Peritonitis

Peritonitis - inflammation of the peritoneum, accompanied by common symptoms of the disease of the body with a violation of the function of vital organs and systems. Depending on the nature of the effusion, there are serous, fibrinous, purulent, hemorrhagic, putrefactive and fecal peritonitis. Of the pathogens, microbial associations are most often sown: staphylo-, streptococci, Escherichia coli, pneumo- and gonococci, and a large group of anaerobes, which have recently become increasingly important.

The main causes of peritonitis: acute destructive appendicitis, perforated ulcer of the stomach and duodenum, acute destructive cholecystitis, diverticulitis of the colon or diverticulitis of the ileum (Meckelian diverticulum), perforation of the colon tumor or rupture of the caecum with tumor intestinal obstruction, traumatic ruptures of hollow organs with closed Abdominal trauma. Less often, peritonitis develops after surgery. When entering the abdominal cavity of gastric contents, pancreatic enzymes, bile, blood, urine develops chemical-toxic peritonitis.

Pathophysiology. Infection and exposure to toxins on the peritoneum lead to hyperemia, edema, fluid transudation into the abdominal cavity, fibrinous overlap on the parietal and visceral peritoneum, which delimit the inflammatory process. In the absence of such discrimination, toxins and microbes spread throughout the abdominal cavity, creating diffuse peritonitis. In the presence of adhesions and adhesions, the inflammatory process will be limited to a certain area of ​​the abdominal cavity, however, the absorption of toxins goes through the lymphatic system, and the irritation of the nerve endings leads to a reflex inhibition of intestinal peristalsis, which, with the progression of peritonitis, can pass into a full dynamic intestinal obstruction. The secretion of fluid into the intestinal lumen continues, but there is practically no resorption, which leads to the sequestration of fluid in the lumen and intestinal wall. Peritonitis is characterized by significant (4-6 l and more during the day) fluid sequestration due to the peritoneal stack, fluid accumulation in the wall and luminal cavity, abdominal cavity.

Peritonitis leads to stimulation of many endocrine organs: within 2-3 days after the onset of peritonitis, the cortical layer of the adrenal cortex stimulates. Epinephrine leads to vasoconstriction, tachycardia and permeability enhancements. The secretion of aldosterone and antidiuretic hormone causes an increase in hypovolemia, a delay in sodium and water. Reduction of the volume of circulating blood and infection (exposure to exotoxins and endotoxins) are the causes of the development of mixed (hypovolemic and septic) shock.

Symptoms, course. The diagnosis of peritonitis is mainly based on the clinical picture of the disease. Examination and intensive conservative treatment should not delay timely and adequate surgical intervention. Initial symptoms correspond to the underlying disease, which leads to the development of peritonitis (acute appendicitis, acute cholecystitis, diverticulitis, etc.). Against this background, there is an increase in the pain syndrome, the pain is sharply increased and spreads rapidly throughout the abdomen. Language in the initial stages is covered, moist. The abdomen is strained in all departments, sharply painful, the symptoms of irritation of the peritoneum are positive, percussion tenderness is maximal in the zone of the primary focus of infection. Should be determined hepatic dullness-smoothness or lack of ee - a sign of perforation of the hollow organ.

Clinical manifestations depend on the stage of peritonitis. Isolate the reflex, toxic and terminal stages. In the terminal stage, the diagnosis of special difficulties does not represent: the face of Hippocrates, dry (like a brush), lined tongue. The abdomen is swollen, tense and painful in all parts, positive symptoms of irritation of the peritoneum, peristalsis absent. Characteristic tachycardia, unstable blood pressure, oliguria. In the analysis of blood - high leukocytosis, the shift of the formula to the left. In biochemical studies - increased bilirubin, creatinine, urea (hepatic-renal failure).

X-ray signs; Free gas under the dome of the diaphragm (perforation of the hollow body), gas in anatomically gas-free structures (inter-loop or sub-diaphragmatic abscess). The presence of fluid levels in the small and large intestine testifies to paralytic intestinal obstruction. Radiographic examination of the chest cavity determines atelectatic pneumonic foci, effusion in the pleural cavity. In diagnostically difficult cases, laparoscopy is used.

An ultrasound is used to diagnose a delimited peritonitis abscess.

Postoperative peritonitis has some peculiarities due to the widespread use of analgesics and antibiotics in the postoperative period. Nevertheless, the diagnosis of postoperative peritonitis with constant monitoring of the patient in most cases can be diagnosed in a timely manner. Exception can only be made by patients who are on artificial ventilation. In the diagnosis, the change in the pain syndrome, the increase in tachycardia, the instability of blood pressure, He-resolved intestinal paresis, changes in blood tests (increase in leukocytosis and shift of the formula to the left, increase in the level of creatinine, urea, bilirubin) are important. When X-ray examination with water-soluble contrast can reveal the inconsistency of the anastomosis sutures - the most common cause of postoperative peritonitis.

Treatment of peritonitis operative. The loss of time with the onset of surgery prompts the development of severe complications (septic and hypovolemic shock) with a fatal outcome. When the patient is in a serious condition, short-term (2-3 hours) training is needed to correct the volemic disorders and bring the patient into an operable state. The operation is performed under intubation anesthesia. As an access with diffuse peritonitis, a wide median laparotomy is used.

Principles of surgical treatment: 1) sanation of the primary focus of infection (eg, apsendectomy, cholecystectomy, suturing of perforated ulcer, etc.) and abdominal cavity, which is washed with isotonic sodium chloride solution or 0.25% novocaine with the addition of antibiotics and antiseptics. The use of furatzin is undesirable; 2) drainage of the abdominal cavity: the most appropriate use of drains from silicone rubber (usually draining the most sloping sections of the abdominal cavity and subdiaphragmatic space). Convenient double-lumen drainage;

Washing drainage through one lumen prevents clogging it with fibrin films, etc. Such a drainage of silicone rubber can remain in the abdominal cavity for up to 2 weeks, but it is desirable to periodically pull up drainage to prevent the development of pressure ulcers on the wall of the bowel; 3) with severe paralytic intestinal obstruction, nasointestinal intubation of the small intestine is necessary, followed by aspiration of intestinal contents, which contributes to an earlier recovery of active peristalsis.

In a number of cases, in the terminal phase of the disease, peritoneal lavage is used in patients - flowing lavage of the abdominal cavity with solutions of antibiotics and antiseptics. The method has its advantages (decrease of intoxication, improvement of kidney function) and disadvantages (prevent natural delimitation of the inflammatory focus, natural protective mechanisms are removed). (There are no statistically significant favorable results, but in some cases good results were obtained.In recent days, with good effect, planned postoperative relaparotomy is used.Over the day after the operation, relaparotomy is performed with thorough washing of the abdominal cavity and drainage.The subsequent relaparotomy is performed in 1-2 days Depending on the nature and quantity of the discharged and the general condition of the patient draining over the drains. In the last decade, extracorporeal detoxification methods have been widely used in the treatment of peritonitis (UV-irradiation of blood, hemosorption, plasmapheresis, hyperbaric oxygenation, etc.).

The forecast is always very serious. Lethality depends on the cause of peritonitis, the timing of surgical treatment (see the relevant sections). Operation on a background of a septic shock gives lethality 80-90%.