Peritonitis is an inflammation of the peritoneum, which is the protective serous membrane between the organs of the digestive system. The disease has an infectious, bacterial nature, observed after surgery or internal mechanical damage. Delayed diagnosis of peritonitis is the cause of dangerous complications.
Features of the disease
Acute surgical pathology is observed due to an aseptic, bacterial inflammatory process of the connective membrane of the abdominal cavity. The main functions are protective, absorption, secretory-resorptive, plastic, bactericidal. The peritoneum prevents the penetration of pathogenic microbes and microorganisms, ensures a fixed arrangement of the organs of the digestive system, produces and absorbs aseptic fluid.
The entry of infectious or viral bacteria into a sterile area provokes inflammation and intoxication of the body. The large internal volume of the abdomen promotes the rapid proliferation of microbes and the rapid absorption of toxins.
The occurrence of abdominal peritonitis depends on the immune system, the pathogenicity of microorganisms, and the amount of leaked intestinal contents.
Cause of occurrence
Peritonitis develops as a result of infection entering the abdominal cavity through the blood, lymph nodes or damaged structure of the digestive system organ when its integrity is damaged or removed. Inflammation of the protective membrane as a result of complications can occur after the consequences of surgical intervention.
The reasons for the development of aseptic peritonitis are the entry of blood, urine, and gastric juice into the abdominal cavity. Penetration of biological materials causes a chemical burn to the shell. Primary peritonitis is characterized by the entry of bacteria through the blood. The process of infection is caused by pneumonia, tuberculosis, kidney damage, and cirrhosis of the liver.
Postoperative peritonitis has causes associated with previous inflammatory diseases:
- inflammation of the reproductive system and pelvic organs in women;
- stomach ulcer, duodenal ulcer;
- hernia;
- pancreatitis;
- cholelithiasis.
The main reason for the development of the disease is the ingress of infectious microorganisms. Peritonitis after surgery for an inflamed vermiform appendage of the cecum occurs when the intervention is untimely, when a rupture of the appendix is observed. Damage to the structure of the appendix leads to the spread of pus and pathogenic bacteria in the abdominal cavity.
Inflammation and burn of the serous membrane occurs as a result of infection, the contents of the digestive tract through the irritated lining of the stomach or duodenum. The close location of the ovaries, uterus and abdominal cavity are the causes of peritonitis in pathologies of the reproductive system in women.
Symptoms
Postoperative peritonitis has symptoms:
- general: hyperthermia, weakness, headache, nausea, vomiting, rapid heartbeat, decreased blood pressure, dry skin, loss of consciousness;
- local: pain, bloating, flatulence, constipation, dry mouth.
The main signs of peritoneal complications depend on the stage of the pathology. The reactive (primary) stage is characterized by severe pain that appears suddenly, tension in the abdominal muscles, pale skin, vomiting, false urge to excrete urine, feces, high fever, and symptoms of intoxication.
The toxic stage of peritonitis, observed one day after the attack, is a decrease in the intensity of spasms, bloating, release of dark bile, dry tongue, hyperthermia, convulsions, loss of consciousness. The terminal (third) stage of development of the pathology is characterized by a change in facial skin tone, loss of abdominal muscle tone, weak intermittent breathing, and a rare heartbeat.
Varieties
The basis for the classification of peritonitis is:
- cause of occurrence: postoperative, aseptic, bacterial, traumatic, hematogenous, cryptogenic;
- course of the disease: chronic;
- mechanism of infection: primary, secondary, tertiary;
- degree of distribution: local, diffuse, total;
- degree of development: reactive, toxic, terminal;
- nature of inflammation: purulent, serous, hemorrhagic, bile, fibrinous.
Features of primary peritonitis are the spread of infection through the blood, secondary are the consequences of surgical intervention after violation of the integrity of the abdominal organs, tertiary are damage to systems when AIDS, tuberculosis and other complications are detected. The local variety is characterized by the proliferation of bacteria in one area of the membrane area, the diffuse type - in half of the sections, with the total type the entire area of the peritoneum is affected. The reactive form of the pathology is observed in the first 24 hours after the attack, the toxic form is observed on the second day, and the terminal form is observed 3 days later in the absence of medical care.
Characterized by the formation of ulcers on the lining of the abdominal cavity. The cause is removal of severe appendicitis.
Serous, hemorrhagic, fibrinous, fecal, bile peritonitis are types of esudative form, which is accompanied by the accumulation of fluid between the sheets of the peritoneum. The differences between the types of the disease are the increased content of fibrin, pus, feces, blood or bile.
Diagnosis
To determine therapy and prescribe methods for treating peritonitis in the postoperative period, a medical examination is carried out. The purpose of diagnosis is to establish the type, degree of development, and spread of inflammation of the abdominal cavity. The first stage is examination of the patient. Palpation of the abdomen allows you to determine the location of pain, the presence or absence of muscle tone in the abdominal region. Mandatory diagnostic procedures for prescribing correct and effective therapy are laboratory tests of blood and urine.
The main instrumental research methods are:
- radiography;
- ultrasonography;
- esophagogastroduodenoscopy;
- CT scan;
- vaginal, rectal examination;
- laparoscopy.
X-rays and ultrasounds of the abdominal cavity and pelvis are carried out to exclude the possibility of diseases, the symptomatic signs of which coincide with the manifestations of impaired renal function, pathologies of the liver, pancreas, urinary, and reproductive systems. An effective diagnostic method is laparoscopy, which involves inserting equipment for internal examination of the abdominal cavity through an opening in the abdomen made under general anesthesia.
Treatment options
Surgery for peritonitis, administration of antibacterial drugs are treatment options. The choice of treatment method depends on the form of the pathology, the accompanying symptomatic signs, and the patient’s condition.
Surgical treatment of peritonitis is prescribed for the acute type of the disease after removal of the inflamed appendix of the cecum, the affected part of the stomach with an ulcer.
During the operation it is assumed:
- administration of anesthesia;
- removal of purulent accumulations from the abdominal wall;
- treating the shell with antibacterial solutions;
- installation of silicone or rubber drainage to drain pus from the abdominal cavity;
- stitching up tears.
During the postoperative period of managing a patient with peritonitis, a drug course of therapy is prescribed to normalize metabolic processes and eliminate possible complications that lead to an increase in the number of deaths after the intervention. The use of antibiotics is contraindicated during pregnancy.
The main drugs are:
- antibacterial agents: Ampicillin, Kanamycin, Oletetrin;
- infusion solutions: Refortan, Perftoran, calcium fluoride solution 10%, Furosemide, Ubretide, Heparin.
In case of peritonitis in surgery, the use of antispasmodics and laxatives is contraindicated. Painkillers reduce intestinal activity, weakening the manifestations of symptoms indicating an acute course of the disease.
Rehabilitation period
The basic rule of the recovery period is to follow a therapeutic diet. Nutrition after peritonitis has three stages, differing in duration:
- early – 3-5 days;
- second – up to 21 days;
- further – complete rehabilitation.
The diet after peritonitis after surgery is aimed at restoring the amount of proteins, carbohydrates and fats in the body. On the first day, the consumption of food and water is prohibited.
Reducing the likelihood of postoperative complications is provided by parenteral nutrition, which provides for the supply of nutrients through a dropper or tube.
After restoring the functioning of the gastrointestinal tract, it is recommended to switch to familiar ingredients. At the second stage of the therapeutic diet, you should drink at least 2 liters per day, eat liquid, pureed, slimy dishes, and observe time intervals between meals. The main ingredients of the daily menu are light soups, cereals, vegetable and fruit purees. The third stage of nutrition involves the inclusion of solid foods at different processing temperatures in the diet, increasing the calorie value of the ingredients.
Complications
Dangerous consequences of the disease occur when the disease is not treated in a timely manner, as well as after surgery. Complications include:
- renal failure;
- infectious shock;
- vascular collapse;
- sepsis;
- intestinal gangrene;
- swelling of the lungs;
- internal bleeding;
- relapse of peritonitis;
- intestinal adhesions;
- dehydration;
- death.
Dangerous consequences arise when first aid is not provided during an exacerbation, the wrong choice of treatment method, or the lack of positive dynamics of recovery after a course of medication. Timely treatment of intestinal peritonitis and successful surgical intervention increase the likelihood of a positive prognosis.
The information on our website is provided by qualified doctors and is for informational purposes only. Don't self-medicate! Be sure to consult a specialist!
Gastroenterologist, professor, doctor of medical sciences. Prescribes diagnostics and carries out treatment. Expert of the group for the study of inflammatory diseases. Author of more than 300 scientific papers.
Peritonitis is the most common postoperative complication during interventions on the abdominal organs. According to the summary data of N.A. Telkova (1958), O.B. Milonova et al. (1990), during these operations, peritonitis is the main cause of mortality (70-75% of cases).
Postoperative peritonitis - types
Postoperative peritonitis, like other forms of acute peritonitis, can be aseptic and septic.
Postoperative aseptic peritonitis, depending on the etiology, can be traumatic, medicinal, hemorrhagic, biliary and enzymatic.
Traumatic peritonitis - mechanical damage to the peritoneum and underlying tissues (without contamination) leads to serous, fibrinous or serous-fibrinous inflammation, which, in most cases, subsides on the 3-4th day after the end of the operation. And because every operation on the abdominal organs is accompanied by more or less trauma to the peritoneum, traumatic peritonitis during these interventions is a natural condition of the postoperative period.
Consequently, the more gently the surgeon treats the adjacent peritoneum during the operation, the less pronounced its inflammatory reaction will be in the postoperative period, and the less often adhesions will form.
Knowing the reaction of the peritoneum to mechanical damage, surgeons often attribute every symptom of peritonitis in the early postoperative period to surgical trauma, and therefore the diagnosis of other types of aseptic and septic peritonitis becomes late. Based on this, if there are signs of peritoneal irritation on the 2-4th day after the end of the operation, it is necessary to conduct a thorough differential diagnosis, including a dynamic study of the morphological composition of the blood.
Drug-induced peritonitis develops when concentrated solutions of antiseptics and antibiotics enter the body.
During timely intervention on the hollow organs of the abdominal cavity, surgeons often treat the lumens of the opened organs with alcohol (70-96%), iodonate solution, and tincture of iodine. If consumed carelessly, these drugs enter the peritoneum, leading to damage (burn) to its structures. In addition, periodically treating the gloves (washing off blood and other contaminants) during the operation with mild antiseptic solutions (furacilin 0.02%, chlorhexidine 0.02%), surgeons dry them with sterile wipes, and then, after wetting the gloves with alcohol, without waiting its fumes immediately plunge your arms into your body. Repeated action of alcohol on the peritoneum leads to a chemical burn, fibrinous inflammation, and the development of adhesions.
Moreover, for the treatment and prevention of infection, antibiotics are actively used, as well as by intra-abdominal administration. At the same time, we know that highly concentrated solutions of some antibiotics, and even more so their powdered forms, contribute to the formation of fibrinous (serous-fibrinous) peritonitis and adhesive disease.
There is no doubt that in many cases antibiotics must be administered into the body, but their concentration should be several times lower than with intramuscular injection.
Hemorrhagic peritonitis develops due to the effusion of blood in the torso. The blood that comes out of the vessel coagulates and is then transformed into a necrotic substrate, the resorption of which occurs (if there is no contamination) under conditions of aseptic inflammation. Based on this, upon completion of the operation, the abdominal cavity must undergo sanitation and revision for hemostasis, which is recorded in the operation protocol.
Biliary peritonitis occurs when bile flows into the free abdominal cavity. Such complications, in most cases, develop after timely interventions on the hepatobiliary system or liver injuries are completed. Bile acids and other components of bile lead to irritation of the mesothelium and sharply increase the permeability of blood vessels of the microcirculatory system, which is realized by serous inflammation.
Enzymatic peritonitis develops when the active enzymes of the pancreas evade during its injuries or during destructive forms of pancreatitis. The entry of lipase, phospholipase, amylase, trypsin and other very active enzymes into the body causes serous or, more often, serous-hemorrhagic inflammation of the peritoneum.
Most often (60-70%) mixed flora takes part in the development of septic peritonitis, which is represented by the following groups of microorganisms:
- cocci - 50-60%;
- gram-negative microbes - 40-50%;
- non-spore-forming anaerobes - 30-40%.
Mechanism of contamination in postoperative peritonitis:
- contamination during surgery;
- progression of existing peritonitis before surgery (progressive peritonitis);
- translocation of microorganisms through physically sealed seams;
- divergence of anastomotic seams;
- development of acute surgical disease of the abdominal organs in the early postoperative period.
Classification of acute peritonitis according to the prevalence of the process:
- Serous.
- Fibrinous.
- Hemorrhagic.
- Purulent.
- Putrefactive.
- Transitional forms.
Depending on the stage:
- Stage I - reactive (6-8 hours).
- a little stage - monoorgan failure (24-48 hours).
- Stage III - multiple organ failure (later 48 hours).
Local limited peritonitis is an inflammatory process of the abdominal cavity involving the parietal and/or visceral peritoneum, which is quite effectively delimited from the free abdominal cavity. Limited peritonitis includes infiltrates and ulcers of the abdominal cavity (interintestinal, pelvic, subphrenic, subhepatic, etc.).
we should pay special attention to subdiaphragmatic infiltrates, which occur very violently and persistently, and are difficult to treat. According to their clinical course (intense pain, fever, leukocytosis), they are often confused with subphrenic abscesses and are subjected to puncture or timely intervention.
Differential diagnosis is based on dynamic observation, repeated analysis of ultrasound and X-ray data, and computed tomography.
Local unrestricted peritonitis is an inflammatory process involving the parietal and/or visceral peritoneum, affecting one of the sections of the abdominal cavity and not having delimiting adhesions.
Diffuse peritonitis is an inflammatory process that spreads to two or more parts of the abdominal cavity. For example: right iliac region and pelvic region; subhepatic space, right lateral canal and subdiaphragmatic region, etc.
Non-specialized (total) peritonitis is an inflammatory process that affects the entire visceral and parietal peritoneum.
Depending on the nature of the exudate, peritonitis may not only be typical serous, fibrinous, etc. but also in the form of transitional (mixed) forms - serous-fibrinous, serous-purulent, purulent-hemorrhagic, etc.
Pathogenesis of homeostasis disorders in acute peritonitis
The reactive stage is characterized mostly by neuro-reflex disorders of homeostasis: pain, tachycardia, nausea, vomiting, centralization of blood circulation, oliguria, etc.
The stage of monoorgan failure, in most cases, occurs with symptoms of acute intestinal failure.
Due to the disruption of the physiological functions of the intestine (barrier, motor, secretory, excretory, absorption), which occur in stage II peritonitis, disorders of the passage of intestinal contents, digestive and absorption properties, intermediate metabolism and water-electrolyte balance develop. All this is manifested by severe disorganization of homeostasis and metabolic toxemia.
Moreover, increasing toxemia (tissue, microbial), damage to the lymphoid apparatus of the mesentery, bacterial translocation (penetration of microbes into blood and lymphatic vessels), activation of macrophages and other cells of the circulatory system lead to a sharp increase in the blood level of cytokines and other active inflammatory factors, which causes the development of SIRS: fever, chills, severe tachycardia, shortness of breath, arterial hypotension, oliguria, severe microcirculation disorders.
In addition, bloating and a marked increase in intra-abdominal pressure are realized by disruption of portal and renal blood flow, disorganization of liver and kidney function.
The described homeostasis disorders develop as a cascade reaction, ending in persistent multiple organ failure.
Therefore, if the negative effects of acute intestinal failure syndrome are not eliminated in a timely manner, it is prohibited to count on a positive outcome from the treatment of peritonitis. Based on this, you need to know the main components of acute intestinal failure.
Pathological components that make up acute intestinal failure syndrome:
- disturbance of intestinal motility;
- violation of secretory function;
- disruption of digestive activity;
- violation of excretory function;
- disorganization of interstitial exchange;
- malabsorption;
- disturbance of enteral nutrition;
- water-electrolyte imbalance;
- toxemia (metabolic, tissue, microbial);
- increased intra-abdominal pressure;
- development of mesenteric lymphangitis and lymphadenitis;
- sudden activation of the local immune system;
- intensive production by macrophages and other cells of various inflammatory factors: cytokines (interferon, interleukins - 1, 6, 8, 10, tumor necrosis factor, etc.), pharmacologically active mediators (histamine, kinins, prostaglandins, platelet activating factor, nitric oxide, leukotrienes , thromboxane, etc.);
- a pronounced increase in the permeability and porosity of the vascular wall;
- induction of multiple organ failure;
- bacterial translocation (bacteremia);
- provocation of the development of sepsis.
Prevention, correction or treatment of specific pathological effects of acute intestinal failure are an obligatory element of pathogenetically based therapy of peritonitis.
The severity and characteristics of the clinical course of peritonitis are determined along with the nature of the exudate and the prevalence of the process, primarily the stage of the disease. Based on this, the symptoms of peritonitis will be outlined depending on the stage of the pathological process.
Intense local pain that suddenly appears or grows rapidly.
Anxiety, confusion, horror of death.
The belly is of a simple shape or retracted (scaphoid) and does not participate in the act of breathing.
Positive symptoms of peritoneal irritation:
- abdominal wall tension;
- Kushnerenko-Cheremsky cough symptom - increased pain when coughing. It is most typical when the parietal peritoneum is affected in the lower abdomen;
- a symptom of a deep breath is increased pain when taking a deep breath. It is most typical when the peritoneum is affected in the upper abdomen;
- Shchetkin-Blumberg symptom (decompression symptom) - a sharp increase (appearance) of pain with rapid withdrawal of the hand during deep palpation;
- percussion symptom of Razdolsky - increased (appearance) of pain when lightly tapping 2.3 fingers on the abdominal wall;
- Voskresensky's symptom (shirt symptom) is an increase (appearance) of pain with rapid movement along the anterior abdominal wall, covered with a stretched shirt or T-shirt, four bent fingers with slight compression of the abdomen. The symptom should be identified by moving the hand from a less painful place to the territory of the greatest pain;
- Kulenkampf's symptom is a sharp pain in the anterior wall of the rectum upon digital examination. The symptom is clearly expressed when the pelvic peritoneum is affected.
The greatest difficulties in diagnosing postoperative septic, and even more so aseptic peritonitis appear in the reactive stage, during local progression, because the course in the first days is virtually no different from the simple postoperative course during interventions on the abdominal organs. During operations on organs of other areas, the diagnosis of postoperative peritonitis does not present significant difficulties if a systematic examination of the patient is performed every day.
Of all the outlined signs, the most informative for postoperative peritonitis are: general condition, as well as well-being, pain, impaired gastrointestinal motility, symptoms of peritoneal irritation, tachycardia, fever.
Each patient endures the postoperative period in his own way. At the same time, there is a non-specialized pattern: the more days pass after the end of the operation, the better the health and condition. If the patient’s condition does not stabilize within 2-3 days after the end of the operation and there are no sufficiently objective explanations for this, one should think about possible complications, including intra-abdominal ones.
Intense pain after surgery on the abdominal organs is not uncommon; in most cases, during the first or second days, it slowly subsides by the third or fourth day. Based on this, if abdominal pain does not subside or, after subside, appears again and increases, then the patient has a high probability of developing or progressing peritonitis.
Motility of the gastrointestinal tract after timely interventions on the abdominal organs is restored in most cases on its own or by the method of drug and physical stimulation on the 3-4th days after the end of the operation. If the patient does not resolve gastric (intestinal) paresis on the 4-5th day and there is no objective explanation for this (anastomositis, truncal vagotomy, electrolyte disturbances, etc.) or the passage disorder has appeared by this time and is progressing, a possible circumstance in order for the condition to be possible postoperative peritonitis.
Tension of the abdominal wall and other symptoms of irritation of the peritoneum after surgery on the abdominal organs are a completely natural phenomenon in the first two days, after which these symptoms disappear quite quickly (on the 3-4th day). Tension of the abdominal wall that persists on the 3-4th day or appears in combination with local soreness as well as unexpressed other symptoms of peritoneal irritation indicates the development of peritonitis.
Tachycardia is an obligatory concomitant of peritonitis. Based on this, if the patient has tachycardia for a long time (more than 3 days) after the operation, it is necessary to immediately take all necessary measures to exclude peritonitis.
Fever is a very important symptom of postoperative peritonitis. Prolonged relieving fever without pulmonary complications constantly indicates an existing inflammatory process - wound suppuration or developing (progressive) peritonitis. The presence of hectic fever and chills indicates widespread purulent peritonitis and the transition of the process to stage II.
It should be noted that unjustified relaparotomies are seen very rarely, while belated relaparotomies for postoperative peritonitis are an everyday occurrence. Based on this, constant, special vigilance of the attending physician is required when caring for patients in the postoperative period.
Diagnosis of acute postoperative peritonitis
Of particular importance in making a diagnosis is the dynamic study of the morphological composition of peripheral blood. Increasing leukocytosis, a shift in the white blood count to the left, the appearance of toxic granularity of neutrophils, lymphopenia, and increased ESR indicate the presence (progression) of an inflammatory process.
With local limited peritonitis, ultrasound can provide fairly objective data, as well as its localization and prevalence.
In all cases that raise serious doubts, a consultation should be convened, and to resolve the issue of the presence of postoperative peritonitis, more often resort to revision of the abdominal cavity or laparoscopy.
Making a diagnosis of acute postoperative peritonitis in the stage of monoorgan failure does not pose any difficulties, because its symptoms at this time are very clear and manifest:
The patients are lethargic, the couple are loaded, the condition is serious.
Secondary vomiting, which does not bring relief; the vomit contains decomposed bile (the color of coffee grounds) and has an unpleasant odor.
Among all pathologies of the abdominal organs, peritonitis (inflammation of the peritoneum) has the highest mortality rate. The later a patient sees a doctor, the lower his chances of recovery. Mortality rates have dropped significantly in recent years due to significant advances in medicine. However, in some cases, even the most experienced surgeons are powerless.
Important historical facts
Medicine has been familiar with the clinical picture of peritonitis for a long time. Its surgical treatment was carried out in Ancient Egypt and India. The first description of the disease was made by the ancient Greek physician Hippocrates. The exact date is not known, but doctors still use his collection to this day to clarify symptoms and make a diagnosis.
In Russia, the first description of the pathology was made at the beginning of the 19th century by V. Shabanov (a military surgeon). At the same time, operations to open the abdominal cavity began.
A significant contribution to the history of cure for peritonitis was made by V. Kerte in 1892, who insisted on the need to perform the operation first and postpone other measures until the postoperative period. Thanks to this statement, it was possible to significantly reduce the percentage of deaths from 87% to 66%. A similar picture was observed in Russia. Emergency surgical intervention began to be used here in 1913.
In the treatment of peritonitis, antibiotics have become a major finding and have reduced mortality in the reactive period by up to 15%.
What is peritonitis
Peritonitis is an inflammation of the serous sheets of the abdominal cavity, in most cases caused by bacterial flora. The most common causative agents of infection are streptococci and Escherichia coli.
Causes and types of disease
The course of the disease can be:
- Acute. Its symptoms are pronounced and cause great suffering to the patient.
- Chronic. It is quite rare (in 0.3-0.5% of cases). This form can occur during a long-term inflammatory process of other organs. The signs are vague, so it is not always possible to determine the cause of the illness in time.
1-1.5% of patients are diagnosed primary a form of peritonitis, characterized by the penetration of pathogens into the abdominal cavity through:
- lymphatic system;
- blood;
- fallopian tubes.
It can be:
- gastric and pancreatic juice;
- bile;
- blood;
- urine.
Sometimes the disease occurs against the background of:
All peritonitis can be divided into the following forms, depending on the nature of the damage:
- Fibrous (adhesive). Lead to the formation of adhesions on the surface of internal organs. In this regard, their work is disrupted and characteristic complaints arise.
- Serous. They manifest themselves in the accumulation of serous exudate inside the abdominal cavity. Such patients complain of severe pain, high fever and persistent vomiting.
- Hemorrhagic. Associated with irritation of the peritoneum due to blood penetration. This pathology can occur as a result of injuries and extensive bleeding associated with the underlying disease.
- Biliary. Occurs after bile enters the abdominal cavity. The substance is extremely aggressive. It quickly leads to necrosis of surrounding tissues and spreads through the systemic bloodstream, poisoning the body as a whole and causing serious consequences.
- Purulent. They are caused by specific purulent flora and occur when the integrity of the membranes of the abdominal organs is violated and the contents are thrown into the peritoneal space. The cause may be acute gastrointestinal diseases or abdominal trauma.
- Feces. They occur as a result of perforation of the intestinal wall and the entry of its contents out.
- Putrid. Such peritonitis occurs as a consequence of a ruptured appendix.
The development of peritonitis is the most common complication of operations on the abdominal organs. Mortality from it reaches 70-75% of all deaths resulting from such interventions.
Based on the area of damage, peritonitis occurs:
- Local (limited). When the boundaries of the inflammatory process can be clearly defined.
- Diffuse. If peritonitis develops over the entire surface of the peritoneum and does not have clear edges.
If left untreated, peritonitis, regardless of the original cause, becomes bacterial, because the weakened peritoneum is not able to protect the body from infections.
Characteristic symptoms
Acute peritonitis progresses rapidly. The main symptoms depend on the stage at which the disease is:
- Reactive period(24 hours after infection) begins with severe abdominal pain that has a clear localization. They can radiate to other parts of the body, most often to the shoulder blade and collarbone. Gradually, the pain loses its epicenter, and the patient may feel pain throughout the abdominal area. The general symptoms are mild, but the patient’s appearance already has some features: pointed facial features and a pained expression, dark circles under the eyes combined with pale skin. In medicine, this sign is called the “Hippocratic face.”
- Toxic period(4-72 hours) is expressed in increasing general intoxication and can be manifested by severe vomiting that does not bring relief. In its composition you can find bile, feces, and blood. The patient's body temperature rises significantly and the pulse quickens (up to 120-140 beats per minute). Due to the large loss of fluid, dehydration occurs very quickly. The patient may feel a state of “euphoria” and a decrease in pain, which is a dangerous symptom and does not indicate recovery.
- Terminal period(72 hours or more) is final and quickly leads to death. According to statistics, only 10% of patients manage to survive after such a pathology. The form is considered irreversible due to damage to nearby organs and disruption of the functioning of the entire body. The vomiting only gets worse, inappropriate behavior is observed, and perspiration appears on the forehead. When palpating the abdomen, no reaction occurs; this is due to the death of the nerve endings of the peritoneum. The abdomen becomes full of gases, and urine and feces are largely not excreted.
Most patients may notice a characteristic putrid odor of vomit, a greenish face, a coated tongue, and severe jaundice.
If obvious signs of intoxication appear (vomiting, fever, increased heart rate, etc.) in combination with severe abdominal pain, you must take a horizontal position and call an ambulance. Before her arrival, you should not take any independent action.
Temporary relief should not be a reason to refuse hospitalization. If left untreated, peritonitis quickly affects internal organs and leads to worsening of the condition.
Informative diagnostic methods
During the initial visit, the patient is examined. Its appearance may already indicate a pathological process occurring in the body.
At palpation(palpating, stroking) the abdomen, a pronounced tension in its walls is revealed.
The use of the following techniques gives positive results:
- Shchetkin-Blumberg. Gently pressing on the abdominal wall and sharply removing the fingers causes increased pain.
- Voskresensky. Passing the hand through the patient's shirt, along the abdominal wall from the urinary process, increases the pain.
- Medel. With light percussion (tapping) on the abdominal wall, an exacerbation of pain is observed.
The technique is widely used auscultation which consists of listening to various noises made by internal organs. For this, special devices are used.
If peritonitis is suspected, the patient may have:
- “splash noise”;
- “deathly silence”;
- "the sound of a falling drop."
Laboratory blood tests will help identify the presence of intoxication; for this you need to take:
- general and detailed analysis;
- biochemistry;
- coulogram.
The combination of a significant increase in leukocytes, neutrophils and ESR (erythrocyte sedimentation rate) indicates the presence of a purulent process.
To identify this source, an extensive radiography abdominal cavity using contrast (barium mixture).
The following signs may indicate peritonitis:
- Presence of “Kloiber bowls”. The image clearly shows swollen areas of the intestine filled with gas and liquid. In the vertical position of the patient, the fluid in these formations is placed horizontally.
- "Sickle" symptom. Detection of free gas diaphragm under the dome.
To determine the presence of free liquid, it is carried out Ultrasound(ultrasound examination) of the abdominal cavity.
In some cases it will be necessary to CT(computed tomography).
If after the studies the diagnosis cannot be confirmed or its cause remains unclear, an additional abdominal puncture(laparocentesis) and examination with an endoscope, which is inserted through a small puncture (diagnostic laparoscopy).
Detection of postoperative peritonitis is significantly complicated:
- the impossibility of performing many techniques;
- taking medications.
Due to the high mortality rate from postoperative peritonitis, at the slightest suspicion, patients are recommended to undergo an ultrasound or CT scan of the abdominal cavity.
The life of a patient diagnosed with peritonitis depends on many factors. Early diagnosis significantly increases the patient's chances.
Surgery
Peritonitis can only be eliminated in a hospital setting. After an accurate diagnosis is made, the patient is urgently sent for surgery. Every minute of delay reduces the chance of a favorable outcome of the procedure.
To reduce risks during surgery, it is necessary to carry out some preparatory measures:
- directly on the operating table, cerucal (10-20 mg) or midazolam (5 mg) is administered intravenously;
- to reduce stomach acidity, use ranitidine (50 mg) or omeprazole (40 mg);
- perform artificial ventilation;
- infusion therapy is used, which consists of administering a saline solution (about 1.5 liters) using a dropper;
- install catheters on the bladder, central and peripheral veins.
According to indications, the list can be supplemented.
During the operation, the following algorithm is followed:
- open the abdominal cavity;
- remove or isolate the source of infection;
- the cavity is rinsed using special solutions;
- carry out drainage (if necessary);
- carry out measures to decompress (reduce pressure) in the small intestine;
- suturing.
Surgical intervention is performed using laparotomy (dissection of the abdominal wall). Basically, the middle technique is used (from the navel to the beginning of the pubis), which allows optimal access to all organs and parts of the abdominal cavity.
Disinfection is the most important step. It is carried out by the following means:
- 0.02% aqueous solution of chlorhexidine;
- 0.6% sodium hypochloride solution.
On average, 8 to 10 liters of antiseptic agents are used for sanitization. When the liquid remains clear after washing, the procedure is completed.
Installation of a nasogastrointestinal tube allows for decompression of the small intestine.
Drainage of the abdominal cavity or its individual sections is carried out through the anus.
Before the end of the operation, the patient is provided with special drains made of vinyl chloride for administering drugs and suctioning out exudate.
Recovery postoperative period
In the first 72 hours after surgery, the patient is closely monitored:
- Diagnostics and assessment of pressure, respiration, pulse, discharge from drains are carried out hourly;
- to avoid the slightest hypothermia, all injected solutions warm up the patient’s body temperature;
- for 3 days the lungs are on artificial ventilation, for sufficient oxygen supply to tissues and organs;
- relieve pain syndromes using analgesics, antispasmodics, painkillers and narcotic substances;
- carry out infusion therapy with crystalloid and colloid solutions;
- regularly administer glucose solution;
- restore intestinal perilstatics.
The most common problems after surgery include:
Called inflammation of the peritoneum. This condition is extremely dangerous for the body, as it disrupts the functioning of all vital organs. Acute peritonitis requires emergency medical attention, otherwise it can lead to death within a short time.
Peritonitis can be primary or secondary. Primary peritonitis of the abdominal cavity is rare (more often in children) and is caused by damage to the peritoneum by microorganisms that penetrated hematogenously, lymphogenously or through the uterine (fallopian) tubes. Secondary peritonitis occurs as a result of the spread of infection from various organs of the abdominal cavity when they are inflamed, perforated or damaged.
Causes of peritonitis
Peritonitis develops when exposed to an infectious (less commonly viral) agent. The peritoneum does not have its own protective capabilities, inflammation spreads quickly, and a huge amount of toxins are produced that quickly poison the entire body.
Pathogenic microorganisms most often enter the peritoneum from internal organs, which for some reason (trauma, surgery, perforation) have lost their tightness, and their contents have entered the abdominal cavity, causing inflammation, suppuration, and decay there. Sometimes the cause of peritonitis lies in the intracavitary factor.
Among other causes of peritonitis, intestinal dysfunction plays an important role. Various types of intestinal obstruction in their final stage with developed intestinal necrosis, acute pancreatitis, thrombosis of mesenteric vessels and perforation of tumors of the gastrointestinal tract, gynecological diseases can cause peritonitis.
From a clinical point of view, alcoholic peritonitis is interesting, the pathogenetic cause of which may lie in Mallory-Weiss syndrome, in a toxic perforated ulcer and other conditions. This type of peritonitis is interesting in that it very rarely causes typical or even alarming symptoms, leading to death or serious complications.
Classification of peritonitis
Peritonitis can be primary or secondary.
Primary, also known as idiopathic or viral peritonitis, occurs extremely rarely, as a result of a primary infectious lesion of the abdominal organs and peritoneum. In the case of viral peritonitis, the infection penetrates the peritoneum hematogenously, or through the lymphatic vessels, and occasionally through the fallopian tubes. Viral peritonitis accounts for no more than 1% of all cases of the disease.
Depending on the reason, there are:
- Infectious peritonitis;
- Perforated peritonitis;
- Traumatic peritonitis:
- Postoperative peritonitis.
According to the nature of the inflammatory exudate:
- Serous peritonitis;
- Purulent peritonitis;
- Hemorrhagic peritonitis;
- Fibrinous peritonitis;
- Gangrenous peritonitis.
By degree of distribution:
- Local peritonitis;
- Generalized peritonitis;
- General (total) peritonitis.
By localization:
- Limited (enclosed) peritonitis;
- Diffuse peritonitis.
By traumatic factor:
Acute diffuse peritonitis in most cases develops as a complication of various diseases of the abdominal cavity - perforated ulcer of the stomach, intestines, purulent appendicitis, thrombosis of mesenteric vessels, liver abscess, etc. The causative agent of the inflammatory process in the peritoneum is intestinal microflora: E. coli in combination with streptococci, staphylococci, dysentery bacilli.
In accordance with the etiological factors, the following forms of the disease are distinguished:
- perforated diffuse peritonitis - associated with perforated ulcers of the stomach, duodenum, large and small intestines;
- biliary peritonitis- occurs as a result of perforation of the gallbladder, and in some cases without it;
- septic peritonitis - postpartum.
- pneumococcal peritonitis - occurs with pneumonia, in patients with severe nephritis, etc.
- postoperative peritonitis;
- traumatic peritonitis - associated with mechanical injuries, wounds with cold steel or firearms.
A constant symptom of acute general peritonitis is pain. Severe pain forces the patient to go to bed. They sharply intensify with the slightest movement, coughing, or shaking. The patient's face is pale, cold sticky sweat appears on the forehead, blood pressure drops, and the pulse becomes thready. In the future, intense pain may subside, especially during the period of accumulation of exudate in the abdominal cavity. The passage of feces and gases stops, and there is no peristalsis. In this case, vomiting and persistent hiccups are observed. In the early stages of the development of the disease, the vomit contains food residues. In advanced cases of the disease, vomiting may become fecal in nature.
Acute purulent peritonitis
The causes of acute purulent peritonitis can be:
- An 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.
- Perforation of abdominal organs (perforated gastric ulcer, perforation of typhoid ulcer of the small intestine, etc.), as a result of which infected contents spill into the abdominal cavity and cause peritonitis.
- 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 the abdominal cavity and cause the development of an acute purulent inflammatory process in it.
- 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, most often occurring as a complication of any inflammatory process, perforation or damage in the abdominal cavity. That is why, in case of inflammation of the peritoneum, one cannot limit oneself 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.
Biliary peritonitis
The cause of biliary peritonitis is most often acute inflammation of the gallbladder, usually caused by strangulation of the stone and the presence of a virulent infection, the gallbladder is greatly enlarged, and the bile contains flakes or pus and is dirty yellow or gray. The disease is often complicated by acute cholangitis, due to the spread of infection to the bile ducts. Bile may leak from the bladder bed. Increased pressure in the bile ducts, for example due to an unremoved stone in the common bile duct, increases the flow of bile, the accumulation of which around the bile ducts contributes to the development of their stricture.
The severity of symptoms depends on the degree of spread of bile throughout the abdominal cavity and its infection. The entry of bile into the free abdominal cavity leads to severe shock. Bile salts chemically irritate the peritoneum, which causes exudation of large volumes of plasma into the ascitic fluid. The outpouring of bile is accompanied by severe diffuse pain in the abdomen. On examination, the patient is motionless, the skin is pale, low blood pressure, persistent tachycardia, board-like rigidity and diffuse pain on palpation of the abdomen are noted. Intestinal paresis often develops, so in patients with unexplained intestinal obstruction, biliary peritonitis should always be excluded. After a few hours, a secondary infection occurs, which is manifested by an increase in body temperature against the background of persistent abdominal pain and soreness.
Peritonitis with appendicitis
Late admission of patients and late diagnosis are the most common causes of complications in acute appendicitis. In the first two days, inflammation of appendicitis is characterized by the absence of complications; the process usually does not extend beyond the appendix, although destructive forms and even perforation can be observed, especially often in children and the elderly. On days 3-5 the following usually occur: perforation of the appendix, local peritonitis, thrombophlebitis of the veins of the mesentery of the appendix, appendiceal infiltrate. After 5 days the following are observed: diffuse peritonitis, appendiceal abscesses, portal vein thrombophlebitis - pylephlebitis, liver abscesses, sepsis.
Inflammation of the appendix develops into inflammation of the peritoneum in 10-15% of cases. It is precisely this development of events that doctors are afraid of, and it is for this reason that they try to be careful with pain in the abdominal area. The difference between the two diseases is that the signs of inflammation of the peritoneum are more pronounced. They are to some extent similar to the signs of appendicitis, but appear with greater force, so in this case doctors have much less doubt about the diagnosis.
Peritonitis after surgery
Peritonitis is a common and serious complication after surgery on the abdominal organs. The cause of its occurrence is most often: failure of anastomotic sutures, duodenal stump, destructive changes in the abdominal organs (acute pancreatitis, necrosis of the stomach or intestinal wall with an incorrect assessment of their viability, perforation of acute ulcers, acute mechanical intestinal obstruction, etc.), infection of the abdominal cavity during surgery or its inadequate sanitation in those operated on for peritonitis.
There is no universal clinical picture of postoperative peritonitis. The difficulty in diagnosing such a complication lies in the fact that the patient has undergone surgery and is already in serious condition, is being intensively treated with medications, including antibiotics, hormones, and is receiving painkillers. The situation becomes more complicated if the patient was operated on for peritonitis (for example, peritonitis that occurred after perforated appendicitis or perforated gastric ulcer, duodenal ulcer). Here it is fundamentally important to distinguish newly emerging postoperative peritonitis from existing (ongoing) peritonitis for which the patient was operated on. Diagnosis of postoperative peritonitis is especially difficult in elderly, malnourished patients with a severe course of the underlying or concomitant disease.
The main thing in the diagnosis of postoperative peritonitis is the early detection of this complication before the development of classic, pronounced symptoms, starting with "Facies Hyppocratica", "board-shaped abdomen", including numerous symptoms of peritoneal irritation, when peritonitis becomes widespread (spread) and passes in its development from the phase absence of signs of sepsis during the sepsis phase.
There are no absolute signs to recognize the onset of peritonitis in the postoperative period. Therefore, much depends on the correct organization of dynamic monitoring of the patient in the postoperative period using clinical and laboratory tests that reveal the progressive increase in endogenous intoxication.
Symptoms of peritonitis
Inflammation of the peritoneum is roughly indicated by an increase in the torso, strenuous walking, and a sudden deterioration in the condition of diseases of the abdominal organs.
Acute peritonitis is a generalized disease that occurs with high fever and very high leukocytosis (100 thousand cells or more per 1 mm3). The abdomen is tucked up, tense and painful. Urination and defecation are impaired and often absent. Sometimes vomiting, tenesmus, and rapid, shallow, chest-type breathing occur. The eyes are sunken, the mucous membranes are red, the capillary refill rate is over 2 s. The pulse is rapid, small in filling, even thread-like. The fluid aspirated during laparocentesis is cloudy, serous, purulent or bloody, containing fibrin flakes.
With chronic peritonitis, all of the above signs may not be detected. The animal is apathetic, drowsy, the belly is somewhat enlarged and saggy. Therefore, chronic peritonitis is often diagnosed only during laparotomy (opacity of the peritoneum, thickening, plaque, pinpoint bleeding).
But the blood status is indicative for both courses of peritonitis (accelerated ESR, leukocytosis with a hyperregenerative shift of the nucleus to the left until the appearance of young and young cells).
Acute peritonitis has several phases of development:
- The reactive phase lasts from 12 to 24 hours;
- Toxic phase, duration from 12 to 72 hours;
- The terminal phase occurs after an interval of 24 to 72 hours from the onset of the disease and lasts several hours.
Thus, acute peritonitis can be fatal within 24 hours of the onset of the disease.
Treatment of peritonitis
Peritonitis requires urgent surgery. The consequences of treatment directly depend on the urgency of the surgical intervention. The operation consists of removing the source of inflammation, sanitizing the abdominal cavity, and draining it. At the same time (as well as in the postoperative period), the water and electrolyte balance, the functions of organs and systems, damage to which is inevitable during peritonitis, is restored.
After the operation, antibiotics and massive infusion therapy are prescribed, aimed at restoring immunity, gastrointestinal functions, and preventing complications.
General principles of treatment of peritonitis:
- possible earlier elimination of the source of infection during surgery;
- evacuation of exudate, washing of the abdominal cavity with antibacterial drugs and adequate drainage of it with tubular drainages;
- elimination of paralytic intestinal obstruction by aspiration of contents through a nasogastric tube, decompression of the gastrointestinal tract, and use of medications;
- correction of volemic, electrolyte, protein deficiencies and acid-base status with the help of adequate infusion therapy;
- restoration and maintenance of kidney, liver, heart and lung function at an optimal level;
- adequate antibiotic therapy.
Peritonitis is an acute or chronic inflammation of the peritoneum. Peritonitis is a fairly common disease that requires serious treatment. What is the diet for peritonitis, only the attending physician can answer, taking into account the patient’s individual indicators, but a number of general recommendations for this disease can still be identified.
General information about the disease
The manifestation of symptoms of peritonitis can be both local and general. In the presence of a disease, the functioning of organs and systems in the body is disrupted. Inflammation of the peritoneum is caused by pathogenic microflora. According to the nature of penetration of this microflora, peritonitis can be primary or secondary. Primary peritonitis is caused by the penetration of pathogenic microflora through the blood and lymph or through the fallopian tubes. The causes of secondary peritonitis are:
- Infection in the abdominal organs
- Perforation of the genitals
- Penetrating abdominal wounds
- Leakage of anastomotic sutures
The following can cause peritonitis:
- Microflora of the digestive tract (staphylococci, enterococci, Escherichia coli or streptococci)
- Microflora not related to the digestive tract (gonococci, pneumococci and mycobacteria)
Peritonitis, depending on the severity of the course, can be acute, subacute and chronic. Symptoms of inflammation in the abdominal cavity are:
- Abdominal pain that gets worse with deep breaths
- Increased body temperature, but not always
- Perspiration, that is, cold sweat
- Reflex vomiting
- Rapid pulse
- Nausea
Nutrition for peritonitis
After surgery, for some time nutrition for peritonitis is based on tube enteral solution administration. This method involves introducing food solutions into the stomach or intestines through a probe, which give the body the necessary boost of energy after natural digestion.
Nutrition after peritonitis surgery
When the rehabilitation period is over, with the permission of the attending physician, you can switch to following a diet for peritonitis. The calorie content of the diet will be 2500-3000 kcal daily. You will need to exclude the following foods from your diet:
- Products containing fiber and essential oils: peppers, mustard, onions, legumes, turnips, garlic, cabbage, radishes and mushrooms
- Tea, cocoa and strong brewed coffee
- Carbonated and alcoholic drinks
- All kinds of smoked meats
- Pickles and marinades
- Chocolate
The basis of nutrition should be made up of the following list of foods and drinks:
- Up to two soft-boiled eggs per day or an omelet for a couple of them
- Vegetables that do not contain a lot of rough fiber
- Low-fat milk and fresh dairy products
- Lenten varieties of fish, poultry and meat in dishes
- Vegetable, dairy and cereal soups
- Sweet berries and fruits
- Dried bread
- Rose hip decoction
- Jam and honey
A diet for peritonitis must be followed. Its preparation should be discussed with the attending physician, since he knows the individual and genetic characteristics of your body.