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Causes of peritonitis. Acute peritonitis. Possible consequences of pathology

Peritonitis is an inflammatory, bacterial, aseptic process of a local or diffuse nature that develops in the abdominal cavity. This process is a severe complication of destructive and inflammatory diseases of the peritoneal organs.

Peritonitis occurs when the serous lining of the abdominal cavity, also called the peritoneum, becomes inflamed. This inflammatory process falls into the category of dangerous surgical conditions under the general name “acute abdomen.”

The development of the disease is characterized by intense pain in the abdominal area, tension in the muscle tissue of the abdominal cavity, and a rapid deterioration in the patient’s condition and well-being.

Peritonitis of the abdominal cavity is a common disease with a high mortality rate. Today, the mortality rate from inflammation of the peritoneum is 15–20%, although until recently this figure was much higher and varied between 60–72%.

Causes of the disease

The causes of peritonitis can be very diverse and primarily depend on the type and characteristics of the inflammatory process, which can be primary or secondary.

Primary type of peritonitis - develops as an independent disease as a result of bacterial infection and pathogens entering the abdominal cavity through the bloodstream and lymphatic system. It is extremely rare - no more often than 2% of all cases of the disease.

Bacteriological infections that can cause the development of inflammation of the peritoneum include both gram-positive and gram-negative bacteria, among which are Enterobacter, Pseudomonas aeruginosa, Proteus, Escherichia coli, streptococci, and staphylococci.

In some cases, the occurrence of an inflammatory process may be associated with the penetration of specific microflora into the abdominal cavity - gonococci, pneumococci, mycobacterium tuberculosis and hemolytic streptococci.

Secondary type - the inflammatory process develops against the background of damage to the abdominal organs or gastroenterological diseases.

We can identify the main factors that can provoke the development of inflammation of the abdominal cavity:

Surgical intervention on the peritoneal organs.
Damage to internal organs located in the abdominal cavity, violation of their integrity.
Various internal processes of an inflammatory nature - salpingitis, appendicitis, cholecystitis. It has been established that in more than 50% of cases the main cause is secondary inflammation.
Inflammations that do not have a direct connection with the abdominal cavity - phlegmon and purulent processes.
In women, peritoneal peritonitis can be triggered by inflammatory processes in the pelvic organs.

In the vast majority of cases, peritonitis acts as a complication of various injuries and diseases of a destructive-inflammatory nature - appendicitis, pyosalpinx, perforated gastric or duodenal ulcer, pancreatitis, pancreatic necrosis, intestinal obstruction, rupture of an ovarian cyst.

Types of peritonitis

Peritonitis is classified according to several parameters, such as the etiology of the disease and the extent of inflammation. Depending on the characteristics of the course, inflammation can be acute or chronic. Chronic peritonitis often develops against the background of a systemic infection of the body - tuberculosis, syphilis. The acute form of peritonitis is characterized by rapid development and rapid manifestation of clinical symptoms.

Depending on the characteristics of the etiology, the inflammatory process in the peritoneum can be bacterial, developing as a result of the penetration of infection into the abdominal cavity, as well as abacterial, that is, provoked by aggressive agents of non-infectious origin. Such non-infectious pathogens include blood, bile, gastric juice, pancreatic juice, and urine.

Depending on the area and extent of the lesion, the disease is divided into several forms:

Local - exclusively one anatomical element of the peritoneum is involved in the inflammatory process.
Widespread or diffuse - inflammation spreads to several parts of the abdominal cavity.
Total type - characterized by extensive damage to all parts of the peritoneal cavity.

Due to the occurrence:

Traumatic type of peritonitis.
Infectious.
Postoperative.
Probodny.

Depending on the presence of exudate, inflammation of the peritoneum is divided into dry and exudative (wet) type of peritonitis.

Depending on the characteristics and nature of the exudate:

Based on the type of infectious agent, peritonitis is divided into tuberculous, streptococcal, gonococcal, and clostridial.

Depending on the severity and severity of pathogenetic changes, several stages of the inflammatory process are distinguished, each of which has its own characteristic features and symptoms.

The reactive stage of peritonitis is the initial stage of the disease, the symptoms of which appear during the first day after the infection enters the abdominal cavity. The reactive stage is characterized by swelling of the peritoneum, the appearance of exudate and pronounced local reactions.

Toxic stage – occurs within 48–72 hours from the moment of injury. This stage is characterized by intensive development of signs of intoxication.

Terminal stage - characterized by a general deterioration of the body and a weakening of the vital functions of the body, the functioning of the protective-compensatory system is reduced to a minimum.

Symptoms and signs

The main signs of peritonitis can be divided into general and local. Local signs represent the body's response to irritation of the abdominal cavity with exudative fluid, bile or blood. The main local symptoms of peritonitis include severe tension in the anterior wall of the abdominal cavity, pain in the abdominal area, and irritation of the peritoneal cavity, identified during a medical examination.

The first and most pronounced symptom of the initial stage of inflammation of the peritoneum is pain, which can have varying degrees of severity and intensity. The most severe is the pain syndrome that accompanies peritonitis with perforation of internal organs located in the abdominal cavity. Such pain is described in the medical literature as “dagger-like” - sharp, sharp and piercing.

At the initial stage of peritonitis, painful sensations are localized exclusively around the immediate lesion. But after some time, the pain becomes diffuse, generalized, which is associated with the spread of inflamed exudate throughout the internal organs.

In some cases, pain may move and be localized in another area of the abdominal cavity. This does not mean that the inflammatory process has decreased or stopped - this is how damage to another internal organ manifests itself. Sometimes the pain may disappear completely - this is a rather dangerous sign that may indicate the accumulation of an excessive amount of inflammatory fluid.

Characteristic general symptoms of peritonitis are severe nausea, heartburn, vomiting mixed with gastric contents and bile. Vomiting accompanies the entire period of the disease; in later stages of the disease, so-called “fecal” vomiting occurs with an admixture of intestinal contents.

As a result of general intoxication of the body, intestinal obstruction develops, which can be expressed in the form of flatulence, delayed passage of gases or stool disorders.

Other common symptoms of peritonitis:

Increased body temperature, chills.
Significant deterioration in general health – weakness, apathy.
Rapid jumps in blood pressure up to 130–140 beats per minute.
The appearance of a person changes radically - facial features become more pointed, the skin turns pale, cold sweat occurs, the facial expression becomes twisted and suffering.
A person cannot sleep fully, he is tormented by sleep disorders - insomnia or constant drowsiness. In addition, the patient cannot lie down due to acute pain; he tries to take the most comfortable position for himself - most often on his side, with his legs pulled up to his stomach.
In advanced stages of peritonitis, a person experiences confusion and cannot normally and adequately assess what is happening.

With the development of the most complex, terminal stage of peritonitis, the patient’s condition becomes extremely serious: the skin and mucous membranes acquire an unhealthy pale, bluish or yellowish tint, the mucous membrane of the tongue is overdried, and a thick dark coating appears on its surface. The psycho-emotional mood is unstable, apathy is quickly replaced by a state of euphoria.

The symptoms of the disease differ significantly depending on the stage of the inflammatory process. Each of them has its own characteristics and characteristics.

The reactive stage, which is the initial stage, is accompanied by the appearance of spasms and pain in the peritoneum, tension in the anterior abdominal wall, fever, weakness and apathy.

Toxic stage - manifested by some improvement in the patient’s condition, which, however, is imaginary. This period is characterized by intense intoxication of the body, which is expressed in severe nausea and debilitating vomiting. The person’s appearance also leaves much to be desired – pale skin, dark circles under the eyes, sunken cheeks. As medical statistics show, approximately 20% of all cases of peritonitis end in death at the toxic stage.

The terminal stage is considered the most severe and dangerous not only for health, but also for human life. At this stage, the level of the body’s defenses decreases to a minimum level, and the person’s well-being becomes much worse. The abdomen swells sharply, the slightest touch to its surface causes an intense attack of pain.

At the terminal stage of peritonitis, the patient experiences severe swelling of the internal organs, as a result of which the excretion of urine from the body is impaired, shortness of breath, increased heartbeat, and confused consciousness appear. As medical practice shows, even after surgery, only every tenth patient manages to survive.

The symptoms of chronic peritonitis look somewhat different - they are not as pronounced as the signs of acute inflammation and are more “blurred”. The patient is not bothered by debilitating vomiting, nausea, stool disorders or painful spasms in the abdominal area. And therefore, for a long time, the chronic form of the disease can proceed completely unnoticed by a person.

At the same time, long-term intoxication of the body cannot be completely asymptomatic; most often, the presence of chronic peritonitis can be determined by the following signs:

Body weight rapidly decreases, while the diet remains the same.
A person has an elevated body temperature for a long time.
Constipation occurs from time to time.
Increased body sweating.
Periodic pain in the abdominal area.

As the disease progresses, symptoms become more severe and frequent.

Diagnosis of peritonitis

Timely diagnosis of peritonitis is the key to successful and effective treatment. To carry out diagnosis, a clinical blood test is required, on the basis of which the level of leukocytosis is examined.

Ultrasound and X-ray examinations of the abdominal organs are also mandatory, during which specialists examine the presence of exudate in the abdomen - accumulated inflammatory fluid.

One of the diagnostic measures is to conduct a vaginal and rectal examination, which reveals pain and tension in the vaginal vault and rectal wall. This indicates inflammation of the peritoneum and the negative impact of accumulated exudate.

In order to eliminate any doubts in diagnosis, a puncture is taken from the peritoneum, thanks to which the nature of its contents can be examined. In some cases, laparoscopy is recommended. This is a painless, non-invasive diagnostic method, which is carried out using a special device - a laparoscope. As a result of laparoscopy, the doctor receives a complete clinical picture of the disease and is able to make the correct diagnosis.

Treatment

To date, the only effective treatment for abdominal peritonitis remains surgical treatment. Despite the progress of modern medicine, the mortality rate remains quite high. It is for this reason that maximum attention should be paid to the treatment of peritonitis. The most effective method of treatment is considered to be a complex one, combining surgical and drug therapy.

Simultaneously with the surgical intervention, drug treatment is carried out, the main goal of which is to eliminate the infection, as well as prevent the development of possible complications.

The most commonly prescribed medications are:

Broad-spectrum antibiotics - Ampicillin, Methicillin, Benzylpenicillin, Gentamicin, Oletetrin, Kanamycin.
Infusion solutions - such drugs are used to restore lost fluid and prevent possible dehydration of the body. Such solutions include Perftoran and Refortan.
Sorbents and detoxification drugs, the action of which is aimed at preventing toxic shock, removing toxins and waste from the body. The most commonly used solution is calcium chloride 10%.
To eliminate problems with urine excretion from the body, diuretics are used.
If peritoneal peritonitis is accompanied by an increase in body temperature, antipyretic drugs are prescribed.

Antiemetic drugs, such as Metoclopramide, are often used to eliminate vomiting and nausea. If tuberculosis-type peritonitis has been diagnosed, treatment is carried out with anti-tuberculosis drugs - Trichopolum, Gentomycin, Lincomycin.

The main objective of surgical treatment is to eliminate the root cause that provoked the inflammatory process of the peritoneum, as well as to treat peritonitis. Preoperative preparation consists of complete cleansing of the gastrointestinal tract of contents, intravenous administration of the necessary medications, as well as anesthesia.

Surgery is performed by laparotomy, that is, by direct penetration into the abdominal cavity. After this, the surgeon removes the source of inflammation, as well as complete sanitation of the peritoneal cavity. This means that if the cause of peritonitis is an organ, after removal of which a complete cure is possible, resection of this organ is performed. Most often we are talking about the gallbladder or appendix.

The abdominal cavity is washed using special antiseptic solutions, which helps to effectively eliminate the infection and reduce the amount of exudate released. The next stage is intestinal decompression. This is the name of the procedure for removing accumulated gases and liquids from the intestines. To do this, a thin probe is inserted through the rectum or oral cavity, through which fluid is suctioned from the abdominal cavity.

Drainage of the peritoneum is carried out using special hollow drainage tubes, which are inserted in several places - under the liver, on both sides of the diaphragm and in the pelvic area. The final stage of surgery is suturing. Sutures can be placed with or without drainage, depending on the severity of the disease.

In simple forms of peritonitis, a continuous suture is applied, without drainage tubes. In the case of more severe, purulent forms of inflammation, suturing is carried out simultaneously with the introduction of drainage tubes, through which the exudate is removed.

Treatment of peritonitis is carried out only in a hospital setting; independent treatment is not allowed. It is important to remember that no more than 72 hours pass from the moment of damage to the peritoneum until the development of the most severe, terminal stage. Therefore, any delay in seeking qualified medical help and performing an operation is fraught with the most unfavorable consequences for a person’s health and life.

Peritonitis is an inflammation of the peritoneum, the thin membrane that lines the abdominal wall and protects the internal organs. The inflammation is usually caused by a bacterial or fungal infection of this membrane. There are two main types of peritonitis. Primary acute peritonitis is caused by the spread of infection into the blood and lymph nodes of the abdominal cavity. This type of peritonitis is rare - less than 1% of all diagnosed cases. The secondary type of peritonitis is more common. It occurs when an infection enters the peritoneum from the gastrointestinal tract and biliary tract. In both cases, the consequences of peritonitis are very serious and can be life-threatening unless emergency medical measures are taken.

Main symptoms

The clinical picture of peritonitis develops quickly and is manifested by acute symptoms that can lead to painful shock. Possible signs of peritonitis include:

dull or sharp pain of a diffuse nature over all surfaces of the anterior abdominal wall;
a sharp increase in body temperature to critical levels;
complete lack of appetite;
severe thirst and dry mouth;
a feeling of heaviness in the stomach is accompanied by the urge to vomit;
a sharp reduction in the volume of urine excreted;
violation of acts of defecation and natural release of gases from the intestines.

Any pain in the abdominal cavity requires immediate medical consultation. Acute peritonitis can develop within a few hours and lead to sudden death of the patient. Therefore, you should seek medical help promptly.

Reasons for the development of inflammation

The primary form of acute purulent peritonitis is often caused by diseases of the liver, stomach and female genital organs. Any stagnation of fluid in the abdominal cavity is a favorable environment for the proliferation of pathogenic microorganisms. often acute purulent peritonitis occurs as a result of ectopic pregnancy, ascites, appendicitis.

The following causes of peritonitis are no less common:

pancreatitis with pancreatic necrosis;
cholelithiasis;
perforation of a stomach ulcer;
acute poisoning with toxic substances;
burn disease;
spontaneous abortions and miscarriages;
criminal terminations of pregnancy in early and late stages.

In some cases, peritonitis develops after peritoneal dialysis. This may be a consequence of violation of aseptic rules during medical procedures.

Clinical diagnosis of acute purulent peritonitis

For timely diagnosis of peritonitis, a clear clinical picture is important. The use of various painkillers can distort it. Therefore, in case of acute pain in the abdomen and abdominal cavity, you should not take analgesics on your own. Wait for the ambulance to arrive. An experienced specialist will examine you and prescribe appropriate treatment.

By visual inspection you can determine:

pain on palpation;
tension of the anterior abdominal wall;
swelling in the abdominal area;
change in color of the skin of the anterior abdominal wall, up to a bluish tint;
blood pressure is reduced;
pulse is increased;
skin covered with sticky sweat;
intestinal peristalsis cannot be heard during auscultation;
the sick person experiences severe pain in the peritoneum;
body temperature is increased to 39 - 40 degrees Celsius.

The following procedures are performed in a hospital setting:

general blood test with a detailed leukocyte formula;
blood chemistry;
blood culture for bacterial carriage;
analysis of fluid obtained by puncture of the abdominal cavity;
computed tomography of the abdominal organs;
X-ray examination of the abdominal cavity and pelvic organs in women can quickly detect the cause of peritonitis.

Ultrasound examination is usually not effective due to poor acoustics through the inflamed peritoneum.

Treatment

At the first symptoms of peritonitis, you should seek medical help. The death of a sick person can occur within a few hours after the first signs of this disease appear. Mandatory hospitalization in the surgical department is indicated. Emergency surgical intervention is carried out to eliminate the cause of peritonitis and disinfect the peritoneum.

Subsequently, antibacterial therapy is used to control the growth and abundance of bacterial microflora. During the recovery period, drugs are used that promote tissue regeneration and restore the normal functioning of all abdominal organs.

When choosing an antibiotic, the doctor is based on data from a preliminary analysis of the bacterial microflora of the contents of the inflammatory substrate in the peritoneal cavity. Antibiotic sensitivity is determined. The course of treatment is at least 14 days.

Diet after peritonitis

In the first hours after surgery for peritonitis, complete food and drink rest is prescribed. It is only allowed to wet the patient’s lips. Restoration of blood volume and intercellular fluid is carried out parenterally using intravenous infusions of glucose, blood plasma and saline.

In the future, the diet for peritonitis should include pureed foods, mucous porridges, and jelly. Products that cause active intestinal motility are excluded. The determination of the final diet largely depends on the cause of peritonitis, that is, on the underlying disease. If your gallbladder is removed, this will be one diet; if you have a gastric resection, you will be given completely different recommendations. The amount of food in one serving should be sharply reduced. Meals should be frequent and small.

Prevention and treatment of dysbiosis is important. After surgery on the peritoneum and against the background of antibacterial therapy, the intestinal microflora suffers significantly. Therefore, your doctor may recommend the use of special supplements that include lactobacilli, bifidobacteria, and various strains of E. coli.

Possible complications

Complications of peritonitis can be divided into immediate consequences and long-term health problems. immediate complications include sepsis, blood clotting, death of the patient, acute renal failure, bleeding, collapse, and shock. In the future, peritonitis can be reminiscent of adhesive disease, postoperative hernias, and intestinal motility disorders. A number of patients who have suffered acute purulent peritonitis develop intestinal obstruction and oncological diseases of the abdominal organs. In women, peritonitis can complicate obstetric history. More than 20% of women who have suffered acute peritonitis subsequently experience difficulty in achieving a physiological pregnancy.

The peritoneum is a shell in the form of two sheets. The spaces they form contain serous fluid. The main function of the peritoneum is to create partitions between internal organs and muscles, as well as fixation in a suspended state with the help of mesenteries and ligaments. The peritoneum protects the internal organs in another way. When it encounters microbes, substances are produced that lead to the death of harmful microorganisms. Peritonitis is an inflammation of the peritoneum, leading to disruption of the functioning of all systems and organs located in this area. What are the symptoms of the pathology?

Peritonitis - inflammation of the peritoneum

Peritonitis begins to develop when the peritoneum cannot cope with the huge number of invading and multiplying microbes. In this situation, the peritoneum becomes a source of infection. This disease is life-threatening and can end sadly if adequate measures are not taken to localize the inflammation and normalize the condition.

The introduction and spread of infection in the abdominal cavity most often develops as a result of trauma to the organs of this area, a violation of their integrity. The cause may be a disease of the internal organs. Rarely, peritonitis can develop when microorganisms are carried into the area by blood or lymph.

In most cases, peritonitis does not occur as an independent disease, but as a complication of diseases of the abdominal organs. For example, appendicitis, intestinal obstruction, as well as the duodenum, if measures are not taken in a timely manner, end in peritonitis. Inflammation of the peritoneum is caused by the destruction of the organ after the disintegration of the tumor. Necrosis of a fragment of the intestine due to a hernia, trauma to the abdominal cavity, accompanied by injury, rupture of an organ, partial destruction of the wall of the stomach or intestines by a foreign body can also result in peritonitis.

Sometimes, with heart disease, fluid accumulates in the abdominal cavity, which, in the event of unfavorable developments, suppurates. This becomes another cause of peritonitis.

Not all types of peritonitis are caused by pathogenic microorganisms. For example, blood entering the abdominal cavity due to a violation of the integrity of the vessel also leads to peritonitis. In this case, the type of disease is called aseptic or germ-free. The disease lasts at this level for no more than 6 hours. After this period, microbes from the intestinal area penetrate into the hematoma. After this, peritonitis becomes common.

Signs of peritonitis

Manifestations of peritonitis are due to the reasons that provoked its development. But the main signs of one stage or another are the same in any case.

Reactive stage

This is the first stage, it occupies the first day of the disease. The lesions are local in nature. Patients first feel sharp pains that appear unexpectedly. In this case, you can accurately determine the place where the pain comes from. Some compare the pain at this stage to the blow of a dagger.

The localization of pain is associated with the organ that became the source of the disease. For example, with appendicitis, pain will be felt in the inferolateral zone on the right. If this is a perforation of a stomach ulcer, then pain will appear in the hypochondrium on the left or. The pain is felt strongly, and it gradually spreads.

Sometimes there are periods when the pain seems to subside. But it won't last long. Relief lasts no more than 2 – 3 hours. Then things escalate.

The patient has a rather characteristic appearance:

pale skin, bluish tint;
cold sweat;
suffering expression.

The pain bothers a person greatly; he, as a rule, tries to ease its intensity by taking certain poses. For example, lie on your side and tuck your knees, don’t cough, don’t puff out your stomach.

A characteristic symptom of peritonitis is a disc-shaped abdomen. This symptom is expressed in an overly tense abdomen. It is very painful to feel. To check for peritonitis, you can use the Shchetkin-Blumberg method: press on the stomach, and then quickly remove your hand.

Also typical signs will be a false urge to defecate or urinate, and repeated vomiting. Other signs considered symptoms of peritonitis indicate intoxication of the body. This is an increase in temperature, rapid pulse, dry mouth, severe thirst.

Toxic

This is the second stage. During this period, the person is in serious condition. All signs indicating the presence of poisoning appear. This stage takes approximately two days and begins 24 hours after the onset of the disease. The symptoms of the first stage are smoothed out. The muscles of the abdominal wall are slightly tense and may generally be normal. The pain is mild and vague. A person’s appearance at the moment also has common typical features:

pale lips;
cold extremities;
blue nose, ears, nails.

The mouth remains dry and consciousness may be impaired. This is expressed in complete indifference, less often in excitement. The patient may lose consciousness. The patient lies without moving. Does not respond to palpation of the abdomen. persists, only the vomit takes on a different color. They become dark, brown, and smelly. There is little or no urine. The temperature rises to very high numbers: 40 - 42°. Breathing becomes unstable, pulse is very weak.

Terminal stage (irreversible)

This is the third stage, it occurs three days after the onset of the disease. After three, and sometimes even two days, it ends in the death of the patient. The condition can be classified as extremely serious. The appearance of all patients in this situation is the same. This complex of external manifestations is called the “face of Hippocrates”:

bluish moist skin;
sunken cheeks;
overly sharpened features.

The abdomen is soft, there is no painful sensation at all, palpation does not cause discomfort. The pulse cannot be felt, breathing is weak or may be completely absent, the pressure is not determined. Human life at this stage is possible only in intensive care with the use of artificial life support systems.

Diagnosis of peritonitis

If peritonitis has developed in a confined space, as happens in encysted peritonitis, it can be difficult to make a diagnosis. Diagnosis is also difficult for ulcers that are a consequence of laparotomy interventions (subdiaphragmatic, interloop, pelvic, abscesses, ulcers of the right iliac fossa).

With indolent processes, the disease may manifest itself as short-term pain, which is replaced by general malaise. Anemia, exhaustion, and a person may develop a fever. There are no local signs, so the doctor may consider that an infection has settled in the body or a tumor process is occurring somewhere.

It is very difficult to identify this type of peritonitis. It is necessary to conduct a comprehensive examination, including many tests, vaginal and rectal examinations. Of course, it is better to carry out such diagnostics in a hospital. The diagnosis can be made by analyzing the entire clinical picture. Attention is paid to whether there is intoxication, and, of course, to the condition of the peritoneum. To ensure the correctness of the diagnosis, use the results of radiography and laparoscopy.

If a patient is suspected of having local or diffuse peritonitis, he is urgently sent to the hospital.

You should not give drugs to relieve pain, because this greatly changes the picture of what is happening. Then in the hospital it may be difficult to make a diagnosis. To alleviate the condition, an ice pack is placed on the stomach. Polyglucin is administered intravenously. It will help avoid severe dehydration and infectious-toxic shock. The drug must be administered by drip. Quantity 400 – 800 ml. glucose (5%) or sodium chloride is also administered. These drugs alleviate the patient’s general condition, create safer conditions for transportation, and serve as some preparation for the upcoming operation.

Treatment of peritonitis

If the diagnosis is established, emergency surgery is performed. During the operation they act according to the circumstances. After examining all the tissues, the affected areas of the organs are sutured, tumors are removed, and bleeding is stopped. Existing purulent foci are brought back to normal, they are washed with antiseptic solutions. It is advisable to use Ringer's solution.

If the inflammation has affected large areas, then washing is carried out over several days. After surgery, it is administered in large quantities. They also direct actions to eliminate dehydration.

The famous surgeon S.I. Spasokukotsky noted back in 1926 that if the operation was performed in the first hours after the development of inflammation, then 90% of patients recover. The operation results in recovery in 50% of cases within the first 24 hours. And only 10% have a chance of survival if the operation is performed after the third day.

In our time, approximately the same trend continues. Surgical intervention ends with recovery on the first day. At the second stage, the success of treatment is already doubtful. Recovery occurs if the organs and systems are not severely affected. At the third stage, it is not possible to correct the condition, because irreparable changes occur to the internal organs.

Preventive actions

Prevention of this disease lies in informing people about it. Only people who have knowledge about the stages of this disease and its other features can take adequate measures in time and avoid the sad part.

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Peritonitis is a process of inflammation of the peritoneum. With peritonitis, organ functioning is disrupted due to severe intoxication of the body. The connective tissue of the peritoneum envelops all the internal organs of the abdominal cavity and serves as a limiter between the internal environment of the abdominal cavity and the abdominal muscles.

When exposed to pathogenic microorganisms or chemical agents on the surface of the peritoneum, it is capable of releasing special substances that stop this process. If the number of pathogenic factors is large, then the peritoneum becomes involved in inflammation and peritonitis occurs. Peritonitis is a very life-threatening condition. If it occurs, emergency medical attention and urgent treatment are required, otherwise death is possible.

What it is?

Peritonitis is an inflammation of the parietal and visceral layers of the peritoneum, which is accompanied by a severe general condition of the body. The general definition does not fully reflect the problematic nature of the pathology: from the point of view of a practical surgeon, abdominal abscesses should be excluded from the general definition.

As a rule, peritonitis threatens the patient's life and requires emergency medical attention. The prognosis in case of untimely or inadequate treatment of peritonitis is very unfavorable.

Causes

Peritonitis is primary, when the disease develops as a result of microorganisms entering the abdominal cavity through the blood or lymph flow, and secondary, when the disease develops due to inflammation, perforation, or damage to organs located in the abdominal cavity.

The following reasons can be identified that lead to the occurrence of peritonitis:

Damage to abdominal organs;
Operations performed on the abdominal organs;
Hematogenous peritonitis (pneumococcal, streptococcal, etc.);
Inflammatory processes occurring in the abdominal organs (salpingitis, etc.);
Inflammatory processes of any origin, not related to the abdominal organs (abdominal wall, purulent processes localized in the retroperitoneal tissue).
Perforations in the abdominal organs (stomach or duodenum with peptic ulcer, appendix with gangrenous or phlegmonous appendicitis, gallbladder with destructive cholecystitis, colon with).

There are bacterial and aseptic peritonitis. The causative agents of bacterial peritonitis are both aerobic microorganisms (Escherichia coli, Klebsiella, Proteus, Pseudomonas aeruginosa, staphylococci) and anaerobic (bacteroides, clostridia, peptococci). Often, peritonitis is provoked by a microbial association, that is, a combination of several microorganisms.

Aseptic peritonitis develops when the peritoneum comes into contact with blood, gastrointestinal contents, bile, and pancreatic juice. It is noteworthy that after a few hours, microflora is involved in the pathological process and aseptic peritonitis turns into bacterial.

Symptoms of peritonitis

All symptoms observed during peritonitis can be divided into local and general. Local symptoms occur in response to irritation of the peritoneum by exudate, bile, and gastric contents. These include abdominal pain, tension in the muscles of the anterior abdominal wall, as well as positive symptoms of peritoneal irritation, which the doctor can identify during examination.

General symptoms develop against the background of intoxication of the body. These are nonspecific symptoms such as fever, weakness, nausea, vomiting, and confusion. In addition, the patient has not only signs of inflammation of the peritoneum, but also symptoms of the underlying disease that provoked peritonitis.

Symptoms of abdominal peritonitis by stage:

Diagnostics

Diagnosis of abdominal peritonitis includes a thorough history taking and assessment of the patient's complaints. The chronic pathology of the digestive organs, 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) are clarified.

Instrumental examination methods:

Ultrasound of the abdominal organs (if indicated and pelvis);
X-ray of the abdominal cavity (in case of perforation of the ulcer - the presence of free gas, in case of intestinal obstruction - Kloiber cups);
laparocentesis (puncture of the abdominal cavity - obtaining a massive effusion);
puncture through the posterior vaginal fornix (for pelvic inflammatory processes);
diagnostic laparoscopy.

Laboratory research methods are used:

general blood test (increase in leukocytes to 12,000 and above or decrease in leukocytes to 4,000 and below, shift of the formula to the left, acceleration of ESR);
biochemical blood test (albumin, liver enzymes, sugar, pancreatic enzymes, etc.);
general urine analysis;
the acid-base state is determined.

During a clinical examination, the pulse (up to 120), blood pressure (a decrease is noted), respiratory rate and abdomen are assessed. The abdominal wall is palpated, the abdominal cavity is auscultated, and signs of peritoneal irritation are determined.

Complications

Complications depend on the specific type of inflammation. The most common ones include:

Vectidating intestinal obstruction - have a close connection with the adhesions described above, because they lead to difficulty in moving the intestinal contents.
Intraperitoneal adhesions (abnormal permanent connections between two inflamed areas of the peritoneal surface; sometimes adhesions can occur between the peritoneum and intestines);
Intraperitoneal and subdiaphragmatic abscesses are closed cavities containing pus, separated from the rest of the abdominal cavity by adhesions. Their opening may be the starting point for re-inflammation of the peritoneum.

Treatment consists mainly of surgery and eliminating the cause of inflammation of the peritoneum, for example, filing a stomach ulcer or removing appendicitis. In addition, treatment with antibiotics and analgesics may be used.

How to treat peritonitis?

According to modern concepts, one of the main factors determining the severity and unfavorable outcome of peritonitis is the syndrome of endogenous intoxication.

In the initial stages of development, surgical methods with radical sanitation of the primary lesion and abdominal cavity are widely and successfully used. However, firstly, it is not always possible to carry out radical sanitation of a purulent focus; secondly, by the time of surgery, the inflammatory process in the abdominal cavity may acquire the character of a generalized infection. Based on the above, the interest of modern medicine in methods of removing toxic products from the intestinal lumen is understandable.

It is quite logical to increase the detoxification effect achieved by drainage of the gastrointestinal tract in combination with enterosorbents. In this regard, it is justified to search for enterosorbents that would have all the positive qualities of granular sorbents, but differ from them in fluidity and the acquired ability to pass through various drainages. Experimental data and clinical observations indicate that enterosorption using polyphepane can be used in a set of measures to combat endotoxicosis in general peritonitis.

With some exceptions (limited peritonitis of gynecological origin), the diagnosis of “acute peritonitis” implies the need for urgent surgical intervention to determine and eliminate the source of peritonitis and sanitation.

S.I. Spasokukotsky spoke about the need for timely treatment back in 1926: “For peritonitis, surgery in the first hours gives up to 90% of recoveries, on the first day - 50%, after the third day - only 10%.” It should be noted that in 1926 there were no antibiotics, which sharply increased the recovery rate.

After operation

In the postoperative period, some problems may arise related to the normal functioning of the intestines, severe pain, and the development of purulent complications. Recommended:

observation of the patient, hourly assessment of respiratory rate, pulse, diuresis, central venous pressure, drainage discharge;
infusion therapy with colloid and crystalloid solutions is carried out;
to warm patients, infusion media are heated to body temperature;
the lungs are ventilated for 72 hours to ensure sufficient oxygen supply to organs and tissues;
a glucose solution is administered through a nasogastric tube;
early restoration of intestinal motility;
prevention of pain syndrome. Narcotic analgesics are used in combination with non-steroidal anti-inflammatory drugs. Fentanyl, morphine, ketorolac are used.

Prevention

Peritonitis, as a rule, is a complication of existing diseases of the abdominal organs. It often develops against the background of appendicitis, pancreatitis, and stomach ulcers. The goal of preventing peritonitis is to inform the population about its danger and timely diagnosis of diseases leading to it.

Forecast

The duration of treatment for peritonitis depends on the causes of the disease and the severity of the disease.

On average, this is 2-4 weeks, but with a widespread and advanced process, the prognosis is unfavorable. For periods up to 24 hours, the prognosis for peritonitis is generally favorable; for periods above 24 hours, mortality ranges from 20 to 90%.

In its course, peritonitis can be either acute (caused by a pyogenic, predominantly mixed infection) or chronic (caused in most cases by the tuberculosis bacillus).

Acute purulent peritonitis causes:

1. Inflammatory disease of any of the abdominal organs (acute appendicitis, cholecystitis, strangulated hernia, inflammation of the internal genital organs in women, etc.), in which the infection spreads from the main focus to the peritoneum.

2. Perforation of the abdominal organs (perforated gastric ulcer, perforation of a typhoid ulcer of the small intestine, etc.), as a result of which the infected contents spill into the abdominal cavity and cause peritonitis.

3. Injuries to the abdominal organs, which include not only penetrating wounds of the abdominal wall and abdominal organs, but also some blunt (closed) injuries to these organs, such as the intestines. In both of these cases, pyogenic microbes penetrate the abdominal cavity and cause the development of an acute purulent inflammatory process in it.

4. Hematogenous (i.e., through the bloodstream) spread of infection to the peritoneum from some distant inflammatory focus, for example, with tonsillitis, osteomyelitis, sepsis, which, however, is very rare.

Thus, peritonitis is always a secondary disease, most often occurring as a complication of any inflammatory process, perforation or damage in the abdominal cavity. That is why, with inflammation of the peritoneum, one cannot limit oneself to the diagnosis of “peritonitis”, but it is necessary to establish its primary source, which is actually the primary disease, and peritonitis is only its complication. True, this is often possible only in the initial stage of peritonitis or during surgery.

Initially, acute purulent peritonitis occurs as a local inflammatory process. A striking example of such local peritonitis is local inflammation of the peritoneum in acute appendicitis. With local peritonitis, the inflammatory process is very often delimited by fibrinous adhesions from the rest of the healthy or free abdominal cavity. In such cases, they speak of limited peritonitis.

If such adhesions delimit purulent effusion, then such a local process is called encysted peritonitis (for example, appendiceal abscesses, etc.). However, in some cases, as the infection spreads, the entire peritoneum or a significant part of it can quickly become involved in the inflammatory process. This is general or diffuse peritonitis.

Peritonitis signs and symptoms. Several hours usually pass between the immediate cause of purulent peritonitis (inflammation, trauma) and the appearance of its first signs. The clinical picture of peritonitis consists of a number of general and local signs, which, however, do not remain unchanged, but vary depending on the degree and stage of development of the infectious-inflammatory process in the abdominal cavity.

It is necessary to emphasize the special importance of the initial or early symptoms of purulent peritonitis, appearing in the first hours from the onset of the development of the inflammatory process. It is in this initial period of development of peritonitis that appropriate treatment (surgery, etc.) gives the greatest success. In the later stages of peritonitis, when many of the “classic” symptoms of this serious and dangerous disease appear, the chances of saving the patient are sharply reduced. That is why early diagnosis of peritonitis is so important.

In the initial stage of development of peritonitis, the main symptoms of peritoneal irritation occur: local pain, protective tension of the abdominal muscles and the Shchetkin-Blumberg symptom.

The initial pain and place of greatest tenderness in peritonitis usually correspond to the location of its source. For example, with a perforated gastric ulcer, pain is felt in the epigastric region, with acute appendicitis - mainly in the right iliac region. As the inflammatory process develops, the pain spreads throughout the abdomen. In some cases, extensive irritation of the peritoneum can even lead to shock.

It should be borne in mind that in particularly severe forms of peritonitis (septic peritonitis), pain may be almost absent due to dulling of the patient’s sensitivity due to severe intoxication of the body. When palpating the abdomen, the pain associated with peritonitis intensifies.

The Shchetkin-Blumberg pain symptom is very characteristic of both the initial stage of development of peritonitis and its subsequent course. This valuable sign of irritation or inflammation of the peritoneum is that if you gradually and slowly press on the abdominal wall in the area of \u200b\u200bthe inflammatory focus with a finger or fingers, and then immediately remove your fingers, the patient will feel acute pain.

The most important and characteristic sign of inflammation of the peritoneum is tension of the abdominal muscles - a kind of protective reflex, the starting point of which is the inflamed area of the peritoneum. Tension of the abdominal muscles is especially pronounced in cases where inflammation affects the part of the parietal peritoneum, which covers the anterolateral wall of the abdomen from the inside.

Sometimes the tension in the abdominal wall is expressed so sharply that in these cases they say: “The stomach is like a board.” Although this sign is one of the most constant in local and general peritonitis, in some cases it can be mild or even completely absent, for example in some cases of peritonitis of gynecological origin, septic peritonitis, etc.

Tension of the abdominal muscles may also be absent in cases where inflammation involves the posterior sections of the parietal peritoneum (i.e., covering the posterior wall of the abdominal cavity), as happens, for example, with retrocecal appendicitis. Tension of the abdominal muscles may be mildly expressed or even also absent in the elderly, in persons with a flabby abdominal wall (for example, in multiparous women), in very severely ill patients, in shock, as well as in the late stages of development of peritonitis.

The initial signs of peritonitis are accompanied by other symptoms: lack of appetite, nausea, vomiting, belching, fever, change in pulse, change in blood (leukocytosis, change in formula, acceleration of ROE).

An increase in temperature (up to 38° and above) is often observed with peritonitis, but is not, however, a constant sign, since peritonitis can sometimes develop at normal temperatures. It is important to note that with peritonitis, the temperature in the rectum is higher than in the armpit (by at least 1°).

A much more constant and characteristic sign of peritonitis is an increasing increase in heart rate with a progressive decline in cardiac activity. True, in the very initial stage of development of peritonitis, the pulse may even be slow, but this stage is very short-lived (up to 6-8 hours) and is quickly replaced by a characteristic increase in pulse rate (up to 120-150 beats per minute) and a gradual weakening of its filling.

It is also very characteristic that the pulse rate often “overtakes” the patient’s temperature. As you know, when the temperature rises by 1°, the pulse usually increases by 8-10 beats per minute. With peritonitis, this ratio is disrupted and the pulse, as a rule, is more frequent than would be expected given the patient’s temperature. Therefore, with any acute pain in the abdomen, a pulse that “overtakes” the temperature always raises suspicion of peritonitis. However, it should be remembered that in the initial stage of development of peritonitis, the pulse, as already mentioned, may be slow and becomes faster only later.

As the inflammatory process spreads and intoxication of the patient’s body increases, the initial signs of peritonitis appear more sharply and are joined by more and more new ones, indicating the progression of the process and the severity of the patient’s condition. These signs are characteristic not of the initial, but of the late stage or phase of development of progressive peritonitis.

The appearance and position of a patient with such progressive peritonitis is very characteristic. The patient's facial features become sharpened, the lips are bluish, the eyes become dull, the sclera are jaundiced, the eyeballs sink, blueness appears around them, the face acquires a pale grayish, bluish or jaundiced tint with a pained expression. This type of face, characteristic of the late stages of the development of peritonitis, received a special name - the face of Hippocrates.

A patient with diffuse peritonitis usually lies on his back with his legs bent. With local peritonitis, patients prefer to lie on the side where the affected organ is located, for example, with appendicitis - on the right side, etc. In the advanced stage of peritonitis, the patient suffers from thirst, uncontrollable vomiting and hiccups. Due to profuse and frequent vomiting, dehydration occurs (dry lips, tongue, hoarseness, decreased amount of urine).

The initial local pain and local tension in the abdominal muscles become increasingly widespread and can spread to the entire abdomen, although the intensity of pain and muscle tension sometimes even decreases.

Signs of intestinal paralysis are increasing. Vomiting becomes more frequent and becomes fecal in nature, the abdomen swells (flatulence), which causes difficulty in cardiac activity and breathing, the participation of the abdominal wall in respiratory movements weakens or is completely absent.

When the abdomen is tapped, a tympanic sound (the sound of a drum) is heard, and when auscultated, the usual intestinal sounds caused by peristalsis are not heard, and the so-called “deathly silence” reigns in the abdominal cavity. In the abdominal cavity, inflammatory effusion (exudate) accumulates in increasing quantities, which is determined by tapping in sloping areas of the abdomen in the form of a dullness that moves or disappears when the patient changes position.

In some cases, valuable data for judging the nature of the process are obtained by examining the pelvic organs through the vagina or rectum (for example, accumulation of pus in the pouch of Douglas, severe pain upon palpation, the presence of gynecological diseases, etc.).

As peritonitis progresses and intoxication increases, the patient's condition quickly deteriorates, breathing becomes rapid, shallow, chest-type; heart sounds are muffled, blood pressure gradually drops, extremities become cold, protein, casts, indican, etc. appear in the urine. The patient’s consciousness remains until the end of his life, although he becomes indifferent to his surroundings, a terminal state occurs and death usually occurs at 5-7. th day.

The signs just described are characteristic of an advanced period of peritonitis, that stage when the usual treatment of the patient is no longer able to save the patient. Therefore, it is practically very important to recognize acute purulent peritonitis in the initial stages of its development, when timely and correct treatment can, as stated, save the patient’s life.

The most important signs of peritonitis in the initial stage of its development are: abdominal pain, aggravated by palpation, local protective muscle tension, Shchetkin-Blumberg symptom and changes in pulse. All other signs join these basic ones only as the inflammatory process develops.

In general, recognizing acute purulent peritonitis in most cases does not cause any particular difficulties. It is much more difficult and difficult to determine the source (primary focus) of peritonitis.

It should, however, be borne in mind that the clinical picture of general peritonitis described above and the severity of its symptoms may be less pronounced in cases where the onset of peritonitis was preceded by antibiotic treatment for any primary inflammatory process in the abdominal cavity. In addition, depending on the cause of peritonitis, certain characteristic symptoms may be observed. Thus, in the clinical picture of perforated peritonitis, i.e., resulting from perforation of a hollow organ, there may be a period of subjective improvement (euphoria stage), when the patient’s well-being improves for some period, pain subsides, vomiting often stops, abdominal muscle tension the wall decreases, although objectively the general condition of the patient remains severe (see “Perforated ulcer of the stomach and duodenum”). In weakened patients with a severe general condition, peritonitis occurs against the background of a general unresponsiveness of the body, as a result of which the entire clinical picture is “erased.” Some clinical features are observed in biliary, typhoid, streptococcal and pneumococcal peritonitis.

Acute purulent peritonitis should be distinguished from some other diseases of the abdominal cavity (acute intestinal obstruction, perforated gastric ulcer, etc.). However, it should be borne in mind that in the absence of proper treatment (most often surgical), all these diseases inevitably lead to the development of peritonitis. Thus, it is possible to distinguish them from peritonitis only in the early stages. Some diseases, to some extent, can resemble the picture of an “acute abdomen”, for example, renal colic, and sometimes food poisoning. However, anamnesis and a thorough examination of the patient allow in most cases to make a correct diagnosis.

With local (limited) acute purulent peritonitis, all the above-described signs of general (spread) peritonitis are, of course, less pronounced. In particular, important signs such as abdominal pain and abdominal muscle tension are noted only in the affected area of the peritoneum. With local peritonitis, the resulting inflammatory infiltrate either gradually resolves or suppurates and leads to the formation of an intraperitoneal abscess.

Peritonitis first aid. As soon as any disease is suspected that can lead to the development of peritonitis, or the presence of symptoms of already beginning peritonitis or an acute abdomen is discovered, it is necessary to urgently send the patient to the nearest hospital, since the only way to save his life in most cases is an urgent operation and the strictest hospital treatment -bed rest.

Here it is appropriate to recall a very important rule: at the slightest suspicion of general or local peritonitis or with an accurately established diagnosis of this disease, the use of various painkillers by a paramedic - morphine, pantopon, etc. - is strictly prohibited, since, by reducing pain and some other signs of peritonitis, they only darken its picture and thereby make its timely recognition and treatment very difficult.

The use of laxatives and enemas is also prohibited, which, by enhancing intestinal motility, prevent the delimitation of the inflammatory process and, on the contrary, contribute to its deterioration, causing, for example, perforation of the appendix in acute appendicitis, etc.

In cases of decline in cardiac activity, cardiac medications are used (camphor oil, caffeine, cardiazol, cordiamine); in case of cyanosis, inhale oxygen.

When transporting a patient, you should provide him with maximum comfort and peace.

If there is a delay in hospitalization, the patient is prescribed strict bed rest in a semi-sitting position with bent legs, cold on the stomach, drinking is limited, and eating any food is prohibited. Antibiotics are used (penicillin with streptomycin, synthomycin, colimycin, etc.), intravenous administration of saline or glucose solution, drip enema from saline with 5% glucose solution (up to 2-4 liters per day); for severe pain - injections of analgesics (morphine or others). If gastric perforation or damage to the gastrointestinal tract is absolutely excluded as the cause of peritonitis, then it is advisable to perform gastric lavage or insert a permanent tube into the stomach.

Peritonitis prevention. Prevention of acute purulent peritonitis consists of timely and correct treatment of those diseases and injuries that most often cause peritonitis, namely all acute diseases of the abdominal organs (acute appendicitis, perforated gastric ulcer, acute intestinal obstruction, strangulated hernia, etc.). Timely first and emergency surgical care (including the use of antibiotics) for penetrating abdominal wounds has the same preventive value. To prevent postoperative peritonitis, strict adherence to the rules of asepsis and the use of antibiotics during surgical operations is necessary.