abdomen with carbon dioxide. The practice is currently used by surgical teams in order to perform laparoscopic surgery.
The standard of care for mucinous adenocarcinoma with clinical condition PMP involves cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC), by surgical oncologists who specialize in treating PMP. Some surgeons also apply early post-operative intraperitonial chemotherapy (EPIC), adjunct to surgical cytoreduction and HIPEC. In situations where surgery is not required immediately, patients can be monitored via CT scans, tumor marker laboratory tests, and physical symptoms, to determine when, and if, surgery is warranted. Although some surgical procedures may be rather extensive, patients can and do recover from surgery, and the majority of these patients can and do live productive lives.
In debulking, the surgeon attempts to remove as much tumor as possible. CRS or cytoreductive surgery involves surgical removal of the peritoneum and any adjacent organs which appear to have tumor seeding. Since the mucus tends to pool at the bottom of the abdominal cavity, it is common to remove the ovaries, fallopian tubes, uterus, and parts of the large intestine. Depending upon the spread of the tumor, other organs might be removed, including but not limited to the gallbladder, spleen, and portions of the small intestine and/or stomach. For organs that cannot be removed safely (like the liver), the surgeon strips off the tumor from the surface.
Pneumoperitoneum can be described as peritoneal emphysema, just as pneumomediastinum can be called mediastinal emphysema, but "pneumoperitoneum" is the usual name.
Omental infarction, or omental torsion, is an acute vascular disorder which compromises tissue of the greater omentum—the largest peritoneal fold in the abdomen.
Lipodermatosclerosis (also known as "chronic panniculitis with lipomembranous changes", "hypodermitis sclerodermiformis", "sclerosing panniculitis", and "stasis panniculitis") is a skin and connective tissue disease. It is a form of lower extremity panniculitis, an inflammation of the layer of fat under the epidermis.
Neutrophilic lobular panniculitis is a cutaneous condition characterized by inflammation of the subcutaneous fat.
Complications are often diagnosed post-operatively, which can be differentiated through duplex ultrasound scanning and are bit observed until 24 to 48 hours for early complications such as drainage, infection, formation of haematocele, rupture, etc., but also for 1 to 6 weeks during follow-up on out-patient basis.
Asbestos is a known cause of peritoneal mesothelioma in humans.
A 1975 study of three small villages in central Cappadocia, Turkey—Tuzköy, Karain and Sarıhıdır—found that peritoneal mesothelioma was causing 50% of all deaths. Initially, this was attributed to erionite, a zeolite mineral with similar properties to asbestos, but detailed epidemiological investigation demonstrated that the substance causes the disease mostly in families with a genetic predisposition to mineral fiber carcinogenesis. The studies are being extended to other parts of the region.
Because a splenic rupture permits large amounts of blood to leak into the abdominal cavity, it can result in shock and death. Generally a nonoperative approach is chosen in those who are hemodynamically stable with non-worsening symptoms. During this period of nonoperative management strict bed rest between 24–72 hours with careful monitoring along with a CT 7 days after the injury.
If an individual's spleen is enlarged, as is frequent in mononucleosis, most physicians will advise against activities (such as contact sports) where injury to the abdomen could be catastrophic.
Patients whose spleens have been removed must receive immunizations to help prevent infections such as pneumonia. This helps to replace the lost function of this organ.
Acquired perforating dermatosis (also known as "Acquired perforating collagenosis") is clinically and histopathologically similar to perforating folliculitis, also associated with chronic kidney failure, with or without hemodialysis or peritoneal dialysis, and/or diabetes mellitus, but not identical to Kyrle disease.