Peritonitis is a local or diffuse inflammation of the serous cover of the abdominal cavity-the peritoneum. Clinical signs of peritonitis are abdominal pain, muscle tension of the abdominal wall, nausea and vomiting, stool and gas retention, hyperthermia, severe General condition. Diagnosis of peritonitis is based on anamnesis, the identification of positive peritoneal symptoms, ultrasound data, radiography, vaginal and rectal studies, laboratory tests. Treatment of peritonitis is always surgical (laparotomy, sanitation of the abdominal cavity) with adequate preoperative and postoperative antibacterial and detoxification therapy.
Causes of peritonitis
Classification
Symptoms of peritonitis
Diagnostics
Treatment of peritonitis
Prognosis and prevention
Prices for treatment
General information
Peritonitis is a severe complication of inflammatory and destructive diseases of the abdominal cavity, accompanied by pronounced local and General symptoms, the development of multiple organ failure. Mortality from peritonitis in gastroenterology is 20-30%, and in the most severe forms reaches 40-50%.
The peritoneum (peritoneum) is formed by two serous sheets passing into each other - visceral and parietal, covering the internal organs and walls of the abdominal cavity. The peritoneum is a semipermeable, actively functioning membrane that performs many important functions: resorptive (absorption of exudate, lysis products, bacteria, necrotic tissues); exudative (release of serous fluid), barrier (mechanical and antimicrobial protection of the abdominal cavity), etc. The most important protective property of the peritoneum is its ability to delimit inflammation in the abdominal cavity due to fibrous adhesions and scars, as well as cellular and humoral mechanisms.
Causes of peritonitis
The etiological link in peritonitis is bacterial infection, in most cases represented by nonspecific microflora of the gastrointestinal tract. It may be gram-negative (Enterobacter, E. coli, Proteus, Pseudomonas aeruginosa) and gram-positive (staphylococci, streptococci) aerobes; gram (of fuzobakterii, Bacteroides) and gram (of eubacteria, clostridia, peptococci) anaerobes. In 60-80% of cases, peritonitis is caused by an Association of microbes-often E. coli and Staphylococcus. Less often, the development of peritonitis is due to specific microflora-gonococci, hemolytic Streptococcus, pneumococci, Mycobacterium tuberculosis. Therefore, for the choice of rational treatment of peritonitis, bacteriological inoculation of the contents of the abdominal cavity with the determination of the sensitivity of the isolated microflora to antibacterial drugs is of paramount importance.
In accordance with the etiology distinguish primary (idiopathic) and secondary peritonitis. Primary peritonitis is characterized by penetration of microflora into the abdominal cavity by lymphogenic, hematogenous or fallopian tubes. Direct inflammation of the peritoneum may be associated with salpingitis, enterocolitis, tuberculosis of the kidneys or genitals. Primary peritonitis occurs infrequently-in 1-1.5% of cases.
In clinical practice, much more often have to deal with secondary peritonitis, developing as a result of detsruktivno-inflammatory diseases or injuries of the abdominal cavity. Most often, peritonitis complicates the course of appendicitis (perforated, phlegmonous, gangrenous), perforated gastric ulcer or duodenal ulcer, piosalpinx, rupture of ovarian cyst, intestinal obstruction, hernia infringement, acute occlusion of mesenteric vessels, Crohn's disease, diverticulitis, phlegmonous-gangrenous cholecystitis, pancreatitis, pancreonecrosis and other diseases.
Posttraumatic peritonitis develops as a result of closed and open injuries of the abdominal cavity. The causes of postoperative peritonitis may be anastomotic failure, ligature defects, mechanical damage to the peritoneum, intraoperative infection of the abdominal cavity, hemoperitoneum with inadequate hemostasis. Separately, there are carcinomatous, parasitic, granulomatous, rheumatoid peritonitis.
Classification
According to the etiology distinguish bacterial and abacterial (aseptic, toxic-chemical) peritonitis. The latter develop as a result of irritation of the peritoneum with aggressive non-infectious agents (bile, blood, gastric juice, pancreatic juice, urine, chyletic fluid). Abacterial peritonitis quite quickly takes on the character of microbial due to the addition of infectious agents from the lumen of the gastrointestinal tract.
Depending on the nature of peritoneal effusion distinguish serous, fibrinous, hemorrhagic, bile, purulent, fecal, putrefactive peritonitis.
According to the clinical course of peritonitis are divided into acute and chronic. Given the prevalence of lesions on the surface of the peritoneum distinguish delimited (local) and diffuse peritonitis. Variants of local peritonitis include subdiaphragmatic, appendicular, subhepatic, inter-intestinal, pelvic abscesses. Diffuse peritonitis is said when peritoneal inflammation has no tendency to limit and clear boundaries. According to the degree of lesion of the peritoneum, diffuse peritonitis is divided into local (developing in one anatomical area, near the source of infection), common (covering several anatomical areas) and common (with total lesion of the peritoneum).
In the development of peritonitis, it is customary to allocate an early phase (up to 12 hours), a late (up to 3-5 days) and a final (from 6 to 21 days from the onset of the disease). In accordance with the pathogenetic changes distinguish reactive, toxic and terminal stages of peritonitis. In the reactive stage of peritonitis (24 hours from the moment of lesion of the peritoneum), a hyperergic reaction to irritation of the peritoneum is noted; in this phase, local manifestations are maximally expressed and General symptoms are less pronounced. The toxic stage of peritonitis (from 4 to 72 hours) is characterized by an increase in intoxication (endotoxic shock), an increase and predominance of General reactions. In the terminal stage of peritonitis (later than 72 hours), there is a depletion of protective and compensatory mechanisms, deep violations of vital functions of the body develop.
Symptoms of peritonitis
In the reactive period of peritonitis, abdominal pain is noted, the localization and intensity of which are determined by the cause of inflammation of the peritoneum. Initially, the pain has a clear localization in the area of the source of inflammation; it can radiate to the shoulder or supraclavicular area due to irritation of the nerve endings of the diaphragm with purulent-inflammatory exudate. Gradually, the pain spreads throughout the abdomen, become unsteady, lose a clear localization. In the terminal period, due to paralysis of the nerve endings of the peritoneum, the pain syndrome becomes less intense.
Characteristic symptoms of peritonitis are nausea and vomiting of gastric contents, which in the initial stage arise reflexively. In later periods of peritonitis, the emetic reaction is due to intestinal paresis; in the vomit there is an admixture of bile, then - the contents of the intestine (fecal vomiting). Due to severe endotoxicosis, paralytic intestinal obstruction develops, clinically manifested by stool retention and non-discharge of gases.
With peritonitis, even in the earliest stage, attention is drawn to the appearance of the patient: a pained expression, adynamia, pallor of the skin, cold sweat, acrocyanosis. The patient assumes a forced position that relieves pain-often on his side or back with his legs tucked up to his stomach. Breathing becomes superficial, the temperature is elevated, hypotension is noted, tachycardia 120-140 beats per minute, not corresponding to subfebrility.
In the terminal stage of peritonitis, the patient's condition becomes extremely severe: consciousness is confused, euphoria is sometimes observed, facial features are sharpened, the skin and mucous membranes are pale with an jaundiced or cyanotic tinge, the tongue is dry, overlaid with a dark plaque. Belly swollen, with palpation is not painful auscultation auscultated "deathly silence".
Diagnostics
Palpatory examination of the abdomen reveals positive peritoneal symptoms: shchetkin-Blumberg, Voskresensky, Medel, Bernstein. Percussion of the abdomen with peritonitis is characterized by dulling of sound, which indicates effusion in the free abdominal cavity; auscultatory picture suggests a decrease or absence of intestinal noises, the symptom of "deathly silence", "falling drops", "splash noise"is heard. Rectal and vaginal examination of peritonitis allows to suspect inflammation of the pelvic peritoneum (pelvioperitonitis), the presence of exudate or blood in the Douglas space.
Overview radiography of the abdominal cavity in peritonitis, due to perforation of hollow organs, indicates the presence of free gas (symptom "sickle") under the dome of the diaphragm; with intestinal obstruction, Cloiber bowls are found. Indirect x-ray signs of peritonitis are high standing and limited excursion of the diaphragm dome, the presence of effusion in the pleural sinuses. Free fluid in the abdominal cavity can be determined by ultrasound examination.
Changes in General blood analysis in case of peritonitis (leukocytosis, neutrophilia, increased erythrocyte sedimentation rate) indicate a purulent intoxication. Laparocentesis (puncture of the abdominal cavity) and diagnostic laparoscopy are indicated in cases that are unclear for diagnosis and allow to judge the cause and nature of peritonitis.
Treatment of peritonitis
Detection of peritonitis is the basis for emergency surgery. Therapeutic tactics for peritonitis depends on its cause, but in all cases, the same algorithm is followed during the operation: laparotomy, isolation or removal of the source of peritonitis, intra - and postoperative sanitation of the abdominal cavity, decompression of the small intestine is shown.
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