Peritonitis of the abdominal cavity: symptoms, treatment, causes. Signs of peritonitis: the main symptoms in acute and chronic inflammation The first signs of peritonitis in humans

Peritonitis - this is an inflammation of the parietal and visceral peritoneum, usually of a secondary nature, accompanied by a syndrome of intoxication, which leads to disruption of the activity of all organs and systems - multiple organ failure.

• Frequency - 5,5 on the 100000
• Complicates 4,3 – 20,5% all acute surgical and gynecological diseases
• Lethality - 20 — 30%

Anatomical features of the structure of the peritoneum

The peritoneum is covered with a layer of polygonal flat cells called mesothelium. It is followed by the boundary (basement) membrane, then the superficial fibrous collagen layer, the elastic (superficial and deep) network, and the deep cribriform collagen layer. The last layer is the most developed and occupies more than half of the entire thickness of the peritoneum, it is here that the peritoneum is abundantly penetrated by a rich network of lymphatic and blood vessels.

The peritoneum consists of parietal and visceral sheets, which are a single continuous shell. The visceral layer covers the organs, the parietal layer lines the inside of the anterior and posterior walls of the abdomen, the walls of the small pelvis. The parietal sheet of the peritoneum is rich in endings of sensory nerves, it reacts with pain to any irritation: chemical, thermal, mechanical. Pain is always localized. But their number is not the same - there are more nerve endings in the upper floor, and noticeably less in the pelvis. This is of great clinical importance - for example, the accumulation of purulent effusion under the right dome of the diaphragm causes sharp pains extending to the shoulder and neck (phrenicus symptom), and the accumulation of effusion in the pelvis can be almost asymptomatic.

But the visceral sheet of the peritoneum is almost not sensitive, therefore, irritation of the organs from the outside is not of a painful nature. On the other hand, stretching of the internal organs and the peritoneum covering them (for example, with intestinal obstruction) leads to sharp pains, which are called visceral.

CLASSIFICATION OF PERITONITIS.

BY THE NATURE OF PENETRATION OF THE INFECTION

1. Primary peritonitis, (1-3%). Occurs without damage to the integrity or inflammation of organs abdominal cavity and is the result of spontaneous hematogenous infection in the abdominal cavity from other organs. For example, this is pneumococcal peritonitis in children (the drift of pneumococci from the lungs with pneumonia). As a rule, this is a monoinfection.
2. secondary peritonitis, occurs most frequently. Its cause is perforation or inflammation of the abdominal organs, trauma (open and closed) of the abdominal organs, postoperative peritonitis. For example, peritonitis in acute gangrenous appendicitis, perforated ulcer, necrosis of the intestine during its volvulus, etc.
3. Tertiary peritonitis. It is also called: sluggish, recurrent, persistent, recurrent. it lingering course peritonitis in debilitated patients. The patient does not die for several weeks, but cannot get better either, clinical picture erased, the reaction from the peritoneum decreases, but does not disappear completely. Develops with various forms impaired immunity, in HIV-infected, malnourished patients, patients with intestinal fistulas, with concomitant diseases (tuberculosis diabetes, SLE, etc.

NATURE OF PATHOLOGICAL AGENT AND SPECIFIC INFECTION:

1. Biliary peritonitis
2. Enzymatic (pancreatic enzymes) peritonitis
3. urinary peritonitis
4. Fecal peritonitis
5. Hemorrhagic peritonitis
6. colibacillary peritonitis
7. Specific forms of peritonitis: Syphilitic, Tuberculous, Candidomycosis, Carcinomatous, etc.

All peritonitis from 1. to 6. despite a different cause, proceed according to a single law. If at first they have a different clinical picture, then in the end they all end with a purulent-fibrinous process, severe intoxication, multiple organ failure and, in the absence of adequate surgical treatment- the death of the patient.

The course of specific peritonitis (7) proceeds depending on the type of infection, almost all of them are chronic, require the appointment of specific drugs (for example, anti-tuberculosis), and surgery is usually not needed.

BY THE PREVALENCE OF THE PROCESS (according to Fedorov V.D.).

This classification is important for determining the timing of peritonitis and its severity, and also determines the choice of surgery and postoperative management.

one). Local:

A. Local limited peritonitis are abdominal abscesses. Hence, each abscess of the abdominal cavity must be considered as peritonitis, albeit limited and possibly small in area, but proceeding according to all the laws of peritonitis.

B. Local unlimited peritonitis, this is peritonitis, frolicking in only one anatomical region and having no reason for limitation. Usually he just did not have time spread throughout the abdomen. For example, a patient had a perforation of the appendix, but he was immediately operated on.

2). Common

A. Diffuse peritonitis, this is peritonitis, covering a significant part of the abdominal cavity (1 or 2 floors of the abdominal cavity, but not all). For example, a patient was admitted with a perforation of the appendix, during the operation he was found to have pus in both iliac regions, he reached the navel and above, but the upper floor of the abdominal cavity remained free - such peritonitis will be considered diffuse. It should be noted that in other classifications the word "diffuse" may have a different meaning, for example, be a synonym for the word spilled.

B. Diffuse peritonitis, This is peritonitis covering all three floors of the abdominal cavity

B. General peritonitis or total, essentially the same as diffuse peritonitis, but emphasizing the totality of the lesion of the abdominal cavity. At present, this term is almost never used.

Recently, proposals have been considered to simplify this classification and divide it into only two forms (Saveliev V.S., Eryukhin E.A. 2009): 1. Local peritonitis; 2 Widespread (diffuse) peritonitis.

BY NATURE

1. Serous peritonitis. Indicates short periods of inflammation. In the abdominal cavity there is a transparent light effusion, odorless, light yellow or yellow effusion. The amount may be small or significant.
2. Serous fibrinous peritonitis. White fibrin clots appear, they float in the effusion, or are located on the peritoneum. Usually there are more of them where the source of inflammation is located. They are easy to remove or wash away from the intestinal wall or peritoneum.
3. Purulent peritonitis. The exudate turns into pus, thickens, becomes opaque. Pus in the abdominal cavity usually sooner or later becomes colibacillary (Gr-) and differs from those abscesses that we see in soft tissues(cocci, Gr+), where the pus is usually creamy. In the abdominal cavity, purulent effusion is liquid, dirty gray in color, with spots of fat. Gradually, a sharp specific smell appears.
4. Purulent-fibrinous peritonitis. Not only does a large amount of pus and fibrin appear in the abdominal cavity, but the latter begins to cover large areas of the peritoneum. Fibrin penetrates deep into the walls of organs and it is not possible to simply remove it from the walls of the intestines, if you make an effort, then the peritoneum will be torn off with fibrin up to the muscle layer. Fibrin, richly covered with infection, glues intestinal loops into extensive conglomerates in the center of which abscesses form.

One of the important classifications of peritonitis, this classification according to STAGES (according to Simonyan K.S.).

It primarily reflects pathophysiological changes in the body, depending on the stage of the process, as well as those associated with these processes clinical manifestations.

This classification assumes three stages of pathophysiological changes occurring in the body. It is based on the relationship of protective (immune) forces and the forces of infection in the abdominal cavity. With the gradual depletion of the body's immune properties and damage to internal organs due to intoxication, one stage of peritonitis passes into another. The division into stages by time (24, 24-72 hours, 72 hours or more) is approximate and conditional. Depending on the individual characteristics of the organism, the presence of concomitant immune-depressive diseases (diabetes, HIV, tuberculosis), as well as on the characteristics of the infection, these terms can vary significantly in both directions.

Reactive stage (24 hours)

Local and general reaction of the body to infection in the abdominal cavity. It is manifested by a violent protective reaction of the body to infection. From the side of the peritoneum: hyperemia, increased vascular permeability, exudation, formation of fibrin films, gluing of the intestines. Gradual transformation of serous effusion into purulent.

General reaction: nonspecific inflammatory hypothalamic-pituitary-adrenal reaction, intoxication with exo and endotoxins. Hormones (GCS), catecholamines and microbial toxins stimulate the production of interleukins. But despite the intoxication, all organs and systems cope with their function. If the operation is performed within 24 hours and the source of peritonitis is removed, the body copes with the infection and recovery occurs.

Clinically the patient complains of very severe pain in the abdomen, possibly a forced position (posture of the "embryo" with a perforated ulcer). Intoxication appears and grows: fever to subfibril numbers, tachycardia, tachypnea, dry mouth. Sometimes vomiting. Leukocytosis and a shift of the leukoformula to the left appear in the blood, mainly due to an increase in the stab forms of neutrophils by more than 5.

When examining the abdomen: the latter partially or completely does not take part in breathing. Pain, muscle tension of the anterior abdominal wall (rigidity, defence), positive symptoms of peritoneal irritation (Shchetkin-Blumberg symptom, Mendel symptom - tapping with the fingertips), pain in the pelvic peritoneum during rectal or vaginal examination.

Mortality for this stage is not typical and does not exceed 3%.

Toxic stage (24-72 hours).

Depletion of the protective and compensatory forces of the body, a breakthrough of biological barriers that restrain endogenous intoxication(these primarily include the liver, peritoneum, intestinal wall). Severe intoxication with exo- and endotoxins, interleukins, cell destruction products leads to damage to all organs and systems and the development of multiple organ failure, which is initially reversible (multiorgan dysfunction).

If you perform an operation at this stage, one removal of the source of peritonitis may not be enough. Treatment of the disease requires a set of measures to drain the abdominal cavity, suppress infection with antibiotics, correct intoxication and water and electrolyte disorders, etc. During active therapeutic measures, disturbances in the activity of all organs gradually disappear, and the body copes with the infection.

Clinically: Severe condition. Usually any peritonitis in this stage is diffuse. Dry tongue (like a brush), dry lips, vomiting. The muscles of the anterior abdominal wall are tense, positive symptoms of peritoneal irritation. Percussion (and ultrasound) can determine the effusion in the sloping areas of the abdominal cavity.

A detailed picture of intoxication. "The face of Hippocrates" haggard, with sunken eyes. The patient is adynamic and his posture expresses, as it were, impotence. Pulse is fast, weak, falling arterial pressure, hectic nature of temperature, breathing is frequent, free, noisy.

Multiple organ failure manifests itself as oliguria, intestinal paresis (deathly silence, bloating), impaired consciousness (stupor or euphoria). In the blood, leukocytosis, a shift of the formula to the left to young forms and myelocytes.

Lethality reaches 20%.

Terminal stage (over 72 hours).

In the absence of surgery, purulent effusion spreads throughout the abdominal cavity. Fibrin, which has absorbed a large amount of infection, covers the parietal and visceral peritoneum, the intestinal walls stick together to form infiltrates, in which interloop abscesses are born. The waste products of microorganisms, the products of cell decay are absorbed into the blood, causing severe intoxication. Local and general defense mechanisms are completely untenable. Septic shock may develop. After 72 hours, intoxication and hypoxia lead to the development of severe damage to all organs and systems, their severe hypoxia occurs. The changes that result from this in the internal organs are severe dystrophic and irreversible character(hyalinosis, amyloidosis of cardiomyocytes, hepatocytes, necrosis of the epithelium of the renal tubules, etc.). There is renal failure, shock lung, impaired (CNS), consciousness, destruction of immunity, toxic damage to the liver, depression of cardiac activity, which ultimately leads to the death of the patient.

One of the manifestations of multiple organ failure is severe intestinal paresis. Despite the fact that physically it remains sealed, in the conditions of the terminal stage of peritonitis it becomes permeable to gram-intestinal microflora, which in in large numbers freely enters the intestinal lumen into the abdominal cavity.

Clinically the terminal phase of peritonitis manifests itself as signs of severe intoxication + severe multiple organ failure. The condition is extremely difficult. The face of Hippocrates. Adynamia, prostration, psychosis, coma. Vomiting with a fecal odor is possible. Tachycardia, thready pulse, decreased blood pressure. Decreased diuresis or oliguria. Respiratory depression, decreased suturation (blood oxygen levels indicated by bedside monitors). To maintain life and raise blood pressure, such patients are often transferred to inotropic support (constant intravenous administration of dopamine), to improve respiratory function, patients are transferred to mechanical ventilation.

The abdomen is painful, bloating, with auscultation "deathly silence", while muscle tension is not expressed.

In the blood, a sharp shift in the formula to the left: a large number of young forms and myelocytes, the number of stab neutrophils is 15-30 units, hyperleukocytosis, which in some cases can be replaced by leukopenia

Principles of treatment of peritonitis

• early hospitalization;
• Early surgery including:
  • elimination of sources of peritonitis;
  • thorough sanitation of the abdominal cavity;
  • drainage of the abdominal cavity;
  • according to indications - decompression small intestine;
• Complex intensive postoperative therapy, including:
  • rational antibiotic therapy;
  • detox therapy;
  • correction of homeostasis disorders;
  • treatment and prevention of enteral insufficiency.

Surgery

Preoperative preparation Indication - severity physical condition, exceeding the value of 12 points on the APACHE II scale.

The preparation time for the operation should not exceed 1.5-2 hours.

The general scheme of preoperative preparation, along with generally accepted hygiene measures, includes: catheterization of the central vein, bladder, stomach - the rule of "three catheters"; jet (with cardiopulmonary insufficiency - drip) intravenous administration of low-concentrated polyionic crystalloid solutions in a volume of up to 1000-1500 ml; transfusion of 400-500 ml of colloidal solutions to replenish the volume of circulating fluid; correction of hemodynamics and oxygen transport; intravenous use broad spectrum antibiotics.

The need for intravenous antibiotics in the preoperative period is determined by the inevitable mechanical destruction during surgical intervention of biological barriers that delimit the area of ​​the infectious process. Therefore, the operation should be performed against the background of creating a therapeutic concentration of antibacterial drugs in the blood and tissues, which for most of them is achieved 30-60 minutes after intravenous administration. It is practically impossible to carry out a complete correction of homeostasis disorders before surgery; it is enough to achieve only stabilization of blood pressure and CVP, and an increase in diuresis. Preoperative preparation begins immediately after the diagnosis is established and ends in the operating room, successively moving into the anesthetic management of the operation.

Operation steps for peritonitis

• Operational access;
• Elimination of the source of peritonitis;
• Evacuation of exudate and toilet of the abdominal cavity;
• Blind suturing of the wound or the introduction of drains or tampons into the abdominal cavity.

The best access for widespread peritonitis is a median laparotomy, which provides the possibility of a full revision and sanitation of all parts of the abdominal cavity. If widespread purulent or fecal peritonitis is detected only during an operation performed from a different incision, then you should switch to a median laparotomy. Removal of pathological contents and revision of the abdominal organs

After opening the abdominal cavity, the pathological contents are removed as completely as possible - pus, blood, bile, feces, etc. Special attention they turn to the places of accumulation of exudate - subdiaphragmatic spaces, lateral channels, the cavity of the small pelvis.

The next stage is a revision of the abdominal organs in order to identify the source (or sources) of peritonitis. Under the condition of stable hemodynamics of the patient, this may be preceded by the introduction of 150-200 ml of a 0.25% solution of procaine (novocaine) into the root of the mesentery of the small intestine and under the parietal peritoneum. Since, under conditions of peritonitis, hydraulic trauma to the mesentery and infection of its tissue are undesirable, the same effect can be achieved by simply introducing 300-400 ml of a 0.5% solution of novocaine into the abdominal cavity. Based on the results of the revision, the severity of peritonitis, the possibility of simultaneous elimination of its source and the state of the patient's strength to transfer the required amount of surgery are assessed.

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 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 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 severe and dangerous disease, 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 with special severe forms peritonitis (septic peritonitis), pain may be almost 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 ​​​​the inflammatory focus, and then immediately remove the fingers, then the patient feels acute pain.

The most important and hallmark 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 parts 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 increases initial signs peritonitis act 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 dull, the sclera is icteric, the eyeballs sink, a 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 (dryness of the lips, tongue, hoarseness of the 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 tapping 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, i.e. resulting from perforation of a hollow organ, there may be a period of subjective improvement (euphoria stage), when the patient's state of health improves for a certain period, 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 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 gastric 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 early dates. Some diseases to some extent may resemble the picture " acute abdomen”, such as 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 pain in the abdomen and tension of the abdominal muscles, are noted only in the affected area of ​​\u200b\u200bthe 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.

It is appropriate here to recall 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 thereby making it very difficult to recognize and treat it in time.

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, you should provide him 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); at 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 proper treatment of those diseases and injuries that are most often the cause of peritonitis, namely all acute diseases abdominal organs (acute appendicitis, perforated stomach ulcer, acute intestinal obstruction, strangulated hernia, etc.). The same preventive value has a timely first and urgent surgical care(including the use of antibiotics) for penetrating wounds of the abdomen. For the prevention of postoperative peritonitis, strict adherence to the rules of asepsis and the use of antibiotics during surgical operations are necessary.

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 foreign body may 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, which are a consequence of laparotomy interventions (subdiaphragmatic, interloop, pelvic, abscesses, ulcers of the right iliac fossa), also have difficulties in diagnosing.

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 in 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 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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Peritonitis is an inflammatory, bacterial, aseptic process of a local or diffuse nature that develops in the abdominal cavity. This process is a serious complication of destructive-inflammatory diseases of the peritoneal organs.

Peritonitis is an inflammation of the serous membrane of the abdominal cavity, also called the peritoneum. This inflammatory process belongs to the category of dangerous surgical conditions under the general name "acute abdomen".

The development of the disease is characterized by intense pain in the abdomen, tension in the muscle tissues of the abdominal cavity, and a rapid deterioration in the condition and well-being of the patient.

Peritonitis of the abdominal cavity is a common disease with a high rate of death. To date, the mortality rate from inflammation of the peritoneum is 15–20%, although until recently this figure was much higher and varied between 60–72%.

Causes of the disease

The causes of peritonitis can be very diverse and primarily depend on the type and characteristics of the inflammatory process, which can be primary or secondary.

The primary type of peritonitis - develops as an independent disease as a result of bacterial infection and pathogens entering the abdominal cavity through the bloodstream system, lymph flow. It is extremely rare - no more than 2% of all cases of the disease.

Bacteriological infections that can cause the development of inflammation of the peritoneum include both gram-positive and gram-negative bacteria, among which enterobacter, Pseudomonas aeruginosa, Proteus, coli, streptococci, staphylococci.

In some cases, the occurrence of an inflammatory process may be associated with the penetration into the abdominal cavity of specific microflora - gonococci, pneumococci, Mycobacterium tuberculosis and hemolytic streptococci.

Secondary type - the inflammatory process develops against the background of damage to the abdominal organs or gastroenterological diseases.

It is possible to identify the main factors that can provoke the development of inflammation of the abdominal cavity:

• Surgical intervention on the organs of the peritoneum.
• Damage to the internal organs located in the abdominal cavity, violation of their integrity.
• Various internal processes of an inflammatory nature - salpingitis, appendicitis, cholecystitis. Found that in more than 50% of cases the main cause of secondary inflammation.
• Inflammations that do not have a direct connection with the abdominal cavity - phlegmon and purulent processes.
• In women, peritonitis of the peritoneum can be triggered by inflammatory processes in the pelvic organs.

In the majority of cases, peritonitis acts as a complication of various injuries and diseases of a destructive-inflammatory nature - appendicitis, pyosalpinx, perforated gastric or duodenal ulcer, pancreatitis, pancreatic necrosis, intestinal obstruction, ovarian cyst rupture.

Varieties of peritonitis

Peritonitis is classified according to several parameters - such as the etiology of the disease, the extent of inflammation. Depending on the characteristics of the course, inflammation can be acute or chronic. Chronic peritonitis often develops against the background of a systemic infection of the body - tuberculosis, syphilis. The acute form of peritonitis is characterized by rapid development and rapid manifestation of clinical symptoms.

Depending on the characteristics of the etiology, the inflammatory process in the peritoneum can be bacterial, developing as a result of infection entering the abdominal cavity, as well as abacterial, that is, provoked by aggressive agents of non-infectious origin. Such non-infectious pathogens include blood, bile, gastric juice, pancreatic juice, urine.

Depending on the area and extent of the lesion, the disease is divided into several forms:

1. Local - only one anatomical element of the peritoneum is involved in the inflammatory process.
2. Widespread or diffuse - inflammation spreads to several parts of the abdominal cavity.
3. Total type - characterized by an extensive lesion of all parts of the peritoneal cavity.

Due to occurrence:

• Traumatic type of peritonitis.
• Infectious.
• Postoperative.
• Probodnaya.

Depending on the presence of exudate, inflammation of the peritoneum is divided into dry and exudative (wet) type of peritonitis.

Depending on the features and nature of the exudate:

• Purulent.
• Serous.
• Gallic.
• Fecal.
• fibrinous.
• Hemorrhagic.

According to the type of infectious agent, peritonitis is divided into tuberculous, streptococcal, gonococcal, clostridial.

Depending on the severity and severity of pathogenetic changes, several stages of the inflammatory process are distinguished, each of which has its own characteristics and symptoms.

The reactive stage of peritonitis is the initial stage of the disease, the symptoms of which appear during the first day after the infection enters the abdominal cavity. The reactive stage is characterized by swelling of the peritoneum, the appearance of exudate and severe local reactions.

Toxic stage - occurs within 48-72 hours from the moment of injury. This stage is characterized by the intensive development of signs of intoxication.

The terminal stage is characterized by a general deterioration of the body and a weakening of the vital functions of the body, the functioning of the protective-compensatory system is reduced to a minimum.

Symptoms and signs

The main signs of peritonitis can be divided into general and local. Local signs are the body's response to irritation of the abdominal cavity with exudative fluid, bile or blood. The main local symptoms of peritonitis include a strong tension of the anterior wall of the abdominal cavity, pain in the abdomen, irritation of the peritoneal cavity, identified during a medical examination.

The first and most pronounced symptom of the initial stage of inflammation of the peritoneum is pain, which may have varying degrees expression and intensity. The most severe is the pain syndrome that accompanies peritonitis with perforation of the internal organs located in the abdominal cavity. Such pain is described in the medical literature as "dagger" - sharp, sharp and penetrating.

At the initial stage of peritonitis, pain is localized exclusively around the immediate lesion. But after a while, the pain becomes diffuse, generalized, which is associated with the spread of inflamed exudate throughout the internal organs.

In some cases, pain can move and be localized in another area of ​​the abdominal cavity. This does not mean that the inflammatory process has decreased or stopped - this is how another lesion manifests itself. internal organ. Sometimes the pain can disappear completely - this is a rather dangerous sign that may indicate intestinal paresis or the accumulation of an excessive amount of inflammatory fluid.

The characteristic general symptoms of peritonitis are severe nausea, heartburn, vomiting mixed with gastric contents and bile. Vomiting accompanies the entire period of the disease; in the later stages of the disease, the so-called "fecal" vomiting occurs with an admixture of intestinal contents.

As a result of general intoxication of the body, intestinal obstruction develops, which can be expressed in the form of flatulence, gas retention, or stool disorders.

Other common symptoms of peritonitis:

• Increased body temperature, chills.
• Significant deterioration in general well-being - weakness, apathy.
• Rapid jumps in blood pressure up to 130-140 beats per minute.
• The appearance of a person changes dramatically - facial features become more pointed, the skin turns pale, cold sweat appears, the facial expression becomes twisted, suffering.
• A person cannot sleep fully, he is tormented by sleep disorders - insomnia or constant sleepiness. In addition, the patient cannot lie down due to acute pain, he tries to take the most comfortable position for himself - most often on his side, with his legs pulled up to his stomach.
• At the advanced stages of peritonitis, a person has a confused mind, he cannot normally, adequately assess what is happening.

With the development of the most complex, terminal stage of peritonitis, the patient's condition becomes extremely severe: the skin and mucous membranes acquire an unhealthy pale, cyanotic or yellowish tint, the mucous membrane of the tongue is overdried, a thick coating of dark color appears on its surface. Psycho-emotional mood is characterized by instability, apathy is quickly replaced by a state of euphoria.

Symptoms of the disease differ significantly depending on the stage of the inflammatory process. Each of them has its own characteristics and features.

The reactive stage, which is the initial one, is accompanied by the appearance of spasms and pains in the peritoneum, tension of the anterior wall of the abdomen, fever, weakness and apathy.

The toxic stage is manifested by some improvement in the patient's condition, which, however, is imaginary. This period is characterized by intense intoxication of the body, which is expressed in severe nausea and debilitating vomiting. Appearance a person also leaves much to be desired - pale skin, dark circles under the eyes, sunken cheeks. As medical statistics show, approximately 20% of all cases of peritonitis end in death at the toxic stage.

The terminal stage is considered the most difficult and dangerous not only for health, but also for human life. At this stage, the level of the body's defenses decreases to a minimum level, and the person's well-being becomes much worse. The abdomen swells sharply, the slightest touch to its surface causes an intense attack of pain.

At the terminal stage of peritonitis, the patient has a strong swelling of the internal organs, as a result of which the excretion of urine from the body is disturbed, shortness of breath, increased heartbeat, and confusion appear. As medical practice shows, even after surgery, only every tenth patient manages to survive.

Symptoms of chronic peritonitis look a little different - they are not as pronounced as signs of acute inflammation and are more "blurred". The patient is not disturbed by debilitating vomiting, nausea, stool disorders or painful abdominal cramps. And so for a long time chronic form the disease can proceed completely unnoticed by a person.

At the same time, prolonged intoxication of the body cannot be completely asymptomatic, most often the presence of chronic peritonitis can be determined by the following signs:

• Body weight is rapidly decreasing, while the diet remains the same.
• For a long time, a person has an elevated body temperature.
• Constipation occurs from time to time.
• Increased sweating of the body.
• Periodic pain in the abdomen.

As the disease progresses, the symptoms become more pronounced and frequent.

Diagnosis of peritonitis

Timely diagnosis of peritonitis is the key to successful and effective treatment. Required for diagnosis clinical analysis blood, on the basis of which the level of leukocytosis is examined.

It is also mandatory to conduct an ultrasound and x-ray examination of the abdominal organs, during which experts study the presence of exudate in the abdomen - there is an accumulated inflammatory fluid.

One of the diagnostic measures is to conduct a vaginal and rectal examination, which allows you to identify soreness and tension in the vaginal fornix and rectal wall. This indicates inflammation of the peritoneum and the negative impact of accumulated exudate.

In order to eliminate any doubts about the diagnosis, a puncture is taken from the peritoneum, thanks to which it is possible to examine the nature of its contents. In some cases, laparoscopy is recommended. This is a painless, non-invasive diagnostic method, which is carried out using a special device - a laparoscope. As a result of the laparoscopy performed, the doctor receives a complete clinical picture of the disease and is able to make the correct diagnosis.

Treatment

To date, the only effective method treatment of peritonitis of the abdominal cavity remains surgical treatment. Despite the progress modern medicine the death rate remains high. It is for this reason that the treatment of peritonitis should be given maximum attention. The most effective is a complex method of treatment that combines surgical and drug therapy.

Simultaneously with surgery, drug treatment is carried out, the main purpose of which is to eliminate the infection, as well as to prevent the development of possible complications.

The most commonly prescribed medications are:

1. Broad-spectrum antibiotics - Ampicillin, Methicillin, Benzylpenicillin, Gentamicin, Olethetrin, Kanamycin.
2. Infusion solutions - such drugs are used to restore lost fluid and prevent possible dehydration of the body. Such solutions include Perftoran and Refortan.
3. Sorbents and detoxification preparations, the action of which is aimed at preventing toxic shock, removing toxins and toxins from the body. The most commonly used solution is calcium chloride 10%.
4. Diuretic drugs are used to eliminate violations of the excretion of urine from the body.
5. If peritonitis of the peritoneum is accompanied by an increase in body temperature, antipyretic drugs are prescribed.

Antiemetics such as metoclopramide are often used to control vomiting and nausea. In the event that tuberculosis-type peritonitis has been diagnosed, treatment is carried out with the help of anti-tuberculosis medicines- Trichopolum, Gentomycin, Lincomycin.

The main task of surgical treatment is to eliminate the root cause that provoked the inflammatory process of the peritoneum, as well as to drain the abdominal cavity in case of peritonitis. Preoperative preparation consists in the complete cleansing of the gastrointestinal tract from the contents, intravenous administration of the necessary drugs, as well as anesthesia.

Surgery is performed by laparotomy, that is, by direct penetration into the abdominal cavity. After that, the surgeon removes the focus of inflammation, as well as complete sanitation of the peritoneal cavity. This means that if the cause of peritonitis is an organ, after the removal of which a complete cure is possible, a resection of this organ is performed. Most often we are talking about the gallbladder or appendix.

Abdominal lavage is performed using special antiseptic solutions, which contributes to effective elimination infections and a decrease in the amount of exudate released. The next step is bowel decompression. This is the name of the procedure for removing accumulated gases and liquids from the intestines. To do this, through the rectum or oral cavity a thin probe is inserted, through which fluid is suctioned from the abdominal cavity.

Drainage of the peritoneum is performed using special hollow drainage tubes, which are inserted in several places - under the liver, on both sides of the diaphragm and in the pelvic area. The final stage of surgery is suturing. Sutures can be applied with or without drainage, depending on the severity of the disease.

With simple forms of peritonitis, a continuous suture is applied, without drainage tubes. In the case of more severe, purulent forms of inflammation, suturing is carried out simultaneously with the introduction of drainage tubes, through which exudate is removed.

Treatment of peritonitis is carried out only in stationary conditions, self-treatment is not allowed. It is important to remember that no more than 72 hours pass from the moment the peritoneum is damaged to the development of the most severe, terminal stage. Therefore, any delay in seeking qualified medical assistance and performing an operation is fraught with the most adverse consequences for human health and life.

Inflammation of the peritoneum. It can be local (inflammation of the peritoneum in a limited area) and diffuse (inflammation of the entire peritoneum). As a rule, it is a complication of another inflammatory process in the abdominal cavity. The most important clinical sign of the presence of peritonitis is a sharp increase in pain at the moment when the doctor releases his hand, which he previously pressed on the abdomen.

Peritonitis

Peritonitis is a formidable complication that has claimed the lives of millions of people. The danger of peritonitis is due to the sudden onset against the background of well-being and the rapid development of symptoms. MedAboutMe provides a classification of the disease, and also talks about the clinical picture, diagnosis and treatment of peritonitis.

To understand what peritonitis is, you need to get a general idea of ​​\u200b\u200bthe anatomical structure of the abdominal cavity.

The diaphragm limits the abdominal cavity from the chest from above, and the pelvic diaphragm - from below. The abdominal muscles are located on the sides and in front, and the lumbar part of the spine with adjacent muscle fibers is located behind.

From the inside, the abdominal cavity is lined with thin sheets of the serous membrane - the peritoneum - which are the receptacle for the internal organs.

Peritonitis is an inflammatory process that is localized in the peritoneum. The disease is extremely dangerous for human life and health - in the absence of treatment, all organs and systems of the body are involved in the process.

Relevance of the disease

The relevance of the disease is due to the high mortality rates in the event of inflammation of the peritoneum. Mortality from an acute abdomen up to the middle of the twentieth century was about seventy to eighty percent of cases. Firearms and knife wounds lead to damage to internal organs, infection of the abdominal cavity.

Currently, cases of an acute abdomen are ten times less common, but the significance and danger of the disease have not changed from this. A person with peritonitis belongs to the group severe patients, which requires careful examination and treatment.

Historical digression

Deaths after surgical interventions were common until the middle of the twentieth century. For hundreds of years, doctors did not know that they needed to treat their hands with disinfectant solutions and sterilize surgical instruments. Hands without disposable gloves were in contact with the wound surface, which led to the penetration of infection and the development of inflammation. The rules of asepsis and antiseptics, which are now used throughout the world everywhere, were approved and introduced into medical practice later. It is sanitary and hygienic measures that reduce the number of postoperative complications.

Stages of peritonitis

Surgeons differentiate the stages of peritonitis in order to assess the degree of risk, the danger to the patient's life. Unlike many other diseases, with peritonitis, every hour of delay matters. That is why the stages of peritonitis are classified by duration.

First stage

The first stage lasts for a day after the manifestation of the disease. During this period, local symptoms due to irritation of the peritoneum dominate. Symptoms of intoxication increase gradually over twenty-four hours.

Second stage

The reactive stage of peritonitis passes into the toxic stage. Local clinical manifestations are replaced by general intoxication. The infectious agent spreads throughout the body with the blood and lymph flow, thereby involving other organs and systems in the pathological process.

Third stage

The third stage occurs seventy-two hours after the onset of the disease. The general well-being of a person becomes extremely difficult. Intoxication turns into sepsis - a complication with a high probability of death. That is why this stage is called the terminal stage.

Thus, the stages of peritonitis are an important prognostic criterion for the patient's life.

Classification of peritonitis

Acute abdomen is classified not only by the stages of the disease. MedAboutMe talks about ways to differentiate.

Depending on the type clinical course There are three forms of the disease.

• Acute peritonitis

The most common form of this nosology. The disease occurs suddenly against the background of general well-being. Clinical symptoms correspond to the classical ideas of surgeons. If left untreated, it leads to death.

• Subacute peritonitis

Erased form, which begins with acute pain in the abdomen. Gradually, the symptoms subside, and the pain syndrome becomes moderate. Most often, discomfort is localized in the lower abdominal cavity. The pain is aggravated by pressure and a change in body position.

• Chronic peritonitis

The chronic form has an erased clinical picture. Due to the nonspecificity of symptoms, the diagnosis of chronic peritonitis is based on the results laboratory methods research.

The nature of the exudate

Peritonitis, like any inflammatory process in the body, is accompanied by the release of specific fluid from blood vessels or damaged organs. Depending on the nature of the exudate, the following types of peritonitis are distinguished:

• Serous

The exudate is represented by a liquid, poor in protein and cellular structures.

• Serous-fibrinous

Intermediate stage between serous and fibrinous exudate.

• fibrinous

Fibrin strands cover the sheets of the peritoneum, leading to the formation of adhesions.

• Fibrinous-purulent

Fibrinous-purulent exudate occurs due to the addition of a secondary infection.

• Purulent

Purulent peritonitis occurs when the integrity of the abdominal organs is violated. Microbes enter the peritoneum and seed the surface. Purulent peritonitis, like fecal peritonitis, is characterized by a high lethality of the disease.

• bilious

Perforation of the gallbladder leads to leakage of bile into the free abdominal cavity.

• Fecal

It often occurs with a traumatic lesion of the abdominal cavity. With perforation of the descending department colon, sigmoid and rectum feces fall on the peritoneum. The abundance of bacteria causes a sharp development of symptoms and causes an acute picture of the disease. Massive bacterial contamination of the intestinal tract is a poor prognostic sign.

• Hemorrhagic

Blood is mixed with an inflammatory effusion.

Symptoms of the disease are directly related to the type of exudative component. For example, a pronounced pain syndrome in bile peritonitis in the first hours of the disease tends to fade. The period of relative well-being and well-being is replaced by the addition of a secondary infection, and the re-development of the pain syndrome.

Thus, the nature of the exudate determines the tactics of managing and treating the patient, and also affects the outcome of the disease.

The structural features of the abdominal cavity led to the creation of another classification of peritonitis - according to the prevalence of the process.

• local process

Local process is limited and unlimited. An intra-abdominal abscess is referred to as a limited process, when the inflammation is contained by the capsule. Unlimited peritonitis occupies one pocket of the abdominal cavity.

• Common Process

Widespread peritonitis is not limited to a single area - inflammation occupies a vast space. So, diffuse peritonitis is localized in two to five anatomical areas, and a diffuse process captures more than six areas.

Peritonitis: causes

Peritonitis belongs to the group of polyetiological diseases. It means that various reasons lead to inflammation of the peritoneum.

• Inflammation of the abdominal organs

Bacterial peritonitis is caused by the entry of an infectious agent into the abdominal cavity from the affected organ. Most often, bacterial peritonitis occurs due to rupture of the inflamed appendicular process - appendicitis. Less common with cholecystitis and gynecological diseases. Peritonitis is a complication of the underlying disease, since the serous membrane becomes infected a second time.

• Organ perforation

Organ perforation occurs spontaneously against the background of an inflammatory process in the abdominal organs.

• Hematogenous infection

Hematogenous - it is also aseptic inflammation - occurs when an infection enters from an inflammatory focus, which is located outside the abdominal cavity. The hematogenous route of involvement of the peritoneum is extremely rare in diseases such as tonsillitis and osteomyelitis.

• Injury

Among the injuries most common are: wounds of the abdominal cavity with a sharp or blunt object, a fall from a height, as well as injuries resulting from traffic accidents. Injury to the intestine leads to the spread of infection to the peritoneum.

The clinical picture depends both on the cause of the disease and on the stage of acute peritonitis.

The disease is characterized by an acute onset with the appearance of pain in the abdomen. The pain syndrome is initially localized where the "catastrophe" occurred, and then the person cannot determine exactly where it hurts - the pain syndrome is diffuse. A change in body position, which is accompanied by tension in the anterior abdominal wall, increases the pain syndrome.

The severity and nature of pain depend on the cause of peritonitis. So, the destruction of the pancreas is considered the most painful, as a result of which the enzymes enter the peritoneum. The aggressive environment of pancreatic juice is comparable to the ingress of hydrochloric acid on unprotected skin.

• Nausea, vomiting

The proximity of the pain and vomiting centers in the medulla oblongata cause vomiting in humans. The contents of the stomach are completely emptied.

• Resistant belly

On external examination, attention is drawn to the plank-shaped abdomen. The muscles of the anterior abdominal wall are in tension due to irritation of the peritoneum.

• Increase in body temperature

An increase in body temperature - hyperthermia - is referred to as an intoxication syndrome. The degree of increase depends on the pathogenicity of the infectious agent. Body temperature often rises above thirty-eight degrees.

• Tachycardia

A nonspecific sign of an acute abdomen is a rapid pulse. Tachycardia reflects the severity of intoxication: the more frequent heart contractions, the more dangerous the disease.

• Drop in blood pressure

In the terminal stage, blood pressure drops, which is a poor prognostic sign for a person. Low numbers reflect the terminal stage of the disease, when the compensatory reactions of the body can not cope with inflammation.

• Thirst

In addition to pain in the abdomen, a person is tormented by thirst. Heavy drinking does not bring relief. On examination, the tongue in the first stage is coated with an abundant dry white coating, and in the toxic and terminal stages - with a brown coating.

• Dry skin

Dryness skin and mucous membranes are clearly visible on the face, as well as in other places with a thin subcutaneous fat layer. Facial features are sharpened.

• convulsions

Violation of the water-electrolyte balance leads to the development of convulsive syndrome. Spastic contractions are observed mainly in the lower extremities. As the disease progresses, convulsions spread upward.

• Oliguria

Peritonitis in children and adults leads to a decrease in the daily volume of urination - oliguria. As a result, toxins that the body normally removes with urine remain in the person. There is a vicious circle of intoxication.

• Imaginary well-being

The acute pain syndrome is replaced by a stage of imaginary well-being. The pain syndrome subsides for a while, the person feels better. However, after a while, the pain returns with renewed vigor. Temporary improvement in well-being is a dangerous condition. Since there are cases when a person feels better and refuses medical care. The stage lasts one to three hours, depending on the cause of the disease.

• Inhibition of peristalsis

Peritonitis in adults and children is characterized by a slowdown or complete cessation of peristaltic waves. Intestinal peristalsis cannot be heard either with the ear or with a phonendoscope.

• Peritoneal irritation

The clinical picture of peritonitis is due to individual characteristics person. People with high threshold pain sensitivity more tolerant of unpleasant sensations more easily endure pain. In this case, an inattentive attitude towards oneself leads to a late appeal for medical care which also affects the outcome of the disease. Acute peritonitis does not tolerate delay - when the first symptoms appear, you should immediately consult a doctor.

• Confusion

Confusion of consciousness is caused by a cascade of biochemical reactions against the background of a pronounced pain syndrome and general intoxication of the body. A person cannot remember the date and day of the week, forgets the names and names of objects. However, in the initial stages of the disease, a person retains clarity of consciousness.

The classic course of an acute abdomen is characteristic of a diffuse form of the disease. Peritonitis in adults, when the inflammatory process is limited to a capsule or infiltrate, occurs in a limited area of ​​​​the abdominal cavity.

Signs of peritonitis are important diagnostic criteria when making a diagnosis.

Peritonitis in adults

In addition to these symptoms of acute peritonitis, adults are more likely than children to have chronic nonspecific peritonitis. Chronic peritonitis has an erased clinical picture. The gradual development of the disease explains the absence of severe symptoms: acute abdominal pain, nausea and vomiting. At the beginning of the disease, the body compensates for the toxins that the pathogen releases. Over time, intoxication leads to the development of asthenic syndrome. Chronic peritonitis is characterized by: a decrease in body weight, an increase in temperature to thirty-seven - thirty-seven and a half degrees. The person complains of general weakness, fatigue, drowsiness. The pain syndrome occurs episodically and does not affect daily activities. However, during sports, a person pays attention to increased sweating. There may be shortness of breath when physical activity. The act of defecation causes difficulties - constipation occurs, and there is also a feeling of incomplete emptying of the intestine. Violation of physiological functions is due to a violation of the peristaltic activity of the gastrointestinal tract, the occurrence of adhesions in the abdominal cavity.

The causes of chronic nonspecific peritonitis are usually tubercle bacillus, pneumococci.

Peritonitis in children

Peritonitis in children goes through stages of development similar to the clinical picture of an adult. The danger of the disease in a baby is due to the fact that the child has difficulty describing his feelings. That is why pediatricians find themselves in more difficult conditions when diagnosing a disease.

Peritonitis in children is characterized by a pronounced pain syndrome and a rapid increase in intoxication - the immune system of children is just beginning its development path and the protective reactions of the body are not fully formed.

During the war, surgeons always had a difficult task - how to diagnose peritonitis in the field. Years of clinical observation led to the creation of classifications of the acute abdomen, as well as the identification of criteria for the disease.

In everyday life, doctors have no difficulty in diagnosing acute peritonitis. The specific clinical picture, as well as modern diagnostic methods, make it possible to make an accurate diagnosis with timely seeking medical help.

Diagnosis of peritonitis begins with the identification of patient complaints. Surgeons specify the time of development of the pain syndrome, and also find out the cause of what happened. A conscious person describes his sensations and their localization. If a person is unconscious, the specialist interviews the patient's relatives, and if they are absent, he immediately proceeds to a physical examination.

Physical examination

Toxins, as well as exudate, irritate the peritoneal receptors. As a result, during palpation, when the surgeon palpates the human abdomen, the pain syndrome increases. The muscle fibers of the anterior abdominal wall reflexively contract. When the surgeon presses deeply with the fingers of one hand on the abdominal wall, and then abruptly releases, pain occurs. This symptom is called the positive Shchetkin-Blumberg symptom.

When rolling in a supine position from the back to the stomach, a "splash noise" is clearly audible.

In the supine position, the abdomen takes the form of a “frog” - it flattens in the anterior-posterior size. Thickening in lateral dimensions is due to the fact that the fluid moves into the side pockets of the abdominal cavity.

After a physical examination, the surgeon proceeds to diagnose peritonitis using laboratory methods.

The nurse takes venous blood from the patient for examination. Tests are given on an emergency basis, and the surgeon will know the results in less than thirty minutes after blood sampling.

• Clinical blood test

A clinical blood test reflects the symptoms of general intoxication of the body. The number of leukocytes - the protective cells of the body - is increased compared to the norm. Shift leukocyte formula to the left indicates the active stage of the inflammatory process. The erythrocyte sedimentation rate also increases. In the presence of bleeding, erythrocytes and hemoglobin are reduced.

• Blood chemistry

Based on biochemical analysis, a conclusion is made about the involvement of other organs in the pathological process and the degree of intoxication. So, an increase in the concentration of uric acid and urea, may mean the development kidney failure at the patient. In turn, an increase in liver enzymes is a sign of liver damage.

• Hemostasiogram

When examining a hemostasiogram, a specialist detects an increase in blood clotting.

Instrumental Methods

Diagnosis of peritonitis is not complete without instrumental research methods. The surgeon chooses the method on an individual basis, based on complaints and the stage of the disease.

• Ultrasound procedure

One of the signs of peritonitis - the accumulation of exudate in the abdominal cavity - the specialist reveals with the help of ultrasound.

• X-ray examination

X-ray shows areas of blackout in places with inflammatory effusion.

• Abdominal puncture

Under the control of an ultrasound sensor, a person with peritonitis is performed laparocentesis. The specialist inserts a thin needle through the anterior abdominal wall and collects the effusion. The specialist sends the resulting fluid for examination to determine the nature of the exudate.

• Diagnostic laparoscopy

Laparoscopic examination is performed in doubtful cases for differential diagnosis diseases with other nosologies, as well as with suspicion of chronic peritonitis.

Peritonitis must be treated as quickly as possible, immediately after confirming the diagnosis of inflammation of the peritoneum. Delay at all stages of diagnosis increases the risk of death.

The tasks of the surgeon during treatment are: elimination of the cause of peritonitis and sanitation of the abdominal cavity, as well as etiopathogenetic and symptomatic treatment after surgery.

Surgical treatment

Although laparoscopy is modern method surgical intervention, the treatment of an acute abdomen often occurs through laparotomy. The advantages of the incision of the anterior abdominal wall include: a wide operating field and speed of access.

During surgery, the surgeon eliminates the cause - sanitizes the focus of inflammation, sutures the perforation of the internal organ or removes the damaged organ. After that, the abdominal cavity is washed with antiseptic solutions. The edges of the wound are sutured, leaving room for drainage - a tube through which the inflammatory exudate will be released into the postoperative period.

Surgical treatment is an integral component of eliminating the cause of peritonitis and recovering the patient.

Conservative therapy of peritonitis supplements surgery. The goal is to eradicate the causative agent of infection, restore the function of organs and systems of the body, that is, complete recovery.

• Antibiotic therapy

Antibacterial therapy is carried out with broad-spectrum antibiotics that act on several types of infectious agents at once. The greatest bioavailability is achieved with intravenous administration of drugs.

• Correction of metabolic disorders

In the postoperative period, the patient is given infusion solutions that reduce the severity of symptoms of intoxication and restore water and electrolyte balance.

• Diuretics

In the absence of signs of impaired renal function, urination is stimulated by certain groups of diuretics. Thus, toxins are removed from the body, and their concentration in the blood falls. The general well-being of the patient improves.

• Anticoagulants

Each surgical intervention presents a risk of thrombosis. Anticoagulant therapy prevents a reactive increase in blood clotting.

Depending on the stage of the disease and the presence of complications, therapeutic treatment can be supplemented with the introduction of blood components, non-steroidal anti-inflammatory drugs, antipyretic and antiemetic drugs.

Sanitary and hygiene procedures

The medical staff takes care of postoperative sutures once a day. The nurse examines the wound surface and treats the sutures with disinfectant solutions. After performing sanitary and hygienic procedures, a clean bandage is applied.

Preventive measures are aimed at reducing the risk of developing a life-threatening disease. Thanks to prevention, it is possible to timely identify and begin treatment of diseases that can potentially be complicated by peritonitis. These include peptic ulcer of the stomach and duodenum, and cholelithiasis, and cholecystitis, as well as other nosologies.

Preventive checkups

Screening research methods have proven their effectiveness. Preventive examinations reduce the likelihood of developing concomitant diseases, and also allow you to identify diseases on the early stages before the onset of clinical symptoms.

During screening examinations, the doctor talks about the danger of the disease, methods of diagnosis. Educational activities increase the literacy of the population, thus reducing the number of complications.

As a rule, peritonitis is a complication of acute and chronic diseases of the abdominal cavity, retroperitoneal space and small pelvis. The likelihood of peritonitis decreases if a person does not self-medicate, goes to medical institutions for diagnosis and choice of treatment, and also follows the recommendations of specialists.

Compliance with the rules of asepsis and antisepsis

In addition to treatment chronic diseases and performing screening studies, it should be remembered that sanitary and hygienic procedures are an integral component of postoperative recovery. The sutures that were placed on the anterior abdominal wall during the operation can become infected if the rules of asepsis and antisepsis are not followed. Drainage introduced into the abdominal cavity often serves as the entrance gate of infection. That is why postoperative wound care is recommended to be performed at least once a day.

Statistically, postoperative complications occur more often in children - babies show interest in surgical dressings, opening the way for infectious agents. Parents whose children are in the hospital after surgical treatment of peritonitis should explain to their child that the postoperative wound should not be touched. This will reduce the risk of complications and life threatening states.

Knowledge anatomical structure of the abdominal cavity, as well as an understanding of the causes of an acute abdomen, help to understand what peritonitis is. The disease is characterized by: a vivid clinical picture against the background of general well-being, a rapid deterioration in well-being. acute pain, which is caused by irritation of the receptors of the serous membrane of the abdominal cavity, gradually increases.

When the first symptoms of acute peritonitis appear, you should immediately consult a doctor. Only a specialist identifies signs of peritonitis, can make an accurate diagnosis and prescribe treatment. Self-treatment increases the likelihood of death, especially when it comes to peritonitis in children.