Peritonitis in children pediatric surgery. How does abdominal peritonitis develop in children?

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What kind of disease is peritonitis and what causes peritonitis in children?

What to do with peritonitis in children?

Lead a healthy lifestyle, strengthen your children, feed them healthy food so that the child’s body can resist infections.

This pathology is widely known in the practice of pediatric surgery under the names “diplococcal”, “pneumococcal”, “cryptogenic” or “primary” peritonitis. The disease most often occurs in girls aged 3 to 7 years. It has been established that the infection enters the abdominal cavity through the vagina with the development of endosalpingitis. At older ages, this disease occurs much less frequently. This fact is explained by the appearance of Döderlein's rods in the vagina, which, by creating an acidic environment, prevent the development of hard-nuclear microflora. The widespread introduction of laparoscopy has made it possible to convincingly confirm this point of view and change the tactics of treating such patients.

With a localized process, a transparent or cloudy mucous effusion is present in the lower floor of the abdominal cavity, stretching behind the manipulator. The largest amount is detected in the pelvic cavity. The uterus and fallopian tubes are somewhat edematous, moderately hyperemic, the ovaries are intact. Already in this early stage diseases, even in the absence of hyperemia of the parietal and visceral peritoneum, note pronounced inflammatory changes in the ampullary area of ​​the fallopian tubes. The fimbriae are sharply hyperemic, with petechial hemorrhages, and due to pronounced edema, they are moved apart to the sides in the form of a corolla. This sign is called the “red corolla” symptom and is caused by the presence of endosalpingitis, which indicates the primary localization of the inflammatory process. In this regard, it is advisable to characterize this pathology as primary ampullary pelvioperitonitis.

As the disease progresses, the effusion becomes purulent in nature, its quantity increases, but its viscous mucous consistency still remains. Endoscopically, a picture of acute purulent pelvioperitonitis is revealed. At this moment, the fallopian tubes sharply thicken due to edema, pronounced hyperemia of all pelvic organs and petechial hemorrhages appear on the peritoneum. Even with such severity of the process, the ovaries, as a rule, remain intact; oophoritis is observed extremely rarely.

Clinical picture and diagnosis Clinically, two forms of primary ampullary pelvioperitonitis are distinguished - toxic and local. The toxic form is characterized by an acute and violent onset of the disease. Severe pain in the abdomen is noted, usually in its lower parts. Body temperature most often rises to 38-39 °C. Vomiting can be repeated. Loose stools often occur, which occurs when peristalsis increases due to a pronounced inflammatory process in the abdominal cavity.

Significant severity of the general condition is observed, despite the short period that has passed from the onset of the disease (sometimes only 2-6 hours). The child is usually restless, moans, the skin is pale, the eyes are shiny. The tongue is dry, covered with a white coating. When examining the abdomen, all the signs of severe peritonitis are revealed: sharp pain and clear rigidity in all parts of the anterior abdominal wall, but somewhat greater below the navel and on the right. The Shchetkin-Blumberg symptom is positive. Moderate intestinal paresis is also noted. In many cases, it is possible to detect the phenomena of vulvovaginitis with mucopurulent discharge from the vagina. When examining peripheral blood, high leukocytosis is found (up to 20x10 9 /l and higher).

In recent years in clinical picture primary ampullary pelvioperitonitis, changes have occurred, characterized by the predominance of localized (local) forms. The toxic form of the disease occurs quite rarely (no more than 5% of cases).

In the localized form of primary ampullary pelvioperitonitis, the clinical picture is erased, intoxication is not expressed, pain is often localized in the lower abdomen or even only in the right iliac region. At the same time, body temperature does not reach high numbers and is often within the range of 37.5-38 °C. However, a more acute sudden onset of the disease, the presence of ARVI at the time of examination or ARVI suffered the day before - all these signs make one suspect primary ampullary pelvioperitonitis. However, even with typical manifestation diseases are carried out surgery, since the surgeon cannot absolutely exclude the diagnosis of acute appendicitis. Perform unnecessary appendectomy, potentially causing serious complications. postoperative complications, such as adhesive intestinal obstruction (AIO), progression inflammatory process etc. Laparoscopy allows you to confirm or exclude the diagnosis with high accuracy.

Treatment and prognosis Diagnostic laparoscopy often becomes therapeutic. Aspiration of pus is performed and an antiseptic solution is administered. Appendectomy is not performed in such cases. All patients are prescribed antibacterial therapy with penicillins or cephalosporins for 5-7 days. The prognosis is always favorable.

7.12.2. Appendiceal peritonitis

Peritonitis is a common and most severe complication of acute appendicitis in childhood, occurring in 8-10% of all cases of the disease, and in children of the first 3 years of life 4-5 times more often than in older children. In recent years, it has been possible to reduce mortality among patients hospitalized in the initial phases of the disease, but running forms mortality remains very high.

Classification Of the many proposed classifications, the most widespread is the principle of dividing peritonitis according to the stages of the process and the prevalence of peritoneal damage, the severity of intestinal paresis (Fig. 7-15).

The most appropriate division of peritonitis into local and diffuse should be considered. Local peritonitis, in turn, is divided into limited and unlimited. The latter is characterized by inflammatory changes in the affected area with possible leakage of exudate into the adjacent area along the path of natural distribution (right lateral canal and pelvic cavity). With diffuse peritonitis, inflammatory changes in the peritoneum extend beyond the focus, not along the path of natural spread. Extension of the inflammatory process beyond the right lateral canal should practically be considered diffuse peritonitis.

The most common discharge in peritonitis is three phases its course (reactive, toxic and phase of polymorphic disorders), reflecting the severity of the clinical manifestations of the disease. The phase nature of the course of peritonitis is confirmed by changes in central hemodynamics, microcirculation, and immunological reactivity.

Pathogenesis diffuse peritonitis is a complex chain of functional and morphological changes in systems and organs. The anatomical 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, underdevelopment greater omentum. Intoxication and metabolic disorders increase faster, and many protective reactions become pathological.

The leading role in the pathogenesis of peritonitis belongs to the microbial factor and the state of the body's immunoreactivity. The nature and severity of changes depend on the severity of pathological processes. It has been established that in most cases peritonitis is a polymicrobial disease. The dominant role in its development belongs to E. coli, but other microorganisms are also of great importance: enterococci, Klebsiella and others, as well as anaerobes. In a targeted study, anaerobic flora is cultured in more than a third of patients, and in the formation of intra-abdominal abscesses - in almost 100% of cases. This fact must be taken into account when prescribing empirical antibiotic therapy, since many antibiotics are ineffective against anaerobic infection.

One of the leading factors in the development of pathophysiological changes that occur during peritonitis is the resorption by the peritoneum of toxic products of purulent exudate from the abdominal cavity. The surface of the peritoneum in children, especially young children, is relatively larger than in adults. It has been established that during peritonitis, especially in its initial stages, the resorption of toxic products by the peritoneum occurs very intensively. As a result, bacterial toxins and decay products of microbial bodies enter the blood and lymph in large quantities. It is the absorption of toxic products that causes a chain of various pathophysiological disorders, including dehydration, circulatory disorders, hyperthermia, acid-base disorders, etc.

With appendiceal peritonitis, children develop dehydration and circulatory disorders quite quickly. Biologically released in large quantities active substances have a vasodilating effect, which increases the permeability of the vascular wall and promotes the release of water and low molecular weight proteins from the vascular bed. Exudation of fluid and protein into the abdominal cavity increases. At the same time, there is a significant loss of water due to frequent vomiting and loose stools. Fluid loss is also aggravated by perspiration and shortness of breath. With intestinal paresis, a massive accumulation of fluid occurs in its lumen. Massive loss of fluid from the bloodstream leads to a significant decrease in blood volume and, consequently, hemoconcentration. Hypovolemia and the hypoxemia that develops after it cause spasm of peripheral vessels and renal vessels, which leads to redistribution of blood while maintaining vital nutrition important organs, mainly the heart and brain (centralization of blood circulation). In response to this, compensatory tachycardia occurs, leading to overstrain of the heart muscle and disruption of heart function.

A decrease in renal blood flow contributes to a decrease in urine filtration in the renal glomeruli and the occurrence of renal ischemia. Subsequently, renal dysfunction leads to water, electrolyte and metabolic disorders.

Due to spasm of skin vessels, heat transfer decreases, which aggravates hyperthermia. A significant increase in body temperature (39-40 °C and above) occurs in most patients with purulent peritonitis. In young children with hyperthermia, due to increased energy consumption, energy reserves are very quickly depleted, metabolic disorders and disorders of respiratory and respiratory functions occur. of cardio-vascular system. All this can lead to adrenal insufficiency.

One of the important pathophysiological links in the development of peritonitis is metabolic disorder. With peritonitis, the replenishment of energy resources with food is disrupted, and the use of carbohydrates from the body’s own reserves (liver glycogen) begins. Then proteins and fats are used as an energy source, the breakdown of which under conditions of tissue hypoxia leads to the accumulation of under-oxidized products. The detoxification function of the liver gradually begins to suffer. In severe peritonitis, protein metabolism disorders develop. Protein loss occurs with exudate, diffusion into the intestinal lumen. Dysproteinemia develops.

The formation of acidic products changes the pH of the blood - metabolic acidosis occurs. First, metabolic changes are sufficiently compensated by breathing (due to compensatory shortness of breath and increased excretion carbon dioxide) and kidneys (by reabsorption of sodium and release of excess acid radicals). Compensatory mechanisms are very quickly depleted in conditions of peritonitis due to the limitation of respiratory excursions due to paresis and intestinal bloating, as well as due to hemodynamic disorders. Acidosis enters the stage of decompensation.

With peritonitis, significant disturbances in electrolyte metabolism also occur. Vomiting and loose stools lead to loss of fluid and electrolytes (potassium, sodium, chloride ions). As potassium and chloride ions are lost against the background of a decrease in plasma volume, disturbances in the acid-base balance occur, consisting in the development of intracellular acidosis against the background of extracellular alkalosis (Darrow mechanism). Depletion of the cell in potassium ions contributes to disruption of ATP synthesis and a decrease in energy reserves, which leads to a weakening of the contractile force of the myocardium and respiratory muscles. Shortness of breath, tachycardia occur, the stroke volume of the heart decreases and circulatory failure develops with phenomena of general tissue hypoxia. Potassium ion deficiency reduces smooth muscle tone, leading to the development and progression of gastrointestinal paresis.

Consequently, the main pathophysiological processes in peritonitis are hypovolemia and disturbances of central and peripheral hemodynamics, changes in water-electrolyte balance and acid-base status, and dysfunction of vital organs. In severe peritonitis, these disorders can be considered manifestations of peritoneal shock.

Most of these violations are reflected in clinical symptoms. It is only necessary to take into account that in children under 3 years of age, protective mechanisms quickly turn into pathological ones, and general clinical symptoms prevail over local ones.

The course of diffuse peritonitis is accompanied by pronounced disturbances in the immunological reactivity of the child’s body, which have a clearly defined phase character.

In the reactive phase of peritonitis, a tension in the factors of natural nonspecific reactivity, an increase in the activity of p-lysines, the number of leukocytes, lymphocytes, an increase in the level of immunoglobulins in the blood serum, an increase in the absolute number of rosette-forming cells, and a decrease in the relative number of T- and B-lymphocytes are noted.

In the toxic phase, there is a further increase in the general level of nonspecific indicators, but there is a change in the number of functionally active leukocytes and a drop in the concentration of serum immunoglobulins.

In the phase of multiple organ disorders, complete failure is noted protective forces, a catastrophic decrease in the indicators of both specific and nonspecific immune reactions.

Clinical picture The history usually includes pain, vomiting, and increased body temperature. In the future, the pain may subside somewhat, but hyperthermia persists, although sometimes insignificant; general state may also improve somewhat, but never recovers to a satisfactory level. After the “bright interval,” deterioration occurs: abdominal pain intensifies again, vomiting appears, and the general condition progressively worsens. The presence of such a gap is apparently associated with the destruction and necrosis of nerve endings in the appendix. The onset of a period of deterioration is explained by the involvement of the entire peritoneum in the inflammatory process as a result of perforation vermiform appendix or violation of the integrity of the conglomerate during “covered” perforation. It is possible to develop peritonitis without perforation of the appendix due to the passage of microflora through the altered wall. The speed of onset of perforation and the duration of the “clear interval” depend on the age of the patient: what smaller child, the faster the perforation occurs and the shorter the period of apparent improvement. The use of antibiotics sharply erases the severity of the clinical manifestations of appendicitis, which increases the likelihood of developing peritonitis. Antibiotics cannot stop the destructive process that has already begun, but their use reduces the severity of pain, temperature reaction and general disorders, while inflammation of the peritoneum progresses. Therefore, the use of antibiotics, especially in young children, until the cause of abdominal pain is determined is contraindicated.

Diagnostics When examining a child with appendiceal peritonitis, a significant severity of the general condition is noted. Skin pale, sometimes have a “marble” tint. The eyes are shiny, the tongue is dry, with a white coating. Usually there is shortness of breath, which is more pronounced the younger the child. It is often possible to establish a discrepancy between the pulse rate and the degree of increase in body temperature. The abdomen is swollen, sharply painful on palpation in all parts, the protective muscle tension and the Shchetkin-Blumberg symptom, most pronounced in the right iliac region.

Sometimes there is tenesmus, loose, frequent stools in small portions, painful and frequent urination. Rectal examination reveals severe pain and overhang of the rectal wall.

In young children, the general condition may be slightly impaired at first, which is associated with good compensatory capabilities of the cardiovascular system at this age. Respiratory failure may come to the fore. After some time, decompensation of the cardiovascular and respiratory systems, as well as metabolic processes, occurs, as a result of which the patient’s condition begins to progressively deteriorate. At an early age, with appendicular peritonitis, loose stools are more often observed, sometimes Green colour with mucus.

Treatment Peritonitis in children is a difficult task and consists of three main stages: preoperative preparation, surgical intervention and the postoperative period.

Preoperative preparation Immediate surgical intervention for peritonitis in conditions of significant violations internal environment body - a serious mistake. These changes can be aggravated during surgery and in the postoperative period under the influence of surgical trauma, anesthesia errors and further progression of the pathological process.

The purpose of preoperative preparation is to reduce disturbances in hemodynamics, acid-base status and water-electrolyte metabolism.

The basis of preoperative preparation is the fight against hypovolemia and dehydration. The degree of dehydration can be determined using the following formula using hematocrit values.

where m is body weight, k is the coefficient (for children over 3 years old - 1/5, for children under 3 years old - 1/3).

When carrying out infusion therapy, first of all, solutions of hemodynamic and detoxification action are prescribed (dex-stran, medium molecular mass 30000-40000, albumin, dext-ran, average molecular weight 50000-70000, Ringer's solution, blood plasma). The volume and quality of infusion therapy depend on the severity of peritonitis, the nature of hemodynamic disorders and the age of the patient. The entire complex of preoperative measures should be carried out in a fairly short time(no more than 2-3 hours).

Therapy with broad-spectrum antibiotics begins already in the preoperative period. Intravenous administration of £)cephalosporin is recommended III generation(cefotaxime, ceftriaxone) or inhibitor-protected penicillin (amoxicillin + clavulanic acid), under the protection of which the operation is performed. In the postoperative period, the administration of antibiotics is continued in the form of combined antibiotic therapy (cephalosporin + aminoglycoside + metronidazole or amoxicillin-Nclavulanic acid + aminoglycoside), which allows covering the entire spectrum of potential pathogens of peritonitis (Gram-negative bacteria, enterococci and anaerobes) Intubation and gastric lavage help reduce intoxication, improvement of breathing, prevention of aspiration. An important role, especially in children in the first months of life, is played by the fight against hyperthermia, pneumonia, pulmonary edema, and convulsions.

Surgery Surgical intervention begins when hemodynamic processes, acid-base status, water-electrolyte metabolism are compensated and stabilized, and body temperature does not exceed subfebrile levels. Surgery for peritonitis is carried out to eliminate the primary focus, sanitation and drainage of the abdominal cavity. The effect on the primary focus is appendectomy. Further tactics depend on the depth of changes in the intestines and peritoneum. The most important thing in this situation is to assess peristalsis and circulatory disorders.

Features of surgical tactics for appendiceal peritonitis depend on its phase.

In the reactive phase during surgery, abundant purulent effusion in the abdominal cavity is usually detected. The intestinal loops are somewhat swollen, hyperemic, without fibrin overlay and circulatory disturbances. Despite the fact that the inflammatory process spreads to the entire abdominal cavity, local symptoms still predominate; the body, as it were, copes with the disturbances that have arisen, using its own reserves. Among intraoperative measures in the reactive phase important role are given to thorough sanitation of the abdominal cavity. Then the surgical wound is sutured tightly, leaving a silicone drainage or a polyethylene tube from a disposable blood transfusion system in the pelvis. Drainage is introduced through an additional puncture incision in the right iliac region, slightly above and lateral to the “appendicular” incision. For its correct fixation, the abdominal wall is pierced in an oblique (at an angle of 45°) direction, after which the drainage is placed in the right lateral canal and maximally on the pelvic floor (for boys - between the rectum and bladder, for girls - between the rectum and uterus). The diameter of the holes in the section of the tube located in the pelvis should not exceed 0.5 cm. With smaller holes, the drainage quickly becomes clogged, and with larger ones, suction of the intestinal wall, omentum, and fatty deposits is possible. The drainage tube is fixed on the skin with silk sutures (Fig. 7-16).

During the toxic phase of peritonitis, a large amount of pus, significant paresis (up to paralysis), and severe circulatory disorders with fibrin deposits on the intestinal loops can be found in the abdominal cavity. Surgical tactics during this phase of peritonitis are in general principles similar to those during the previous phase, but have features. Simultaneous rinsing of the abdominal cavity should be more thorough and use a large amount of rinsing solution. For significant intestinal paresis, use various methods its decompression: intubation of the small intestine through a gastrostomy, cecostomy, retrograde through the anus, or “decanting” the contents of the small intestine into the large intestine. As with the exudative phase of peritonitis, aspiration drainage of the pelvic cavity is carried out using a drainage tube. The root of the mesentery of the small intestine is inoculated with a 0.25% procaine solution. Epidural anesthesia is indicated, which is performed in the postoperative period.

In the phase of polymorphic disorders, deep functional disorders of the intestine are revealed during surgery. Due to its paralysis, stasis and dilation of the small intestine due to the accumulation of fluid and gases is noted. In this case, delimited abscesses in the abdominal cavity are more often detected. After dividing the intestinal loops, it is advisable not to suture the midline laparotomy wound (laparostomy). After thorough sanitation of the abdominal cavity, the pelvic cavity is drained with a silicone tube. The intestines are covered with a plastic film with multiple holes up to 5 mm, and impregnated Vaseline oil napkins, over which separate sutures without tension bring the skin closer to the aponeurosis, covering only the edges of the napkins. 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 microcirculation in the intestines, restore peristalsis and relieve the inflammatory process. In this phase of peritonitis, decompression of the gastrointestinal tract is of particular importance. After 2-3 days, a repeat operation is performed: the napkins and film are removed, the wound is sanitized, the abdominal wall is sutured tightly through all layers with U-shaped mattress silk sutures. The edges of the wound are separated from the fused intestine so that the intestinal loops are not deformed during stitching.

Postoperative treatment After the operation, the patient is created exalted position in bed by raising its head end at an angle of 30°, which facilitates the child’s breathing and promotes the outflow of exudate to the lower abdomen. Place a cushion under the bent knees to prevent the child from sliding down.

It is extremely important to carefully monitor cardiac activity (pulse, blood pressure, ECG), breathing, protein composition of the blood, water-electrolyte balance, acid-base state of the blood. During the first 2-3 days, body temperature, pulse, blood pressure, and respiratory rate are monitored every 2-4 hours. Carefully measure the volume of fluid drunk and parenterally administered and excreted in urine and vomit.

In addition to the general condition (reaction to the environment, appetite, normalization of gastrointestinal function), extremely important indicators of the course of the inflammatory process in the abdominal cavity are the dynamics of the temperature reaction and the picture of peripheral blood.

Complex therapeutic measures consists of the following points: the fight against toxicosis and infection, the elimination of hemodynamic disorders and hypovolemia, the correction of water-electrolyte and metabolic changes, the elimination of anemia and hypoproteinemia.

Great importance should be given to the prevention and treatment of respiratory disorders. The complex of these measures includes decompression of the stomach by introducing a probe into it. The constant presence of a probe in the first 2-3 days after surgery prevents aspiration, helps reduce intra-abdominal pressure, increasing the ventilation capabilities of the respiratory system.

Prevention and treatment of respiratory failure are necessary throughout the immediate postoperative period. According to indications, catheterization of the tracheobronchial tree is performed, followed by suction of mucus. This makes it possible to prevent the development of atelectasis and pneumonia.

In the early postoperative period, homeostasis disturbances may again occur due to surgical trauma and the ongoing inflammatory process. The main ones are disturbances of hemodynamics, acid-base status and water-electrolyte balance. More than a third of patients with diffuse peritonitis have similar disorders with symptoms of severe metabolic acidosis. It is extremely rare, in very severe forms of peritonitis, that metabolic alkalosis is observed. Correction of hemodynamic changes and metabolic acidosis does not differ from that carried out in the preoperative period. It is achieved by intravenous administration of plasma, high molecular weight drugs, and 4% sodium bicarbonate solution. Metabolic alkalosis is corrected by intravenous administration 7.5% potassium chloride solution, on average from 8 to 10 ml (0.5 ml/kg body weight) diluted. Respiratory acidosis that occurs in the postoperative period is eliminated by dosed oxygen therapy and evacuation of gastric contents using a tube. Correction of water-electrolyte metabolism disorders does not differ from that carried out before surgery.

The success of treatment for peritonitis largely depends on the rational use of antibiotics. Combination antibiotic therapy is indicated (based on third-generation cephalosporins or inhibitor-protected penicillins). For children undergoing repeated surgery due to complications (subhepatic, subdiaphragmatic abscesses, intestinal fistulas, etc.). For patients with previous hospitalization and antibiotic therapy, as well as for postoperative peritonitis, the antibiotics of choice are carbapenems (imi-penem + cilastatin, meropenem) in monotherapy or in combination with aminoglycosides. An important link in the postoperative period in patients with peritonitis is the normalization of intestinal functions. In severe peritonitis, intestinal paresis often lasts for several days. To combat postoperative paresis, repeated hypertensive enemas are used, agents that stimulate peristalsis are prescribed subcutaneously (0.05% solution of neostigmine methyl sulfate, 0.1 ml per 1 year of life), and intravenous transfusions of hypertonic dextrose solutions (10-20 ml of 40% solution) , 10% sodium chloride solution (psG2-shgna 1 year of life) and potassium chloride solutions. The infusion of the latter is carried out in a dextrose solution by drip. The safest concentration of potassium chloride is 1%. It is necessary to monitor the regularity of stool: if it is delayed, cleansing enemas are done once every 2 days. Taking into account the possibility of formation of infiltrates and abscesses in the abdominal cavity in the postoperative period, control over the temperature reaction and the content of peripheral blood leukocytes is necessary. For all patients, even in the absence of complaints, it is advisable to periodically conduct a digital examination of the rectum for the timely detection of pelvic infiltrate or abscess, since the use of antibiotics smoothes out their clinical manifestations. Treatment of peritonitis in children, especially young children, is a task that requires an individual approach, taking into account many factors. Only massive complex therapy can be effective for this serious disease.

7.12.3. Peritonitis in newborns

Peritonitis in newborns is a serious complication of various etiologies. pathological conditions. These include necrotizing enterocolitis, gastrointestinal malformations, acute appendicitis, iatrogenic perforations of hollow organs, bacterial infection of the peritoneum by contact, hematogenous and lymphogenous routes in sepsis. The most common cause of peritonitis is perforation of the gastrointestinal tract wall (84% of cases). Intrauterine intestinal perforations with developmental defects 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, lymphogenous and transplacental infection, is now rarely observed. In the postnatal period, infection of the peritoneum occurs through contact with purulent periarteritis and periphlebitis of the umbilical vessels, liver abscesses, purulent diseases retroperitoneal space, phlegmon of the anterior abdominal wall. These forms also occur rarely today.

Classification. Peritonitis in newborns is classified as follows.

Based on etiology. Perforated : necrotizing enterocolitis (posthypoxic, septic); malformations of the gastrointestinal tract (segmental defect of the muscular layer of the wall of a hollow organ, complications with atresia, volvulus, meconium ileus, Hirschsprung's disease); acute appendicitis; destructive cholecystitis and cholangitis; Iatrogenic perforation of hollow organs. Imperforate peritonitis: hematogenous, lymphogenous infection of the peritoneum; contact infection of the peritoneum.

By time of occurrence: prenatal; postnatal.

According to the degree of distribution in the abdominal cavity: diffuse; delimited.

According to the nature of the effusion in the abdominal cavity: fibroadhesive; fibrinous-purulent; fibrinous-purulent, fecal.

Clinical picture postnatal perforated peritonitis in newborns with intestinal wall defects is manifested by acute symptoms of peritoneal shock on the 2-3rd day of life. The child is lethargic and moans. The skin is pale gray, acrocyanosis. Breathing is frequent and shallow due to the high position of the diaphragm dome. Heart sounds are muffled. Notice the sharp swelling, tension and pain in the abdomen, and the expansion of the subcutaneous venous network. With peritonitis, newborns often experience hyperemia of the skin in the lower abdomen and genitals. Intestinal peristalsis cannot be heard. Percussion above the liver reveals a box sound - a symptom of the disappearance of hepatic dullness. Celebrate constant vomiting intestinal contents, stool and gases do not pass away.

Diagnosis The diagnosis is confirmed by a survey x-ray of the abdominal organs. Significant pneumoperitoneum is detected under the dome of the diaphragm (Fig. 7-17).

Treatment Treatment is only surgical. After puncture of the abdominal cavity and reduction of intra-abdominal pressure, comprehensive preoperative preparation is carried out for 2-3 hours, aimed at eliminating the symptoms of centralization of blood circulation. Preference is given to upper transverse laparotomy, which allows for a full examination of the abdominal organs. The intestinal loop with the perforation area is sutured to abdominal wall in the form of an intestinal fistula. After this, the abdominal cavity is washed with antiseptic solutions and sutured, leaving drainage.

Prevention Currently Special attention pay attention to the prevention of peritonitis in newborns. Early diagnosis developmental defects and diseases leading to peritonitis, can significantly reduce its frequency and improve treatment results.

7.12.4. Necrotizing enterocolitis

One of the most common reasons postnatal perforative peritonitis (60% of all perforations) - hemorrhagic or septic infarction that develops as a result of circulatory disorders in the wall of the gastrointestinal tract. Among children during the adaptation period, necrotizing enterocolitis occurs in 0.25%, and among children requiring intensive care in the neonatal period - in 4%. Necrotizing enterocolitis is a polyetiological disease. In the early neonatal period, the disease develops in children who have suffered severe neonatal hypoxia and asphyxia; it can also be a complication of infusion therapy and replacement blood transfusion administered through the umbilical vein; it can develop with decompensation of severe birth defect heart and decompensated form of Hirschsprung's disease. Irrational use of antibiotics also contributes to the development of enterocolitis. Along with the direct damaging effect of some antibiotics (ampicillin, tetracycline) on the intestinal mucosa, the suppression of colonization resistance of saprophytic flora with the development of severe dysbiosis is essential. Despite the variety of etiological factors, the pathogenesis of necrotizing enterocolitis involves severe microcirculatory disorders in the wall of the gastrointestinal tract. Centralization of blood circulation occurs with spasm of mesenteric vessels (up to complete cessation of blood circulation), which is resolved by intestinal paresis with hemorrhages. Morphologically, large or small infarctions of the intestinal wall are identified. More frequent defeat premature babies are explained by the low resistance of their capillaries to pressure changes in the vascular bed. Predominantly, damage occurs to the distal ileum and the angles of the colon (ileocecal, hepatic, splenic, sigmoid). The process begins with necrosis of the mucous membrane, and then spreads to the submucosal, muscular and serous layers, ending with perforation (Fig. 7-18).

Clinical picture and diagnosis In the clinical picture of necrotizing enterocolitis in children who have suffered chronic perinatal hypoxia and infection, a clear staged course of the disease is noted.

Stage I can be regarded as prodromal. The condition of children at risk who have suffered perinatal hypoxia and infection is closer to severe due to neurological disorders, respiratory and cardiovascular disorders. From the gastrointestinal tract, symptoms of dyskinesia are detected. Sluggish intermittent sucking, regurgitation during and after feeding with milk, occasionally bile, malnutrition, aerophagia, bloating, restlessness of the child while stroking the abdomen in the absence of symptoms of peritoneal irritation, delayed passage of meconium stool, and rapid loss of body weight are clearly expressed. X-rays show increased uniform gas filling of all parts of the gastrointestinal tract with slight thickening of the intestinal walls.

Stage II is characterized by clinical manifestations of necrotizing enterocolitis. In newborns on the 5-9th day of life, the condition worsens, the symptoms of dynamic intestinal obstruction increase, the body weight deficit is 10-15% due to dehydration. The child sucks poorly, regurgitates with an admixture of bile, abdominal bloating increases, and local pain appears, most often in the right iliac region. The passage of feces is frequent, occurs in meager portions, with an admixture of mucus and greens. The color of the stool is determined by the nature of the pathological intestinal microflora. Thus, staphylococcal dysbacteriosis is characterized by pronounced general toxicosis, and in liquid foamy stool- slime and greens. A gram-negative infection is more characterized by severe dehydration, scanty, porous, pale yellow stool with mucus and a large water spot. A plain X-ray of the abdominal organs shows increased uneven gas filling of the gastrointestinal tract with a shadowing zone corresponding to the area of ​​maximum intestinal damage. The stomach is distended, with fluid levels. Thickening of the shadows of the intestinal walls is characteristic due to their edema, inflammation and interloop effusion. The rigidity of the intestinal walls leads to straightening of their contours. Submucosal cystic pneumatosis of the intestinal wall appears (Fig. 7-19). In severe cases, gas is detected in the portal system of the liver (Fig. 7-20). Progressive dehydration and loss of body weight further disrupt the microcirculation of the intestinal wall and contribute to the progression of the necrotic process. Violations of the barrier function of the intestinal wall are accompanied by severe infectious toxicosis.

Stage III - (pre-perforation) intestinal paresis is expressed. The duration of the stage is no more than 12-24 hours. The condition is very serious, symptoms of toxicosis and exicosis are pronounced, characterized by persistent vomiting of bile and “feces”, severe bloating, pain and tension throughout the abdomen. Peristalsis is sluggish, but audible. Feces and gases do not pass. The anus is closed. During a rectal examination (finger, probe), scarlet blood is released. Radiologically, due to hydroperitoneum, shading of the abdominal cavity increases, the external contours of the intestinal loops lose their clear outline (Fig. 7-21).

Stage IV - (spread perforated peritonitis) is characterized by symptoms of peritoneal shock and intestinal paralysis. The peculiarity of perforated peritonitis in necrotizing enterocolitis is a significant area of ​​intestinal damage, the severity of the adhesive-inflammatory process in the abdominal cavity, and moderate pneumoperitoneum (Fig. 7-22).

A more favorable complication of necrotizing enterocolitis is limited peritonitis, observed in a third of cases during treatment. A child with clinical symptoms enterocolitis in the abdominal cavity (usually in the iliac region) a dense infiltrate appears with clear contours, moderately painful. Against the background of conservative therapy, both complete resorption of the infiltrate and its abscess formation with the formation of an intestinal fistula on the anterior abdominal wall are possible. When conducting differential diagnosis Great difficulties arise, since the clinical manifestations are similar to acute appendicitis.

Peritonitis is an inflammatory process of the abdominal mucosa. In most cases he acts secondary disease, occurs against the background of other internal inflammatory processes.

Peritonitis in adults and children has distinctive features. Firstly, this concerns the etiology of the disease; in children the number of causes is much shorter; in most cases, peritonitis is observed after acute appendicitis. Secondly, the process of diagnosis and treatment in children is a little more complicated, especially for young children who cannot articulate symptoms. How to recognize peritonitis in time, and what treatment methods should be used?

General characteristics of peritonitis in children

In children it is considered not a very common condition; the percentage of patients does not exceed 2%. The most dangerous disease is between the ages of 0 and 3 years. After 5 years, children are no longer included in the group special risk, the shape of their abdominal cavity allows you to quickly eliminate the symptoms of the disease and stop the process.

Inflammation of the peritoneum at a young age develops quite quickly. The cavity is small in size and the internal organs function clearly, so the inflammatory process can cover its cavity or develop locally.

The nature of the disease is influenced by the following indicators:

• Primary disease and its form;
• Child's age;
• General health and immune defense.

The prognosis of peritonitis in children is also different. If the diagnosis is correctly determined in time and specialized therapy is carried out, the child can quickly return to normal life. Lack of specialized care can lead to the most adverse consequences, including death.

What can cause peritonitis?

The key reasons for the development of peritonitis in children are internal pathological processes. Experts place acute in first place. This inflammation of the cecum, which requires urgent removal, in children can penetrate into especially severe forms. Peritonitis in such cases occurs as a complication.

Other possible causes include the following pathological conditions:

• Intra-abdominal bleeding (can be caused by many disorders);
• Tears and large cracks in the peritoneum;
• Acute intestinal obstruction;
• Extensive helminthic infestations;
• Injury to the abdominal cavity, loss of integrity internal organs;
• Sepsis caused by internal inflammation of the navel;
• Diplococcal infectious disease;
• Complications after surgery;
• Meconium in the peritoneum.

To eliminate the disease, an integrated approach is required; treatment is prescribed to eliminate the primary disease and peritonitis.

How to recognize a disease in a child?

The main danger of peritonitis is in childhood, when the symptoms are vague and the child cannot yet determine the nature of the pain.

With peritonitis, the child’s condition sharply worsens, he becomes capricious, cries, and refuses to eat. This occurs as a result of acute pain caused by the inflammatory process.

Then other symptoms develop:

• The pain is localized in the right side, intensifies with movement, and has a sharp, stabbing character;
• Nausea with frequent bouts of vomiting, after which the patient does not feel better, first the stomach contents come out, then bile and parts of feces appear;
• Extensive diarrhea, stool has a liquid, foamy consistency;
• with frequent release of gases;
• Heaviness in the intestines caused by impaired peristalsis;
• The smallest children become in the form of a fetus with bent knees, so the pain subsides a little;
• Heart rate increases;
• Body temperature rises to 38 or more;
• The skin becomes dry, pale, and looks like marble;
• The mouth feels dry;
• Blood pressure decreases.

The disease progresses very actively, and the symptoms only intensify. At an advanced stage of peritonitis, the child’s central nervous system is affected, so loss of consciousness, dysfunction of some organs, and even coma may occur.

How to diagnose peritonitis in children?

The specialist examines the child very carefully, listens to all complaints from the child or parents, and palpates the abdomen. With peritonitis, the pain intensifies when pressed.

Also mandatory procedures is to measure body temperature, blood pressure and pulse.

To confirm the diagnosis, the doctor must observe the child’s condition for several hours; with peritonitis, the condition worsens.

You should undergo a number of laboratory tests:

• General and biochemical analysis blood and culture;
• General urine analysis and culture.

It is impossible to confirm the diagnosis without a number of instrumental studies:

• CT and MRI;
• Ultrasound;
• Electrocardiogram;
• Laparoscopy;
• Radiography.

After a set of diagnostic procedures, urgent specialized treatment is prescribed.

Treatment

Peritonitis requires drastic treatment measures and urgent surgical intervention. But before this it is necessary to go through a number of preparatory procedures.

To begin with, medicinal preparation is carried out, including the following procedures:

• Full antibacterial therapy to destroy infection;
• General anesthesia;
• Acceptance of funds for withdrawal;
• Symptomatic treatment.

This is followed by surgery, the source of peritonitis is eliminated, and the abdominal cavity is subject to antiseptic treatment. After surgery, a drain is placed for postoperative treatment. The full treatment course lasts at least 7 days. All this time the child must remain in the hospital under strict supervision.

Experts say that self-medication in case of peritonitis can be dangerous for the child’s life. Warming up, folk remedies, washing and others unconventional methods They have no effect, they only provoke inflammation. Therefore, peritonitis should be eliminated only by specialists in a hospital setting and as soon as possible.

After surgery, you should also not deviate from the prescribed therapy and rehabilitation. Otherwise, complications may arise in the form of an abscess and other processes that are dangerous to the health and even the life of the child.

What kind of disease is peritonitis? This acute stage an inflammatory process that occurred due to dysfunction of the peritoneum. Most often, peritonitis in children occurs with appendicitis, after surgery to remove it. If the child is not helped in a timely manner, serious complications and death may follow.

Peritonitis in children differs significantly from the adult disease, since the internal organs of children are not fully formed, and the systems work at full capacity. In case of illness, only the surgeon selects the treatment method; self-medication and the use of traditional medicine are completely unacceptable.

The article will discuss peritonitis. What kind of disease is this, what are its symptoms and causes of development? We will also talk about treatment and prognosis, prevention and possible complications.

Reasons for the development of the disease

Doctors identify factors that provoke the development this state in children. The main causes of peritonitis:

• exacerbation of acute appendicitis;
• bleeding in the abdominal cavity;
• intestinal obstruction;
• worms;
• inflammatory processes in internal organs or in the abdominal cavity;
• umbilical sepsis;
• infections;
• ruptures in the abdominal cavity;
• injuries and wounds in the abdominal area;
• the presence of meconium in the peritoneum.

It is very difficult in children. This disease is more common among adults. But it is in children that appendiceal peritonitis most often occurs after surgery (appendicitis requires such treatment). The symptoms are very similar to other diseases of the peritoneum. And the younger the child, the more difficult it is to make an accurate diagnosis.

Goes through the following stages:

• Reactive period. Lasts about a day.
• Toxic stage- lasting 72 hours.
• Terminal stage, obvious signs of the disease appear, persist heat.

Each stage has its own signs and symptoms; the earlier the disease is detected, the greater the chance of avoiding complications.

Classification

Depending on the causes of peritonitis and its spread, the following classifications have been developed:

• According to the distribution of peritonitis, there are: local; spilled; general.
• According to the location of the disease in children, the following forms are distinguished: Appendicular - it is characterized by the collection of blood, cells and pus around the appendix; in children (cryptogenic), most often occurs in children between 4 and 7 years of age. The form of the disease affects only girls, when the infection enters the peritoneum through the vagina. Peritonitis in newborns occurs due to perforation of the wall of the gastrointestinal tract or the development of defects in the intestines. Combined peritonitis - when pus and fluid accumulate directly in the peritoneum.

Symptoms

Acute pain in children occurs in very rare cases. Since the child’s body is just forming, the symptoms of peritonitis in children manifest themselves with a general deterioration of their condition. It should be noted that all characteristic features diseases are not clearly expressed.

The main symptoms of peritonitis in children, if it is caused by appendicitis, injury or infection:

• tearfulness, anxiety of the child;
• sluggish appearance;
• poor appetite;
• insomnia;
• high body temperature;
• bloating;
• diarrhea or constipation;
• abdominal pain;
• dry skin.

Primary peritonitis is characterized by rapid development of the disease. Observed following signs:

• high body temperature;
• pain in the lower abdomen;
• vomit;
• diarrhea;
• pale and dry skin;
• sparkling eyes;
• white coating on the tongue;
• thirst.

With a localized form of peritonitis in children, the symptoms are less striking, but appear as follows:

• discomfort in the right side of the abdomen;
• body temperature not higher than 38 degrees;
• rapidly developing symptoms ARVI.

Parents should note that the symptoms of the disease in children differ significantly from those in adults. At the initial stage, signs of the disease may not be observed at all. But, nevertheless, peritonitis develops further and can turn into a purulent form, because the focus of inflammation is rapidly increasing.

Adults must pay attention to the following: alarming symptoms, and immediately apply for medical care. Sound the alarm if your child:

• vomiting and nausea;
• body temperature above 38 degrees;
• sharp pain in the right side of the abdomen;
• general condition quickly deteriorates;
• intestinal dysfunction;
• painful and frequent urination;
• loss of appetite;
• very tense abdominal muscles.

At an early stage, symptoms sometimes disappear and a temporary improvement in well-being occurs (false), but the body temperature remains high. The child feels better, but then the condition worsens sharply, and the symptoms begin to appear with renewed vigor. During the period of false improvement, treatment cannot be stopped, since the causes that provoked peritonitis have not been completely eliminated.

In later stages of the disease there are following symptoms peritonitis in children:

• eyes constantly water and shine;
• the skin becomes gray;
• absence of bowel movements for several days;
• rapid pulse;
• severe throbbing abdominal pain.

Diagnostics

At the first signs of illness, you should immediately seek medical help. The doctor examines the patient, takes blood and urine for analysis, and conducts ultrasound diagnostics.

In severe and advanced cases, puncture and surgical intervention are performed, the peritoneum can be punctured and fluid and pus can be pumped out (in case of emergency).

Treatment

The only way treatment of severe peritonitis - surgical intervention. The surgeon performs a laparotomy and examines the peritoneum. If necessary, the cause of infection is eliminated, the peritoneal cavity is washed antibacterial agents and antibiotics. After suturing the wound, a small drain is attached to administer antibiotics.

In the postoperative period of peritonitis, children are treated as follows:

• Antibiotics are injected into a vein.
• The child is given antipyretic drugs.
• Prescribed medications for intoxication and to improve blood circulation.
• They put them on a strict diet.

It is very important to adhere to a special diet after treatment of peritonitis. After surgery, the child can eat:

• broths (chicken or turkey);
• yoghurts without additives (classic);
• vegetable puree;
• rice porrige on the water;
• berries and fruits.

You should not take any food or medications without your doctor's knowledge. If all the rules for the treatment of peritonitis in children and clinical guidelines If the doctors are followed, recovery will come very quickly.

Complications

Despite the level modern medicine, peritonitis is dangerous due to a number of complications:

• adhesive diseases;
• sepsis;
• kidney dysfunction;
• disruptions in the functioning of the gastrointestinal tract.

In this case, complications may not arise immediately, but several years after primary peritonitis in children. These are fairly common occurrences in pediatric surgery.

Rehabilitation and prevention

Prevent this serious illness you can, the main thing is to adhere to a healthy lifestyle, which includes:

• proper nutrition;
• adherence to sleep and wakefulness;
• compliance with personal hygiene rules;

You also need to remember two important rules:

• at the first suspicion, parents should seek professional help;
• Do not self-medicate, it can lead to serious complications and even the death of the baby.

The key to success in treating this disease is timely surgical intervention. The prognosis for recovery in such cases is positive.

Forecast

The disease develops gradually, the initial stage passes into the compensated stage (when the body itself is able to cope with inflammation). However, after this, the stage of decompensation begins (the body is no longer able to fight, it has lost all its strength, the patient is very weakened and lethargic). In this case, only surgical intervention can save the child’s life. Of great importance in the success of the operation is timely access to a doctor and the general health of the child at the time of hospitalization.

Let's sum it up

Peritonitis, in medicine, is called inflammation abdominal area. Moreover, this disease in children has a number of distinctive features. Their organs and systems continue to form, so the symptoms are not so clearly expressed. You should carefully monitor the child and show him to the surgeon at the first symptoms. Delay in dealing with this disease can cost the child’s life. Risk fatal outcome with peritonitis in children it accounts for 50-90% of all cases.

Parents should do everything to prevent the development of peritonitis in children. It is necessary to promptly treat diseases of internal organs and infections that can provoke the development of peritonitis. Even a minor illness or simple gastrointestinal disorder can result in serious consequences. To avoid this terrible disease, the whole family must try to lead a correct lifestyle, organize the child proper nutrition, make sure that he has good rest. Parents bear full responsibility for the life and health of their children. Only proper organization of a child’s life can minimize the risk of developing dangerous diseases.

The disease peritonitis in children occurs as a complication after surgery, for example, when appendicitis was removed. The disease is classified into two types: primary and secondary. Primary is easier than secondary, but if you ignore the child’s complaints, the consequences can be very serious, even fatal.

Peritonitis in children differs from a similar disease in adults, because the organs are not fully formed, and the body systems are working at full capacity. Treatment is prescribed by a doctor; self-medication is unacceptable.

Children's appendiceal peritonitis has two main types.

Free

Free peritonitis or widespread form. This variety includes several types that determine where the source of the disease is located:

• Localization of inflammation in the area of ​​the cecum, name: local unlimited;
• The area of ​​inflammation does not extend beyond the lower part of the peritoneum, name: diffuse;
• The process of inflammation covers the bottom and middle of the peritoneum, name: diffuse;
• The entire cavity is affected, name: general.

Very often, free peritonitis accompanies the so-called purulent effusion. Fluid accumulates at the site of localization, complicating the course of the disease and its treatment.

Abscessing

Abscessing peritonitis or localized form. In this case, the following are possible:

• Appendiceal infiltrate, when the appendix area is thickened with products of the inflammatory process (blood, cells, purulent effusion);
• Periappendicular abscess of three degrees, means total suppuration;
• A combined form, when an extensive abscess and purulent effusion complicate the problem;
• Form of total inflammation – This is the most dangerous subtype of peritonitis for a child’s life; it is also accompanied by infectious-toxic shock.

Severe consequences of the second type are sometimes inevitable.

Why does peritonitis occur?

The causes of this disease in a child are varied, the list is as follows:

Most often, appendicular peritonitis occurs, since it is very difficult to diagnose, especially small ones: the symptoms are similar to other diseases.

Stages of appendiceal peritonitis:

1. Reactive. Valid for about a day from the moment of localization.
2. Toxic. Lasts up to 72 hours.
3. Terminal. Signs appear on the third day.

At each stage, appendicular peritonitis has specific symptoms. The sooner appropriate treatment is started, the greater the chance of avoiding serious complications.

Symptoms

Adults should pay attention that the baby’s condition is deteriorating right before our eyes. It is worth noting that the signs of the disease in children can be very different from the corresponding symptoms in adults or the elderly. The initial stage in the first ones is not so identified, the symptoms are smoothed out, and the signs do not make themselves felt. However, peritonitis develops and can become purulent as the focus of inflammation grows.

What symptoms should adults respond to:

• Nausea and vomiting;
• High body temperature of the baby (more than 38 degrees);
• Sharp pain in the right hypochondrium, then spreading throughout the entire abdominal cavity;
• The general condition worsens: the child is capricious, restless, and experiences severe weakness;
• Intestinal dysfunction (diarrhea and obstruction are equally possible);
• Frequent urination, often accompanied by pain;
• Sleep disturbance (fears and insomnia);
• Loss of appetite;
• The abdominal muscles are tense (easy to determine by palpation).

At an early stage, some symptoms sometimes disappear, a false improvement in health occurs, but the body temperature remains high. The child experiences relief, but then the condition worsens sharply, and the symptoms appear with renewed vigor.

During false improvement, treatment should not be stopped under any circumstances, since the causes of peritonitis have not been eliminated.

Late stages are characterized by the following symptoms:

• The complexion takes on a gray tint;
• The eyes shine and water;
• The mucous membrane dries out, the child experiences extreme thirst;
• The tongue becomes covered with a white coating;
• The heart rate increases noticeably;
• Abdominal bloating occurs;
• The chair disappears;
• Palpation becomes painful.

Diagnostics

The first thing parents should do is call a doctor immediately. After the diagnosis is established, the child is hospitalized.

Inpatient diagnostics include:

• Blood tests;
• Urine tests;
• Ultrasound examination;
• X-ray pictures.

In serious situations: puncture, laparoscopy (surgical examination), laparocentesis (puncture, pumping out pus or fluid).

Treatment

Most often, treatment is impossible without surgery. The causes of the inflammatory process may be different, but surgical intervention is inevitable.

Operation

The operation for inflammation of the peritoneum takes place in several stages:

1. Preparation for surgery. The set of measures depends on the stage and type of the disease. Sometimes this takes more than three hours.
2. Surgery to eliminate the cause of inflammation. Possible removal of a section of intestine.
3. Washing the area special composition, including an antibiotic and other antibacterial drugs.
4. Stitching. The wound is sutured, a drain is inserted, and sanitization solutions are injected through it after the operation, during the recovery period.

Drugs

In parallel with the above, powerful infusion therapy is carried out:

• Injections with antibiotics;
• Medicines to reduce body temperature;
• Products for improving metabolism and blood microcirculation.

Rehabilitation and prevention

After the operation, the child is under the supervision of a doctor. It is necessary to ensure the correct position (head raised). It is necessary to prevent infection, further dehydration and intoxication of the body.

If the baby experiences pain, painkillers are administered. A gentle diet is followed to normalize intestinal function. Tests are done regularly.

Peritonitis is a dangerous disease. It is absolutely unacceptable to self-medicate and delay calling an ambulance. It is important not to miss the initial stage and seek medical help in a timely manner. Sometimes, this is the only way to save a child’s life.


As a preventative measure, educational outreach is carried out among the population. Adults should understand that timely seeking help from a specialist will help avoid complications. The key to success in the treatment of this disease is a clear understanding of what is happening and prompt surgical intervention. The prognosis for recovery in such cases is always positive.