Signs of peritonitis: the main symptoms of acute and chronic inflammation. Surgical complications. Peritonitis. Symptoms of the disease How to treat peritonitis

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 to create partitions between internal organs and muscles, as well as fixation in a suspended state with the help of mesenteries and ligaments. The peritoneum protects the internal organs in another way. When it encounters microbes, substances are produced that lead to the death of harmful microorganisms. Peritonitis is an inflammation of the peritoneum, leading to disruption of the functioning 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 of 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. Rarely, peritonitis can develop when microorganisms are carried into the 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 the duodenum, if measures are not taken in a timely manner, end in peritonitis. Inflammation of the peritoneum is caused by the destruction of the organ after the disintegration of the tumor. Necrosis of a fragment of the intestine due to a hernia, trauma to the abdominal cavity, accompanied by injury, rupture of an organ, partial destruction of the wall of the stomach or intestines by a foreign body can also result in peritonitis.

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

Not all types of peritonitis are caused by pathogenic microorganisms. For example, blood entering the abdominal cavity due to a violation of the integrity of the vessel also leads to peritonitis. In this case, the type of disease is called aseptic or germ-free. The disease lasts at this level for no more than 6 hours. After this period, microbes from the intestinal area penetrate into the hematoma. After this, peritonitis becomes common.

Signs of peritonitis

Manifestations of peritonitis are due to the reasons that provoked its development. But the main signs of one stage or another are the same in any case.

Reactive stage

This is the first stage, it occupies the first day of the disease. The lesions are local in nature. 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 to the blow of a dagger.

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

Sometimes there are periods when the pain seems to subside. But it won't last long. Relief lasts no more than 2 – 3 hours. Then things escalate.

The patient has a rather characteristic appearance:

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

The pain bothers a person greatly; he, as a rule, tries to ease its intensity by taking certain poses. For example, lie on your side and tuck your knees, don’t cough, don’t puff out your stomach.

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

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

Toxic

This is the second stage. During this period, the person is in serious condition. All signs indicating the presence of poisoning appear. This stage takes approximately two days and begins 24 hours after the onset of the disease. The symptoms of the first stage are smoothed out. The muscles of the abdominal wall are slightly tense and may generally be normal. The pain is mild and vague. A person’s appearance at the moment also has common typical features:

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

The mouth remains dry and consciousness may be impaired. This is expressed in complete indifference, less often in excitement. The patient may lose consciousness. The patient lies without moving. Does not respond to palpation of the abdomen. persists, only the vomit takes on a different color. They become dark, brown, and smelly. There is little or no urine. The temperature rises to very high numbers: 40 - 42°. Breathing becomes unstable, pulse is very weak.

Terminal stage (irreversible)

This is the third stage, it occurs three days after the onset of the disease. After three, and sometimes even two days, it ends in 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”:

• bluish moist skin;
• sunken cheeks;
• overly sharpened features.

The abdomen is soft, there is no painful sensation at all, palpation does not cause discomfort. The pulse cannot be felt, breathing is weak or may be completely absent, the 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 happens in encysted peritonitis, it can be difficult to make a diagnosis. Diagnosis is also difficult for ulcers that are a consequence of laparotomy interventions (subdiaphragmatic, interloop, pelvic, abscesses, ulcers of the right iliac fossa).

With indolent processes, the disease may manifest itself as short-term pain, which is replaced by general malaise. Anemia, exhaustion, and 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 occurring somewhere.

It is very difficult to identify this type of peritonitis. It is necessary to conduct a comprehensive examination, including many tests, vaginal and rectal examinations. Of course, it is better to carry out such diagnostics 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 ensure the correctness of the diagnosis, use the results of radiography and laparoscopy.

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

You should not give drugs to relieve 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 avoid severe dehydration and infectious-toxic shock. The drug must be administered by drip. Quantity 400 – 800 ml. glucose (5%) or sodium chloride is also administered. These drugs alleviate the patient’s general condition, create safer conditions for transportation, and serve as some preparation for the upcoming operation.

Treatment of peritonitis

If the diagnosis is established, emergency surgery is performed. During the operation they act according to the circumstances. After examining all the tissues, the affected areas of the 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 the inflammation has affected large areas, then washing is carried out over several days. After surgery, it is administered in large quantities. They also direct actions to eliminate dehydration.

The famous surgeon S.I. Spasokukotsky noted back in 1926 that if the operation was performed in the first hours after the development of inflammation, then 90% of patients recover. The operation results in recovery in 50% of cases within the first 24 hours. And only 10% have a chance of survival if the operation is performed after the third day.

In our time, approximately the same trend continues. Surgical intervention ends with recovery on the first day. 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 to the internal organs.

Preventive actions

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

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Diagnosis of peritonitis, like all acute human diseases, is based on a comprehensive assessment of medical history, local symptoms, signs of inflammation and intoxication, and characteristic complications.

Complaints.

As a rule, rather intense, dull, constant pain in the abdomen approximately corresponds to the extent of the process, intensifying with breathing and movement. Irradiation to the shoulder girdle is possible due to irritation of the diaphragm. Feeling unwell. There is often nausea. The chair is delayed.

Anamnesis.

It is necessary to find out the duration of the disease, changes in the nature and location of pain, the dynamics of toxic manifestations, and signs of complications.

In a large number of cases, it is possible to identify signs of a previous disease (appendicitis, cholecystitis, exacerbation of peptic ulcer), a typical complication of which is peritonitis. Often, against the background of some improvement in well-being and a decrease in previous abdominal pain, they suddenly intensify and become widespread. From this moment on, your health deteriorates sharply, dry mouth and thirst appear, and your heart rate increases.

General inspection.

The patient, as a rule, lies on his back or on his side with his hips adducted to the stomach; he does not change his position, since any movement or attempt to stand up leads to increased pain. If the patient was sitting, then when trying to lie down, increased pain in the abdomen or the appearance of pain in the shoulder girdle (a symptom of irritation of the phrenic nerve) force him to return to a sitting position. This is the so-called “Vanka-Vstanka” symptom.

Speech is quiet. If the patient is not addressed, he will not scream, demanding attention. Such behavior of the patient, especially his quiet groan while breathing, should always cause special concern to the doctor.

It is necessary to pay attention to the severity of all parts of the infectious process and intoxication - temperature, tachycardia, frequency and depth of breathing, the state of consciousness, the violation of which is the most striking reflection of severe intoxication, blood pressure, dryness of the mucous membranes of the tongue and the inner surface of the cheeks.

Tachycardia 100-120 per minute and above, blood pressure is normal or with a tendency to decrease, shortness of breath 20-24 per minute.

Toxic encephalopathy may manifest itself as lethargy, agitation or delirium.

Paleness, especially marbling of the skin, reflects a deep violation of microcirculation.

Special inspection.

The abdomen is usually symmetrical, somewhat swollen, and does not participate in breathing. By palpation, severe diffuse pain, tension and Mendelian and Shchetkin-Blumberg symptoms are determined. Usually there is a sharp weakening or absence of peristaltic noise.

It is necessary to check the presence of free gas by the disappearance of hepatic dullness and free fluid by the presence of dullness of percussion sound in the lateral regions, which disappears when turning on the side.

Rectal and vaginal examination may reveal sagging of the fornix and pain due to the accumulation of inflammatory exudate.

In the general blood test - pronounced leukocytosis, a pronounced shift to the left to young. Biochemical analysis reveals normo- or hyperglycemia, a moderate increase in urea, creatinine, ALAT, ASAT, alkaline phosphatase, and signs of disseminated intravascular coagulation syndrome.

Laboratory examination.

Laboratory examination reveals pronounced leukocytosis (14-20x10 9 /l), usually with a shift in the leukocyte formula to the left, lympho- and monocytopenia, aneosinophilia, thrombocytopenia. To objectify the assessment of the degree of intoxication, the Kalf-Kalif Leukocyte Intoxication Index (LII) is used.

In the reactive phase, as a rule, it reaches 4, in the toxic phase – 8, in the terminal phase – it can reach values ​​of 12 – 18.

During a biochemical examination, it is possible to detect an increase in hematocrit, urea, creatinine, transaminases, bilirubin, glucose, lactate, a violation of the coagulation system, a shift in acid-base balance, an increase in pCO 2, a decrease in pO 2 - evidence of dysfunction of various organs and systems.

Additional research.

The presence of free gas and liquid can be confirmed by ultrasound examination.

An X-ray examination can reveal free gas, Kloiber cups, high standing domes of the diaphragm, limitation of their mobility due to swelling or muscle tension. In severe cases, signs of ARDS are found in the lungs.

If there is doubt about the diagnosis, laparoscopy is performed, during which the source, extent and nature of peritonitis can be established.

The presence of peritonitis can be confirmed by laparocentesis if characteristic exudate is obtained.

In reactive and terminal phases The clinical manifestations of peritonitis vary significantly.

In the reactive phase, pain prevails. An area of ​​greatest pain is often identified, corresponding to the primary focus of inflammation. The tension of the abdominal wall muscles is pronounced. A sharply tense abdomen looks somewhat retracted - “scaphoid”, this is especially characteristic of peritonitis with perforation of hollow organs. The symptoms of Mendel and Shchetkin-Blumberg are distinct. Peristalsis is usually sharply weakened.

There are no obvious signs of dehydration. Tachycardia reaches 90 - 100 per minute, shortness of breath is rare. It is possible to identify some elements of the erectile phase of shock - arousal, increased blood pressure.

Neutrophilic lekocytosis 12-18x10 9 /l, lymphocytopenia and monocytopenia, aneosinophilia. Biochemical tests do not reveal any significant deviations.

In the terminal phase, it can be very difficult to establish a diagnosis of peritonitis if it is not possible to find out the history of the disease from relatives.

Mild vomiting of stagnant contents is repeated several times a day. Stool on its own, or after an enema, is usually scanty, often foul-smelling (septic).

An adynamic, lethargic, severely dehydrated patient with sunken eyes, sharpened facial features, breathes shallowly quickly, often with a quiet groan. He cannot stick out his dry “brush-like” tongue, since the inner surfaces of his cheeks are also dry.

The abdomen is significantly distended and unevenly slightly painful. Mendel's and Shchetkin-Blumberg's symptoms are questionable. Percussion sound is uneven. You can detect a symptom of “deathly silence” - when instead of intestinal sounds, respiratory and vascular sounds are heard. When you shake the abdominal wall with your hand, a “splashing noise” may be heard.

Plain radiographs reveal multiple Kloiber cups.

Tachycardia is above 120, blood pressure is reduced, especially after transportation, it is maintained close to normal only against the background of intensive infusion. Shortness of breath is about 30, blood oxygen saturation is often reduced (StO 2). In the lungs there are spherical shadows of different sizes, characteristic of ARDS, hydrothorax.

In the blood test, normocytosis is sometimes leukopenia, a sharp shift to the left, to young, sometimes plasma cells.

Biochemical analysis showed pronounced signs of MODS.

General principles of treatment.

Based on materials from the 31st All-Union Congress of Surgeons (1986) and the 1st International Congress in Moscow (1995), the general principles of treatment of peritonitis contain 4 points:

Preoperative preparation. It is impossible to completely correct homeostasis disorders before surgery. But it is always better to postpone the operation for 2-3 hours for targeted preparation. It is enough to achieve stabilization of blood pressure and central venous pressure, diuresis of 25 ml/hour. The total volume of infusion before surgery is 1.5-2.0 l over 2 hours. In advanced processes, when hemodynamic disturbances are pronounced (fluid loss of more than 10% of body weight), the infusion volume increases to 3-4 l over 2-3 h.

The subclavian vein is always catheterized. This provides a higher infusion rate and the ability to control central venous pressure.

Bladder catheterization is advisable to measure hourly diuresis as an objective criterion for the effectiveness of infusion therapy.

Preparation of the gastrointestinal tract. Emptying the stomach with a tube is mandatory. In case of advanced processes, the probe must be in the stomach constantly, during the entire preoperative period, during the operation and for some time after it. Until intestinal motility resumes.

Anesthesia. The main method of pain relief during operations for peritonitis is multicomponent anesthesia with the use of mechanical ventilation.

Surgical treatment. The operation consists of seven sequential stages.

Peritonitis is an inflammatory disease that affects the peritoneum. This condition poses a huge danger to the body, since the result of such a pathology is a disruption in the functioning of all vital organs. Symptoms of peritonitis vary depending on the degree of the disease and its form: acute and chronic.

Causes

The following factors can contribute to the occurrence of abdominal peritonitis:

• infectious diseases;
• perforation or destruction of abdominal organs;
• penetrating wounds of the abdominal cavity, resulting in infection;
• hematogenous spread of infection from foci in organs and tissues.

How does the disease manifest itself?

External symptoms of peritonitis are determined taking into account the manifestations of the disease that contributed to the occurrence of the inflammatory process in the abdominal cavity. In addition, the signs of the presented disease help determine the stage at which its development and type occur.

Local and general manifestations

A disease such as peritonitis has local and general manifestations. The first include those that serve as reactions to irritation of the peritoneum. These signs serve as a protective mechanism, and the location of their concentration depends on the area and zone of the pathological focus.

Local manifestations of peritonitis include:

• pain syndrome;
• abdominal muscle tension;
• signs of peritoneal irritation detected during diagnosis.

Painful sensations

Pain syndrome is one of the first manifestations of peritonitis. Taking into account the root cause of the disease, the nature and intensity of pain is determined. The maximum severity is the pain that occurs during perforation of internal organs. For such a case, it is sharp, sudden, and in strength resembles a blow with a dagger. In medical terminology, such pains are called dagger pains.

The intensity of pain is determined by the effect and composition of the irritating component. Pain permeates a person with maximum intensity during acute pancreatitis. The reason for this condition is explained by the presence of enzymes that are present in pancreatic juice. It is they who have the maximum effect, comparable to a burn, on the abdominal cavity.

Severe pain can contribute to fainting. In some cases, the person is very overexcited. Pain limits the patient's mobility, as a result of which he must remain in the same position for a long time. It becomes very difficult to breathe from the stomach.

Initially, the pain is concentrated and acts in the affected area. But after some time it takes on a spilled character. This condition indicates that the inflammatory process begins to spread throughout the abdominal cavity. At the same time, the reverse process may be observed: the initially diffuse pain will be realized.

Pain syndrome during peritonitis occurs due to irritation of the peritoneum. After all, it is characterized by rich innervation and sensitivity to various types of stimuli. The transition of localized pain into diffuse pain is associated with the transition of inflammation from the parietal layer of the peritoneum to the visceral one.

There are cases when the pain changes the area of ​​concentration, which indicates a transition of the inflammatory process. In the current situation, it is not diffuse, but localized. For example, the pain will subside for a while, but intensify while going to the toilet. Such symptoms indicate that the pathology has affected the peritoneum, which covers the bladder. During a diagnostic study, it is very important to determine the primary location of the pain syndrome.

Pain relief is an unfavorable development of events in peritonitis. The reason for this process is the accumulation of a significant amount of fluid in the abdominal cavity or intestinal paresis.

Tense abdominal muscles

This symptom is very often accompanied by pain. Tension occurs due to a reflex contraction of the abdominal muscles. The tense state of the muscles also corresponds to the zone of innervation. If there is maximum tension and all abdominal reflexes have disappeared, then this condition is due to perforation of the ulcer. Using medical terminology, such a stomach is called “board-shaped”. Tension can be detected even visually without palpation.

Muscle tension can be local. If effusion biliary peritonitis occurs, then the abdominal wall becomes dense in the area of ​​​​the projection of the gallbladder. Muscle defense is one of the early signs of peritonitis. This condition can come and go. There is no tense state of the abdominal muscles in weakened and elderly people.

Common manifestations of peritonitis include:

• increased body temperature;
• frequent vomiting;
• rapid heartbeat;
• low blood pressure;
• decreased diuresis;
• dry skin and pointed facial features;
• increased acidity;
• confusion.

Obstetric peritonitis

Obstetric peritonitis is a disease that occurs due to injury to the uterus. Its development occurs 4–9 days after surgery. Obstetric peritonitis is conventionally divided into clinical forms, thanks to which it is possible to correctly prescribe therapeutic measures.

Obstetric peritonitis has the following symptoms:

• flatulence, intestinal paresis;
• hyperthermia;
• presence of liquid contents in the stomach;
• dyspnea;
• tachycardia;
• vomit;
• intoxication.

It is impossible to eliminate obstetric peritonitis with the help of therapeutic measures. Here we can only talk about a temporary effect, and after 3-4 hours all manifestations of the disease return again. The only way out is to perform an operation.

Acute phase of the disease

Acute peritonitis is a disease that, when detected, requires urgent hospitalization. If medical care is not provided to the patient in time, death is possible.

Acute purulent appendicitis, perforation of stomach and intestinal ulcers contribute to the development of this form of the disease. The following stages of acute peritonitis are distinguished:

1. Reactive. The duration of the phase is 12–24 hours. It manifests itself as acute pain that affects the entire abdomen. The pain syndrome affects the area of ​​primary damage with maximum intensity. During the reactive stage, the patient experiences tension in the abdominal muscles, increased pain at the slightest attempt to change benefits, and he always sleeps in the fetal position. This condition in medicine is called the Shchetkin-Blumberg symptom. Acute pancreatitis in the reactive phase causes chills and fever.
2. Toxic. It lasts 12–72 hours. It is characterized by an improvement in the patient's condition, but all this only seems. In a person, the severity of the pain syndrome decreases, abdominal tension goes away, and a state of euphoria and lethargy arises. The patient's facial features become sharper and the skin has a pale tint. Vomiting and a feeling of nausea occur. Intestinal motility and urination are reduced. Acute peritonitis in the toxic stage begins to form the first manifestations of dehydration - dry mouth. It is very difficult for a person to take liquid due to vomiting. When diagnosing the toxic stage of peritonitis, the mortality rate is 20%.
3. Terminal. Its symptoms begin to affect the human body 24–72 hours after viral peritonitis has formed. Its duration is no more than a few hours. There are manifestations of dysfunction of all organs and systems. The patient is in prostration and does not understand what is happening to him. The eyes and cheeks become sunken, and an earthy tint to the skin appears. Often this condition is accompanied by vomiting of putrefactive matter. In addition to the presented manifestations, a person experiences cold sweat, tachycardia, shortness of breath, a sharp drop in temperature, and bloating. Therapy at the terminal stage of the disease does not give the desired effect, so the mortality rate for this condition is about 90%. Peritonitis in the terminal phase leads to death within 24 hours from the onset of the disease.

How does diffuse peritonitis manifest itself in the acute phase?

Acute diffuse peritonitis is a complication of various diseases of the abdominal cavity. Such pathologies include:

• perforated ulcer of the stomach, intestines;
• purulent appendicitis;
• thrombosis of mesenteric vessels;
• liver abscess.

The cause of the development of the inflammatory process is the presence of intestinal microflora in the peritoneum: Escherichia coli in combination with streptococci, dysentery bacillus, and staphylococci. The following classification of peritonitis is distinguished:

1. Perforated – there is a connection with a perforated ulcer of the stomach, large and small intestines, duodenum.
2. Gallbladder - the reason for its development is the result of perforation of the gallbladder.
3. Septic – postpartum.
4. Pneumococcal – occurs with pneumonia and in patients with severe nephritis.
5. Postoperative peritonitis.
6. Traumatic – occurs due to mechanical injuries, wounds from cold steel and firearms.

This disease has the following manifestations:

• pain syndrome;
• sharp increase in pain at the slightest movement, cough;
• pale facial skin;
• drop in blood pressure;
• thready pulse.

In the future, pain may ease, especially at the time of accumulation of exudate in the abdominal cavity. There is a lack of passage of gases and feces, vomiting and hiccups intensify. The vomit contains food debris. If the disease is at the last stage, then vomiting becomes fecal in nature.

Characteristics of acute purulent peritonitis

Acute purulent peritonitis can occur for the following reasons:

1. Inflammatory damage to any of the abdominal organs. Such ailments include appendicitis, cholecystitis, inflammation of the internal genital organs in women, and strangulated hernia. In this case, acute purulent peritonitis occurs due to the spread of infection from the main focus to the peritoneum.
2. Perforation of abdominal organs. Such diseases include perforated ulcers of the stomach and small intestine. The result of this process is infection of the abdominal cavity.
3. Damage to abdominal organs.
4. Hematogenous spread of infection to the peritoneum from some inflammatory focus. Acute purulent peritonitis is observed with tonsillitis, osteomyelitis, and sepsis.

Manifestations of chronic peritonitis

Manifestations of peritonitis in chronic form are muted and not expressed. The patient does not experience acute pain, vomiting, or muscle tension. For this reason, chronic peritonitis can go unnoticed for a long time. Symptoms of the disease are associated with prolonged, chronic intoxication of the body. The following manifestations of the disease are distinguished:

• weight loss;
• increased sweating;
• prolonged low-grade fever;
• periodic constipation;
• periodic abdominal pain.

Viral peritonitis

Viral peritonitis is a disease that develops due to a primary infectious lesion of the abdominal organs. Viral peritonitis allows infection to enter the peritoneum through the bloodstream or lymphatic flow. Viral peritonitis is diagnosed extremely rarely, in only 1% of cases.

Peritonitis in young patients

Peritonitis in children has a number of features. For example, in children, peritonitis very rarely occurs due to cholecystitis, pancreatitis, or test ulcers of the stomach and intestines.

In young children, the general condition is initially slightly impaired due to the excellent compensatory capabilities of the cardiovascular system. The first thing that may worry a child is the phenomenon of respiratory failure. After some time, decompensation of the cardiovascular system occurs, which results in a progressive deterioration of the baby’s condition.

In cases of severe clinical manifestations of appendicitis, antibiotics are used. Such actions increase the likelihood of such a serious complication as peritonitis in children. At an early age, with the appendicular form of peritonitis, loose stools appear, sometimes green, with mucus.

Diagnostics

The diagnosis is made based on the characteristic manifestations of peritonitis and the results of a blood test. This analysis should contain a purulent-toxic shift in the leukocyte formula. Diagnostics also includes x-ray examination and ultrasound of the abdominal organs. If the doctor has doubts, he can refer the patient for laparoscopy. Diagnosis of peritonitis must be urgent, because this condition requires immediate therapeutic measures.

Therapy

Peritonitis can only be treated surgically. If there is an acute phase of the disease, then after intestinal surgery the intake of food, water and painkillers is prohibited. The patient should only be in a supine position.

Before surgery is performed, the patient is prepared to stabilize his condition. Preparatory measures include restoring water balance, eliminating pain shock and normalizing blood pressure.

Intestinal surgery is performed under general anesthesia. At this time, the primary source of infection is eliminated, the abdominal cavity is washed with antiseptics and drains are installed.

After intestinal surgery, the doctor prescribes drug treatment for peritonitis, which includes taking antibacterial drugs. In addition, after surgery it is very important to carry out therapy aimed at maintaining the vital functions of the body. After intestinal surgery and registration, the patient should not attend work for 1–2 months.

If we talk about the prognosis, then after surgery when local peritonitis is diagnosed, it is favorable. If the purpose of the operation is to eliminate diffuse peritonitis, then the mortality rate after it is 20–30%.

Illness after surgery

Peritonitis after intestinal surgery is the most severe, often fatal purulent-septic complication. With this disease, various microorganisms are absorbed. The development of peritonitis after intestinal surgery depends to some extent on the state of the microorganism and its resistance to infection.

After intestinal surgery, a change in the organ's absorption capacity and barrier function is observed. In addition, after surgery, the permeability of the intestinal walls increases and bacterial flora may enter there. Atony of the stomach after surgery contributes to its expansion and overflowing with contents. Vomiting with blood after surgery indicates a violation of microcirculation, hemorrhage of the walls of the stomach and intestines.

The word "peritonitis" comes from the Latin terms peritoneum - peritoneum, abdominal cavity and the characteristic suffix itis, which indicates an inflammatory process. The source of the pathological process is bacteria that enter from the cavity of the stomach or intestines, where they are constantly located, into the sterile space between these organs. Sometimes microorganisms can penetrate from the outside, which also leads to peritonitis of the abdominal cavity.

What is peritonitis

Normally, the peritoneum is sterile, despite the fact that the small and large intestines are densely populated with both beneficial and opportunistic microflora, where even single strains of pathogenic bacteria can be found. In this environment there is a stable state, implying that microorganisms are strictly in their environment, where they receive useful substances from incoming food.

Despite the abundance of bacteria living in the intestines and even in the stomach, the space between the loops is absolutely sterile. In order to prevent accidental penetration of potentially harmful agents, the organs are enclosed in a special elastic tissue, a kind of “film”.

Therefore, abdominal peritonitis means:

1. Violation of the integrity of any of the organs of the digestive system.
2. Inflammatory process in this organ or external contamination as a result of injuries or poorly performed surgical operations.
3. Once in an uncharacteristic environment, microorganisms begin to multiply wildly.
4. This causes a vivid clinical picture of systemic inflammation, the infection penetrates the circulatory system.
5. Additionally, there may be ingress of pus and necrotic areas during intestinal peritonitis.
6. General intoxication and sepsis begin.

The peritoneum is a thin membrane that ensures the sliding and safe functioning of all organs of the gastrointestinal tract and is extremely susceptible to the development of inflammation due to the huge number of small blood vessels designed for the rapid transfer of useful substances to the internal organs. Therefore, general sepsis as a complication of the inflammatory process begins within the first day, and by the end of the third day, without proper intervention from a doctor, the patient’s condition may become hopeless.

Peritonitis is an extremely life-threatening disease. Without treatment, it is fatal in 95% of cases. Before the invention of antibiotics, even with timely treatment, mortality reached 70-80%.

Currently, everything depends solely on the patient’s timely visit to the doctor, adequate measures to eliminate the lesion along with the source of infection, cleansing and detoxification measures.

Causes of peritonitis

The common cause of peritonitis of the intestine or abdominal cavity is always perforation of the film lining individual organs and penetration into the sterile cavity of pus, necrotic tissue with a huge amount of harmful bacteria and other harmful microflora. Considering that this area of ​​the human body is practically not protected from dangerous “strangers”, inflammation begins in 90% of cases.

The immediate causes of the disease are:

1. Appendicitis. Inflammation of the appendix of the cecum in 87% of cases ends in peritonitis in the absence of timely surgical intervention. A small area of ​​the intestine becomes blocked, and pathogenic putrefactive microflora quickly develops in it. After just a few hours, the appendix turns into a reservoir with pus and necrotic tissue, and then this lesion bursts, spreading throughout the abdominal cavity. Appendicitis is the most common cause of peritonitis and the most dangerous complication of inflammation of the caecum.
2. Perforation of stomach ulcer or duodenum. The ulcer itself, although it is a fairly serious disease of the gastrointestinal tract, does not cause peritonitis. The epigastric epithelium is a fairly dense and stable tissue, so destruction occurs slowly. Perforation means a hole through which caustic gastric juice, enzymes, and bacteria enter the abdominal cavity.
3. Pancreatic necrosis. This is a severe, life-threatening complication of acute pancreatitis: the pancreas dies completely or partially, a purulent focus forms in place of the cells, which is aggravated by the abundance of enzymes. This substance quickly poisons the body, causing general sepsis.
4. Intestinal obstruction and blockage of the small or large intestine provokes the death of entire loops. Necrotization begins inside the loops, but quickly spreads to the peritoneum. A separate risk factor is megacolon - a condition of overstretched colon or rectum, in which motility is almost completely absent and a focus of infectious infection develops.
5. Injuries, penetrating wounds. Peritonitis of the abdominal cavity is possible both as a result of intestinal rupture, and without damage to internal organs - the infection simply enters the sterile space from the outside.
6. Malignant tumors of the stomach or intestines often become the direct cause of peritonitis during their breakdown. This is one of the most severe types of disease, because along with pus, destruction products and toxins enter the blood.

Women and men are equally susceptible to developing the disease, however, gynecological diseases can become an additional risk for the development of peritonitis. Specific “female diseases” that, without treatment, can also provoke the penetration of infectious agents into the peritoneum:

• ectopic pregnancy and ruptured fallopian tubes;
• severe purulent inflammation of the ovaries;
• death of the fetus in the uterus with further development of general sepsis.

It is also believed that women suffer the disease worse and more severely due to the relatively denser arrangement of all organs in the peritoneum and the associated accelerated spread of infection.

Patients with chronic intestinal ulcers, such as Crohn's disease and ulcerative colitis, are also at particular risk. These conditions are more likely to cause fistulas, since the intestines are constantly in the active phase of transporting food bolus. Patients with chronic diseases are advised to carefully monitor their condition.

Kinds

In the vast majority of cases, the disease becomes acute, developing in a matter of hours. Subacute and chronic forms are uncharacteristic and are very rare due to the structural features of the abdominal cavity.

Depending on the pathogenesis, the following types of disease are distinguished:

1. Primary - provoked by foci of infection that are not located directly in the peritoneum. Sometimes it occurs in patients with tuberculosis, more often in patients with cirrhosis of the liver. During the primary form, the infection enters the bloodstream from foci unrelated to the gastrointestinal tract. This species is not considered common.
2. Secondary - occurs most often; in more than 70% of cases, the immediate cause is appendicitis. It is also provoked by any diseases of the gastrointestinal tract at the stage of infection penetration into the peritoneum, trauma, or insufficiently sterile surgical interventions.
3. Tertiary - appears in patients with severe immune disorders, usually in patients with AIDS. Sometimes it can be chronic because inflammation develops relatively slowly.

Of no small importance is the type of course of the disease, depending on the presence of pus and its quantity:

1. Purulent peritonitis- the most severe form, sepsis spreads very quickly, harmful microorganisms actively develop in the abdominal cavity. Intestinal peritonitis against the background of obstruction, appendicitis provoke this type of course.
2. Aseptic - can manifest itself against the background of perforation of a stomach ulcer, toxic-chemical damage to the peritoneum (hydrochloric acid of gastric juice).
3. Hemorrhagic- addition of a large amount of blood, internal bleeding.
4. Dry - with a small amount of effusion (exudate), manifests itself in patients with impaired immunity and a weak leukocyte response of the body.

The disease can begin from a local area and then progress to the stage of general infection. Local or localized peritonitis is less dangerous, and the prognosis for the patient’s life is better. There is also a total form with complete damage to the peritoneum, which most often ends in the death of the patient.

Symptoms

Inflammation of the peritoneum is not a disease that can be missed. This is an acute condition with systemic damage and rapid, sometimes lightning-fast development.

Early signs of peritonitis become clear and characteristic:

1. Severe pain in the peritoneum, which intensifies with each passing hour. Symptoms of peritonitis include persistent, non-spasmodic soreness.
2. Nausea and vomiting, regardless of food and liquid intake. This process does not bring relief to the patient.
3. Characteristic symptoms include tension in the abdominal wall - the abdomen becomes hard to the touch.
4. The patient experiences severe thirst. It must be remembered that drinking is prohibited, as is eating, and any liquid or solids will be immediately returned through vomiting.
5. Sometimes there is diarrhea or a complete absence of stool, as well as the passage of intestinal gases, especially against the background of intestinal blockage.
6. Another characteristic symptom: when trying to listen to the abdomen, there are no sounds of normal intestinal motility.
7. The temperature rises to critical levels. There is chills, general weakness, the patient's condition is poor and quickly becomes critical.

At the first signs of peritonitis or suspicion of it, you must immediately call an ambulance. The rate of development of a peritoneal infection is two to three days; by the end of the first day, children, elderly or weakened people may develop a coma against the background of general sepsis. Without treatment, death is almost inevitable.

Prevention

Despite the fact that there are many causes of the disease, the most common is a complication of appendicitis. Inflammation of the appendage of the cecum is quite difficult to miss, since it is characterized by intense pain.

In this regard, prevention measures include the following:

1. You should not try to “drown out” pain in the abdomen with painkillers.
2. It is imperative to establish the reason, even if it seems obvious.
3. Any of the signs of appendicitis, intestinal obstruction and other emergency conditions is a reason to call an ambulance immediately, without waiting for the morning, the end of the working day, etc.
4. Wounds and injuries of the abdominal cavity, even closed ones, are always dangerous due to the development of peritonitis.

The rest of prevention comes down to timely and adequate treatment of chronic diseases - stomach and duodenal ulcers, Crohn's disease, ulcerative colitis. It is necessary to monitor the presence of foci of infection, even chronic ones: pancreatitis, cirrhosis of the liver, even relatively harmless pyelonephritis can cause complications in the form of inflammation of the peritoneum.

Treatment

Peritonitis is treated only surgically. The operation involves opening the abdominal cavity under general anesthesia, removing foci of infection along with affected and necrotic tissue. The prognosis depends on the stage of development of the pathology.

There are three in total:

• Reactive - the first 12 hours, with a correctly determined diagnosis and performed surgery, the patient’s recovery is almost guaranteed.
• Toxic - after 24 hours of development of peritonitis. General sepsis begins. The prognosis is questionable even with competent surgical intervention.
• Terminal - occurs after 72 hours, irreversible, in 99% it ends in the death of the patient, regardless of medical measures.

After the operation, a course of antibiotics is prescribed, which is carried out first as an inpatient and then continued on an outpatient basis. Patients are fed parenterally to avoid penetration into the gastrointestinal tract. Complications are possible in the form of the need to remove part of the intestines, stomach, and the appearance of fistulas.

Izvozchikova Nina Vladislavovna

Gastroenterologist, Infectious disease specialist, Pulmonologist

Experience: 36 years

1975-1982, 1MMI, San-Gig, highest qualification, infectious disease doctor

Peritonitis is a limited or diffuse (widespread) inflammation of the serous membrane of the abdominal cavity (peritoneum), that is, the tissue that lines it from the inside and surrounds the organs, blood vessels and nerve trunks located in it. This condition is a consequence of the complicated course of various inflammatory and destructive diseases of organs.

In this article we will introduce you to the causes, symptoms, methods of diagnosis and treatment of peritonitis in adults. You will also receive information about the prognosis of this life-threatening condition.

Lethal outcomes from inflammation of the peritoneum can reach significant values ​​- according to statistics, in gastroenterological diseases, death from such a complication occurs in 20-30% of patients, and in severe illnesses this figure reaches 40-50%. We may recall that it was traumatic peritonitis after an injury to the abdominal cavity that caused the death of A. S. Pushkin.

A little anatomy

The human peritoneum consists of 2 layers (layers) passing into each other:

• visceral - external, covering the muscles and bone joints that form the abdominal cavity;
• parietal - lining the internal organs.

The tissue that forms the peritoneum is semi-permeable. It is involved in various processes and, as a membrane, performs many functions:

• absorbs exudate released during the lysis of microorganisms or during necrotic processes in tissues;
• secretes serous fluid necessary to “lubricate” organs and tissues;
• protects tissues from microbial and mechanical damage, etc.

The most significant protective property of this tissue of the human body is its ability to stop inflammatory processes that occur in the abdominal cavity. This property is ensured by the formation of adhesions that limit inflammation, as well as by immune mechanisms that are triggered in its walls during such processes.

Causes

The root cause of the inflammatory reaction in the tissues of the abdominal cavity, which leads to peritonitis, in most cases is a bacterial infection (caused by microflora located in the digestive tract). The following gram-negative and gram-positive microorganisms can provoke this complication:

• bacteroides;
• clostridia;
• Pseudomonas aeruginosa;
• peptococci;
• Proteus;
• enterobacter;
• eubacteria;
• fusobacteria.

In the vast majority of cases - according to various statistical data, 60-80% - inflammation of the peritoneum is caused not by one, but by an association of microbes. More often, this pathological process is provoked by E. coli or staphylococci. In more rare cases, the development of peritonitis is caused by pathogens such as pneumococcus, Koch's bacillus (), and hemolytic streptococcus.

Considering the above-described facts about the variability of possible pathogens of peritonitis, when prescribing treatment, the doctor must wait for the results of an analysis of the sensitivity of pathogenic microflora to antibiotics.

Types of peritonitis

Depending on the etiological factor, the following types of peritonitis are distinguished:

• idiopathic (or primary) - occur when pathogenic microorganisms enter along with the flow of lymph, blood or through the fallopian tubes in diseases such as tuberculosis of the genitourinary organs;
• secondary - develop as a result of injuries or inflammatory-destructive diseases of organs and are usually detected in perforated, gangrenous or phlegmonous, or duodenal intestines, ruptures of ovarian cysts, pancreatic necrosis, phlegmonous-gangrenous and other pathologies.

Depending on the microbial factor, peritonitis is:

• bacterial – provoked by inflammation caused by microorganisms;
• aseptic - caused by substances that are aggressive towards the peritoneum and provoke inflammation.

In the clinical practice of surgeons, secondary peritonitis occurs more often than idiopathic peritonitis, which occurs in only 1-1.5% of patients.

Traumatic peritonitis is classified into a separate group:

• arising as a result of closed or open injuries causing damage to the abdominal organs;
• arising as a result of surgical interventions, accompanied by anastomotic failure, suture defects, accidental mechanical trauma to the peritoneum and the development of hemoperitoneum (blood accumulation).

Special types of peritonitis include the following:

Depending on the nature of the fluid accumulating in the abdominal cavity, the following types of peritonitis are distinguished:

• serous;
• fibrinous;
• purulent;
• hemorrhagic.

The nature of the peritoneal lesion may be as follows:

• limited - an abscess or infiltrate occurs on the peritoneum;
• unlimited – the area of ​​inflammation does not have clear boundaries and is diffuse.

The prevalence of peritoneal lesions may be as follows:

• local - only one anatomical zone of the peritoneum is affected;
• common – inflamed from 2 to 5 zones;
• total (or general) – 6 or more zones are affected.

According to the clinical course, in most cases, peritonitis is acute. However, sometimes the inflammation takes a protracted course, in such situations the pathological process is considered chronic.

The above characteristics of peritonitis are difficult to remember for people who do not have a medical education, so in practice the more simplified formulation “acute” is often used. The remaining classifications are usually omitted and used only for maintaining medical records.

Stages of acute peritonitis

The development of peritonitis is divided into the following stages:

• early – lasts 12 hours;
• late – 3-5 days;
• final – 6-21 days.

Depending on the severity of inflammation, the following stages are distinguished:

• reactive - a hyperergic reaction that occurs in response to irritation of the peritoneal tissue and is manifested to a greater extent by local rather than general symptoms;
• toxic – expressed in an increase in signs of intoxication of the body in response to inflammation;
• terminal – manifested by signs of exhaustion of the body and is accompanied by dysfunction of vital systems and organs.

Symptoms

In the reactive phase of peritonitis, abdominal pain appears, the intensity and location of which depends on the location of the main source of inflammation. At first, pain sensations are clearly limited to one zone and, due to irritation of the nerves of the diaphragm by the accumulated purulent exudate, they can radiate to the supraclavicular region or shoulder. They are not constantly present and periodically become quieter or disappear completely. Then the pain gradually loses its original intensity, covers the entire abdomen, becomes constant and loses its primary precise localization.

Against the background of pain during peritonitis, the following typical symptoms are determined:

• periodic vomiting of the contents of the stomach or intestines with inclusions of bile, followed by vomiting of feces (intestinal vomiting);
• signs of paralytic intestinal obstruction in the form of bloating.

With peritonitis, even the patient’s appearance is significantly affected:

• pained look on the face;
• adynamic;
• pale skin;
• cyanosis of mucous membranes;
• cold sweat.

In bed, it becomes easier for the patient if he lies on his side or back, tucking his legs bent at the knees to his chest or stomach. Severe pain, signs of intoxication and purulent inflammation lead to respiratory failure (it becomes superficial), hypotension, increased temperature and increased heart rate to 120-140 beats per minute.

When the terminal phase begins, the patient's condition worsens even more. He develops the following symptoms:

• confusion;
• sharpening of facial features;
• pallor with a icteric or bluish tint;
• dry tongue with a dark coating;
• upon auscultation of the abdomen, the so-called “deathly silence” is determined, which develops due to the lack of peristalsis in the digestive organs;
• When palpating the abdomen, bloating and significantly less pain are detected.

Diagnostics

To diagnose peritonitis, the doctor examines the patient and listens to his complaints. Palpation of the abdomen reveals the following symptoms:

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

When tapping the anterior abdominal wall, the doctor determines a dullness of sound that occurs due to swelling of the inflamed peritoneal tissue and effusion in the abdominal cavity. Depending on the stage of peritonitis, the following symptoms are determined by listening:

• "falling drop";
• “splash noise”;
• "deathly silence."

When examining the vagina and rectum, the doctor can identify signs of pelvioperitonitis, which occurs when there is inflammation of the peritoneal tissue lining the pelvis.

To confirm the diagnosis, the patient undergoes the following studies:

• radiography - when hollow organs break through under the dome of the diaphragm, the “sickle” symptom is determined, and with the development of intestinal obstruction, Kloiber’s cups are detected;
• expanded - leukocytosis, increased ESR levels and neutrophilia are detected.

More often, diagnosing peritonitis is not difficult, but in complex clinical cases, the study can be supplemented by invasive techniques such as diagnostic laparoscopy or laparocentesis.

Treatment

After peritonitis is detected, the patient undergoes emergency surgery. Its technique depends on the root cause of the complication and is always aimed at eliminating the source of the infectious or other agent irritating the peritoneum.

• During the operation, a laparotomy is always performed, which gives the surgeon the opportunity to sufficiently examine the peritoneal tissue and identify all possible sources of perforation (for example, in the intestines or stomach). To eliminate perforations, suturing is performed, which, if necessary, can be supplemented by a colostomy, resection of a necrotic area of ​​an organ, and other forced measures.
• During an emergency operation, the surgeon’s actions are always aimed only at eliminating the causes of peritonitis, and other reconstructive interventions are postponed to a later date, since their implementation under the current conditions is impossible due to the purulent-inflammatory process. During the first intervention, the doctor always performs intra- and postoperative sanitation of the abdominal cavity and provides decompression of the small intestine. For this purpose, antiseptic solutions are used, which are pre-cooled to +4-6 °C. Their volume can vary depending on the clinical case from 8 to 10 liters.
• Decompression of part of the small intestine is performed using nasointestinal intubation, which involves inserting a probe through the nasal cavity into the small intestine. In the future, it can be used for the purposes of enterosorption (evacuation of intestinal contents) and artificial nutrition.
• Drainage of the colon during surgery to eliminate peritonitis is performed through the anus. At the end of the intervention, drainage from vinyl chloride is always installed in the abdominal cavity. In the future, such a system of tubes is used to remove exudate that continues to accumulate and introduce antibacterial drugs to eliminate pathogenic microorganisms.

After the operation, the patient is prescribed antibacterial drugs, and the elimination of the consequences of intoxication is achieved with the help of infusions of solutions for intravenous administration. Immunocorrectors, infusions of leukocyte mass and ozonated solutions are added to the drug therapy plan. In addition, symptomatic therapy is prescribed, aimed at eliminating emerging symptoms: pain, flatulence, etc. For this, the following can be used:

• narcotic analgesics;
• potassium preparations;
• ganglion blockers;
• anticholinergics, etc.

Some patients are indicated for physiotherapeutic procedures such as diadynamic therapy and electrical stimulation of the intestines.

If possible, the following methods aimed at cleansing the blood are included in the postoperative treatment plan:

• plasmapheresis;
• ILBI (intravenous laser irradiation of blood);