The disease is peritonitis. Peritonitis. Classification of peritonitis. Anatomical features of the structure of the peritoneum. Peritonitis clinic. Stages of peritonitis. Treatment of peritonitis. Causative agents of bacterial peritonitis

Peritonitis is an acute or chronic inflammation of the peritoneum, accompanied by both local and general symptoms of the disease with dysfunction of organs and body systems (Kuzin M.I., 1982).

Peritonitis is one of the most severe complications of various diseases and injuries to the abdominal organs. The progressive development of a suppurative process in a closed, anatomically complex abdominal cavity, the rapid growth of intoxication and the resulting serious hemodynamic and respiratory disturbances, severely impaired metabolism, extremely complicate the treatment of purulent peritonitis. Hence the high mortality rates. According to M.I. Kuzin (1982), the mortality rate ranged from 25-90%, other authors indicate a limit of 50 - 60% (Savchuk B.D., 1979; Shalimov A.N., 1981; Savelyev V.S. et al., 1986). According to Sh.I. Karimov, the mortality rate was 13–60%.

The domestic school of surgeons also made a significant contribution to the study and development of treatment methods for patients with peritonitis. In 1881 A.I. Schmidt performed the world's first laparatomy, and in 1924 S.I. Spasokukotsky was the first to stitch up a laparotomy wound tightly. For more than a hundred years, peritonitis has attracted the attention of surgeons, but even today, according to the expression of A.N. Bakuleva – “Peritonitis remains a never-aging problem.”

Epidemiology, classification and etiological structure of peritonitis

The incidence of peritonitis is 3–4.5% of the number of patients with surgical diseases. According to autopsies, this figure is higher and amounts to 11–13%. Acute surgical diseases of the abdominal organs in 80% of cases are the cause of peritonitis, 4-6% are closed abdominal injuries and in 12% of cases peritonitis occurs as a complication after surgery. The mortality rate for diffuse forms of peritonitis in Russia is more than 33%.

The modern classification of peritonitis was proposed by V.S. Savelyev et al. (2002):

Classification of peritonitis

1.Primary peritonitis

A. Spontaneous peritonitis in children

B. Spontaneous peritonitis in adults

C. Peritonitis in patients with continuous peritoneal dialysis

D. Tuberculous peritonitis

2.Secondary peritonitis

A. Caused by perforation and destruction of abdominal organs

B. Postoperative peritonitis

C. Post-traumatic peritonitis

D. Peritonitis due to anastomotic leakage

3. Tertiary peritonitis

A. Peritonitis without pathogen identification

B. Peritonitis caused by fungal infection

C. Peritonitis caused by microorganisms with low pathogenicity

4. Intra-abdominal abscesses

A. Associated with primary peritonitis

B. Associated with secondary peritonitis

C. Associated with tertiary peritonitis

Primary peritonitis is an extremely rare form of peritonitis of hematogenous origin with infection of the peritoneum from an extraperitoneal source. It most often occurs in patients with liver cirrhosis, as well as in women with genital pathology. Very often the pathogen is not verified. In children, primary peritonitis occurs either in the neonatal period or at 4-5 years of age against the background of systemic diseases (systemic lupus erythematosus). The most common pathogens are streptococcus and pneumococcus.

Secondary peritonitis is the most common form of abdominal infection. In 80% of cases it occurs due to destruction of the abdominal organs and 20% is due to postoperative peritonitis.

The term tertiary peritonitis was introduced by O.D. Potstein, J.L. Meakius (1990) to characterize widespread damage to the peritoneum in cases where it is not possible to clearly localize the source, and flora atypical for peritonitis, resistant to many antibiotics, is sown from the peritoneal fluid. Almost 100% mortality.

Until recently, in our work we used the classification of B.D. Savchuk, which is given below.

Stages of purulent peritonitis

1. Reactive (first 24 hours, for perforated forms up to 6 hours)

2. Toxic (24-72 hours, for perforated forms 6 - 24 hours)

3. Terminal (more than 72 hours for perforated forms more than 24 hours)

According to this classification, local limited peritonitis has a clear intraperitoneal localization in one or several areas of the abdominal cavity, local unlimited peritonitis occupies no more than two anatomical areas of the abdominal cavity. With diffuse peritonitis, the pathological process occupies 2-5 areas, and with diffuse inflammation it spreads to more than 5 areas of the abdominal cavity.

According to the nature of the exudate, they are distinguished:

Serous;

Serous-fibrinous;

Serous-hemorrhagic

Enzymatic;
Chemical peritonitis.

The last 4 forms are classified as abacterial.

There are also special forms of peritonitis: carcinomatous and fibroplastic (iatrogenic).

Based on the nature of the flora sown from the abdominal cavity, peritonitis caused by:

Pathogenic flora. Moreover, more often it is a mixed aerobic - anaerobic flora. In all types of peritonitis, gram-negative flora (Enterobacteriacaeas) dominates, usually in combination with anaerobes (Bacteriodes spp., Clostridium spp., etc.), staphylococci and enterococci are less often isolated.

2. Tuberculosis infection, gonococcus, pneumococcus

Causes of peritonitis:

1. Destructive appendicitis - 15 – 60%;

2. Destructive cholecystitis - 3.7 – 10%;

3. Perforated gastroduodenal ulcers - 7 - 24%;

4. Trauma to the abdominal organs - 8 - 10%;

5. Intestinal perforation - 3%;

6. O. pancreatitis - 3 - 5%;

7. OKN - 13%;

8. Mesenteric thrombosis - 2%;

9. Gynecological peritonitis - 3%

Peritonitis is called inflammation of the peritoneum. This condition is extremely dangerous for the body, as it disrupts the functioning of all vital organs. Acute peritonitis requires emergency medical attention, otherwise it can lead to death within a short time.

Peritonitis is caused by an infection or foreign substance (pancreatic enzymes, bile, etc.) that has entered the abdominal cavity. The main reason why the infection penetrates to the peritoneum is purulent melting of the abdominal organ, trauma to the hollow organs of the abdominal cavity, trauma, including surgical trauma, in the area of the abdominal organs.

The most common infectious agents that cause peritonitis are streptococci, staphylococci, Pseudomonas aeruginosa, Escherichia coli, gonococci, pneumococci, mycobacterium tuberculosis, and anaerobic microorganisms.

The main cause of infectious peritonitis is acute purulent appendicitis, somewhat less commonly, perforation of a gastric and duodenal ulcer, acute purulent cholecystitis, acute pancreatitis, acute purulent inflammation of the pelvic organs, ruptures of the stomach, intestines, and bladder as a result of injuries or an advanced tumor process.

Types of peritonitis

Peritonitis can be primary or secondary.

Primary, also known as idiopathic or viral peritonitis, occurs extremely rarely, as a result of a primary infectious lesion of the abdominal organs and peritoneum. In the case of viral peritonitis, the infection penetrates the peritoneum hematogenously, or through the lymphatic vessels, and occasionally through the fallopian tubes. Viral peritonitis accounts for no more than 1% of all cases of the disease.

Depending on the reason, there are:

Infectious peritonitis;
Perforated peritonitis;
Traumatic peritonitis:
Postoperative peritonitis.

According to the nature of the inflammatory exudate:

Serous peritonitis;
Purulent peritonitis;
Hemorrhagic peritonitis;
Fibrinous peritonitis;
Gangrenous peritonitis.

By degree of distribution:

Local peritonitis;
Generalized peritonitis;
General (total) peritonitis.

By localization:

Limited (enclosed) peritonitis;
Diffuse peritonitis.

By traumatic factor:

Acute peritonitis has several phases of development:

The reactive phase lasts from 12 to 24 hours;
Toxic phase, duration from 12 to 72 hours;
The terminal phase occurs after an interval of 24 to 72 hours from the onset of the disease and lasts several hours.

Thus, acute peritonitis can be fatal within 24 hours of the onset of the disease.

The symptoms of peritonitis in the initial, reactive phase initially coincide with the symptoms of the underlying disease, which become sharper and brighter. Typically, the onset of acute peritonitis is indicated by increased pain, spreading to the entire abdomen, the peak of pain is noted in the area of the primary focus. The abdomen becomes tense and board-shaped. The symptoms of peritoneal irritation are sharply positive, the most famous of which is the Shchetkin-Blumberg symptom: when palpating the abdomen with a quick withdrawal of the hands, sharp pain occurs. The patient tries to lie on his side with his legs brought to the stomach (“fetal position”), any attempt to change the position increases the pain. Speech is quiet, moans are weak. Body temperature is increased.

Symptoms of peritonitis in the toxic stage can be misleading in that there is an apparent improvement. The pain subsides, the abdomen ceases to be tense, and the patient enters a state of lethargy or euphoria. His facial features become sharper, pallor appears, and nausea and vomiting are possible. Sometimes vomiting takes on a painful, debilitating character. Urinary excretion and intestinal motility decrease, and even when listening, the usual intestinal sounds cannot be heard (symptom of “deafening silence”). The mucous membranes of the oral cavity are dry, but fluid intake is difficult due to lethargy or vomiting. About 20% of patients die at this stage.

Symptoms of peritonitis in the terminal stage indicate a deep dysfunction of all body systems and the onset of a decompensation phase, when the body's defenses are depleted. The patient is in prostration, indifferent to what is happening, sometimes at this stage an intoxication mental disorder occurs. The face takes on an earthy tint, the eyes and cheeks become sunken (the so-called “Hippocratic mask”), and cold sweat appears. Possible vomiting of putrefactive contents of the small intestine. Shortness of breath and tachycardia develop, body temperature, previously elevated, drops. The abdomen is swollen and painful, but there is no protective muscle tension. The Shchetkin-Blumberg symptom becomes mild. About 90% of patients die at this stage.

Diagnosis of peritonitis

The diagnosis is made based on the characteristic symptoms of peritonitis and blood tests. In the blood test, a purulent-toxic shift in the leukocyte formula is observed. X-ray diagnostics and ultrasound examination of the abdominal organs are used, and in doubtful cases, laparoscopy.

It must be said that the diagnosis of peritonitis should be as urgent as possible, since the condition requires urgent treatment.

Treatment of peritonitis

Treatment of peritonitis is carried out in the emergency surgery department. If you suspect acute peritonitis, you should not take food, water or painkillers, use heating pads or give enemas, the patient should maintain a supine position. The treatment of peritonitis, with the exception of rare cases (limited peritonitis, state of agony, etc.), is surgery.

Before the operation, preparations are carried out aimed at at least partially stabilizing the patient’s condition. Preparation consists of replenishing fluid balance, relieving pain shock and normalizing blood pressure.

Surgical intervention for the treatment of peritonitis is performed under general anesthesia. During the operation, the primary infectious focus is eliminated, the inflammatory effusion is removed, the abdominal cavity is washed with antiseptics and drainage is installed. Then the intestinal obstruction that developed as a result of sepsis is restored, and intestinal compression is eliminated. After the operation, it is time for drug treatment of peritonitis, for which active antibacterial therapy is used, as well as therapy aimed at maintaining the vital functions of the body.

Video from YouTube on the topic of the article:

Update: October 2018

In the famous Soviet-era comedy “Pokrovsky Gate” there is a wonderful episode in which Rimma Markova (surgeon), smoking a cigarette on a clip, answers her friend on the phone that she should cut without waiting for peritonitis (we were talking about appendicitis). Indeed, this condition poses a serious threat to the patient’s life, and delaying the operation is literally like death.

According to statistics, the disease is diagnosed in 15-20% of patients with an “acute abdomen”, and in 11-43% it causes emergency laparotomy (revision of the abdominal organs). Despite significant advances in medicine, the mortality rate for this pathology is quite high and ranges from 5 to 60 percent or more. The wide range of numbers is explained by many factors: the cause and stage of the process, its prevalence, the age of the patient, concomitant pathology, and others.

Peritonitis: definition

Peritonitis is called aseptic inflammation or bacterial infection of the peritoneum, and, accordingly, develops in the abdominal cavity. This process is a serious complication of inflammatory diseases of the abdominal organs and is included in the group of acute surgical pathologies referred to as “acute abdomen”. According to statistics, this disease develops in 15–20% of cases in patients with acute surgical diseases, and the need for emergency laparotomy for this reason reaches 43%. Mortality with such a complication is observed in 4.5–58% of cases. The huge range of numbers is explained by many factors (the cause and stage of the process, its prevalence, the age of the patient, and others).

The high mortality rate for this condition is explained by two factors:

failure of patients to seek specialized care in a timely manner;
an increase in the number of elderly patients (the process is not so acute, which leads to late consultation with a doctor);
an increase in the number of patients with cancer;
errors and difficulties in diagnosing the process, inappropriate treatment;
severe course of the process if it spreads (spread peritonitis).

A little anatomy

The abdominal cavity is lined from the inside with a serous membrane called the peritoneum. The area of this shell reaches 210 meters and is equal to the area of the skin. The peritoneum has 2 layers: parietal and visceral. The visceral peritoneum covers the internal organs of the abdomen and pelvis and is their third layer, for example, the uterus has the endometrium (inner layer), myometrium and serosa.

The parietal layer covers the abdominal walls from the inside. Both layers of the peritoneum are represented by a single continuous membrane and are contiguous over the entire area, but form a closed sac - the abdominal cavity, which contains about 20 ml of aseptic fluid. If in men the abdominal cavity is closed, then in women it communicates with the external genitalia through the fallopian tubes. Visually, the peritoneum looks like a shiny and smooth membrane.

The peritoneum performs a number of important functions. Due to the secretory-resorptive and absorption functions, the serous membrane produces and absorbs up to 70 liters of fluid. The protective function is ensured by the content of lysozyme, immunoglobulins and other immune factors in the abdominal fluid, which ensures the elimination of microorganisms from the abdominal cavity. In addition, the peritoneum forms ligaments and folds that secure the organs. Due to the plastic function of the peritoneum, the focus of inflammation is delimited, which prevents further spread of the inflammatory process.

Causes of the disease

The leading cause of this complication is bacteria that penetrate the abdominal cavity. Depending on the route of entry of microorganisms, there are 3 types of inflammation of the peritoneum:

Primary peritonitis

The inflammatory process in this case occurs against the background of preserved integrity of the internal organs of the abdomen and is a consequence of spontaneous blood dissemination of bacteria into the peritoneum. Primary inflammation of the peritoneum is in turn divided into:

spontaneous peritonitis in children;
spontaneous inflammation of the peritoneum in adults;
tuberculous inflammation of the peritoneum.

Pathogenic pathogens represent one type of infection or monoinfection. The most common type is streptococcus pneumoniae. In sexually active women, inflammation of the peritoneum is usually caused by gonococci and chlamydia. In the case of peritoneal dialysis, gram-positive bacteria (eubacteria, peptococci and clostridia) are detected.

In children, spontaneous inflammation of the peritoneum, as a rule, occurs in the neonatal period or at 4–5 years. At four to five years of age, systemic diseases (scleroderma, lupus erythematosus) or kidney damage with nephrotic syndrome are a risk factor for the development of this complication.

Spontaneous inflammation of the peritoneum in adults often occurs after emptying (drainage) of ascites, which is caused by cirrhosis of the liver or after long-term peritoneal dialysis.

Tuberculous damage to the peritoneum occurs with tuberculous damage to the intestines, fallopian tubes (salpingitis) and kidneys (nephritis). Mycobacterium tuberculosis enters the serous tissue of the abdominal cavity through the bloodstream from the primary source of infection.

Secondary peritonitis

Secondary inflammation of the peritoneum is the most common type of described complication and includes several varieties:

inflammation of the peritoneum caused by impaired integrity of internal organs (as a result of their perforation or destruction);
postoperative;
post-traumatic inflammation of the peritoneum as a result of blunt trauma to the abdominal area or penetrating injury to the abdominal cavity.

The causes of the first group of inflammation of the peritoneum are the following types of pathologies:

inflammation of the appendix (appendicitis), including perforation of the appendix (gangrenous and perforated appendicitis);
inflammation of the internal genital organs in women (salpingitis and oophoritis, endometritis), as well as ruptures of an ovarian cyst or fallopian tube during ectopic pregnancy or in the case of pyosalpinx;
intestinal pathology (intestinal obstruction, intestinal diverticula, Crohn's disease with perforation of ulcers, perforation of duodenal ulcers, perforation of intestinal ulcers of other etiologies: tuberculosis, syphilis, etc., malignant intestinal tumors and their perforation);
diseases of the liver, pancreas and biliary tract (gangrenous cholecystitis with perforation of the gallbladder, suppuration and rupture of various hepatic and pancreatic cysts, rupture of parapancreatic cysts, cholelithiasis).

Peritonitis after surgery is classified as a separate group, despite the fact that this type of disease is caused by abdominal trauma. But it should be taken into account that the injury caused by the operation is inflicted on the patient under certain conditions, in compliance with the rules of asepsis, and the negative response of the body to the surgical injury is associated with complex anesthetic management.

Post-traumatic inflammation of the peritoneum occurs as a result of a closed abdominal injury or due to a penetrating injury to the abdomen. Penetrating wounds can be caused by a gunshot wound, stab-cutting objects (knife, sharpening) or due to iatrogenic factors (endoscopic procedures accompanied by damage to internal organs, abortion, uterine curettage, hysteroscopy).

Tertiary peritonitis

This type of inflammation of the peritoneum is the most difficult to diagnose and treat. Essentially, this is a relapse of previous inflammation of the peritoneum, and, as a rule, occurs after surgery in those patients who have experienced emergency situations, as a result of which their body’s defenses are significantly suppressed. The course of this process is characterized by an erased clinical picture, with the development of multiple organ failure and significant intoxication. Risk factors for tertiary peritoneal inflammation include:

significant exhaustion of the patient;
a sharp decrease in plasma albumin levels;
identification of microorganisms resistant to multiple antibiotics;
progressive multiple organ failure.

Tertiary inflammation of the peritoneum is often fatal.

Development mechanism

How quickly this complication will develop and how severe it will be is largely determined by the state of the body, the virulence of microorganisms, and the presence of provoking factors. The mechanism of development of peritoneal inflammation includes the following points:

intestinal paresis (lack of peristalsis), which leads to disruption of the absorption function of the peritoneum, as a result of which the body becomes dehydrated and loses electrolytes;
dehydration leads to a decrease in blood pressure, which results in rapid heartbeat and shortness of breath;
the rate of development of the inflammatory process and its prevalence are directly proportional to the number of pathogenic microbes and the severity of intoxication;
microbial intoxication is complemented by autointoxication.

Classification

There are many classifications of inflammation of the peritoneum. Today the classification recommended by WHO is used:

Depending on the current:

acute peritonitis;
chronic inflammation of the peritoneum.

Depending on the etiological factor:

aseptic inflammation of the peritoneum;
microbial (infectious) peritonitis.

Origin of the complication:

inflammatory;
perforated (perforation of internal organs);
traumatic;
after operation;
hematogenous;
lymphogenous;
cryptogenic.

Depending on the exudate:

serous peritonitis;
hemorrhagic;
fibrinous;
purulent peritonitis;
putrid or ichorous.

Depending on the spread of inflammation:

delimited (appendicular, subphrenic, subhepatic and others);
common:
- diffuse – damage to the peritoneum covered 2 floors of the abdominal cavity;
- diffuse - inflammation of the peritoneum in more than two areas of the abdominal cavity;
- general - the inflammatory process is widespread over the entire area of the peritoneum.

Viral peritonitis does not develop in humans; it is diagnosed only in animals (cats, dogs).

Symptoms

With peritonitis, the symptoms are very diverse, but have a number of similar signs. The clinical picture of this disease depends on its stage and primary pathology, the age of the patient, previous treatment and the presence of severe concomitant processes. Elderly patients, in whom inflammation of the peritoneum is mild and atypical, requires special attention. Signs of peritonitis are combined into a number of characteristic syndromes.

Pain syndrome

This syndrome is inherent in every form of inflammation of the peritoneum. The localization of pain, its irradiation and nature depend on the primary disease. For example, if a stomach or duodenal ulcer is perforated, a very sharp pain occurs, like a stab with a knife (dagger pain), and the patient may lose consciousness. In this case, the pain syndrome is localized in the epigastric region. In case of perforation of the appendix, the patient indicates the localization of pain in the iliac region on the right.

As a rule, sudden sharp pain and rapid development of the disease up to a shock-like state are observed in such acute surgical pathologies as strangulation intestinal obstruction, pancreatic necrosis, perforation of the intestinal tumor, thrombosis of the mesenteric veins. In the case of an inflammatory disease, the clinical picture increases gradually. The intensity of pain depends on the duration of peritonitis.

The maximum severity of the pain syndrome is at the beginning of the disease, and the pain intensifies with the slightest movement of the patient, changing body position, sneezing or coughing, and even when breathing. The sick person takes a forced position (on the sore side or on the back), with his legs brought to his stomach and bent at the knees, tries not to move, cough and holds his breath. If the primary focus is located in the upper abdomen, the pain radiates to the scapula or back, supraclavicular region or behind the sternum.

Dyspeptic syndrome

With peritonitis, intestinal and stomach disorders manifest themselves in the form of nausea and vomiting, retention of stool and gas, loss of appetite, false urge to defecate (tenesmus), and diarrhea. At the onset of the disease, nausea and vomiting occur reflexively, due to irritation of the peritoneum.

With further progression of inflammation of the peritoneum, intestinal failure increases, which leads to disruption of motor-evacuation function (weakening and then complete absence of peristalsis), and is manifested by retention of stool and gases. If the inflammatory focus is localized in the pelvis, tenesmus, repeated loose stools and urination disorders occur. Similar symptoms are characteristic of retrocecal phlegmonous or gangrenous appendicitis.

Case Study

At night (as usual), a young woman of 30 years old was delivered by ambulance. Complaints of very severe pain in the lower abdomen for 5 - 6 hours. The pain becomes more intense over time, pulling, sometimes cutting. The temperature is 38 degrees, there is nausea, vomiting several times, frequent and painful urination. First of all, they called the gynecologist on duty. On examination, the abdomen is tense, painful in the lower sections, the Shchetkin-Blumberg sign is positive, more in the iliac region on the right. During a gynecological examination, the uterus is not enlarged, elastic, displacement behind the cervix is sharply painful. The area of the appendages is sharply painful; it is not possible to palpate possible inflammatory formations. The posterior fornix bulges, sharply painful on palpation. When performing a puncture through the posterior vaginal fornix, a large amount of turbid peritoneal fluid (more than 50 ml) was obtained. Preliminary diagnosis: Pelvioperitonitis (inflammation of the peritoneum in the pelvis) Acute right-sided adnexitis? I called a surgeon for a consultation. The surgeon is very experienced, palpated the abdomen and with the words: “Not mine,” retired to his room. The patient received infusion therapy for two hours. After 2 hours, the patient’s condition did not improve, the pain syndrome persists. She decided on exploratory laparotomy. The surgeon refused to assist. After dissecting the abdominal wall and examining the appendages (slight hyperemia of the fallopian tube on the right - mild salpingitis), a surgeon appears in the operating room (apparently, something suggested that maybe “it’s his”) and stands at the table. He inspects the intestines, primarily the cecum, and discovers gangrenous retrocecal appendicitis. An appendectomy is performed and the abdominal cavity is drained. The postoperative period was uneventful.

I cited this case as an example: it is easy to miss peritonitis even with such a banal disease as appendicitis. The vermiform appendix is not always located in a typical manner; it is not without reason that surgeons say that appendicitis is the monkey of all diseases.

Intoxication-inflammatory syndrome

Typical signs of this syndrome are temperature that rises to 38 degrees and above, fever alternating with chills, an increase in leukocytes in the peripheral blood and an acceleration of ESR. Breathing becomes more frequent, its frequency exceeds 20 respiratory movements per minute, the pulse increases (fastens) to 120 - 140 per minute. It is typical that the heart rate does not correspond to the increasing temperature (the pulse is ahead of the temperature).

Peritoneal syndrome

This syndrome is caused by many signs detected during examination of the patient, palpation and auscultation of the abdomen, determination of pulse, blood pressure and respiratory rate:

Face of Hippocrates

Hippocrates was the first to describe a suffering face, characteristic of widespread inflammation of the peritoneum. The patient’s facial features become sharpened due to dehydration (dehydration), and there is a pained expression on the face. The skin is pale, sometimes with an earthy or gray tint, dry mucous membranes, yellowness of the sclera. As the disease progresses, a cyanotic skin color appears. Drops of sweat appear on the forehead, especially after each painful attack.

Abdominal examination

The mobility of the abdominal wall during breathing is assessed by examining the abdomen. The abdomen either participates in breathing to a limited extent or does not participate at all. There may be a change in the shape of the abdomen (asymmetry or retraction - tension in the abdominal muscles).

Auscultation and percussion

When listening to the intestines, weakened peristalsis or its complete absence (deafening silence) and the appearance of pathological intestinal sounds are determined. Percussion (percussion of the abdominal cavity): liver dullness disappears, tympanitis (drumming sound) is detected in all areas of the abdomen. In some cases, it is possible to identify accumulated fluid.

Palpation

When palpating the anterior wall of the abdomen, its pain is determined, usually sharp, the abdomen is tense - board-shaped in the case of perforation of a hollow organ, the Shchetkin-Blumberg symptom (a sign of irritation of the peritoneum) is determined. There may be a lack of abdominal muscle tension, which is observed in elderly patients, with exhaustion, in case of severe intoxication, or the retroperitoneal or pelvic location of the primary focus.

A characteristic sign of peritoneal irritation is the Shchetkin-Blumberg symptom. During palpation of the abdomen, the patient feels pain, and after applying pressure at the site of greatest pain and the doctor abruptly removing the hand, the pain intensifies significantly.

When performing a rectal and vaginal examination, you can palpate an infiltrate, an abscess (abscess) or an accumulation of inflammatory fluid in the pelvis. In women, pain, flattening or bulging of the posterior vaginal fornix is determined.

Diagnostics

Diagnosis of abdominal peritonitis includes a thorough history taking and assessment of the patient's complaints. The chronic pathology of the digestive organs, how the disease began, its course, the severity of pain and intoxication syndromes, the duration of the disease (up to 24 hours, two days or 72 hours or more) are clarified. During a clinical examination, the pulse (up to 120), blood pressure (a decrease is noted), respiratory rate and abdomen are assessed. The abdominal wall is palpated, the abdominal cavity is auscultated, and signs of peritoneal irritation are determined. Laboratory research methods are used:

general blood test (increase in leukocytes to 12,000 and above or decrease in leukocytes to 4,000 and below, shift of the formula to the left, acceleration of ESR);
biochemical blood test (albumin, liver enzymes, sugar, pancreatic enzymes, etc.);
general urine analysis;
the acid-base state is determined.

Instrumental examination methods:

Ultrasound of the abdominal organs (if indicated and pelvis);
X-ray of the abdominal cavity (in case of perforation of the ulcer - the presence of free gas, in case of intestinal obstruction - Kloiber cups);
laparocentesis (puncture of the abdominal cavity - obtaining a massive effusion);
puncture through the posterior vaginal fornix (for pelvic inflammatory processes);
diagnostic laparoscopy.

Treatment

Treatment of this complication requires immediate hospitalization and, as a rule, emergency surgery. Under no circumstances should the disease be treated on an outpatient basis, since the course of this disease is unpredictable and, in addition to surgical intervention, requires observation of the patient both before and after surgery.

Treatment of peritonitis must be timely and comprehensive and consists of several stages:

preoperative preparation;
surgical intervention;
intensive care and monitoring after surgery.

Preoperative preparation

Preparation for surgery should be complete and last no more than 2, maximum 3 hours. Preoperative preparation includes:

catheterization of the central vein (installation of a subclavian catheter);
urinary catheterization;
gastric emptying (removal of gastric contents using a gastric tube);
massive infusion therapy of colloids and crystalloids of at least 1.5 liters (replacement of circulating blood volume, normalization of microcirculation disorders, fight against metabolic acidosis);
preparation for anesthesia (premedication);
administration of antibiotics (drugs are selected empirically before surgery);
antienzyme therapy;
normalization of the cardiovascular system;
maintaining liver and kidney function.

Surgery

Surgical intervention has the following goals:

eliminate the primary focus that caused inflammation of the peritoneum;
cleansing the abdominal cavity;
intestinal decompression;
effective drainage of the abdominal cavity.

Operation stages:

Anesthesia

Anesthesia for surgery is carried out in several stages. Endotracheal anesthesia is preferable; in extreme cases, spinal anesthesia (SMA) is performed. When performing SMA, a catheter is placed in the subdural space through which local anesthetics (lidocaine) are administered in the postoperative period, which reduces the need to use narcotic drugs.

Access

In case of inflammation of the peritoneum, a median laparotomy is performed (an incision from the pubis to the navel and above, to the sternum), which provides good access to all floors of the abdominal cavity.

Eliminating the source of the complication

After an incision in the anterior abdominal wall, an inspection of the abdominal organs is carried out and the original source of the disease is established. Further surgical intervention is carried out depending on the situation. In case of perforation or rupture of an organ, the wound is sutured; in case of inflammation (appendicitis, pyovar, etc.), the organ is removed. In case of intestinal obstruction, intestinal resection with anastomosis is performed, and in the case of purulent inflammation of the peritoneum, enterostomies are formed.

Sanitation of the abdominal cavity

The effusion is removed from the abdominal cavity; after its elimination, the abdominal cavity is repeatedly washed with antiseptic solutions (chlorhexidine, dioxidine, furacillin) and dried.

Bowel decompression

A tube with numerous side holes is inserted into the small intestine. Administration is carried out through the nose, rectum or enterostomy (necessary for removing gases from the intestines).

Drainage

Drainage of the abdominal cavity is carried out with silicone or rubber tubes (exited to the anterior abdominal wall), which should ensure the removal of effusion from all parts of the abdomen.

Suturing the wound

The operation ends with suturing the postoperative wound or applying a laparostomy. During laparostomy, the abdominal wall is not sutured; only the edges of the wound are brought together with special sutures.

Postoperative therapy

Management of the postoperative period should be carried out under monitoring, be complete and adequate, with a quick change of prescriptions and tactics in the absence of positive dynamics.

Postoperative patient management includes:

adequate pain relief;
carrying out intensive infusion therapy (up to 10 liters per day);
carrying out detoxification therapy (hemodialysis and lymphosorption, administration of diuretics, hemosorption, lavage of the abdominal cavity through drains or sanitation through laparostomy);
prescription of antibiotics in maximum doses, intravenous route of administration (combination of cephalosporins with aminoglycosides and metronidazole);
immunocorrective therapy;
prevention of intestinal paresis (administration of proserin) and intestinal failure syndrome (administration of atropine, potassium preparations);
normalization of the functioning of all organs and systems;
prevention of complications.

Care and monitoring of the patient after surgery

Patient care begins immediately after completion of the operation and should continue until the patient is able to work. In this regard, in the postoperative period there are 3 phases (conditionally):

early – lasts from 3 to 5 days;
late – first 2 – 3 weeks (hospital stay until discharge);
remote – until you go back to work or become disabled.

Postoperative care in the early phase

The patient is transported on a gurney to the intensive care ward, where he is carefully transferred to a special functional bed with clean linens. The patient is provided with warmth and comfort. It is placed in the legs, on a blanket, and on the postoperative wound (no more than half an hour), which will prevent bleeding from the wound and somewhat reduce the pain.

The patient is placed in a Fowler's position in bed - the head end is raised 45 degrees, and the legs are slightly bent at the knee and hip joints. If the patient is unconscious (under anesthesia), he is laid horizontally, removing the pillow from under his head. To avoid retraction of the tongue, the head is tilted back slightly and the lower jaw is brought out. In the first 2–3 days after surgery, the patient is prescribed fasting and strict bed rest. If necessary, artificial ventilation of the lungs is continued, and if the patient’s condition is satisfactory, he is periodically given inhalations of humidified oxygen.

The first dressing change is carried out on day 2, under the supervision of a doctor. If the bandage has become loose or bleeding from the wound has increased, dressing should be done earlier. Honey. The nurse monitors not only the pulse, respiratory rate, blood pressure (every hour) and temperature, but also controls urine output (the urinary catheter is left in place for another 2 to 3 days after surgery) and the amount and nature of discharge through the drains. The drains are periodically washed, and the dressings on the drains are changed by a doctor.

The patient’s nutrition after surgery begins on the 2nd day and parenterally (infusion therapy). Basically, parenteral nutrition includes the administration of 10% glucose and amino acid salts. The volume of infusions is calculated according to the formula: 50 – 60 ml/kg of patient’s body weight.

On the first day after surgery, the patient is not given anything to drink, and to relieve thirst, the lips are wiped with a damp cloth. As soon as peristalsis is established (usually on day 2), the patient is allowed to drink (1 teaspoon of water every hour) and proceeds to enteral nutrition (administration of liquid food and mixtures through a nasogastric tube).

It is undesirable for the patient to remain in bed for a long time (physical inactivity provokes postoperative complications). Taking into account the patient's condition, early activation is started.

By the end of the first day, the patient should begin to actively behave in bed (turn over, bend, straighten limbs). On the 2nd - 3rd postoperative day, the patient first sits down in bed, then, after several deep breaths and exhalations and clearing his throat, he must get up and walk around the room, after which the patient is put to bed. Honey helps to lift the patient. sister. As the condition improves and pain decreases, the patient expands the regimen according to the doctor’s instructions.

Late phase

As soon as the patient establishes constant peristalsis, the passage of gases is established and stool appears, he is transferred to independent feeding. Food is taken at room temperature, in small portions, up to 6 times a day.

During the first week, food should be liquid (broths: water after boiling is drained and replaced with new one, soft-boiled eggs, jelly and jelly, pureed vegetables with a small amount of butter).
On days 3–4, the patient’s menu includes pureed cottage cheese, boiled beef, lamb, pureed chicken and fish, slimy porridges and soups (rice, oatmeal). Coarse fiber and foods that are difficult to digest and irritate the digestive tract (legumes, cabbage, radishes and radishes, stringy meat, skin and cartilage of poultry and fish, cold drinks) are excluded. The intake of fats should come from vegetable oils, sour cream and cream, and a small amount of butter. Easily digestible carbohydrates (marmalade and honey, jam, marshmallows, chocolate, etc.) are limited. Dried bread or yesterday’s baked bread is included in the menu for 5–7 days.
Free mode (walks around the department and on the hospital grounds) is prescribed for 6–7 days. If the postoperative period is favorable, the sutures are removed on days 8–9, and the drains are removed on days 3–4. The patient is usually discharged on the day the sutures are removed.

Distant phase

After discharge, the patient must follow a number of medical recommendations:

limiting heavy lifting (no more than 3 kg) and heavy physical activity for 3 months;
sexual rest for up to 1.5 months;
performing therapeutic exercises (training the respiratory and cardiovascular systems, strengthening the abdominal muscles and preventing the development of hernias, restoring working capacity).

Rehabilitation of the patient is facilitated by skiing, hiking, hiking, and swimming. The patient is also recommended for sanatorium treatment.

The patient should eat sparingly (up to 5 times a day), not overeat, but also not starve. It is recommended to boil, steam, stew or bake food (without crust). Limit the consumption of foods that irritate the gastrointestinal tract (spices, peppers, marinades and pickles, bitter and sour vegetables: sorrel, radish, garlic, onions, radishes). You should avoid refractory fats (margarine, lard, smoked foods) and limit your consumption of sugar (sweets, jam) and baked goods.

Consequences and complications

Early complications of peritonitis that can occur in the acute period in the absence of timely treatment include life-threatening conditions:

infectious-toxic shock;
acute vascular insufficiency and collapse;
bleeding;
development of sepsis;
acute renal failure;
intestinal gangrene;
cerebral edema;
dehydration;
pulmonary edema;
DIC syndrome;
death of the patient.

Long-term consequences of peritonitis (after surgical treatment):

formation of intra-abdominal adhesions;
infertility (in women);
interintestinal abscess;
intestinal eventration;
ventral hernia;
intestinal paresis and obstruction.

Forecast

The prognosis after peritonitis largely depends on the duration of the clinical picture before medical care, the extent of peritoneal damage, the age of the patient and concomitant pathology. The mortality rate for this complication still remains at a high level, for example, with diffuse inflammation of the peritoneum it reaches 40%. But with timely and adequate therapy, early surgical intervention in compliance with all the requirements for performing an operation for this complication, a favorable outcome is observed in 90% of cases or more.

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

Acute purulent peritonitis causes:

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

2. Perforation of the abdominal organs (perforated gastric ulcer, perforation of a typhoid ulcer of the small intestine, etc.), as a result of which the infected contents spill 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 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, most often occurring as a complication of any inflammatory process, perforation or damage in the abdominal cavity. That is why, with inflammation of the peritoneum, one cannot limit oneself to the diagnosis of “peritonitis”, but it is necessary to establish its primary source, which is actually 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 by 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, appendiceal abscesses, etc.). However, in some cases, as the infection spreads, the entire peritoneum or a significant part of it can quickly become involved in the inflammatory process. This is general or diffuse peritonitis.

Peritonitis signs and symptoms. Several hours usually pass between the immediate cause of purulent peritonitis (inflammation, trauma) and the appearance of its first signs. 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 is necessary to emphasize the special 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 appropriate treatment (surgery, etc.) gives the greatest success. In the later stages of peritonitis, when many of the “classic” symptoms of this serious and dangerous disease appear, the chances of saving the patient are sharply reduced. That is why early diagnosis of peritonitis is so important.

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

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

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

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

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

Sometimes the tension in the abdominal wall is expressed so sharply that in these cases they say: “The stomach is like a board.” Although this sign is one of the most constant in local and general peritonitis, in some cases it can 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 involves the posterior sections of the parietal peritoneum (i.e., covering the posterior wall of the abdominal cavity), as happens, for example, with retrocecal appendicitis. Tension of the abdominal muscles may be mildly expressed or even also absent in the elderly, in persons with a flabby abdominal wall (for example, in multiparous women), in very severely ill patients, in shock, as well as in the late stages of development of peritonitis.

The initial signs of peritonitis are accompanied by other symptoms: lack of appetite, nausea, vomiting, belching, fever, change in pulse, change in blood (leukocytosis, change in formula, acceleration of ROE).

An increase in temperature (up to 38° and above) is often observed with peritonitis, but is not, however, a constant sign, 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 (by 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 development of peritonitis, the pulse may even be slow, but this stage is very short-lived (up to 6-8 hours) and is quickly replaced by a characteristic increase in pulse 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, when the temperature rises by 1°, the pulse usually increases by 8-10 beats per minute. With peritonitis, this ratio is disrupted and the pulse, as a rule, is more frequent than would be expected given the patient’s temperature. Therefore, with any acute pain in the abdomen, a pulse that “overtakes” the temperature always raises suspicion of peritonitis. However, it should be remembered that in the initial stage of development of peritonitis, the pulse, as already mentioned, may be slow and becomes faster only later.

As the inflammatory process spreads and intoxication of the patient’s body increases, the initial signs of peritonitis appear more sharply and are joined by more and more new ones, 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 development of progressive peritonitis.

The appearance and position of a patient with such progressive peritonitis is very characteristic. The patient's facial features become sharpened, the lips are bluish, the eyes become dull, the sclera are jaundiced, the eyeballs sink, blueness appears around them, the face acquires a pale grayish, bluish or jaundiced tint with a pained expression. This type of face, characteristic of the late 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 his legs bent. 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, uncontrollable vomiting and hiccups. Due to profuse and frequent vomiting, dehydration occurs (dry lips, tongue, hoarseness, decreased amount of urine).

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

Signs of intestinal paralysis are increasing. Vomiting becomes more frequent and becomes fecal in nature, the abdomen swells (flatulence), which causes difficulty in cardiac activity and breathing, the participation of the abdominal wall in respiratory movements weakens or is completely absent.

When the abdomen is tapped, a tympanic sound (the sound of a drum) is heard, and when auscultated, the usual intestinal sounds caused by peristalsis are not heard, and the so-called “deathly silence” reigns in the abdominal cavity. In the abdominal cavity, inflammatory effusion (exudate) accumulates in increasing quantities, which is determined by tapping in sloping areas of the abdomen in the form of a dullness that moves or disappears 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, accumulation of pus in the pouch of Douglas, severe pain upon palpation, the presence of gynecological diseases, etc.).

As peritonitis progresses and intoxication increases, the patient's condition quickly deteriorates, breathing becomes rapid, shallow, chest-type; heart sounds are muffled, blood pressure gradually drops, extremities become cold, protein, casts, indican, etc. appear in the urine. The patient’s consciousness remains until the end of his life, although he becomes indifferent to his surroundings, a terminal state occurs and death usually occurs at 5-7. th day.

The signs just described are characteristic of an 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 stated, 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 changes in pulse. All other signs join these basic ones only as the inflammatory process develops.

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

It should, however, be borne in mind that the clinical picture of general peritonitis described above and 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. Thus, 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 well-being improves for some 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 weakened patients with a severe general condition, peritonitis occurs against the background of a general unresponsiveness of the body, as a result of which the entire clinical picture is “erased.” Some clinical features are observed in biliary, typhoid, streptococcal and pneumococcal peritonitis.

Acute purulent peritonitis should be distinguished from some other diseases of the abdominal cavity (acute intestinal obstruction, perforated gastric ulcer, etc.). However, it should be borne in mind that in the absence of proper treatment (most often surgical), all these diseases inevitably lead to the development of peritonitis. Thus, it is possible to distinguish them from peritonitis only in the early stages. Some diseases, to some extent, can resemble the picture of an “acute abdomen”, for example, renal colic, and 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-described signs of general (spread) peritonitis are, of course, less pronounced. In particular, important signs such as abdominal pain and abdominal muscle tension are noted only in the affected area of the peritoneum. With local peritonitis, the resulting inflammatory infiltrate either gradually resolves or suppurates and leads to the formation of an intraperitoneal abscess.

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

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

The use of laxatives and enemas is also prohibited, which, by enhancing intestinal motility, prevent the delimitation of the inflammatory process and, on the contrary, contribute to its deterioration, causing, for example, perforation of the appendix in acute appendicitis, etc.

In cases of decline in cardiac activity, cardiac medications are used (camphor oil, caffeine, cardiazol, cordiamine); in case of cyanosis, inhale oxygen.

When transporting a patient, you should provide him with maximum comfort and peace.

If there is a delay in hospitalization, the patient is prescribed strict bed rest in a semi-sitting position with bent legs, cold on the stomach, drinking is limited, and 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); for 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 gastric lavage or insert a permanent tube into the stomach.

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