Causes of peritonitis of the abdominal cavity. Peritonitis of the abdominal cavity: what is it, symptoms, treatment, causes, signs Peritonitis of the abdominal cavity prognosis

The peritoneum is a shell in the form of two sheets. The spaces they form contain serous fluid. The main function of the peritoneum is the creation of partitions between the internal organs and muscles, as well as fixation in a suspended state with the help of mesentery and ligaments. The peritoneum protects the internal organs in yet another way. When it encounters microbes, substances are produced that lead to the death of harmful microorganisms. Peritonitis - inflammation of the peritoneum, leading to disruption of all systems and organs located in this area, what are the symptoms of the pathology?

Peritonitis - inflammation of the peritoneum

Peritonitis begins to develop when the peritoneum cannot cope with the huge number of invading and multiplying microbes. In this situation, the peritoneum becomes a source that spreads the infection. This disease is life threatening and can end sadly if adequate measures are not taken to localize the inflammation and normalize the condition.

The introduction and spread of infection in the abdominal cavity most often develops as a result of trauma to the organs of this area, a violation of their integrity. The cause may be a disease of the internal organs. Occasionally, peritonitis can develop when microorganisms are brought into this area by blood or lymph.

In most cases, peritonitis does not occur as an independent disease, but as a complication of diseases of the abdominal organs. For example, appendicitis, intestinal obstruction, as well as duodenal ulcers, in case of untimely measures taken, end in peritonitis. The destruction of the organ after the collapse of the tumor leads to inflammation of the peritoneum. The necrosis of a fragment of the intestine during a hernia, trauma to the abdominal cavity, accompanied by injury, rupture of the organ, partial destruction of the wall of the stomach or intestines by a foreign body can also result in peritonitis.

Sometimes, with heart disease, fluid accumulates in the abdominal cavity, which suppurates in the event of an unfavorable development of events. This becomes another cause of peritonitis.

Not all types of peritonitis are caused by pathogens. For example, getting into the abdominal cavity of blood due to violation of the integrity of the vessel also leads to peritonitis. In this case, the type of disease is called aseptic or non-microbial. The disease at this level lasts no more than 6 hours. After this period, microbes from the intestinal zone penetrate into the hematoma. After that, peritonitis becomes normal.

Signs of peritonitis

Manifestations of peritonitis are due to the reasons that provoked its development. But the main features of this or that stage coincide in any case.

Reactive stage

This is the first stage, it takes the first day of the course of the disease. The damage is local. Patients first feel sharp pains that appear unexpectedly. In this case, you can accurately determine the place where the pain comes from. Some compare the pain at this stage with a dagger strike.

Localization of pain is associated with the organ that became the source of the development of the disease. For example, with appendicitis, pain will be felt in the lower lateral zone on the right. If this is a perforation of a stomach ulcer, then the pain will appear in the hypochondrium on the left or. The pain is felt strongly, while it gradually spreads.

Sometimes there are periods when the pain seems to subside. But this is not for long. Relief lasts no more than 2 - 3 hours. Then everything escalates.

The patient has a rather characteristic appearance:

• pale skin, bluish tint;
• cold sweat;
• suffering expression.

Pain greatly disturbs a person, he, as a rule, tries to alleviate their intensity by taking certain postures. For example, lie on your side and tuck your knees, do not cough, do not inflate your stomach.

A characteristic symptom of peritonitis is a disc-shaped abdomen. This symptom is expressed in an overly tense abdomen. His feeling is very painful. To check for peritonitis, you can apply the Shchetkin-Blumberg method: press on the abdomen, and then quickly remove your hand.

Also typical signs will be false urge to defecate or urinate, repeated vomiting many times. Other signs that are considered symptoms of peritonitis indicate intoxication of the body. This is an increase in temperature, rapid pulse, dry mouth, intense thirst.

toxic

This is the second stage. During this period, the person is in a serious condition. All signs indicating the presence of poisoning are manifested. This stage takes about two days, begins 24 hours after the onset of the disease. Symptoms of the first stage are smoothed out. The muscles of the abdominal wall are slightly tense, they can generally be normal. Pain sensations are not strong, blurry. The appearance of a person at the moment also has common typical features:

• pale lips;
• cold extremities;
• bluish nose, ears, nails.

Dry mouth persists, consciousness may be disturbed. This is expressed in complete indifference, less often in excitement. The patient may lose consciousness. The patient lies without moving. Doesn't respond to palpation. persists, only the vomit acquires a different color. They become dark, brown, fetid. Little or no urine. The temperature rises to very high figures: 40 - 42 °. Breathing becomes unstable, the pulse is very weak.

Terminal stage (irreversible)

This is the third stage, it comes three days after the onset of the disease. After three, and sometimes even after two days, it ends with the death of the patient. The condition can be classified as extremely serious. The appearance of all patients in this situation is the same. This complex of external manifestations is called the "face of Hippocrates":

• cyanotic moist skin;
• sunken cheeks;
• overly sharp features.

The abdomen is soft, there is no pain at all, palpation does not cause discomfort. The pulse is not palpable, breathing is weak, may be completely absent, pressure is not determined. Human life at this stage is possible only in intensive care with the use of artificial life support systems.

Diagnosis of peritonitis

If peritonitis has developed in a confined space, as occurs in encysted peritonitis, it can be difficult to make a diagnosis. Ulcers that are a consequence of laparotomy interventions (subdiaphragmatic, interloop, pelvic, abscesses, ulcers of the right iliac fossa) also have diagnostic difficulties.

With sluggish processes, the disease can manifest itself as short-term pain sensations, which are replaced by general malaise. Anemia, exhaustion, a person may develop a fever. There are no local signs, so the doctor may consider that an infection has settled in the body or a tumor process is going on somewhere.

It is very difficult to identify this type of peritonitis. It is necessary to conduct a comprehensive examination, including many tests, vaginal, rectal examinations. Of course, such a diagnosis is best done in a hospital. The diagnosis can be made by analyzing the entire clinical picture. Attention is paid to whether there is intoxication, and, of course, to the condition of the peritoneum. To make sure the diagnosis is correct, use the result of radiography, laparoscopy.

If the patient is suspected of local or diffuse peritonitis, he is urgently sent to the hospital.

You should not give drugs to eliminate pain, because this greatly changes the picture of what is happening. Then in the hospital it may be difficult to make a diagnosis. To alleviate the condition, an ice pack is placed on the stomach. Polyglucin is administered intravenously. It will help to avoid severe dehydration and infectious-toxic shock. It is necessary to inject the drug drip. Quantity 400 - 800 ml. glucose (5%) or sodium chloride is also administered. These drugs facilitate the general condition of the patient, create safer conditions for transportation, and serve as some preparation for the upcoming operation.

Treatment of peritonitis

If the diagnosis is established, an emergency operation is performed. During the operation, they act according to the circumstances. After examining all tissues, the affected areas of organs are sutured, tumors are removed, and bleeding is stopped. Existing purulent foci are brought back to normal, they are washed with antiseptic solutions. It is advisable to use Ringer's solution.

If inflammation has affected significant areas, then washing is carried out for several days. After the operation is administered in large quantities. Also direct actions to eliminate dehydration.

The famous surgeon S. I. Spasokukotsky noted back in 1926 that if the operation was performed in the first hours after the development of inflammation, then 90% of patients recover. The operation during the first day gives recovery in 50% of cases. And only 10% have a chance to survive if the operation is done later than the third day.

In our time, approximately the same trend continues. Surgical intervention on the first day ends with recovery. At the second stage, the success of treatment is already doubtful. Recovery occurs if the organs and systems are not severely affected. At the third stage, it is not possible to correct the condition, because irreparable changes occur with the internal organs.

Preventive actions

Prevention of this disease is to inform people about. Only people who have knowledge about the stages of this disease and about its other features can take adequate measures in time and avoid the sad part.

Video material for the curious, but not for the faint of heart. Surgical complications. Relaparoscopy for biliary peritonitis:

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In its course, peritonitis can be either acute (caused by a pyogenic, predominantly mixed infection) or chronic (caused in most cases by a tubercle bacillus).

Acute purulent peritonitis causes:

1. Inflammatory disease of any of the abdominal organs (acute appendicitis, cholecystitis, strangulated hernia, inflammation of the internal genital organs in women, etc.), in which the infection spreads from the main focus to the peritoneum.

2. Perforation of the abdominal organs (perforated stomach ulcer, perforation of a typhoid ulcer of the small intestine, etc.), as a result of which the infected contents are poured into the abdominal cavity and cause peritonitis.

3. Injuries to the abdominal organs, which include not only penetrating wounds of the abdominal wall and abdominal organs, but also some blunt (closed) injuries to these organs, such as the intestines. In both of these cases, pyogenic microbes penetrate into the abdominal cavity and cause the development of an acute purulent inflammatory process in it.

4. Hematogenous (i.e., through the bloodstream) spread of infection to the peritoneum from some distant inflammatory focus, for example, with tonsillitis, osteomyelitis, sepsis, which, however, is very rare.

Thus, peritonitis is always a secondary disease that occurs most often as a complication of any inflammatory process, perforation or injury in the abdominal cavity. That is why, with inflammation of the peritoneum, one should not be limited to the diagnosis of "peritonitis", but it is necessary to establish its primary source, which in fact is the primary disease, and peritonitis is only its complication. True, this is often possible only in the initial stage of peritonitis or during surgery.

Initially, acute purulent peritonitis occurs as a local inflammatory process. A striking example of such local peritonitis is local inflammation of the peritoneum in acute appendicitis. With local peritonitis, the inflammatory process is very often delimited with the help of fibrinous adhesions from the rest of the healthy or free abdominal cavity. In such cases, they speak of limited peritonitis.

If such adhesions delimit purulent effusion, then such a local process is called encysted peritonitis (for example, appendicular abscesses, etc.). However, in some cases, as the infection spreads, the entire peritoneum or a significant part of it can be quickly involved in the inflammatory process. This is general or diffuse peritonitis.

Peritonitis signs and symptoms. Between the immediate cause that causes purulent peritonitis (inflammation, trauma) and the appearance of its first signs, several hours usually pass. The clinical picture of peritonitis consists of a number of general and local signs, which, however, do not remain unchanged, but vary depending on the degree and stage of development of the infectious-inflammatory process in the abdominal cavity.

It should be emphasized the particular importance of the initial or early symptoms of purulent peritonitis, appearing in the first hours from the onset of the development of the inflammatory process. It is in this initial period of development of peritonitis that the appropriate treatment (operation, etc.) gives the greatest success. In the later stages of the development of peritonitis, when many of the "classic" symptoms of this serious and dangerous disease appear, the chances of saving the patient are sharply reduced. That is why the early diagnosis of peritonitis is so important.

In the initial stage of the development of peritonitis, the main symptoms of peritoneal irritation occur: local pain, protective tension of the abdominal muscles and Shchetkin-Blumberg's symptom.

The initial pain and the site of greatest tenderness in peritonitis usually correspond to the location of its source. So, for example, with a perforated stomach ulcer, pain is felt in the epigastric region, with acute appendicitis - mainly in the right iliac region. As the inflammatory process develops, the pain spreads throughout the abdomen. In some cases, extensive irritation of the peritoneum can even lead to shock.

It should be borne in mind that in especially severe forms of peritonitis (septic peritonitis), pain may almost be absent due to the dulling of the patient's sensitivity due to severe intoxication of the body. When feeling the abdomen, pain in peritonitis intensifies.

Very characteristic both for the initial stage of the development of peritonitis, and for its subsequent course, is the pain symptom of Shchetkin-Blumberg. This valuable sign of irritation or inflammation of the peritoneum is that if a finger or fingers gradually and slowly press on the abdominal wall in the area of ​​\u200b\u200bthe inflammatory focus, and then immediately remove the fingers, then the patient feels acute pain.

The most important and characteristic sign of inflammation of the peritoneum is the tension of the abdominal muscles - a kind of protective reflex, the starting point of which is the inflamed area of ​​the peritoneum. The tension of the abdominal muscles is especially pronounced in cases where inflammation captures the parietal peritoneum, which covers the anterior-lateral wall of the abdomen from the inside.

Sometimes the tension of the abdominal wall is expressed so sharply that in these cases they say: "The stomach is like a board." Although this symptom is one of the most constant in local and general peritonitis, however, in some cases it may be mild or even completely absent, for example, in some cases of peritonitis of gynecological origin, septic peritonitis, etc.

Tension of the abdominal muscles may also be absent in cases where inflammation captures the posterior sections of the parietal peritoneum (i.e., covering the back wall of the abdominal cavity), as is the case, for example, with retrocecal appendicitis. Tension of the abdominal muscles may be mild or even absent also in the elderly, in persons with a flabby abdominal wall (for example, in multiparous women), in very serious patients, in shock, and also in the late stages of peritonitis.

Other symptoms join the initial signs of peritonitis: lack of appetite, nausea, vomiting, belching, fever, pulse change, blood changes (leukocytosis, change in formula, acceleration of ESR).

An increase in temperature (up to 38 ° and above) is often observed with peritonitis, but is not, however, a permanent symptom, since peritonitis can sometimes develop at normal temperatures. It is important to note that with peritonitis, the temperature in the rectum is higher than in the armpit (at least 1 °).

A much more constant and characteristic sign of peritonitis is an increasing increase in heart rate with a progressive decline in cardiac activity. True, in the very initial stage of the development of peritonitis, the pulse can even be slow, but this stage is very short-lived (up to 6-8 hours) and is quickly replaced by a characteristic increase in heart rate (up to 120-150 beats per minute) and a gradual weakening of its filling.

It is also very characteristic that the pulse rate often "overtakes" the patient's temperature. As you know, with an increase in temperature by 1 °, the pulse usually quickens by 8-10 beats per minute. With peritonitis, this ratio is disturbed and the pulse, as a rule, is more frequent than would be expected at the patient's temperature. Therefore, with any acute pain in the abdomen, the pulse, "overtaking" the temperature, always causes suspicion of peritonitis. However, it should be remembered that in the initial stage of the development of peritonitis, the pulse, as already mentioned, can be slow and only increases later.

As the inflammatory process spreads and intoxication of the patient's body intensifies, the initial signs of peritonitis appear more sharply and more and more new ones join them, indicating the progression of the process and the severity of the patient's condition. These signs are characteristic not of the initial, but of the late stage or phase of the development of progressive peritonitis.

The appearance and position of a patient with such progressive peritonitis is very characteristic. The patient's facial features are sharpened, the lips are bluish, the eyes grow dim, the sclera is icteric, the eyeballs sink, blue appears around them, the face acquires a pale grayish, cyanotic or icteric hue with a suffering expression. This type of face, characteristic of the later stages of the development of peritonitis, received a special name - the face of Hippocrates.

A patient with diffuse peritonitis usually lies on his back with bent legs. With local peritonitis, patients prefer to lie on the side where the affected organ is located, for example, with appendicitis - on the right side, etc. In the advanced stage of peritonitis, the patient suffers from thirst, indomitable vomiting and hiccups. Due to profuse and frequent vomiting, dehydration of the body occurs (dry lips, tongue, hoarseness of voice, decrease in the amount of urine).

The initial local pain and local tension of the abdominal muscles become more diffuse and can spread to the entire abdomen, although the intensity of pain and muscle tension sometimes even decreases.

Growing signs of intestinal paralysis. Vomiting becomes more frequent and acquires a fecal character, the abdomen swells (flatulence), which causes difficulty in cardiac activity and respiration, the participation of the abdominal wall in respiratory movements is weakened or completely absent.

When the abdomen is tapped, a tympanic sound (the sound of a drum) is heard, and when auscultated, the usual intestinal noises due to peristalsis are not heard, and the so-called "deathly silence" reigns in the abdominal cavity. In the abdominal cavity, an inflammatory effusion (exudate) accumulates more and more, which is determined by percussion in the sloping places of the abdomen in the form of dullness, moving or disappearing when the patient changes position.

In some cases, valuable data for judging the nature of the process are obtained by examining the pelvic organs through the vagina or rectum (for example, the accumulation of pus in the Douglas space, severe pain on palpation, the presence of gynecological diseases, etc.).

As peritonitis progresses and intoxication increases, the patient's condition deteriorates rapidly, breathing becomes rapid, superficial chest type; heart sounds are muffled, blood pressure gradually drops, limbs become cold, protein, cylinders, indican, etc. appear in the urine. The patient's consciousness persists until the end of life, although he becomes indifferent to the environment, a terminal state occurs and death usually takes 5-7- th day.

The signs just described are characteristic of the advanced period of peritonitis, that stage when the usual treatment of the patient is no longer able to save the patient. Therefore, it is practically very important to recognize acute purulent peritonitis in the initial stages of its development, when timely and correct treatment can, as said, save the patient's life.

The most important signs of peritonitis in the initial stage of its development are: abdominal pain, aggravated by palpation, local protective muscle tension, Shchetkin-Blumberg symptom and a change in pulse. All other signs join these main ones only as the inflammatory process develops.

In general, the recognition of acute purulent peritonitis in most cases does not cause much difficulty. It is much more difficult and more difficult to determine the source (primary focus) of peritonitis.

However, it should be borne in mind that the clinical picture of general peritonitis described above, all the severity of its symptoms, may be less pronounced in cases where the onset of peritonitis was preceded by antibiotic treatment for any primary inflammatory process in the abdominal cavity. In addition, depending on the cause of peritonitis, certain characteristic symptoms may be observed. So, in the clinical picture of perforated peritonitis, that is, resulting from perforation of a hollow organ, there may be a period of subjective improvement (euphoria stage), when the patient feels better for a period, the pain subsides, vomiting often stops, abdominal muscle tension the wall decreases, although objectively the general condition of the patient remains severe (see "Perforated ulcer of the stomach and duodenum"). In debilitated patients with a severe general condition, peritonitis occurs against the background of a general unresponsiveness of the body, as a result of which the entire clinical picture is "erased". Some clinical features are observed in biliary, typhoid, streptococcal and pneumococcal peritonitis.

Acute purulent peritonitis should be distinguished from some other diseases of the abdominal cavity (acute intestinal obstruction, perforated stomach ulcer, etc.). True, it should be borne in mind that in the absence of proper treatment (most often surgical), all these diseases inevitably lead to the development of peritonitis. Thus, it is possible to distinguish them from peritonitis only in the early stages. Some diseases to some extent may resemble the picture of an "acute abdomen", for example, renal colic, sometimes food poisoning. However, anamnesis and a thorough examination of the patient allow in most cases to make a correct diagnosis.

With local (limited) acute purulent peritonitis, all the above signs of general (diffuse) peritonitis are, of course, less pronounced. In particular, such important signs as abdominal pain and tension of the abdominal muscles are noted only in the affected area of ​​the peritoneum. With local peritonitis, the resulting inflammatory infiltrate either gradually resolves or suppurates and leads to the appearance of an intraperitoneal abscess.

Peritonitis first aid. As soon as any disease that could lead to the development of peritonitis is suspected, or the presence of symptoms of already beginning peritonitis or an acute abdomen in general is detected, it is urgent to refer the patient to the nearest hospital, since the only way to save his life in most cases is an urgent operation and the strictest hospitalization. - bed rest.

Here it is appropriate to recall a very important rule: at the slightest suspicion of general or local peritonitis or with an accurately established diagnosis of this disease, the use of various painkillers by an average health worker - morphine, pantopon, etc. - is strictly prohibited, since, reducing pain and some other signs of peritonitis, they only obscure its picture and thus make its timely recognition and treatment very difficult.

It is also forbidden to use laxatives and enemas, which, by increasing intestinal motility, prevent the delimitation of the inflammatory process and, conversely, contribute to its deterioration, causing, for example, perforation of the appendix in acute appendicitis, etc.

With symptoms of decline in cardiac activity, cardiac agents are used (camphor oil, caffeine, cardiazole, cordiamine); with symptoms of cyanosis - inhalation of oxygen.

When transporting a patient, he should be provided with maximum comfort and peace.

With a delay in hospitalization, the patient is prescribed strict bed rest in a semi-sitting position with bent legs, cold on the stomach, limit drinking, eating any food is prohibited. Antibiotics are used (penicillin with streptomycin, synthomycin, colimycin, etc.), intravenous administration of saline or glucose solution, drip enema from saline with 5% glucose solution (up to 2-4 liters per day); with severe pain - injections of analgesics (morphine or others). If gastric perforation or damage to the gastrointestinal tract is absolutely excluded as the cause of peritonitis, then it is advisable to perform a gastric lavage or insert a permanent tube into the stomach.

Peritonitis prevention. Prevention of acute purulent peritonitis consists in the timely and correct treatment of those diseases and injuries that most often cause peritonitis, namely all acute diseases of the abdominal organs (acute appendicitis, perforated gastric ulcer, acute intestinal obstruction, strangulated hernia, etc.). Timely first and emergency surgical care (including the use of antibiotics) for penetrating abdominal wounds has the same preventive value. For the prevention of postoperative peritonitis, strict adherence to the rules of asepsis and the use of antibiotics during surgical operations are necessary.

Inflammation of the peritoneal sheets and intestines is called the medical term "peritonitis". Pathology is accompanied by severe symptoms. In case of untimely provision of first aid, the patient is threatened with death. The process is provoked by fungi, bacteria and pathological conditions of the intestine (for example, cancer), which threaten perforation with the entry of foreign contents into the cavity with peritoneal sheets.

What is peritonitis?

The concept of peritonitis describes inflammation that has developed in the abdominal cavity against the background of cancer, bacterial or aseptic lesions of the connective tissue layer. More often the serous layer of the peritoneum becomes inflamed. Peritonitis refers to acute surgical conditions, united by the general term "acute abdomen". In 20% of cases with diagnosed inflammation, surgery is needed. According to statistics, 0.05-0.3% of people on the planet suffer from peritonitis, while mortality is 65-70%.

The use of modern techniques can reduce mortality to 15-19.5%, but in the conditions of providing timely assistance.

Types of disease

The division of intestinal peritonitis is carried out into two types:

• primary, when the condition develops independently as a result of microbial infection of the peritoneum;
• secondary, when inflammation appears against the background of other pathologies that have developed in the abdominal cavity, small pelvis;
• tertiary - sluggish, persistent, appearing against the background of treatment of secondary inflammation of the intestine (characterized by mild severity, complexity of diagnosis).

By type of infection

According to this parameter, intestinal peritonitis is distinguished:

• microbial - penetration through the blood or lymph and the rapid development of viable bacteria in the abdominal cavity (occurs against the background of damage to other organs);
• aseptic - poisoning of the peritoneum with gastric juice, urine, pancreatic enzymes, blood, biofluids in cancer;
• radiological, medicinal - intoxication with aggressive chemical components during the treatment of wounds during operations;
• barium - intestinal damage with contrast radiography during the diagnosis of background pathology.

By the nature of the effusion

• purulent, developing against the background of damage to the body by staphylococci, gonococci and Escherichia coli;
• bloody, hemorrhagic, arising against the background of injury or perforation of the ulcer;
• serous, when the intestine becomes inflamed against the background of the accumulation of large volumes of protective fluid;
• fecal or mixed with other intestinal contents;
• fibrinous, when due to the accumulation of a specific protein in the liquid part of the blood with the release of fibrin films, which leads to the fusion of peritoneal sheets with intestinal tissues;
• bile, when pancreatic juice or bile acids from a ruptured gallbladder or bile ducts are poured into the peritoneum.

By process stage

Peritonitis is classified into the following conditions:

• without blood poisoning;
• severe purulent inflammation (abdominal sepsis);
• the spread of sepsis to the surrounding tissues with the formation of purulent foci;
• shock sepsis, accompanied by a violation of the transport of oxygen to the organs and the development of insufficiency, a general disorder of the organs.

Distribution

The division by this parameter implies the presence of:

• local peritonitis, which developed locally, that is, around the wound or injured focus;
• unlimited peritonitis - with spread to neighboring tissues and organs;
• periappendicular, when inflammation occurs against the background of fusion of the appendix with the blind or small intestine, and the inflammation manifests itself in a capsular-purulent form;
• widespread, when peritonitis in cancer reaches the deep layers of the peritoneum (infection of up to 60% of the cavity);
• spilled, covering more than 60% of the peritoneal space with especially severe symptoms;
• total, when there is a general inflammation of the peritoneum, intestines and other organs.

Main reasons

Common causative agents of peritonitis are bacteria. In 60-80% it is staphylococci and Escherichia coli.

Other types of peritonitis are closely related to such conditions:

1. Bacteria as primary infection.
2. Secondary provocateurs are pathogenic-destructive pathologies, such as:
   • perforation of a gastric or duodenal ulcer;
   • phlegmonous,;
   • accumulation of pus in the fallopian tubes or rupture of egg cysts (in women);
   • intestinal obstruction;
   • squeezing the gate of the hernia;
   • diverticulitis;
   • acute inflammation of the gallbladder;
   • inflammation of the pancreas;
   • acute vascular insufficiency caused by obstruction;
   • chronic inflammation of the intestine (Crohn's disease);

In connection with the development of background pathologies (cancer, etc.), the symptoms of peritonitis are similar to them, and only with the rapid development of inflammation, specific signs are observed:

1. Severe pain in the abdomen, without a clear location. The sensation intensifies with movement. When the pain subsides, the prognosis worsens due to an increased risk of nerve receptor death.
2. Severe nausea with bouts of vomiting of gastric contents, and later - bile-feces. Vomiting does not bring relief, dehydration develops.
3. Flatulence, seething and swelling of the intestines.
4. Decreased or complete absence of intestinal peristalsis.
5. The adoption by the patient of the fetal position, due to the mitigation of pain in this position.
6. Marbling of skin tone.
7. Drying of lips, skin, oral cavity.
8. Fever, fever.
9. Tachycardia with weak heartbeat.
10. Falling BP.
11. Nervous tension, psychosis, panic attacks.

Staged symptoms of intestinal peritonitis:

• At the first stage, severe pain, fever, nausea with vomiting develops. Duration - the first 24 hours.
• In the toxic phase (2-3 days), dehydration and weakness of the cardiovascular system develop additionally.
• The terminal stage is characterized by a particularly severe course - loss of consciousness, onset of coma, dysfunctions of all organs.

Features of the disease in children

The prognosis and severity of peritonitis depends on the age of the child. The main causes of the disease:

Symptoms:

1. rapid and sharp deterioration in the condition of the baby;
2. fever, restlessness, lack of appetite;
3. non-localized abdominal pain, vomiting, diarrhea or constipation;
4. tension of the abdominal muscles according to the type of "disc-shaped abdomen";
5. earthy skin tone, drying of the integument;
6. development of the clinic of irritated peritoneum.

Peritonitis is the process of inflammation of the peritoneum. With peritonitis, there is a violation of the functioning of the organs due to a strong. The connective tissue of the peritoneum envelops all the internal organs of the abdominal cavity and serves as a limiter between the internal environment of the abdominal cavity and the abdominal muscles.

When exposed to pathogens or chemical agents on the surface of the peritoneum, it is able to release special substances that stop this process. If the number of pathogenic factors is large, then the peritoneum is involved in inflammation and peritonitis occurs. Peritonitis is a very life-threatening condition. When it occurs, emergency medical attention and urgent treatment are required, otherwise a fatal outcome is possible.

Peritonitis is a very serious condition!

Peritonitis is classified as primary and secondary. In primary peritonitis, the causative agent is microorganisms that have entered the peritoneum along with the blood flow from the infectious focus in the body. At the same time, the integrity of the peritoneum is preserved.

Allocate primary peritonitis:

• spontaneous children's primary peritonitis (more often girls under 7 years old);
• spontaneous adult primary peritonitis (due to ascites, a side effect of hemodialysis);
• primary peritonitis in persons with active tuberculosis.

Secondary peritonitis is accompanied by damage or rupture of all layers of the peritoneum as a result of a penetrating injury to the abdomen or a violation of the integrity of one of the internal organs.

Secondary peritonitis is classified into:

1. peritonitis caused by a violation of the integrity of internal organs;
2. peritonitis caused by penetrating or blunt abdominal trauma;
3. peritonitis that developed in the postoperative period.

There is tertiary peritonitis, which develops in the abdominal cavity after peritonitis has already taken place. That is, in fact, it is a recurrence of peritonitis. Fortunately, it is rare. Its feature is an erased course, severe intoxication and failure of almost all internal organs. It occurs with a strong depletion of the body's defenses. Such peritonitis often does not respond to ongoing therapy and ends in the death of the patient.

Bacterial etiology of peritonitis

Great lives in the intestines, but the effect of only some of them can lead to peritonitis. This is because some of them die in an oxygen environment, that is, they are strict anaerobes. Another part is subject to controlled death due to the anti-infective ability of the peritoneum.

Depending on the conditions in which peritonitis occurred, there are 2 of its forms:

• hospital;
• out-of-hospital.

The process of development of peritonitis

The speed and severity of the development of symptoms of peritonitis largely depends on the state of the body, on the pathogenicity of microbes, and on the presence of provoking factors.

The main points in the development of peritonitis are as follows:

1. Paresis of the intestine, as a result of which the function of absorption is impaired, and the body loses large amounts of water and electrolytes.
2. Dehydration and a decrease in pressure in the vessels leads to a strong heartbeat, shortness of breath.
3. The rate of development of peritonitis and the massiveness of the peritoneal lesion depends on the number of pathogenic bacteria, the magnitude of intoxication.
4. Autointoxication joins the intoxication caused by microbes. In response to the aggression of microorganisms, antibodies are released in the blood that attack the lipopolysaccharide wall of the bacterium. The compliment system is activated and many active substances are released, the action of which is manifested by intoxication.

If the human body is weakened or the microorganism is highly pathogenic, then peritonitis is not limited, but becomes diffuse or widespread. Especially the spread is facilitated by increased peristalsis, as well as blood and exudate in the abdominal cavity.

Clinical manifestations of peritonitis

Symptoms depend on the cause of the disease, so the initial signs can be very diverse. But there are several successive stages, depending on the time of onset of symptoms.

Reactive stage

Develops in the first day. There is severe pain, the patient can clearly determine the localization. If the cause of peritonitis is the perforation of a hollow organ, then this pain is described as a dagger. For example, perforation is described as severe sharp pain in the epigastric region, rupture of the appendix is ​​described as pain in the right iliac region.

The pain gradually spreads to other areas of the abdomen. Sometimes, after the onset, the pain becomes less intense and does not bother the patient so much. This is how a symptom of imaginary well-being manifests itself. After a while, the pain returns.

The face of a patient with peritonitis is very typical. It is pale, sometimes even with an earthy tint. Covered with drops of sweat at the time of pain. Facial features are sharpened due to dehydration. The strongest pain forces the patient to take a comfortable position in order to somehow alleviate it. More often, a person lies on his side with bent legs, spares his stomach in every possible way, trying not to strain it.

When examining such a patient, tense abdominal muscles are found - a board-shaped abdomen. The Shchetkin-Blumberg symptom is pronounced, in which a sharp withdrawal of the hand from the surface of the abdomen at the time of palpation leads to increased pain.

The patient is worried about repeated vomiting, after which there is no improvement. First it is vomiting water, then bile. Body temperature rises to febrile numbers, fever is often accompanied by chills. On examination, the mucous membranes are dry due to dehydration, thirst is disturbing. The amount of urine excreted decreases.

toxic stage

It develops on the second or third day. The general condition of the patient worsens. Peritoneal symptoms are less pronounced. Microcirculation is disturbed. Outwardly, this is manifested by the cyanosis of the nose, earlobes, fingers and toes. The patient is very pale. Severe dehydration leads to impaired brain function. Consciousness is depressed, the patient is indifferent to what is happening. Sometimes, on the contrary, he can be excited, delirious. On examination, palpation of the abdomen does not give any reaction.

Vomiting of bile continues, in advanced cases of intestinal contents. Urine is allocated little, may not be at all. The fever reaches high numbers, up to 42 degrees. Disturbed by severe shortness of breath and palpitations. The pulse becomes thready.

terminal stage

It is also called irreversible. If the patient's condition does not improve by the third day, then the disease is already irreversible and most often ends in death. The patient is in a very serious condition. Dehydration is expressed to the maximum. At the same time, facial features are sharpened so much that it becomes difficult to recognize a person. Since ancient times, such a face was called the face of Hippocrates: pale, with a bluish tinge, sunken eye sockets with dark circles under the eyes.

Palpation of the abdomen does not provide objective data. The patient does not respond to palpation of the abdomen. Breathing is disturbed, and artificial lung support is often required. There is no pulse in the peripheral arteries. Such a patient needs intensive treatment and resuscitation.

Methods for diagnosing peritonitis

Treatment of peritonitis - surgical method

In order to diagnose peritonitis, the doctor must be based on the data of the clinic of the disease, the medical history, external symptoms, and the patient's examination data.

Data from blood tests and instrumental data are important.

Changes in the hemogram are aimed at increasing the number of white blood cells, shifting the formula to the left, and increasing the ESR. These are universal signs of inflammation. Hemoglobin falls, the number of red blood cells decreases. Due to the thickening of the blood, its clotting is disturbed.

The main role is played by ultrasound of the abdominal cavity. It shows the primary localization of peritonitis, the affected organ and the degree of spread of the process in the peritoneum. The sooner a person with symptoms of peritonitis seeks help, the better their chances of recovery. Therefore, in case of a disease that is accompanied by fever, indomitable vomiting, abdominal pain, it is necessary to call a doctor. If he suspects peritonitis, he will urgently refer such a patient to a hospital.

Methods for the treatment of peritonitis

Peritonitis is treated surgically. The operation is prescribed urgently, after appropriate preparation of the patient. The surgeon will open the abdominal cavity, eliminate the cause of peritonitis, suture the diseased organ, make an revision, wash the internal organs and peritoneum with an antiseptic and saline solution. If peritonitis has affected a large part of the peritoneum, the wound is not tightly sutured, but additional lavage of the abdominal cavity is performed on the second and third days.

Actively carry out therapy with antibacterial drugs and correction of water and electrolyte balance.

The problem of treating peritonitis occupied many outstanding minds from Hippocrates to S.I. Spasokukotsky. At the beginning of the 20th century, the latter determined the relationship between the speed of surgical care and the outcome of the disease. The sooner such a patient got on the operating table, the more likely was his recovery.

The reactive stage is not yet so severe, violations can be corrected, the body is not exhausted by the disease. The second stage, toxic, already leads to significant changes in the internal environment of the body and recovery is doubtful. In the third terminal stage, multiple organ failure develops, it will end fatally.

Preoperative preparation and monitoring

• For a successful surgical intervention, it is necessary to carry out preoperative preparation.
• The patient is obligated to catheterize the peripheral and central veins, the bladder, apply premedication.
• Midazolam (5 mg) and 10–20 mg of cerucal are administered on the operating table. Atropine is contraindicated, as there is a high probability of developing bradycardia.
• Enter drugs that help reduce the acidity of gastric juice (about 40 mg of omeprazole or famotidine / ranitidine 50 mg in a vein).
• During the operation, infusion therapy is carried out in an amount of at least 1.5 liters of saline, if necessary, plasma and blood products are added.
• Carry out artificial ventilation of the lungs, supply oxygen.

In the case when the patient lies on the operating table, and there is more than 25 ml of contents in the stomach, there is a real threat of aspiration. This is the name of the entry of the contents of the stomach into the lumen of the bronchial tree. Gastric juice can cause burns of the bronchial mucosa, trachea. Complications of aspiration include multiple pulmonary atelectasis, bronchospasm, respiratory failure, and pulmonary edema.

Aspiration of small amounts of gastric juice may subsequently lead to aspiration pneumonia.

Therefore, in anesthetic practice in patients with peritonitis, ganglioblockers and anticholinergics are not used - drugs that can reduce tone.

Antibacterial therapy is carried out with a combination of antibiotics that act on both Gram-plus and Gram-minus bacteria. With community-acquired peritonitis, this is intravenous administration of cefotaxime and metronidazole. With intrahospital - cefepime and metronidazole. If peritonitis developed in the hospital against the background of ongoing antibiotic therapy, carbapenems are used.

Postoperative period

Antibiotic therapy for peritonitis is mandatory

In the postoperative period, some problems may arise associated with the normal functioning of the intestine, severe pain, and the development of purulent complications. Recommended:

• observation of the patient, hourly assessment of respiratory rate, pulse, diuresis, central venous pressure, drainage discharge;
• infusion therapy is carried out with colloid and crystalloid solutions;
• for warming patients, infusion media are heated to body temperature;
• the lungs are ventilated for 72 hours to provide sufficient oxygen to organs and tissues;
• inject glucose solution through a nasogastric tube;
• early recovery of intestinal motility;
• pain syndrome prevention. Narcotic analgesics are used in combination with non-steroidal anti-inflammatory drugs. Use fentanyl, morphine, ketorolac.

Prevention of the development of peritonitis

It consists in bringing to the population the main symptoms of peritonitis, its consequences. It is necessary that everyone knows how to act in case of suspected peritonitis and, with reliable signs, immediately call an ambulance. Prevention of primary peritonitis consists in timely

Peritonitis as a surgical complication:

What it is?

Peritonitis is an inflammation of the peritoneum. The victim has a stomach ache, stool and gases are delayed, vomiting and tension of the abdominal muscles appear. He is in a serious physiological condition, suffers from an excess of heat in the body, which leads to a rapid increase in temperature.

Peritonitis of the abdominal cavity is treated only surgically.

The peritoneum is a serous cover that protects the organs of the gastrointestinal tract. The peritoneum is parietal and visceral.

The first type of shell protects the inner wall of the abdomen. Visceral covers the surface of the organs inside the parietal sheet.

Causes of peritonitis

Infectious peritonitis is caused by bacteria and microbes. The following microorganisms provoke the disease:

• fusobacterium;
• enterobacter;
• Proteus;
• streptococcus;
• eubacterium;
• peptococcus;
• Pseudomonas aeruginosa;

In most cases, viral peritonitis is caused by Escherichia coli and staphylococci.

In addition to microbes, there are other causes of the disease:

• inflammation processes taking place in the peritoneum ( , );
• defect of the digestive system;
• the appearance of through holes in the abdominal organs (or the stomach during an ulcer, appendix, colon);
• surgical interventions in the abdominal organs;
• inflammation of the phlegmon of the abdominal cover of the abdomen, the processes of decay in the retroperitoneal tissue.

Symptoms

There are 3 stages of the disease. So everyone has their own symptoms. The main signs of peritonitis:

• increased temperature and blood pressure;
• nausea with vomiting;
• dry mouth;
• cardiopalmus.

Peritonitis in children has the same signs as symptoms in adults

Symptoms of the first stage of the disease

This is a long-term abdominal pain that worsens with a change in body position. The patient lies down and tries not to move. The Shchetkin-Blumberg symptom allows you to detect this ailment.

It is necessary to slowly press on the wall of the abdomen, hold your hand for 3-6 seconds and sharply remove it. The occurrence of a sharp pain indicates that a person suffers from peritonitis.

Also, the disease can be determined using the symptom of Mendel. You need to tap on the entire abdomen. If the pain intensifies, the person is sick. This method establishes the location of the pathology.

Symptoms of the second stage of peritonitis

The pain in her stomach and the tension in her muscles are subsiding. Stool retention begins to appear, frequent vomiting with an unpleasant odor.

The heartbeat also accelerates (more than 115 beats per minute), pressure decreases, body temperature increases. Intoxication symptoms appear.

Symptoms of the third stage of the disease

Due to lack of water, the patient's skin becomes pale, facial features become sharp. There is a rapid heartbeat, low blood pressure, incomplete breathing, bloating.

There is no peristalsis - wave-like contractions of the walls of the digestive tract, leading to the movement of food.

The patient's psychological state changes dramatically due to intoxication (poisoning): from adynamia (loss of strength) to euphoria (a state of bliss). In rare cases, there is delirium, confusion of consciousness.

Types and stages of peritonitis

• Peritonitis of the intestine of the first stage(reactive, duration - half a day). The body begins to fight the infection that has entered the peritoneum. This leads to localized inflammation in the form of edema, hyperemia (overflow of blood vessels in the body area), and accumulation of exudate.

Exudate is a fluid that is released in the tissues of organs due to blood vessels during the inflammatory process. At first it is serous, later, due to an increase in the number of bacteria and leukocytes, it becomes purulent.

The peritoneum limits the problem area from healthy parts of the body. Therefore, this stage is characterized by the formation of adhesions in the peritoneum and nearby organs.

Puffiness and infiltration may appear near the located organs. The latter is the penetration into the tissues of substances that are not their normal component.

• Peritonitis of the second stage(toxic, duration from 3 to 5 days). The body's immune response to inflammation is enhanced. Microorganisms, their waste products (endotoxins) and proteins (polypeptides, proteases) enter the bloodstream and lymphatic system. Signs of peritonitis of the 2nd stage: suppression of the contractile function of the intestine, degeneration of the digestive organs, hemodynamic disorders (lowering blood pressure), failure of blood clotting. Purulent peritonitis can lead to disruption of the cardiovascular system ( , , endocarditis).
• Peritonitis of the intestine of the third stage(terminal, duration - 1-3 weeks). There is an abrupt drop in body temperature, chills, frequent pulse, lowering of pressure, pallor of the epidermal membranes (skin). There is also nausea, accompanied by vomiting, rapid weight loss, acute abdominal pain, diarrhea. Work on creation of protein worsens. The amount of ammonium and glycol in the blood increases. The brain cells swell, the volume of the substance of the spinal cord increases.

Due to the occurrence, medicine distinguishes the following types of disease:

• Idiopathic abdominal peritonitis. Appears due to the ingress of bacteria along with the outflow of lymph, blood or through the tubes of the uterus with enterocolitis , , genital tuberculosis. Another name is viral peritonitis.
• Secondary intestinal peritonitis. Occurs with injuries, inflammatory diseases of the organs. Observed at:
  • appendicitis;
  • peptic ulcer of the stomach or duodenum;
  • disease "";
  • pancreatic necrosis (impaired pancreatic function);
  • (severe chronic disease of the gastrointestinal tract);
  • with inflammation;
  • occlusion of the mesenteric vessels (impaired circulation of the vessels supplying the mesentery);
  • (inflammation of the lining of the large intestine).

Secondary peritonitis is more common than primary, which occurs in 2% of victims.

For microbial reasons, it happens:

• infectious peritonitis. Appears due to aggressive substances trapped in the abdominal cavity. They cause an inflammatory process;
• viral peritonitis. It is provoked by inflammation caused by microorganisms.

Peritonitis resulting from injuries is divided into:

• appearing due to open or closed injuries that cause defects in the organs of the peritoneum;
• arising from surgery. Accompanied by a violation of the position of the seams, the failure of the junction of individual elements of the network and the accumulation of blood.

There are special types of peritonitis:

According to the composition of the substance accumulating in the abdominal cavity, there are:

• purulent (purulent peritonitis has a high level of lethal outcome);
• hemorrhagic (blood is mixed with exudate);
• serous (effusion consists of a liquid with a low concentration of protein elements);
• mixed (serous-fibrinous);
• fecal (appears with injuries of the abdominal cavity);
• bile (bile flows into a vulnerable place);
• fibrinous (fibrinogen fibers cover the peritoneum, forming adhesions).

According to the shape of the lesion of the peritoneum, there are:

• unlimited. The zone of inflammation is diffuse, without precise boundaries;
• limited. In a problematic place, an accumulation of pus appears in the organs and a thickening of cells in the tissues of the body.

According to the area of ​​\u200b\u200bdamage, it happens:

• Local. Harm is caused to one anatomical region of the abdominal cavity;
• Common. 2-5 zones are affected;
• General. Inflamed from 6 or more areas.

Peritonitis is acute and chronic. The acute form of the disease proceeds in three stages, described above. Chronic peritonitis occurs when , .

Peritonitis in children

Acute peritonitis is common in children. They are vulnerable to disease because their immunity is only beginning to adapt to the environment. It is more difficult for children to make a correct diagnosis due to the difficulty of describing the symptoms. Acute peritonitis poses a threat to the life of the child.

Peritonitis in adults

Infectious peritonitis of adults practically does not bother. They are more affected by chronic or purulent peritonitis. It is more difficult to detect due to the lack of significant symptoms.

First, the body copes with microbes. Later, weight loss appears, body temperature rises to 37.5 ° C, drowsiness, heaviness.

Diagnostics

The initial stage includes examining the patient and identifying symptoms:

• Medel;
• Bernstein;
• Voskresensky;
• Shchetkin-Blumberg.

The patient is being tested:

• Radiography. A sickle symptom is established under the diaphragm. With intestinal obstruction, the Kloiber bowl is determined.
• Blood analysis. An increase in the number of leukocytes is also detected;
• Ultrasound of the peritoneum.

In rare cases, laparoscopy is indicated.

Treatment

After the detection of peritonitis, the patient is determined by a surgical operation. It aims to eliminate the root cause. In other ways, the disease cannot be cured.

Surgery

The patient is hospitalized and preoperative measures are taken to treat peritonitis:

• relieve pain shock - inject anesthesia;
• bring pressure back to normal by introducing food, fluids, medicines.

It also helps to normalize the amount of water in the human body and destroy infections.

During surgery, a laparotomy is performed, treating all the contents with a special antibacterial agent. The abdominal wall is cut to reveal through holes in the stomach or intestines. The perforations are sutured, the pus, along with part of the hollow organs, is cut off and removed.

During an emergency operation, when peritonitis progresses in the last stages, the surgeon eliminates only the cause of the disease. The remaining measures are scheduled for the next period, because purulent inflammation prevents their implementation.

Decompression of the small intestine is performed by nasointestinal intubation. This is the introduction of a hose through the oral or nostril cavity. It is also used to evacuate intestinal contents and implement artificial nutrient intake.

Drainage - removal of fluid using rubber tubes - of the large intestine is carried out to eliminate peritonitis through the anus. The event includes the removal of exudate and the introduction of antimicrobial solutions to destroy harmful microorganisms.

Treatment after surgery

Peritonitis after surgery requires special treatment. It is a reception of drugs that destroy the pathogenic microflora, restore the activity of the digestive tract and normalize the immune system.

Also, the patient is credited with a diet that he must adhere to for a week. Peritonitis in children is treated in the same way as in adults.

Medical treatment

The following types of drugs are prescribed:

• antibiotics. Penicillin-Teva, benzylpenicillin, ceftriaxone, gentamicin and others;
• diuretics, the active ingredients of which are Indapamide (trade name - "Arifon"), Spironolactone ("Veroshpiron"), Torasemide ("Trigrim");
• means to remove toxic substances from the body. These include "Calcium gluconate", "Splenin", "Unithiol" and others;
• infusion solutions ("Hemodez", "Gelatinol", "Reopoliglyukin");
• blood products - "Albumin" (5% and 20% solutions), "protein", "fibrinogen";
• non-steroidal anti-inflammatory drugs - Ketoprofen, Arcoxia, Indomethacin;
• anti-vomiting agents. Contain ondansetron ("Emeset"), domperidone ("Motilium");
• drugs aimed at preventing the development of intestinal paresis. This is "Neostigmine", "Physostigmine".

Also used:

• ultraviolet irradiation of blood;
• plasmapheresis (purification and return of blood back to part of the circulatory system);
• intravenous laser blood irradiation;
• hemodialysis;
• cleansing the lymph from toxic substances;
• hyperbaric oxygen therapy (method of using oxygen under high pressure).

Important! In the event of pain in the abdomen, in no case should you take painkillers. This may lead to a reduction in symptoms. Then it will be more difficult for the doctor to recognize the disease.

Diet after surgery

The patient needs to take liquid in a proportion of 50-60 milliliters per kilogram of body weight per day.

After the normalization of the digestive system, the administration of vitamin mixtures is prescribed using a probe through the mouth or nose. When recovering, dietary nutrition is prescribed for a long time.

The composition of the diet is as follows:

• low-fat broths;
• vegetable puree;
• fruits, kissels, berry compotes.

Gradually increase calorie content by adding boiled and steamed meat, chicken eggs, and dairy products to the diet.

Cannot be eaten:

• fatty meats;
• smoked;
• chocolate and confectionery;
• spices;
• coffee and carbonated drinks;
• legumes.

Complementary and Alternative Treatments at Home

Before the arrival of specialists, first aid should be provided using folk remedies. Otherwise, the risk of death increases.

• Ice. It is necessary to wrap ice in a cloth, lightly impose on the stomach. This will reduce the pain.
• Turpentine. It is necessary to prepare a compress from purified turpentine and vegetable oil in a ratio of 1 to 2, respectively. Apply to belly.

Prevention

Purulent peritonitis can be avoided by observing the following rules:

• do not delay the treatment of diseases that can lead to serious complications (appendicitis, etc.);
• get 50% -60% of all energy per day from fruits, vegetables and other foods rich in vitamins and chemical elements;
• give up unhealthy foods (fast food, sweet carbonated drinks, etc.);
• avoid hypothermia of the body;
• avoid stress;
• do not take medicines without consulting a doctor;
• get enough sleep, do not forget to rest after work;
• wash fruits, vegetables, berries and hands thoroughly before eating.

Forecast

30% of patients with peritonitis die, and with multiple organ failure, the lethal outcome is 90%. Peritonitis in children is even more dangerous due to their weak immune systems.

It all depends on the type, degree of the disease and on timely access to an ambulance.

Treatment of peritonitis in the first hours allows you to save 90% of those operated. After a day, this figure reaches 50%, after three - 10%.

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