Peritonitis of internal organs. Peritonitis of the abdominal cavity: symptoms, treatment, causes. Illness after surgery

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

Peritonitis

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

To understand what peritonitis is, you need to make general idea about the anatomical structure of the abdominal cavity.

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

The inside of the abdominal cavity is lined with thin layers of serous membrane - the peritoneum - which are a container for the internal organs.

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

Relevance of the disease

The relevance of the disease is due to high mortality rates when inflammation of the peritoneum occurs. The mortality rate from acute abdomen until the mid-twentieth century was about seventy to eighty percent of cases. Firearms and stab wounds led to damage to internal organs and infection of the abdominal cavity.

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

Historical excursion

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

Stages of peritonitis

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

First stage

The first stage lasts for 24 hours after the onset of the disease. During this period, local symptoms due to irritation of the peritoneum dominate. Symptoms of intoxication increase gradually over twenty-four hours.

Second stage

The reactive stage of peritonitis passes into the toxic stage. To replace the locals clinical manifestations general intoxication sets in. The infectious agent spreads throughout the body through the blood and lymph, thereby involving other organs and systems in the pathological process.

Third stage

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

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

Classification of peritonitis

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

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

• Acute peritonitis

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

• Subacute peritonitis

The erased form, which begins with acute pain in the abdomen. Gradually, the symptoms subside, and the pain becomes moderate. Most often, unpleasant sensations are localized in lower sections abdominal cavity. The pain intensifies with pressure and changes in body position.

• Chronic peritonitis

Chronic form has a blurred clinical picture. Due to the nonspecificity of symptoms, the diagnosis of “chronic peritonitis” is made based on the results laboratory methods research.

By the nature of the exudate

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

• Serous

Exudate is represented by a liquid poor in protein and cellular structures.

• Serous-fibrinous

An intermediate stage between serous and fibrinous exudate.

• Fibrinous

Fibrin threads cover the layers of the peritoneum, leading to the formation of adhesions.

• Fibrinous-purulent

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

• Purulent

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

• Gall

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

• Fecal

More often occurs with traumatic injury to the abdominal cavity. For perforation of the descending colon, sigmoid and rectum feces enter the peritoneum. The abundance of bacteria causes a sharp development of symptoms and causes an acute picture of the disease. Massive bacterial contamination of the intestinal tract is a poor prognostic sign.

• Hemorrhagic

Blood mixes with inflammatory effusion.

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

Thus, the nature of the exudate determines the management and treatment of the patient, and also affects the outcome of the disease.

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

• Local process

The local process can be limited or unlimited. A limited process includes an intra-abdominal abscess, when the inflammation is contained by the capsule. Unlimited peritonitis occupies one abdominal pocket.

• Common process

Widespread peritonitis is not limited to a single area - inflammation occupies a wide area. Thus, diffuse peritonitis is localized in two to five anatomical areas, and the diffuse process involves more than six areas.

Peritonitis: causes

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

• Inflammation of the abdominal organs

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

• Organ perforation

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

• Hematogenous infection

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

• Injury

Among the most common injuries are: injuries to the abdominal cavity with a sharp or blunt object, falls from a height, as well as injuries received as a result of road accidents. Intestinal injury leads to the spread of infection to the peritoneum.

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

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

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

• Nausea, vomiting

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

• Resistant belly

Upon external examination, attention is drawn to the board-shaped abdomen. The muscles of the anterior abdominal wall are tense due to irritation of the peritoneum.

• Increased body temperature

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

• Tachycardia

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

• Drop in blood pressure

In the terminal stage arterial pressure falls, which serves as a bad prognostic sign for a person. Low numbers reflect the terminal stage of the disease, when the body's compensatory reactions cannot cope with inflammation.

• Thirst

In addition to abdominal pain, a person is tormented by thirst. Drinking plenty of water does not bring relief. Upon examination, the tongue in the first stage is covered with a copious dry white coating, and in the toxic and terminal stages - with a brown coating.

• Dry skin

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

• Convulsions

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

• Oliguria

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

• Imaginary well-being

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

• Inhibition of peristalsis

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

• Peritoneal irritation

The clinical picture of peritonitis is due to individual characteristics person. People with a higher threshold for pain sensitivity are more tolerant of unpleasant sensations and tolerate pain more easily. In this case, inattention to oneself leads to late seeking medical help, which also affects the outcome of the disease. Acute peritonitis does not tolerate delay - when the first symptoms appear, you should immediately consult a doctor.

• Confusion

Confusion of consciousness is caused by a cascade of biochemical reactions against the background of severe pain and general intoxication of the body. A person cannot remember the date and day of the week, forgets names and names of objects. However, on initial stages illness, a person maintains clarity of consciousness.

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

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

Peritonitis in adults

In addition to the listed symptoms of acute peritonitis, chronic nonspecific peritonitis occurs more often in adults than in children. Chronic peritonitis has a blurred clinical picture. The gradual development of the disease explains the absence severe symptoms: acute abdominal pain, nausea and vomiting. At the onset of the disease, the body compensatoryly copes with the toxins released by the pathogen. Over time, intoxication leads to the development of asthenic syndrome. Chronic peritonitis is characterized by: loss of body weight, increase in temperature to thirty-seven - thirty-seven and a half degrees. The person complains of general weakness, increased fatigue, and drowsiness. The pain occurs sporadically and does not affect daily activities. However, during sports, a person pays attention to increased sweating. Shortness of breath may occur when physical activity. The act of defecation causes difficulties - constipation occurs, and there is also a feeling of incomplete bowel movement. Violation of physiological functions is caused by a violation of the peristaltic activity of the gastrointestinal tract and the occurrence of adhesions in the abdominal cavity.

The causes of chronic nonspecific peritonitis are usually tubercle bacilli and pneumococci.

Peritonitis in children

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

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

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

In everyday life, doctors do not experience difficulties in making a diagnosis of acute peritonitis. The specific clinical picture, as well as modern diagnostic methods, make it possible to make an accurate diagnosis if you seek medical help in a timely manner.

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

Physical examination

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

When rolling in a supine position from back to stomach, a “splashing noise” is clearly audible.

In the supine position, the abdomen takes on the shape of a “frog” - it flattens in anteroposterior size. Thickening in lateral dimensions is explained by the fact that fluid moves into the lateral pockets of the abdominal cavity.

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

The nurse takes from the patient venous blood for examination. The tests are performed on an emergency basis, and the surgeon learns the results in less than thirty minutes after the blood is taken.

• Clinical blood test

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

• Blood chemistry

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

• Hemostasiogram

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

Instrumental methods

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

• Ultrasonography

One of the signs of peritonitis - the accumulation of exudate in the abdominal cavity - is identified by a specialist using ultrasound.

• X-ray examination

X-rays show areas of darkening in areas with inflammatory effusion.

• Abdominal puncture

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

• Diagnostic laparoscopy

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

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

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

Surgical treatment

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

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

Surgical treatment is an integral component of eliminating the cause of peritonitis and the patient’s recovery.

Conservative therapy for peritonitis complements surgical treatment. The goal is to eradicate the infectious agent, restore the function of organs and body systems, that is, complete recovery.

• Antibiotic therapy

Antibacterial therapy is carried out with antibiotics wide range actions that affect several types of infectious agents at once. The greatest bioavailability is achieved with intravenous administration drugs.

• Correction metabolic disorders

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

• Diuretics

In the absence of signs of renal dysfunction, urination is stimulated by certain groups of diuretics. Thus, toxins are eliminated from the body and their concentration in the blood decreases. The patient's general well-being improves.

• Anticoagulants

Every surgical intervention poses a risk of thrombosis. Anticoagulant therapy prevents a reactive increase in blood clotting.

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

Sanitary procedures

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

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

Preventive examinations

Screening research methods have proven their effectiveness. Preventive examinations reduce the likelihood of developing concomitant diseases, and also make it possible to identify diseases in the early stages - even before the appearance of clinical symptoms.

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

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

Compliance with the rules of asepsis and antisepsis

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

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

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

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

Peritonitis is one of the most severe complications of purulent inflammatory processes and injuries of the abdominal organs. The development of peritonitis is accompanied by a rapid increase in symptoms of intoxication, as well as the occurrence of severe hemodynamic, metabolic and respiratory disorders.

Peritonitis is an acute or chronic inflammatory process that affects the layers of the peritoneum. As peritonitis progresses, the inflammatory process becomes systemic and is accompanied by the development of severe life disorders. important functions(respiratory disorders, dysfunction of cardio-vascular system etc.). Treatment of peritonitis is carried out in a surgical hospital. Mortality in the development of acute peritonitis, even with timely provision of specialized medical care, ranges from 20 to 35%.

The code for peritonitis according to ICD 10 is K65. Acute peritonitis is classified as K65.0, other specified peritonitis - K65.8, unspecified - K65.9.

What is abdominal peritonitis?

The peritoneum is the serous tissue that lines the internal surfaces of the abdominal wall (parietal peritoneum) and the abdominal organs (visceral peritoneum). The peritoneum provides the following functions:

• protective (protection of internal organs from injury);
• barrier (prevents the penetration of pathogenic microorganisms);
• absorptive (absorbs fluid secreted in the abdominal cavity, protein breakdown products, inflammatory and non-inflammatory exudate, etc.);
• excretory (exudation of fluid through the serous membranes of the small intestine);
• plastic (the peritoneum is able to secrete fibrin and stimulate the formation of adhesions that limit the spread of inflammatory processes). After operations on the abdominal organs, fibrin helps strengthen the sutures and facilitate faster healing of the postoperative wound.

The development of peritonitis is accompanied by inflammatory damage to both the parietal and visceral layers of the peritoneum. In this case, the resulting pathological exudate (reaction to irritation of the peritoneum and impaired vascular permeability) is initially serous or serous-fibrinous (serous peritonitis or serous-fibrinous peritonitis). The progression of inflammation is accompanied by a change in the nature of the exudate to purulent (purulent peritonitis).

The pathogenesis of peritonitis is divided into three stages:

• local inflammatory process, accompanied by the formation and activation of local and general immunity;
• entry into the systemic circulation of bacteria, their toxins, protein breakdown products, etc., accompanied by the development of endotoxin shock;
• severe sepsis with septic shock accompanied by severe multiple organ failure.

What causes peritonitis?

The main reasons for the development of peritonitis are:

• infectious agents;
• chemical irritants (bile, urine, blood, stomach contents).

Pathogenic microorganisms can enter the abdominal cavity (AC) due to wounds, hematogenous or lymphogenous introduction of infection from distant infectious foci, necrotic processes due to strangulated hernias, etc.

Irritation of the peritoneum by chemical irritants can occur with abdominal trauma (rupture of the intestine, spleen, liver, development of post-traumatic intra-abdominal bleeding, etc.), and such inflammatory processes as acute cholecystitis (bile peritonitis), pancreatitis.

Most peritonitis is mixed, that is, the inflammatory process is caused by both bacteria and chemicals. The most massive infection of the peritoneum by bacteria, as well as its irritation by chemicals, is accompanied by fecal peritonitis (entry of intestinal contents into the abdominal cavity due to a violation of the integrity of the intestine). In this regard, fecal peritonitis has the most unfavorable prognosis.

Peritonitis after surgery can occur due to insufficient functioning of protective mechanisms. With a low level of local and general immunity, residual exudate and blood in the operation area does not resolve and becomes infected with local opportunistic flora, followed by the formation of limited peritonitis. As the inflammatory process progresses, acute peritonitis spreads to the entire peritoneum and diffuse peritonitis develops.

Peritonitis of the abdominal cavity: causes

Infectious peritonitis is most often caused by a combination of bacterial flora. In most cases, these are non-clostridial anaerobes in combination with Escherichia coli. Peritonitis can also be caused by Pseudomonas aeruginosa, Proteus, enterobacteria, staphylococci, streptococci, bacteroides, fusobacteria, clostridia, peptococci, peptostreptococci, etc.

The main reasons for the development of peritonitis are:

• acute destructive appendicitis (peritonitis after appendicitis is the leading cause of inflammation of the peritoneum);

• perforation of stomach and duodenal ulcers;
• ulcerative-necrotic processes in the intestines in patients with typhoid fever;
• abdominal injuries accompanied by rupture of the liver, spleen, intestines, etc.;
• perforation of intestinal diverticula;
• torsion of intestinal polyp with bleeding and necrosis;
• ovarian apoplexy (a rare cause of peritonitis in women);
• disintegration of a malignant neoplasm;
• necrosis of the strangulated organ due to hernia;
• rupture of the intestinal wall by a foreign body;
• acute destructive cholecystitis or pancreatitis;
• necrosis of a section of the intestine due to volvulus;
• torsion of pedunculated fibroids with subsequent bleeding and necrosis of fibroids, etc.

Postpartum peritonitis can develop in patients with:

• prenatal infection of the uterine cavity;
• long anhydrous interval;
• massive bleeding during childbirth;
• poor postpartum sanitation of the uterine cavity (parts of the placenta remain in the uterus).

Classification of peritonitis

According to the duration of the inflammatory process, acute, subacute and chronic peritonitis is distinguished.

According to the type of introduction of pathogenic microorganisms, inflammation is distinguished in PD:

• primary, caused by the primary introduction of infection into the PD (primary peritonitis in children, tuberculous peritonitis, etc.);
• secondary, developing as a result of complications of inflammation of the PD organs, abdominal injuries or operations on the PD organs. In most cases, secondary peritonitis is caused by polymicrobial (combined) bacterial flora;
• tertiary, associated with the addition of nosocomial (nosocomial) infection after treatment of primary or secondary peritonitis. With tertiary peritonitis, new sources of infection often develop associated with the movement of bacteria from the intestinal lumen into the preperitoneal tissue, liver (liver abscesses), etc. With this type of inflammation of the peritoneum, there is often a blurred clinical picture of peritonitis, a sluggish course of peritonitis that is difficult to respond to antimicrobial therapy, as well as chronic inflammation.

According to prevalence, peritonitis is divided into local (limited and non-limited) and widespread.

The nature of the inflammatory exudate can be serous, fibrinous, purulent, mixed. Depending on the type of impurities in the inflammatory exudate, inflammation of the peritoneum can be bile, enzymatic (pancreatogenic), hemorrhagic, fecal, ascitic.

According to the flow phases there are:

• reactive peritonitis (uncomplicated by sepsis);
• toxic (accompanied by the development of sepsis);
• terminal (accompanied by severe sepsis);
• inoperable conditions (development of infectious-septic shock).

Symptoms of peritonitis in adults

The clinical picture of peritonitis is determined by the location of the source of infection (intestinal peritonitis, pelvioperitonitis), the prevalence of inflammation, the state of the patient’s immune system, as well as his age and the presence of concomitant pathologies.

Classic symptoms of abdominal peritonitis are:

• systemic inflammatory reaction (leukocytosis, fever, tachycardia, tachypnea, etc.);
• multiple organ failure (heart, kidney, liver, respiratory);
• sepsis and septic shock.

The main symptoms of abdominal peritonitis in children and adults

In most cases, patients complain of intense, severe abdominal pain (sometimes radiating to the lower back and shoulder girdle), weakness, nausea, vomiting, fever, chills, extreme thirst and dry mouth, stool retention.

Patients are lethargic, lethargic or restless (in severe cases, delirium and hallucinations are possible). Speech is quiet, barely intelligible, and groaning breathing may occur. Patients either lie on their sides or sit with their legs tucked to their stomach. At the same time, the appearance of the “Vanka-stand up” symptom is noted, that is, if the patient was lying down, when trying to sit him down or straighten his legs, he immediately takes the original lying position, due to a sharp increase in pain. If the patient was sitting, when trying to lay him down, he also tries to quickly return to his original position.

Upon examination, attention is drawn to the pallor and cyanotic appearance of the patient’s skin (possible marbling of the skin), dry mucous membranes and a “sandpapery” tongue (pronounced dryness of the tongue). There is severe tachycardia (less often bradycardia), increased body temperature, and decreased blood pressure. When auscultating the heart, muffled heart sounds are noted.

On palpation, the abdomen is painful, sharply swollen, and significantly tense. There is a lack of peristalsis (toxic paresis of the intestinal muscles), the so-called symptom of “deathly silence”.

Signs of peritonitis of the abdominal cavity in women can be the discharge of purulent exudate from the vagina, as well as the overhang of its vaults during a vaginal examination, due to the accumulation of pathological exudate in the abdominal cavity.

During palpation, it is noted positive symptoms:

• Shchetkin-Blumberg (most typical for intestinal peritonitis against the background of appendicitis), characterized by an increase in pain intensity when the doctor removes his hand after pressing on the anterior abdominal wall;
• Voskresensky

Resurrection symptom

• Mendelian - manifested by a sharp increase in pain after light tapping of the fingers on the anterior abdominal wall.

It is also possible to experience vomiting with a specific fecal odor, sharpening of facial features, lack of urination (a manifestation of renal failure), etc.

Diagnosis of peritonitis

The diagnosis is made on the basis of specific symptoms, as well as data from instrumental and laboratory studies. The blood test shows significant leukocytosis with a shift to the left, high ESR, thrombocytopenia, anemia, increased leukocyte index.

When performing an ultrasound of the PD organs, free fluid is detected, the source of infection can be identified (inflammation of the appendix, liver abscess, acute cholecystitis, etc.). When performing a survey X-ray of the BP, accumulations of free gas and signs of intestinal obstruction are detected.

To monitor the patient’s condition, a blood gas test, biochemical blood test, coagulogram, etc. are performed.

How to treat peritonitis?

Treatment of peritonitis is carried out surgically or intensive care unit. Prognosis during development this complication extremely serious and accompanied by a high risk of death.

Elimination of the primary source of infection and limitation of the spread of inflammation is carried out surgically. Drainage and lavage of the abdominal cavity with solutions of antibiotics and antiseptics are also indicated.

Additionally, systemic antimicrobial therapy is mandatory. The use of cefuroxime, ceftazidime, cefotaxime, vancomycin, combinations of metronidazole with cephalosporins and clindamycin, etc. is indicated.

Additionally, detoxification and symptomatic therapy is carried out. Symptomatic treatment is aimed at maintaining cardiovascular and respiratory system, restoration of kidney function, elimination of blood clotting disorders and metabolic disorders, etc.

Prognosis and consequences of peritonitis

Peritonitis is one of the most severe complications in purulent abdominal surgery. The prognosis for the development of PD inflammation is always serious. The risk of death ranges from 20 to 35%. In this regard, if peritonitis is suspected, the patient must be immediately hospitalized.

What are the consequences of appendicitis with peritonitis?

The inflammatory process in the peritoneum increases the risk of the formation of a massive adhesive process, which can subsequently lead to constant pain in the abdomen, constipation and intestinal obstruction.

Article prepared
Infectious disease doctor A.L. Chernenko

Peritonitis is an inflammation of the peritoneum. The disease is considered within the framework of the concept of “acute abdomen,” which is characterized by abdominal pain and muscle tension in the anterior abdominal wall. Despite the fact that treatment methods are becoming more and more improved every year, peritonitis does not become less dangerous. Mortality rates for peritonitis are still quite high. Thus, with local peritonitis, the mortality rate is 4-6%, and with diffuse peritonitis - more than 45%.

The peritoneum is the serous membrane covering the abdominal organs. The peritoneum lining inner wall The abdomen is called parietal, and the surface of the organs is called visceral. The total area of ​​the peritoneum is approximately 2m2.

The peritoneum has absorptive capacity, which is designated as a resorptive function. At the same time, it has the ability to secrete fluid, as well as fibrin, into the abdominal cavity - this is an exudative function. Normally, these processes are balanced and the abdominal cavity contains only a small amount of fluid between the sheets of peritoneum. During a pathological condition, exudation processes are activated, which is why fluid can accumulate in a significant volume in the abdominal cavity.

Peritonitis happens primary when the disease develops due to the entry of microorganisms into the abdominal cavity through the blood or lymph, and secondary when the disease develops due to inflammation, perforation, or damage to organs located in the abdominal cavity.

The following reasons can be identified that lead to the occurrence of peritonitis:

1. Inflammatory processes occurring in the abdominal organs (salpingitis, etc.);
2. Perforations in the abdominal organs (stomach or duodenum with, appendix with gangrenous or phlegmonous appendicitis, gallbladder with destructive cholecystitis, colon with nonspecific);
3. Damage to abdominal organs;
4. Operations performed on the abdominal organs;
5. Hematogenous peritonitis (pneumococcal, streptococcal, etc.);
6. Inflammatory processes of any origin not related to the abdominal organs (phlegmon of the abdominal wall, purulent processes, localized in the retroperitoneal tissue).

Distinguish bacterial And aseptic peritonitis. The causative agents of bacterial peritonitis are both aerobic microorganisms ( coli, Klebsiella, Proteus, ), and anaerobic (bacteroides, clostridia, peptococci). Often, peritonitis is provoked by a microbial association, that is, a combination of several microorganisms.

Aseptic peritonitis develops when the peritoneum comes into contact with blood, gastrointestinal contents, bile, and pancreatic juice. It is noteworthy that after a few hours, microflora is involved in the pathological process and aseptic peritonitis turns into bacterial.

Types of peritonitis

Depending on the prevalence of the inflammatory process, the following forms of peritonitis are distinguished:

• Local (occupies one anatomical section of the abdominal cavity);
• Widespread (2-5 anatomical sections of the abdominal cavity are involved);
• Total (six or more anatomical parts of the abdominal cavity are involved).

It is also important to consider the type of exudate. So, depending on the nature of the exudate, the following forms of peritonitis are distinguished:

• Serous;
• Fibrinous;
• Purulent;
• Hemorrhagic;
• Gall;
• Fecal;
• Mixed.

Peritonitis can also be acute or chronic. Chronic form of the disease more common in systemic infections of the body (syphilis, tuberculosis). Acute peritonitis proceeds in three phases: reactive, toxic, terminal.

The first stage (reactive) is recorded in the first 12-24 hours of the disease. During this period, swelling of the peritoneum occurs, exudation with fibrin loss. In the clinical picture, local symptoms of the disease are especially pronounced.

The second stage (toxic) develops after 24-72 hours. During this period, toxicosis increases, as a result of which general intoxication symptoms prevail over local ones.

The third stage (terminal) develops after 72 hours. This period is characterized by severe intoxication.

All symptoms observed during peritonitis can be divided into local and general. Local symptoms occur in response to irritation of the peritoneum by exudate, bile, and gastric contents. These include abdominal pain, tension in the muscles of the anterior abdominal wall, as well as positive symptoms of peritoneal irritation, which the doctor can identify during examination. General symptoms develop against the background of intoxication of the body. These are nonspecific symptoms such as fever, weakness, tachycardia, nausea, vomiting, and confusion.

In addition, the patient has not only signs of inflammation of the peritoneum, but also symptoms of the underlying disease that provoked peritonitis.

Symptoms of the first stage of peritonitis

The first signs of peritonitis are constant, unremitting abdominal pain, which intensifies with changes in body position. Therefore, the patient lies on his back or on his side with his knees brought to his stomach and tries not to move too much. The localization of pain depends on the location pathological process in the peritoneum.

During the examination of the patient, the doctor is able to identify tension in the muscles of the anterior abdominal wall. With peritonitis, positive symptoms of peritoneal irritation are noted. So, to determine the Shchetkin-Blumberg symptom, you need to slowly press on the stomach, fix your hand for a couple of seconds, and then sharply pull it away. If at this moment there is sharp pain, which means the person has peritonitis.

Mendel's sign is determined by percussion (tapping) of the entire abdomen. Based on the patient’s reaction, the doctor can not only determine the increase in pain, but also the localization of the pathological process.

The patient's general symptoms include fever, tachycardia, increased blood pressure, dry mucous membranes, and nausea with vomiting.

During this period, abdominal pain may become less severe. Tension of the muscles of the anterior abdominal wall, as well as symptoms of peritoneal irritation are present, but become less obvious. Symptoms such as stool retention and bloating caused by intestinal paresis come to the fore. There is profuse vomiting with a foul odor.

General intoxication symptoms increase. The patient's heart rate increases (over 120 beats per minute), and blood pressure drops. The temperature rises, the tongue and oral mucosa are dry, and the facial features are sharpened.

Symptoms of the third stage of peritonitis

Intoxication becomes even more pronounced. Due to dehydration, the patient’s skin turns pale, facial features become sharpened, and the mucous membrane of the mouth and tongue are dry. The rapid heartbeat and low blood pressure persist, and breathing becomes rapid and shallow.

The abdomen is distended, there is no peristalsis, and there is profuse vomiting of gastric and intestinal contents.

Due to severe intoxication, the nervous system suffers: the patient is either adynamic or falls into euphoria. Confusion and delirium may occur.

For symptoms of "acute abdomen" next research:

• - leukocytosis is noted, as well as a shift in the leukocyte formula to the left;
• Rectal and vaginal examination - allows you to detect severe pain in the wall of the rectum or vaginal vault, caused by irritation of the pelvic peritoneum by peritoneal inflammatory exudate;
• X-ray examination of the abdominal organs - allows you to determine the darkening of the abdominal cavity due to the exudate accumulated in it;
• Ultrasound of the abdominal cavity - allows you to detect the presence of free fluid.
• Laparocentesis (abdominal puncture) - allows you to examine the contents of the abdominal cavity;
• Laparoscopy - performed when there is doubt about the diagnosis.

Treatment of peritonitis - surgery. The purpose of surgical treatment is to eliminate the cause that led to the development of peritonitis, as well as drainage of the abdominal cavity.

The sequence of surgical procedures for peritonitis looks like this:

The earlier the operation is performed, the better the prognosis for recovery. It is optimal to perform the operation in the first hours of the disease. Surgery, carried out a couple of days after the appearance of the first symptoms, significantly reduces the patient’s chances of recovery. Therefore, if you experience abdominal pain, you should not hesitate, you should urgently consult a doctor.

In addition, the treatment of peritonitis is supplemented with medications. The goal of drug treatment is the elimination of pathogenic microflora, as well as the correction of metabolic disorders. The following groups of drugs are used:

• Antibiotics - mainly broad-spectrum antibiotics are used (gentamicin, sigmamycin, benzylpenicillin, ampicillin, ceftriaxone);
• Detoxification agents (10% calcium chloride solution);
• Infusion solutions (5% and 25% glucose solutions, hemodez, Ringer's, Hartmann's solutions);
• Colloidal products and protein blood products (plasma, albumin, protein);
• Diuretics (furosemide, mannitol);
• NSAIDs (ibuprofen, paracetamol);
• Antiemetics (metoclopramide);
• Anticholinesterase drugs (proserin) are used to prevent the development of intestinal paresis.

Note:If you experience abdominal pain, do not prescribe painkillers yourself. This will cause the symptoms of the disease to become less pronounced and ambiguous, making it difficult for the doctor to determine the correct diagnosis.

After surgery, it is important to continue drug treatment to prevent complications from occurring.

On the second day after surgery they begin parenteral nutrition. The volume of infusion therapy is approximately 50-60 ml per kilogram of body weight per day. When intestinal motility is restored, they switch to enteral nutrition: administration of nutritional mixtures using a probe through the mouth and nose. The composition of the mixtures and the duration of such feeding are determined by the doctor.

If the dynamics are positive and normal bowel function is restored, they switch to natural nutrition. This usually occurs no earlier than the fifth day after surgery. It is necessary to adhere to a low-calorie diet. During this period, it is recommended to eat low-fat meat broths, vegetable purees, jelly and compotes. Gradually increase the calorie content of the diet by adding meat, eggs, and dairy products. You should not eat rich meat broths, smoked meats, spices, confectionery, chocolate, coffee, carbonated drinks, or legumes.

Peritonitis is inflammation of the abdominal cavity. It manifests itself as a complication after pathologies - the entry of microbes into the body through the blood or lymph, which is called primary peritonitis. Secondary peritonitis includes damage and inflammation of the digestive organs. All this leads to the accumulation of fluid in the peritoneum, intoxication of the body and deterioration of health. In this article we will look at what symptoms adults experience during illness.

The disease is characterized by severe tension and soreness of the abdominal muscles. There are three stages during which the number of symptoms and pain levels may increase. In addition to local pain, there is also general symptoms.

In normal conditions, there is a small amount of fluid between the sheets of the abdominal cavity. Inflammation begins for one of the following reasons:

• entry of harmful microorganisms– streptococcus, Pseudomonas aeruginosa or Escherichia coli, Klebsiella, Proteus, pneumococcus and others;
• organ perforation digestive system . When perforation occurs, a through defect is formed in the organ, which leads to the entry of various fluids into the peritoneum;
• accidental damage to internal organs during surgery;
• mechanical injury to the abdomen in domestic conditions ;
• diseases digestive system organs– from salpingitis and appendicitis to cholecystitis;
• inflammation of the tissue behind the peritoneum and abdominal walls, having no connection with the insides. These are purulent processes, phlegmon and others.

Important. There is an increased risk of organ damage and subsequent inflammation during exacerbations and untimely treatment of the following diseases: ulcer in the duodenum or stomach, nonspecific ulcerative colitis in colon, reactive pancreatitis, intestinal obstruction, phlegmonous or gangrenous appendicitis, destructive cholecystitis of the gallbladder.

Classification

The disease is classified according to several criteria:

• by type of pathogen;
• due to development;
• by prevalence;
• according to form:
• according to the type of exudate (liquid released during the disease).

Form

There are chronic and acute forms. In the first case, peritonitis occurs with syphilis or tuberculosis. In the second case, everything depends on the phase, which can be toxic, reactive and terminal.

1. Reactive. Duration: first 12-24 hours. It is characterized by a feeling of nausea, swelling of the abdomen and increased local pain in it, fever, and vomiting.
2. Toxic. Deadline: 2-3 days after the first stage. Toxicosis and symptoms of general intoxication of the body appear. It is characterized by severe vomiting, dehydration, decreased blood pressure, and increased heart rate to 110-120 beats.
3. Terminal. Deadline: 3 days after the second stage. Severe intoxication of the body, serious condition of the patient. It is characterized by a decrease in pain due to the death of nerve endings, apathy, weak pulse, and greatly reduced blood pressure.

Prevalence

There are local, widespread and total. In the first case, inflammation occurs in one anatomical section of the peritoneum, in the second - in two to five, and in total - in six or more.

Reason for development

Depending on the cause of inflammation, five types of peritonitis are distinguished.

Table 1. Types of peritonitis

The sixth type includes cryptogenic peritonitis, in which it is not possible to accurately determine the cause of inflammation.

Type of pathogen

There are two categories - bacterial and aseptic. The first occurs due to the corresponding pathogens - aerobic and other harmful microorganisms. The second occurs when the contents of the gastrointestinal tract or digestive juice, bile, or blood enter the cavity. After a few hours, the aseptic process turns into a bacterial one due to the development of pathologies in the microflora.

Exudate

Depending on the fluid that is released from the tissues, there are the following types of disease:

• fecal;
• purulent;
• gall;
• serous;
• fibrinous;
• hemorrhagic.

There is also mixed type, combining several categories at once.

Video - Intestinal peritonitis (inflammation of the peritoneum) purulent, fecal, serous

Symptoms

There are local and general symptoms. The first category is characterized by local abdominal pain and muscle tension. They intensify when pressed (palpation). Severe pain forces a person to lie only in the fetal position: on his side with his legs bent and brought to his stomach.

General symptoms are nausea, weakness, rapid heartbeat, fever up to 37-39 0, confusion and other disorders that do not occur in the abdomen.

Fact: in this case, the abdominal muscles are in constant tension, regardless of the stage.

Stages of inflammation

Table 1. Stages of inflammation

Stage	Local symptoms	General symptoms
First	Continuous abdominal pain. If you try to change your body position, the pain intensifies.	Increased blood pressure, rapid heartbeat, feeling of nausea, vomiting, dry mucous membranes.
Second	Soreness and tension subside as intoxication begins.	Pronounced bloating, profuse vomiting, stool retention, increased heart rate, increased temperature to 38-39 degrees, decreased blood pressure.
Third	Local symptoms may be mild or completely absent due to worsening general condition person	Severe intoxication and dehydration. Dry mucous membranes, pale skin, bloating, tachycardia and low blood pressure, frequent and shallow breathing, lack of peristalsis, severe vomiting contents of the intestines and stomach. Because of serious condition disorders appear nervous system– delirium, confusion, mood swings.

Complications and consequences

In case of untimely treatment or complex cases (hospitalization 12 or more hours after the onset of symptoms) and after surgery, the following consequences are possible:

• paresis;
• hepatitis;
• cerebral edema;
• pneumonia;
• eventeration;
• bleeding;
• dehydration;
• encephalopathy;
• intestinal fistulas;
• peritoneal abscess;
• pathologies in the kidney area;
• intestinal obstruction;
• necrosis of intestinal tissue;
• multiple organ failure.

How do doctors diagnose the disease?

For peritonitis, the following types of diagnostics are carried out:

1. Analysis of a person’s complaints and lifestyle.
2. Physical examination and palpation of the abdomen. A characteristic sign is the desire to lie in the fetal position.
3. General urine analysis.
4. Measurement of temperature and blood pressure.
5. Ultrasound of the peritoneum to determine free fluid.
6. A clinical blood test to determine leukocytosis - changes in cellular composition with an increase in the number of white blood cells.
7. Rectal and vaginal examination to determine severe tenderness in the rectum and vaginal vault, respectively.
8. X-ray of the peritoneum to determine the darkening of the cavity against the background of fluid accumulation.
9. Puncture to examine the contents of the peritoneum.

If the doctor doubts the diagnosis, he prescribes laparoscopy - modern look surgery using a special device that makes small holes in the abdomen.

Important: a person’s health and life depends on the stage of inflammation and the promptness of assistance. If the operation is not performed in time, the inflammation will lead to death in just 4-6 days.

How does the treatment proceed?

Surgery and treatment required medications. The operation allows you to eliminate the causes that caused peritonitis and drain the peritoneum (remove the fluid accumulated inside). During the operation, doctors:

• carry out preparations - clean and rinse the gastrointestinal tract, perform pain relief;
• cut the anterior wall of the peritoneum;
• eliminate the source. It all depends on the cause of the inflammation. For example, doctors may remove gallbladder, appendix, suturing the walls of the organ or resection of the ulcer;
• wash the peritoneum with antiseptic agents;
• carry out intestinal decompression;
• introduce a drainage system;
• suturing the wound.

Important: under no circumstances should you voluntarily take painkillers to relieve pain. This will reduce the severity of symptoms, which will make it more difficult for the doctor to make a diagnosis.

Drug treatment

May include the use of one or several groups of funds:

Fact: prevention of inflammation lies in the proper treatment and control of diseases of the digestive system, be it acute appendicitis, cholecystitis, ulcers in the stomach or duodenum, pancreatitis.

What should be the post-operative care?

To reduce the risk of complications, it is necessary to continue treatment with medications. At the end of the operation, doctors prescribe parenteral nutrition (when mixtures are administered intravenously) in a proportion of 50-60 ml per 1 kg of human weight. It begins on the second day and lasts several days.

To restore the functioning of the intestines, doctors prescribe enteral nutrition (special nutritional mixtures). The solutions themselves are administered into the nose and mouth using a probe. The duration and type of nutrition is determined by the doctor.

Fact: During the day, the doctor examines the wound and changes the bandage, ensuring its cleanliness and condition. When replacing, it is necessary to use a drainage tube and antiseptics.

Diet

After five days from the date of surgery, it is necessary to ensure that there are no complications, positive dynamics of recovery and normal functioning of the intestine. If everything is in order, then natural nutrition is prescribed:

• first, a low-calorie diet - vegetable purees, compotes and jelly, meat broths;
• Over time, you can increase your caloric intake and eat dairy products, meat and eggs. The main thing is to listen to the body’s reactions to food;
• It is strictly forbidden to consume confectionery and smoked products, spices, coffee, soda, bean dishes, and chocolate.

Peritonitis is an inflammation that requires immediate medical treatment and control by doctors. The earlier the surgery is performed, the better the prognosis and the lower the chances of serious complications. At the first signs of inflammation, you must immediately call ambulance and do not self-medicate.

Peritonitis – inflammation of the peritoneum, leading to dysfunction of all body systems.

The peritoneum is formed by two serous layers (visceral and parietal), which line the abdominal cavity and cover the internal organs. The peritoneum is a semi-permeable membrane that performs the following functions:

• resorptive, which consists in the ability to absorb the contents of the abdominal cavity;
• exudative, which consists of secreting serous fluid;
• barrier, that is, it protects the internal organs of the abdominal cavity from mechanical damage, and also provides antimicrobial protection.

Inflammation of the peritoneum occurs under the influence bacterial infection, which is often represented by nonspecific microflora of the gastrointestinal tract (staphylococci, streptococci, E. coli, Proteus, Enterobacter, clostridia, and so on). Much less often, the development of peritonitis occurs under the influence of specific microflora (mycobacterium tuberculosis, hemolytic streptococcus, gonococcus and others).

Classification

By etiology:

1. Primary (hematogenous or lymphogenous infection);
2. Secondary (occurs as a result of the development of acute surgical diseases or injuries of the abdominal organs);
3. Tertiary (occurs in the absence of an infectious focus in the postoperative period after secondary peritonitis).

By prevalence:

1. Local, which in turn is divided into limited (abscess or infiltrate) and unlimited;
2. Common.

By the nature of the exudate:

1. Serous;
2. Fibrinous;
3. Purulent;
4. Hemorrhagic;
5. Fecal;
6. Gall.

The following phases of development of peritonitis are distinguished:

1. Reactive - lasts 24 hours (12 hours for perforated peritonitis). All are activated protective systems body;
2. Toxic - 24 – 48 hours (12 – 24 hours for perforated peritonitis). Multiple organ dysfunction is observed;
3. Terminal - over 48 – 72 hours (over 24 hours for perforated peritonitis). Multiple organ failure syndrome is noted.

In most cases, doctors are faced with secondary peritonitis, which occurs as a result of destructive-inflammatory diseases or trauma to the abdominal cavity. As a rule, peritonitis is a complication of the following diseases:

• acute appendicitis;
• acute cholecystitis;
• perforated ulcer;
• gynecological pathology;
• intestinal obstruction;
• strangulated hernia;
• abdominal trauma;
• acute pancreatitis.

The prognosis of peritonitis largely depends on the timeliness of treatment specialized assistance. As is known, there is a possibility of death resulting from multiple organ failure. That is why it is necessary to promptly treat the underlying pathology, which can cause the development of peritonitis. Under no circumstances should you neglect your condition; you must immediately seek help from medical institution when disturbing symptoms appear.

Symptoms

The clinical picture of peritonitis depends on the phase of the process.

During the reactive phase, intense abdominal pain is noted, which intensifies during movement and breathing. In this regard, the person takes a forced position, which looks like this: the person lies on his back or on his side with his legs brought to his stomach. Changing this position leads to increased pain, which is why, as a rule, a person does not change the forced position. Severe intoxication is manifested by an increase in body temperature to 38 ° C and above, the appearance of general weakness, and a decrease in performance. There is also a change in behavior: the person becomes irritable and agitated. Tachycardia (increased heart rate) up to 100–120 beats per minute appears, and blood pressure increases slightly. The respiratory rate reaches 24 - 28 per minute. In some cases, nausea, vomiting (most often one-time), and stool retention occur.

The toxic phase is characterized by the development of multiple organ dysfunction. The clinic of severe intoxication of the body comes to the fore. Fever body has a hectic character. There are complaints of dry mouth, bloating, and severe generalized abdominal pain. The skin becomes pale, which is associated with impaired microcirculation, and facial features become sharpened. High blood pressure, which was observed during the reactive phase of peritonitis, tends to decrease, tachycardia persists (over 120 beats per minute). Also, in some cases, vomiting of stagnant contents occurs.

In the terminal phase of peritonitis, the body's functional reserves are depleted, resulting in the development of multiple organ failure syndrome. Progression of cardiovascular, respiratory and renal failure is observed. The appearance of icteric staining of the skin and visible mucous membranes indicates a dysfunction of the liver. Abdominal pain is significantly reduced, noted sudden swelling abdomen, there is no tension in the muscles of the anterior abdominal wall. Body temperature decreases and becomes below normal. In addition, there is adynamia and the development of delirium (clouding of consciousness, accompanied by impaired attention, thinking and perception of the surrounding world).

Diagnostics

Since the presence of abdominal pain comes to the fore, the doctor begins to palpate the abdomen, during which tension in the muscles of the anterior abdominal wall is noted. However, it is worth noting that the progression of the inflammatory process leads to a decrease in the degree of manifestation of tension, which is an unfavorable diagnostic criterion. Also during palpation the presence of peritoneal symptoms is checked. The following peritoneal symptoms are distinguished:

• Shchetkin-Blumberg (sharp increase in pain due to withdrawal of the hand after pressure);
• Voskresensky (sliding symptom, “shirt” symptom) – characterized by increased pain when holding the hand from top to bottom from the xiphoid process to the left and right iliac regions;
• Mendel (amplification painful sensations with percussion of the anterior abdominal wall.

During percussion of the abdomen, the disappearance of hepatic dullness is revealed, which indicates the presence of free gas in the abdominal cavity. Also, in some cases, there is a dullness of percussion sound in the lateral parts of the abdomen, which is possible due to the accumulation of free fluid in the abdominal cavity.

When performing rectal and vaginal examinations, sagging of the fornix and severe pain are revealed, which is characteristic of the accumulation of inflammatory exudate.

General laboratory tests are characterized by:

• general analysis blood - pronounced leukocytosis with a shift in the leukocyte formula to the left, as well as lymphocytopenia and monocytopenia. In some cases, there is a decrease in platelet levels (thrombocytopenia);
• general urinalysis - the presence of leukocytes, protein or red blood cells in the urine indicates impaired renal function. It is also important to monitor the amount of urine excreted;
• biochemical blood test - hypoproteinemia, increased urea, creatinine, bilirubil, ALT, AST, changes in electrolytes.

The following instrumental diagnostic methods are used:

• Ultrasound of the abdominal organs. The simplest and most informative study that allows you to determine the presence of free fluid and gas in the abdominal cavity, as well as study the condition of the gallbladder, liver, spleen, pancreas and kidneys;
• X-ray of the abdominal cavity. The presence of free gas will be indicated by the so-called Kloiber cups and the high position of the diaphragm dome;
• laparoscopy is a minimally invasive surgical operation that allows you to assess the condition of the internal organs of the abdominal cavity using an optical device (laparoscope);
• diagnostic laparotomy is a surgical opening of the abdominal cavity performed for diagnostic purposes in order to establish an accurate diagnosis.

The following auxiliary scales for determining the severity of peritonitis are distinguished:

1. APACHE II (1985), APACHE III (1991) scales. (Used in the USA and Canada).
2. SAPS scale (1984), SAPS II (1993), MODS (1995), SOFA (1996). (Used in Europe).
3. MIP. Mannheim peritonitis index (M. Linder, 1987)

Risk factors according to MIP

Age over 50 years - 5 points

Female gender - 5 points

Presence of organ failure - 7 points

Presence of a malignant tumor - 4 points

Duration of peritonitis >24 hours - 4 points

Large intestine as a source of peritonitis - 4 points

Diffuse peritonitis - 6 points

Exudate:

Transparent - 0 points

Cloudy-purulent - 6 points

Fecal putrefactive - 12 points

MIP< 21 балла (1 степень тяжести) – летальность составляет 2,3%.

MIP 21-29 points (severity degree 2) – mortality rate is 22.5%.

MIP > 29 points (grade 3) – mortality rate is 59.1%.

As you know, peritonitis is a life-threatening condition in which any delay can lead to irreparable consequences. That is why you should never neglect your well-being, but should immediately seek medical help when the first disturbing symptoms appear.

Treatment

The development of peritonitis is an indication for urgent surgery, the purpose of which is to eliminate the source of infection. The most optimal quick access is a midline laparotomy that allows visualization of the entire abdominal cavity. After opening the abdominal cavity, the exudate is evacuated. Next, an audit of the internal organs is carried out to establish the cause of the development of peritonitis. Once the source is detected, it is eliminated and reliably isolated. In the reactive phase of peritonitis, it is allowed radical operations, including anastomosis, however, in the terminal phase the volume of the operation is reduced to a minimum. After eliminating the source of peritonitis, sanitation of the abdominal cavity is performed, which is carried out by washing the cavity with antiseptic solutions and isotonic solutions. The volume of solutions used is 4–6 liters; in advanced cases, the volume of liquid increases to 8–10 liters. Next, drainage of the abdominal cavity is performed, that is, drains are installed to the source of peritonitis and to all sloping areas of the abdominal cavity. The surgical operation is completed by suturing the laparotomy wound. Suturing the wound tightly without drainage is used only in the presence of local, unrestricted serous peritonitis; in all other cases, the wound is sutured using drainage.

Antibiotics are prescribed as medications to combat pathogenic microflora. As a rule, not monotherapy is used, but a combination of two antibiotics. In addition, preference is given to broad-spectrum antibacterial agents that affect both gram-positive and gram-negative flora. The following routes of antibiotic administration are used:

• local (intra-abdominal) – the drug is administered through drainage;
• general (for example, intravenous administration of an antibiotic) - this route of administration allows for a systemic effect of the antibiotic on the human body.

Balanced infusion therapy is also used, thanks to which the following effects are achieved:

• replenishment of the deficit of BCC (circulating blood volume);
• regulation of volume and normalization of central hemodynamics;
• normalization of blood electrolyte composition;
• neutralization of metabolic acidosis;
• replenishment of energy costs.

Adequate pain relief is necessary in the postoperative period, since the patient experiences severe pain. For this purpose, non-steroidal anti-inflammatory drugs with pronounced analgesic activity are used. If necessary, they resort to stronger drugs - narcotic analgesics.

To normalize microcirculation in organs and tissues, as well as to prevent thromboembolic complications, drugs such as heparin, fraxiparin, clexane, and so on can be used.

Also, if necessary, medications are prescribed whose action is aimed at maintaining the activity of the cardiovascular system.

Medicines

To influence pathogenic microflora, they are used antibacterial drugs. In the treatment of peritonitis, preference is given to broad-spectrum antibiotics that affect both gram-positive and gram-negative microflora. Such drugs include:

• cephalosporins(ceftriaxone, cefepime, cefotaxime, cefoperazone). The mechanism of action of these drugs is to disrupt the synthesis of the cell wall of the microorganism, which leads to the prevention of further growth and development of the bacterium. Cephalosporins are distributed in many tissues, organs and secretions (with the exception of the prostate gland), which makes it possible to use them for various diseases bacterial nature. While receiving data antibacterial agents the following side effects may occur: nausea, vomiting, abdominal pain (mainly in the epigastric region), headache, tremor, and occasionally convulsions;
• penicillins(ampicillin, amoxicillin). They have a bactericidal effect, which is achieved by disrupting the synthesis of the cell wall of the microorganism. Penicillins are distributed in many internal organs, tissues and biological fluids. Particularly high concentrations of the drug are found in the lungs, kidneys, intestinal mucosa, pleural and peritoneal fluids, as well as in the organs of the reproductive system. In some cases, while taking penicillins, side effects such as headache, nausea, vomiting, abdominal pain, stool disorder, and tremor occur;
• carbapenems(imipinem, meropenem). The mechanism of action of these antibacterial agents is the inhibition of penicillin-binding proteins of the cell wall of the microorganism, as a result of which its synthesis is disrupted, thereby achieving a bactericidal effect. They are distributed quite well throughout the body, creating therapeutic concentrations in almost all internal organs, tissues and secretions. While taking this group of antibacterial agents, the development of such side effects such as nausea, vomiting, diarrhea, dizziness, drowsiness, soreness and infiltration at the injection site. It is important to note that these antibiotics are used parenterally because they are acid-stable.

In addition, representatives of 5-nitroimidazole are used, in particular metronidazole, which is highly effective against anaerobic microflora. The effect of the drug is achieved by inhibiting the synthesis of nucleic acids in the DNA of the microorganism, which leads to its death. The drug achieves its bactericidal effect in most tissues and fluids of the body (lungs, liver, kidneys, brain, saliva, bile, amniotic fluid, vaginal secretions, cerebrospinal fluid, and so on). Able to penetrate the blood-brain and placental barriers.

Infusion therapy is also prescribed, which consists of intravenous administration of infusion solutions. Initially, colloidal solutions are used, the volume of which is determined depending on the degree of dehydration and hemodynamic disorders, but, as a rule, is not less than 1 - 1.5 liters. Simultaneously with colloidal solutions, isotonic electrolyte solutions can be prescribed, the purpose of which is to correct sodium and chlorine in the patient’s body.

Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit the enzyme COX (cyclooxygenase), which leads to disruption of the synthesis of prostaglandins from arachidonic acid. As a result, the following effects are achieved: antipyretic, anti-inflammatory, analgesic. Since patients experience severe pain in the postoperative period, injectable forms of NSAIDs with a pronounced analgesic effect, for example, ketorolac, are prescribed. In case of severe pain that is not relieved by the use of NSAIDs, they resort to the prescription of narcotic analgesics that have maximum analgesic activity. Long-term use of painkillers, especially non-steroidal anti-inflammatory drugs, threatens the development of exacerbation of the patient's gastrointestinal disease. That is why these funds are prescribed only in acute period, and after relief of the pain syndrome, they are canceled.

Folk remedies

Peritonitis is life-threatening threatening condition, in which any delay can lead to death. That is why you should immediately seek help from a medical facility and under no circumstances follow recommendations for treatment at home. It is important to understand that the success of treatment largely depends on the timing of completion surgical intervention and the completeness of the volume of postoperative therapy.

Since peritonitis is often secondary, preventive measures are aimed at timely detection and treatment of pathology, which can subsequently lead to the development of peritonitis. Such diseases include: acute appendicitis, gastric or duodenal ulcers, cholecystitis, intestinal obstruction, and so on. Preventive measures postoperative peritonitis consists of following the surgical technique, adequate hemostasis, carefully checking the integrity of the anastomoses, and sanitation of the abdominal cavity.

The information is for reference only and is not a guide to action. Do not self-medicate. At the first symptoms of the disease, consult a doctor.