Treatment of purulent inflammations. What are purulent inflammations of different types and why do they develop. Types of purulent inflammation of the skin and their treatment

Purulent inflammation is characterized by the formation of purulent exudate. This is a creamy mass, consisting of cells and tissue detritus of the focus of inflammation, microorganisms, blood cells. The number of the latter is 17–29%, mainly viable and dead granulocytes. In addition, the exudate contains lymphocytes, macrophages, and often eosinophilic granulocytes. Pus has a specific odor, a bluish-greenish color of various shades, the protein content in it is more than 3-7%, globulins usually predominate, the pH of the pus is 5.6-6.9.

Purulent exudate contains various enzymes, primarily proteases, capable of splitting dead and dystrophically altered structures in the lesion, including collagen and elastic fibers, so purulent inflammation is characterized by tissue lysis. Along with polymorphonuclear leukocytes capable of phagocytizing and killing microorganisms, bactericidal factors (immunoglobulins, complement components, etc.) are present in the exudate. Bactericidal factors produce viable leukocytes, they also arise from the decay of dead leukocytes and enter the exudate along with blood plasma. In this regard, pus retards the growth of bacteria and destroys them. Neutrophilic leukocytes of pus have a diverse structure depending on the time of their entry from the blood into the area of ​​suppuration. After 8-12 hours, polymorphonuclear leukocytes in pus die and turn into "purulent bodies".

The cause of purulent inflammation is pyogenic (pyogenic) staphylococci, streptococci, gonococci, typhoid bacillus, etc. Purulent inflammation occurs in almost any tissues and organs. Its course can be acute and chronic. The main forms of purulent inflammation: abscess, phlegmon, empyema, purulent wound, acute ulcers.

● Abscess - delimited purulent inflammation with the formation of a cavity filled with purulent exudate. It occurs in viable tissues after a strong impact of microorganisms or in dead tissues, where autolysis processes increase.

◊ Already a few hours after the onset of purulent inflammation around the accumulation of exudate, a shaft of blood cells is visible: monocytes, macrophages, lymphocytes, eosinophils, fibrin accumulations containing polymorphonuclear leukocytes. At the same time, fibrin, which has chemotaxis to polymorphonuclear leukocytes, stimulates their emigration from the vessels and entry into the inflammation site. On fibrin, circulating immune complexes are deposited - chemoattractants for complement, which has pronounced histolytic properties. After three days, the formation of granulation tissue begins around the abscess and a pyogenic membrane appears. Through the vessels of the granulation tissue, leukocytes enter the abscess cavity and partially remove decay products from it. With immunodeficiency, the patient has a tendency to melt the tissues surrounding the abscess. In the chronic course of an abscess, the granulation tissue matures, and two layers appear in the pyogenic membrane: the inner layer facing the cavity, consisting of granulations, fibrin, detritus, and the outer layer of mature connective tissue.



● Phlegmon-purulent diffuse inflammation with impregnation and exfoliation of tissues with purulent exudate. The formation of phlegmon depends on the pathogenicity of the pathogen, the state of the body's defense systems, the structural features of the tissues where the phlegmon arose and where there are conditions for the spread of pus. Phlegmon usually occurs in the subcutaneous fat, intermuscular layers, appendix wall, meninges, etc. (Fig. 4-4). Phlegmon of fibrous fatty tissue is called cellulite.

◊ Phlegmon is of two types:

mild if lysis of necrotic tissues predominates;

hard, when coagulative necrosis and gradual rejection of tissues occur in the inflamed tissue.

Rice. 4-4. Purulent leptomeningitis and encephalitis. Stained with hematoxylin and eosin (x150).

◊ Complications of phlegmon. Arterial thrombosis is possible, and necrosis of the affected tissues occurs, for example, gangrenous appendicitis. Often, the spread of purulent inflammation to the lymphatic vessels and veins, in these cases, purulent thrombophlebitis and lymphangitis occur. Phlegmon of a number of localizations, under the influence of gravity of pus, can drain along the muscle-tendon sheaths, neurovascular bundles, fatty layers into the underlying sections, forming accumulations there that are not enclosed in a capsule (cold abscesses, or swells). More often, such a spread of pus causes acute inflammation of organs or cavities, for example, purulent mediastinitis is an acute purulent inflammation of the mediastinal tissue. Rejection of necrotic and coagulated tissues with solid phlegmon can lead to bleeding. Sometimes there are complications associated with severe intoxication, which always accompanies purulent inflammation.

◊ Outcomes. The healing of phlegmonous inflammation begins with its delimitation with the formation of a rough scar. Usually, the phlegmon is removed surgically, followed by scarring of the surgical wound. With an unfavorable outcome, generalization of infection with the development of sepsis is possible.

● Empyema - purulent inflammation of body cavities or hollow organs. The reasons for the development of empyema are both purulent foci in neighboring organs (for example, lung abscess, empyema of the pleural cavity), and a violation of the outflow of pus with purulent inflammation of hollow organs (gall bladder, appendix, fallopian tube, etc.). At the same time, local defense mechanisms are violated (constant renewal of the contents of hollow organs, maintenance of intracavitary pressure, which determines blood circulation in the wall of a hollow organ, synthesis and secretion of protective substances, including secretory immunoglobulins). With a long course of purulent inflammation, obliteration of hollow organs occurs.

● A purulent wound is a special form of purulent inflammation that occurs as a result of suppuration of a traumatic, including a surgical wound, or when a focus of purulent inflammation is opened into the external environment with the formation of a wound surface. There are primary and secondary suppuration in the wound.

◊ Primary suppuration occurs immediately after trauma and traumatic edema.

◊ Secondary suppuration - recurrence of purulent inflammation.

The participation of bacteria in suppuration is part of the process of biological cleansing of the wound. Other features of a purulent wound are associated with the conditions of its occurrence and course.

◊ Complications of a purulent wound: phlegmon, purulent-resorptive fever, sepsis.

◊ The outcome of a purulent wound is its healing by secondary intention with the formation of a scar.

● Acute ulcers are most often in the gastrointestinal tract, less often on the surface of the body. By origin, primary, secondary and symptomatic acute ulcers are distinguished.

◊ Primary acute ulcers occur on the surface of the body, in the esophagus or stomach with direct action on the skin or mucous membrane of damaging factors (acids, alkalis, thermal exposure, microorganisms). Sometimes primary acute ulcers are a consequence of dermatitis (erysipelas, contact dermatitis, etc.). Purulent-necrotic tissue changes are characteristic, and the predominance of one or another component depends on the etiological factor. The healing of such ulcers usually leaves scars.

◊ Secondary acute ulcers occur with extensive burns of the body, ischemia of the gastrointestinal tract, etc.

◊ Symptomatic acute ulcers occur with stress, endocrinopathies, medication, neuro-reflex, trophic, vascular, specific.

The morphology of secondary and symptomatic acute ulcers is largely similar. Their localization is mainly the stomach and duodenum. Often there are several such ulcers. Their size is initially small, but multiple ulcers tend to merge. At the bottom of the ulcer - necrotic detritus impregnated with fibrin and covered with mucus. In the submucosal layer expressed neutrophilic, sometimes eosinophilic infiltration. Steroid ulcers are characterized by a mild inflammatory reaction around the ulcer and intense sclerosis.

◊ Complications of acute ulcers: vessel erosion and gastrointestinal bleeding, with steroid ulcers, sometimes perforation of the organ wall.

◊ The outcome of uncomplicated secondary acute ulcers is usually tissue healing.

It is characterized by the predominance of PNL (preserved and decaying) in the exudate.

The most common cause is pyogenic microorganisms (staphylococci, streptococci, gonococci, meningococci, Pseudomonas aeruginosa, etc.).

A characteristic morphological feature is histolysis, tissue melting by proteolytic enzymes of leukocytes (neutral proteases collagenase, elastase, cathepsin and acid hydrolases).

Purulent inflammation can be limited (abscess) and diffuse (phlegmon); purulent inflammation in pre-existing cavities with accumulation of pus in them is called empyema.

a. Abscesses may be single or multiple; the latter are often formed in organs with septicopyemia due to microbial embolism.

Embolic purulent nephritis.

Macroscopic picture: the kidneys are enlarged (affect symmetrically), flabby in consistency. In the cortical and medulla, numerous rounded small foci of a grayish-yellow color, the size of a pinhead (1-2 mm), often surrounded by a hemorrhagic halo, are visible in the cortical and medulla.

Microscopic picture: in the cortical and medulla, numerous foci of purulent inflammation (abscesses) are visible, represented by the accumulation of PMNs, in the center of the foci, the kidney tissue is melted, microbial emboli are visible. Around the foci of inflammation, the vessels are dilated, full-blooded.

The outcome of the abscess: at the site of abscesses (histolysis), scars form; in some cases, the abscess takes a chronic course: a connective tissue capsule is formed around it, the inner layer of which is represented by granulation tissue (pyogenic membrane).

b. Phlegmon - diffuse (diffuse) purulent inflammation:

More often occurs in the subcutaneous tissue, in the fascia, along the neurovascular bundles;

Inflammation 137

Diffuse purulent inflammation can also occur in parenchymal organs, in the pia mater.

Purulent mite about meningitis - occurs with meningococcal infection, as well as with septicopyemia due to microbial embolism.

Macroscopic picture: the soft meninges are thickened, dull, saturated with a thick greenish-yellow mass (pus). Furrows and convolutions are smoothed out. More significant changes are expressed on the surface of the frontal, temporal and parietal lobes, which is why the brain looks like it is covered with a "green cap".

Microscopic picture: the pia mater is sharply thickened and diffusely infiltrated with PMNs. The vessels of the membranes and the substance of the brain adjacent to them are dilated and full-blooded. Fibrin strands are found in the subarachnoid space. Perivascular and pericellular edema is expressed in the substance of the brain.

Outcome: resorption of exudate, recovery.

Complications:

a) meningoencephalitis - occurs when inflammation passes from the membranes to the substance of the brain;

Purulent diseases of the skin and subcutaneous tissue include such pathological phenomena as furuncle, abscess, hydradenitis, carbuncle, phlegmon, etc. Most often, the causative agent of such diseases is staphylococcal flora (70-90%), and the factors for the development of purulent-inflammatory diseases of the skin and subcutaneous fat include a decrease in general and local resistance and immune defense of the body and the presence of a sufficient amount of microflora for the development of the disease.

Types of purulent inflammation of the skin and their treatment

Furuncle

Furuncle is a purulent-necrotic inflammation of the hair follicle, as well as the tissues that surround it. In the process of development, inflammation covers the sebaceous gland and surrounding tissues. The pathogen is predominantly Staphylococcus aureus, and contributing factors are pollution and non-compliance with hygiene standards, cracks, hypothermia, beriberi, and a number of others. On skin devoid of hair, boils do not develop.

Treatment of boils carried out according to the general canons of the treatment of surgical infection. It is important that when the boil is located above the nasolabial fold, it is necessary to carry out active detoxification, antibacterial, anti-inflammatory, restorative therapy, bed rest is required here, as well as a ban on chewing and talking. Food should only be served in a liquid state. The ancient formula is especially important here - squeezing a boil on the face is deadly!

In chronic recurrent furunculosis, in addition to general and local treatment, it is also important to undergo non-specific stimulating treatment in the form of autohemotherapy. The method of transfusion of small doses of canned blood, immunization with staphylococcal toxoid, γ-globulin, subcutaneous administration of an autovaccine or staphylococcal vaccine are also used. After the analysis of the immunogram, immunostimulating treatment is often prescribed to correct immunodeficiency, laser irradiation of autologous blood and ultraviolet irradiation.

Carbuncle

The fact that confluent purulent-necrotic inflammation affects several hair follicles and sebaceous glands, with the formation of extensive general necrosis of the skin and subcutaneous tissue. More often this pathology is provoked by staphylococcus aureus, but infection with streptococcus is also possible. With the formation of extensive necrosis, suppuration develops around it. Signs of intoxication are noticeable. Possible complications in the form of lymphangitis, thrombophlebitis, lymphadenitis, sepsis and meningitis.

Carbuncle Treatment carried out in a hospital, while bed rest is required. Under general anesthesia, excision of a purulent-necrotic focus is performed. At the same time, restorative, detoxifying, anti-inflammatory, antibacterial treatment is mandatory. If the process develops on the face, liquid nutrition and a ban on talking are prescribed.

Hydradenitis

Purulent inflammation of the apocrine sweat glands located in the armpits is called "hydradenitis". The process can also develop in the perineum and in women in the nipple area.

The infection penetrates through the lymphatic vessels or through the damaged skin through the ducts of the glands and a painful dense nodule appears in the skin, and the process ends with the spontaneous opening of the abscess with the formation of a fistula. Infiltrates merge and there is a conglomerate with multiple fistulas.

Hidradenitis differs from a boil in the absence of pustules and necrosis. In addition, hydradenitis develops in the thickness of the skin, and other types of lymph node damage develop in the subcutaneous tissue.

Predominantly using a radical operation and excising conglomerates of inflamed sweat glands. Another option is anti-inflammatory radiation therapy. In case of relapse, specific immunotherapy and restorative drugs are prescribed.

Abscess or ulcer

An abscess, or abscess, is a limited accumulation of pus in various organs or tissues.

An abscess may develop as a result of penetration of an infection through damaged skin, but it may also be the result of a complication of local infections such as furuncle, hidradenitis, lymphadenitis, etc., or metastatic abscesses in sepsis.

Treatment of abscesses involves both medical therapy and surgery.

Phlegmon

Phlegmon is a diffuse inflammation of the intermuscular, subcutaneous, retroperitoneal and other tissues. The development of phlegmon is initiated by both aerobic and anaerobic microbes. Phlegmons are divided into serous, purulent and putrefactive. With the serous form, conservative treatment is possible, but the remaining forms are treated according to the general principles for the treatment of surgical infections.

characterized by the formation of purulent exudate. It is a mass consisting of detritus of tissues of the focus of inflammation, cells, microbes. The exudate contains granulocytes, lymphocytes, macrophages, often eosinophilic granulocytes. Purulent inflammation is caused by pyogenic microbes - staphylococci, streptococci, gonococci, typhoid bacillus.

Purulent exudate has a number of qualities that determine the biological significance of this form of inflammation. It contains various enzymes, primarily proteases, capable of breaking down dead and dystrophically altered structures in the lesion, including collagen and elastic fibers, so purulent inflammation is characterized by tissue lysis.

The main forms of purulent inflammation are abscess, phlegmon, empyema, purulent wound.

Abscess

Phlegmon

Purulent, unrestricted diffuse inflammation, in which purulent exudate impregnates and exfoliates tissues. The formation of phlegmon depends on the pathogenicity of the pathogen, the state of the body's defense systems, as well as on the structural features of the tissues in which it arose and where there are conditions for the spread of pus.

Phlegmon can be soft if the lysis of necrotic tissues prevails, and hard when coagulative necrosis of tissues occurs in the phlegmon, which are gradually rejected.

Phlegmonous inflammation can be complicated by thrombosis of blood vessels, resulting in necrosis of the affected tissues. Purulent inflammation can spread to the lymphatic vessels and veins, and in these cases, purulent thrombophlebitis and lymphangitis occur. The healing of phlegmonous inflammation begins with its delimitation, followed by the formation of a rough scar. With an unfavorable outcome, generalization of infection with the development of sepsis may occur.

empyema

This is a purulent inflammation of the body cavities or hollow organs. The reason for the development of empyema is both purulent foci in neighboring organs (for example, lung abscess and empyema of the pleural cavity), and a violation of the outflow of pus in case of purulent inflammation of hollow organs - the gallbladder, appendix, fallopian tube.

festering wound

A special form of purulent inflammation, which occurs either as a result of suppuration of a traumatic, including surgical, or other wound, or as a result of opening a focus of purulent inflammation into the external environment and the formation of a wound surface.

An abscess (abscess, abscess) is a purulent inflammation, accompanied by tissue melting and the formation of a cavity filled with pus. It can be formed in muscles, subcutaneous tissue, bones, internal organs or in the surrounding tissue.

abscess formation

Abscess Causes and Risk Factors

The cause of an abscess is a pyogenic microflora that enters the patient's body through damage to the mucous membranes or skin, or is introduced with blood flow from another primary focus of inflammation (hematogenous route).

The causative agent in most cases becomes a mixed microbial flora, which is dominated by staphylococci and streptococci in combination with various types of coli, for example, Escherichia coli. In recent years, the role of anaerobes (clostridia and bacteroids), as well as associations of anaerobic and aerobic microorganisms in the development of abscesses, has significantly increased.

Sometimes there are situations when the pus obtained during the opening of an abscess, when sown on traditional nutrient media, does not give rise to microflora. This indicates that in these cases the disease is caused by uncharacteristic pathogens, which cannot be detected by conventional diagnostic methods. To a certain extent, this explains the cases of abscesses with atypical course.

Abscesses can occur as an independent disease, but more often they are a complication of some other pathology. For example, pneumonia can be complicated lung abscess, and purulent tonsillitis - paratonsillar abscess.

With the development of purulent inflammation, the body's defense system seeks to localize it, which leads to the formation of a limiting capsule.

Forms of the disease

Depending on location:

  • subphrenic abscess;
  • paratonsillar;
  • peripharyngeal;
  • soft tissues;
  • lung;
  • brain;
  • prostate;
  • periodontal;
  • intestines;
  • pancreas;
  • scrotum;
  • Douglas space;
  • appendicular;
  • liver and subhepatic; and etc.
Subcutaneous tissue abscesses usually end in complete recovery.

According to the features of the clinical course, the following forms of abscess are distinguished:

  1. Hot or spicy. It is accompanied by a pronounced local inflammatory reaction, as well as a violation of the general condition.
  2. Cold. It differs from the usual abscess in the absence of general and local signs of the inflammatory process (fever, redness of the skin, pain). This form of the disease is characteristic of certain stages of actinomycosis and osteoarticular tuberculosis.
  3. Leaky. The formation of a site of accumulation of pus does not lead to the development of an acute inflammatory reaction. The formation of an abscess occurs over a long period of time (up to several months). It develops against the background of the osteoarticular form of tuberculosis.

Abscess symptoms

The clinical picture of the disease is determined by many factors and, above all, by the location of the purulent process, the cause of the abscess, its size, and the stage of formation.

Symptoms of an abscess localized in superficial soft tissues are:

  • puffiness;
  • redness;
  • sharp soreness;
  • an increase in local, and in some cases, general temperature;
  • dysfunction;
  • fluctuation.

Abscesses of the abdominal cavity are manifested by the following symptoms:

  • intermittent (intermittent) fever with a hectic type of temperature curve, that is, subject to significant fluctuations during the day;
  • severe chills;
  • headache, muscle and joint pain;
  • lack of appetite;
  • severe weakness;
  • nausea and vomiting;
  • delay in passing gases and stools;
  • tension in the muscles of the abdominal wall.

When an abscess is localized in the subdiaphragmatic region, patients may be disturbed by shortness of breath, cough, pain in the upper abdomen, aggravated at the time of inspiration and radiating to the shoulder blade and shoulder.

With pelvic abscesses, reflex irritation of the rectum and bladder occurs, which is accompanied by the appearance of tenesmus (false urge to defecate), diarrhea, frequent urination.

Retroperitoneal abscesses are accompanied by pain in the lower back, the intensity of which increases with flexion of the legs in the hip joints.

The symptoms of a brain abscess are similar to those of any other volumetric formation (cysts, tumors,) and can vary over a very wide range, ranging from a minor headache to severe cerebral symptoms.

A lung abscess is characterized by a significant increase in body temperature, accompanied by severe chills. Patients complain of pain in the chest, worse when trying to take a deep breath, shortness of breath and dry cough. After the opening of the abscess in the bronchus, a strong cough occurs with profuse sputum discharge, after which the patient's condition begins to improve rapidly.

Abscesses in the oropharynx (retropharyngeal, paratonsillar, peripharyngeal) in most cases develop as a complication of purulent tonsillitis. They are characterized by the following symptoms:

  • severe pain radiating to the teeth or ear;
  • sensation of a foreign body in the throat;
  • spasm of the muscles that prevents the opening of the mouth;
  • soreness and swelling of regional lymph nodes;
  • increase in body temperature;
  • weakness;
  • nasal voice;
  • the appearance of an unpleasant putrefactive odor from the mouth.

Diagnosis of an abscess

Superficially located abscesses of soft tissues do not cause difficulties in diagnosis. With a deeper location, it may be necessary to perform an ultrasound and / or diagnostic puncture. The material obtained during the puncture is sent for bacteriological examination, which allows to identify the causative agent of the disease and determine its sensitivity to antibiotics.

Abscesses of the oropharynx are detected during an otolaryngological examination.

Abscesses can occur as an independent disease, but more often they are a complication of some other pathology. For example, pneumonia can be complicated by a lung abscess, and purulent tonsillitis can be complicated by a paratonsillar abscess.

Diagnosis of abscesses of the brain, abdominal cavity, and lungs is much more difficult. In this case, an instrumental examination is carried out, which may include:

  • Ultrasound of the abdominal cavity and small pelvis;
  • magnetic resonance or computed tomography;

Abscess treatment

In the initial stage of development of an abscess of superficial soft tissues, anti-inflammatory therapy is prescribed. After maturation of the abscess, it is opened, usually on an outpatient basis. Hospitalization is indicated only in severe general condition of the patient, the anaerobic nature of the infectious process.

As an aid in the treatment, as well as for the prevention of complications of subcutaneous fat abscesses, it is recommended to use Ilon ointment. The ointment should be applied to the affected area under a sterile gauze bandage or patch. Depending on the degree of suppuration, the dressing should be changed once or twice a day. The duration of treatment depends on the severity of the inflammatory process, but, on average, to obtain a satisfactory result, you need to apply the ointment for at least five days. Ointment Ilon K is sold in pharmacies.

Treatment of lung abscess begins with the appointment of broad-spectrum antibiotics. After receiving the antibiogram, the antibiotic therapy is adjusted taking into account the sensitivity of the pathogen. If there are indications, in order to improve the outflow of purulent contents, bronchoalveolar lavage is performed. The ineffectiveness of conservative treatment of an abscess is an indication for surgical intervention - resection (removal) of the affected area of ​​the lung.

Treatment of brain abscesses in most cases is surgical, as they can lead to dislocation of the brain and cause death. A contraindication to the removal of abscesses is their localization in deep and vital structures (subcortical nuclei, brain stem, thalamus). In this case, they resort to puncturing the abscess cavity, removing the purulent contents by aspiration, followed by washing the cavity with an antiseptic solution. If multiple flushing is required, the catheter through which it is passed is left in the cavity for a while.

Prevention

Prevention of the development of abscesses is aimed at preventing the entry of pathogenic pyogenic microflora into the patient's body and includes the following measures:

  • careful observance of asepsis and antiseptics during medical interventions, accompanied by damage to the skin;
  • timely conduct of primary surgical treatment of wounds;
  • active rehabilitation of foci of chronic infection;
  • increasing the body's defenses.

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