Acute inflammation of the peritoneum. The main causes and manifestations of inflammation of the peritoneum

There is a wonderful episode in the well-known comedy of the Soviet era “Pokrovsky Gates” in which Rimma Markova (a surgeon), smoking a cigarette on a clip, answers her friend on the phone that she should cut without waiting for peritonitis (it was about appendicitis). Indeed, this state is serious threat for the life of the patient, and the delay in the operation in literally words of death are like.

According to statistics, the disease is diagnosed in 15-20% of patients with an "acute abdomen", and in 11-43% it causes an emergency laparotomy (revision of the abdominal organs). Despite significant advances in medicine, mortality in this pathology is quite high and ranges from 5 to 60 percent or more. A large range of numbers is explained by many factors: the cause and stage of the process, its prevalence, the age of the patient, comorbidities, and others.

Peritonitis: definition

Peritonitis is called aseptic inflammation or bacterial infection of the peritoneum, and, accordingly, develops in the abdominal cavity. This process is a formidable complication of inflammatory diseases of the abdominal organs and is included in the group of acute surgical pathologies referred to as "acute abdomen". According to statistics, this disease develops in 15-20% of cases in patients with acute surgical diseases, and the need for emergency laparotomy in this regard reaches 43%. Mortality with such a complication is noted in 4.5 - 58% of cases. The huge range of numbers is explained by many factors (the cause and stage of the process, its prevalence, the age of the patient, and others).

The high mortality in this condition is due to two points:

• untimely treatment of patients for specialized care;
• an increase in the number of elderly patients (the process is not so acute, which leads to a late visit to the doctor);
• an increase in the number of patients with cancer;
• errors and difficulties in diagnosing the process, inappropriate treatment;
• severe course of the process in case of its spread (diffuse peritonitis).

A bit of anatomy

The abdominal cavity is lined from the inside with a serous membrane called the peritoneum. The area of ​​this shell reaches 210 meters and is equal to the area of ​​the skin. The peritoneum has 2 sheets: parietal and visceral. The visceral peritoneum covers the internal organs of the abdomen and pelvis and is their third layer, for example, the uterus has the endometrium (inner layer), myometrium and serosa.

The parietal sheet covers the abdominal walls from the inside. Both layers of the peritoneum are represented by a single continuous membrane and contact over the entire area, but form a closed bag - the abdominal cavity, which contains about 20 ml of aseptic fluid. If in men the abdominal cavity is closed, then in women it communicates with the external genitalia with the help of the fallopian tubes. Visually, the peritoneum looks like a shiny and smooth shell.

The peritoneum performs a number of important functions. Due to the secretory-resorptive and absorption functions, the serous membrane produces and absorbs up to 70 liters of fluid. The protective function is provided by the content of lysozyme, immunoglobulins and other immunity factors in the abdominal fluid, which ensures the elimination of microorganisms from the abdominal cavity. In addition, the peritoneum forms ligaments and folds that fix the organs. Due to the plastic function of the peritoneum, the focus of inflammation is delimited, which prevents the further spread of the inflammatory process.

Causes of the disease

The leading cause of this complication is bacteria that enter the abdominal cavity. Depending on the route of entry of microorganisms, 3 types of inflammation of the peritoneum are distinguished:

Primary peritonitis

The inflammatory process in this case occurs against the background of the preserved integrity of the internal organs of the abdomen and is the result of spontaneous blood dissemination of bacteria into the peritoneum. Primary inflammation of the peritoneum, in turn, is divided into:

• spontaneous peritonitis in children;
• spontaneous inflammation of the peritoneum in adults;
• tuberculous inflammation of the peritoneum.

Pathogenic pathogens represent one type of infection or monoinfection. Streptococcus pneumoniae are the most common. In sexually active women, inflammation of the peritoneum is usually caused by gonococci and chlamydia. In the case of peritoneal dialysis, gram-positive bacteria (eubacteria, peptococci and clostridia) are detected.

In children, spontaneous inflammation of the peritoneum, as a rule, occurs in the neonatal period or at 4–5 years of age. At four or five years of age, systemic diseases (scleroderma, lupus erythematosus) or kidney damage with nephrotic syndrome serve as a risk factor for the development of this complication.

Spontaneous inflammation of the peritoneum in adults often occurs after emptying (draining) of ascites, which is due to cirrhosis of the liver or after prolonged peritoneal dialysis.

Tuberculous lesions of the peritoneum occur with tuberculous lesions of the intestines, fallopian tubes (salpingitis) and kidneys (nephritis). Mycobacterium tuberculosis with blood flow from the primary focus of infection enter the serous cover of the abdominal cavity.

Secondary peritonitis

Secondary inflammation of the peritoneum is the most common variety described complication and includes several varieties:

• inflammation of the peritoneum due to impaired integrity of internal organs (as a result of their perforation or destruction);
• postoperative;
• post-traumatic inflammation of the peritoneum as a result of blunt trauma to the abdomen or penetrating injury to the abdominal cavity.

The causes of the first group of inflammation of the peritoneum are the following types of pathologies:

• inflammation of the appendix (appendicitis), including perforation of the appendix (gangrenous and perforated appendicitis);
• inflammation of the internal genital organs in women (salpingitis and oophoritis, endometritis), as well as ruptured ovarian cysts or fallopian tube with an ectopic pregnancy or in the case of pyosalpinx;
• intestinal pathology (intestinal obstruction, intestinal diverticula, Crohn's disease with perforation of ulcers, perforation of duodenal ulcers, perforation of intestinal ulcers of other etiologies: tuberculosis, syphilis, etc., malignant tumors of the intestine and their perforation);
• diseases of the liver, pancreas and biliary tract (gangrenous cholecystitis with perforation of the gallbladder, suppuration and rupture of various hepatic and pancreatic cysts, rupture of parapancreatic cysts, cholelithiasis).

Peritonitis after surgery is released in separate group, despite the fact that this type of disease is caused by an injury to the abdomen. But it should be taken into account that the trauma caused by the operation is applied to the patient under certain conditions, in compliance with the rules of asepsis, and the negative response of the body to the surgical trauma is associated with complex anesthetic management.

Post-traumatic inflammation of the peritoneum occurs as a result of a closed abdominal injury or due to a penetrating wound of the abdomen. Penetrating wounds can be caused by a gunshot wound, stabbing objects (knife, sharpening) or due to iatrogenic factors (endoscopic procedures accompanied by damage to internal organs, abortion, curettage of the uterus, hysteroscopy).

Tertiary peritonitis

This type inflammation of the peritoneum is the most difficult in both diagnosis and treatment. In fact, this is a recurrence of the transferred peritoneal inflammation, and, as a rule, occurs after surgery in those patients who have experienced emergency situations, as a result of which their body's defenses are significantly suppressed. The course of this process is characterized by an erased clinic, with the development of multiple organ failure and significant intoxication. Risk factors for tertiary peritoneal inflammation include:

• significant exhaustion of the patient;
• a sharp decrease in the content of albumin in plasma;
• identification of microorganisms resistant to multiple antibiotics;
• progressive multiple organ failure.

Tertiary inflammation of the peritoneum is often fatal.

Development mechanism

How quickly this complication develops, and how difficult it will be, is largely determined by the state of the body, the virulence of microorganisms, and the presence of provoking factors. The mechanism of development of inflammation of the peritoneum includes the following points:

• paresis of the intestine (lack of peristalsis), which leads to a violation suction function peritoneum, as a result of which the body is dehydrated and loses electrolytes;
• dehydration leads to a decrease in pressure, which ends with a rapid heartbeat and shortness of breath;
• the rate of development of the inflammatory process and its prevalence are directly proportional to the number pathogenic microbes and severity of intoxication;
• microbial intoxication is complemented by autointoxication.

Classification

There are many classifications of inflammation of the peritoneum. To date, the classification recommended by WHO is used:

Depending on the flow:

• acute peritonitis;
• chronic inflammation of the peritoneum.

Depending on the etiological factor:

• aseptic inflammation of the peritoneum;
• microbial (infectious) peritonitis.

Origin of the complication:

• inflammatory;
• perforative (perforation of internal organs);
• traumatic;
• after operation;
• hematogenous;
• lymphogenous;
• cryptogenic.

Depending on the exudate:

• serous peritonitis;
• hemorrhagic;
• fibrinous;
• purulent peritonitis;
• putrid or ichorous.

Depending on the spread of inflammation:

• delimited (appendicular, subdiaphragmatic, subhepatic and others);
• common:
  • diffuse - the defeat of the peritoneum covered 2 floors of the abdominal cavity;
  • spilled - inflammation of the peritoneum more than two areas of the abdominal cavity;
  • general - the inflammatory process is distributed throughout the area of ​​\u200b\u200bthe peritoneum.

Viral peritonitis does not develop in humans, it is diagnosed only in animals (cats, dogs).

Symptoms

With peritonitis, the symptoms are very diverse, but have a number of similar signs. Clinic this disease depends on its stage and primary pathology, the age of the patient, previous treatment and the presence of severe concomitant processes. Particular attention is required for elderly patients, in whom inflammation of the peritoneum proceeds blurred and atypically. Signs of peritonitis are combined into a number of characteristic syndromes.

Pain syndrome

This syndrome is inherent in every form of inflammation of the peritoneum. Localization of pain, its irradiation and character depends on the primary disease. For example, in the case of perforation of a stomach or duodenal ulcer, a very sharp pain like a stab (dagger pain), the patient may lose consciousness. In this case, the pain syndrome is localized in the epigastric region. In the case of perforation of the appendix, the patient indicates the localization of pain in the iliac region on the right.

As a rule, sudden sharp pain and rapid development of the disease up to a shock-like state are observed in such acute surgical pathologies as strangulation intestinal obstruction, pancreatic necrosis, perforation of an intestinal tumor, mesenteric vein thrombosis. In the case of an inflammatory disease, the clinical picture increases gradually. The intensity of pain depends on the duration of peritonitis.

The maximum severity of the pain syndrome is at the beginning of the disease, while the pain intensifies with the slightest movement of the patient, a change in body position, sneezing or coughing, and even when breathing. The sick person takes a forced position (on a sore side or on his back), with his legs brought to his stomach and bent at the knees, tries not to move, coughs and holds his breath. If the primary focus is located in the upper abdomen, the pain radiates to the shoulder blade or back, supraclavicular region or behind the sternum.

Dyspeptic syndrome

With peritonitis, intestinal and stomach disorders are manifested in the form of nausea and vomiting, retention of stools and gases, loss of appetite, false urge to defecate (tenesmus), and diarrhea. At the beginning of the disease, nausea and vomiting occur reflexively, due to irritation of the peritoneum.

As inflammation of the peritoneum further progresses, intestinal insufficiency increases, which leads to a violation of the motor-evacuation function (weakening, and then a complete absence of peristalsis), and is manifested by a delay in stool and gases. If the inflammatory focus is localized in the small pelvis, tenesmus, multiple loose stools and urination disorders join. Similar symptoms characteristic of retrocecal phlegmonous or gangrenous appendicitis.

Case Study

At night (as usual), a young woman of 30 years old was delivered by ambulance. Complaints of very severe pain in the lower abdomen for 5-6 hours. The pains become more intense over time, pulling, sometimes cutting. The temperature is 38 degrees, there is nausea, there was vomiting several times, frequent and painful urination. First of all, the gynecologist on duty was called. On examination, the abdomen is tense, painful in the lower sections, the Shchetkin-Blumberg symptom is positive, more in the iliac region on the right. During gynecological examination the uterus is not enlarged, elastic, displacements behind the neck are sharply painful. The region of the appendages is sharply painful, it is not possible to feel possible inflammatory formations. The posterior fornix swells, sharply painful on palpation. When performing a puncture through the posterior vaginal fornix, a large number of cloudy peritoneal fluid (more than 50 ml). Preliminary diagnosis: Pelvic peritonitis (inflammation of the peritoneum in the small pelvis) Acute right-sided adnexitis? I called for a consultation with a surgeon. The surgeon is very experienced, he palpated the stomach and with the words: “Not mine”, he retired to his place. Within two hours the patient was carried out infusion therapy. After 2 hours, the patient's condition did not improve, the pain syndrome persists. The decision was made to perform an exploratory laparotomy. The surgeon refused to assist. After dissection abdominal wall and examining the appendages (a slight hyperemia of the fallopian tube on the right - mild salpingitis), the surgeon appears in the operating room (apparently, something suggested that it might be “this is his”) and stands at the table. He conducts an audit of the intestine, primarily the caecum, and discovers gangrenous retrocecal appendicitis. An appendectomy is performed, the abdominal cavity is drained. The postoperative period without features.

I gave this case as an example: it is easy to miss peritonitis even, it would seem, with such a banal disease as appendicitis. The vermiform appendix is ​​not always located typically, it is not for nothing that surgeons say that appendicitis is the monkey of all diseases.

Intoxication-inflammatory syndrome

Typical signs of this syndrome are the temperature, which rises to 38 degrees and above, fever alternates with chills, the growth of leukocytes in the peripheral blood and the acceleration of ESR. Breathing becomes more frequent, its frequency exceeds 20 respiratory movements per minute, the pulse quickens (frequently) to 120 - 140 per minute. It is characteristic that the heart rate does not correspond to the rising temperature (the pulse is ahead of the temperature).

Peritoneal syndrome

This syndrome is caused by a variety of signs found during examination of the patient, palpation and auscultation of the abdomen, the determination of the pulse, blood pressure and respiratory rate:

• The face of Hippocrates

For the first time, the suffering face, characteristic of widespread inflammation of the peritoneum, was described by Hippocrates. The patient's facial features are sharpened due to dehydration (dehydration), a pained expression on the face. The skin is pale, sometimes earthy or gray, the mucous membranes are dry, the sclera is yellow. As the disease progresses, a cyanotic skin color appears. Beads of sweat appear on the forehead, especially after each pain attack.

• Examination of the abdomen

The mobility of the abdominal wall during breathing is assessed by examining the abdomen. The abdomen either participates in breathing to a limited extent, or does not participate at all. It is possible to change the shape of the abdomen (asymmetry or retraction - tension in the abdominal muscles).

• Auscultation and percussion

When listening to the intestine, weakened peristalsis or its complete absence (death silence), the appearance of pathological intestinal noises are determined. Percussion (percussion of the abdominal cavity): hepatic dullness disappears, tympanitis (drum sound) is determined in all areas of the abdomen. In some cases, it is possible to determine the accumulated fluid.

• Palpation

When probing the anterior wall of the abdomen, its pain is determined, as a rule, sharp, the abdomen is tense - board-shaped in case of perforation of a hollow organ, the Shchetkin-Blumberg symptom (a sign of peritoneal irritation) is determined. It is possible that there is no tension in the abdominal muscles, which is observed in senile patients, with exhaustion, in case of severe intoxication, or in the retroperitoneal or pelvic location of the primary focus.

A characteristic sign of peritoneal irritation is the Shchetkin-Blumberg symptom. During the palpation of the abdomen, the patient feels pain, and after pressure at the site of the greatest pain and the doctor abruptly withdraws the hand, the pain increases significantly.

During rectal and vaginal examination you can feel the infiltrate, abscess (abscess) or accumulation of inflammatory fluid in the small pelvis. In women, soreness, smoothness or bulging of the posterior vaginal fornix is ​​determined.

Diagnostics

Diagnosis of abdominal peritonitis includes a thorough history taking and assessment of the patient's complaints. The chronic pathology of the digestive organs is specified, how the disease began, its course, the severity of pain and intoxication syndromes, the duration of the disease (up to 24 hours, two days or 72 hours or more). During a clinical examination, the pulse is evaluated (up to 120), blood pressure (a decrease is noted), respiratory rate and abdomen. The abdominal wall is palpated, the abdominal cavity is auscultated, signs of peritoneal irritation are determined. From laboratory methods research uses:

• complete blood count (leukocyte growth up to 12000 and above or decrease in leukocytes up to 4000 and below, formula shift to the left, ESR acceleration);
• biochemical blood test (albumin, liver enzymes, sugar, pancreatic enzymes, etc.);
• general urine analysis;
• the acid-base state is determined.

Instrumental examination methods:

• Ultrasound of the abdominal organs (according to indications and the small pelvis);
• radiography of the abdominal cavity (with perforation of the ulcer - the presence of free gas, with intestinal obstruction - the Kloiber bowl);
• laparocentesis (puncture of the abdominal cavity - obtaining a massive effusion);
• puncture through the posterior vaginal fornix (in inflammatory processes of the small pelvis);
• diagnostic laparoscopy.

Treatment

Therapy of this complication requires immediate hospitalization and, as a rule, emergency surgery. Under no circumstances should the disease be treated on an outpatient basis, since the course of this disease is unpredictable and, in addition to surgical intervention, requires observation of the patient both before and after surgery.

Treatment of peritonitis should be timely and comprehensive and consists of several stages:

• preoperative preparation;
• surgical intervention;
• intensive therapy and monitoring after surgery.

Preoperative preparation

Preparation for surgery should be complete and last no more than 2, maximum 3 hours. Preoperative preparation includes:

• catheterization of the central vein (installation of a subclavian catheter);
• urinary catheterization;
• gastric emptying (removal of gastric contents using a gastric tube);
• massive infusion therapy of colloids and crystalloids of at least 1.5 liters (compensation of circulating blood volume, normalization of microcirculation disorders, combating metabolic acidosis);
• preparation for anesthesia (premedication);
• the introduction of antibiotics (drugs before surgery are selected empirically);
• antienzymatic therapy;
• normalization of activities of cardio-vascular system;
• maintaining the functioning of the liver and kidneys.

Surgery

Operational intervention pursues the following goals:

• eliminate the primary focus that caused inflammation of the peritoneum;
• cleansing the abdominal cavity;
• bowel decompression;
• effective drainage of the abdominal cavity.

Operation steps:

• Anesthesia

Anesthesia for the operation is carried out in several stages. Preferred endotracheal anesthesia, V last resort held spinal anesthesia(SMA). When performing SMA in the subdural space, a catheter is removed through which local anesthetics (lidocaine) are injected into postoperative period which reduces the need for drugs.

• Access

In case of inflammation of the peritoneum, a median laparotomy is performed (an incision from the pubis to the navel and above, to the sternum), which provides good access to all floors of the abdominal cavity.

• Eliminate the source of the complication

After an incision of the anterior abdominal wall, an audit of the abdominal organs is carried out and the primary source of the disease is established. Further surgical intervention is carried out depending on the situation. In case of perforation or rupture of the organ, the wound is sutured; in case of inflammation (appendicitis, pyovar, etc.), the organ is removed. In intestinal obstruction, intestinal resection is performed with anastomosis, and in the case of purulent inflammation of the peritoneum, enterostomies are formed.

• Sanitation of the abdominal cavity

The effusion is removed from the abdominal cavity, after its elimination, the abdominal cavity is repeatedly washed with antiseptic solutions (chlorhexidine, dioxidine, furacillin) and dried.

• Bowel decompression

A tube with numerous side holes is inserted into the small intestine. The introduction is carried out through the nose, rectum or enterostomy (necessary to remove gases from the intestines).

• Drainage

Drainage of the abdominal cavity is carried out with silicone or rubber tubes (brought to the anterior abdominal wall), which should ensure the removal of effusion from all parts of the abdomen.

• Wound closure

The operation ends with suturing the postoperative wound or applying a laparostomy. During laparostomy, the abdominal wall is not sutured, only the edges of the wound are brought together with special sutures.

Postoperative Therapy

The management of the postoperative period should be carried out under monitoring, be complete and adequate, with a quick change in appointments and tactics in the absence of positive dynamics.

Postoperative management of patients includes:

• adequate anesthesia;
• carrying out intensive infusion therapy (up to 10 liters per day);
• carrying out detoxification therapy (hemodialysis and lymphosorption, administration of diuretics, hemosorption, washing of the abdominal cavity through drainages or sanitation through laparostomy);
• prescribing antibiotics for maximum doses, route of administration intravenous (combination of cephalosporins with aminoglycosides and metronidazole);
• immunocorrective therapy;
• prevention of intestinal paresis (administration of prozerin) and syndrome intestinal failure(introduction of atropine, potassium preparations);
• normalization of the work of all organs and systems;
• prevention of complications.

Care and supervision of the patient after surgery

Patient care begins immediately after the completion of the operation and should continue until the patient recovers. In this regard, in the postoperative period, 3 phases are distinguished (conditionally):

• early - lasts from 3 to 5 days;
• late - the first 2 - 3 weeks (stay in the hospital until discharge);
• remote - until the moment of going to work or getting a disability.

Postoperative care in the early phase

The patient is transported on a gurney to the intensive care unit, where he is carefully transferred to a special functional bed with clean linens. The patient is provided with warmth and comfort. It is placed in the legs, on a blanket, and on a postoperative wound (no more than half an hour), which will prevent bleeding from the wound and somewhat reduce pain.

The patient in bed is given the Fowler position - the head end is raised by 45 degrees, and the legs are slightly bent at the knee and hip joints. If the patient is unconscious (under anesthesia), he is laid horizontally, removing the pillow from under his head. In order to avoid retraction of the tongue, the head is thrown back a little and removed lower jaw. In the first 2-3 days after the operation, the patient is prescribed hunger and strict bed rest. If necessary, continue artificial ventilation of the lungs, and in the case of a satisfactory condition of the patient, he is periodically given inhalations of humidified oxygen.

The first dressing change is carried out on the 2nd day, under the supervision of a doctor. If the bandage has slipped or the bleeding from the wound has increased, the dressing is carried out earlier. Honey. the sister monitors not only the pulse, respiratory rate, pressure (every hour) and temperature, but also controls the excretion of urine (the urinary catheter is left for another 2-3 days after the operation) and the amount and nature of the discharge through the drainage. The drains are periodically washed, the change of dressings at the drains is carried out by a doctor.

The patient's nutrition after surgery begins on the 2nd day and by parenteral route (infusion therapy). Basically, parenteral nutrition includes the introduction of 10% glucose and amino acid salts. The volume of infusions is calculated according to the formula: 50 - 60 ml / kg of the patient's body weight.

On the first day after the operation, the patient is not allowed to drink, and to relieve thirst, the lips are wiped with a damp cloth. As soon as peristalsis is established (usually on day 2), the patient is allowed to drink (1 teaspoon of water every hour) and proceed to enteral nutrition (introduction of liquid food and mixtures through a nasogastric tube).

It is undesirable for the patient to stay in bed for a long time (physical inactivity provokes the occurrence of postoperative complications). Taking into account the patient's condition, they begin to activate it early.

By the end of the first day, the patient should begin to actively behave in bed (turn, bend, unbend the limbs). On the 2nd - 3rd postoperative day, the patient first sits down in bed, then, after several deep breaths - exhalations and coughing, he must get up and walk around the ward, after the patient is put to bed. The rise of the patient helps honey. sister. As the condition improves and pain decreases, the patient expands the regimen according to the doctor's instructions.

late phase

As soon as the patient establishes a constant peristalsis, gas discharge is established and stool appears, he is transferred to independent nutrition. Food is taken at room temperature, fractionally, up to 6 times a day, in small portions.

• During the first week, food should be liquid (broths: after boiling, water is drained and replaced with a new one, soft-boiled egg, jelly and jelly, vegetable puree with a little butter).
• On the 3rd - 4th day, the patient's menu includes mashed cottage cheese, boiled beef, mutton, chicken and mashed fish, mucous porridges and soups (rice, oatmeal). Coarse fiber and foods that are difficult to digest and irritate the digestive tract (legumes, cabbage, radish and radish, sinewy meat, skin and cartilage of poultry and fish, cold drinks) are excluded. The intake of fats should be due to vegetable oils, sour cream and cream, a small amount of butter. Easily digestible carbohydrates are limited (marmalade and honey, jam, marshmallows, chocolate, etc.). Dried bread or yesterday's baking is included in the menu for 5-7 days.
• Free mode (walking around the department and on the territory of the hospital) is scheduled for 6-7 days. With a favorable course of the postoperative period, the sutures are removed on the 8th - 9th day, and the drains are removed on the 3rd - 4th. The patient is discharged, as a rule, on the day the sutures are removed.

remote phase

After discharge, the patient must follow a number of medical recommendations:

• restriction of heavy lifting (no more than 3 kg) and heavy physical activity for 3 months;
• sexual rest up to 1.5 months;
• performance therapeutic gymnastics(training of the respiratory and cardiovascular systems, strengthening the abdominal muscles and preventing the development of hernias, rehabilitation).

Rehabilitation of the patient is facilitated by skiing, hiking, close tourism, swimming. Also, the patient is recommended sanatorium treatment.

In nutrition, the patient should adhere to fragmentation (up to 5 times a day), do not overeat, but do not starve. Food is recommended to be boiled, steamed, stewed or baked (without a crust). Limit the consumption of foods that irritate the gastrointestinal tract (spices, peppers, marinades and pickles, bitter and sour vegetables: sorrel, radish, garlic, onion, radish). You should abandon refractory fats (margarine, lard, smoked meats) and limit the consumption of sugar (sweets, jams) and rich pastries.

Consequences and complications

Early complications of peritonitis, which can occur in the acute period in the absence of timely treatment, include life-threatening conditions:

• infectious-toxic shock;
• acute vascular insufficiency and collapse;
• bleeding;
• development of sepsis;
• acute renal failure;
• gangrene of the intestine;
• cerebral edema;
• dehydration;
• pulmonary edema;
• DIC;
• death of the patient.

Long-term effects of peritonitis (after surgical treatment):

• the formation of intra-abdominal adhesions;
• infertility (in women);
• interintestinal abscess;
• bowel eventration;
• ventral hernia;
• intestinal paresis and its obstruction.

Forecast

The prognosis after suffering peritonitis largely depends on the duration of the clinical picture before the provision of medical care, the prevalence of peritoneal lesions, the age of the patient and comorbidities. Mortality with this complication still remains at a high level, so, with diffuse inflammation of the peritoneum, it reaches 40%. But with timely and adequate therapy, early surgical intervention in compliance with all the requirements of the operation for this complication, a favorable outcome is observed in 90% of cases or more.

Peritonitis is a condition of inflammation of the serous membrane (peritoneum) surrounding the internal organs that are located in the abdomen. The name comes from the Latin word "peritoneum", which translates as "peritoneum", and the suffix - "it" means "inflammation".

Inflammation of the peritoneum

The disease is severe, if timely medical care is not provided, the outcome can be fatal. What is it and why are the consequences so dangerous?

Causes

Types of peritonitis

If they are divided into groups, then three types of peritonitis can be distinguished:

• primary;
• secondary;
• tertiary.

Primary peritonitis

Inflammation occurs without violating the integrity of the internal organs, since bacteria enter the peritoneum through the blood or lymph (in a woman, also through the genitals).

The bacteria that cause peritonitis can be both gram-negative and gram-positive.

In women who are sexually active, peritonitis can be provoked by gonococci or chlamydia.

Quite rare, but still occurs in such a way that inflammation is caused by Mycobacterium tuberculosis, namely, with tuberculosis of the intestines, kidneys, fallopian tubes, and other organs.

This type of peritonitis occurs spontaneously, both in children (aged 5 to 7 years) and in adults.

It develops when the abdominal organs are damaged (stab or gunshot wounds) And during the formation of destructive-inflammatory diseases, such as:

• appendicitis (inflammation of the appendix);
• salpingitis (inflammation of the fallopian tubes);
• perforated ulcer of the duodenum or stomach;
• Crohn's disease;
• pancreatitis ();
• gangrenous cholecystitis (inflammation of the gallbladder);
• diverticulitis (inflammation of the intestines);
• endometritis in women;
• ovarian cyst (during its rupture) and more.

In such cases, bacteria will soon join the diseases themselves, which help in the development of the peritonitis process.

If at primary peritonitis they try to eliminate only bacteria from the patient's peritoneum, then in the secondary - primary care is aimed at the speedy cure or removal of the affected organ.

Secondary peritonitis may be transferred operation in the abdominal organs. During the operation, bacteria can enter the patient's body (the same Staphylococcus aureus, which is opportunistic and is present almost everywhere), and the injured organism can react violently to this.

Tertiary peritonitis

This species is extremely rare. In fact, this is a recurrence of already transferred and cured peritonitis. But, when the body is weak, and the immune system is not able to deal with any difficulties, peritonitis can return. It can't be prevented, but doctors are obliged to do everything to reduce the risk of recurrence of inflammation of the peritoneum (taking immunostimulants, antibiotic therapy, etc.).

Classification

Peritonitis can be classified not only by its causes, but also by a number of other factors:

1. By etiology:

• aseptic or toxic-chemical, without exposure to bacteria, caused by irritation of the peritoneum with blood or bile, possibly other biological fluids that enter the peritoneum and thereby cause inflammation;
• bacterial peritonitis is caused by microorganisms we already know

1. According to the duration of the flow and the speed of occurrence:

• acute inflammation of the peritoneum, the inflammation process occurs in a matter of hours and is either quickly treated or leads to the death of the patient;
• chronic, may have a long course with a not pronounced clinical picture, most often occurs in pensioners.

1. By prevalence, which abdominal levels are affected:

• delimited or local (subhepatic, appendicular, pelvic and many others);
• widespread, it is common when the entire space of the abdomen is affected, local or diffuse with a clear localization on one or two floors, and diffuse when inflammation affects several anatomical regions.

1. According to which organ or organ system caused the process of inflammation of the peritoneum:

• blood - hemorrhagic;
• lymph - lymphogenous;
• infectious;
• postoperative;
• post-traumatic.

Symptoms of inflammation of the peritoneum

Peritoneal symptoms occur from the very beginning of inflammation of the peritoneum and worsen as the disease develops if proper medical care is not provided.

Peritonitis can be identified by the following symptoms:

• severe pain in the abdomen;
• hardening of the abdominal muscles;
• bloating;
• increased body temperature;
• manifestation of nausea and vomiting;
• constipation and flatulence.

Also, depending on how much the disease has worsened, there are three stages of peritonitis and their characteristic symptoms.

Reactive stage

It is observed during the first day from the onset of inflammation of the peritoneum. Pain appears sharply at the site of the affected organ. Usually, patients characterize it as a cutting pain, sometimes with irradiation to the shoulder blades or to the clavicular zone.

The patient has to lie on his side, bending his legs under him to reduce pain.

Over time, it loses its clear localization and spreads throughout the abdomen. A little later, a period of “imaginary attenuation of pain” begins, in fact, it immediately returns with even greater force.

The patient's abdomen with inflammation of the peritoneum is tight, sometimes retracted, practically does not participate in the act of breathing.

A positive symptom of Shchetkin-Blumberg, when, with pressure on sore spot, the doctor removes his hand, and the pain only intensifies.

Patients have a "face of Hippocrates": pallor and even earthy complexion, sunken eyes, facial features become sharp due to dehydration, cold sweat appears on the forehead, despite the rise in temperature.

During auscultation and percussion, the sound is deaf, reminiscent of a drum roll, a decrease in intestinal motility or its complete stop is felt.

All these symptoms are called peritoneal syndrome with inflammation of the peritoneum.

The patient is also tormented by nausea and vomiting, which does not bring relief due to the fact that it occurs as a result of spasmodic movements of the stomach.

toxic stage

Coming on the second day from the onset of inflammation. Pain is reduced and peritoneal symptoms become weaker.

But the patient notes: severe intoxication, lack of stools and gases (in rare cases, diarrhea), dehydration, the tongue is coated with a gray coating.

Microcirculation is disturbed, as a result of which the nose, tips of the ears and fingers turn blue. The patient has a violation of consciousness, he is either delirious, or remains indifferent to everything. Pulse fluctuates 120 to 140 beats per minute, severe dyspnoea.

terminal stage

If no measures are taken on the third day, and the patient does not improve, then this is a reliable sign that a fatal outcome is possible in the near future.

Therefore, the terminal stage is often called irreversible. All symptoms of inflammation worsen, dehydration reaches its limit.

Only resuscitation measures, life support with the help of apparatuses and intravenous injections, as well as immediate surgical intervention.

Diagnostics

It is important to establish the diagnosis of peritonitis in the next few hours after the onset of inflammation. It is necessary to establish the causes and find out in which organ the pathological process occurs.

For this, a number of diagnostic tests and analyzes are used:

• examination of the patient, palpation of the abdomen;
• collection of anamnesis;
• the study of existing diseases at the time of the onset of inflammation of the peritoneum;
• complete blood count (with peritonitis, it shows an increase in the number of leukocytes and neutrophils, as well as accelerated erythrocyte sedimentation);
• biochemical parameters of blood with inflammation of the peritoneum will exceed the norm;
• will show the degree of development of peritonitis, which organs are affected and determine the localization of the process;
• x-ray examination of the abdominal organs;
• puncture of the abdominal cavity (laparocentesis);
• laparoscopy (opening the abdominal cavity and sanitation of organs).

Establishing the diagnosis of peritonitis always entails surgical intervention and postoperative sanitation of the patient's organs.

Treatment

Inflammation of the peritoneum can be fatal if the process is not stopped in time. Therefore, it is important to prescribe therapy quickly and correctly. It consists of preoperative preparation of the patient, the operation itself and a course of rehabilitation with intensive care.

Preoperative preparation the patient begins with catheterization of the clavicular vein, as well as the bladder. This is necessary to administer medications and monitor improvement (if there is more urine, then dehydration is reduced and the recovery process is underway).

Further, food debris is removed from the gastrointestinal tract and the amount of gastric juice is reduced to a minimum. Since if it gets into the abdominal organs, it can provoke a burn. Preparation for anesthesia and the introduction of antibiotics. If necessary, artificially support the ventilation of the lungs, the work of the liver and heart.

Patient photo:

During the operation, the doctor makes an incision from the pubis to the sternum in order to have access to all the organs of the abdominal cavity. There is a focus of inflammation (affected organ or bacteria), and if possible, the wound is cauterized or sutured, and if not, then the organ is removed completely or partially.

Next, the doctor sanitizes the internal organs, repeatedly washing them with antiseptic agents. After that, decompression of the small and large intestines is performed, and a drain is installed to administer antibiotics and eliminate exudate.

The last stage is the imposition of a laporostomy, when the edges of the peritoneum are brought together with special sutures.

Postoperative rehabilitation with peritonitis is aimed at maintaining the patient's condition, administering 10% glucose intravenously (since the first two days the patient is forbidden to drink and eat).

The diet after surgery should include:

• liquid soups;
• rubbed ;
• vegetable purees;

Be sure to exclude:

• acute;
• salty;
• fatty;
• heavy;
• alcohol.

The patient should start moving around the ward as early as possible, sit, stand. If the operation is performed correctly and the body responds adequately to all procedures, then there is no need to fear a recurrence of inflammation of the peritoneum.

Prevention inflammation of the peritoneum has not been developed, but it is in your power to protect yourself from this by monitoring your health and timely treatment of the diseases that have arisen. After all, peritonitis is a rather dangerous disease, which is better not to face adults and children.

Many people ask the question: "Peritonitis - what is it?" It is about this dangerous disease that this article will tell.

So, peritonitis is an inflammatory process that can develop in the peritoneum or in the membrane of the abdominal cavity. Most patients and their relatives perceive this diagnosis in a fatal sense. However, some of its forms, subject to timely and correct operation, can be completely cured.

Causes

So, we will understand what peritonitis is, we will also consider the causes of its occurrence. Generally speaking, this disease has one main cause - the entry into the abdominal cavity of a foreign substance (bile, pancreatic enzyme) or pathogenic microorganisms. This "unauthorized" penetration, in turn, also has causes, namely: damage to the abdominal organs (including as a result of surgical interventions), inflammatory damage and further purulent fusion of the abdominal organs.

Also, peritonitis can be caused by the following microorganisms: gonococcus, pneumococcus, Pseudomonas aeruginosa, tuberculosis microbacteria, Escherichia coli, streptococcus, staphylococcus.

Quite often, infectious peritonitis is the result of phlegmonous acute appendicitis, much less often - perforation of the duodenal ulcer and stomach, ruptures of the bladder and digestive organs (neglected tumor or injury), acute pancreatitis or purulent cholecystitis.

Varieties

In most cases, acute peritonitis is diagnosed, which carries a mortal danger for a person. Therefore, timely medical attention is very important.

There are several main types of this disease:

• Depending on the localization, peritonitis can be diffuse, general or local. In the latter case, a small area of ​​the abdominal cavity is affected, with diffuse inflammation - its separate part, in general - the entire cavity.
• By origin, infectious and aseptic peritonitis are distinguished.
• According to the type of pathogen, peritonitis of the abdominal cavity can be streptococcal and staphylococcal, caused by mixed flora or Escherichia coli.
• Depending on the causes of occurrence, there are such types of this disease: traumatic, postoperative, perforative, hematogenous, occurring during inflammatory and other pathological processes that can occur in the abdominal cavity.
• According to the source of origin, abdominal peritonitis can be appendicular or result from perforation of a stomach ulcer.
• The clinical course is subacute, acute and chronic. Specialists also distinguish the fulminant form of this disease, which is accompanied by septic shock.

Symptoms

Yet peritonitis - what is it? How does it manifest itself? Let's look at the symptoms of this disease. So, the reactive stage of peritonitis is accompanied by abdominal sensations, pains, the strength and location of which are associated with the cause of the inflammation of the abdominal cavity.

First of all, pain sensations are localized directly at the site of the development of the inflammatory process, while it can radiate to the area above the collarbone or to the shoulder due to irritation in the diaphragm by purulent masses of nerve endings. After some time, the pain gradually spreads throughout the entire abdomen, loses its exact location and becomes a passing character. Due to the development of paralysis in the nerve endings of the abdominal cavity at the terminal stage, the pain begins to manifest itself somewhat weaker.

Very often peritonitis of the abdominal cavity is accompanied by nausea with vomiting of stomach contents. Such a process at the first stages of the development of this disease proceeds at the reflex level. For more late stages vomiting is caused by paresis in the intestines, along with vomiting bile and intestinal contents are excreted. As a result of pronounced endotoxicosis, there is paralytic ileus bowel, the symptoms of which are stool retention and flatulence.

Already in the early stages of peritonitis, it becomes characteristic appearance the victim - the performance of cold sweat, adynamia, pallor of the skin, acrocyanosis, as well as a suffering facial expression. In this case, the patient tries to take forced positions to relieve pain - as a rule, this is a position lying on his back or on his side with his legs tucked in. The heartbeat quickens, breathing becomes shallow, body temperature rises.

At the terminal stage, a strong deterioration in the patient's condition occurs: facial features become sharp, a state of euphoria is noted, confusion occurs, the mucous surfaces and skin turn pale, acquiring a bluish or icteric tint, the mucous membrane of the tongue dries up, the tongue is covered with a dark coating. In addition, there is bloating, the palpation of which is almost painless, but when dried, silence is noted.

Bacterial etiology

Peritonitis - what is it? Why does it arise? Many people are interested in the answers to these questions. Let's try to figure it out. A large number of microorganisms live in the intestine, but only exposure to some of them can provoke peritonitis. This happens due to the fact that some die in an oxygen environment, in other words, they are strict anaerobes. Others are subject to controlled death, which is provided by the anti-infective ability of the abdominal cavity. Depending on the conditions that resulted in this disease, two of its main forms are distinguished - out-of-hospital and hospital.

Development

The severity and speed of the development of the disease largely depend on the presence of provoking factors, the pathogenicity of microbes and the state of the body. The development of peritonitis has the following main points:

• A decrease in pressure in the vessels and dehydration lead to shortness of breath and a strong heartbeat.
• Intestinal paresis leads to impaired absorption, the body begins to lose a large amount of electrolytes and water.
• The massiveness of the lesion and the rate of development of the disease directly depend on the level of intoxication and the number of pathogenic bacteria.
• Together with intoxication, which was caused by microbes, autointoxication appears. In the blood, in response to the aggression of microorganisms, antibodies begin to be released that attack the lipopolysaccharide wall of bacteria. The compliment system comes into activity, a large number of active substances are released, their action is manifested by intoxication.

Clinical manifestations

Peritonitis - what is it? Its initial symptoms are quite varied. They are directly related to the cause that caused the disease. That is why initial signs can be so different. However, there are several successive stages, which were mentioned earlier, they are associated with the time of onset of symptoms. Let's consider them in more detail.

stage reactive

This stage develops in the first 24 hours. Severe pain appears, it is at this time that localization can be clearly determined. If the cause of this disease was the perforation of the internal organ, then this pain is characterized as a dagger. For example, a rupture of the appendix is ​​described as pain that occurs in the right iliac region, a perforation of a stomach ulcer is described as a sharp, severe pain in the epigastric region.

Gradually, the pain begins to spread to other areas of the abdomen. It happens that after the appearance of the pain ceases to be intense and is no longer so disturbing. This is a manifestation of a symptom of imaginary well-being. The patient's face becomes pale, sometimes acquires an earthy hue. At the time of the onset of pain, the face is covered with drops of sweat. Due to dehydration, the features become sharper.

Severe pain forces the patient to take a comfortable position in order to alleviate it. On examination, you can find that the abdominal muscles are tense - a plank-shaped abdomen. In addition, there is a Shchetkin-Blumberg symptom - at the time of palpation, a sharp removal of the hand from the surface of the abdomen provokes severe pain. Also, viral peritonitis is accompanied by vomiting, after which there is no improvement. Water comes out first, then bile. The body temperature rises, there is often a fever with chills. The mucous membranes become dry due to dehydration, the patient is thirsty. The amount of urine excreted also decreases.

Stage toxic

This stage occurs on the second or third day. The general condition of the patient worsens, despite the fact that the symptoms of the disease are less pronounced. Microcirculation is disturbed. This is manifested by cyanosis of the toes and hands, earlobes, nose. The patient is very pale. As a result severe dehydration brain dysfunction occurs. A person is indifferent to what is happening, consciousness is oppressed. Or vice versa - he is delirious and very excited. Feeling the abdomen does not lead to any reactions. Vomiting of bile continues, if the case is neglected - intestinal contents. Little or no urine is produced. The temperature reaches high numbers (up to 42 degrees). The pulse becomes thready. Disturbed by palpitations and severe shortness of breath.

Stage terminal

In another way, it is called irreversible. If by the third day the patient's condition does not improve, then purulent peritonitis is irreversible and in most cases ends in death. The patient has very serious condition. Dehydration is the most pronounced. At the same time, facial features are sharpened so much that it becomes difficult to recognize a person. This view has long been called the face of Hippocrates: a bluish tint, pallor, dark circles under the eyes, sunken eye sockets.

Palpation of the abdomen does not provide objective data. The patient does not respond to touch. Breathing is disturbed, artificial support for the working capacity of the lungs is necessary. There is no pulse in the peripheral arteries. In such a situation, resuscitation assistance is required, as well as intensive treatment.

Diagnosis and treatment

One of the stages of diagnosis is a blood test. Purulent peritonitis is diagnosed through urine, blood tests, X-ray and ultrasound examinations, as well as examination of the patient.

In case of the slightest suspicion of this disease, urgent hospitalization is required. When there is a sharp pain, there is no time to waste. It is strictly forbidden to take painkillers and laxatives, drink water and food, give enemas, and self-medicate. While waiting for qualified medical care, it is necessary to put the patient in a comfortable position, and something cold can be applied to the stomach.

As soon as a diagnosis is made, for example, viral peritonitis, it is treated by emergency surgery. Its main goal is to drain the abdominal cavity and eliminate the focus of inflammation (removal of the inflamed appendix, sewing in a perforated ulcer, etc.). In addition, a number of activities are being carried out, their main goal is to reduce intoxication and combat intestinal paresis.

Conservative treatment for all forms of this disease is not practiced, since any delay can provoke serious violations of the basic functions of the body, the spread of infection through internal organs and subsequent death.

Peritonitis - surgery and preoperative preparation

In order for the surgical intervention to be successful, competent preoperative preparation is required. IN without fail the patient is catheterized with the bladder, central and peripheral veins, premedication is used. The patient is administered on the operating table drugs "Cerukal" (10-20 mg) and "Midazolam" (5 mg). It is strictly forbidden to administer "Atropine", as it can provoke the development of bradycardia. Drugs are introduced that help reduce the acidity of gastric juice (50 mg of Ranitidine / Famotidine or 40 mg of Omeprazole).

During the operation, infusion therapy is carried out (about 1.5 liters of saline), if necessary, blood and plasma preparations are added. Implemented artificial ventilation lungs, oxygen is supplied.

If the patient's stomach contains more than 25 ml of contents when he lies down on the operating table, there is a threat of aspiration. In other words, getting into the lumen of the bronchial tree of the contents of the stomach. Gastric juice can cause burns of the mucous membrane of the trachea, bronchi. Complications of aspiration - pulmonary edema, respiratory failure, bronchospasm, numerous pulmonary atelectasis. Aspiration of a small amount of gastric juice can provoke aspiration pneumonia. In this regard, in anesthetic practice, anticholinergics and ganglioblockers are not used - drugs that reduce the tone of the lower esophageal sphincter.

Antibacterial therapy is carried out by a combination of antibiotics that simultaneously act on gram-minus and gram-plus bacteria. In the case of out-of-hospital disease - intravenous administration of "Metronidazole" and "Cefotaxime". Intrahospital - "Metronidazole" and "Cefepim". If intestinal peritonitis has developed in the hospital as a result of ongoing antibiotic therapy, carbapenems are used.

Postoperative period

With peritonitis, antibiotic therapy is indispensable. After the operation, there may be problems associated with the development of purulent deposits, severe pain, as well as impaired bowel function.

After peritonitis, the following is mandatory:

• Patient monitoring - hourly assessment of pulse rate, respiration, central venous pressure, diuresis, drainage discharge.
• Infusion therapy is carried out with crystalloid and colloid solutions.
• Infusion media for warming patients are heated to body temperature.
• For 72 hours, artificial ventilation of the lungs continues to provide oxygen to tissues and organs.
• A glucose solution is injected through a nasogastric tube.
• Prevention of pain syndrome.

If the patient has been diagnosed with peritonitis, after the operation, he should be under the close supervision of doctors. At this stage, narcotic analgesics are used in conjunction with anti-inflammatory nonsteroidal drugs. Ketorolac, Morphine, Fentanyl are used.

Folk methods

Very dangerous disease peritonitis. The consequences of it can be irreversible, therefore, relying on means traditional medicine not worth it. However, in its arsenal there are reliable methods by which you can alleviate the condition of a person before providing qualified medical care.

• Thirst is one of the symptoms, while the patient is strictly forbidden to feed and drink. To quench thirst, you can give the patient ice, while you can not allow him to swallow melt water.
• A little ice should also be put on the patient's stomach, the main thing is that it does not press. A rubber bladder is filled with ice and hung over the abdomen so that it touches it lightly.
• If there is no ice, you can make a compress on the stomach - vegetable oil and purified turpentine are dismounted in a ratio of 2:1.

If a person can endure pain, it is advisable not to take any measures to alleviate his condition. This can lead to a blurring of the clinical picture, which will prevent the specialist from making a correct diagnosis.

To prevent dangerous inflammation abdominal cavity, you need to be attentive to your health, produce early diagnosis, in time to treat diseases of internal organs.

Development prevention

It consists in conveying to people information about the main symptoms of this disease. It is important that everyone knows that at the slightest suspicion of peritonitis, an ambulance team should be called immediately. Exactly at timely treatment is the prevention of this disease.

A slightly different mechanism is observed in cholecystitis and cholelithiasis. In this case, flowing bile peritonitis develops. There is no destruction or rupture of the gallbladder. The main mechanism is the slow leakage of bile into the peritoneal cavity. In this case, the reaction of the peritoneum to the aggressive action of bile ( bile contains bile acids) is proportional to its quantity. Since bile does not pour out immediately, but slowly sweats, its amount may initially be negligible. The clinical picture in this period is erased, and the classic symptoms may be absent. However, with gradual sweating, the volume of bile increases. When a large volume of bile irritates the peritoneum, the classic picture of peritonitis appears.

With a simultaneous massive outflow of bile, for example, with a rupture of the gallbladder, peritonitis develops rapidly with the phenomenon of abdominal shock. The degree of the reactive process is affected not only by the amount of bile and the rate of its outflow, but also by the nature of the bile.

Abdominal injury

As a result of open and closed injuries, post-traumatic peritonitis develops. With open injuries of the abdominal cavity, direct infection of the peritoneum occurs. So, through a defect in the abdominal wall, there is direct contact of non-sterile environment with the peritoneal cavity. Bacteria that have penetrated from the air become the source of the inflammatory process. With closed injuries, the mechanism for the development of peritonitis is due to a violation of the integrity of the internal organs. Thus, closed abdominal injuries may be accompanied by rupture of the spleen and other internal organs. In this case, their contents, poured into the peritoneal cavity, cause peritonitis.

In addition, the cause of peritonitis may be pathologies of the pancreas ( in one percent of cases), spleen and urinary bladder.

Causative agents of bacterial peritonitis

The cause of infection in peritonitis may be the most various bacteria. It can be both specific microbial flora and nonspecific microflora of the intestinal tract.

Microorganisms that can cause peritonitis

specific flora	non-specific flora
hemolytic streptococcus; gonococci; pneumococci; mycobacterium tuberculosis.	aerobic microorganisms ( those that use oxygen in the course of their life).	anaerobic microorganisms ( those that do not use oxygen in the course of their life).
	coli ( in 60 percent of cases); proteus; klebsiella; enterobacter; staphylococcus and streptococcus ( 20 percent or more of cases).	clostridia; bacteroids; fusobacteria; peptococci and peptostreptococci.
In 50 - 60 percent of cases of peritonitis, microbial associations are observed. They are presented simultaneously by 2 or 3 pathogens. Most often it is Escherichia coli and staphylococcus aureus, as well as anaerobic non-clostridial flora.

Causes of aseptic peritonitis

In aseptic peritonitis, it is not the bacterial flora that irritates the peritoneum, but such aggressive agents as blood, urine, gastric juice or pancreatic juice. Such peritonitis is also called toxic-chemical, because the action of enzymes and acids contained in the blood or pancreatic juice is similar to a chemical burn. It is worth noting that aseptic peritonitis itself does not exist for long. Already after 6 - 8 hours, the bacterial flora joins it, and it becomes bacterial.

A special type of aseptic peritonitis is barium peritonitis. This type of peritonitis is extremely rare, but its mortality exceeds 50 percent. It develops as a result of the release of barium from the gastrointestinal tract. This happens during radiological methods diagnostics with barium contrast ( for example, with irrigoscopy).

Types of peritonitis

There are many varieties of peritonitis, which are classified according to various criteria.

Criterion	Type of peritonitis
Because of	traumatic; perforated ( or perforated); postoperative; infectious.
According to the traumatic factor	bacterial; aseptic.
According to the mechanism of infection	primary; secondary.
According to the degree of distribution	local ( or local); diffuse; total.
According to the nature of the inflammatory content	purulent; serous; hemorrhagic; fibrinous.
By the presence of exudate	exudative ( he is wet); dry.
Type of infectious agent	streptococcal; tuberculosis; clostridial; gonococcal.

From a clinical point of view, the most important and informative classification is according to the degree of distribution and the nature of the inflammatory content. The differentiation of peritonitis according to the type of infectious agent is very important for the prognosis of the disease. Knowing the type of microorganism, you can choose the most accurate treatment. However, in practice, to identify the etiological factor ( i.e. the causative agent of peritonitis) very hard.

Exudative peritonitis

Exudative peritonitis is one in which inflammatory fluid accumulates in the peritoneal cavity. Normally, a small amount of fluid is present in the cavity, which ensures that there is no friction between the visceral and parietal layers of the peritoneum. This liquid is aseptic, meaning it does not contain bacteria.

When, as a result of various mechanisms, an infection enters the cavity, destruction of the surface layer of the peritoneum occurs. This leads to the occurrence of intense exudative processes, which are accompanied by the accumulation of inflammatory fluid. Initially, the volume of fluid that accumulates in the peritoneal cavity is small. However, as the pathological process progresses, it increases. The amount of liquid can vary from several tens of milliliters ( 50 - 70 ) up to several liters ( 1 – 2 ). The main key point in the development of the disease is intoxication. It is known that the total area of ​​the abdominal cover is equal to the total area of ​​the skin, that is, approximately 2 square meters. All toxins that accumulate in the cavity penetrate into the bloodstream and very quickly lead to intoxication of the body. Together with the blood flow, bacteria and their toxins are carried to the organs, affecting them. As a result of such a generalized dissemination of infection, multiple organ failure develops.

A feature of exudative peritonitis is that, simultaneously with the accumulation of fluid in the peritoneal cavity, the body loses water. It is known that all water in the body is divided into intracellular and extracellular fluid. Intracellular refers to the fluid contained in tissue cells. The extracellular fluid is the interstitial fluid ( fluid between cells) and intravascular ( blood plasma) liquid.

IN healthy body 60-65 percent falls on the intracellular volume of fluid, 40-35 percent on the extracellular part. However, with peritonitis, an abnormal third space is formed. This space is nothing more than a peritoneal cavity. In it, due to hemodynamic disturbances ( impaired vascular tone, increased permeability of the vascular wall) fluid accumulates both from the vascular bed and from the tissues. Thus, the body loses water and experiences dehydration. This condition is complicated by vomiting, along with which fluid and electrolytes are also lost.

Depending on the nature of the inflammatory fluid, serous, purulent, hemorrhagic or fibrinous peritonitis is distinguished.

Serous peritonitis
With serous peritonitis, fluid accumulates in the peritoneal cavity, which is poor in protein and cellular elements. Such inflammation is observed in the first 2-3 days of illness. After that, fibrin heats up in it, and it becomes serous-fibrinous. If the purulent flora is activated, then serous peritonitis evolves into purulent.

fibrinous peritonitis
With fibrinous peritonitis, a large amount of fibrin accumulates in the inflammatory fluid. This leads to the formation of fibrin films that cover the sheets of the peritoneum. This type of peritonitis can progress to adhesive peritonitis.

Hemorrhagic peritonitis
This form of peritonitis is observed when the blood that has entered the peritoneal cavity is mixed with the liquid. This blood can form during injuries ( traumatic peritonitis) or pour out during perforation of organs.

Dry peritonitis

With dry peritonitis in the peritoneal cavity is observed a small amount liquids. The difference of this fluid is the high content of fibrinogen in it. Fibrinogen is a protein that forms the basis of a blood clot during clotting. Its concentration increases with inflammatory reactions, as well as with injuries of the epithelium. When in contact with the sheets of the inflamed peritoneum, fibrinogen turns into fibrin. Fibrin condenses the inflammatory fluid, making it thicker, due to its physicochemical properties. Also, on the surface of the peritoneum, it falls out in the form of threads and villi, and forms films on the surface of the internal organs. These fibrin structures subsequently stick together. For this reason, dry peritonitis is also called adhesive.

On the one hand, this process is carried out by the body with a protective purpose. After all, with the formation of adhesive fibrin structures, the place of inflammation is delimited. Dry peritonitis is less likely to be spilled. However, at the same time, due to the massive adhesive process, adhesions are formed between the peritoneum and the intestine. This type of peritonitis often proceeds violently. Despite the absence of a large effusion in the peritoneal cavity and the limited process, it proceeds with severe hypovolemia ( decrease in blood volume).

Dry peritonitis is often observed in the tuberculous etiology of this disease. At the same time, the sheets of the peritoneum swell sharply, and tuberculous tubercles form on their surface. At the same time, there is practically no liquid in the peritoneal cavity, or it is contained in a small amount. As the tubercles progress, they begin to spread to the intestines and other organs. Sometimes they become so thickened and compacted that they deform the organ.
With dry peritonitis, the syndrome of disseminated intravascular coagulation often develops.

Purulent peritonitis

This type of peritonitis is caused by such putrefactive flora as staphylococci, gonococci, Escherichia coli, and most often by an association of these microorganisms. As a rule, purulent peritonitis proceeds in an exudative form. But there is also a purulent-caseous form, in which multiple localized abscesses form in the peritoneal cavity. Most often, purulent peritonitis develops as a result of perforation of purulent appendicitis or other organs.

Purulent peritonitis proceeds very quickly and is characterized by a pronounced intoxication syndrome. Many representatives of the purulent flora produce toxins that are tropic ( more preferred) to various types of fabrics. Some toxins are especially selective to the epithelium of the vascular wall. Penetrating into the bloodstream, they cause swelling and vasodilation, leading to numerous hemorrhages in the organs. Phases of peritonitis with purulent form are sharply expressed, the erased clinic is not observed. The symptoms of general intoxication and disturbances in water and electrolyte metabolism prevail. Often, especially with streptococcal peritonitis, there is confusion, delirium. Purulent peritonitis is distinguished by its high mortality. Chronic and sluggish forms of purulent peritonitis are extremely rarely observed.

Tuberculous peritonitis

Peritonitis caused by Mycobacterium tuberculosis is called tuberculous. This is the most common form of chronic peritonitis. Tuberculous peritonitis mainly affects children. However, it is also common among adults. In 99.9 percent of cases, this is secondary peritonitis, which developed during dissemination of the pathogen from the primary focus. In children, this focus is the lungs and lymph nodes. Among women ( the ratio of men and women with this pathology is 1 to 9) are the internal reproductive organs. This ratio of men and women is explained by the fact that in women the uterus communicates with the peritoneal cavity through the fallopian tubes. Such a message ensures the rapid spread of mycobacteria into the peritoneal cavity in case of tuberculosis of the internal genital organs.

Tuberculous peritonitis can occur both in dry form and in exudative form. The peculiarity of this type of peritonitis is that it can occur in erased clinical forms without distinct phases. Symptoms of intoxication ( fever, weakness) can exist for weeks or even months. Such a sluggish course of peritonitis is accompanied by a violation of metabolic, endocrine and other body functions. The symptoms of the underlying disease, that is, tuberculosis, are added to the characteristic symptoms of peritonitis. The main such symptoms are weight loss, prolonged fever, excessive sweating, periodic coughing, and others. The acute course of tuberculous peritonitis is observed relatively less frequently.

In addition to these forms of peritonitis, there is the so-called anaerobic peritonitis, which is caused by anaerobic flora. It develops as a result of gunshot wounds or as a complication of childbirth or abortion. The inflammatory fluid has a fetid odor, and multiple abscesses develop in the peritoneal cavity. A distinctive feature of biliary peritonitis is a slight irritation of the peritoneum. Despite the general signs of intoxication, classic local symptoms ( plank belly, muscle tension) are not expressed.

Local and general symptoms of peritonitis

Symptoms of peritonitis are divided into local and general. Local symptoms include those that develop in response to peritoneal irritation ( inflammatory exudate, blood, bile). These symptoms develop as a protective mechanism, and the zone of their localization depends on the area and location of the pathological focus.

Local symptoms of peritonitis are:

• pain;
• tension in the abdominal muscles;
• symptoms of peritoneal irritation detected during examination.

Pain

Pain is the very first symptom of peritonitis. Its nature and intensity depends on the cause of peritonitis. The brightest and most intense pain is observed with perforation of internal organs, for example, the stomach or duodenum. In this case, it appears abruptly, suddenly, and in terms of strength it resembles a blow with a dagger ( described in medical literature as dagger pain). The intensity of the pain syndrome is also influenced by the composition of the irritating substance. So, the most intense pain is observed with pancreatic necrosis or acute pancreatitis. Enzymes, which are contained in pancreatic juice, have a maximum, comparable to a burn, irritating effect on the peritoneum. Severe pain can lead to pain shock and loss of consciousness. Sometimes the patient may become agitated. However, most often the pain restricts the patient's movements, forcing him to take a certain position. Breathing in the stomach becomes difficult, rare and superficial.

The pain that appears in this case is first localized and limited to the area where the pathological focus is located. However, after a couple of hours, the pain takes on a diffuse character. This is due to the spread of pathological contents in the abdominal cavity. At the same time, the opposite can also be observed. Initially diffuse pain can be localized.

Pain in peritonitis is caused by irritation of the sheets of the peritoneum. After all, the peritoneum has a rich innervation and is sensitive to any kind of stimuli. The transition of localized pain to diffuse pain is also explained by the transition of inflammation from the parietal peritoneum to the visceral one. The parietal sheet of the peritoneum, which covers the walls, receives innervation from the corresponding walls of the abdomen. For example, the sheet covering the anterior abdominal wall is innervated by the intercostal nerves. Therefore, the resulting pains have a clear localization. At the same time, the visceral peritoneum is innervated by the autonomic nervous system. Pain that occurs when the visceral peritoneum is irritated does not have a clear localization, but is diffuse in nature.

Sometimes pain can simply change localization, which also means the transition of the inflammatory process. But in this case, the inflammatory process is not diffuse, but localized. For example, the pain may subside for a while and increase with urination. This means that the pathological process has moved to the peritoneum covering the bladder. In diagnosis, it is important to find out the primary localization of pain.
The disappearance of pain is bad sign with peritonitis. This may be due to the accumulation of large amounts of fluid in the abdominal cavity or paresis ( lack of peristalsis) intestines.

Tension of the abdominal muscles

Tension of the abdominal muscles, or muscle defense, occurs almost simultaneously with pain. The appearance of this symptom is due to a reflex contraction of the abdominal muscles. Muscle tension also corresponds to the zone of innervation. The maximum muscle tension with the disappearance of all abdominal reflexes is observed when the ulcer is perforated. Such a belly is also called "board-shaped" in the medical literature. Muscle tension in this case can be seen visually, even before palpation.

The tension can also be local. For example, with exudative bile peritonitis, the abdominal wall thickens in the projection of the gallbladder.
Muscular protection is an early local symptom. At the same time, as intestinal paresis develops and exudate accumulates, it disappears. Lack of muscle tension can be seen in debilitated patients, usually the elderly.

Symptoms of peritoneal irritation detected during examination

The classic objective symptom of peritoneal irritation is Shchetkin-Blumberg's symptom. The symptom reveals the presence of inflammation and irritation in the peritoneum.

Methodology
The patient is in a supine position with legs bent at the knees ( for maximum relaxation of the abdominal wall). The doctor slowly presses his hand on the area of ​​the anterior abdominal wall, where the inflammatory process is supposed. In this case, the patient notes pain. With a sharp withdrawal of the hand, the pain increases sharply. Such a symptom is considered positive. If, when the hand is taken away, the pain does not change its intensity, then the symptom is considered negative.

With a pronounced muscle tension, the symptom is difficult to determine. Also, diagnosis is difficult in the case when intestinal paresis has developed.

Of great diagnostic value are the general symptoms of peritonitis. They are caused by the penetration of toxins into the blood and general intoxication.

Common symptoms of peritonitis are:

• temperature;
• repeated vomiting;
• cardiopalmus;
• low pressure;
• decrease in diuresis;
• dry skin and pointed facial features;
• signs of acidosis increase in acidity);
• confusion.

In the clinic of peritonitis, it is customary to identify several stages, which are characterized by their own symptoms.

Symptoms of peritonitis by stages

Reactive stage

The reactive or initial phase is characterized by the predominance of local symptoms and the initial development of general ones. Its duration ranges from several hours to several days. In acute purulent peritonitis, its duration is limited to 24 hours.

In this stage, the patient is in a forced position, usually lying on his back with his legs brought to his stomach. Common symptoms such as fever and palpitations appear. The temperature is determined by the vital activity of bacteria and their penetration into the blood. The degree of temperature rise is directly proportional to the pathogenicity of microorganisms. So, with streptococcal and staphylococcal peritonitis, the temperature rises to 39 - 40 degrees Celsius. With tuberculosis - 38 degrees. At the same time as the temperature rises, the number of heart beats increases. At this stage of the development of the disease, it is associated with increased temperature. It is known that for every degree raised, the heart increases the number of its contractions by 8 beats per minute.

Nausea and vomiting also appear at this stage. The patient's tongue becomes coated and dryish. When examining the patient, superficial gentle breathing is revealed. With moderate pain syndrome, consciousness is clear, with pain shock- confused. Also at this stage, objective symptoms of peritoneal irritation, such as Shchetkin-Blumberg's symptom, are detected.

toxic stage

This stage lasts from 24 to 72 hours. General symptoms begin to prevail in it, which are caused by general intoxication, disturbances in water and electrolyte metabolism and metabolic disorders.
Toxins with the blood and lymph flow are carried throughout the body. First of all, they reach the liver and lungs, resulting in liver failure and lung distress. Breathing becomes frequent, superficial, sometimes intermittent. The patient continues to be tormented by vomiting, while the vomit becomes fetid.

The main complications at this stage are associated with dehydration and fluid and electrolyte disturbances. Due to impaired vascular tone and changes in the permeability of the vascular wall ( everything is caused by the action of toxins) fluid seeps into the peritoneal cavity. A state of anhydremia develops, which is characterized by a decrease in the level of fluid in the body. The patient is tormented by thirst, which is not relieved by drinking. The tongue becomes dry, lined with a brown coating. Blood pressure drops, and the heart rate compensatory increases to 140 beats per minute. At the same time, due to hypovolemia ( low blood pressure) heart tones become muffled and weak.
Frequent vomiting leads to the loss of not only water, but also body salts. Due to hypokalemia and hyponatremia, seizures or arrhythmia may occur.

The patient's condition worsens even more when oliguria develops. At the same time, the daily volume of urine decreases from the norm of 800 - 1500 to 500 ml. It is known that all metabolic products are excreted from the body with urine. These include urea, uric acid, indican. However, with oliguria, they are not excreted, but remain in the body. This leads to even greater intoxication of the body.

At the same time, local symptoms of peritonitis become erased. Muscle tension disappears, and it is replaced by bloating. At this stage, intestinal paresis develops, which is characterized by the absence of its peristalsis. The pain also subsides or completely disappears, which is associated with the accumulation of exudate in the peritoneal cavity.

If you do not take emergency measures, then this stage can go into the terminal.

terminal stage

This stage develops after 72 hours or more from the onset of the disease. It is characterized by dehydration of the body and the development of a precomatous state. The patient's face at this stage corresponds to the descriptions of Hippocrates ( facies Hippocratica). The features of such a face are sharpened, the eyes and cheeks sink, the complexion acquires an earthy hue. The skin becomes very dry and tight to such an extent that the temples are pressed in. Consciousness is confused, the patient most often lies motionless. The abdomen is strongly inflated, its palpation is painless. The patient's pulse is thready, breathing is intermittent.
Today terminal stage is, of course, extremely rare.

Expression of local and common symptoms with peritonitis depends on the degree of its spread and the cause of the disease. The classic staged course is observed with diffuse peritonitis. With localized forms, the symptoms are not so pronounced.

Symptoms of chronic peritonitis

The classic symptoms of peritonitis in its chronic form, as a rule, are erased and not expressed. The patient does not complain of acute pain, vomiting or muscle tension. Therefore, for a long time this type of peritonitis can go unnoticed.
At the same time, the main symptoms are associated with long-term, chronic intoxication of the body.

Symptoms of chronic peritonitis are:

• weight loss;
• excessive sweating;
• long subfebrile temperature;
• periodic constipation;
• recurrent abdominal pain.

Weight loss and increased sweating are persistent symptoms with chronic tuberculous peritonitis ( the most common form of chronic peritonitis). These symptoms are due to intoxication of the body with the decay products of mycobacteria.

Other symptoms of chronic peritonitis are due to adhesions. So, chronic peritonitis most often occurs in a dry form, which is characterized by an adhesive process. The adhesions that form at the same time tighten the intestinal loops and disrupt its motor activity. Thus, the syndrome of periodic intestinal obstruction develops. The patient is tormented by periodic constipation, which becomes more frequent as the disease progresses. There are also pains in the abdomen, periodic swelling. As the adhesions spread, the symptoms become more frequent and more severe.

Diagnosis of peritonitis

Diagnosis of peritonitis is based on anamnestic data and the clinical picture. History data ( medical history) are especially important in chronic forms of peritonitis. Knowing what the patient was ill with earlier or what he is ill with now, it is possible to assume with the greatest accuracy the place of the primary infection. In chronic peritonitis, the objective data revealed during the examination are scarce and therefore the doctor may resort to additional examination methods. One such study is diagnostic laparoscopy. This diagnostic method allows you to visually examine the peritoneal cavity without making large incisions on the abdomen, as during surgery. During this manipulation, the doctor examines the sheets of the peritoneum through a tube combined with a lens and assesses their condition. As a rule, in chronic peritonitis, the peritoneum is covered with fibrin films, and adhesions form between its sheets.

In acute and diffuse peritonitis, diagnosis is not difficult. As a rule, the patient's complaints and objective data revealed during the examination are sufficient for the diagnosis. The main symptoms that the doctor reveals during the examination are associated with irritation of the peritoneum. These symptoms are muscle tension, a positive Shchetkin-Blumberg symptom.

Treatment of peritonitis with medicines

The lethality of peritonitis today is still high, so the problem of treatment is very relevant. Since peritonitis in 99 percent of the case is secondary disease, then its treatment should begin with the elimination of the root cause. As a rule, it consists in surgical intervention to remove a burst appendix, suture a perforated ulcer, or remove a purulent gallbladder. At the same time, drug treatment is carried out, aimed at correcting all those disorders that develop with peritonitis. Thus, the treatment of peritonitis should be complex and combine various methods.

Treatment of peritonitis with drugs is aimed at eliminating the infection ( causing peritonitis), to correct metabolic disorders, as well as to prevent the development of complications.

Drug group	Representatives	Mechanism of action	How to use
Antibiotics Antibacterial therapy is the mainstay in the treatment of bacterial peritonitis. Since the most common cause of peritonitis is a microbial association of 2 and 3 organisms, it is advisable to prescribe antibiotics a wide range.	From the penicillin group: benzylpenicillin; ampicillin; methicillin. From the group of aminoglycosides: kanamycin; gentamicin. From the group of macrolides: sigmamycin; olethrin.	interfere with the synthesis of components cell wall thus preventing further proliferation of bacteria in the peritoneal cavity. Antibiotics from the group of aminoglycosides block the synthesis of proteins necessary for bacteria for their vital activity.	With moderate peritonitis, antibiotics are mainly prescribed intramuscularly. Usually appointed loading doses antibiotics. Benzylpenicillin - 15.000.000 units each ( action units) per day, ampicillin and methicillin - 3-4 grams each, gentamicin - from 2 to 3 mg per kg of body weight. The daily dose is divided into 2 - 4 doses. In severe cases and in case septic shock antibiotics are prescribed intravenously.
Infusion solutions They are used to restore lost fluid, as well as to prevent dehydration and hyperthermia.	5 and 25 percent glucose solution: refortan; perftoran.	Due to their high osmolarity, these solutions retain fluid in the vascular bed. Replenish the lost water and body salts.	All of these drugs are given by intravenous drip ( extremely rare - jet). The volume of the prescribed solution is determined individually based on the amount of fluid lost by the body.
Detoxification agents and sorbents This group of drugs is used to remove toxins and bacteria from the body. Drugs are needed to prevent the development of toxic shock and other complications.	hemodez.	It binds toxins that have penetrated into the blood from the peritoneal cavity and removes them.	The volume of the solution depends on the age and condition of the patient. On average, from 200 to 500 ml is administered intravenously.
	10% calcium chloride solution.	Normalizes the permeability of the vascular wall ( which is disturbed by peritonitis), thereby preventing the penetration of toxins through it.	10 ml of a 10% solution is diluted in 200 ml of isotonic solution and injected intravenously.
Diuretics This category of drugs is used for forced diuresis. The method of forced diuresis is prescribed together with detoxification drugs and hypertonic solutions for the speedy removal of toxins from the body.	furosemide. This drug is prescribed with caution, especially in severe water and electrolyte disorders.	Blocks sodium reabsorption, thereby increasing urine volume. It has a quick but short-term effect.	One - two ampoules of the drug is administered intravenously after the hypertonic solution has been introduced. For example, at the end of the dropper with 400 ml of 20% glucose or mannitol solution, 4 ml is injected ( 40 mg) furosemide.
Antipyretics To eliminate temperature.		They block the synthesis of substances that are involved in inflammation and increase the temperature.	Paracetamol - 500 mg each ( one tablet) 4 times a day. Ibuprofen - 400 mg each ( one tablet) 2-3 times a day.
Antiemetics Used in the treatment of peritonitis to eliminate symptoms such as nausea and vomiting.	metoclopramide.	It has a tonic effect on the muscles of the gastrointestinal tract. It blocks the receptors of the vomiting center and thus has an antiemetic effect.	Administered intravenously or intramuscularly at 10 mg ( 2 ampoules) two or three times a day. The maximum daily dose is 60 mg.
Anticholinesterase drugs They are used to restore the motor function of the intestine and prevent its paresis.	ubretide; prozerin.	They increase the tone of the intestinal muscles and increase its peristalsis, preventing the development of paresis.	Ubretide is administered intramuscularly, once at a dose of 0.5 mg ( one ampoule). Re-injection is done only after 24 hours. Prozerin is administered subcutaneously, at a dose of 1 ml of a 0.05% solution twice a day.
Anticoagulants They are used to prevent thrombosis, which are characteristic of purulent peritonitis.	heparin.	Reduces platelet aggregation, preventing the formation of blood clots. It also reduces the permeability of the vascular wall.	Can be used both intravenously and subcutaneously. It is also prescribed after surgery. The dose ranges from 25,000 to 50,000 IU per day.
Anabolic drugs In patients with peritonitis, the rate of catabolic ( decay process) reactions are maximally increased. Therefore, drugs are prescribed that reduce this process.	In order to activate anabolic processes, anabolic steroids are prescribed: retabolil; insulin along with glucose.	Retabolil activates the processes of anabolism, mainly due to the synthesis of proteins in the body. Insulin increases energy processes in the body.	Retabolil is administered intramuscularly 100-200 mg to men, 50-100 mg to women once a week. Based on the calculation that one unit of insulin falls on 5 mg of glucose, 250 to 500 ml of a 10% glucose solution is administered intravenously along with insulin.

Treatment of peritonitis should be individualized. It is necessary to take into account the features of the course of the pathological process, the form of peritonitis ( dry or wet), as well as the etiological factor. The latter plays a decisive role in the effectiveness of treatment. So, with tuberculous peritonitis, anti-tuberculosis drugs are prescribed - isoniazid, rifampicin, ethambutol. If anaerobic flora is suspected - lincomycin, trichopolum, gentamicin, and also carry out hyperbaric oxygenation ( oxygen supply under high pressure ). In aseptic peritonitis caused by acute pancreatitis, anti-enzymes are prescribed - counterkal. With diffuse forms of peritonitis, the method of washing the peritoneum is used ( peritoneal dialysis).

It should be noted that the appointment of painkillers for peritonitis is contraindicated. First, painkillers lubricate clinical picture which is especially dangerous in the acute period of the disease. And this applies to all pathologies related to the section " acute abdomen» in surgery. Secondly, most painkillers weaken the motor activity of the intestine, thereby accelerating the development of intestinal paresis. It is also not allowed to administer laxatives that contribute to the spread of the pathological process.

Surgery for peritonitis

When is surgery needed for peritonitis?

The detection of peritonitis is an absolute indication for emergency surgical intervention. The course of the procedure depends on the cause that provoked inflammation of the peritoneum, but in all cases the operation has the same goals and is carried out according to a certain algorithm.

The goals of surgical intervention for peritonitis are:

• removal of exudate fluid released from blood vessels during inflammation) and infected tissues;
• resection or isolation of the source of infection;
• decompression ( release from liquids and gases) gastrointestinal tract;
• sanitation of the abdominal cavity.

The stages of the operation for inflammation of the serous cover of the peritoneum are:

• preoperative preparation;
• providing access;
• elimination or delimitation of the focus of infection;
• lavage of the abdominal cavity;
• bowel decompression;
• drainage ( creating conditions for a constant outflow of content) abdominal cavity;
• suturing the wound.

Preparing for the operation

The main task of preoperative preparation is to correct the disturbed functions of the body.

The stages of preparatory therapy for the patient are:

• intravenous infusion of drugs;
• emptying the gastrointestinal tract;
• anesthesia.

Medical preparation of the patient
The nature of infusion therapy depends on the age and weight of the patient and the presence of concomitant diseases. In some cases, venous catheterization is appropriate, which allows you to increase the rate of infusion and better control the process.

The goals of intravenous influence are:

• Replenishment of the volume of circulating blood.
• Correction of violations of the central and peripheral circulation.
• Providing the necessary concentration of antibiotics in tissues to reduce the spread of infection and prevent septic shock. With a pronounced syndrome of multiple organ failure and unstable blood circulation, the patient is artificially ventilated.

Cleansing the gastrointestinal tract
If peritonitis is diagnosed at an early stage, a single emptying of the stomach with a probe is performed. With more advanced processes, the probe is left for the entire recovery period after the operation. cleansing lower divisions bowel is carried out with the help of enemas.

Anesthesia
Anesthesia in the surgical treatment of peritonitis is carried out on the basis of multicomponent anesthesia and the use of muscle relaxants. Recently, spinal anesthesia has been widely used. An obligatory stage of anesthesia is novocaine blockade. This procedure reduces the need for narcotic analgesics. Novocaine also improves tissue trophism and eliminates reflex vascular spasm, which ensures earlier restoration of the functionality of the gastrointestinal tract.

The incision during the operation
Surgical intervention for inflammation of the serous membrane of the peritoneum is performed using a median laparotomy ( an incision that is made along the white line of the abdomen, from the lower end of the sternum to the pubis). This type of laparotomy provides access to all areas of the abdominal cavity. Depending on the location of the focus of infection, the incision made can be expanded in the required direction. Correction of an abdominal wound with the help of special retractors provides an opportunity to quickly and with a minimum level of trauma gain access to any part of the abdominal cavity. In cases where widespread purulent peritonitis is diagnosed only during an operation that is performed from another incision, the doctor switches to a median laparotomy.

Removal or delineation of the cause of peritonitis
Elimination of the source of peritonitis is the main goal of the operation. The doctor's actions at this stage of the operation depend on which organ is the source of infection. If the cause of inflammation is an organ, the removal of which is possible ( appendix or gallbladder ), then a resection of this organ is performed. If peritonitis has caused perforation of a hollow organ, it is sutured. It can also be performed removal of the affected area of ​​the gastrointestinal tract with the imposition of a colostomy or enterostomy ( methods of bringing out the small intestine or colon) or isolation of the focus of infection. With peritonitis that occurs after intestinal surgery, due to the insolvency of the anastomotic sutures ( union of two hollow organs) in some cases, non-radical operations are performed. Such manipulations include the suction of purulent contents with the help of drainage tubes, the isolation of the source of peritonitis by tamponing, the removal of the inter-intestinal anastomosis to the outside.

Abdominal cleansing
Washing the abdominal cavity with special solutions reduces the number of pathogens in the exudate and contributes to a more effective elimination of infection. In order to preserve the integrity of the serous layer, the use of gauze wipes to remove pus is excluded. Also, due to the danger of violation of the serous cover, dense fibrin deposits are not eliminated ( substance produced during blood clotting). The compositions that are used for washing are pre-cooled to a temperature that varies from +4 to -6 degrees. This procedure allows you to achieve vasoconstriction and reduce the intensity of metabolic processes, the level of which increases sharply in this disease.

Bowel decompression
To remove accumulated fluid and gases from the intestine, a long probe with a large number of holes is passed into the small intestine through the oral cavity. Also, the probe can be passed through the rectum. If the suction of the contents is not effective, the doctor performs an ileostomy ( passage of part of the small intestine outward through an opening in the abdominal wall). The large intestine, if necessary, is drained through the anus. In rare situations, a stoma is placed to place the probe ( artificially created hole and brought to the front wall of the abdominal region) to the stomach or appendix.

Abdominal cleansing
For drainage of the abdominal cavity, special hollow tubes are used. Drainages are introduced into the right and left pelvic area, on both sides of the diaphragm and under the liver. If purulent peritonitis was detected during the operation and the cause of the infection was eliminated, then peritoneal lavage is performed ( introduction of special preparations through the catheter into the abdominal cavity and its removal after some time). This procedure allows you to effectively clean the abdominal cavity.

Stitching surgical wound
The method of completion of the operation depends on how the residual infection will be treated.

Options for suturing the surgical incision are:

• Continuous suture without drainage- this method is used at a low level of infection, when there is no risk of abscesses. In such cases, the calculation is based on the fact that the body can independently cope with infectious process with the help of antibiotics.
• Incision suture with passive drainage- drains are used to drain exudate and introduce antibiotics.
• Approximation of the edges of the wound- used when installing drainage near the abdominal wall to flush the peritoneum and remove pus.
• open way- is used in the presence of a large amount of pus or extensive inflammation of the tissues of the abdominal wall. With this method, the exudate is removed through open wound which is covered with tampons.

Postoperative period

The patient's condition after surgery for peritonitis requires close attention, since factors such as previous anesthesia, surgical trauma and malnutrition join the inflammation.

Directions of postoperative therapy are:

• taking antibiotics to reduce the number of harmful microbes in the body;
• carrying out therapeutic measures aimed at detoxifying the body;
• correction of metabolic disorders;
• restoration of intestinal functionality.

Is hospitalization required to treat peritonitis?

Hospitalization is necessary for the treatment of peritonitis. Outpatient ( at home) treatment of peritonitis in any form is unacceptable. Peritonitis is acute surgical pathology with an unpredictable course, the lethality of which is very high. At any stage of this disease, complications can occur that endanger the life of the patient. Therefore, at the slightest suspicion of peritonitis, emergency hospitalization is necessary. After complex treatment in a hospital, long-term observation by a surgeon is necessary.

Nutrition for peritonitis

Diet therapy is an important link postoperative rehabilitation after peritonitis. Surgery causes a violation of the functionality of the body, so the reserves of proteins, fats and carbohydrates are depleted. Therefore, the patient's diet after peritonitis should be balanced and include all the elements to normalize energy metabolism. Definition of final diet ( composition, duration) depends on the cause that caused peritonitis. The postoperative period is divided into several stages, which determine the nature of the patient's nutrition.

phases recovery period are:

• first ( early) - lasts from 3 to 5 days;
• the second - duration from 2 to 3 weeks;
• third ( distant) - ends with the full restoration of the patient's ability to work.

Nutrition at the first stage

Providing full support for the patient after surgery with the necessary nutritional ingredients is possible only with the help of artificial nutrition. To meet the body's needs for protein and prevent complications, the patient is given parenteral feeding ( administering nutrients intravenously). When intestinal motility appears, the patient is transferred to enteral nutrition ( the introduction of mixtures using a probe through the mouth, nose or a special hole in the abdominal wall). The composition of the diet and duration are determined by the physician, depending on the general condition of the patient. Parenteral and enteral feeding can reduce the likelihood of complications and shorten the recovery period after peritonitis surgery.

Nutrition at the second stage

With the appearance of a chair and the positive dynamics of the state of the body, the patient is transferred to a natural diet. The main rule of feeding is the gradual introduction of new products and constant monitoring of the patient's well-being.
For some period ( 2 to 5 days) after finishing artificial feeding the patient is assigned special diet with a low energy value (up to 1000 kilocalories per day). A patient needs to consume about 20 grams of proteins and fats and 200 grams of carbohydrates per day. The amount of table salt should be limited to a minimum, and fluid intake should be at least 2 liters per day. The consistency of the dishes should be liquid or semi-liquid.

• kissel, jelly vegetable, fruit, meat);
• weak meat broth;
• boiled eggs ( soft-boiled);
• homemade fruit and berry juices;
• vegetable puree with butter.

With good tolerance of this diet and the absence of liquid stool the patient is transferred to a more varied diet, which is followed throughout the entire time of treatment in the hospital.

The main diet of the second phase of rehabilitation after surgical treatment of peritonitis
The diet should satisfy all the needs of the patient in nutrients and promote the healing of organs affected during the operation. Also, one of the key goals of the diet is to restore the functionality of the gastrointestinal tract.

Principles of compiling a menu for a patient after treatment of peritonitis
Increased protein content - a sufficient amount of it is part of the following products:

• eggs;
• meat ( lamb, beef, turkey, rabbit meat);
• fish ( saury, salmon, sardine);
• fish products ( caviar, cod liver);
• dairy ( hard and semi-hard cheeses, sour cream, cream).

Minimum dose easily digestible carbohydrates- It is necessary to reduce the consumption of products such as:

• sugar;
• marmalade;
• jam;
• rich and other products made from wheat flour;
• sugar substitutes.

A sufficient amount of complex carbohydrates - products that contain the required rate of these elements are:

• brown rice;
• carrot;
• eggplant;
• potato;
• legumes;
• dried apricots;
• prunes.

Balanced intake of fats - the recommended sources of fats after peritonitis are:

• vegetable oil ( corn, sunflower, olive);
• butter;
• sour cream, cream, milk, cottage cheese;
• medium fat fish.

Also, nutrition in the postoperative period should help increase the body's resistance to infections and the healing of a postoperative wound.

The rules of the basic diet are:

• Diet- should consist of 5 - 6 meals.
• Pauses between meals- no more than 4 hours. Dinner - 1 - 2 hours before going to bed.
• Meal temperature– average. Avoid too hot or cold food.
• food consistency- liquid, mushy. Cooked food may have a denser texture than porridge, but should be served pureed.
• Recommended heat treatment- Boiling or steaming. It is also allowed to use the oven, but without the formation of a crust on the products.
• Rest after meals- if possible, especially at lunchtime, after eating, it is necessary to take a horizontal position for 15 to 30 minutes.
• Fluid intake- tea, milk and other drinks should be consumed 20 to 30 minutes after eating. The amount of liquid taken at a time should not exceed 1 glass.

So that the food consumed does not have an aggressive effect on the organs of the digestive system, it is necessary to exclude products that are strong causative agents of secretion.

Products that provoke increased secretory activity of the stomach include:

• rich meat and vegetable broths;
• smoked, dried sausages;
• salted, pickled fish;
• industrial canned food;
• baking products;
• tomato sauce, ketchup, soy sauce, mustard, horseradish;
• salted, pickled vegetables;
• sour, salty, spicy dressings for dishes;
• not mature enough or sour fruit;
• stale vegetable and animal edible fats;
• chocolate;
• coffee, cocoa;
• drinks containing carbonic acid.

Foods that should be kept to a minimum in a basic diet include:

• whole grain products- bread made from coarsely ground flour, durum pasta, cereals from whole grain cereals;
• vegetables- white cabbage, broccoli, peas, green beans, spinach, dried mushrooms;
• fruits- dates, gooseberries, currants, apples, bananas, grapefruits, oranges, avocados.

You should also consume dishes in minimal quantities, which include sinewy meat or rough connective tissue animal origin ( skin, cartilage, tendons).

The daily norms of the chemical composition of the main diet are:

• squirrels- 100g ( 60 percent animal origin);
• fats– from 90 to 100 grams ( 30 percent vegetable);
• carbohydrates- 400 grams;
• calories- from 2800 to 2900 kilocalories.

The amount of table salt consumed by the patient per day should not exceed 6 grams.

The diet of a patient with peritonitis should be rich in vitamins and minerals, the lack of which can be replenished with vitamin and mineral supplements. The main indicator that should be guided by when compiling the menu is the patient's well-being. If, when eating certain foods, the patient experiences discomfort in the epigastric region, nausea or vomiting, such products or products should be discarded.

• Bread- wheat products baked yesterday or dried in the oven.
• Soups- cooked on potato or carrot broth. Foods such as cereals may be added ( needs to be well cooked), vegetables ( should be wiped), milk. You can fill the first dishes with butter.
• Meat- cutlets ( steam, boiled), casseroles, soufflés. Recommended beef, lamb ( non-greasy), pork ( circumcised), chicken, turkey.
• Fish- use low-fat varieties for boiling or steaming in a whole piece. The skin is removed first. Cutlets or meatballs from fish fillet, aspic are also possible.
• Dairy- milk, low-fat cream, non-acidic kefir, cottage cheese, yogurt, fermented baked milk. Products can be consumed on their own or used to make casseroles, mousses, creams.
• Eggs- boiled soft-boiled, steam omelettes.
• Kashi- boiled in water or milk from cereals such as buckwheat, semolina, rice.
• Vegetables- potatoes, carrots, beets. Vegetables can simply be boiled, mashed, pancakes are cooked from them ( steam), cutlets ( steam), soufflé.
• Finished goods- milk sausage, unsalted low-fat ham, children's sausages, cheese curds.
• Dessert- jelly, jelly, unsweetened compote.
• Beverages- juices from sweet berries diluted with water, weakly brewed tea, rosehip broth.

The dishes of the approximate menu for 1 day are:

• Breakfast- 1 soft-boiled egg, rice porridge in milk, tea.
• Late breakfast- granulated ( non-sour) cottage cheese, a decoction of wild rose.
• Dinner- potato soup without meat, steamed chicken cutlets and carrot puree, compote of their dried fruits.
• afternoon tea- a decoction of wheat bran with dried bread.
• Dinner- boiled fish, boiled vegetable salad, tea with milk.
• 1 - 2 hours before bedtime- 1 glass of milk.

Nutrition in the third stage

In most cases, the third phase of the postoperative period coincides with discharge from the hospital and transfer to outpatient treatment. Gradually, new products are introduced into the patient's diet, while controlling the reaction of the body.

The rules according to which the transition to a more varied diet is carried out are:

• reducing restrictions on the types of heat treatment used;
• a gradual increase in caloric intake;
• replacement of mashed food with solid foods.

Restrictions to be observed until full recovery are:

• reduced sugar intake;
• minimal use of hot seasonings and spices;
• reducing the amount of indigestible food ( animal fats, legumes, fatty meats, deep fried foods).

The principles must be continued fractional nutrition, distributing the daily calorie intake ( from 2300 to 2500) in accordance with the rules of a healthy diet.

Distribution principles daily calories are (data are given as a percentage of the total food volume):

• breakfast - 20;
• late breakfast - 10;
• lunch - 35;
• afternoon snack - 10;
• dinner - 20;
• late dinner - 5.

Prevention of dysbacteriosis after peritonitis

Of great importance in the recovery after peritonitis is the prevention of dysbacteriosis ( decrease in beneficial and increase in harmful bacteria in the intestines).

The rules of nutrition that will help restore the intestinal microflora are:

• Avoiding or reducing consumption of all types of sugar and its substitutes ( honey, maple syrup, corn syrup, glucose, fructose, maltose, sorbitol, sucrose).
• Exclusion of foods prepared using fermentation processes ( beer, wine, cider, ginger ale).
• Minimal consumption of foodstuffs that may contain yeast and mold ( cheeses, vinegar, marinades, bakery products, raisins, kvass).
• Exclusion of dishes, which include dyes, flavors, flavor enhancers. A large concentration of these elements is found in fast food.
• The use of stewed carrots and beets. The composition of these vegetables includes pectin - a substance that has a sorbent ( suction) property and promotes the removal of toxins from the body.
• Inclusion in the menu of dairy and lactic acid products ( kefir, cottage cheese, yogurt, koumiss, milk). It should be noted that the benefit to the body in the fight against dysbacteriosis is brought dairy products, the period of which does not exceed 1 day. After 24 hours, saprophytic bacteria develop in kefir and cottage cheese, which inhibit intestinal function and can cause constipation.
• The use of foods enriched with lactobacilli and bifidobacteria. Fermented milk products such as bifidok, biokefir, fermented milk lactobacterin are enriched with such elements.
• Adding slimy soups and cereals made from buckwheat or oatmeal to the menu. These dishes improve bowel function and prevent diarrhea.

Can peritonitis be treated at home?

Peritonitis is a disease that requires immediate attention medical assistance. From the beginning of the development of the disease to the terminal phase, a short period of time passes, the duration of which does not exceed 3 days. Therefore, untimely diagnosis and operation can lead to the death of the patient.

With peritonitis, blood, urine, bile, feces, stomach contents enter the abdominal cavity, as a result of which the body experiences severe intoxication. It is possible to remove the source of infection and eliminate the consequences of peritonitis only in special clinical setting using medical equipment and a wide range of drugs. In the hospital, the patient is provided with adequate preoperative preparation, which makes it easier to endure surgery. After the operation is completed, the patient undergoes multilevel postoperative therapy to prevent complications. It is impossible to implement all stages of peritonitis treatment at the appropriate level at home.

Consequences of peritonitis

The consequences of peritonitis are the development of numerous complications both during the disease itself and in the recovery period.

Complications of peritonitis in the acute period of the disease are:

• acute renal failure;
• pulmonary complications;
• toxic shock;
• body dehydration.

Acute renal failure

Acute renal failure is severe consequence peritonitis, which is characterized by a sharp decrease in kidney function. It is known that the main function of the kidneys is to remove toxic metabolic products from the body. Due to damage to the kidneys by bacterial toxins that spread with the blood flow from the peritoneal cavity throughout the body, this function drops sharply. The result of this is the retention of these products in the human body.

The most dangerous waste product of our body is urea. Its increased content in the blood is called uremia. The danger of this condition lies in the fact that, being an osmotically active substance, it carries water with it. Easily passing through cell membranes, urea, penetrating into the cell, leads to cellular overhydration. At the same time, the cell becomes swollen and swollen, and its functions are lost.

Also, urea can fall out and form crystals, which will subsequently be deposited in the organs. With renal failure, there is also a delay in nitrogenous bases in the body. The greatest danger is ammonia, which, due to its lipophilicity, easily penetrates into the brain tissue, damaging it.

Unfortunately, damage to the kidney tissue is often irreversible. Therefore, acute renal failure can often flow into a chronic form. Morphological examination of people who died from peritonitis revealed numerous necrosis in the kidneys ( areas of necrosis) and hemorrhages.

Pulmonary complications

Pulmonary complications develop in the toxic stage of peritonitis, when toxins and bacteria from the peritoneal cavity are carried through the bloodstream throughout the body. Getting into the lungs, they cause stagnation of blood, disrupting the process of oxygen transfer to them. The main mechanism of damage is to reduce the synthesis of surfactant ( a substance that keeps the lungs from collapsing). The result of this is acute distress syndrome, which is manifested by severe shortness of breath, cough, and chest pain. Its severity is proportional to the severity of peritonitis. The further the underlying disease progresses, the more respiratory failure increases. The patient becomes cyanotic skin color turns blue), it registers frequent and shallow breathing, strong heartbeat. Without correction of respiratory disorders, distress syndrome turns into pulmonary edema. Pulmonary edema is one of the most severe complications, which can lead to death. This condition is characterized by the fact that the pulmonary alveoli are filled with liquid instead of air. As a result, the patient begins to suffocate, as he does not have enough air.

toxic shock

Toxic shock is one of the causes of death in peritonitis. It develops in the toxic stage, when toxins spread from the focus of inflammation throughout the body. It is known that one of the pathogenetic links in peritonitis is increased vascular permeability. Bacteria and their toxins easily pass into the bloodstream through the damaged wall. Together with the blood, they are carried throughout the body, causing multiple organ failure. First they enter the liver, then the lungs, heart and kidneys. At the same time, water rushes from the vessels into the peritoneal cavity, as a result of which blood pressure drops. If a very large amount of toxins enters the blood at the same time, then all these stages occur very quickly. The temperature rises sharply, the pressure drops, and the patient has a confused mind. Simultaneously developed multiple organ failure progresses very quickly. Toxic shock has a very high percentage of deaths that can develop within a few hours.

Dehydration

Dehydration of the body or exsicosis is characterized by the loss of fluid from the body from 5 percent of the norm or more. With exicosis, there is a lack of water not only in the bloodstream, but also in all cells of the body. Since water is the source of life, it is involved in all metabolic processes in the human body. Its deficiency affects the work of all organs and systems. Tissues that have lost water lose their function. Severe damage to the brain, kidneys and liver develops.

Complications of peritonitis in the postoperative period of the disease are:

• infection of the postoperative suture;
• repeated peritonitis;
• intestinal paresis;
• adhesions.

These complications are the most frequent in the list of numerous consequences of peritonitis. Recurrent peritonitis develops in one case out of a hundred. This complication necessitates a second operation. It can develop with insufficient drainage of the operated cavity, inadequate antibiotic therapy, or for a number of other reasons. As a rule, recurrent peritonitis is more severe and even more difficult to treat.

Infection of the postoperative suture is also a common complication. The risk of developing it is highest in people who are overweight or who have diabetes. Suppuration of the suture is observed in the early postoperative period. The seam becomes red, swollen and painful. After a couple of days, pus begins to flow out of it. In parallel, the patient develops a temperature, chills, general well-being worsens.

Intestinal paresis is manifested by the lack of motor activity of the intestine. It is a formidable complication, as it is difficult to correct. Most often it develops with diffuse peritonitis or as a result of long-term operations. In this case, the patient is tormented by painful swelling, prolonged constipation. Intestinal paresis can also develop during the period of the disease itself. In this case, it complicates the diagnosis of peritonitis, as it does not give the classic symptoms of peritoneal irritation and muscle tension.

Adhesions are almost inevitable in peritonitis. Any violation of the integrity of the peritoneum, including its inflammation, is accompanied by the development of an adhesive process. As a result, connective tissue strands are formed that connect the loops of the intestine. The adhesive process develops in the late postoperative period. Adhesions can cause initially partial, and then complete intestinal obstruction. Their manifestation is prolonged pain in the abdomen and constipation. The complexity of the adhesive process lies in the fact that in most cases, re-opening of the abdominal cavity and removal of adhesions is required. This is necessary in order to restore intestinal obstruction, since a far advanced adhesive process tightens the intestinal loops so much that it blocks its obstruction.

The consequence of peritonitis is also prolonged exhaustion of the patient. His recovery takes months. Patients may lose a significant portion of their body weight. This happens because with peritonitis there is an increased breakdown of all the building materials of our body ( proteins, fats, carbohydrates). This phenomenon is also called the catabolic storm. Therefore, patients who have undergone peritonitis are maximally exhausted and weakened.

The lethality of peritonitis is still high. With purulent and diffuse peritonitis, according to various sources, it is 10-15 percent of cases. The outcome largely depends on timely hospitalization. A favorable outcome of the disease is possible in 90 percent of cases with an operation performed within a few hours after the entry of gastric or intestinal contents into the abdominal cavity. If the surgical intervention was carried out during the day, the probability of a favorable outcome is reduced to 50 percent. When conducting surgical treatment after the third day, the positive chances of the patient do not exceed 10 percent.

Inflammation of the peritoneum (peritonitis) develops with the introduction of pathogenic microbes into it or the ingress of certain chemicals. The peritoneum is a two-layer membrane that lines the abdominal cavity and surrounds the stomach, intestines, and other abdominal organs. This membrane supports the abdominal organs and protects them from infection; however, sometimes the peritoneum itself can become infected with bacteria or other microorganisms. The infection usually spreads from organs within the abdomen. Inflammation can cover the entire peritoneum or be limited to only one abscess. A rupture anywhere in the gastrointestinal tract is the most common route for infection to enter the peritoneum. In most cases, microbes are transferred to the peritoneum directly from any inflammatory focus located in one or another abdominal organ (acute appendicitis, cholecystitis, inflammation of the female genital organs, intestinal volvulus, etc.), as well as with penetrating wounds of the abdomen and with perforation of hollow abdominal organs (perforation of the stomach and intestines, gallbladder, etc.). Less often, the infection is introduced by the hematogenous route from the inflammatory focus (tonsillitis, etc.).

There are two forms of peritonitis: diffuse, when inflammation captures most of the peritoneum, and limited, in which inflammation spreads to a relatively limited area of ​​it.

The most severe form is diffuse peritonitis, which develops as a result of a sudden entry into the abdominal cavity of gastrointestinal contents (when a hollow organ is perforated), or pus (when an abscess breaks). In these cases, suddenly there is a very severe sharp pain in the abdomen. Nausea and vomiting soon join this. Vomiting or urge to it is constantly repeated. Initially, the vomit contains food debris, and then a greenish liquid appears. The pain in the abdomen grows, becomes unbearable. The slightest movement of the patient or touching the abdomen causes an exacerbation of pain. The abdomen becomes tense. On palpation, the tension of the abdominal wall is clearly defined. The general condition of the patient deteriorates sharply, the skin becomes pale, the pulse is frequent, breathing is superficial, respiratory excursions of the abdominal wall are sharply limited or absent. Body temperature rises. Moreover, the temperature in the armpit is much lower than in the rectum. In the future, intestinal paresis and bloating occur. During auscultation, intestinal noises in the abdomen are not audible. The appearance of the patient changes sharply, the eyes sink, the nose becomes sharp, the face becomes covered with cold sticky sweat, cyanosis appears, the tongue becomes dry.

In cases where peritonitis develops as a result of the transition of inflammation from one or another abdominal organ, the general condition and subjective complaints of the patient initially remain characteristic of the inflamed abdominal organ. But then in the general condition there is a sharp deterioration. Pain in the abdomen becomes more diffuse, peristaltic noises cease to be heard. Palpatory data are of decisive importance for the diagnosis in these cases. If earlier, soreness and tension of the abdominal wall were determined in the area of ​​​​the primary inflammatory focus, then with peritonitis they quickly capture the entire abdomen. There is a sharp deterioration in the general condition of the patient.

With limited peritonitis, only symptoms characteristic of inflammation of one or another abdominal organ (appendicitis, cholecystitis, adnexitis, etc.) are initially determined. Only after some time, symptoms characteristic of limited inflammation of the peritoneum appear: soreness and tension of the abdominal wall are noted not throughout the abdomen, but in some part of it. In other areas, the abdomen remains softer, less painful, and the tension of the abdominal wall is not expressed, or is expressed slightly.

Diagnostics

. Medical history and physical examination. . X-ray, ultrasound examination and computed tomography of the abdomen. . Blood tests will show an elevated white blood cell count. . May be needed diagnostic operation(laparotomy).

Treatment

Treatment - urgent operation eliminating the cause of peritonitis. At the same time, intensive therapy is carried out: infusions of isotonic sodium chloride solution, glucose solutions, plasma, blood substitutes, as well as cardiac drugs and antibiotics. In the postoperative period, a constant aspiration of gastric contents is established. For excitation of peristalsis, prozerin, physostigmine, 10-20 ml of hypertonic sodium chloride solution are injected intravenously.

Large doses of antibiotics are given intravenously to treat bacterial peritonitis. . Surgery is often necessary when peritonitis results from a disease that has caused perforation of the intestinal tract, such as gastric and duodenal ulcers or a ruptured appendix. . Intravenous administration fluids and food are usually needed to prevent dehydration and give the bowel a rest. . Analgesics may be used to relieve pain. . A tube that passes through the nose into the intestine is attached to a suction device to remove the contents from the temporarily paralyzed intestine.

Prevention

. Prompt treatment of any contagious disease, injury or illness associated with abdominal cavity. . Attention! See a doctor or call immediately ambulance if you experience severe abdominal pain that persists for more than 10 or 20 minutes and is accompanied by any other signs of peritonitis.