Cryptogenic peritonitis in girls. Secondary peritonitis in children, their characteristics and diagnosis What you can do

Inflammation of the peritoneum, accompanied by general symptoms of a disease of the body with dysfunction of vital organs and systems. Depending on the nature, serous, fibrinous, purulent, hemorrhagic, putrefactive and fecal peritonitis are distinguished.

Of the pathogens, microbial associations are most often sown: staphylo-, streptococci, Escherichia coli, pneumo- and gonococci and a large group of anaerobes, which have recently been given increasing importance.

Peritonitis is characterized by severe general symptoms, including endogenous intoxication and multiple organ failure. Mortality with peritonitis has always remained one of the highest and reached 55-90% in postoperative surgical peritonitis.

Causes of peritonitis

The main causes of peritonitis: acute destructive appendicitis, perforated ulcer of the stomach and duodenum, acute destructive cholecystitis, diverticulitis of the colon or diverticulitis of the ileum (Meckel's diverticulum), perforation of a tumor of the colon or rupture of the cecum with tumor intestinal obstruction, traumatic ruptures of hollow organs when closed abdominal injury. Less commonly, peritonitis develops after surgery.

Primary peritonitis

Primary peritonitis is an inflammatory process that develops without violating the integrity of hollow organs, the result of spontaneous hematogenous dissemination of microorganisms into the peritoneal cover or translocation of a specific monoinfection from other organs. The causative agent, as a rule, is a certain type of microorganism.

Types of primary peritonitis:

• Spontaneous peritonitis in children.
• Spontaneous peritonitis of adults (ascites-peritonitis, dialysis peritonitis, etc.).
• Tuberculous peritonitis.

Secondary peritonitis

Secondary peritonitis is the most common type of disease and combines all forms of inflammation of the peritoneum that develops as a result of destruction or trauma of the abdominal organs.

Types of secondary peritonitis:

• Peritonitis caused by perforation and destruction of abdominal organs.
• Postoperative peritonitis.
• Post-traumatic peritonitis with closed abdominal trauma, with penetrating abdominal wounds.

Tertiary peritonitis

Tertiary peritonitis is an inflammation of the peritoneum of a “recurrent” nature (“persistent” or “recurrent” peritonitis). Develops in the absence of sources of infection and/or after surgery for secondary peritonitis, performed in full, but against the background of a pronounced depletion of the body’s defense mechanisms.

The course of this form is characterized by a blurred clinical picture, possible multiple organ dysfunction and the manifestation of endotoxicosis, refractory to the treatment. The source of the pathological process is rarely determined.

Symptoms of peritonitis

Peritonitis usually develops acutely and quickly. In the absence of treatment, from the onset of the inflammatory process to the death of the patient, often only 2-3 days pass.

Symptoms of peritonitis include sharp abdominal pain that constantly increases with changes in position, nausea, vomiting, a rapid rise in temperature up to high numbers, accompanied by chills and sweating; loss of appetite.

Upon examination, a hard, painful abdomen is detected, a rapid pulse, and sometimes a drop in blood pressure. In the blood, the number of leukocytes, cells that fight infection, increases.

An X-ray examination of the abdominal cavity usually shows fluid-filled, stretched intestinal loops, and when the patient is in an upright position, accumulation of air under the diaphragm, which is a specific diagnostic sign of perforation of hollow organs.

Diagnosis of peritonitis

When examining the abdomen, attention is drawn to limited mobility of the anterior abdominal wall during breathing, and sometimes asymmetry of the abdomen. When palpating the abdomen, the protective tension of the muscles of the anterior abdominal wall is determined.

The abdomen is like a board when a hollow organ is perforated. The Shchetkin-Blumberg symptom appears. Hepatic dullness disappears with the accumulation of fluid in the abdominal cavity or the presence of gas under the diaphragm. In the blood there is leukocytosis, with a shift of the formula to the left, accelerated erythrocyte sedimentation rate.

Hemoglobin and hematocrit increase. The acid-base balance is disturbed, the content of creatinine and blood urea increases. Differential diagnosis is carried out mainly in the early stage (reactive) of the development of peritonitis.

Peritonitis is differentiated from acute pancretitis, thromboembolism of mesenteric vessels, acute intestinal obstruction, renal and hepatic colic, intra-abdominal bleeding, acute pneumonia and pleurisy, and some forms of myocardial infarction.

Treatment of peritonitis

Detection of peritonitis serves as the basis for emergency surgical intervention. Therapeutic tactics for peritonitis depend on its cause, however, in all cases, the same algorithm is followed during the operation: laparotomy is indicated, isolation or removal of the source of peritonitis, intra- and postoperative sanitation of the abdominal cavity, and decompression of the small intestine.

The surgical approach for peritonitis is a median laparotomy, which provides visualization and reach of all parts of the abdominal cavity. Elimination of the source of peritonitis may include suturing the perforation, appendectomy, colostomy, resection of necrotic intestine, etc.

All reconstructive interventions are postponed to a later date. For intraoperative sanitation of the abdominal cavity, solutions cooled to +4-6°C are used in a volume of 8-10 liters.

Decompression of the small intestine is achieved by installing a nasogastrointestinal tube; Drainage of the colon is performed through the anus. The operation for peritonitis is completed by installing vinyl chloride drains into the abdominal cavity for aspiration of exudate and intraperitoneal administration of antibiotics.

Postoperative management of patients with peritonitis includes infusion and antibacterial therapy, the appointment of immunocorrectors, transfusion of leukocytes, intravenous administration of ozonated solutions, etc.

For antimicrobial therapy of peritonitis, a combination of cephalosporins, aminoglycosides and metronidazole is more often used, providing an effect on the entire spectrum of possible pathogens.

In the treatment of peritonitis, the use of extracorporeal detoxification methods (hemosorption, plasmapheresis, lymphosorption, hemodialysis, enterosorption, etc.), hyperbaric oxygenation, ultraviolet blood irradiation, ILBI is effective.

In order to stimulate peristalsis and restore the functions of the gastrointestinal tract, the prescription of anticholinesterase drugs (proserin), ganglion blockers (dimecoline, benzohexonium), anticholinergic drugs (atropine), potassium supplements, physiotherapy (electrical stimulation of the intestine, diadynamic therapy) is indicated.

Prevention of peritonitis

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.

Peritonitis in children

Most often, peritonitis in children is a consequence of inflammation of the appendix. In addition, in children peritonitis is also caused by infectious enterocolitis, provoked by staphylococcus or the causative agent of typhoid fever. In children of the first year of life, about eighty percent of cases of peritonitis are associated precisely with a violation of the stomach wall due to enterocolitis. Congenital defects of the wall of the gastrointestinal tract organs, which cause peritonitis, are also possible. Sometimes, very rarely, peritonitis occurs in children due to inflammation of the ovaries or gall bladder.

Symptoms of peritonitis in children

The course of the disease varies greatly in children of different ages. In addition, the cause of peritonitis also affects the symptoms and severity of peritonitis. But this disease is most difficult in the youngest patients.

This is due to the fact that the baby’s internal organs are not yet developed and their structure before the age of seven contributes to the spread of infection. And children’s immunity is still far from perfect.

The baby's body temperature increases to thirty-eight to thirty-nine degrees. The baby may vomit and his tummy hurts. The baby either cannot find a place for himself, or, on the contrary, is too passive.

If peritonitis develops, the heart rhythm may become abnormal. And if you take a blood test at this moment, the level of leukocytes will be greatly increased.

With peritonitis, the youngest children often have loose and frequent stools, but older children, on the contrary, experience constipation. The further the process develops, the worse the child’s condition. He is thirsty all the time, his skin turns pale and acquires an earthy tint.

The mucous membranes are overdried, and there is practically no urine excretion. It is the violation of the ratio of water and salt in the body of a small patient that poses the greatest danger.

If peritonitis is caused by inflammation of the appendix (appendicular peritonitis), then at the beginning of the disease you may not even notice a deterioration in the baby’s condition. First, breathing may change, and then all other symptoms appear.

Another form of peritonitis, cryptogenic, is more typical for little girls from three to six years of age. With this form of peritonitis, the infection enters the internal organs through the vagina.

After a certain number of years, the vaginal microflora will be established and will prevent pathogenic microbes from entering the body. This form of peritonitis immediately makes itself felt with acute abdominal pain and high fever.

What to do for peritonitis in children

There are no other options but to urgently call an ambulance. Before the ambulance arrives, you can give your baby a drug to reduce body temperature based on paracetamol or ibuprofen.

You can treat your baby's skin with alcohol to cool him down a little. Cold packs can be applied to the armpits, back of the head and forehead. You can’t do anything else without professionals.

Doctors will definitely put the baby on a drip in order to maintain the water-salt balance in the body. Using a dropper, glucose, saline liquids, and hemodez are administered.

If necessary, the child may be given an oxygen mask or given medications to ease the functioning of the heart and blood vessels. In case of peritonitis, surgical intervention is necessary, but which organs it will affect depends on the form in which the peritonitis occurs, how severe the baby’s condition is and how old he is.

Questions and answers on the topic "Peritonitis"

Question:Hello. My son was operated on and diagnosed with initial peritonitis. Pus in the abdominal cavity. REASON NOT FOUND. I'm worried that the situation may happen again. What to do and how to prevent such an incident? The hospital conducted an examination - FGDS, ultrasound of the abdominal organs, but the cause was not established!

Answer: Blood and urine tests are required. In children, spontaneous inflammation of the peritoneum usually occurs in the neonatal period or at 4–5 years of age. At four to five years of age, systemic diseases (scleroderma, lupus erythematosus) or kidney damage with nephrotic syndrome are a risk factor for the development of this complication.

Question:Hello, can you tell me if the spleen can become enlarged during peritonitis?

Answer: Peritonitis can become a complication of pathologies of the spleen, one of the symptoms of which is its enlargement.

Question:I am 34 years old. The wound does not heal well after abdominal surgery or after peritonitis. 12 days have passed since the stitch was re-sutured, and the wound is leaking periodically. They installed some kind of rubber band, but so far it’s useless. Maybe something needs to be taken? Thank you.

Answer: If you have a drain installed again, the wound will not heal until it is removed. Try using healing ointments like Solcoseryl.

Question:How often does peritonitis occur after cesarean section?

Answer: Peritonitis is a fairly rare complication of cesarean section. As a rule, it develops in cases where an infection has entered the abdominal cavity. The route of its penetration can be very different - from foci of chronic inflammation, from the genital organs, from the external environment, etc. That is why one of the contraindications to a planned cesarean section is the presence of acute infections in any organ, be it the lungs, intestines or the genitourinary system.

Question:Hello, my son (11 years old) had peritonitis, 3 months have passed since the operation. Lumps appeared on the seam, the surgeon said that there was no need to worry and not to apply or lubricate anything. He says that it is the inner seam threads that are coming out that have not dissolved due to the characteristics of the body. It happens? or did he sew it up with the wrong threads? Do I need to treat the seam and with what? Will the seam be ruined after removing all these threads?

Answer: Such cases are not uncommon. During surgical treatment, the wound is sutured in layers (i.e., layer by layer). The aponeurosis is sutured using standard threads (nylon based). Depending on the recovery characteristics of each organism, wound healing occurs. These features are determined genetically at birth. The formation of “tubercles” in the projection of the postoperative suture are called granulomas. The body did not accept the thread (as a foreign body). The thread cannot digest and process completely and therefore “protects” the foreign body, like an infectious agent, from the body by forming a capsule (granuloma). Granulomas are dense, round, painless formations. Rubbing ointments and treating these formations will not lead to their resorption. Sometimes they remain for life, sometimes they resolve. It is not worth removing the threads artificially, since they are currently holding the abdominal wall. When these threads are removed, divergence of the aponeurosis may occur, which is not desirable and is associated with more serious problems.

Question:Hello! My 5-year-old daughter had a stomach ache in the evening and started vomiting. We immediately took her to the hospital. She underwent surgery - the diagnosis was: Primary peritonitis, secondary appendicitis. 2 weeks after the operation the child caught a cold - severe cough. Question: will the seams come apart? And how terrible is this disease, can it happen again? Thank you.

Answer: Most likely it is pelvioperitonitis. Unfortunately, this pathology periodically occurs in children (especially girls). After 2 weeks, all stitches are restored and healed. Dehiscence of postoperative sutures should not occur within this time frame. Pelvioperitonitis (primary peritonitis) is a disease in which fluid accumulates in the abdominal cavity. Normally, the abdominal cavity secretes fluid (in order for the “organs to stick together”) and in certain situations (inflammatory, hypothermia, viral infections, etc.) can cause greater fluid to be released into the abdominal cavity, which leads to its inflammation. Perhaps this is the only case, but sometimes they can be repeated, it is impossible to predict.

Peritonitis is an inflammation of the peritoneum. The peritoneum is not the source of primary purulent infection. It is directly related to all organs of the abdominal cavity and is affected secondarily, i.e. through these organs. Therefore, peritonitis is diverse due to its occurrence (primary, secondary, post-traumatic, postoperative, etc.). Peritonitis is one of the severe purulent diseases in children, which is also accompanied by mortality and many complications.
Anatomy and physiology. All abdominal organs are covered by peritoneum: some are partially covered (pancreas, duodenum, bladder, etc.); others - completely. This creates duplications, folds, and pockets of various sizes. There are visceral and parietal (parietal) layers of the peritoneum. Anatomically, we are not talking about a cavity as a current one, but about a narrow space between organs, creating conditions of capillarity. The transverse colon and mesentery divide the abdominal cavity into 2 floors. The upper floor contains the stomach, liver, and spleen; in the lower - the intestines and pelvic organs. The floors are connected by lateral channels, through which exudate can spread in both directions. The greater omentum, which consists of four layers of peritoneum, is of exceptional importance in delimiting the purulent process. The peritoneum has a rich network of blood and lymphatic vessels, which drain into the inferior and superior vena cava. This explains the possibility of infection spreading from the peritoneum to the pleura and vice versa. The parietal layer of the peritoneum is innervated by the sacral plexus, lumbar intercostal nerves and phrenic nerves. The visceral layer is the autonomic nervous system. The parietal leaf reacts with pain to any irritant, the visceral leaf is almost insensitive to pain. Of great importance for clinicians is the reflex interaction between the sensory nerves of the parietal peritoneum and the muscles of the anterior abdominal wall.

The peritoneum is characterized by a high capacity for exudation and resorption. Exudation is the reaction of the peritoneum to any irritant. The exudate released in response to a microbial irritant is higher in bactericidal activity than blood. A massive bacterial invasion is required for peritonitis to develop. Resorption occurs osmotically and diffusely directly into the bloodstream (water and water-soluble substances) or by resorption from the mesothelium into the interlymphatic spaces (colloids, bacteria, etc.). In the early stages of inflammation of the peritoneum, increased resorption is observed; venous stasis and intestinal paralysis sharply impede it. In addition to the production of exudate, the protective function of the peritoneum includes the plastic ability of the peritoneum. Thanks to it, the inflammatory focus is demarcated (fibrin falls out, adhesions and adhesions form).

Morphology. At the site of contact with infection, hyperemia of the peritoneum is first observed, then serous exudate appears, then it becomes cloudy due to the influx of leukocytes and fibrin, and becomes purulent. Changes begin in the visceral layer of the peritoneum. The smooth, shiny surface of the peritoneum becomes matte, rough, and fine-grained. Then fibrinous deposits appear, which are extensive in places where pus accumulates. The inflammatory exudate contains bacteria, cellular elements, leukocytes, fibrin, a lot of protein, and intestinal contents. Based on the nature of the pus, one can assume the type of pathogen. If an anaerobic infection causes inflammation, then the pus acquires a fetid odor of decomposing tissues, E. coli will produce pus with a brown tint and the smell of feces, coccal flora will produce liquid exudate with fibrin. The exudate may contain an admixture of air, blood, pancreatic enzymes, etc. The intestinal wall is swollen and thinned from the contents. By the nature of morphological changes one can judge the severity of peritonitis and the prognosis of the disease.

The greater omentum takes part in inflammation, limiting the process. Enclosed ulcers form and drain onto the skin. They may be emptied into the intestinal lumen or abdominal cavity. With massive infection and other reasons, delineation does not occur and the movement of pus occurs along the right and left lateral canals, along the subphrenic fissure, between the intestinal loops. General peritonitis is rare. In pathoanatomical and clinical terms, they do not have the same meaning, since peristalsis may be absent in diffuse peritonitis.

Pathophysiology and pathogenesis.
Purulent peritonitis- a serious illness with profound impairment of vital functions. The disease is especially severe in infants and young children.
Intoxication, circulation disorder, dehydration. The surface of the peritoneum in children of the younger age group is equal to the surface area of ​​the skin. Therefore, microbial toxins and cell breakdown products are absorbed into the blood and lymph through a huge surface. Mobilization of vasoactive substances occurs: adrenaline, norepinephrine, glucocorticoids, histamine, kinins. They cause expansion of capillaries and increase the permeability of their walls. Exudation of fluid and protein into the abdominal cavity increases. There is also a loss of fluid in the intestines with vomiting and perspiration. Vasodilation in the periphery and loss of fluid from the bloodstream lead to hypovolemia of the microcirculation. The amount of blood in the internal organs increases (centralization of blood circulation). Resorption is impaired and this further aggravates hypovolemia. This is followed by hemoconcentration and metabolic disorders.

Purulent peritonitis is accompanied by an increase in body temperature to 39-40 "due to an imbalance between heat production and heat transfer, a disorder of interstitial metabolism. An increase in temperature by 1° causes an increase in basal metabolism by 13%. Children of the younger age group are especially affected. They experience depletion of energy reserves, the brain, adrenal glands and other organs suffer. Mainly liver glycogen is used, and subsequently proteins and fats, the breakdown of which under hypoxic conditions leads to the accumulation of lactic and pyruvic acids, keto acids. Metabolic acidosis occurs. At first, acidosis is compensated by breathing and kidneys, then intestinal paresis occurs, abdominal pain limits respiratory excursions and acidosis passes into the stage of decompensation.

Violation of mineral metabolism. In parallel with fluid loss, there is also a loss of electrolytes (potassium, sodium, chlorine). There is a decrease in potassium in the cell and an increase in sodium (transmineralization). Depletion of cells in potassium leads to decreased muscle tone, paralysis of smooth muscles, and progressive paresis of the gastrointestinal tract.
Thus, the pathogenesis of peritonitis is based on intoxication, hypovolemia, abdominal pain, hyperthermia, electrolyte imbalance, dehydration, intestinal paresis and other disorders that should be taken into account during preoperative preparation and subsequent treatment.

Clinical picture.
The main symptoms of peritonitis:
1) abdominal pain;
2) protective tension of the abdominal muscles;
3) Shchetkin-Blumberg symptom;
4) paralytic intestinal obstruction.
Constant abdominal pain- the earliest sign of peritonitis. Its initial location corresponds to the source of infection. With the appearance of effusion, the pain spreads and covers the entire abdomen. An important symptom is considered to be muscle protection, which depends on the nature of the effusion and occurs constantly, just like the Shchetkin-Blumberg symptom. Intestinal motility fades slowly with the development of peritonitis. Muscle deflation is replaced by bloating with the onset of general peritonitis. Secondary symptoms are vomiting and hyperthermia. tachycardia, sometimes collapse. The skin color is pale, the facial expression is pained, the tongue is dry and coated.

Preoperative preparation includes all elements of program 2, with the following additions:
- oxygen therapy through a face mask with constant positive airway pressure with transfer to mechanical ventilation;
- for arterial hypotension (systolic pressure is reduced by 10-15% of the age norm) intravenously 20 ml/kg of 0.9% sodium chloride solution for 20-30 minutes; with persistent hypotension, 5-10 ml of fresh frozen plasma at a rate of up to 0.5 ml/kg-min against the background of dopamine titration 3-5 µg/kg-min;
- after stabilization of blood circulation, catheterization of the internal jugular vein with subsequent monitoring of central venous pressure (optimal level 3-5 cm
- angioprotection: dicinone 0.1 ml/kg, contrical 500-1000 units/kg, prednisolone 5 mg/kg or hydrocortisone for intravenous administration 15-25 mg/kg intravenously.

The criteria for the adequacy of training are the same as in program 2, with an emphasis on hemodynamic stability and adequacy of gas exchange.

Surgical treatment
Local and general treatment of peritonitis is carried out. The goal of local treatment is to eliminate the source of infection and sanitize the abdominal cavity, and general treatment is to fight infection and intoxication, restore impaired functions of organs and systems. During laparotomy, the source of peritonitis is found and eliminated (appendectomy, cholecystectomy, suturing the wall of a hollow organ, etc.), and if it is absent, then pus is removed from all parts of the abdominal cavity and thoroughly washed with Ringer's solution (8-10 liters of solution). Washing is a generally accepted method of local treatment of peritonitis, based on the mechanical removal of billions of microbial bodies, cell breakdown products, fibrin and other elements of the purulent process. While in case of local and diffuse peritonitis a one-time lavage is sufficient, in case of general peritonitis, lavage is planned after 1 day, 2 days, etc. from the beginning of the first wash until the complete elimination of the inflammatory process. Drainage of the abdominal cavity is carried out in exceptional cases when the source of infection cannot be removed. The best drainage is a perforated tube, through which constant rinsing is carried out after the operation for 2-4 days. In recent years, laparoscopic surgery and sanitation of the abdominal cavity have shown high effectiveness. Minor trauma to the abdominal wall and prevention of intestinal adhesions to the postoperative scar make this method attractive for pediatric surgeons. To combat intestinal paresis, antegrade and retrograde intubation is performed with removal of contents, and in severe cases, an ileostomy or cecostomy is applied.
General treatment after surgery is a continuation of preoperative preparation with the same tasks and monitoring.

In children, peritonitis of an appendicular and cryptogenic nature is most common; in addition, peritonitis of newborns is especially distinguished. Peritonitis in children, resulting from inflammatory processes of the gallbladder and perforation of a duodenal ulcer, is extremely rare and, according to the clinical picture of the disease, is no different from peritonitis in adults (as well as post-traumatic).

Appendicular peritonitis. Peritonitis is the most severe complication of acute appendicitis in childhood, occurring in 6.2-25% of cases of acute appendicitis, and in children under 3-11 years of age 4-5 times more often than in older children

age.

This is explained by the late diagnosis of acute appendicitis due to the blurred clinical picture, the predominance of general symptoms over local ones, the lack of experience of outpatient doctors, and the widespread use of antibiotics that change the clinical picture of appendicitis, but do not prevent the progression of the inflammatory process in the abdominal cavity. In any case, if the inflammatory process extends beyond the right lateral recess, it should be considered diffuse peritonitis.

Anatomist and physiological characteristics of the child’s body affect the course of appendiceal peritonitis. The smaller the child, the faster the purulent process spreads to all parts of the peritoneum. This is facilitated by the low plastic properties of the peritoneum and the functional underdevelopment of the greater omentum. Intoxication increases faster, metabolic processes develop

violations.

It should be noted, however, that in children under 3 years of age, protective mechanisms quickly turn into pathological ones, and general clinical symptoms prevail over local ones.

In the reactive phase of the disease, the child’s body loses oxygen, proteins and water, but this does not affect cellular metabolism, enzyme systems function normally, therefore at this stage in the child, local symptoms prevail over the general ones. The child is restless, does not sleep, refuses food, asks

Drink. Vomiting appears. The abdomen has a normal shape, detect active and passive muscle tension, Shchetkin's symptom -J! Bloomberg turns positive. With comparative palpation of the abdomen, these symptoms are most pronounced in the right subiliac region. The stool is usually normal.

In the toxic phase, disturbances in cellular metabolism occur. In addition to the deficiency of water, salt and proteins, there is a dysfunction of the enzyme system, the cell mass loses anions and cations. Clinical symptoms are caused by signs of intoxication that come to the fore. The child continues to worry, at times weakness sets in, facial features become sharpened, vomiting is frequent and green. The mucous membranes of the mouth and tongue become dry. Tachycardia is pronounced. The abdomen changes its configuration somewhat and becomes swollen. Soreness occurs, active and passive muscle protection is more pronounced in all parts of the abdomen. The Shchetkin-Blumberg symptom is sharply positive. Stool in young children is often liquid with mucus and greens.

The terminal phase is characterized by deeper disturbances in body function and the effects of toxins on all organs and systems, including the central nervous system. During this period, severe disturbances of hemodynamics, acid-base status, and water-electrolyte balance are observed.

The main symptoms are impaired peripheral microcirculation: pallor of the skin and mucous membranes, marbled skin pattern, “pale spot” symptom. The skin is cold, damp, with a gray tint. There is shortness of breath and shallow breathing. Changes also occur in the child’s behavior: lethargy, adynamia, lethargy, especially with hyperthermia, and delirium appear. Hyperthermia is a symptom characteristic of peritonitis, reaching high numbers (39-40°C), and is difficult to respond to drug therapy.

Hemodynamic disturbances are expressed in tachycardia, decreased arterial and central venous pressure, and are explained by hypovolemia.

When examining the abdomen in older children, pronounced widespread muscle tension is detected (“board-shaped” abdomen). In young children, early developing intestinal paresis relatively easily overcomes the resistance of the abdominal muscles, and the abdomen looks bloated. Peristaltic sounds are not heard. Symptoms of peritoneal irritation are pronounced. On rectal examination of the patient, sagging of the fornix and severe pain are noted. The differential diagnosis of peritonitis is especially difficult in young children, since its symptoms have significant similarities with the clinical picture of pleuropneumonia, severe forms of dyspepsia, dysentery and a number of other somatic and infectious diseases. In this case, it is necessary to take into account the initial manifestations of the disease. If a patient has peritonitis of the appendix,

If the disease is paired, then at the beginning of the disease abdominal pain prevails over all symptoms, then other symptoms appear. The main symptom of peritonitis, which removes all doubts, is, of course, passive muscle tension in the abdomen, which remains even if the child is induced to sleep; To do this, after a cleansing enema, a 3% solution of chloral hydrate is injected into the rectum. Doses of the drug depending on age are as follows: up to 1 year - 10-15 ml; from 1 year to 2 years - 15-20 ml; from 2 to 3 years - 20-25 ml. The child falls asleep after 15-20 minutes, motor excitement disappears, psycho-emotional reactions and active tension in the abdomen are relieved. Examination of a child during sleep allows not only to differentiate active from passive defence, but also to obtain reliable data on pulse rate and respiration, and also facilitates examination of the child and auscultation of the abdomen and chest.

If the diagnosis cannot be clarified, then surgical intervention is recommended, but it is more advisable to first perform laparoscopy and establish an accurate diagnosis. In children in serious condition, as well as young children, laparoscopy should be performed under intubation anesthesia.

The examination plan for a patient with peritonitis to determine the severity of the condition and the phase of the disease must include a number of laboratory and functional research methods: determination of hemoglobin, hematocrit, and electrolyte levels. Tachycardia, decreased arterial and increased central venous pressure, changes in the rheogram indicate a violation of central and peripheral hemodynamics. The appearance of alkalosis, usually associated with significant hypokalemia, is considered an unfavorable prognostic indicator.

Treatment of peritonitis consists of three main parts: preoperative preparation, surgical intervention and postoperative management of the patient.

The basis of preoperative preparation is the fight against hypovolemia and dehydration. For infusion therapy, solutions of hemodynamic and detoxification action are used (hemodez, rheopolyglucin, polyglucin, albumin, Ringer's solution, blood plasma).

Intravenous administration of broad-spectrum antibiotics is mandatory. Probing and gastric lavage are manipulations aimed at reducing intoxication, improving breathing, and preventing aspiration.

An important factor in preparing the patient for surgery and anesthesia is the fight against hyperthermia, carried out both by physical methods (cooling) and medications. Intubation combined anesthesia is indicated.

Surgical treatment involves two tasks: eliminating the source of peritonitis and sanitation of the abdominal cavity.

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The generally accepted approach for adult patients with widespread peritonitis is midline laparotomy. In pediatric surgery, access is dictated by the stage of peritonitis and the age of the child. In the reactive stage (the first 24 hours), especially in children under 3 years of age, the Volkovich-Dyakonov approach is used [Isekov Yu. F. et al., 1980; Dreyer K.L. et al., 1982]. This access, despite the relatively small size of the abdominal cavity in children, does not interfere with the main task of surgical intervention - sanitation of the abdominal cavity. If peritonitis has been diagnosed for a long time (more than 3 days), a median laparotomy is indicated.

The next sequential stages of the operation are evacuation of exudate, elimination of the source of peritonitis, toilet of the abdominal cavity and suturing of the abdominal cavity.

Exudate is removed using an electric suction. Appendectomy is performed with the obligatory immersion of the stump into purse-string and z-shaped sutures. Toilet of the abdominal cavity is carried out by lavage. The basis of the washing medium is isotonic or weak hypertonic saline solutions, a solution of furatsilin at a dilution of 1:5000, in which most surgeons include antibiotics (aminoglycosides) at a rate of 1 g/l. The total volume of liquid for rinsing is 2-3 liters. Lavage is performed as the final procedure after completion of the appendectomy.

The final stage of the operation causes the greatest controversy among both adult and pediatric surgeons. The question of whether to suture the abdominal cavity tightly and leave drains and tampons in place has not been finally resolved. Proponents of blind suture use microirrigators to administer antibiotics.

Drainage of the abdominal cavity is carried out using special drainages made of silicone rubber, a strip of rubber gloves, but in particularly severe cases of widespread peritonitis in the terminal phase, it is not necessary to suture the median laparotomy wound. After thorough sanitation of the abdominal cavity, drainage is performed with a silicone tube of the small pelvis. The intestines are covered with plastic film with multiple diamond-shaped holes cut out with a diameter of up to 5 mm, and napkins soaked in petroleum jelly are placed on top. Above them, the skin with the aponeurosis is brought together with separate sutures without tension, covering only the edges of the napkin. The absence of compression on the intestines and the possibility of free exit of infected exudate from the abdominal cavity through the wound help improve intestinal microcirculation, restore peristalsis and relieve the inflammatory process. After 2-3 days, a repeat operation is performed: the napkins and film are removed, the abdominal wall wound is sutured tightly through all layers. The edges of the wound are separated from the intestine so much that when they are sutured, the intestinal loops are not deformed.

Peritoneal dialysis, unfortunately, does not guarantee against such complications as the occurrence of residual ulcers in the abdominal cavity, infiltrates, eventration, and the formation of fistulas. Peritoneal dialysis in pediatric practice is used according to strict indications - with widespread peritonitis and in its terminal phase.

In all other cases, the operation should end with thorough sanitation of the abdominal cavity and the introduction of microirrigators for antibacterial therapy in the postoperative period. The success of treatment of peritonitis is largely determined by the correct management of the patient after surgery, with the obligatory consideration of the following provisions: 1) massive antibacterial therapy, correction of metabolic disorders and the fight against intoxication; 2) the struggle to restore the motor-evacuation function of the digestive tract.

Peritonitis is in most cases a polymicrobial disease, in which associations of microorganisms are cultured, often with a clear predominance of intestinal flora, as well as Proteus and Pseudomonas aeruginosa; anaerobes make up an average of 30%, and in the lumen of the gangrenous process, non-spore-forming anaerobic flora was found in 100% [Kuzin M.I., 1983; Roy V.P., 1983], bacteroids are most often isolated. During treatment, the microflora can change significantly towards the predominance of gram-negative. Aminoglycosides (kanamycin, gentamicin), cephalosporins, semisynthetic penicillins (ampicillin, carbenicillin), and nitrofurans have the greatest activity in children against the associated peritoneal flora among modern antibiotics. Considering the role of anaerobic flora, the use of metronidazole is indicated for peritonitis. It is necessary to remember the influence of antibiotics on the biocenosis of the body and the development of dysbacteriosis, which in turn can cause auto-reinfection of the patient in the postoperative period.

Intravenous and intraperitoneal administration of antibiotics in combination, as well as intramuscular injections, are generally accepted. In recent years, works have appeared in the literature on the intra-arterial and endolymphatic routes of antibiotic administration for peritonitis.

The volume of infusion therapy consists of the daily age requirement, calculated according to the Aberdeen table, the deficit of circulating blood volume and pathological losses due to hyperthermia through perspiration, sweating of fluid into the intestinal lumen during paresis. The calculation is based on 10 ml/(kg-day) for each degree above 37°C, 10 mg/(kg-day) for every 10 breaths above normal, 20 ml/(kg-day) for second degree paresis, 40 ml/ (kg-day) for third degree paresis.

The qualitative composition of the injected solutions is determined by the body’s needs for proteins, carbohydrates, electrolytes, and the need to bind and remove toxins.

Low molecular weight plasma substitutes are prescribed: hemodez at the rate of 10 ml/(kg-day), rheopolyglucin 15 ml/kg, canned blood, plasma or protein plasma substitutes at the rate of 1-2.5 g of protein/(kg-day). The remaining volume of fluid is replenished with a 10% glucose solution with insulin and potassium.

When restoring bcc, hemoglobin indicators should be no lower than 100 g/l, hematocrit - no lower than 30%, total protein - 60 g/l, A/G ratio - 1 -1.2, potassium content - 3.5-4.5 mmol/l.

Energy costs are replenished by transfusing a 10-20% glucose solution, 6-8 ml of 96° alcohol per 100 ml of 10% glucose (1 g of glucose - 4 calories; 1 g of alcohol - 7.5 calories).

In case of prolonged severe peritonitis and the impossibility of oral nutrition, parenteral nutrition using amino acids and fat emulsions is prescribed. Restoring the motor-evacuation function of the gastrointestinal tract is one of the main tasks of intensive care for patients with peritonitis in the postoperative period.

Since intoxication and deterioration of regional blood flow play a major role in the pathogenesis of intestinal paresis, its treatment necessarily involves detoxification therapy and improvement of hemodynamics. The complex for combating paresis of the gastrointestinal tract also includes its decompression (probing of the stomach, intubation of the intestine in advanced stages), the administration of hypertensive and siphon enemas, stimulation of peristalsis with a 0.05% solution of proserin or dimecaine (0.1 ml for 1 year of life , but not more than 1 ml), the use of novocaine blockades and epidural anesthesia. According to G. A. Bairov, the presence of appendiceal peritonitis is an indication for the use of epidural anesthesia. When catheterizing the epidural space, the tip of the catheter should be at the level of the IV-V thoracic vertebrae (radiological control is required), the duration of anesthesia is 4-5 days, the intervals between the administration of trimecaine are 3 hours. The infusion therapy program should provide for replenishment of the body's need for potassium . The administration of sorbitol has a good effect in preventing paresis.

In recent years, works have appeared indicating the high effectiveness of hyperbaric oxygenation for peritonitis [Gorokhovsky V.I., 1981; Isakov Yu. F. et al., 1981]. Improving tissue oxygenation, stimulating regenerative processes, improving microcirculation and rheological properties of blood and cellular immune mechanisms explain the therapeutic effect of this method.

For detoxification purposes, the literature of recent years has noted the use of hemo- and lymphosorption. However, there is not much experience in pediatric surgical practice in the use of these treatment methods.

Cryptogenic peritonitis. In clinical practice in children

togenic peritonitis is relatively rare. He is famous

in the literature under various names: primary, hematogenous, pneumococcal, diplococcal, etc. None of the names is absolutely accurate, since the routes of infection of the abdominal cavity have not been clarified, the nature of the microflora of the peritoneal exudate is diverse, and there may be no growth of the microflora.

Girls are more likely to suffer from cryptogenic peritonitis. Thus, of the 127 patients with cryptogenic peritonitis described by N. L. Kush (1973), 122 were girls. This indicates a connection between this disease and the condition of the genitals. Children aged 3 to 8 years are most often affected. The decrease in incidence in older girls is associated with a change in the vaginal environment to the acidic side, which is not favorable for the proliferation of pneumococcus.

There are three forms of cryptogenic peritonitis: toxic, septicopyemic, localized. In recent years, a milder, often abortive course of the disease has become more common.

Severe forms are characterized by an acute onset of the disease, a rapidly progressive course (2-5 hours) with increasing intoxication. Patients complain of abdominal pain, often of uncertain localization, but sometimes localized in the lower abdomen or in the first half. High body temperature (up to 39° and even 40°C), hyperleukocytosis are noted.

On examination, abdominal bloating, pain on palpation in all parts, and a positive Shchetkin-Blumberg sign are noted. Peristalsis is not heard. On rectal examination, overhang of the anterior wall of the rectum is observed.

Peritoneal exudate is liquid, sticky, cloudy, odorless, without fibrin. The amount of effusion varies and depends on the severity of the disease. Hyperemia of intestinal loops, tubes, tubal fimbriae, and sometimes subserous hemorrhages are noted. Histological examination of the appendix reveals signs of periappendicitis.

There are fairly uniform reports in the literature about the causative agent of cryptogenic peritonitis, indicating a diplococcal infection (pneumococcus) with a large percentage of sterile cultures. Only a thorough bacteriological study with inoculation of the exudate on various nutrient media and dynamic monitoring of microbial growth for 10 days makes it possible to identify microbes in 90% of patients with hematogenous peritonitis [Polyak M. S., Zhigulin V. P., 1970]. In half of the patients, the isolated bacteria belong to a monoculture, in others - to associations belonging to species that grow in the intestines: bacteria of the Escherichia coli group, enterococci, clostridia, staphylococcus. The peculiarity of these microbes is their tendency to anaerobiosis. Moreover, in children from 1 year to 4 years old, coccal bacteria predominate: staphylococcus, enterococcus, pneumococcus. Gram-negative

Rods, along with coccal flora, are isolated in children over 4 years of age. In severe forms of peritonitis, pneumococcus, beta-hemolytic streptococcus, and Escherichia coli with hemolytic activity are more often isolated.

Most authors believe that in case of cryptogenic peritonitis, surgical intervention is advisable, mainly due to the difficulties of differential diagnosis with acute appendicitis. Laparoscopy allows you to make the correct diagnosis and, in the presence of cryptogenic peritonitis, introduce antibiotics into the abdominal cavity.

It is most advisable to prescribe antibiotics from the aminoglycoside group, chloramphenicol, ampicillin.

The surgical intervention ends with removal of exudate, appendectomy and administration of antibiotics. In the postoperative period, detoxification and antibacterial therapy continues.

Peritonitis in newborns. Peritonitis in newborns is a serious complication of a number of different diseases and malformations of the gastrointestinal tract.

Almost until the 40s of this century, the diagnosis of peritonitis in newborns was made only at autopsy. Malformations and “spontaneous perforations” were considered the main cause of peritonitis.

Further development of science, morphological and experimental studies have made it possible to establish that the genesis of many “spontaneous” perforations lies in ischemia of the intestinal wall - a disease that has received the name “necrotizing enterocolitis” in the world literature since the 60s of our century. The first successful surgical intervention for peritonitis in a newborn was performed in 1943.

Peritonitis in newborns is a polyetiological disease and, as numerous studies have shown, its causes can be: 1) malformations of the gastrointestinal tract; 2) necrotizing enterocolitis; 3) iatrogenic intestinal perforation; 4) bacterial infection of the peritoneum by contact, hematogenous or lymphogenous route in sepsis.

According to our data, in 85% of cases the cause of peritonitis is perforation of the wall of the gastrointestinal tract.

Intrauterine intestinal perforations (with intestinal malformations) lead to aseptic, adhesive peritonitis, postnatal ones - to diffuse fibrinous-purulent, fecal peritonitis. With necrotizing enterocolitis against the background of intensive therapy, limited peritonitis may develop.

Non-perforative fibrinous-purulent peritonitis, which develops in utero with hematogenous and lymphogenous, transplacental infection and with ascending infection of the birth canal, is rare. In the postnatal period, infection of the peritoneum is more often observed by contact with purulent periarteritis and periphlebitis of the umbilical vessels, abscess

liver disease, purulent diseases of the retroperitoneal space, phlegmon of the anterior abdominal wall, purulent omphalitis.

We propose a working classification of peritonitis in newborns as follows.

I. According to etiological and pathogenetic characteristics. A. Perforated peritonitis:

1) with necrotizing enterocolitis:

a) posthypoxic,

b) septic;

2) with malformations of the gastrointestinal tract:

a) segmental defects of the wall of a fallen organ,

b) developmental defects causing mechanical obstruction of the stomach
pre-intestinal tract;

1) with hematogenous, lymphogenous infection of the peritoneum;

2) in case of contact infection of the battlewort.
II. According to the time of onset of peritonitis:

1) prenatal,

2) postnatal.

III. According to the degree of spread of the process in the abdominal cavity:

1) spilled,

2) limited.

IV. According to the nature of the effusion in the abdominal cavity:

1) fibroadhesive,

2) fibrinous-purulent,

3) fibrinous-purulent, fecal.

The clinical picture and diagnosis of peritonitis are largely determined by its etiology.

Perforated peritonitis is characterized by a sharp deterioration in the patient's condition, manifested by symptoms of peritoneal shock, lethargy, adynamia, and sometimes anxiety. The skin is grayish-pale, dry, cold. Breathing is frequent, shallow, groaning, muffled heart sounds, tachycardia. Sharp bloating, tension, pain on palpation. Peristalsis is not audible. Hepatic dullness is not detected. Vomiting mixed with bile and intestinal contents. Chair And gases do not pass away. When radiography is performed in a vertical position, free air under the dome of the diaphragm is determined. Small compensatory capabilities quickly lead to severe disturbances of homeostasis and the death of the child after 12-24 hours.

The clinical picture of diffuse non-perforative peritonitis is characterized by a more gradual increase in symptoms of intoxication and intestinal paresis with a pronounced hyperthermic reaction and changes in the hemogram (neutrophilia, increased ESR, etc.). As a rule, the reaction from the anterior abdominal wall is more pronounced: hyperemia, infiltration, dilated venous network, swelling of the external genitalia. Hepatosplenomegaly is significantly expressed. Radiologically, hydroperitoneum is noted.

The vivid clinical picture of peritonitis at the height of the disease, as a rule, does not cause diagnostic difficulties.

The causes of perforation of the gastrointestinal tract may be the following malformations: 1) malformations causing mechanical intestinal obstruction: a) with phenomena of obstructive obstruction (atresia, meconium ileus, Hirsch. prung disease); b) with symptoms of strangulation (volvulus, strangulated internal hernia); 2) segmental defects of the wall of the gastrointestinal tract (defect of the muscle layer of an isolated section of the wall of a hollow organ, angiomatosis of the intestinal wall).

Defects that cause mechanical obstruction of the gastrointestinal tract in 50% of cases lead to intrauterine intestinal perforation and adhesive peritonitis. By the time the baby is born, the perforation is usually closed, and the leaked meconium is calcified. There are two types of intrauterine peritonitis: 1) fibroadhesive (significant adhesions in the abdominal cavity); 2) cystic (formation of a cystic cavity with fibrous walls in the free abdominal cavity, communicating with the intestinal lumen through a perforation).

Postnatal perforations of the gastrointestinal tract due to developmental defects are always accompanied by fibrinous-purulent, fecal peritonitis.

It is difficult to diagnose intrauterine adhesive peritonitis before surgery. Moderate pain and tension in the abdominal muscles against the background of symptoms of small intestinal atresia and radiologically detectable calcifications in the free abdominal cavity help to suspect it. In cystic peritonitis, a cystic cavity in the free abdominal cavity, often adjacent to the anterior wall, is determined radiologically. The walls of the cyst are thickened, calcified, and a high level of fluid is detected in its lumen.

Segmental malformations of the gastrointestinal tract in the first days of life of children do not have symptoms that portend a catastrophe. Perforation always develops acutely, in the midst of complete well-being, on the 3rd-6th day of life it manifests itself as a picture of peritoneal shock. Clinically and radiologically, this group of patients has a large amount of free gas in the abdominal cavity, which leads to severe respiratory and cardiac disturbances.

A feature of perforated peritonitis in necrotizing enterocolitis is the large area of ​​intestinal damage and the severity of the adhesive-inflammatory process in the abdominal cavity. Pneumoperitoneum is moderate.

A more favorable form of peritoneal complications of necrotizing enterocolitis in newborns is limited peritonitis, observed in "/3 ​​cases. In these cases on Against the background of symptoms of enterocolitis, a dense infiltrate with clear contours appears in the abdominal cavity, moderately painful, often localized in the right iliac region. When opening the intestinal lumen and abscess formation of the infiltrate, note

There is an increase in its size, the child’s anxiety increases, especially when palpating the abdomen. Tension of the abdominal wall muscles is revealed, and the general condition worsens. Often these symptoms are difficult to catch, since they appear against the background of a severe, usually septic, condition.

Limited peritonitis at the infiltration stage is subject to conservative treatment, which in 38% of cases leads to relief of the inflammatory process. We give preference to the following antibiotics: the cephalosporin group, oxacillin, gentamycin. Selective decontamination of the intestine is indicated, and in the most severe cases, complete decontamination in a gnotobiological isolator.

Selective decontamination is prescribed from the moment of enteral feeding by administering antibiotics that are not absorbed by the intestinal mucosa. Most often, gentamicin is prescribed at a dose of 10 mg/(kg-day), kanamycin at 10-20 mg/(kg-day), nevigramon at 0.1 mg/(kg-day) for a period of 7-10 days from subsequent administration of bifidum-bacterin 2.5-5 doses 3-4 times a day for a period of 2-4 weeks under the control of stool analysis for dysbacteriosis.In addition, along with replacement therapy, stimulating therapy (antistaphylococcal drugs, anti-coliplasm) is recommended , drugs that relieve the immune block (levamisole, thymalin, prodigiosan), desensitizing agents.Vitamins and enzyme preparations are prescribed according to general principles.

Surgical treatment of necrotizing enterocolitis is indicated: 1) at the stage of diffuse perforated peritonitis; 2) with acute intestinal infarction; 3) at the stage of pre-perforation with the ineffectiveness of intensive conservative therapy for 6-12 hours and an increase in clinical and radiological symptoms; 4) with abscess formation of the abdominal cavity infiltrate.

Transrectal access is most often used. In case of diffuse peritonitis, the operation of choice is resection of the necrotic part of the intestine with the removal of a double intestinal stoma. After simultaneously washing the abdominal cavity with solutions of antiseptics and antibiotics, the latter is sutured, leaving a catheter for the administration of antiseptics (dioxidine). In case of total damage to the colon, we recommend a shutdown operation by placing an unnatural anus on the terminal ileum (ileostomy).

In cases of abscess formation of the abdominal infiltrate, an abscessotomy is necessary. Through a small incision in the anterior abdominal wall, the abscess cavity is drained as gently as possible, without disturbing the delimiting capsule. As a rule, a low intestinal fistula is formed. A feature of intestinal fistulas in newborns is their independent closure when the underlying disease is relieved.

Online access. It is advisable to use a transrectal or transverse incision.

In patients with intrauterine adhesive peritonitis, it is necessary

It is necessary to carry out separation of adhesions, resection of the atretic part of the intestine, followed by an end-to-end or side-to-side anastomosis. We use a single-row U-shaped silk seromuscular suture.

For segmental defects of the colon, the operation of choice is to isolate the perforation zone on the abdominal wall in the form of a colostomy. Gastric perforations are sutured with double-row sutures. The abdominal cavity is washed with solutions of antiseptics and antibiotics and sutured tightly. Reconstructive closure of the colostomy is carried out after 3- 4 months

Iatrogenic peritonitis. Iatrogenic perforations include perforations of the gastrointestinal tract that occur when probing techniques, instrumental examination methods, and cleansing enemas are violated. Mechanical trauma is the main cause of iatrogenic perforation of the wall of a hollow organ, mainly the rectum, the region of the rectosigmoid zone.

In all cases, perforation of the rectum penetrated into the abdominal cavity, was localized on the anterior wall in the zone of the transitional fold of the peritoneum, and was accompanied by diffuse hemorrhagic-purulent fecal peritonitis.

A sharp deterioration in the child's condition, accompanied by symptoms of peritoneal shock, usually occurs immediately after the manipulation. The typical clinical picture of diffuse peritonitis develops very quickly.

The operation of choice for rectal perforation is suturing the perforation hole with the application of a proximal sigmostoma. Sanitation of the abdominal cavity is carried out according to general rules.

Non-perforative peritonitis. Non-perforative or septic peritonitis develops in newborns due to intrauterine or postnatal infection. According to our data, it occurs in 16% of cases.

With intrauterine infection, a severe septic process with serous-purulent peritonitis, pleurisy, pericarditis and meningitis, caused by both gram-positive and gram-negative flora, often develops hematogenously and lymphogenously.

In the postnatal period, peritonitis occurs when a purulent infection passes through contact from the umbilical vessels or from the retroperitoneal space.

Non-perforative postnatal peritonitis in approximately 50% of cases is limited in nature.

In newborns, in the case of intrauterine infection, symptoms of peritonitis appear on the 1st day of life. Clinical symptoms are general and local in nature: severe toxicosis, vomiting of bile, bloating And abdominal pain, stool retention. The abdominal wall is thickened, tense, shiny, and hyperemia appears.

X-ray reveals significant hydroperitoneum, darkening the abdominal cavity and leading to unclear contours of the intestinal loops. There is darkening of the upper floor of the abdominal cavity due to hepatosplenomegaly.

The clinical picture of postnatal peritonitis develops gradually against the background of a focus of purulent infection. There is a gradual deterioration of the condition and an increase in toxicosis, symptoms of paresis of the gastrointestinal tract appear: vomiting, bloating, stool retention, then tension in the muscles of the abdominal wall increases and swelling is noted, which spreads to the external genitalia. With limited peritonitis, the infiltrate of the abdominal cavity passes to the anterior abdominal wall, often in the area of ​​inflammation of the umbilical vessels.

X-rays reveal hydroperitoneum and intestinal paresis; the intestinal walls are not thickened. Thickening of the anterior abdominal wall. In the case of infiltration, a darkening appears in the abdominal cavity, pushing aside the intestinal loops.

Therapeutic tactics for non-perforative peritonitis initially consist of conservative antibacterial and infusion therapy to stop both the primary source of infection and incipient peritonitis. If there is no effect V within 6-12 hours and an increase in clinical and radiological symptoms, surgery is recommended. The abdominal cavity is immediately washed with solutions of antiseptics and antibiotics with mandatory drainage of the source of purulent infection.

N. S. Tokarenko (1981) proposes laparocentesis with catheterization of the abdominal cavity and fractional rinsing with antibiotic solutions for the treatment of septic peritonitis.

With limited peritonitis at the stage of abscess formation, abscessotomy and drainage of the abscess cavity are indicated.

Peritonitis in children is an acute inflammation of the abdominal cavity, which poses a danger to the child’s health and can be fatal. It develops, as a rule, against the background of another inflammatory process, abdominal trauma, infection or violation of the integrity of internal organs, etc. It manifests itself as a sharp deterioration in well-being, signs of intoxication and other negative symptoms. Treatment includes drug therapy and surgery.

Causes of peritonitis in a child

In childhood, the development of secondary and primary forms of peritonitis is possible. The first type is much more common and may be due to the following factors:

• Availability .
• Acute inflammation of the peritoneum, provoked by various pathological processes in the body.
• Exacerbation of appendicitis – appendiceal peritonitis.
• Umbilical sepsis.
• Entry of pathogenic organisms or food particles into the abdominal cavity.

The primary form is diagnosed quite rarely and can be provoked by blunt or acute abdominal trauma, ruptures of internal organs, intestinal obstruction, and hemorrhage into the abdominal cavity. The cause of the pathology may be the entry of meconium (feces of newborns) into the peritoneum of the baby, as well as a diplococcal infection.

Peritonitis develops gradually. First of all, the child’s well-being worsens, he experiences weakness, lack of appetite and sleep disturbances. The psycho-emotional state worsens, the baby becomes capricious, restless and irritable. He often cries and refuses games and other entertainment.

Symptoms of general intoxication are observed: increased body temperature to 38-38.5⁰C, nausea and vomiting. Dyspeptic disorders are of concern: diarrhea or diarrhea, abdominal pain that is not clearly localized, and excessive tension of the peritoneum. The skin acquires a grayish tint. The outcome of the disease depends on how quickly and efficiently medical care is provided.

There are several forms of peritonitis:

Diplococcal develops in school-age children, predominantly female. Pathogenic (pneumococcal) microorganisms enter the abdominal cavity through the female genital organs due to reduced vaginal immunity. The disease manifests itself very acutely: a sharp and significant increase in body temperature, severe diarrhea, abdominal pain and the development of an abscess.

Tuberculous peritonitis develops against the background of tuberculosis and is manifested by abnormal bowel movements, weakness and exhaustion, painful sensations in the abdominal cavity, and an increase in temperature to febrile levels.

Exudative peritonitis is characterized by the accumulation of serous fluid. The disease is accompanied by an enlarged abdomen, skin tension, problems with blood circulation and the development of respiratory failure.

If alarming signs appear, you should contact your surgeon. The doctor will conduct a visual examination and palpation of the abdomen. To confirm the diagnosis, laboratory tests (CBC and OAM), X-ray examination and ultrasound of the abdominal organs are prescribed. If the diagnosis of “peritonitis” is confirmed, the child is immediately hospitalized and receives qualified medical care in a hospital setting.

To treat peritonitis in children, surgical intervention is used - laparotomy. An incision is made in the abdominal cavity and the condition of the peritoneum is examined, the cause of the pathology is eliminated, and the cavity is sanitized with an antiseptic or antibacterial solution. A drainage is inserted into the incision, through which the peritoneum is washed and exudate is pumped out.

To maintain well-being, alleviate the child’s condition and prevent relapse after surgery, medications are prescribed:

• Intravenous administration of broad-spectrum antibiotics.
• The use of antipyretic drugs (Nurofen, Panadol, Paracetamol). The form and dosage depends on the age and weight of the small patient.
• Carrying out infusion therapy.
• The use of drugs that normalize blood circulation and have a detoxifying effect.

Timely provision of qualified assistance and compliance with all doctor’s instructions during the postoperative period will avoid complications and speed up recovery.

Peritonitis in any shape or form is extremely dangerous for a child, therefore, when the first symptoms of the disease appear, you should immediately seek help from a doctor and undergo the necessary examination. For a speedy recovery and prevention of relapse of the disease, you should strictly follow all the specialist’s recommendations, adhere to a diet and undergo rehabilitation.

Peritonitis- inflammation of the peritoneum, which is a type of connective tissue consisting of two sheets. The first is lined with the walls of the abdominal cavity, the second is its internal organs. The disease threatens the child’s life and therefore requires urgent medical attention. The prognosis due to inadequate or untimely treatment is very unfavorable.

Peritonitis in children differs in a number of features, since their organs and systems are not yet fully formed. Most often, the disease is a complication after, less often, other factors can become causes of childhood peritonitis.

Depending on the causes, primary and secondary peritonitis can be diagnosed. Most often, the second type is diagnosed against the background of other diseases:

If the cause of inflammation of the peritoneum is not an internal disease, but some random factor from the outside, this is primary peritonitis in children, which is diagnosed less often than secondary. Its reasons may be:

• bleeding of various kinds into the abdominal cavity;
• ruptures and injuries of organs;
• intestinal obstruction;
• diplococcal infection (a disease caused by this type of bacteria has a similar name - diplococcal peritonitis);
• accidental entry of meconium into the peritoneum of a newborn;
• impaired integrity of organs in the abdominal cavity.

Prevention of the primary form is the usual safety measures, avoiding traumatic situations. In the case of a secondary disease, everything will depend on the health of the baby and the ability of his body to cope with primary infections. It is very important to recognize peritonitis in time, but this can be quite difficult to do in children.

Symptoms and signs

The first symptoms of peritonitis in a child are not sharp pain, as many parents mistakenly believe. The little organism is still just being formed. As a result, the general condition first worsens, and the symptoms of inflammation can be expressed very vaguely. If the baby has been injured in the abdominal area, has recently suffered appendicitis or an infection mentioned above in the causes of secondary peritonitis, you need to monitor his condition extremely carefully. Symptoms of the disease include:

• obvious deterioration in the general condition of the child;
• anxiety, nervousness, moodiness, irritability, causeless crying;
• lack of appetite;
• poor sleep (not falling asleep at all or constantly waking up and crying);
• temperature can rise to 38°C;
• vomit;
• long absence of stool or, conversely,;
• pain in the abdominal area, but not localized in any one place;
• the stomach is tense, if you try to touch it, the baby will worry and cry;
• the skin becomes dry and acquires a distinct earthy tint.

In many ways, the child’s future health after peritonitis will depend on how promptly the parents noticed the disease and provided first aid. Children with such signs should be seen by a doctor as soon as possible. For this, an ambulance is called. The surgeon will palpate the abdomen and assess the general condition of the little patient. In such cases, blood and urine tests are required, and X-ray and ultrasound examinations of the organs in the abdominal cavity are performed. If the doctor diagnoses peritonitis, the child is immediately hospitalized and surgery is scheduled.

Treatment

Peritonitis in children of any age requires mandatory surgical intervention. A laparotomy is performed (the abdominal wall is cut to gain access to the internal organs), and the condition of the peritoneum is examined. If possible, the main cause of inflammation is eliminated, the abdominal cavity is thoroughly washed with an antibiotic (solution) or other, more gentle antibacterial agents. After the edges of the wound are sutured, a drainage is inserted into it, which serves to sanitize the peritoneum with antibiotics. After surgery, treatment involves prescribing:

• massive infusion therapy;
• intravenous antibiotics;
• antipyretic drugs;
• means to eliminate intoxication and improve blood microcirculation;
• special diet: doctors will tell parents what to feed a child with peritonitis; Chicken broth, plain yoghurts, pureed vegetables (zucchini, potatoes or pumpkin), rice water, water-based cereals, honey, fruits and berries with low acidity are usually allowed.

Before the ambulance arrives, parents can take the following measures to alleviate the baby’s condition:

• antipyretic drugs based on ibuprofen or paracetamol;
• wipe the skin with alcohol to reduce the temperature;
• apply cold compresses to the forehead, back of the head, and armpits.

Without doctors, nothing more can be done with a sick child. With correct and timely surgery, as well as if all recommendations are followed in the postoperative period, the child’s health after peritonitis is completely restored and does not indicate the disease.