home Folk remedies How does peritonitis manifest? Causes of aseptic peritonitis

How does peritonitis manifest? Causes of aseptic peritonitis

Update: October 2018

In the famous Soviet-era comedy “Pokrovsky Gate” there is a wonderful episode in which Rimma Markova (surgeon), smoking a cigarette on a clip, answers her friend on the phone that she should cut without waiting for peritonitis (we were talking about appendicitis). Indeed, this condition poses a serious threat to the patient’s life, and delaying the operation is literally like death.

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

Peritonitis: definition

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

High mortality rate this state is explained by two points:

failure of patients to seek specialized care in a timely manner;
an increase in the number of elderly patients (the process is not so acute, which leads to late consultation with a doctor);
an increase in the number of patients with cancer;
errors and difficulties in diagnosing the process, inappropriate treatment;
severe course of the process if it spreads (spread peritonitis).

A little anatomy

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

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

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

Causes of the disease

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

Primary peritonitis

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

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

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

In children, spontaneous inflammation of the peritoneum, as a rule, occurs in the neonatal period or at 4–5 years. 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.

Spontaneous inflammation of the peritoneum in adults often occurs after emptying (drainage) of ascites, which is caused by cirrhosis of the liver or after long-term peritoneal dialysis.

Tuberculous damage to the peritoneum occurs with tuberculous damage to the intestines, fallopian tubes (salpingitis) and kidneys (nephritis). Mycobacterium tuberculosis enters the serous tissue of the abdominal cavity through the bloodstream from the primary source of infection.

Secondary peritonitis

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

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

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

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

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

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

Tertiary peritonitis

This type of inflammation of the peritoneum is the most difficult to diagnose and treat. Essentially, this is a relapse of previous inflammation of the peritoneum, and, as a rule, occurs after surgery in those patients who have experienced emergency situations, as a result of which their body’s defenses are significantly suppressed. Flow this process characterized by an erased clinical picture, with the development of multiple organ failure and significant intoxication. Risk factors for tertiary peritoneal inflammation include:

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

Tertiary inflammation of the peritoneum is often fatal.

Development mechanism

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

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

Classification

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

Depending on the current:

acute peritonitis;
chronic inflammation of the peritoneum.

Depending on the etiological factor:

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

Origin of the complication:

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

Depending on the exudate:

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

Depending on the spread of inflammation:

delimited (appendicular, subphrenic, subhepatic and others);
common:
- diffuse – damage to the peritoneum covered 2 floors of the abdominal cavity;
- diffuse - inflammation of the peritoneum in more than two areas of the abdominal cavity;
- general - inflammatory process distributed over the entire area of the peritoneum.

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

Symptoms

With peritonitis, the symptoms are very diverse, but have a number of similar signs. The clinical picture of this disease depends on its stage and primary pathology, the age of the patient, previous treatment and the presence of severe concomitant processes. Elderly patients, in whom inflammation of the peritoneum is mild and atypical, requires special attention. Signs of peritonitis are combined into a number of characteristic syndromes.

Pain syndrome

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

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

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

Dyspeptic syndrome

With peritonitis, intestinal and stomach disorders manifest themselves in the form of nausea and vomiting, retention of stool and gases, loss of appetite, false urges for defecation (tenesmus), diarrhea. At the onset of the disease, nausea and vomiting occur reflexively, due to irritation of the peritoneum.

With further progression of inflammation of the peritoneum, intestinal failure increases, which leads to disruption of motor-evacuation function (weakening, and then complete absence peristalsis), and is manifested by retention of stool and gases. If the inflammatory focus is localized in the pelvis, tenesmus occurs, repeated loose stool and urinary disorders. Similar symptoms are characteristic of retrocecal phlegmonous or gangrenous appendicitis.

Case Study

At night (as usual), a young woman of 30 years old was delivered by ambulance. Complaints of very severe pain in the lower abdomen for 5 - 6 hours. The pain becomes more intense over time, pulling, sometimes cutting. Temperature 38 degrees, nausea, vomiting several times, frequent painful urination. First of all, they called the gynecologist on duty. On examination, the abdomen is tense and painful lower parts, the Shchetkin-Blumberg symptom is positive, more in the iliac region on the right. During a gynecological examination, the uterus is not enlarged, elastic, displacement behind the cervix is sharply painful. The area of the appendages is sharply painful; it is not possible to palpate possible inflammatory formations. The posterior fornix bulges, sharply painful on palpation. When performing a puncture through the posterior vaginal fornix, a large amount of turbid peritoneal fluid (more than 50 ml) was obtained. Preliminary diagnosis: Pelvioperitonitis (inflammation of the peritoneum in the pelvis) Acute right-sided adnexitis? I called a surgeon for a consultation. The surgeon is very experienced, palpated the abdomen and with the words: “Not mine,” retired to his room. For two hours the patient was treated infusion therapy. After 2 hours, the patient’s condition did not improve, the pain syndrome persists. She decided on exploratory laparotomy. The surgeon refused to assist. After dissection abdominal wall and examination of the appendages (slight hyperemia of the fallopian tube on the right - mild salpingitis), a surgeon appears in the operating room (apparently, something suggested that maybe “it’s his”) and stands at the table. He inspects the intestines, primarily the cecum, and discovers gangrenous retrocecal appendicitis. An appendectomy is performed and the abdominal cavity is drained. The postoperative period was uneventful.

I cited this case as an example: it is easy to miss peritonitis even, it would seem, with such a banal disease like appendicitis. The vermiform appendix is not always located in a typical manner; it is not without reason that surgeons say that appendicitis is the monkey of all diseases.

Intoxication-inflammatory syndrome

Typical signs of this syndrome serve as a temperature that rises to 38 degrees and above, fever alternating with chills, an increase in leukocytes in the peripheral blood and an acceleration of ESR. Breathing becomes more frequent, its frequency exceeds 20 respiratory movements per minute, the pulse increases (fastens) to 120 - 140 per minute. It is typical that the heart rate does not correspond to the increasing temperature (the pulse is ahead of the temperature).

Peritoneal syndrome

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

Face of Hippocrates

Hippocrates was the first to describe a suffering face, characteristic of widespread inflammation of the peritoneum. The patient’s facial features become sharpened due to dehydration (dehydration), and there is a pained expression on the face. Skin pale, sometimes earthy or gray in color, dry mucous membranes, yellowness of the sclera. As the disease progresses, a cyanotic skin color appears. Drops of sweat appear on the forehead, especially after each painful attack.

Abdominal examination

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

Auscultation and percussion

When listening to the intestines, weakened peristalsis or its complete absence (deafening silence) and the appearance of pathological intestinal sounds are determined. Percussion (percussion of the abdominal cavity): disappears liver dullness, tympanitis (drumming sound) is detected in all areas of the abdomen. In some cases, it is possible to identify accumulated fluid.

Palpation

When palpating the anterior wall of the abdomen, its pain is determined, usually sharp, the abdomen is tense - board-shaped in the case of perforation of a hollow organ, the Shchetkin-Blumberg symptom (a sign of irritation of the peritoneum) is determined. There may be a lack of abdominal muscle tension, which is observed in elderly patients, with exhaustion, in case of severe intoxication, or the retroperitoneal or pelvic location of the primary focus.

A characteristic sign of peritoneal irritation is the Shchetkin-Blumberg symptom. During palpation of the abdomen, the patient feels pain, and after pressing in the place the greatest pain and the sudden removal of the hand by the doctor, the pain intensifies significantly.

When performing a rectal and vaginal examination, you can palpate an infiltrate, abscess (ulcer) or accumulation inflammatory fluid in the small pelvis. In women, pain, flattening or bulging of the posterior vaginal fornix is determined.

Diagnostics

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

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.

Treatment

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

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

preoperative preparation;
surgical intervention;
intensive care and monitoring after surgery.

Preoperative preparation

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

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

Surgery

Surgical intervention has the following goals:

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

Operation stages:

Anesthesia

Anesthesia for surgery is carried out in several stages. Endotracheal anesthesia is preferable, in as a last resort Spinal anesthesia (SMA) is performed. When performing SMA, a catheter is placed in the subdural space through which local anesthetics (lidocaine) are administered in the postoperative period, which reduces the need to use narcotic drugs.

Access

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

Eliminating the source of the complication

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

Sanitation of the abdominal cavity

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

Bowel decompression

A tube with numerous side holes is inserted into the small intestine. Administration is carried out through the nose, rectum or enterostomy (necessary for removing gases from the intestines).

Drainage

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

Suturing the wound

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

Postoperative therapy

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

Postoperative patient management includes:

adequate pain relief;
carrying out intensive infusion therapy (up to 10 liters per day);
carrying out detoxification therapy (hemodialysis and lymphosorption, administration of diuretics, hemosorption, lavage of the abdominal cavity through drains or sanitation through laparostomy);
prescribing antibiotics in maximum doses, route of administration intravenous (combination of cephalosporins with aminoglycosides and metronidazole);
immunocorrective therapy;
prevention of intestinal paresis (administration of proserin) and intestinal failure syndrome (administration of atropine, potassium preparations);
normalization of the functioning of all organs and systems;
prevention of complications.

Care and monitoring of the patient after surgery

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

early – lasts from 3 to 5 days;
late – first 2 – 3 weeks (hospital stay until discharge);
remote – until you go back to work or become disabled.

Postoperative care in the early phase

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

The patient is placed in a Fowler's position in bed - the head end is raised 45 degrees, and the legs are slightly bent at the knees and hip joints. If the patient is unconscious (under anesthesia), he is laid horizontally, removing the pillow from under his head. To avoid retraction of the tongue, the head is slightly thrown back and out lower jaw. In the first 2–3 days after surgery, the patient is prescribed fasting and strict bed rest. If necessary, artificial ventilation of the lungs is continued, and if the patient’s condition is satisfactory, he is periodically given inhalations of humidified oxygen.

The first dressing change is carried out on day 2, under the supervision of a doctor. If the bandage has become loose or bleeding from the wound has increased, dressing should be done earlier. Honey. The nurse monitors not only pulse, respiratory rate, blood pressure (every hour) and temperature, but also controls urine output ( urinary catheter after the operation, leave for another 2 - 3 days) and the amount and nature of discharge through the drains. The drains are periodically washed, and the dressings on the drains are changed by a doctor.

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

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

It is undesirable for the patient to remain in bed for a long time (physical inactivity provokes postoperative complications). Taking into account the patient's condition, early activation is started.

By the end of the first day, the patient should begin to actively behave in bed (turn over, bend, straighten limbs). On the 2nd - 3rd postoperative day, the patient first sits down in bed, then, after several deep breaths and exhalations and clearing his throat, he must get up and walk around the room, after which the patient is put to bed. Honey helps to lift the patient. sister. As the condition improves and pain decreases, the patient expands the regimen according to the doctor’s instructions.

Late phase

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

During the first week, food should be liquid (broths: water after boiling is drained and replaced with new one, soft-boiled eggs, jelly and jelly, pureed vegetables with a small amount of butter).
On days 3–4, the patient’s menu includes pureed cottage cheese, boiled beef, lamb, pureed chicken and fish, slimy porridges and soups (rice, oatmeal). Excluded coarse fiber and foods that are difficult to digest and irritate the digestive tract (legumes, cabbage, radishes and radishes, stringy meat, skin and cartilage of poultry and fish, cold drinks). The intake of fats should be due to vegetable oils, sour cream and cream, a small amount of butter. Easily digestible carbohydrates (marmalade and honey, jam, marshmallows, chocolate, etc.) are limited. Dried bread or yesterday’s baked bread is included in the menu for 5–7 days.
Free mode (walks around the department and on the hospital grounds) is prescribed for 6–7 days. If the postoperative period is favorable, the sutures are removed on days 8–9, and the drains are removed on days 3–4. The patient is usually discharged on the day the sutures are removed.

Distant phase

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

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

Rehabilitation of the patient is facilitated by skiing, hiking, close-range tourism, swimming. The patient is also recommended for sanatorium treatment.

The patient should eat sparingly (up to 5 times a day), not overeat, but also not starve. It is recommended to boil, steam, stew or bake food (without crust). Limit the consumption of foods that irritate the gastrointestinal tract (spices, peppers, marinades and pickles, bitter and sour vegetables: sorrel, radish, garlic, onions, radishes). You should avoid refractory fats (margarine, lard, smoked foods) and limit your consumption of sugar (sweets, jam) and baked goods.

Consequences and complications

Early complications of peritonitis that may occur in acute period in case of absence timely treatment, life-threatening conditions include:

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

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

Forecast

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

Peritonitis is a limited or diffuse (widespread) inflammation of the serous membrane of the abdominal cavity (peritoneum), that is, the tissue that lines it from the inside and surrounds the organs located in it, blood vessels and nerve trunks. This condition is a consequence of the complicated course of various inflammatory and destructive diseases of organs.

In this article we will introduce you to the causes, symptoms, methods of diagnosis and treatment of peritonitis in adults. You will also receive information about the prognosis of this life-threatening condition.

Lethal outcomes from inflammation of the peritoneum can reach significant values - according to statistics for gastroenterological diseases, death from such a complication occurs in 20-30% of patients, and with serious illnesses this figure reaches 40-50%. We may recall that it was traumatic peritonitis after an injury to the abdominal cavity that caused the death of A. S. Pushkin.

A little anatomy

The peritoneum (in the image - peritoneum) limits the abdominal cavity and covers the organs located in it.

The human peritoneum consists of 2 layers (layers) passing into each other:

visceral - external, covering the muscles and bone joints that form the abdominal cavity;
parietal - lining the internal organs.

The tissue that forms the peritoneum is semi-permeable. She is involved in different processes and how the membrane performs many functions:

absorbs exudate released during the lysis of microorganisms or during necrotic processes in tissues;
secretes serous fluid necessary to “lubricate” organs and tissues;
protects tissues from microbial and mechanical damage, etc.

The most significant protective property of this tissue of the human body is its ability to stop inflammatory processes that occur in the abdominal cavity. This property is ensured by the formation of adhesions that limit inflammation, as well as by immune mechanisms that are triggered in its walls during such processes.

Causes

The root cause inflammatory reaction in the tissues of the abdominal cavity, which leads to peritonitis, in most cases becomes bacterial infection(caused by microflora found in digestive tract). The following gram-negative and gram-positive microorganisms can provoke this complication:

In the vast majority of cases - according to various statistical data, 60-80% - inflammation of the peritoneum is caused not by one, but by an association of microbes. More often like this pathological process provoked by Escherichia coli or staphylococci. In more in rare cases The development of peritonitis is caused by pathogens such as pneumococcus, Koch's bacillus (), and hemolytic streptococcus.

Considering the above-described facts about the variability of possible pathogens of peritonitis, when prescribing treatment, the doctor must wait for the results of a sensitivity test pathogenic microflora to antibiotics.

Types of peritonitis

Depending on the etiological factor, the following types of peritonitis are distinguished:

idiopathic (or primary) - occurs when pathogenic microorganisms along with the flow of lymph, blood or fallopian tubes for diseases such as tuberculosis of the genitourinary organs;
secondary - develop as a result of injuries or inflammatory-destructive diseases of organs and are usually detected in perforated, gangrenous or phlegmonous, or duodenal intestines, ruptures of ovarian cysts, pancreatic necrosis, phlegmonous-gangrenous and other pathologies.

Depending on the microbial factor, peritonitis is:

bacterial – provoked by inflammation caused by microorganisms;
aseptic - caused by substances that are aggressive towards the peritoneum and provoke inflammation.

IN clinical practice surgeons, secondary peritonitis occurs more often than idiopathic peritonitis, which occurs in only 1-1.5% of patients.

IN separate group Traumatic peritonitis is distinguished:

arising as a result of closed or open injuries, causing damage to the abdominal organs;
arising as a result of surgical interventions, accompanied by anastomotic failure, suture defects, accidental mechanical trauma to the peritoneum and the development of hemoperitoneum (blood accumulation).

Special types of peritonitis include the following:

Depending on the nature of the fluid accumulating in the abdominal cavity, the following types of peritonitis are distinguished:

serous;
fibrinous;
purulent;
hemorrhagic.

The nature of the peritoneal lesion may be as follows:

limited - an abscess or infiltrate occurs on the peritoneum;
unlimited – the area of inflammation does not have clear boundaries and is diffuse.

The prevalence of peritoneal lesions may be as follows:

local - only one anatomical zone of the peritoneum is affected;
common – inflamed from 2 to 5 zones;
total (or general) – 6 or more zones are affected.

According to the clinical course, in most cases, peritonitis is acute. However, sometimes the inflammation takes a protracted course, in such situations the pathological process is considered chronic.

The above characteristics of peritonitis are difficult to remember for people who do not have a medical education, so in practice the more simplified formulation “acute” is often used. The remaining classifications are usually omitted and used only for maintaining medical records.

Stages of acute peritonitis

The development of peritonitis is divided into the following stages:

early – lasts 12 hours;
late – 3-5 days;
final – 6-21 days.

Depending on the severity of inflammation, the following stages are distinguished:

reactive - a hyperergic reaction that occurs in response to irritation of the peritoneal tissue and manifests itself to a greater extent local, rather than general symptoms;
toxic – expressed in an increase in signs of intoxication of the body in response to inflammation;
terminal – manifested by signs of exhaustion of the body and is accompanied by dysfunctions of vital functions important systems and organs.

Symptoms

At the early stage of peritonitis, the patient pays attention to the appearance of intermittent pain in the abdomen, the prevalence and intensity of which gradually increases.

In the reactive phase of peritonitis, abdominal pain appears, the intensity and location of which depends on the location of the main source of inflammation. At first, pain sensations are clearly limited to one zone and, due to irritation of the nerves of the diaphragm by the accumulated purulent exudate, they can radiate to the supraclavicular region or shoulder. They are not constantly present and periodically become quieter or disappear completely. Then the pain gradually loses its original intensity, covers the entire abdomen, becomes constant and loses its primary precise localization.

Against the background of pain during peritonitis, the following typical symptoms are determined:

periodic vomiting of the contents of the stomach or intestines with inclusions of bile, followed by vomiting of feces (intestinal vomiting);
signs of paralytic intestinal obstruction in the form of bloating.

With peritonitis, even appearance patient:

pained look on the face;
adynamic;
pale skin;
cyanosis of mucous membranes;
cold sweat.

In bed, it becomes easier for the patient if he lies on his side or back, tucking his legs bent at the knees to his chest or stomach. Severe pain, signs of intoxication and purulent inflammation lead to respiratory failure (it becomes superficial), hypotension, increased temperature and increased heart rate to 120-140 beats per minute.

When the terminal phase begins, the patient's condition worsens even more. He develops the following symptoms:

confusion;
sharpening of facial features;
pallor with a icteric or bluish tint;
dry tongue with a dark coating;
upon auscultation of the abdomen, the so-called “deathly silence” is determined, which develops due to the lack of peristalsis in the digestive organs;
When palpating the abdomen, bloating and significantly less pain are detected.

Diagnostics

To diagnose peritonitis, the doctor examines the patient and listens to his complaints. Palpation of the abdomen reveals the following symptoms:

Voskresensky;
Bernstein;
Shchetkin-Blumberg;
Medel.

When tapping the anterior abdominal wall, the doctor determines a dullness of sound that occurs due to swelling of the inflamed peritoneal tissue and effusion in the abdominal cavity. Depending on the stage of peritonitis, the following symptoms are determined by listening:

"falling drop";
“splash noise”;
"deathly silence."

When examining the vagina and rectum, the doctor can identify signs of pelvioperitonitis, which occurs when there is inflammation of the peritoneal tissue lining the pelvis.

To confirm the diagnosis, the patient undergoes the following studies:

radiography - when hollow organs break through under the dome of the diaphragm, the “sickle” symptom is determined, and with the development of intestinal obstruction, Kloiber’s cups are detected;
expanded - leukocytosis, increased ESR levels and neutrophilia are detected.

More often, diagnosing peritonitis is not difficult, but in complex clinical cases, the study can be supplemented by invasive techniques such as diagnostic laparoscopy or laparocentesis.

Treatment

After peritonitis is detected, the patient undergoes emergency surgery. Its technique depends on the root cause of the complication and is always aimed at eliminating the source of the infectious or other agent irritating the peritoneum.

During the operation, a laparotomy is always performed, which gives the surgeon the opportunity to sufficiently examine the peritoneal tissue and identify all possible sources of perforation (for example, in the intestines or stomach). To eliminate perforations, suturing is performed, which, if necessary, can be supplemented by a colostomy, resection of a necrotic area of an organ, and other forced measures.
During an emergency operation, the surgeon’s actions are always aimed only at eliminating the causes of peritonitis, and other reconstructive interventions are postponed until later. late date, since their implementation under the current conditions is impossible due to the purulent-inflammatory process. During the first intervention, the doctor always performs intra- and postoperative sanitation of the abdominal cavity and provides decompression of the small intestine. For this purpose they use antiseptic solutions, which are pre-cooled to +4-6 °C. Their volume may vary depending on clinical case from 8 to 10 liters.
Decompression of part of the small intestine is performed using nasointestinal intubation, which involves inserting a probe through the nasal cavity into the small intestine. In the future, it can be used for the purposes of enterosorption (evacuation of intestinal contents) and artificial nutrition.
Drainage of the colon during surgery to eliminate peritonitis is performed through the anus. At the end of the intervention, drainage from vinyl chloride is always installed in the abdominal cavity. In the future, such a system of tubes is used to remove exudate that continues to accumulate and introduce antibacterial drugs to eliminate pathogenic microorganisms.

After the operation, the patient is prescribed antibacterial drugs, and the elimination of the consequences of intoxication is achieved with the help of infusions of solutions for intravenous administration. Immunocorrectors, infusions of leukocyte mass and ozonated solutions are added to the drug therapy plan. In addition, it is assigned symptomatic therapy, aimed at eliminating emerging symptoms: pain, flatulence, etc. For this, the following can be used:

narcotic analgesics;
potassium preparations;
ganglion blockers;
anticholinergics, etc.

Some patients are indicated for physiotherapeutic procedures such as diadynamic therapy and electrical stimulation of the intestines.

If possible, plan postoperative treatment The following methods aimed at cleansing the blood are included:

plasmapheresis;
ILBI (intravenous laser irradiation of blood);

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. Peritonitis often occurs as a complication of other serious diseases, such as: nonspecific ulcerative colitis, acute pancreatitis, appendicitis, liver disease, dysentery, perforation of a stomach 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 the nature of the 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: when 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 nausea and vomiting begin first. 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, and 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. The mortality rate at 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, in which a purulent-toxic shift is noted leukocyte formula. X-ray and ultrasonography. It is vital to identify peritonitis on initial 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 have gained popularity ( hyperbaric oxygen therapy, ultraviolet irradiation of blood, plasmapheresis, hemosorption).

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 patients with peritonitis.

Peritonitis is an inflammation of the peritoneum - thin shell covering the abdominal organs. Peritonitis is considered a life-threatening condition and requires emergency medical attention.

Typically, signs of peritonitis appear suddenly. The main ones are: sudden, intense abdominal pain, nausea, temperature 38 ºC or higher. Peritonitis is associated with a bacterial or fungal infection that enters the abdominal cavity from outside or from another part of the body. Most often, peritonitis occurs as a result of infection or injury to the abdominal organs.

Peritonitis is dangerous disease, which must be recognized as early as possible and treated urgently to avoid fatal complications. Therefore, suspicion of peritonitis is an indication for urgent hospitalization. The infection that causes peritonitis is treated with antibiotic injections or antifungal medications, depending on the type of pathogen. In some cases, surgery may be required.

Peritonitis can lead to death, despite the best efforts of doctors. The danger of this disease is due to the fact that the infection can quickly spread through the blood to vital important bodies(sepsis). According to statistics, approximately one in ten cases of peritonitis caused by perforation (the appearance of a hole) in the intestinal wall leads to fatal outcome, although this largely depends on the cause of the disease, age and general health of the person. Peritonitis associated with cirrhosis and kidney dialysis is less likely to cause death, but it still poses a health risk.

Symptoms of peritonitis

One of the main symptoms of peritonitis is pain in the abdomen. Often the pain is sudden, acute and its intensity constantly increases. Other possible symptoms of peritonitis:

nausea;
vomit;
lack of appetite;
chills;
temperature 38ºC or higher;
cardiopalmus;
inability to urinate or decreased amount of urine;
bloating.

If you are undergoing peritoneal dialysis for kidney failure, the fluid that comes into the collection bag will likely be cloudier than usual and may contain white flakes or lumps. If peritonitis is caused by cirrhosis, there may be no abdominal pain at all. Instead, there is a general bad feeling, as well as the development of complications from the liver: an increase in the size of the abdomen due to the accumulation of fluid in it, as well as confusion.

Causes of peritonitis

Peritonitis occurs when the peritoneum becomes infected with bacteria or fungi. The peritoneum is a thin layer of tissue inside the abdominal cavity.

Secondary peritonitis- the most common type of inflammation of the peritoneum. The cause of secondary peritonitis is the spread of infection from any organ of the abdominal cavity or other part of the body. Common reasons secondary peritonitis:

perforation of a stomach ulcer (rupture of the stomach wall);
acute pancreatitis (inflammation of the pancreas);
severe peritoneal trauma, such as a knife or bullet wound;
diseases digestive system, such as Crohn's disease or diverticulitis.

Both Crohn's disease and diverticulitis can cause inflammation of the large intestine. If the inflammation is particularly severe, the wall of the large intestine is damaged and its contents, rich in bacteria, enter the abdominal cavity, causing an infection.

Less commonly, peritonitis occurs as a result of direct infection of the peritoneum - primary (spontaneous) peritonitis. Typically, primary peritonitis is associated with the accumulation of infected fluid in the abdominal cavity in cirrhosis of the liver or peritoneal dialysis in renal failure.

Damage to the liver can cause scarring, called cirrhosis. The most common causes of cirrhosis are alcohol abuse, hepatitis C or fatty liver disease (fatty liver).

Cirrhosis can cause fluid to accumulate in the abdomen (ascites). This fluid is particularly susceptible to contamination and provides a favorable environment for the growth and reproduction of bacteria and fungi. This fluid buildup occurs in up to half of people with cirrhosis, usually many years after they were diagnosed. About 20% of people with ascites caused by cirrhosis will develop peritonitis.

People with kidney failure who undergo peritoneal dialysis have an increased risk of developing peritonitis. Dialysis is a way to cleanse the blood of unnecessary metabolic products. Dialysis replaces the work of the kidneys for patients.

In peritoneal dialysis, the peritoneum acts as a kidney - a filter that cleanses the blood of waste products. A small tube called a catheter is inserted into the abdomen and waste is removed. In rare cases, peritonitis can be caused by equipment introducing an infection into the body.

Diagnosis of peritonitis

To diagnose peritonitis, an examination is required, as well as a series of tests and studies. Your physician will ask you about your symptoms and recent medical conditions, and perform a detailed physical examination. If you have peritonitis, sharp pain occurs when you press on the abdominal wall. An examination will help rule out other diseases with similar symptoms, such as a hernia. The risk of complications from peritonitis is high, so if your GP suspects you have inflammation of the peritoneum, you will most likely be sent straight to hospital for examination and treatment.

Blood and urine tests help confirm the diagnosis of peritonitis. If you have fluid building up in your abdomen, your doctor may use a thin needle to take a sample of the fluid to test for infection.

radiography - using X-rays, a picture is taken in which you can detect a sign of rupture of internal organs - air in the abdominal cavity;
Ultrasound (ultrasound) - uses sound waves to create an image of your abdominal cavity;
CT scan(CT) - a series is being made x-rays, which are assembled by computer into a detailed three-dimensional image of your abdominal organs.

These types of tests help determine damage to internal organs, such as a ruptured appendix, perforated (ruptured) stomach ulcer, or widespread inflammation of the colon.

Treatment of peritonitis

If you are diagnosed with peritonitis, you will most likely be sent to the hospital so doctors can monitor your health.

This is associated with the risk of dangerous complications peritonitis, such as blood poisoning.

The first stage of treatment for peritonitis will be injections of antibiotics or taking antifungal drugs. Usually the course of treatment lasts 10–14 days. If peritonitis was caused by peritoneal dialysis, antibiotics may be injected directly into the abdominal cavity. Research shows this is more effective than intravenous antibiotics.

You will need to dialyze in another way, such as hemodialysis (where the blood is passed through a special filtering machine) until the peritonitis is cured. Painkillers are prescribed to relieve pain.

Many people with peritonitis have trouble digesting and absorbing food, so tube feeding may be necessary. It is inserted into the stomach either through the nose (nasogastric tube) or surgically through the front wall of the abdomen. If these options cannot be used, nutrients may be given directly into your vein (parenteral nutrition).

If internal organs are damaged as a result of infection, they may need to be removed surgically. In some cases, abscesses (cavities filled with pus) appear in the abdominal cavity, from which it is necessary to pump out the pus by puncturing them with a needle. The operation is performed using ultrasound, which helps guide the needle to the abscess. The procedure is usually performed under local anesthesia, so you should not feel any pain.

Besides, surgical intervention required to eliminate the cause of peritonitis if it is associated with damage to internal organs, for example, a ruptured appendix.

Complications of peritonitis

With peritonitis, the infection can enter the bloodstream and spread throughout the body, which is called sepsis. Severe sepsis often accompanied by infection of several organs and a sharp drop in blood pressure, which disrupts the blood supply to vital organs.

Symptoms of sepsis usually appear suddenly. They include:

high temperature (above 38ºC);
chills;
cardiopalmus;
rapid breathing.

Treatment of sepsis involves intravenous fluids and antibiotics. If sepsis is not treated promptly, it can cause septic shock.

Septic shock is sharp drop blood pressure. This results in symptoms of shock, such as cold skin and rapid heartbeat. Sepsis affects many vital processes such as blood pressure, breathing and organ function, which can lead to death. Treatment is usually carried out in the intensive care unit, where it is possible to maintain vital functions of the body during treatment.

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 postoperative surgical peritonitis 55-90%. Despite the fact that such a serious complication as peritonitis after cesarean section is now relatively rare (0.2-0.8%), the mortality rate in this form of purulent-septic diseases remains high and reaches 26-35%.

Peritonitis is an inflammation of the peritoneum, accompanied by the development of severe intoxication of the body. Peritonitis refers to the diffuse spread of inflammation.

Local inflammation is defined as abdominal abscesses (limited peritonitis). Peritonitis is secondary process complicating the course of the underlying disease. Idiopathic (primary) peritonitis, when the source has not been identified in the last 20 years, does not occur at all and is excluded from the classification.

With diffuse peritonitis, according to the distribution in the peritoneum, they are distinguished: local peritonitis, when part or one anatomical area of the cavity is affected; widespread peritonitis, when the process affects several areas, diffuse (general), affecting the entire peritoneum. The severity of intoxication is explained by the enormous length of the peritoneum - almost 10 square meters. m with high exudation by the visceral layer and resorption by the parietal layer. Therefore, toxins quickly and large quantities, enter the blood.

According to etiology, peritonitis is divided into bacterial (infectious), developing when inflammatory diseases internal organs or perforations of hollow organs, as well as injuries; and aseptic peritonitis, when the inflammatory process of the peritoneum is caused or irritated chemical substances, or biological fluids - bile, urine, blood. Exudate can be: serous, hemorrhagic, fibrinous, purulent, putrefactive. Clinical course There are: acute, subacute and chronic. At acute peritonitis emit reactive, toxic and terminal stage currents.