home Audience 6 Symptoms and treatment of abdominal peritonitis. The main causes and manifestations of inflammation of the peritoneum

Symptoms and treatment of abdominal peritonitis. The main causes and manifestations of inflammation of the peritoneum

One of the most dangerous pathologies for any person is inflammation of the peritoneum. Peritonitis is accompanied by a violation of vital important functions body. Against this background, death may occur.

Inflammatory process in abdominal cavity It is not diagnosed as rarely as it seems. In 20% of cases, the development of an “acute abdomen” is observed. Approximately 40% of patients are prescribed immediate laparotomy.

The probability of death varies from 5 to 60%. This takes into account the stage of inflammation of the peritoneum, its causes, the degree of spread of the process and the age of the patient.

How does pathology manifest itself?

Inflammation of the peritoneum is characterized by a variety of symptoms. The clinical picture of the disease depends on the severity of the pathology. Typically the following symptoms are identified:

Particular attention is paid to older people. In them, inflammation of the abdominal cavity often has atypical, erased symptoms. All manifestations are conditionally combined into several groups.

The nature of the pain

This sign is present regardless of how exactly the inflammation of the peritoneum develops. The localization of pain, as well as their nature, are determined by the primary pathology. If a person’s stomach is affected by an ulcer, or the duodenum has undergone similar changes, then the painful sensations have a sharp “dagger” character. Against this background, the patient often loses consciousness from pain.

With strangulation intestinal obstruction, pain occurs suddenly. The patient's condition is approaching shock. Pain syndrome is most pronounced at the very beginning of development pathological process. Its intensification is provoked by even minor movements. When the primary focus is located in the upper abdomen, the pain radiates to the sternum or in the area:

supraclavicular zone;
backs;
shoulder blades.

Features of dyspeptic syndrome

With the development of dyspeptic syndrome against the background of peritonitis, a person becomes very sick, then begins to vomit. Constipation alternates with diarrhea. Gases are retained, which causes severe discomfort in the lower abdomen. The patient's appetite decreases, and sometimes a false urge to defecate appears. Voltage abdominal wall, which occurs in the area of primary inflammation, gradually spreads to the entire abdomen. The person's condition deteriorates sharply.

Irritation of the abdominal cavity reflexively provokes nausea and vomiting. As the pathology progresses, symptoms such as intestinal failure and weakened peristalsis appear. If the inflammatory focus is in the pelvis, the process of urination is disrupted, and the person suffers from repeated diarrhea. Such symptoms are observed with gangrenous appendicitis.

Features of peritoneal syndrome

The facial features of a patient with peritoneal syndrome become pointed. The face takes on an earthy tint. As the pathology progresses, the patient's skin becomes cyanotic in color. Against the background of severe pain, the patient's forehead becomes covered with large drops of sweat.

During an examination of the abdomen, the doctor determines the mobility of the abdominal wall. The patient's abdomen may not take part in the breathing process at all. Sometimes a change in its shape is observed. Often during palpation the hardness of the anterior abdominal wall is revealed.

Why does pathology develop?

stomach ulcer;
duodenal ulcer;
infection that has penetrated the uterine tubes;
cirrhosis;
diverticulitis;
appendicitis;
lupus erythematosus.

The acute form of peritonitis is often caused by tuberculosis. One more trigger mechanism There may be perforation of the gastrointestinal tract caused by a bullet or stabbed abdominal wall. The development of the pathological process is sometimes facilitated by gastric surgery. The most dangerous provocateur is colon cancer.

Clarifying the diagnosis

Inflammatory lesions of the abdominal cavity involve listening to the patient’s complaints and taking an anamnesis. The nature of the painful sensations is clarified and the degree of intoxication is determined. During a clinical examination of the patient, palpation of the abdominal wall and abdominal cavity is performed.

Instrumental diagnostic procedures include the following:

These methods are necessarily used to confirm the diagnosis in combination with a physical examination and blood test.

How can you help a patient?

In case of peritonitis, the patient is prescribed surgery. It involves solving the following problems:

eliminate the primary focus;
clean the abdominal cavity;
decompress the intestines;
drain the abdominal cavity.

First, the doctor resorts to pain relief, which is carried out in stages. The next step is to perform a midline laparotomy. In this case, the surgeon makes a large incision from the navel to the sternum. Then the source of the complication is eliminated. Next, the surgeon removes effusion from the abdominal cavity, rinses with antiseptics and thoroughly dries the tissue.

To remove gases accumulated in the patient's intestinal cavity, a special tube is inserted into the small intestine. Drainage involves removing effusion using rubber or silicone tubes. The final stage of surgery is suturing the wound.

Features of postoperative treatment

After the operation, the patient remains in the hospital for some time. Postoperative therapy involves the following treatment methods:

administration of painkillers;
infusion therapy;
detoxification therapy;
taking antibiotic drugs;
immunocorrection;
normalization of the body's functioning;
relapse prevention.

Infusion therapy involves infusing the patient with an isotonic solution of sodium chloride, glucose solutions, plasma and blood substitutes. Combinations of metronidazole with cephalosporins and aminoglycosides are administered intravenously. To prevent intestinal paresis, the patient is administered prozerin. To relieve intestinal failure, potassium preparations and atropine are indicated.

In the early postoperative period, the patient is advised to consume liquid food. Broths and liquid soups are very useful. In addition, you are allowed to eat soft-boiled eggs, vegetable and fruit purees. The amount of butter should be limited.

On the 4th day, the patient’s diet is allowed to be diversified with well-mashed cottage cheese. You can eat chopped boiled beef or lamb. Boiled pureed fish is allowed. It is useful to include chicken or turkey meat in the patient’s menu. The emphasis should be on the chicken fillet.

You can give a person who has suffered peritonitis porridge with water: oatmeal and millet are best. Coarse fiber should be temporarily eliminated; in addition, the patient should avoid foods that irritate the digestive tract. Do not drink cold liquid. Like food, it should be at room temperature.

It is important to temporarily limit the intake of easily digestible carbohydrates into the patient’s body. You need to give up sweets for now. On the 6-7th day after surgery, the diet can be supplemented with dried black bread, but it should be eaten in small quantities.

Finally

Peritonitis is an inflammation of the peritoneum with the release of exudate, often of an acute nature. Symptoms of the disease are expressed by shifts in the functioning of all organs and systems, severe disturbances of water and electrolyte metabolism. And untimely treatment of abdominal inflammation often leads to death.

Symptoms of abdominal inflammation

Inflammation of the abdominal cavity is manifested by signs of a pathological condition leading to the development of peritonitis. After microorganisms enter the peritoneal wall, a typical inflammatory reaction occurs, manifested by:

inflammatory exudation,
hyperemia,
swelling,
pain,
temperature reaction.

The first symptoms of abdominal inflammation are pain that is specific in nature. The nature of pain lies in irritation of the receptors of the peritoneal walls by inflammatory exudate.

At the onset of the disease, the pain is located directly above the organ whose disease caused the development of peritonitis. The pain is very intense, it is constant, cannot be relieved by analgesics and antipyretics, patients strive to take a position in which the peritoneum is minimally exposed to friction and tension. Often patients lie on their backs with their knees bent and pulled up to their stomach, trying to lie as still as possible.

Objective symptoms of inflammation of the abdominal cavity, which must be checked if there are any complaints of abdominal pain, are Shchetkin-Blumberg symptoms.

To check it, you need to put your hand on the front wall of the peritoneum and plunge it into the abdominal cavity, then sharply remove it. If the patient experiences pain, the symptom is positive.

With limited inflammation, this symptom can be positive only over the area of inflammation, for example, with inflammation of the appendix of the cecum. If the patient experiences pain so intense that it does not allow even superficial indicative palpation, the symptom is considered strongly positive. On examination, local or widespread tension in the muscles of the anterior wall is noted, and with diffuse inflammation, a scaphoid retraction of the muscles may be noted.

The most favorable outcome of the disease, possible with pronounced nonspecific protection of the body, is to limit inflammation in a certain area. This is due to the involvement of the omentum and loss of fibrin strands.

In the initial phase, inflammation of the abdominal cavity is characterized by vomiting. At first it is of a reflex nature, and then can be associated with the paralytic need of the intestines, the paralytic effect of toxins on the stomach. This also explains the absence of intestinal motility noise during auscultation.

In addition to symptoms of the underlying disease that caused the development of peritonitis, there are symptoms of inflammation of the abdominal cavity associated with the development of extensive inflammatory process. This is a fever with a rise in body temperature to subfebrile levels, tachycardia.

Diagnostic symptoms of abdominal inflammation

For diagnosing the disease, tachycardia is very important, since with this disease a characteristic symptom is noted - a discrepancy between the tachycardia and the level of body temperature. With minor fever, tachycardia can be very significant. Usually noted rapid breathing, and the stomach (or one of its halves) does not participate in the act of breathing.

When performing laparoscopy at the beginning of inflammation, the peritoneum looks hyperemic, edematous, thickened, dull, and sometimes rough. Usually these changes are most pronounced directly above the area of the inflammatory focus. Subsequently, exudate begins to accumulate in the peritoneal cavity. Exudate with symptoms of inflammation contains a significant amount of protein.

A blood test reveals leukocytosis, initially slight, with a shift in the leukocyte formula to the left, and an ESR slightly above normal.

Biochemical symptoms of abdominal inflammation:

decrease total protein blood serum,
increased fibrinogen levels,
C-reactive protein,
with inflammation of internal organs, the appearance of specific markers may be observed.

Symptoms of abdominal inflammation at different stages

A day after the onset of the disease, a significant amount of toxic substances enters the blood. An increase in the permeability of the vascular wall at stage 1 of inflammation as a result of exposure to toxic substances leads to the release of a significant part of the blood plasma into the tissue. This is also facilitated by a decrease in protein levels in the blood. Significant hemodynamic disorders occur due to an increase in the vascular bed (vasodilatation).

Loss of large volumes of blood through vomiting,
exit of the liquid part of the blood from the vascular bed,
exudation into the peritoneal cavity

lead to hypovolemia. At this stage, paralytic ileus leads to the absence of bowel sounds upon auscultation, filling of the intestines with gases leads to the appearance of a tympanic sound during percussion, significant bloating, and impaired stool passage.

Symptoms of abdominal inflammation become significantly worse. This leads to an increase in the severity of all symptoms. The fever becomes hectic in nature, the pulse increases significantly, and is characterized by low volume and tension. Blood pressure decreases. Significant intoxication leads to the characteristic appearance that appears with peritonitis. It was described by Hippocrates and received his name. The face of such a patient is pale, the eyes are sunken, the facial features begin to sharpen, the nose and cheekbones protrude significantly on the face. The tongue is coated with a thick yellowish coating and is dry.

The condition of such a patient can be assessed as severe, the expression on his face is pained, and the patient is reluctant to answer questions.

The next stage of inflammation develops 3 days after the onset of the disease. There are severe hemodynamic disorders, disruption of the activity of all organs and systems of the body, which in the final stage can lead to multiple organ failure and death.

At this stage, the symptoms of abdominal inflammation are as follows:

the patient is pale,
his skin is covered with cold, sticky sweat,
there may be disturbances in consciousness,
psychoses.
The pulse is threadlike,
blood pressure is sharply reduced.
Auscultation of the heart reveals dullness of heart sounds and various cardiac arrhythmias.
No bowel sounds are heard on auscultation.
There is no stool, but vomiting of intestinal contents may occur.
Urination is rare, the amount of urine released decreases.

Treatment of abdominal inflammation using traditional methods?

A person who suspects inflammation of the abdominal cavity must be hospitalized in an appropriate institution as soon as possible. The movement of patients who are in a state of inflammation of varying severity is carried out quickly and sparingly. It is necessary to know in advance about the possibility of medical procedures that provide for the initial treatment of inflammation of the abdominal cavity.

The measures that need to be prescribed by a doctor for abdominal pain depend mainly on the underlying disease. Therefore, inflammation of the abdominal cavity with varying degrees of severity is often diagnosed using special studies. This is necessary to make a final diagnosis and decide whether to prescribe an emergency operation or simply to formulate a treatment strategy. It should be noted that doctors prohibit the intake of food, liquids, as well as the use of analgesics and hypnotics when diagnosed with inflammation of the abdominal cavity of varying severity.

Treatment of abdominal inflammation moderate severity

At this stage, complex treatment of inflammation of the abdominal cavity is usually prescribed. However, emergency medical care is often necessary and surgical intervention. It is carried out immediately. Surgical treatment of abdominal inflammation often lasts about three hours. During this time, correction of hemodynamic, electrolyte and some other disturbances is carried out.

How to treat severe inflammation of the peritoneum?

When a person is in a very in serious condition and the emergence internal bleeding The operation begins upon admission to the hospital. At the same time, resuscitation measures are also performed. With the very complicated nature of inflammation and a large volume of therapeutic actions, everything is often coordinated by a council of doctors.

The prognosis of treatment often depends on the degree of inflammation, as well as the duration of its course. Inflammation of the abdominal cavity is often determined from the moment the disease develops until the patient appears in the hospital; in addition, there may be concomitant diseases.

Unfavorable prognosis for the diagnosis of inflammation of the abdominal cavity is often obtained with peritonitis, which has not been treated for a very long time. Also, very often in old age, against the background of inflammation, an obstructed intestine with advanced necrosis gradually appears, as well as thrombosis of abdominal vessels. It should be noted that in case of inflammation, the speed of diagnosis and all necessary procedures the patient's further well-being depends.

Causes of the inflammatory process of the peritoneum

Microbes that cause inflammation are diverse. These include:

In addition to nonspecific inflammations, there are also specific inflammations, for example, peritonitis due to tuberculosis infection of the body. For inflammation of the peritoneum to occur, a change in the macroorganism is necessary - a violation of nonspecific resistance.

The mechanism of penetration of microbes into the body varies. In women, the peritoneal cavity communicates with external environment through the holes fallopian tubes and vagina. This explains the inflammation of the peritoneum due to infection.

In addition, the infection, when diagnosed with inflammation of the abdominal cavity, penetrates into the peritoneal cavity in acute inflammatory diseases of the peritoneal organs - appendicitis, pancreatitis, purulent cholecystitis and empyema of the gallbladder, inflammatory bowel diseases, liver abscesses. Usually in this case purulent inflammation abdominal cavity initially leads to an increase in the permeability of the organ wall and the penetration of microorganisms and discharge into the abdominal cavity.

With the progression of the inflammation process and the absence of adequate therapy the likelihood of perforation of the organ and penetration of purulent contents in large quantities into the peritoneum increases.

Another reason due to which inflammation of the abdominal cavity occurs is the penetration of infected contents during perforation of internal organs, the most common cause is perforation of a stomach ulcer, rupture of an infected appendix or gallbladder, nonspecific ulcerative colitis, rupture of suppurating cysts, such as the liver and pancreas. This is extremely dangerous, because when a hollow organ is perforated, extremely virulent microflora enters the peritoneum, causing a typical process of inflammation.

When diagnosed with inflammation of the abdominal cavity, an infectious agent can penetrate into the peritoneal cavity directly during penetrating wounds in the abdomen, after surgical operations, if the rules of asepsis and antisepsis are not followed or the sutures are incorrectly applied. In women, inflammation of the abdominal cavity can be associated with gynecological pathology: a complication of non-medical abortion or ectopic (for example, tubal) pregnancy, purulent-inflammatory diseases of the female genital organs (such as salpingoophoritis, adnexitis, endometritis).

Inflammation of the abdominal cavity can occur with certain therapeutic diseases: systemic lupus erythematosus, rheumatic disease, some vasculitis. Often inflammation of the peritoneum occurs with tumor lesions of the peritoneum - carcinomatosis.

Depending on the etiology of the process, the exudate in the peritoneal cavity can be serous, serous-hemorrhagic, hemorrhagic, purulent, putrefactive.

How inflammation of the abdominal cavity develops - pathogenesis of the disease

The peritoneum is a serous membrane. It has two layers - visceral and parietal. The visceral layer covers the internal organs of the abdominal cavity, and the parietal layer from the inside belongs to the abdominal wall. Between the sheets there is a minimal amount of liquid, which allows the sheets to slide relative to each other. The serosa has a large number of receptors; therefore, exudate in the peritoneal cavity or fibrin threads irritate the receptors, causing intense pain. The peritoneum ensures the metabolism of substances and fluids, having the ability to both absorb fluid and substances from the peritoneum and secrete fluid containing exudate and fibrin threads.

This ensures the protective function of the peritoneum: the loss of fibrin threads and the participation of the omentum limit the inflammatory process in the abdominal cavity. Such peritonitis is called inflammation of the abdominal cavity, for example, subdiaphragmatic abscess, appendicular, etc. The nature of the exudate, as with other inflammatory processes, can be different. This

serous,
purulent,
serous-purulent,
sometimes hemorrhagic
and putrefactive contents.

Limitation of inflammation in a certain area is usually carried out by soldering the layers of the peritoneum using fibrin threads.

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, which 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, immediate medical attention is required and urgent treatment, 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 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 (appendicitis, cholecystitis, salpingitis, etc.);
Inflammatory processes of any origin, not related to the abdominal organs (phlegmon of the abdominal wall, purulent processes localized in the retroperitoneal tissue).
Perforations in the abdominal organs (stomach or duodenum in case of peptic ulcer, appendix in case of gangrenous or phlegmonous appendicitis, gallbladder in case of destructive cholecystitis, colon in case of nonspecific ulcerative colitis).

There are bacterial and aseptic peritonitis. Pathogens 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

General symptoms develop against the background of intoxication of the body. These are nonspecific symptoms such as fever, weakness, tachycardia, 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. To be confirmed chronic pathology digestive organs, how the disease began, its course, severity of pain and intoxication syndromes, duration of the disease (up to 24 hours, two days or 72 hours or more).

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:

Vecidivating intestinal obstruction– have a close connection with the adhesions described above, because they lead to difficulty in the movement of 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 what has been said, the interest is understandable modern medicine to methods for removing toxic products from the intestinal lumen.

It is quite logical to increase the detoxification effect achieved by drainage 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 normal functioning intestines, severe pain, 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%.

ratings, average:

Peritonitis is a bacterial or aseptic inflammatory process that develops in the abdominal cavity. This process is based on inflammation of the serous membrane of the abdominal cavity, called the peritoneum. Peritonitis belongs to a group of acute surgical conditions collectively called “acute abdomen.”

According to various sources, today peritonitis occurs with a frequency of 0.05 to 0.3 percent among the population. The mortality rate for this pathology is very high. Overall mortality rates for peritonitis have until recently ranged from 60 to 70 percent. At the moment, thanks to modern medicines and the organization of prompt emergency care, the number of deaths has decreased, and the rates vary from 15 to 19.5 percent. Peritonitis is a disease that, according to statistics, is diagnosed in 15–20 percent of patients whose condition requires emergency surgical intervention.

Inflammation of the appendix of the cecum (

appendicitis

) is the most common cause of peritonitis. Today, appendiceal peritonitis is one of the most severe purulent-inflammatory diseases that develops in children. According to some data, this pathology in 72 percent of cases causes the development of childhood

and multiple organ failure.

Interesting facts about peritonitis

Inflammatory processes in the abdominal cavity were known to medicine many centuries BC. There is reliable information that the healers of Ancient Egypt repeatedly encountered this disease and tried to treat it with surgical intervention. The first to describe the complete clinical picture of advanced peritonitis was Hippocrates. The Hippocratic collection that has survived to this day contains a description of a set of symptoms indicating peritonitis. Today, the name of the legendary ancient Greek doctor is used to determine signs of progressive peritonitis. The face of patients with this form of inflammation acquires a characteristic appearance (

pointed facial features, bluish lips, sunken eyeballs

), which is called the face of Hippocrates.

Doctors of ancient India performed operations on

intestines

to prevent peritonitis. The “ant suture” was widely used, in which the edges of the intestinal wound were brought closer together and Bengal ants were released onto their surface. After a while, the bodies of the insects were removed, and the remaining heads and claws held the edges of the wound and made the seam consistent.

In Russia during the Middle Ages, inflammatory processes in the abdominal cavity were combined into one group of diseases, which was called “Antonov fire” and was classified as incurable. The first to describe peritonitis in Russia was the military surgeon Vasily Shabanov, who did so in 1816. The first laparotomy was performed in 1879, although in the history of medicine this achievement is awarded to the American doctor Ephraim McDowell (

1809, surgery for a suppurating ovarian cyst

), and the Russian doctor Schmidt (

1881, suppuration of the spleen due to malaria

The first to insist on surgical treatment of peritonitis was the Polish-Austrian surgeon Johann Mikulicz-Radetzki, who in 1884 reported the successful surgical elimination of diffuse peritonitis and the first attempt to suturing a perforation

Taken several years earlier.

Refuse preliminary conservative therapy in case of peritonitis, the German surgeon Werner Kerte called for immediate operation in his work in 1892. Thanks to this doctor, there was a decrease in the number of deaths due to peritonitis from 87 percent (

1885 – 1904

) up to 66 percent (

1904 – 1914

Similar dynamics were observed in Russia. Thus, in 1913, according to one of the leading surgeons, Ivan Ivanovich Grekov, the spread of surgical treatment of peritonitis contributed to a reduction in mortality from 100 to 60–70 percent (

between the end of the 19th century and the beginning of the 20th century

). The next significant stage in the history of peritonitis in Russia was the period from the early twenties to the end of the forties of the 20th century. The key issues of that time were methods of surgical practice, the need for cleansing and drainage of the abdominal cavity. At the 15th Congress of Surgeons, Dr. Sergei Ivanovich Spasokukotsky was the first to propose tightly suturing the abdominal cavity after removing the cause of peritonitis and eliminating the exudate. Appearance and distribution

antibiotics

influenced the formation of the third period in the history of peritonitis, which is characterized by a decrease in deaths to 15 percent.

It should be noted that the massive use of antibiotics did not live up to the hopes placed on them. The ability of microorganisms to adapt to living conditions led to the fact that new generation antibiotics gradually lost their effect in treatment

infections

Thus, the achieved mortality rate in the first stage of antibiotic use of 15 percent has increased today.

Anatomy of the peritoneum

The peritoneum is the membrane that lines inner surface abdominal cavity (

space below the chest filled with internal organs

) and the surface of some organs. It consists of two leaves, one of which covers the organs (

visceral layer

), and the other is the walls of the cavity (

parietal leaf

). Between these leaves a cavity is formed in the form of a closed bag. This cavity is called the peritoneal cavity. Normally it is filled with a small amount of aseptic liquid. The liquid gives the leaves of the peritoneum a shiny appearance and allows them to slide. The leaves of the peritoneum are not interrupted anywhere, but only pass one into another, thus forming a sealed, closed cavity. In places where one leaf passes into another, folds and ligaments are formed in which blood vessels and nerves pass. These folds provide fixation of the internal organs.

The leaves of the peritoneum consist of several layers, on the surface of which there are microscopic holes (

). Through them, fluid is absorbed from the abdominal cavity. The peritoneum can absorb about 70 liters of fluid per day. Thus, it maintains the constancy of the internal environment of the body (

homeostasis

). In addition to the function of fixing and absorbing fluid, the peritoneum has a bactericidal function. Thus, the peritoneum plays a very important role in the human body, so its damage or inflammation “echoes” throughout the body.

Causes of bacterial peritonitis The main cause of peritonitis is the penetration of infection into the abdominal cavity. Penetration of infection can occur through primary or secondary routes. In the first case, the infection directly penetrates into the peritoneal cavity through the blood or lymph flow. This cause of peritonitis is rare, occurring in 1–2 percent of cases. The most common cause of peritonitis is a violation of the integrity of the abdominal or pelvic organs. In this case, the infection enters the peritoneal cavity through the resulting defect in the organs. Thus, in this case, peritonitis is a complication, and not an independent disease.

The causes of bacterial secondary peritonitis are:

inflammation of the appendix;
perforation of a stomach ulcer or duodenum;
inflammation of the female genital organs;
intestinal pathologies and biliary tract;
abdominal injuries.

Inflammation of the appendix Inflammation of the appendix, or appendicitis, is the cause of secondary peritonitis in more than 50 percent of cases. With this pathology, the infection affects all layers of the appendix. The hole between it and the cecum becomes clogged, and the appendage itself swells. If an emergency appendectomy (surgery to remove the appendix) is not performed at this point, the appendix may rupture. In this case, the entire microbial flora from it spreads to the peritoneum. This kind of appendicitis is called perforated, and the complication is perforation (perforo - to pierce).

Secondary peritonitis may also be a consequence of phlegmonous or gangrenous appendicitis. In the phlegmonous form of the disease, purulent inflammation of the appendix is observed. Pus from it can transfer to the peritoneum with the development of localized peritonitis. With gangrenous appendicitis, a process of necrosis is observed (

) process membranes. Perforation of the appendix with leakage of purulent contents is observed in these cases much more often. In addition, separation of the appendix from the intestine may develop (

self-amputation

). In this case, peritonitis develops against the background of abdominal sepsis.

Perforation of a stomach or duodenal ulcer

Peritonitis, which develops as a result of a violation of the integrity of the stomach or duodenum, is observed in 15 percent of cases.

An ulcer is a deep defect in the mucous membrane of an organ. Gastric or duodenal ulcers are very common and occur in 5 to 10 percent of the population. Its common complication is perforation or perforation. In this case, a through defect is observed in the wall of the stomach or duodenum. Through this defect, the contents of these organs extend beyond their limits and enter the peritoneal cavity. Gastroduodenal contents act on the peritoneum as a chemical, physical and bacterial irritant. The effect of the acidic contents of the stomach on the layers of the peritoneum is similar to

The lower the acidity of the contents, the stronger the burn, and the higher the rate of development of peritonitis.

Inflammation of the female genital organs

Pathologies of the internal genital organs in women cause peritonitis in 10 percent of cases. They can contribute to both primary and secondary inflammation of the peritoneum.

Pathologies of the female internal genital organs that can cause peritonitis are:

salpingitis – inflammation of the fallopian tubes;
salpingoophoritis - inflammation of the fallopian tubes and ovaries;
pyosalpinx - accumulation of pus in the fallopian tubes;
rupture of an ovarian cyst;
rupture of the fallopian tube.

The primary route of infection develops through direct contact of the genital organ, for example, the uterus, with the peritoneum. This mechanism can be observed with salpingitis. The most common secondary pathway develops during organ destruction, for example, when an ovarian cyst or fallopian tube ruptures. Development purulent peritonitis in this case it has an extremely severe course. Peritonitis, which develops with inflammation of the genital organs, is often localized.
Pathologies of the intestines and biliary tract

At various pathologies intestines (

perforation of ulcers or intestinal obstruction

) and biliary tract (

cholecystitis

) peritonitis develops in 5 and 10 percent of cases, respectively.

Pathologies of the intestines and biliary tract that can cause peritonitis are:

intestinal obstruction;
intestinal diverticula;
perforation of ulcers in Crohn's disease;
perforation of ulcers due to colitis;
cholecystitis;
cholelithiasis.

In this case, various mechanisms of infection are observed. Thus, with a perforated intestinal ulcer, there is an outpouring of intestinal contents into the peritoneal cavity and, as a consequence, its infection. Direct inflammation is observed in colitis and enterocolitis.

A slightly different mechanism is observed in cholecystitis and cholelithiasis. In this case, sweaty biliary peritonitis develops. In this case, 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 (

) is proportional to its quantity. Since bile does not pour out immediately, but slowly sweats, its amount may initially be insignificant. The clinical picture in this period is blurred, and classic symptoms may be absent. However, as you gradually sweat, the volume of bile increases. When a large volume of bile irritates the peritoneum, a classic picture of peritonitis appears.

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

Abdominal injuries

As a result of open and closed injuries, post-traumatic peritonitis develops. At open injuries In the abdominal cavity, direct infection of the peritoneum occurs. Thus, through a defect in the abdominal wall, direct contact with non-sterile environment with the peritoneal cavity.

Bacteria

Penetrated from the air, they become a source of inflammation. At closed injuries The mechanism of development of peritonitis is due to a violation of the integrity of 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, become the cause of peritonitis.

In addition, pathologies of the pancreas can be the cause of peritonitis (

in one percent of cases

), spleen and bladder.

Causative agents of bacterial peritonitis

The cause of infection in peritonitis can be a variety of bacteria. This can be either a specific microbial flora or a nonspecific one.

microflora

intestinal tract.

Microorganisms that can cause peritonitis

Specific flora	Nonspecific flora
hemolytic streptococcus; gonococci; pneumococci; Mycobacterium tuberculosis.	aerobic microorganisms (those that use oxygen during their life processes).	anaerobic microorganisms (those that do not use oxygen during their life processes).
	E. coli (in 60 percent of cases); proteus; Klebsiella; enterobacter; staphylococcus and streptococcus (20 percent or more of cases).	clostridia; bacteroides; 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 these are Escherichia coli and staphylococcus, as well as anaerobic non-clostridial flora.

Causes of aseptic peritonitis

In aseptic peritonitis, the peritoneum is irritated not by bacterial flora, but by aggressive agents such as blood, urine, gastric juice or pancreatic juice. This type of 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. Within 6–8 hours, 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 rate exceeds 50 percent. It develops as a result of barium leaving the gastrointestinal tract. This occurs when performing X-ray diagnostic methods with barium contrast (

for example, during irrigoscopy

Types of peritonitis

There are many types of peritonitis, which are classified according to different criteria.

Criterion	Type of peritonitis
Because of	traumatic; perforated (or perforated); postoperative; infectious.
By traumatic factor	bacterial; aseptic.
According to the mechanism of infection	primary; secondary.
By 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 (aka wet); dry.
By type of infectious agent	streptococcal; tuberculous; 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. Distinguishing peritonitis by type of infectious agent is very important for prognosis of the disease. Knowing the type of microorganism, you can select the treatment as accurately as possible. However, in practice, identifying the etiological factor (

that is, 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 the absence of 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 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 (

) up to several liters (

). The main key point in the development of the disease is intoxication. It is known that the total area of the abdominal covering is equal to the total area of the skin, that is, approximately 2 square meters. All toxins that accumulate in the cavity penetrate the blood and very quickly lead to intoxication of the body. Together with the bloodstream, bacteria and their toxins are carried to the organs, affecting them. As a result of such 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 fluid refers to the fluid contained in tissue cells. Extracellular fluid includes interstitial fluid (

fluid between cells

) and intravascular (

blood plasma

) liquid.

In a healthy body, the intracellular volume of fluid accounts for 60 - 65 percent, and the extracellular part - 40 - 35. However, with peritonitis, a pathological third space is formed. This space is nothing more than the 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

Along with this, 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 the disease. After this, the fibrin in it heats up and it becomes serous-fibrinous. If the purulent flora is activated, then serous peritonitis evolves into purulent peritonitis.

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 layers of the peritoneum. This type of peritonitis can develop into adhesive peritonitis.

Hemorrhagic peritonitis This form of peritonitis occurs when blood that has penetrated into the peritoneal cavity is mixed with the fluid. This blood can form during injuries (traumatic peritonitis) or flow out when organs are perforated.

Dry peritonitis

With dry peritonitis, a small amount of fluid is observed in the peritoneal cavity. The difference between this liquid is the high content of fibrinogen in it. Fibrinogen is the name given to the protein that forms the basis

when folding. Its concentration increases with inflammatory reactions, as well as for epithelial injuries. Upon contact with the sheets of inflamed peritoneum, fibrinogen is converted into fibrin. Fibrin thickens the inflammatory fluid, making it thicker, due to its physicochemical properties. It also falls out on the surface of the peritoneum 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 peritonitis.

On the one hand, this process is carried out by the body for a protective purpose. Indeed, with the formation of adhesive fibrin structures, the site of inflammation is delimited. Dry peritonitis is less likely to be diffuse. However, at the same time, due to the massive adhesive process,

between the peritoneum and intestines. This type of peritonitis often occurs violently. Despite the absence of a large effusion in the peritoneal cavity and the limited nature of the process, it occurs with severe hypovolemia (

decreased blood volume

Dry peritonitis is often observed with tuberculous etiology of this disease. In this case, the layers of the peritoneum swell sharply, and tuberculous tubercles form on their surface. In this case, there is practically no liquid in the peritoneal cavity, or it is contained in small quantities. As the bumps progress, they begin to spread to the intestines and other organs. Sometimes they become so thick and compacted that they deform the organ.

With dry peritonitis, disseminated intravascular coagulation syndrome often develops.

Purulent peritonitis

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

Purulent peritonitis occurs very quickly and is characterized by a pronounced intoxication syndrome. Many representatives of purulent flora produce toxins that are tropic (

more preferable

) to various types of fabrics. Some toxins are particularly selective for the epithelium of the vascular wall. Penetrating into the bloodstream, they cause swelling and dilation of blood vessels, leading to numerous hemorrhages in the organs. The phases of peritonitis in its purulent form are sharply expressed, and no clinical manifestations are observed. Symptoms of general intoxication and disturbances of water and electrolyte metabolism prevail. Often, especially with streptococcal peritonitis, confusion and delirium are observed. Purulent peritonitis is characterized by its high mortality rate. Chronic and sluggish forms of purulent peritonitis are extremely rare.

Tuberculous peritonitis

Peritonitis caused by Mycobacterium tuberculosis is called tuberculosis. This is the most common form of chronic peritonitis. Tuberculous peritonitis primarily affects children. However, this is a common occurrence 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, such sites are the lungs and lymph nodes. Among women (

The ratio of men to women with this pathology is 1 to 9

) are the internal genital 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. This message ensures the rapid spread of mycobacteria into the peritoneal cavity during tuberculosis of the internal genital organs.

Tuberculous peritonitis can occur in both dry and exudative forms. The peculiarity of this type of peritonitis is that it can occur in blurred clinical forms without clearly defined phases. Symptoms of intoxication (

fever, weakness

) can exist for weeks and even months. Such a sluggish course of peritonitis is accompanied by a violation of metabolic, endocrine and other functions of the body. To the characteristic symptoms of peritonitis are added the symptoms of the underlying disease, that is, tuberculosis. The main symptoms are weight loss, prolonged fever, increased

sweating

Periodic

and others. The acute course of tuberculous peritonitis is observed relatively less frequently.

In addition to these forms of peritonitis, there is so-called anaerobic peritonitis, which is caused by anaerobic flora. It develops as a result of gunshot wounds or as a complication

or abortions. The inflammatory fluid is different foul odor, and in the peritoneal cavity multiple

abscesses

A distinctive feature of biliary peritonitis is mild irritation of the peritoneum. Despite the general signs of intoxication, classic local symptoms (

“board 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 irritation of the peritoneum (

inflammatory exudate, blood, bile

). These symptoms develop as a protective mechanism, and the area of their localization depends on the area and location of the pathological focus.

Local symptoms of peritonitis are:

pain;
abdominal muscle tension;
symptoms of peritoneal irritation detected during examination.

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

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

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

Sometimes the pain can simply change location, which also means the transition of the inflammatory process. But in this case, the inflammatory process is not diffuse, but localized. For example, pain may be relieved for a while and intensified when urinating. This means that the pathological process has moved to the peritoneum covering the bladder. In diagnosis, it is important to find out the primary location of pain.

The disappearance of pain is an unfavorable sign of peritonitis. This may be due to the accumulation of large amounts of fluid in the abdominal cavity or paresis (

lack of peristalsis

) intestines.

Abdominal muscle tension

Abdominal muscle tension, or muscle guarding, 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. 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. In this case, muscle tension is visible visually, even before palpation.

The voltage can also be local. For example, with effusion biliary peritonitis, the abdominal wall thickens in the area of the gallbladder projection.

Muscle guarding is an early local symptom. At the same time, as intestinal paresis develops and exudate accumulates, it disappears. The absence of muscle tension can be observed in weakened patients, usually in the elderly.

Symptoms of peritoneal irritation revealed during examination

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

Methodology The patient is in a supine position with his knees bent (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 suspected. In this case, the patient notes pain. When the hand is suddenly removed, the pain increases sharply. This symptom is considered positive. If, when the hand is removed, the pain does not change its intensity, then the symptom is considered negative.

With pronounced muscle tension, the symptom is difficult to determine. Diagnosis is also difficult in cases where intestinal paresis has developed.

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

Common symptoms of peritonitis are:

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

At this stage, the patient is in a forced position, usually lying on his back with his legs brought to his stomach. General symptoms such as fever and rapid heartbeat appear. The temperature is caused by the 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. For tuberculosis - 38 degrees. Along with the rise in temperature, the number of heart beats increases. At this stage of the disease, this is associated with elevated temperature. It is known that for every degree raised, the heart increases the number of its contractions by 8 beats per minute.

At this stage there also appears

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

Toxic stage

This stage lasts from 24 to 72 hours. General symptoms begin to prevail in it, which are caused by general intoxication, disturbances of water-electrolyte metabolism and metabolic disorders.

Toxins are carried throughout the body through the blood and lymph. First of all, they reach the liver and lungs, resulting in the development

liver failure

and lung distress. Breathing becomes frequent, shallow, and sometimes intermittent. The patient continues to vomit, and the vomit becomes foul-smelling.

The main complications at this stage are associated with dehydration and water-electrolyte disturbances. Due to disturbances in vascular tone and changes in the permeability of the vascular wall (

everything is caused by toxins

) fluid seeps into the peritoneal cavity. A state of anhydremia develops, which is characterized by a decrease in fluid levels in the body. The patient is thirsty, which does not go away with drinking. The tongue becomes dry, coated with a brown coating.

Arterial pressure

falls, and the heart rate compensatory increases to 140 beats per minute. At the same time, due to hypovolemia (

low blood pressure

) heart sounds become dull and weak.

Frequent vomiting leads to the loss of not only water, but also body salts. Due to hypokalemia and hyponatremia,

convulsions

The patient's condition worsens further 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 removed 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 is replaced by

bloating

At this stage, intestinal paresis develops, which is characterized by the absence of peristalsis. The pain also subsides or completely disappears, which is associated with the accumulation of exudate in the peritoneal cavity.

If emergency measures are not taken, this stage may progress to the terminal stage.

Terminal stage

This stage develops 72 hours or more from the onset of the disease. It is characterized by dehydration 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 become sharper, the eyes and cheeks are sunken, and the complexion acquires an earthy tint. 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, palpation is painless. The patient's pulse is threadlike, breathing is intermittent.

Today, the terminal stage is, of course, extremely rare.

The severity of local and general symptoms of peritonitis depends on the extent of its spread and the cause of the disease. The classic staged course is observed with diffuse peritonitis. In localized forms, the symptoms are not so pronounced.

Symptoms of chronic peritonitis

The classic symptoms of peritonitis in its chronic form are usually erased and not expressed. The patient does not complain of acute pain, vomiting or muscle tension. That's why long time this type of peritonitis can occur 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;
increased sweating;
prolonged low-grade fever;
periodic constipation;
periodic abdominal pain.

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

Other symptoms of chronic peritonitis are caused by adhesions. Thus, chronic peritonitis most often occurs in a dry form, which is characterized by an adhesive process. The adhesions that form in this case tighten the intestinal loops and disrupt its motor activity. Thus, periodic intestinal obstruction syndrome develops. The patient suffers from periodic constipation, which becomes more frequent as the disease progresses. Pain in the abdomen and periodic bloating also appear. As the adhesive process spreads, symptoms become more frequent and severe.

Diagnosis of peritonitis

Diagnosis of peritonitis is based on anamnestic data and clinical picture. History data (

medical history

) are especially important in chronic forms of peritonitis. Knowing what the patient was sick with before or what he is sick with now, we can most accurately predict the location of the primary infection. In chronic peritonitis, 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 layers 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 layers.

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

Treatment of peritonitis with medications

The mortality rate of peritonitis today is still high, so the problem of treatment is very urgent. Since peritonitis in 99 percent of cases is a secondary disease, its treatment should begin with eliminating the root cause. As a rule, it consists of surgery to remove a burst appendix, suturing a perforated ulcer, or removing a purulent gallbladder. At the same time, drug treatment is carried out aimed at correcting all those disorders that develop during peritonitis. Thus, the treatment of peritonitis should be comprehensive and combine various methods.

Treatment of peritonitis with medications is aimed at eliminating the infection (

causing peritonitis

), for correction metabolic disorders, as well as to prevent the development of complications.

Group of drugs	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 or 3 organisms, it is advisable to prescribe antibiotics wide range.	From the penicillin group: benzylpenicillin; ampicillin; methicillin. From the group of aminoglycosides: kanamycin; gentamicin. From the group of macrolides: sigmamycin; oletethrin.	They disrupt the synthesis of cell wall components, thus preventing further proliferation of bacteria in the peritoneal cavity. Antibiotics from the aminoglycoside group block the synthesis of proteins necessary for bacteria to function.	For moderate peritonitis, antibiotics are mainly prescribed intramuscularly. As a rule, loading doses of antibiotics are prescribed. Benzylpenicillin - 15,000,000 units (units of action) per day, ampicillin and methicillin - 3 to 4 grams, 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 lost water and salts of the body.	All these drugs are prescribed intravenously (extremely rarely - in a stream). 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 necessary to prevent the development of toxic shock and other complications.	hemodesis.	Binds toxins that have entered 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, 200 to 500 ml are administered intravenously.
	10 percent calcium chloride solution.	Normalizes the permeability of the vascular wall (which is impaired during peritonitis), thereby preventing the penetration of toxins through it.	10 ml 10 percent solution diluted in 200 ml of isotonic solution and administered 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 to quickly remove toxins from the body.	furosemide This drug is prescribed with caution, especially in cases of severe water and electrolyte disturbances.	Blocks sodium reabsorption, thereby increasing urine volume. It has a quick but short-term effect.	One or two ampoules of the drug are administered intravenously after the hypertonic solution has been administered. For example, at the end of a drip with 400 ml of 20 percent glucose or mannitol solution, 4 ml (40 mg) of furosemide is administered.
Antipyretics To eliminate fever.	paracetamol; ibuprofen.	They block the synthesis of substances that are involved in inflammation and increase the temperature.	Paracetamol – 500 mg (one tablet) 4 times a day. Ibuprofen - 400 mg (one tablet) 2 – 3 times a day.
Antiemetic drugs 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. Blocks receptors of the vomiting center and, thereby, has an antiemetic effect.	Administer intravenously or intramuscularly at 10 mg (2 ampoules) two or three times a day. Maximum daily dose equals 60 mg.
Anticholinesterase drugs Used to restore intestinal motor function and prevent paresis.	ubretid; Proserin.	They increase the tone of the intestinal muscles and enhance peristalsis, preventing the development of paresis.	Ubretide is administered intramuscularly, in a single dose of 0.5 mg (one ampoule). A second injection is given only after 24 hours. Prozerin is administered subcutaneously in a dose of 1 ml of a 0.05 percent solution twice a day.
Anticoagulants They are used to prevent thrombosis, which is 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 units per day.
Anabolic drugs In patients with peritonitis, the rate of catabolic (decomposition process) reactions is 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 anabolic processes, mainly due to the synthesis of proteins in the body. Insulin increases energy processes in the body.	Retabolil is administered intramuscularly at 100–200 mg for men, 50–100 mg for women once a week. Based on the calculation that one unit of insulin is per 5 mg of glucose, 250 to 500 ml of a 10 percent glucose solution is administered intravenously along with insulin.

Treatment of peritonitis should be individualized. It is necessary to take into account the peculiarities of the course of the pathological process, the form of peritonitis (

dry or wet

), as well as an etiological factor. The latter plays a decisive role in the effectiveness of treatment. So, for tuberculous peritonitis, anti-tuberculosis drugs are prescribed - isoniazid, rifampicin, ethambutol. If anaerobic flora is suspected - lincomycin,

trichopolum

Gentamicin, and also carry out hyperbaric oxygenation (

high pressure oxygen supply

). For aseptic peritonitis caused by acute pancreatitis, antienzymes are prescribed - contrical. For diffuse forms of peritonitis, the technique of washing the peritoneum is used (

peritoneal dialysis

It should be noted that the purpose

painkillers

Contraindicated for peritonitis. Firstly, painkillers blur the clinical picture, which is especially dangerous in the acute period of the disease. And this applies to all pathologies related to the “acute abdomen” section in surgery. Secondly, most painkillers weaken intestinal motility, thereby accelerating the development of intestinal paresis. It is also not allowed to administer laxatives, which contribute to the spread of the pathological process.

Surgery for peritonitis When is surgery needed for peritonitis?

Detection of peritonitis is absolute indication in order for emergency surgery to be performed. The course of the procedure depends on the cause that provoked the inflammation of the peritoneum, but in all cases the operation pursues the same goals and is carried out according to a certain algorithm.

The goals of surgical intervention for peritonitis are:

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

The stages of surgery for inflammation of the serous covering of the peritoneum are:

preoperative preparation;
providing access;
elimination or delimitation of the source of infection;
abdominal lavage;
intestinal decompression;
drainage (creation of conditions for constant outflow of contents) of the abdominal cavity;
suturing the wound.

Preparation for surgery The main task of preoperative preparation is to correct impaired body functions.

The stages of preparatory therapy for the patient are:

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

Medication 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 advisable, which allows you to increase the speed of infusions and better control the process.

The goals of intravenous influence are:

Replenishment of circulating blood volume.
Correction of central and peripheral circulatory disorders.
Ensuring the necessary concentration of antibiotics in tissues to reduce the spread of infection and prevent septic shock. In case of severe multiple organ failure syndrome and unstable blood circulation, the patient is given artificial ventilation.

Cleansing the gastrointestinal tract If peritonitis is diagnosed at an early stage, a single gastric emptying is performed using a tube. For more advanced processes, the probe is left in place for the entire recovery period after surgery. Cleansing the lower intestines is carried out using enemas.

Anesthesia Anesthesia during surgical treatment of peritonitis is carried out on the basis of multicomponent anesthesia and the use of muscle relaxants. Spinal anesthesia has recently been widely used. A mandatory step in pain relief is novocaine blockade. This procedure reduces the need for narcotic analgesics. Novocaine also helps improve tissue trophism and eliminate reflex vascular spasm, which ensures earlier restoration of the functionality of the gastrointestinal tract.

Incision during surgery Surgical intervention for inflammation of the serous membrane of the peritoneum is carried out using a median laparotomy (an incision made along the white line of the abdomen, from the lower end of the sternum to the pubis). This type laparotomy provides access to all areas of the abdominal cavity. Depending on the location of the source of infection, the incision made can be expanded in the required direction. Correction of an abdominal wound using special retractors provides the opportunity to quickly and with a minimal level of injury 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.

Removing or delimiting 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 the infection. If the cause of inflammation is an organ whose removal is possible (appendix or gallbladder), then resection of this organ is performed. If peritonitis causes perforation of a hollow organ, it is sutured. Removal of the affected area of the gastrointestinal tract with a colostomy or enterostomy (methods of removing the small intestine or colon) or isolation of the source of infection can also be performed. For peritonitis that occurs after surgery on the intestine, due to the failure of the anastomotic sutures (the connection of two hollow organs), in some cases non-radical operations are performed. Such manipulations include suctioning out purulent contents using drainage tubes, isolating the source of peritonitis using tamponing, and removing the intestinal anastomosis to the outside.

Abdominal cleansing Rinsing the abdominal cavity with special solutions reduces the number of pathogens in the exudate and helps eliminate the infection more effectively. In order to maintain the integrity of the serous layer, the use of gauze pads to remove pus is excluded. Also, due to the danger of disruption of the serous cover, dense deposits of fibrin (a substance that is formed during blood clotting) are not eliminated. The compositions 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 intestines, into the small intestine through oral cavity pass a long probe with a large number of holes. The probe can also be passed through the rectum. If suctioning the contents is not effective, the doctor performs an ileostomy (drawing part of the small intestine out through an opening in the abdominal wall). The colon, if necessary, is drained through anus. In rare situations, to install a probe, a stoma (an opening created artificially and placed on the anterior wall of the abdominal region) is placed on the stomach or appendix.

Abdominal cleansing Special hollow tubes are used to drain the abdominal cavity. Drains are inserted into the right and left area pelvis, on both sides of the diaphragm and under the liver. If during the operation purulent peritonitis was detected and the cause of the infection was eliminated, then peritoneal lavage is performed (introduction of special drugs into the abdominal cavity through a catheter 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 is treated.

Options for suturing the surgical incision are:

Application of a continuous suture without drainage– this method is used when the level of infection is low, when there is no risk of abscesses. In such cases, the assumption is that the body can cope with the problem on its own. infectious process with the help of antibiotics.
Suturing the incision with passive drainage– drainages are used to drain exudate and administer antibiotics.
Bringing the edges of the wound closer together– used when installing drains near the abdominal wall to wash the peritoneum and remove pus.
Open way– used in the presence of a large amount of pus or extensive inflammation of the tissues of the abdominal wall. With this method, 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 inflammation is associated with factors such as anesthesia, surgical trauma and malnutrition.

The areas 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 necessary to treat peritonitis? Treatment of peritonitis requires hospitalization. Outpatient (at home) treatment of peritonitis in any form is unacceptable. Peritonitis is an acute surgical pathology with an unpredictable course, the mortality rate of which is very high. At any stage of this disease, complications may arise that will endanger the patient's life. 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 part of postoperative rehabilitation after peritonitis. Surgery causes disruption of the body's functionality, so reserves

proteins fats

carbohydrates

are depleted. Therefore, the patient’s diet after peritonitis must be balanced and include all elements for normalization energy metabolism. Definition of final

composition, duration

) depends on the cause that caused peritonitis. The postoperative period is divided into several stages, which determine the patient’s nutritional pattern.

The phases of the recovery period are:

first (early) – lasts from 3 to 5 days;
second – duration from 2 to 3 weeks;
third (long-term) – ends when the patient’s ability to work is fully restored.

Nutrition at the first stage

It is possible to provide full support to the patient after surgery with the necessary nutritional ingredients only with the help of artificial nutrition. To meet the body's protein needs and prevent complications, the patient is given parenteral feeding (

administration of nutrients intravenously

). When intestinal peristalsis occurs, the patient is transferred to enteral nutrition (

administration 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 in the second stage

When stool appears and the body’s condition improves, the patient is transferred to natural nutrition. The main rule of feeding is the gradual introduction of new products and constant monitoring of the patient’s well-being.

For some period (

from 2 to 5 days

) after completion of artificial feeding, the patient is prescribed a special diet with low energy value (

up to 1000 kilocalories per day

). The patient needs to consume approximately 20 grams of proteins and fats and 200 grams of carbohydrates per day. The amount of table salt consumed 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.

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

If this diet is well tolerated and there is no loose stool, the patient is transferred to a more varied diet, which is followed throughout the entire period of treatment in the hospital.

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

Principles of creating a menu for a patient after treatment of peritonitisHigh protein content – sufficient amounts are included in the following products:

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

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

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

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

Balanced fat intake – recommended sources of fat 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 healing of the 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.
Food temperature– average. Excessively hot or cold food is excluded.
Food consistency– liquid, mushy. When boiled, food may have a denser structure than porridge, but should be served pureed.
Recommended heat treatment– boiling or steaming. The use of an oven is also allowed, but without forming a crust on the products.
Rest after meals– if possible, especially during lunch hours, after eating, you should take a horizontal position for 15–30 minutes.
Fluid intake– tea, milk and other drinks should be consumed 20–30 minutes after meals. The amount of liquid taken at one time should not exceed 1 glass.

To ensure that the food you eat does not have an aggressive effect on the organs of the digestive system, it is necessary to exclude foods that are strong stimulants of secretion.

Products that provoke increased secretory activity of the stomach include:

rich meat and vegetable broths;
smoked, dried sausages;
salted, marinated fish;
industrial canned food;
baked goods;
tomato sauce, ketchup, soy sauce, mustard, horseradish;
salted, pickled vegetables;
sour, salty, spicy dressings for dishes;
insufficiently ripe or sour fruits;
stale vegetable and animal edible fats;
chocolate;
coffee, cocoa;
drinks containing carbonic acid.

Products whose consumption should be minimal in the main diet include:

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

You should also consume foods that contain stringy meat or rough connective tissue of animal origin (skin, cartilage, tendons) in minimal quantities.

Daily norms chemical composition The main diets are:

squirrels– 100 grams (60 percent animal origin);
fats– from 90 to 100 grams (30 percent vegetable);
carbohydrates– 400 grams;
calorie content– 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

vitamins

microelements

The deficiency of which can be compensated with the help of vitamin and mineral supplements. The main indicator that you should focus on when drawing up a menu is the patient’s well-being. If, when eating certain foods, the patient experiences discomfort in the epigastric region, nausea or vomiting, such foods or products should be discarded.

Bread– wheat products baked yesterday or dried in the oven.
Soups– prepared with potato or carrot broth. Products such as cereals (must be well boiled), vegetables (must be pureed), and milk can be added. You can season first courses with butter.
Meat– cutlets (steamed, boiled), casseroles, soufflé. Recommended are beef, lamb (lean), pork (trimmed), chicken, turkey.
Fish– use low-fat varieties for boiling or steaming in one piece. The skin is first removed. Also possible are cutlets or meatballs made from fish fillets, aspic.
Dairy– milk, low-fat cream, low-fat kefir, cottage cheese, yogurt, fermented baked milk. The products can be consumed independently or used to prepare casseroles, mousses, and creams.
Eggs– soft-boiled, steam omelettes.
Porridge– boiled in water or milk from cereals such as buckwheat, semolina, rice.
Vegetables– potatoes, carrots, beets. You can simply boil vegetables, make puree, pancakes (steam), cutlets (steam), soufflé from them.
Finished goods– milk sausage, unsalted low-fat ham, children’s sausages, curd cheeses.
Dessert– jelly, jelly, unsweetened compote.
Beverages– juices from sweet berries diluted with water, weak tea, rosehip decoction.

Sample menu dishes for 1 day are:

Breakfast– 1 soft-boiled egg, rice porridge with milk, tea.
Late breakfast– granulated (non-acidic) cottage cheese, rosehip decoction.
Dinner– potato soup without meat, steamed chicken cutlets and carrot puree, dried fruit compote.
Afternoon snack– 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 ambulatory treatment. Gradually, new foods are introduced into the patient’s diet, while monitoring the body’s reaction.

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

reducing restrictions on the types of heat treatments used;
gradual increase in caloric intake;
replacing pureed food with solid foods.

Restrictions that must be observed until full recovery are:

reduced sugar intake;
minimal use of hot herbs and spices;
reducing the amount of difficult-to-digest foods (animal fats, legumes, fatty meats, heavily fried foods).

It is necessary to continue to observe the principles of fractional nutrition, distributing daily norm calories (from 2300 to 2500) in accordance with the rules of a healthy diet.

Principles of distribution daily calorie content are (data given as a percentage of total food):

Prevention of dysbiosis after peritonitis Prevention of dysbiosis (reduction of beneficial and increase of harmful bacteria in the intestines) is of great importance during recovery from peritonitis.

Nutritional rules that will help restore intestinal microflora are:

Refusal or reduction in consumption of all types of sugar and its substitutes (honey, maple syrup, corn syrup, glucose, fructose, maltose, sorbitol, sucrose).
Exclusion of products prepared using fermentation processes (beer, wine, cider, ginger ale).
Minimum consumption of food products that may contain yeast and mold (cheeses, vinegar, marinades, bakery products, raisins, kvass).
Avoid foods that contain dyes, flavors, or flavor enhancers. A large concentration of these elements is found in fast food.
Eating stewed carrots and beets. These vegetables contain pectin, a substance that has a sorbing (absorbing) property and helps remove toxins from the body.
Inclusion of dairy and lactic acid products (kefir, cottage cheese, yogurt, kumiss, milk) into the menu. It should be noted that fermented milk products, the duration of which does not exceed 1 day, bring benefits to the body in the fight against dysbiosis. After 24 hours, saprophytic bacteria develop in kefir and cottage cheese, which inhibit intestinal function and can cause constipation.
Consumption of foods enriched with lactobacilli and bifidobacteria. Fermented milk products such as bifidok, biokefir, and fermented milk lactobacterin are enriched with such elements.
Introducing slimy soups and porridges made from buckwheat or oatmeal to the menu. These dishes improve intestinal function and prevent diarrhea.

Is it possible to treat peritonitis at home? Peritonitis is a disease that requires immediate attention medical care. From the onset 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 surgery can cause the patient’s death.

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

Consequences of peritonitis

The consequences of peritonitis include the development of numerous complications both during the illness itself and during the recovery period.

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

acute renal failure;
pulmonary complications;
toxic shock;
dehydration of the body.

Acute renal failure Acute renal failure is a severe consequence of peritonitis, which is characterized by a sharp decrease in renal 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 through the bloodstream 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 in our body is urea. Its increased content in the blood is called uremia. The danger of this condition is that being osmotically active substance, it carries water with it. Easily passing through cell membranes, urea, penetrating into the cell, leads to cellular hyperhydration. In this case, 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, nitrogen bases are also retained in the body. The greatest danger is ammonia, which, due to its lipophilicity, easily penetrates brain tissue, damaging it.

Unfortunately, damage to kidney tissue is often irreversible. Therefore, acute renal failure can often develop into a chronic form. At morphological study in people who died from peritonitis, numerous necrosis is detected 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. Once in the lungs, they cause blood stagnation, disrupting the process of oxygen transfer into them. The main mechanism of damage is a decrease in surfactant synthesis (

a substance that prevents the lungs from collapsing

). The result is an acute distress syndrome, which manifests itself in severe

Cough and chest pain. Its severity is proportional to the severity of peritonitis. The further the underlying disease progresses, the stronger the increase respiratory failure. The patient becomes cyanotic (

skin color turns blue

), he has rapid and shallow breathing and a strong heartbeat. Without correction of respiratory disorders, distress syndrome turns into

pulmonary edema

Pulmonary edema is one of the most severe complications that can be fatal. This condition is characterized by the fact that the pulmonary alveoli fill with fluid instead of air. As a result, the patient begins to choke because 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 source 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 enter the bloodstream through the damaged wall. Together with the blood, they spread 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, causing blood pressure to drop. 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 becomes confused. Simultaneous development of multiple organ failure progresses very quickly. Toxic shock has a very high mortality rate, which can develop within a few hours.

Dehydration

Dehydration or exicosis is characterized by a loss of fluid from the body of 5 percent of normal 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 participates in all metabolic processes in the human body. Its deficiency affects the functioning of all organs and systems. Tissues that have lost water lose their functions. 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 common in the list of numerous consequences of peritonitis. Repeated peritonitis develops in one case out of a hundred. This complication necessitates repeat surgery. It can develop due to insufficient drainage of the operated cavity, inadequate antibiotic therapy, or for a number of other reasons. As a rule, repeated peritonitis is more severe and even more difficult to treat.

Infection of the surgical suture is also a common complication. The risk of its development is greatest in people who are overweight or have illnesses

diabetes mellitus

Supuration 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. At the same time, the patient develops a fever,

General health worsens.

Intestinal paresis is manifested by a lack of intestinal motor activity. It is a serious complication because it is difficult to correct. Most often it develops with diffuse peritonitis or as a result of prolonged operations. In this case, the patient suffers from painful bloating and prolonged constipation. Intestinal paresis can also develop during the period of the disease itself. In this case, it complicates the diagnosis of peritonitis, since it does not give the classic symptoms of peritoneal irritation and muscle tension.

The adhesive process is almost inevitable with peritonitis. Any violation of the integrity of the peritoneum, including its inflammation, is accompanied by the development of adhesions. As a result, connective tissue cords are formed that connect the intestinal loops. The adhesive process develops in the late postoperative period. Adhesions can initially cause 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 it is necessary to re-open the abdominal cavity and remove adhesions. This is necessary in order to restore intestinal obstruction, since an 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 continues for 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 substances of our body (

proteins, fats, carbohydrates

). This phenomenon is also called a “catabolic storm.” Therefore, patients who have suffered peritonitis are as exhausted and weakened as possible.

The mortality rate of peritonitis is still high. With purulent and diffuse peritonitis, according to various sources, it accounts for 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 surgery performed within a few hours after gastric or intestinal contents enter the abdominal cavity. If surgery is performed during the day, the chance of a favorable outcome is reduced to 50 percent. When surgical treatment is performed after the third day, the patient’s positive chances do not exceed 10 percent.

Peritonitis is an inflammation of the tissues lining the abdominal wall and internal organs. This disease has a very great influence and significance in the course of many diseases. The peritoneum is a transparent, shiny and smooth wall with a large surface. It forms a sac that lines the abdominal cavities. Very highly vascularized and innervated.

The causes of inflammation of the peritoneum are different: it can be the result of perforation of the stomach, duodenum, small intestine, colon; the main causes also include appendicitis. Inflammation of the peritoneum is manifested primarily by pain in the abdominal cavity. Advanced inflammation of the peritoneum can lead to serious complications.

Types of inflammation of the peritoneum

Total allocated three types of peritoneal inflammation:

Spontaneous peritonitis;
Secondary peritonitis;
Inflammation of the peritoneum as a consequence of dialysis.

Causes and symptoms of peritoneal inflammation

Most common reasons inflammation of the peritoneum is diseases of the gastrointestinal tract and their complications. Often the starting point for the development of peritonitis is perforation of a gastric ulcer or duodenal ulcer. The sudden entry of the contents of these organs into the abdominal cavity causes a very strong reaction on its part.

In most cases...

Thin or thick perforation, which occurs due to various reasons (during typhus, tuberculosis, syphilis, fungal infection or intestinal cancer), causes similar consequences. As well as intestinal rupture due to direct injury. Acute appendicitis- This is another very common cause of inflammation of the peritoneum.

Another cause of peritonitis may be the transfer of infection to the peritoneum from the tissues surrounding the intestines. Determining this cause of peritoneal inflammation can be difficult if the patient is unable to give a comprehensive interview about the disease.

Pain, as a symptom of developing peritonitis, is initially localized in the area of the organ in relation to which the original cause of the disease is associated (for example, in the right lower abdomen with inflammation of the appendix).

The pain gradually covers the entire abdominal cavity. Its character largely depends on the underlying cause. The pain is often accompanied by vomiting or nausea. The development of inflammation of the peritoneum is accompanied by gas retention and a chair.

Other symptoms of peritonitis include:

pain or tenderness in the abdominal area;
fluid in the abdominal cavity;
gases, constipation;
problems with urination;
nausea and vomiting;
polydipsia;

Prevention and treatment of peritoneal inflammation

Diagnosis of peritonitis diagnosed on the basis of characteristic symptoms, medical examination And laboratory research which include: blood tests, x-rays and CT scan abdominal cavity.

Peritonitis does not always lead to damage to any organ, however, the cause should be found as quickly as possible, and treatment should be taken as soon as possible. short time, because inflammation of the peritoneum can be life-threatening and also cause various complications.

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

intraperitoneal adhesions(abnormal permanent connections between two inflamed areas of the peritoneal surface; sometimes adhesions can occur between the peritoneum and intestines);
recurrent intestinal obstruction– have a close connection with the adhesions described above, because they lead to difficulty in the movement of intestinal contents.
intraperitoneal and subphrenic 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, lining

Peritonitis is considered one of the oldest problems facing surgery, and at the same time, it has not lost its relevance to this day. Peritonitis is an inflammation of the serous membrane covering the internal organs and the abdominal cavity (peritoneum). Similar condition accompanied by disruption of the functioning of internal organs and systems and symptoms of general intoxication of the body. Often peritonitis occurs as a complication of other serious diseases, such as: ulcerative colitis, acute pancreatitis, appendicitis, liver disease, dysentery, perforation of a gastric or duodenal ulcer.

Causes of peritonitis:

By and large, There is only one cause for peritonitis- entry of a foreign substance (pancreatic enzyme, bile) or pathogenic (opportunistic) microorganisms into the abdominal cavity. This “unauthorized” penetration also has its own reasons, the main of which are inflammatory lesions followed by purulent melting of the abdominal organs and trauma to the abdominal organs (including after surgical interventions).

If speak about microorganisms that most often cause peritonitis, then here they are by name: staphylococcus, streptococcus, E. coli, Pseudomonas aeruginosa, pneumococcus, gonococcus, mycobacterium tuberculosis.

Infectious peritonitis often is a consequence of acute phlegmonous appendicitis, less often - perforation of a stomach and duodenal ulcer, acute purulent cholecystitis, acute pancreatitis, ruptures of the digestive organs and bladder (wounds or advanced tumors).

Types of peritonitis

From the previous chapters we can already conclude that there is infectious, perforative, traumatic and postoperative peritonitis. This is a classification of peritonitis depending on the etiology. But there are other ways to classify this disease. For example, based on character inflammatory exudate, serous, hemorrhagic, purulent, fibrinous and gangrenous peritonitis can be distinguished. According to the degree of distribution - local and diffuse (diffuse) peritonitis.

Symptoms of peritonitis

Initial phase of peritonitis“merges” with that of the underlying disease. The first symptom of peritonitis- increased pain that affects the entire abdominal area with the point of highest pain at the site of the primary focus. The tone of the abdominal muscles increases; some figuratively compare the hardness of the muscles during this period to a washboard. Another a clear symptom characterizing peritonitis, is called the Shchetkin-Blumberg symptom: if you quickly withdraw your hand while palpating the abdomen, sharp pain occurs. With peritonitis, the patient instinctively tries to lie on his side and press his knees to his stomach (the so-called fetal position); when trying to move, the pain intensifies. The patient becomes weaker and speech becomes slurred. The temperature is rising.

The initial stage is followed by toxic. The “watershed” between these two stages is very clearly visible: during the toxic stage, the patient feels better, the pain calms down, the stomach relaxes, there are signs of euphoria, or, on the contrary, lethargy. The face turns pale, and first nausea and vomiting begin. Due to the loss of fluid, urination decreases, the mouth becomes dry, but due to vomiting it becomes impossible to replenish the lack of fluid. The intestines seem to freeze, showing no signs of peristalsis. The mortality rate at this stage is 1 in 5.

Last stage - terminal, at which the body’s defenses are completely depleted. The patient no longer becomes completely sane, falls into prostration, does not respond to external stimuli, a so-called intoxication mental disorder occurs. Putrid intestinal contents appear in the vomit. The pulse quickens, shortness of breath appears, and body temperature decreases. Mortality in the terminal stage approaches 100%.

The severity of the symptoms of peritonitis allows it to be diagnosed with a high degree of confidence already upon examination of the patient. As a “control shot,” a blood test is performed, which reveals a purulent-toxic shift in the leukocyte formula. X-ray and ultrasound examinations are also used. It is vital to detect peritonitis at an early stage, since this disease requires urgent treatment.

Treatment of peritonitis

Peritonitis can only be treated surgically. And delay can lead to death, and with a very high degree of probability.

During surgical treatment, first of all, they begin with disinfection of the main infectious focus and the abdominal cavity. For this purpose, use isotonic sodium chloride solution or 0.25% novocaine solution in combination with antibacterial agents and antiseptics (with the exception of furatsilin). Then the abdominal cavity is drained, i.e. form pathways for the outflow of inflammatory exudate using silicone rubber drainages. The drainage can remain in the area of inflammation for up to 2 weeks.

Sometimes in the terminal stage of peritonitis, so-called peritoneal lavage is used. This is a flow-through rinsing of the source of inflammation - the abdominal cavity - with solutions of antiseptics and antibiotics.

Recently, the method of planned relaparotomy has been increasingly used - repeated laparotomy in the postoperative period, which is performed one day after the operation and ends with lavage of the abdominal cavity and installation of drainage. Subsequently, relaparotomy is performed every 2 days, based on the patient’s condition and the amount of exudate discharged through the drainage.

Over the past 15 years, extracorporeal detoxification methods (hyperbaric oxygenation, ultraviolet blood irradiation, plasmapheresis, hemosorption) have gained popularity.

There is no prevention as such for peritonitis. The only thing, if this, of course, can be called prevention, it is worth mentioning once again the importance of early hospitalization and emergency treatment of patients with peritonitis.

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 “itis” means “inflammation”.

Inflammation of the peritoneum

The disease is severe, and if medical assistance is not provided in time, 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 compromising the integrity of the internal organs, since bacteria enter the peritoneum through the blood or lymph (in women, also through the genitals).

The bacteria that cause peritonitis can be either gram-negative or gram-positive.

In women leading sex life, peritonitis can be caused by gonococci or chlamydia.

Quite rare, but it still occurs 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 in both children (aged 5 to 7 years) and adults.

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 are soon added to the diseases themselves, which help in the development of the process of peritonitis.

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

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

Tertiary peritonitis

This species is extremely rare. In fact, this is a relapse of already suffered and cured peritonitis. But, when the body is weak and the immune system is not able to fight any difficulties, peritonitis can return. This cannot be prevented, but doctors are obliged to do everything to reduce the risk of recurrence of peritoneal inflammation (taking immunostimulants, antibacterial therapy, etc.).

Classification

Peritonitis can be classified not only by the reasons for its occurrence, but also by a number of other factors:

By etiology:

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

According to the duration of the course 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, can have a long course with a not clearly expressed clinical picture, most often occurs in pensioners.

By prevalence, which abdominal levels are affected:

limited or local (subhepatic, appendicular, pelvic and many others);
widespread, sometimes general, when the entire abdominal space is affected, local or diffuse with clear localization on one or two floors, and diffuse, when inflammation affects several anatomical areas.

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:

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 in the area of the affected organ. Typically, patients characterize it as a cutting pain, sometimes radiating to the shoulder blades or to the clavicular area.

The patient has to lie on his side with his legs tucked 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, and practically does not participate in the act of breathing.

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

Patients have a “Hippocratic face”: pallor and even sallow complexion, sunken eyes, facial features become sharp due to dehydration, protruding cold sweat on the forehead, despite the rise in temperature.

During auscultation and percussion, the sound is dull, reminiscent of drumming, and 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 also suffers from 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 sensations are reduced and peritoneal symptoms become weaker.

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

Microcirculation is disrupted, causing the nose, tips of the ears and fingers to turn blue. The patient has a disturbance of consciousness, he is either delirious or remains indifferent to everything. Pulse fluctuates 120 to 140 beats per minute, severe shortness of breath.

Terminal stage

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

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

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

Diagnostics

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

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

examination of the patient, palpation of the abdomen;
taking anamnesis;
study of existing diseases at the time of the onset of peritoneal inflammation;
general blood test (with peritonitis, it shows an increase in the number of leukocytes and neutrophils, as well as accelerated erythrocyte sedimentation);
biochemical blood parameters 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;
performing abdominal puncture (laparocentesis);
laparoscopy (opening the abdominal cavity and sanitation of organs).

Establishing a 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 quickly and correctly prescribe therapy. 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, it means dehydration is decreasing and the healing process is underway).

Next, food debris is removed from the gastrointestinal tract and the amount of gastric juice is reduced to a minimum. Because if it gets into the abdominal organs, it can cause a burn. Preparation for anesthesia and administration of antibiotics are carried out. If necessary, ventilation of the lungs, liver and heart function are artificially supported.

Patient photo:

During the operation, the doctor makes an incision from the pubis to the sternum to have access to all abdominal organs. A source of inflammation is located (the affected organ or bacteria), and if possible, the wound is cauterized or sutured, and if not, the organ is removed completely or partially.

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

The last stage is the application of laporastomy, when the edges of the peritoneum are brought together with special sutures.

Postoperative rehabilitation after peritonitis is aimed at maintaining the patient’s condition, administering 10% glucose intravenously (since the patient is prohibited from drinking and eating for the first two days).

The diet after surgery should include:

liquid soups;
rubbed;
vegetable purees;

Be sure to exclude:

spicy;
salty;
fat;
heavy;
alcohol.

The patient should begin to move around the ward, sit, and stand as early as possible. 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 is not developed, but it is within your power to protect yourself from this by monitoring your health and timely treatment of emerging diseases. After all, peritonitis is a rather dangerous disease that it is better not for adults and children to encounter.

Peritonitis is inflammation of the peritoneum. The disease is considered within the framework of the concept of “acute abdomen,” which is characterized by abdominal pain and muscle tension in the anterior abdominal wall. Despite the fact that treatment methods are becoming more and more improved every year, peritonitis does not become less dangerous. Mortality rates for peritonitis are still quite high. Thus, with local peritonitis, the mortality rate is 4-6%, and with diffuse peritonitis - more than 45%.

The peritoneum is the serous membrane covering the abdominal organs. The peritoneum lining inner wall The abdomen is called parietal, and the surface of the organs is called visceral. The total area of the peritoneum is approximately 2m2.

The peritoneum has absorptive capacity, which is designated as a resorptive function. At the same time, it has the ability to secrete fluid, as well as fibrin, into the abdominal cavity - this is an exudative function. Normally, these processes are balanced and the abdominal cavity contains only a small amount of fluid between the sheets of peritoneum. During a pathological condition, exudation processes are activated, which is why fluid can accumulate in a significant volume in the abdominal cavity.

Peritonitis happens primary when the disease develops due to the entry of microorganisms into the abdominal cavity through the blood or lymph, 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:

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

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

Types of peritonitis

Depending on the prevalence of the inflammatory process, the following forms of peritonitis are distinguished:

Local (occupies one anatomical section of the abdominal cavity);
Widespread (2-5 anatomical sections of the abdominal cavity are involved);
Total (six or more anatomical parts of the abdominal cavity are involved).

It is also important to consider the type of exudate. So, depending on the nature of the exudate, the following forms of peritonitis are distinguished:

Peritonitis can also be acute or chronic. Chronic form of the disease more common in systemic infections of the body (syphilis, tuberculosis). Acute peritonitis proceeds in three phases: reactive, toxic, terminal.

The first stage (reactive) is recorded in the first 12-24 hours of the disease. During this period, swelling of the peritoneum occurs, exudation with fibrin loss. In the clinical picture, local symptoms of the disease are especially pronounced.

The second stage (toxic) develops after 24-72 hours. During this period, toxicosis increases, as a result of which general intoxication symptoms prevail over local ones.

The third stage (terminal) develops after 72 hours. This period is characterized by severe intoxication.

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, tachycardia, 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 the first stage of peritonitis

The first signs of peritonitis are constant, unremitting abdominal pain, which intensifies with changes in body position. Therefore, the patient lies on his back or on his side with his knees brought to his stomach and tries not to move too much. The localization of pain depends on the location of the pathological process in the peritoneum.

During the examination of the patient, the doctor is able to identify tension in the muscles of the anterior abdominal wall. With peritonitis, positive symptoms of peritoneal irritation are noted. So, to determine the Shchetkin-Blumberg symptom, you need to slowly press on the stomach, fix your hand for a couple of seconds, and then sharply pull it away. If sharp pain occurs at this moment, it means the person has peritonitis.

Mendel's sign is determined by percussion (tapping) of the entire abdomen. Based on the patient’s reaction, the doctor can not only determine the increase in pain, but also the localization of the pathological process.

The patient's general symptoms include fever, tachycardia, increased blood pressure, dry mucous membranes, and nausea with vomiting.

During this period, abdominal pain may become less severe. Tension of the muscles of the anterior abdominal wall, as well as symptoms of peritoneal irritation are present, but become less obvious. Symptoms such as stool retention and bloating caused by intestinal paresis come to the fore. There is profuse vomiting with a foul odor.

General intoxication symptoms increase. The patient's heart rate increases (over 120 beats per minute), and blood pressure drops. The temperature rises, the tongue and oral mucosa are dry, and the facial features are sharpened.

Symptoms of the third stage of peritonitis

Intoxication becomes even more pronounced. Due to dehydration, the patient’s skin turns pale, facial features become sharpened, and the mucous membrane of the mouth and tongue are dry. The rapid heartbeat and low blood pressure persist, and breathing becomes rapid and shallow.

The abdomen is distended, there is no peristalsis, and there is profuse vomiting of gastric and intestinal contents.

Because of severe intoxication the nervous system suffers: the patient is either adynamic or falls into euphoria. Confusion and delirium may occur.

For symptoms of an “acute abdomen,” the following studies are performed:

- leukocytosis is noted, as well as a shift in the leukocyte formula to the left;
Rectal and vaginal examination - allows you to detect severe pain in the wall of the rectum or vaginal vault, caused by irritation of the pelvic peritoneum by peritoneal inflammatory exudate;
X-ray examination of the abdominal organs - allows you to determine the darkening of the abdominal cavity due to the exudate accumulated in it;
Ultrasound of the abdominal cavity - allows you to detect the presence of free fluid.
Laparocentesis (abdominal puncture) - allows you to examine the contents of the abdominal cavity;
Laparoscopy - performed when there is doubt about the diagnosis.

Treatment of peritonitis - surgery. The purpose of surgical treatment is to eliminate the cause that led to the development of peritonitis, as well as drainage of the abdominal cavity.

The sequence of surgical procedures for peritonitis looks like this:

The earlier the operation is performed, the better the prognosis for recovery. It is optimal to perform the operation in the first hours of the disease. Surgery performed a couple of days after the first symptoms appear significantly reduces the patient’s chances of recovery. Therefore, if you experience abdominal pain, you should not hesitate, you should urgently consult a doctor.

In addition, the treatment of peritonitis is supplemented with medications. The goal of drug treatment is the elimination of pathogenic microflora, as well as the correction of metabolic disorders. The following groups of drugs are used:

Antibiotics - mainly broad-spectrum antibiotics are used (gentamicin, sigmamycin, benzylpenicillin, ampicillin, ceftriaxone);
Detoxification agents (10% calcium chloride solution);
Infusion solutions (5% and 25% glucose solutions, hemodez, Ringer's, Hartmann's solutions);
Colloidal products and protein blood products (plasma, albumin, protein);
Diuretics (furosemide, mannitol);
NSAIDs (ibuprofen, paracetamol);
Antiemetics (metoclopramide);
Anticholinesterase drugs (proserin) are used to prevent the development of intestinal paresis.

Note:If you experience abdominal pain, do not prescribe painkillers yourself. This will cause the symptoms of the disease to become less pronounced and ambiguous, making it difficult for the doctor to determine the correct diagnosis.

After surgery, it is important to continue drug treatment to prevent complications.

On the second day after surgery, parenteral nutrition is started. The volume of infusion therapy is approximately 50-60 ml per kilogram of body weight per day. When intestinal motility is restored, they switch to enteral nutrition: administration of nutritional mixtures using a probe through the mouth and nose. The composition of the mixtures and the duration of such feeding are determined by the doctor.

With positive dynamics, recovery normal operation intestines switch to natural nutrition. This usually occurs no earlier than the fifth day after surgery. It is necessary to adhere to a low-calorie diet. During this period, it is recommended to eat low-fat meat broths, vegetable purees, jelly and compotes. Gradually increase the calorie content of the diet by adding meat, eggs, and dairy products. You should not eat rich meat broths, smoked meats, spices, confectionery, chocolate, coffee, carbonated drinks, or legumes.