Peritonitis in children: causes, symptoms and treatment. Peritonitis in children: symptoms, causes, treatment, consequences Primary peritonitis in girls causes

Peritonitis- inflammation of the peritoneum, which is a type of connective tissue consisting of two sheets. The first is lined with the walls of the abdominal cavity, the second - its internal organs. The disease threatens the life of the child, therefore, requires urgent medical attention. The prognosis due to inadequate or delayed treatment is very unfavorable.

Peritonitis in children is distinguished by a number of features, since their organs and systems have not yet been fully formed. Most often, the disease is a complication after, less often, other factors can become causes of childhood peritonitis.

Depending on the causes, primary and secondary peritonitis can be diagnosed. Most often, the second variety is diagnosed against the background of other diseases:

If the cause of inflammation of the peritoneum is not an internal disease, but some random factor from the outside, this is primary peritonitis in children, which is diagnosed less frequently than secondary. Its reasons may be:

• bleeding of various kinds in the abdominal cavity;
• ruptures and injuries of organs;
• intestinal obstruction;
• diplococcal infection (the disease caused by this type of bacteria has a similar name - diplococcal peritonitis);
• accidental entry of meconium into the peritoneum of a newborn;
• impaired integrity of organs in the abdominal cavity.

Prevention of the primary form are the usual security measures, avoidance of traumatic situations. In the case of a secondary disease, everything will depend on the health of the baby and the ability of his body to cope with primary infections. It is very important to recognize peritonitis in time, but in children it can be quite difficult to do.

Symptoms and signs

The first symptoms of peritonitis in a child are not at all a sharp pain, as many parents mistakenly believe. The small organism is still being formed. As a result, the general condition worsens at first, and the symptoms of inflammation can be expressed very vaguely. If the baby was injured in the abdomen, recently had appendicitis or the infection indicated above in the causes of secondary peritonitis, you need to carefully monitor his condition. The symptoms of the disease include:

• a clear deterioration in the general condition of the child;
• anxiety, nervousness, whims, irritability, causeless crying;
• lack of appetite;
• poor sleep (does not fall asleep at all or constantly wakes up and cries);
• the temperature can rise up to 38°C;
• vomit;
• long absence of stool or, conversely,;
• pain in the abdomen, but not localized in any one place;
• the stomach is tense, if you try to touch it, the baby will get worried and cry;
• the skin becomes dry, acquires a clear earthy tint.

In many ways, the further health of the child after peritonitis will depend on how timely the parents noticed the disease and provided first aid. Children with these symptoms should be seen by a doctor as soon as possible. For this, an ambulance is called. The surgeon will palpate the abdomen, assess the general condition of the small patient. In such cases, blood and urine tests are mandatory, X-ray and ultrasound examinations of organs in the abdominal cavity are performed. If the doctor diagnoses peritonitis, the child is immediately hospitalized and an operation is prescribed.

Treatment

Peritonitis in children of any age requires mandatory surgical intervention. A laparotomy is performed (the abdominal wall is cut to access the internal organs), the state of the peritoneum is examined. If possible, the main cause of inflammation is eliminated, the abdominal cavity is thoroughly washed with an antibiotic (solution) or other, more gentle antibacterial agents. After the edges of the wound are sutured, a drain is inserted into it, which serves to sanitize the peritoneum with antibiotics. After surgery, treatment involves the appointment of:

• massive infusion therapy;
• antibiotics intravenously;
• antipyretic drugs;
• means to eliminate intoxication and improve blood microcirculation;
• special diet: doctors will tell parents how to feed a child with peritonitis; chicken broth, yogurts without additives, mashed vegetables (zucchini, potatoes or pumpkin), rice water, cereals on the water, honey, fruits and berries with low acidity are usually allowed.

Before the arrival of the ambulance, parents can take the following measures to alleviate the condition of the baby:

• antipyretic drugs based on ibuprofen or paracetamol;
• wipe the skin with alcohol to reduce the temperature;
• make cold compresses on the forehead, neck, armpits.

Nothing more can be done with a sick child without doctors. With the correct and timely operation, as well as following all the recommendations in the postoperative period, the health of the child after peritonitis is fully restored and does not let you know about the disease.

Pediatric appendicular peritonitis (inflammation of the peritoneum) is one of the most common complications of acute appendicitis. If you do not catch on in time and do not start a full-fledged treatment, the consequences of such inflammation can be quite severe and even threaten a child's life. Therefore, it is so important to listen to any complaints of the child about feeling unwell and problems with the intestines - with a timely visit to the doctor, it is really possible to cure any form of appendicular peritonitis.

Varieties

To date, there is no single classification of pediatric appendicular peritonitis, although many medical schools offer their own classification schemes for this disease. One of the most complete classifications of inflammation of the peritoneum in appendicitis looks like this.

Common form (free peritonitis):

• Local unlimited (inflammation is localized in the area of ​​the caecum);
• Diffuse (inflammation spreads, but does not go beyond the lower zone of the abdominal cavity);
• Spilled (the inflammatory process is focused in the lower and middle zones of the peritoneum);
• General (there is a total defeat of the entire peritoneum).

Quite often free peritonitis is followed by accumulation of pus, or purulent exudate.

Localized form (abscessing peritonitis):

• Appendicular infiltrate (a seal of cells, blood and pus gathers around the appendix);
• Periappendicular abscess of three degrees (accumulation of pus);
• Combined peritonitis (purulent effusion and abscess at the same time);
• Total form (the most dangerous variety, which is accompanied by sepsis and infectious-toxic shock).

stages

Experts distinguish three successive stages of appendicular peritonitis in children.

Reactive stage(lasts up to 24 hours from the onset of the disease).

At this stage, children have common symptoms of the inflammatory process: general weakness or agitation, vomiting, slight tachycardia, fever (not higher than 38 degrees). There is pain in the abdomen, the muscles of the peritoneum are very tense.

toxic(lasts from 24 to 72 hours).

In the toxic phase, signs of general severe intoxication of the child's body appear. These are pale skin and pointed features, shiny eyes, dry mouth and constant vomiting. Pain sensations in the child are weak, spilled over the entire abdomen.

At this stage, dehydration of the body begins, exudate, a purulent fluid, collects in the abdominal cavity.

terminal stage(appears on the third day).

All the internal systems and organs of the child are affected - cardiovascular and respiratory failure develops, the kidneys and liver suffer.

Symptoms

Signs of appendicular peritonitis in children may differ significantly from similar manifestations in adults and the elderly. Often, at the initial stage in children, the symptoms are smoothed out and almost do not appear, while the inflammation develops and spreads to all areas of the abdominal cavity.

• Vomit;
• Elevated temperature (no more than 38ºC);
• Acute pain in the right iliac region (later spills over the entire abdomen);
• Deterioration of the general condition, weakness, tearfulness;
• intestinal obstruction or diarrhea;
• Frequent urination, may be accompanied by painful sensations;
• Poor sleep, appetite abruptly disappears (in babies);
• Tense abdominal muscles.

After the first stage, a short improvement may occur (the pain subsides, but the temperature invariably keeps), then the condition worsens sharply: the younger the child, the shorter this period of calm.

In the later stages of inflammation of the peritoneum, symptoms of dehydration appear - gray complexion, shiny eyes, dry mucous membranes, white coating on the tongue, rapid pulse. Purulent fluid and gases accumulate in the peritoneum, hence bloating, the stool is completely absent. The pain is often dulled, but the abdomen is very painful on palpation.

Diagnosis and main stages of treatment

If you suspect peritonitis with appendicitis, the most important and useful thing that parents can do is to immediately call a doctor at home. First of all, the surgeon must palpate the abdomen, assess the general condition of the child based on the signs of the disease.

Diagnosis of peritonitis without fail includes blood and urine tests, abdominal ultrasound and x-rays, in complex and controversial cases - diagnostic puncture, laparocentesis (puncture of the abdominal wall and removal of fluid) and laparoscopy (surgical examination).

Treatment of appendicular peritonitis is complex and consists of three important steps:

• Preparing a child for surgery.
• Surgery to cut out the appendix, remove purulent fluid and sanitize (cleanse) the abdominal cavity.
• Postoperative treatment and recovery.

Preoperative preparation

Preparation for surgery for appendicular peritonitis is a very important step: its improper implementation is fraught with problems during the surgical intervention itself and can provoke serious consequences. The complex of preparatory measures depends on the stage and type of inflammation and can last 2-4 hours.

The purpose of preparation for surgery is to reduce disturbances in blood circulation, its parameters, as well as water and mineral metabolism in the child's body.

To restore the volume of blood and fluid in the child's body, infusion therapy is carried out - droppers with saline are prescribed. Then - gastric lavage to reduce intoxication and restore breathing in children, antibiotics.

A special role for babies up to a year of life at this stage is played by therapeutic measures to reduce temperature, the fight against pneumonia, pulmonary edema and convulsions.

Surgery for appendicular peritonitis

Surgical intervention is started when the child's condition is normalized - the processes of blood circulation and water-salt metabolism are restored, the temperature has returned to normal numbers.

The purpose of the operation for children's appendicular peritonitis is to eliminate the primary focus of inflammation, to sanitize and drain the abdominal cavity. To do this, after removing the appendix, the cavity is washed with a solution (furatsilin, isotonic sodium chloride solution, etc.), but further actions depend on the severity of the inflammation and the degree of damage to the internal organs in the child.

In the reactive phase of the disease, the abdominal cavity usually contains a large amount of purulent effusion. After sanitation, the wound is sutured, leaving a silicone drain or a polyethylene tube for blood transfusion. With severe paresis (obstruction) of the intestine in the later stages, intubation of the small intestine is necessary.

Postoperative period

Immediately after the operation, it is important to provide the child with the necessary position in bed: raise the headboard by 30º, put a cushion under the knees. This will return the baby to full nasal breathing, allowing the remaining fluid in the peritoneum to drain into the lower abdomen.

A further set of postoperative measures is designed to prevent toxicosis and the development of infection in the child's body, impaired blood circulation and water-salt metabolism, and anemia.

For this, children's treatment after removal of the appendix should include the following items:

• Complete infusion therapy;
• Painkillers (if necessary);
• Broad-spectrum antibiotics and antipyretics (intravenously);
• Medicines to eliminate intoxication and restore normal blood microcirculation;
• A gentle diet to restore bowel function.

One of the most important tasks in the recovery of a child after appendicular peritonitis is the normalization of bowel function. This requires a sparing diet: on the first day after the removal of the appendix - a little non-carbonated mineral water, on the second or third day, you can enter mashed potatoes, rice water, jelly, steam diet cutlets. If constipation continues 3 days after the appendix is ​​cut out and the abdominal cavity is cleaned, the doctor may prescribe hypertonic enemas and agents to stimulate intestinal motility.

Peritonitis in childhood appendicitis is a serious disease that can take the most dangerous forms. The most important thing is not to miss the symptoms of peritonitis and contact the surgeon as soon as possible. Timely surgical intervention, comprehensive postoperative treatment and a diet in compliance with all medical recommendations are a guarantee that your child will soon forget about a dangerous illness and return to a full life.

Peritonitis is an inflammatory process of the abdominal mucosa. In most cases, it acts as a secondary disease, occurs against the background of other internal inflammatory processes.

Peritonitis in adults and children has distinctive features. Firstly, it concerns the etiology of the disease, in children the number of causes is much shorter, in most cases peritonitis is observed after acute appendicitis. Secondly, the process of diagnosis and treatment in children is a bit more complicated, especially for young children who cannot articulate symptoms. How to recognize peritonitis in time, and what methods of treatment should be used?

General characteristics of peritonitis in children

In babies, it is considered a not very common condition, the percentage of patients does not exceed 2%. The most dangerous disease is between the ages of 0 and 3 years. After 5 years, children are no longer listed as a special risk group, the shape of their abdominal cavity allows you to quickly eliminate the symptoms of the disease and stop the process.

Inflammation of the peritoneum at a young age develops quite quickly. The cavity is small and the internal organs function well, so the inflammatory process can cover its cavity or develop locally.

The nature of the disease is influenced by such indicators:

• Primary disease and its form;
• The age of the child;
• General health and immune defenses.

The prognosis of peritonitis in children is also different. If the diagnosis is correctly determined in time and specialized therapy is carried out, then the child can quickly return to normal life. Lack of specialized care can lead to the most adverse consequences, including death.

What can cause peritonitis?

The key reasons for the development of peritonitis in children are internal pathological processes. In the first place, experts bring acute. This inflammation of the caecum, which requires urgent removal, in children can penetrate in especially severe forms. Peritonitis in such cases occurs as a complication.

Other possible causes include the following pathological conditions:

• Intra-abdominal bleeding (causes can be many disorders);
• Tears and large cracks in the peritoneum;
• Acute intestinal obstruction;
• Worm infestations of an extensive form;
• Injury to the abdominal cavity, violation of the integrity of internal organs;
• Sepsis caused by internal inflammation of the navel;
• Diplococcal infectious disease;
• Complications after surgery;
• Meconium in the abdomen.

To eliminate the disease, an integrated approach is required, treatment is prescribed to eliminate the primary disease and peritonitis.

How to recognize a disease in a child?

The main danger of peritonitis is in childhood, when the symptoms are blurred, and the child cannot yet determine the nature of the pain.

With peritonitis, the child's condition deteriorates sharply, he becomes capricious, cries, refuses to eat. This occurs as a result of acute pain caused by the inflammatory process.

Then other symptoms develop:

• The pain is localized in the right side, increases with movement, has a sharp, stabbing character;
• Nausea with frequent bouts of vomiting, after which the patient does not feel better, first the contents of the stomach come out, then bile and parts of the feces appear;
• Extensive diarrhea, the stool has a liquid foamy consistency;
• with frequent gas emission;
• Heaviness in the intestines caused by a violation of peristalsis;
• The smallest children become in the form of an embryo with bent knees, so the pain subsides a little;
• The heartbeat quickens;
• Body temperature rises to 38 or more;
• The skin becomes dry, pale, looks like marble;
• Feeling dry in the mouth;
• Arterial pressure decreases.

The disease progresses very actively, while the symptoms only intensify. At an advanced stage of peritonitis in a child, the central nervous system is affected, so there may be loss of consciousness, dysfunction of some organs, and even coma.

How to diagnose peritonitis in children?

The specialist very carefully examines the child, listens to all complaints from the child or parents, makes palpation of the abdomen. With peritonitis, the pain is aggravated by pressure.

Also mandatory procedures are the measurement of body temperature, blood pressure and pulse.

To confirm the diagnosis, the doctor must observe the condition of the child for several hours, with peritonitis the condition worsens.

A number of laboratory tests should be carried out:

• General and biochemical blood analysis and culture;
• Urinalysis and culture.

It is impossible to confirm the diagnosis without a number of instrumental studies:

• CT and MRI;
• ultrasound;
• Electrocardiogram;
• Laparoscopy;
• Radiography.

After a complex of diagnostic procedures, urgent specialized treatment is prescribed.

Treatment

Peritonitis requires cardinal measures of treatment, urgent surgical intervention. But before that, you need to go through a number of preparatory procedures.

To begin with, medical preparation is carried out, including the following procedures:

• Complete antibiotic therapy to eradicate the infection;
• General anesthesia;
• Acceptance of funds for withdrawal;
• symptomatic treatment.

This is followed by an operation, the source of peritonitis is eliminated, and the abdominal cavity is amenable to antiseptic treatment. After surgery, a drain is placed for post-surgery treatment. A full treatment course lasts at least 7 days. All this time the child must be in the hospital under strict supervision.

Experts say that self-medication in case of peritonitis can be life-threatening for the child. Warming up, folk remedies, washings and other unconventional methods do not give any effect, they only provoke inflammation. Therefore, peritonitis should be eliminated only by specialists in a stationary mode and as soon as possible.

After the operation, you should also not deviate from the prescribed therapy and rehabilitation. Otherwise, complications may arise in the form of an abscess and other processes that are dangerous to the health and even the life of the child.

In children, peritonitis of the appendicular and cryptogenic nature is most common, in addition, neonatal peritonitis is especially distinguished. Peritonitis in children resulting from inflammation of the gallbladder and perforation of a duodenal ulcer is extremely rare and, according to the clinical picture of the disease, does not differ in any way from peritonitis in adults (as well as post-traumatic ones).

appendicular peritonitis. Peritonitis is the most severe complication of acute appendicitis in childhood, occurs in 6.2-25% of cases of acute appendicitis, and in children under 3-11 years of age 4-5 times more often than in older children.

age.

This is due to the late diagnosis of acute appendicitis due to the blurring of the clinical picture, the predominance of general symptoms over local ones, the lack of experience of polyclinics, the widespread prescription of antibiotics that change the clinical picture of appendicitis, but do not prevent the progression of the inflammatory process in the abdominal cavity. In any case, the release of the inflammatory process beyond the right side pocket should be considered diffuse peritonitis.

The anatomist and the physiological characteristics of the child's body affect the course of appendicular peritonitis. The smaller the child, the faster the purulent process spreads to all parts of the peritoneum. This is facilitated by low plastic properties of the peritoneum, functional underdevelopment of the greater omentum. Intoxication grows faster, metabolic processes develop

violations.

However, it should be noted that in children under 3 years of age, defense mechanisms quickly turn into pathological ones, and general clinical symptoms prevail over local ones.

In the reactive phase of the disease, the child's body loses salt, proteins and water, but this does not affect cellular metabolism, the enzyme systems function normally, therefore, at this stage, the child's local symptoms prevail over the general ones. The child is restless, does not sleep, refuses to eat, asks

Drink. There is vomiting. The abdomen has a normal shape, you detect active and passive muscle tension, Shchetkin's symptom -J! Bloomberg becomes positive. With comparative palpation of the abdomen, these symptoms are most pronounced in the right under the iliac region. The stool is usually normal.

In the toxic phase, disturbances in cellular metabolism occur. In addition to the deficiency of water, salt and proteins, a violation of the function of the enzyme system is noted, the cell mass loses anions and cations. Clinical symptoms are due to prominent signs of intoxication. The child continues to worry, at times adynamia occurs, facial features are sharpened, Vomiting is frequent, green. The mucous membranes of the mouth and tongue become dry. Expressed tachycardia. The abdomen somewhat changes its configuration, becomes swollen. Soreness occurs, active and passive muscular protection is more pronounced in all parts of the abdomen. Symptom Shchetkin - Blumberg sharply positive. The stool in young children is often liquid with mucus and greens.

The terminal phase is characterized by deeper dysfunction of the body and the effects of toxins on all organs and systems, including the central nervous system. During this period, there are severe violations of hemodynamics, acid-base status, water-electrolyte balance.

The main symptoms are violation of peripheral microcirculation: pallor of the skin and mucous membranes, marble pattern of the skin, symptom of "pale spot". The skin is cold, moist, with a gray tint. There is shortness of breath, shallow breathing. Changes also occur in the child's behavior: lethargy, adynamia, lethargy, especially with hyperthermia, and delirium appear. Hyperthermia is a symptom characteristic of peritonitis, reaching high numbers (39-40 ° C), poorly amenable to drug therapy.

Violation of hemodynamics is expressed in tachycardia, a decrease in arterial and central venous pressure, due to hypovolemia.

When examining the abdomen in older children, a pronounced widespread muscle tension (“board-shaped” abdomen) is found. In young children, early developing intestinal paresis relatively easily overcomes the resistance of the abdominal muscles, the abdomen looks swollen. Peristaltic noises are not heard. Symptoms of peritoneal irritation are pronounced. During rectal examination of the patient, overhanging of the arch and sharp pain are noted. The differential diagnosis of peritonitis is especially difficult in young children, since its symptoms are very similar to the clinical picture of pleuropneumonia, severe forms of dyspepsia, dysentery, and a number of other somatic and infectious diseases. In this case, it is necessary to take into account the initial manifestations of the disease. If the patient has peritonitis of the appendix,

of a paired nature, then at the beginning of the disease, pain in the abdomen prevails over all the symptoms, then other symptoms already appear. The main symptom of peritonitis, which removes all doubts, is, of course, the passive muscle tension of the abdominal mouse, which remains even if a drug-induced sleep is caused in the child; for this, after a cleansing enema, a 3% solution of chloral hydrate is injected into the rectum. Doses of the drug, depending on age, are as follows: up to 1 year - 10-15 ml; from 1 year to 2 years - 15-20 ml; from 2 to 3 years - 20-25 ml. The child falls asleep in 15-20 minutes, motor excitation disappears, psycho-emotional reactions and active tension of the abdomen are relieved. The study of the child during sleep allows not only to differentiate the active defense from the passive one, but also to obtain reliable data on the pulse rate, respiration, and also facilitates the examination of the child and the auscultation of the abdomen and chest.

If the diagnosis could not be clarified, then surgical intervention is recommended, but it is more expedient to preliminarily perform laparoscopy and establish an accurate diagnosis. In children who are in serious condition, as well as younger children, laparoscopy should be performed under intubation anesthesia.

The plan for examining a patient with peritonitis to determine the severity of the condition and the phase of the course of the disease must necessarily include a number of laboratory and functional research methods: determination of hemoglobin, hematocrit, and electrolytes. Tachycardia, a decrease in arterial and an increase in central venous pressure, changes in the rheogram indicate a violation of central and peripheral hemodynamics. The appearance of alkalosis, usually associated with significant hypokalemia, is considered a poor prognostic indicator.

Treatment of peritonitis consists of three main fragments: preoperative preparation, surgical intervention and postoperative management of the patient.

The preoperative preparation is based on the fight against hypovolemia and dehydration. For infusion therapy, solutions of hemodynamic and detoxification action are used (hemodez, reopoliglyukin, polyglukin, albumin, Ringer's solution, blood plasma).

Intravenous administration of broad-spectrum antibiotics is mandatory. Probing and gastric lavage are manipulations aimed at reducing intoxication, improving breathing, and preventing aspiration.

An important factor in preparing the patient for surgery and anesthesia is the fight against hyperthermia, carried out both by physical methods (cooling) and by drugs. The intubation combined anesthesia is shown.

Surgical treatment involves two tasks: elimination of the source of peritonitis and sanitation of the abdominal cavity.

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The generally accepted approach for adult patients with widespread peritonitis is midline laparotomy. In pediatric surgery, access is dictated by the stage of peritonitis and the age of the child. In the reactive stage (the first 24 hours), especially in children under 3 years old, Volkovich-Dyakonov access is used [Isekov Yu. F. et al., 1980; Dreyer KL et al., 1982]. This access, despite the relatively small size of the abdominal cavity in children, does not prevent the main task of surgical intervention - sanitation of the abdominal cavity. With diagnosed long-term peritonitis (more than 3 days), median laparotomy is indicated.

The next successive stages of the operation are the evacuation of the exudate, the elimination of the source of peritonitis, the toilet of the abdominal cavity and the suturing of the abdominal cavity.

Exudate is removed using an electric suction. Appendectomy is performed with the obligatory immersion of the stump into the purse-string and z-shaped sutures. The toilet of the abdominal cavity is carried out by washing. The basis of the washing medium is isotonic or weak hypertonic saline solutions, a solution of furacilin at a dilution of 1: 5000, in which most surgeons include antibiotics (aminoglycosides) at a rate of 1 g / l. The total volume of liquid for washing is 2-3 liters. Irrigation is performed as the final manipulation after completion of the appendectomy.

The final stage of the operation causes the greatest controversy among both adult and pediatric surgeons. The question of whether to close the abdominal cavity tightly, leave drains and tampons, has not been finally resolved. Proponents of a blind suture use microirrigators to administer antibiotics.

Drainage of the abdominal cavity is carried out with the help of special drainages made of silicone rubber, a strip of glove rubber, but in especially severe cases of widespread peritonitis in the terminal phase, it is possible not to suture the median laparotomy wound. After a thorough sanitation of the abdominal cavity, drainage is performed with a silicone tube of the small pelvis. The intestines are covered with a plastic film with multiple diamond-shaped holes cut out up to 5 mm in diameter, and napkins soaked in vaseline oil are placed on top. Above them, with separate sutures without tension, the skin approaches the aponeurosis, covering only the edges of the napkin. The absence of compression on the intestines and the possibility of free exit of the infected exudate from the abdominal cavity through the wound contribute to the improvement of intestinal microcirculation, the restoration of peristalsis and the relief of the inflammatory process. After 2-3 days, a second operation is performed: napkins and film are removed, the wound of the abdominal wall is sutured tightly through all layers. The edges of the wound are separated from the intestine so that when they are sewn together, the loops of the intestine are not deformed.

Peritoneal dialysis, unfortunately, does not guarantee against such complications as the occurrence of residual abscesses in the abdominal cavity, infiltrates, eventration, fistula formation. Peritoneal dialysis in pediatric practice is used according to strict indications - with widespread peritonitis and in its terminal phase.

In all other cases, the operation should end with a thorough sanitation of the abdominal cavity, the introduction of microirrigators for antibiotic therapy in the postoperative period. The success of the treatment of peritonitis is largely determined by the correct management of the patient after surgery, with the obligatory consideration of the following provisions: 1) massive antibiotic therapy, correction of metabolic disorders and the fight against intoxication; 2) the struggle for the restoration of the motor-evacuation function of the digestive tract.

Peritonitis is in most cases a polymicrobial disease in which associations of microorganisms are sown, more often with a clear predominance of the intestinal flora, as well as Proteus and Pseudomonas aeruginosa; anaerobes account for an average of 30%, and in the lumen of the gangrenous-altered process, non-spore-forming anaerobic flora was found in 100% [Kuzin M.I., 1983; Roy V.P., 1983], bacteroids are most often isolated. During treatment, the microflora can change significantly towards the predominance of gram-negative. Among modern antibiotics, aminoglycosides (kanamycin, gentamicin), cephalosporins, semi-synthetic penicillins (ampicillin, carbenicillin), nitrofurans have the greatest activity in children against the associated peritoneal flora. Given the role of the anaerobic flora, the appointment of metronidazole is indicated for peritonitis. It is necessary to remember the effect of antibiotics on the biocenosis of the body and the development of dysbacteriosis, which in turn can cause autoreinfection of the patient in the postoperative period.

Intravenous and intraperitoneal administration of antibiotics in combination, as well as intramuscular injections, are generally accepted. In recent years, works have appeared in the literature on the intra-arterial and endolymphatic routes of administration of antibiotics in peritonitis.

The volume of infusion therapy consists of the daily age requirement calculated according to the Aberdeen table, the deficit in circulating blood volume and pathological losses during hyperthermia by perspiration, sweating of fluid into the intestinal lumen during paresis. The calculation is carried out from 10 ml / (kg-day) for each degree above 37 ° C, 10 mg / (kg-day) for every 10 breaths above the norm, 20 ml / (kg-day) with II degree paresis, 40 ml / (kg-day) with paresis of the III degree.

The qualitative composition of the injected solutions is determined by the body's needs for proteins, carbohydrates, electrolytes, the need to bind and remove toxins.

Assign low molecular weight plasma substitutes: hemodez at the rate of 10 ml/(kg-day), reopoliglyukin 15 ml/kg, canned blood, plasma or protein plasma substitutes at the rate of 1-2.5 g of protein/(kg-day). The rest of the fluid is replenished with a 10% glucose solution with insulin and potassium.

When restoring BCC, hemoglobin should be at least 100 g / l, hematocrit - at least 30%, total protein - 60 g / l, A / G ratio - 1 -1.2, potassium content - 3.5-4.5 mmol / l.

Energy costs are replenished due to the transfusion of 10-20% glucose solution, 6-8 ml of 96 ° alcohol per 100 ml of 10% glucose (1 g of glucose-4 calories; 1 g of alcohol - 7.5 calories).

With a protracted severe course of peritonitis and the inability to feed through the mouth, parenteral nutrition is prescribed using amino acids and fat emulsions. Restoration of the motor-evacuation function of the gastrointestinal tract is one of the main tasks of intensive care for patients with peritonitis in the postoperative period.

Since intoxication and deterioration of regional blood flow play a major role in the pathogenesis of intestinal paresis, its treatment necessarily includes detoxification therapy and improvement of hemodynamics. The complex of combating paresis of the gastrointestinal tract also includes its decompression (stomach probing, intestinal intubation in advanced stages), the appointment of hypertonic and siphon enemas, stimulation of peristalsis with a 0.05% solution of prozerin or dimecaine (0.1 ml per 1 year of life , but not more than 1 ml), the use of novocaine blockades and epidural anesthesia. According to G. A. Bairov, the presence of appendicular peritonitis is an indication for the use of epidural anesthesia. When catheterizing the epidural space, the tip of the catheter should be at the level of the IV-V thoracic vertebrae (radiological control is mandatory), the duration of anesthesia is 4-5 days, the intervals between the administration of trimecaine are 3 hours. The program of infusion therapy should provide for the replenishment of the body's need for potassium . A good effect to prevent paresis has the introduction of sorbitol.

In recent years, works have appeared that testify to the high efficiency of hyperbaric oxygenation in peritonitis [Gorokhovskiy VI, 1981; Isakov Yu. F. et al., 1981]. Improvement of tissue oxygenation, stimulation of regenerative processes, improvement of microcirculation and rheological properties of blood and cellular mechanisms of immunity explain the therapeutic effect of this method.

With the purpose of detoxification in the literature of recent years, the use of hemo- and lymphosorption has been noted. However, there is not much experience in pediatric surgical practice on the use of these methods of treatment.

Cryptogenic peritonitis. In clinical practice, children with crypto-

togenic peritonitis is relatively rare. He is known

in the literature under various names: primary, hematogenous, pneumococcal, diplococcal, etc. None of the names is absolutely accurate, since the ways of infection of the abdominal cavity have not been elucidated, the nature of the microflora of the peritoneal exudate is diverse, and the absence of microflora growth is possible.

Girls are more likely to suffer from cryptogenic peritonitis. So, out of 127 patients with cryptogenic peritonitis described by N. L. Kush (1973), 122 were girls. This indicates the connection of this disease with the condition of the genitals. Children aged from 3 to 8 years are more often ill. The decrease in the incidence in older girls is associated with a change in the vaginal environment to the acidic side, which is not favorable for the reproduction of pneumococcus.

There are three forms of cryptogenic peritonitis: toxic, septicopyemic, localized. In recent years, a milder, often abortive course of the disease has been more often noted.

Severe forms are characterized by an acute onset of the disease, a rapidly progressive course (2-5 hours) with an increase in intoxication. Patients complain of pain in the abdomen, often of uncertain localization, but sometimes localized in the lower abdomen or in its first half. There are high body temperature (up to 39 ° and even 40 ° C), hyperleukocytosis.

On examination, there is bloating, pain on palpation in all departments, a positive Shchetkin-Blumberg symptom. Peristalsis is not heard. On rectal examination, an overhang of the anterior wall of the rectum is observed.

Peritoneal exudate - liquid, sticky, cloudy, odorless, without fibrin. The amount of effusion is different and depends on the severity of the disease. Hyperemia of intestinal loops, tubes, tube fringes, sometimes subserous hemorrhages are noted. Histological examination of the appendix revealed signs of periappendicitis.

There are fairly homogeneous reports about the causative agent of cryptogenic peritonitis in the literature, indicating a diplococcal infection (pneumococcus) with a large percentage of sterile cultures. Only a thorough bacteriological study with inoculation of exudate on various nutrient media and dynamic monitoring of microbial growth for 10 days makes it possible to identify microbes in 90% of patients with hematogenous peritonitis [Polyak M.S., Zhigulin V.P., 1970]. In half of the patients, the isolated bacteria belong to a monoculture, in others - to associations belonging to species that vegetate in the intestine: bacteria of the Escherichia coli group, enterococci, clostridia, staphylococcus aureus. A feature of these microbes is their tendency to anaerobiosis. Moreover, in children from 1 to 4 years, coccal bacteria predominate: staphylococcus aureus, enterococcus, pneumococcus. Gram negative

Sticks, along with coccal flora, are isolated in children older than 4 years. In severe forms of peritonitis, pneumococcus, beta-hemolytic streptococcus, Escherichia coli with hemolytic activity are more often isolated.

Most authors believe that surgical intervention is advisable in cryptogenic peritonitis, mainly because of the difficulties of differential diagnosis with acute appendicitis. Laparoscopy allows you to make the correct diagnosis and, in the presence of cryptogenic peritonitis, introduce antibiotics into the abdominal cavity.

The most appropriate is the appointment of antibiotics of the aminoglycoside group, chloramphenicol, ampicillin.

Surgical intervention ends with the removal of exudate, appendectomy and the introduction of antibiotics. In the postoperative period, detoxification and antibacterial therapy continues.

Peritonitis in newborns. Peritonitis in newborns is a serious complication of a number of different diseases and malformations of the gastrointestinal tract.

Almost until the 40s of our century, the diagnosis of peritonitis in newborns was made only at autopsy. Malformations and "spontaneous perforations" were considered the main cause of peritonitis.

Further development of science, morphological and experimental studies made it possible to establish that the genesis of many "spontaneous" perforations is intestinal wall ischemia - a disease that has received the name "necrotizing enterocolitis" in the world literature since the 60s of our century. The first successful surgical intervention for peritonitis in a newborn was performed in 1943.

Peritonitis in newborns is a polyetiological disease and, as numerous studies have shown, its causes can be: 1) malformations of the gastrointestinal tract; 2) necrotizing enterocolitis; 3) iatrogenic intestinal perforations; 4) bacterial infection of the peritoneum by contact, hematogenous or lymphogenous route in sepsis.

According to our data, in 85% of cases, the cause of peritonitis is perforation of the wall of the gastrointestinal tract.

Intrauterine perforations of the intestine (with malformations of the intestine) lead to aseptic, adhesive peritonitis, postnatal - to diffuse fibrinous-purulent, fecal peritonitis. With necrotizing enterocolitis against the background of intensive therapy, the development of limited peritonitis is possible.

Non-perforative fibrinous-purulent peritonitis, which develops in utero with hematogenous and lymphogenous, transplacental infection and with ascending infection of the birth canal, is rare. In the postnatal period, infection of the peritoneum is more often observed by contact with purulent periarteritis and periphlebitis of the umbilical vessels, abscesses

sahe liver, purulent diseases of the retroperitoneal space, phlegmon of the anterior abdominal wall, purulent omphalitis.

We offer a working classification of peritonitis in newborns in the following form.

I. According to etiological and pathogenetic features. A. Perforated peritonitis:

1) with necrotizing enterocolitis:

a) posthypoxic,

b) septic;

2) with malformations of the gastrointestinal tract:

a) segmental defects of the wall of the hollow organ,

b) malformations that cause mechanical obstruction of the stomach
dochno-intestinal tract;

1) with hematogenous, lymphogenous infection of the peritoneum;

2) in case of contact infection of the bojushina.
II. By the time of occurrence of peritonitis:

1) prenatal,

2) postnatal.

III. According to the degree of spread of the process in the abdominal cavity:

1) spilled,

2) limited.

IV. By the nature of the effusion in the abdominal cavity:

1) fibroadhesive,

2) fibrinous-purulent,

3) fibrinous-purulent, fecal.

The clinic and diagnostics of peritonitis are largely determined by its etiology.

Perforated peritonitis is characterized by a sharp deterioration in the patient's condition, manifested by symptoms of peritoneal shock, lethargy, adynamia, and sometimes anxiety. The skin is grayish-pale, dry, cold. Respiration is frequent, shallow, groaning, heart sounds are muffled, tachycardia. Sharp bloating, tension, pain on palpation. Peristalsis is not audible. Hepatic dullness is not defined. Vomiting mixed with bile and intestinal contents. Chair and gases do not escape. When x-rays in a vertical position, free air under the dome of the diaphragm is determined. Small compensatory possibilities quickly lead to severe disturbances of homeostasis and death of the child in 12-24 hours.

The clinical picture of diffuse nonperforative peritonitis is characterized by a more gradual increase in symptoms of intoxication and intestinal paresis with a pronounced hyperthermic reaction and changes in the hemogram (neutrophilia, increased ESR, etc.). As a rule, the reaction from the anterior abdominal wall is more pronounced: hyperemia, infiltration, expanded venous network, swelling of the external genital organs. Significant hepatosplenomegaly. X-ray shows hydroperitoneum.

A bright clinical picture of peritonitis at the height of the disease, as a rule, does not cause diagnostic difficulties.

The following malformations can be the causes of perforation of the gastrointestinal tract: 1) malformations that cause mechanical intestinal obstruction: a) with obstructive obstruction (atresia, meconium ileus, Hirsch. Prung disease); b) with the phenomena of strangulation (inversion of the intestines, strangulated internal hernia); 2) segmental defects of the wall of the gastrointestinal tract (defect of the muscle layer of an isolated section of the wall of a hollow organ, angiomatosis of the intestinal wall).

Malformations that cause mechanical obstruction of the gastrointestinal tract in 50% of cases lead to intrauterine perforation of the intestine and adhesive peritonitis. By the time the baby is born, the perforation usually closes, and the meconium that escapes is calcified. There are two types of intrauterine peritonitis: 1) fibroadhesive (significant adhesive process in the abdominal cavity); 2) cystic (formation of a cystic cavity with fibrous walls in the free abdominal cavity, communicating with the intestinal lumen through a perforation).

Postnatal perforations of the gastrointestinal tract with malformations are always accompanied by fibrinous-purulent, fecal peritonitis.

It is difficult to make a diagnosis of intrauterine adhesive peritonitis before surgery. Moderate soreness and tension of the abdominal muscles against the background of symptoms of atresia of the small intestine and radiographically detectable calcifications in the free abdominal cavity help to suspect it. With cystic peritonitis, a cystic cavity in the free abdominal cavity is determined radiologically, often adjacent to the anterior wall. The walls of the cyst are thickened, calcified, a large level of fluid is determined in its lumen.

Segmental malformations of the gastrointestinal tract in the first days of life of children do not have symptoms that portend a catastrophe. Perforation always develops acutely, among complete well-being, on the 3rd-6th day of life it manifests itself as a picture of peritoneal shock. Clinically and radiographically, this group of patients has a large amount of free gas in the abdominal cavity, which leads to severe respiratory and cardiac disorders.

A feature of perforative peritonitis in necrotizing enterocolitis is a large area of ​​intestinal damage and the severity of the adhesive-inflammatory process in the abdominal cavity. The pneumoperitoneum is moderate.

A more favorable form of peritoneal complications of necrotizing enterocolitis in newborns is limited peritonitis, observed in one third of cases. In these cases on the against the background of symptoms of enterocolitis in the abdominal cavity, a dense infiltrate with clear contours appears, moderately painful, more often localized in the right iliac region. When opening the intestinal lumen and abscess formation of the infiltrate,

there is an increase in its size, the child's anxiety increases, especially with palpation of the abdomen. The tension of the muscles of the abdominal wall is revealed, the general condition worsens. Often these symptoms are difficult to catch, as they appear against the background of a severe, usually septic condition.

Limited peritonitis at the stage of infiltration is subject to conservative treatment, which in 38% of cases leads to the relief of the inflammatory process. We prefer the following antibiotics: a group of cephalosporins, oxacillin, gentamicin. Selective decontamination of the intestine is shown, and in the most severe cases - complete decontamination in the conditions of a gnotobiological isolator.

Selective decontamination is prescribed from the moment of enteral feeding with the introduction of antibiotics that are not absorbed by the intestinal mucosa. Most often, gentamicin is prescribed at a dose of 10 mg / (kg-day), kanamycin at 10-20 mg / (kg "day), nevigramon at 0.1 mg / (kg-day) - for a period of 7-10 days from subsequent appointment of bifidum-bacterin 2.5-5 doses 3-4 times a day for 2-4 weeks under the control of fecal analysis for dysbacteriosis.In addition, along with replacement, stimulating therapy is recommended (antistaphylococcal drugs, anti-coliplasma) , drugs that stop the immune block (levamisole, thymalin, prodigiosan), desensitizing agents... Vitamins and enzyme preparations are prescribed according to general principles.

Surgical treatment of necrotizing enterocolitis is indicated: 1) at the stage of diffuse perforated peritonitis; 2) in acute intestinal infarction; 3) at the stage of preperforation with the ineffectiveness of intensive conservative therapy for 6-12 hours and an increase in clinical and radiological symptoms; 4) with abscessing of the infiltrate of the abdominal cavity.

Transrectal access is more commonly used. With diffuse peritonitis, the operation of choice is resection of the necrotic part of the intestine with the removal of a double intestinal stoma. After simultaneous washing of the abdominal cavity with solutions of antiseptics and antibiotics, the latter is sutured, leaving a catheter for the introduction of antiseptics (dioxidine). With a total lesion of the colon, we recommend the operation of switching off by imposing an unnatural anus on the terminal ileum (ileostomy).

In cases of abscessing of the infiltrate of the abdominal cavity, an abscessotomy is necessary. Through a small incision of the anterior abdominal wall, the abscess cavity is drained as sparingly as possible, without violating the delimiting capsule. As a rule, a low intestinal fistula is formed. A feature of intestinal fistulas in newborns is their independent closure when the underlying disease is relieved.

Operational access. It is advisable to use a transrectal or transverse incision.

In patients with intrauterine adhesive peritonitis, it is necessary

It is necessary to carry out the separation of adhesions, resection of the atrezed section of the intestine, followed by the imposition of an anastomosis end-to-end or side-to-side. We use a single-row U-shaped silk serous-muscular suture.

With segmental defects of the colon, the operation of choice is the allocation of a perforation zone on the abdominal wall in the form of a colostomy. Perforations of the stomach are sutured with double row sutures. The abdominal cavity is washed with solutions of antiseptics and antibiotics and sutured tightly. Reconstructive closure of the colostomy is carried out after 3- 4 months

iatrogenic peritonitis. Iatrogenic perforations include perforations of the gastrointestinal tract that occur when the probing technique, instrumental examination methods, and cleansing enemas are violated. Mechanical trauma is the main cause of iatrogenic perforation of the wall of a hollow organ, mainly the rectum, the region of the rectosigmoid zone.

In all cases, perforation of the rectum was penetrating into the abdominal cavity, localized on the anterior wall in the area of ​​the transitional fold of the peritoneum, accompanied by diffuse hemorrhagic-purulent fecal peritonitis.

A sharp deterioration in the child's condition, accompanied by symptoms of peritoneal shock, usually occurs immediately after the manipulation. A typical clinic of diffuse peritonitis develops very quickly.

The operation of choice for perforation of the rectum is the suturing of the perforation with the imposition of a proximal sigmostoma. Sanitation of the abdominal cavity is carried out according to the general rules.

Nonperforative peritonitis. Nonperforative or septic peritonitis develops in newborns with intrauterine or postnatal infection. According to our data, it occurs in 16% of cases.

With intrauterine infection, a severe septic process with serous-purulent peritonitis, pleurisy, pericarditis and meningitis, caused by both gram-positive and gram-negative flora, often develops hematogenously and lymphogenously.

In the postnatal period, peritonitis occurs during the contact transition of a purulent infection from the umbilical vessels or from the retroperitoneal space.

Nonperforative postnatal peritonitis is limited in about 50% of cases.

In newborns in case of intrauterine infection, the symptoms of peritonitis appear on the 1st day of life. Clinical symptoms are of a general and local nature: severe toxicosis, vomiting of bile, bloating and abdominal pain, stool retention. The abdominal wall is thickened, tense, glossy, hyperemia appears.

X-ray reveals a significant hydroperitoneum, darkening the abdominal cavity and leading to indistinct contours of the intestinal loops. There is a darkening of the upper floor of the abdominal cavity due to hepatosplenomegaly.

The clinical picture of postnatal peritonitis develops, as it were, gradually against the background of a focus of purulent infection. There is a gradual deterioration and an increase in toxicosis, symptoms of paresis of the gastrointestinal tract appear: vomiting, bloating, stool retention, then the tension of the muscles of the abdominal wall increases and its swelling is noted, which extends to the external genital organs. With limited peritonitis, the infiltrate of the abdominal cavity passes to the anterior abdominal wall, more often in the area of ​​​​inflammation of the umbilical vessels.

X-ray reveals hydroperitoneum, intestinal paresis; intestinal walls are not thickened. Thickening of the anterior abdominal wall. In the case of an infiltrate, a blackout appears in the abdominal cavity, pushing the intestinal loops back.

Therapeutic tactics for non-perforative peritonitis initially consists of conservative antibiotic and infusion therapy to stop both the primary focus of infection and incipient peritonitis. With no effect in within 6-12 hours and an increase in clinical and radiological symptoms, surgery is recommended. At the same time, the abdominal cavity is washed with solutions of antiseptics and antibiotics with mandatory drainage of the focus of purulent infection.

N. S. Tokarenko (1981) suggests laparocentesis with abdominal catheterization and fractional lavage with antibiotic solutions for the treatment of septic peritonitis.

With limited peritonitis at the stage of abscess formation, abscessotomy and drainage of the abscess cavity are indicated.

This pathology is widely known in the practice of pediatric surgery under the names "diplococcal", "pneumococcal", "cryptogenic" or "primary" peritonitis. The disease most often occurs in girls aged 3 to 7 years. It has been established that the infection penetrates into the abdominal cavity through the vagina with the development of endosalpingitis. At an older age, this disease is much less common. This fact is explained by the appearance of Döderlein sticks in the vagina, which, creating an acidic environment, prevent the development of natogenic microflora. The widespread introduction of laparoscopy has convincingly confirmed this point of view and changed the tactics of treating such patients.

With a localized process in the lower floor of the abdominal cavity, there is a transparent or cloudy mucous effusion that stretches behind the manipulator. Its greatest amount is detected in the pelvic cavity. The uterus and fallopian tubes are somewhat edematous, moderately hyperemic, the ovaries are intact. Already at this early stage of the disease, even in the absence of hyperemia of the parietal and visceral peritoneum, marked inflammatory changes in the area of ​​the ampulla of the fallopian tubes are noted. The fimbriae are sharply hyperemic, with petechial hemorrhages, due to pronounced edema, they are moved apart in the form of a corolla. This symptom is called the “red corolla” symptom and is caused by the presence of endosalpingitis, which indicates the primary localization of the inflammatory process. In this regard, it is advisable to characterize this pathology as primary ampullar pelvioperitonitis.

With the progression of the disease, the effusion becomes purulent, its quantity increases, but its viscous mucous consistency is still preserved. Endoscopically reveal a picture of acute purulent pelvioperitonitis. The fallopian tubes at this moment sharply thicken due to edema, there is a pronounced hyperemia of all organs of the small pelvis and petechial hemorrhages on the peritoneum. Even with this severity of the process, the ovaries, as a rule, remain intact, the phenomena of oophoritis are observed extremely rarely.

Clinical picture and diagnosis Clinically, two forms of primary ampullar pelvioperitonitis are distinguished - toxic and local. The toxic form is characterized by an acute and rapid onset of the disease. Severe abdominal pain is noted, usually in its lower sections. Body temperature most often rises to 38-39 ° C. Vomiting may be repeated. Often, loose stools are added, which occurs when peristalsis is increased due to a pronounced inflammatory process in the abdominal cavity.

A significant severity of the general condition is observed, despite the short period that has elapsed from the onset of the disease (sometimes only 2-6 hours). The child is usually restless, groans, the skin is pale, the eyes are shiny. Tongue dry, coated with white coating. When examining the abdomen, all signs of severe peritonitis are found: sharp pain and a clear rigidity in all parts of the anterior abdominal wall, but somewhat greater below the navel and on the right. Shchetkin-Blumberg's symptom is positive. Moderate intestinal paresis is also noted. In many cases, it is possible to detect the phenomena of vulvovaginitis with mucopurulent discharge from the vagina. When examining peripheral blood, high leukocytosis is found (up to 20x10 9 /l and above).

In recent years, changes have occurred in the clinical picture of primary ampullar pelvioperitonitis, characterized by a predominant predominance of localized (local) forms. The toxic form of the disease occurs quite rarely (no more than 5% of cases).

With a localized form of primary ampullar pelvioperitonitis, the clinical picture is erased, intoxication is not expressed, pain is often localized in the lower abdomen or even only in the right iliac region. At the same time, body temperature does not reach high numbers and is more often in the range of 37.5-38 ° C. However, a more acute sudden onset of the disease, the presence of ARVI at the time of examination or ARVI transferred the day before - all these signs make one suspect primary ampullar pelvic peritonitis. However, even with a typical manifestation of the disease, surgery is performed, since the surgeon cannot completely exclude the diagnosis of acute appendicitis. An unnecessary appendectomy is performed, potentially dangerous for the occurrence of serious postoperative complications, such as adhesive intestinal obstruction (ILE), progression of the inflammatory process, etc. Laparoscopy allows you to confirm or exclude the diagnosis with high accuracy.

Treatment and prognosis Diagnostic laparoscopy often becomes curative. Aspiration of pus is performed, a solution of antiseptics is injected. Appendectomy is not performed in such cases. All patients are prescribed antibiotic therapy with penicillins or cephalosporins for 5-7 days. The prognosis is always favorable.

7.12.2. appendicular peritonitis

Peritonitis is the most common and most severe complication of acute appendicitis in childhood, occurring in 8-10% of all cases of the disease, and in children of the first 3 years of life 4-5 times more often than at an older age. In recent years, it has been possible to reduce mortality among patients hospitalized in the initial phases of the disease, but in advanced forms, mortality remains very high.

Classification Of the many proposed classifications, the principle of dividing peritonitis according to the staging of the course of the process and the prevalence of peritoneal damage, the severity of intestinal paresis (Fig. 7-15) is most widely used.

The most appropriate should be considered the division of peritonitis into local and diffuse. Local peritonitis, in turn, is divided into limited and unlimited. The latter is characterized by inflammatory changes in the affected area with possible leakage of exudate into the adjacent area along the path of natural distribution (right lateral canal and pelvic cavity). With diffuse peritonitis, inflammatory changes in the peritoneum go beyond the focus, not along the path of natural spread. The exit of the inflammatory process beyond the right lateral canal should practically be considered diffuse peritonitis.

The most widespread in peritonitis is the allocation of three phases of its course (reactive, toxic and phases of polymorphic disorders), reflecting the severity of the clinical manifestations of the disease. The phases of the course of peritonitis are confirmed by changes in central hemodynamics, microcirculation, and immunological reactivity.

Pathogenesis diffuse peritonitis - a complex chain of functional and morphological changes in systems and organs. Anatomical and physiological features of the child's body affect the course of appendicular peritonitis. The smaller the child, the faster the purulent process spreads to all parts of the peritoneum. This is facilitated by low plastic properties of the peritoneum, underdevelopment of the greater omentum. Intoxication and metabolic disorders increase faster, many defensive reactions become pathological.

The leading role in the pathogenesis of peritonitis belongs to the microbial factor and the state of the body's immunoreactivity. The nature and severity of changes depend on the severity of pathological processes. It has been established that in most cases peritonitis is a polymicrobial disease. The dominant role in its development belongs to E. coli, but other microorganisms are also of great importance: enterococci, Klebsiella and others, as well as anaerobes. In a targeted study, anaerobic flora is sown in more than a third of patients, and in the formation of intra-abdominal abscesses - in almost 100% of cases. This fact must be taken into account when prescribing empirical antibiotic therapy, since many antibiotics are ineffective in anaerobic infections.

One of the leading factors in the development of pathophysiological changes that occur with peritonitis is the resorption of toxic products of purulent exudate from the abdominal cavity by the peritoneum. The surface of the peritoneum in children, especially young children, is relatively larger than in adults. It has been established that in peritonitis, especially in its initial stages, the resorption of toxic products by the peritoneum occurs very intensively. As a result, bacterial toxins and decay products of microbial bodies enter the blood and lymph in large quantities. It is the absorption of toxic products that causes a chain of various pathophysiological disorders, including dehydration, circulation disorders, hyperthermia, acid-base disturbances, etc.

In children with appendicular peritonitis, dehydration and circulatory disorders develop quite rapidly. Biologically active substances released in large quantities have a vasodilating effect, which increases the permeability of the vascular wall and promotes the release of water and low molecular weight proteins from the vascular bed. Increased exudation of fluid and protein into the abdominal cavity. In parallel, there is a significant loss of water due to frequent vomiting, loose stools. Fluid loss is also aggravated by perspiration and shortness of breath. With intestinal paresis, there is a massive accumulation of fluid in its lumen. Massive loss of fluid from the bloodstream leads to a significant decrease in BCC and, consequently, hemoconcentration. Hypovolemia and subsequent hypoxemia cause spasm of peripheral and renal vessels, which leads to redistribution of blood while maintaining the nutrition of vital organs, mainly the heart and brain (centralization of blood circulation). In response to this, compensatory tachycardia occurs, leading to overstrain of the heart muscle and disruption of the heart.

A decrease in renal blood flow contributes to a decrease in urine filtration in the renal glomeruli and the occurrence of renal ischemia. In the future, disorders of kidney function lead to water-electrolyte and metabolic disorders.

Due to spasm of skin vessels, heat transfer is reduced, which exacerbates hyperthermia. A significant increase in body temperature (39-40 ° C and above) occurs in most patients with purulent peritonitis. In young children with hyperthermia, due to increased energy consumption, energy reserves are very quickly depleted, metabolic disorders and disorders of the respiratory and cardiovascular system functions occur. All this can lead to adrenal insufficiency.

One of the important pathophysiological links in the development of peritonitis is a metabolic disorder. With peritonitis, the replenishment of energy resources with food is disrupted, the use of carbohydrates from the body's own reserves (liver glycogen) begins. Then, proteins and fats are used as an energy source, the breakdown of which under conditions of tissue hypoxia leads to the accumulation of underoxidized products. Gradually, the detoxification function of the liver begins to suffer. In severe peritonitis, protein metabolism disorders develop. Loss of protein occurs with exudate, its diffusion into the intestinal lumen. Dysproteinemia develops.

The formation of acidic products changes the pH of the blood - metabolic acidosis occurs. First, metabolic shifts are compensated to a sufficient extent by respiration (due to compensatory shortness of breath and increased carbon dioxide release) and kidneys (by reabsorption of sodium and excretion of excess acid radicals). Compensatory mechanisms are very quickly depleted in conditions of peritonitis due to the limitation of respiratory excursions due to paresis and bloating of the intestine, as well as on the basis of hemodynamic disorders. Acidosis passes into the stage of decompensation.

With peritonitis, there are also significant disturbances in electrolyte metabolism. Vomiting and loose stools lead to loss of fluid and electrolytes (potassium, sodium, chloride ions). As the loss of potassium and chlorine ions against the background of a decrease in plasma volume, acid-base balance disorders occur, consisting in the development of intracellular acidosis against the background of extracellular alkalosis (Darrow mechanism). The impoverishment of the cell with potassium ions contributes to the disruption of ATP synthesis and a decrease in energy reserves, which leads to a weakening of the contractile force of the myocardium and respiratory muscles. Shortness of breath, tachycardia occur, the stroke volume of the heart decreases and circulatory failure develops with symptoms of general tissue hypoxia. A deficiency of potassium ions reduces the tone of smooth muscles, leading to the development and progression of paresis of the gastrointestinal tract.

Consequently, the main pathophysiological processes in peritonitis are hypovolemia and impaired central and peripheral hemodynamics, changes in the water and electrolyte balance and acid-base state, and dysfunction of vital organs. In severe peritonitis, these disorders can be considered as manifestations of peritoneal shock.

Most of these disorders are reflected in clinical symptoms. It is only necessary to take into account that in children under 3 years old, protective mechanisms quickly turn into pathological ones, and general clinical symptoms prevail over local ones.

The course of diffuse peritonitis is also accompanied by pronounced violations of the immunological reactivity of the child's body, which have a clearly expressed phase character.

In the reactive phase of peritonitis, the tension of factors of natural nonspecific reactivity, an increase in the activity of p-lysines, the number of leukocytes, lymphocytes, an increase in the level of immunoglobulins in the blood serum, an increase in the absolute number of rosette-forming cells, and a decrease in the relative number of T- and B-lymphocytes are noted.

In the toxic phase, there is a further increase in the overall level of non-specific indicators, however, there is a change in the number of functionally active leukocytes and a drop in the concentration of serum immunoglobulins.

In the phase of multiple organ disorders, the complete failure of the protective forces, a catastrophic decrease in the indicators of both specific and nonspecific immune reactions are noted.

Clinical picture In the anamnesis, as a rule, pain, vomiting, fever are noted. In the future, the pain may subside somewhat, but hyperthermia persists, although sometimes insignificant; the general condition also may improve somewhat, but never recovers to a satisfactory level. After the "light interval" worsening occurs: the pain in the abdomen increases again, vomiting appears, the general condition progressively worsens. The presence of such a gap is apparently associated with the destruction and necrosis of the nerve endings in the appendix. The onset of a period of deterioration is explained by the involvement of the entire peritoneum in the inflammatory process as a result of perforation of the appendix or violation of the integrity of the conglomerate with a “covered” perforation. Perhaps the development of peritonitis and without perforation of the appendix due to the passage of microflora through the altered wall. The speed of the onset of perforation and the duration of the "light interval" depend on the age of the patient: the smaller the child, the faster the perforation occurs and the shorter the period of imaginary improvement. The use of antibiotics sharply erases the severity of the clinical manifestations of appendicitis, which increases the likelihood of developing peritonitis. Antibiotics cannot stop the destructive process that has already begun, but their use reduces the severity of the pain symptom, temperature reaction and general disorders, while peritoneal inflammation progresses. Therefore, the use of antibiotics, especially in young children, is contraindicated until the cause of abdominal pain is established.

Diagnostics When examining a child with appendicular peritonitis, a significant severity of the general condition is noted. The skin is pale, sometimes has a "marble" hue. The eyes are shiny, the tongue is dry, with a white coating. Usually there is shortness of breath, the more pronounced, the younger the child. It is often possible to establish a discrepancy between the pulse rate and the degree of increase in body temperature. The abdomen is swollen, sharply painful on palpation in all departments, protective muscle tension and the Shchetkin-Blumberg symptom are clearly revealed, most pronounced in the right iliac region.

Sometimes there are tenesmus, loose stools in small portions, painful and frequent urination. Rectal examination reveals severe pain and overhanging of the rectal wall.

In young children, the general condition at first may be slightly disturbed, which is associated with good compensatory capabilities of the cardiovascular system at this age. Respiratory failure may come to the fore. After some time, decompensation of the cardiovascular and respiratory systems, as well as metabolic processes, occurs, as a result of which the patient's condition begins to progressively worsen. At an early age, with appendicular peritonitis, loose stools are more often observed, sometimes green with mucus.

Treatment peritonitis in children is a difficult task and consists of three main stages: preoperative preparation, surgery and postoperative period.

Preoperative preparation Immediate surgical intervention for peritonitis in conditions of significant disturbances in the internal environment of the body is a serious mistake. These shifts can be exacerbated during surgery and in the postoperative period under the influence of surgical trauma, anesthesia errors and further progression of the pathological process.

The purpose of preoperative preparation is to reduce hemodynamic disturbances, acid-base status and water-electrolyte metabolism.

The basis of preoperative preparation is the fight against hypovolemia and dehydration. The degree of dehydration can be determined by the following formula using hematocrit values.

where m is body weight, k is a coefficient (for children over 3 years old - 1/5, for children under 3 years old - 1/3).

When conducting infusion therapy, solutions of hemodynamic and detoxification action are primarily prescribed (dex-stran, average molecular weight 30000-40000, albumin, dextran, average molecular weight 50000-70000, Ringer's solution, blood plasma). The volume and quality of infusion therapy depend on the severity of peritonitis, the nature of hemodynamic disorders and the age of the patient. The whole complex of preoperative measures should be performed in a fairly short time (no more than 2-3 hours).

Therapy with broad-spectrum antibiotics begins already in the preoperative period. Recommend intravenous administration of £) third-generation cephalosporin (cefotaxime, ceftriaxone) or an inhibitor-protected penicillin (amoxicillin + clavulanic acid), under the protection of which the operation is performed. In the postoperative period, the administration of antibiotics in the form of combined antibiotic therapy (cephalosporin + aminoglycoside + metronidazole or amoxicillin-Nclavulanic acid + aminoglycoside) is continued, which makes it possible to cover the entire spectrum of potential causative agents of peritonitis (gram-negative bacteria, enterococci and anaerobes). intoxication, improved breathing, prevention of aspiration. An important role, especially in children of the first months of life, is played by the fight against hyperthermia, pneumonia, pulmonary edema, convulsions.

Surgical treatment Surgical intervention is started when hemodynamic processes, acid-base state, water-electrolyte metabolism are compensated and stabilized, and body temperature does not exceed subfebrile numbers. Surgical intervention for peritonitis is carried out in order to eliminate the primary focus, sanitation and drainage of the abdominal cavity. The impact on the primary focus is appendectomy. Further tactics depend on the depth of changes in the intestines and peritoneum. The most important in this situation is the assessment of peristalsis and circulatory disorders.

Features of surgical tactics in appendicular peritonitis depend on its phase.

In the reactive phase during surgery, a profuse purulent effusion in the abdominal cavity is usually found. The intestinal loops are somewhat swollen, hyperemic, without fibrin and circulatory disorders. Despite the fact that the inflammatory process spreads to the entire abdominal cavity, local symptoms still prevail, the body, as it were, copes with the disorders that have arisen, using its own reserves. Among intraoperative measures in the reactive phase, an important role is assigned to a thorough sanitation of the abdominal cavity. Then the surgical wound is sutured tightly, leaving a silicone drainage or a polyethylene tube from a disposable blood transfusion system in the small pelvis. Drainage is introduced through an additional puncture incision in the right iliac region, slightly above and lateral to the "appendicular" incision. For its proper fixation, the abdominal wall is pierced in an oblique (at an angle of 45°) direction, after which the drainage is placed in the right lateral canal and maximally on the bottom of the small pelvis (for boys - between the rectum and bladder, for girls - between the rectum and uterus). The diameter of the holes in the section of the tube located in the small pelvis should not exceed 0.5 cm. With smaller holes, the drainage quickly becomes clogged, and with larger holes, suction of the intestinal wall, omentum, and fatty suspensions is possible. On the skin, the drainage tube is fixed with silk sutures (Fig. 7-16).

In the toxic phase of peritonitis in the abdominal cavity, a large amount of pus, significant paresis (up to paralysis), severe circulatory disorders with fibrin overlays on intestinal loops can be detected. Surgical tactics in this phase of peritonitis in general principles is similar to that in the previous phase, but has some features. Simultaneous washing of the abdominal cavity should be more thorough and using a large amount of washing solution. With significant paresis of the intestine, various methods of its decompression are used: intubation of the small intestine through a gastrostomy, cecostomy, retrograde through the anus or "pumping" the contents of the small intestine into the colon. As in the exudative phase of peritonitis, aspiration drainage of the pelvic cavity is carried out using a drainage tube. The root of the mesentery of the small intestine is cut off with a 0.25% solution of procaine. Epidural anesthesia is indicated, which is carried out in the postoperative period.

In the phase of polymorphic disorders, operations reveal deep functional disorders of the intestine. Due to its paralysis, stasis and expansion of the small intestine due to the accumulation of fluid and gases are noted. In this case, delimited abscesses in the abdominal cavity are more often detected. After separation of the intestinal loops, it is advisable not to suture the median laparotomy wound (laparostomy). After a thorough sanitation of the abdominal cavity, the pelvic cavity is drained with a silicone tube. The intestines are covered with a polyethylene film with multiple holes up to 5 mm, napkins soaked in vaseline oil are applied on top, over which, with separate seams, without tension, the skin is brought closer to the aponeurosis, covering only the edges of the napkins. The absence of compression on the intestines and the possibility of free exit of the infected exudate from the abdominal cavity through the wound contribute to the improvement of microcirculation in the intestines, the restoration of peristalsis and the relief of the inflammatory process. In this phase of peritonitis, decompression of the gastrointestinal tract is of particular importance. After 2-3 days, a second operation is performed: napkins and film are removed, the wound is sanitized, the abdominal wall is sutured tightly through all layers with U-shaped mattress silk sutures. The edges of the wound are separated from the soldered intestine so that the loops of the intestines are not deformed during stitching.

Postoperative treatment After surgery, the patient is placed in an elevated position in the bed by raising its head end at an angle of 30°, which facilitates the child's breathing and facilitates the outflow of exudate into the lower abdomen. A roller is placed under bent knees so that the child does not slide down.

It is extremely important to carefully monitor cardiac activity (pulse, blood pressure, ECG), respiration, blood protein composition, water and electrolyte balance, and the acid-base state of the blood. During the first 2-3 days, body temperature, pulse, blood pressure, respiratory rate are monitored every 2-4 hours. Carefully measure the volume of drunk and parenterally administered fluid and excreted with urine and vomit.

In addition to the general condition (reaction to the environment, appetite, normalization of the function of the gastrointestinal tract), extremely important indicators of the course of the inflammatory process in the abdominal cavity are the dynamics of the temperature reaction and the picture of peripheral blood.

The complex of therapeutic measures consists of the following points: the fight against toxicosis and infection, the elimination of hemodynamic disorders and hypovolemia, the correction of water-electrolyte and metabolic shifts, the elimination of anemia and hypoproteinemia.

Great importance should be attached to the prevention and treatment of respiratory disorders. The complex of these measures includes decompression of the stomach by inserting a probe into it. The constant presence of the probe in the first 2-3 days after surgery prevents aspiration, helps to reduce intra-abdominal pressure, increasing the ventilation capacity of the respiratory system.

Prevention and treatment of respiratory failure is essential throughout the immediate postoperative period. According to indications, catheterization of the tracheobronchial tree is carried out, followed by suction of the mucus. This makes it possible to prevent the development of atelectasis and pneumonia.

In the early postoperative period, homeostasis disturbances may again occur due to surgical trauma and the ongoing inflammatory process. The main ones are violations of hemodynamics, acid-base state and water-electrolyte balance. More than a third of patients with diffuse peritonitis have similar disorders with symptoms of severe metabolic acidosis. Extremely rarely, with very severe forms of peritonitis, the phenomena of metabolic alkalosis are also noted. Correction of hemodynamic changes and metabolic acidosis does not differ from that carried out in the preoperative period. It is achieved by intravenous administration of plasma, macromolecular drugs, 4% sodium bicarbonate solution. Metabolic alkalosis is corrected by intravenous administration of a 7.5% solution of potassium chloride, on average from 8 to 10 ml (0.5 ml/kg of body weight) in dilution. Respiratory acidosis that occurs in the postoperative period is eliminated by dosed oxygen therapy and evacuation of gastric contents using a probe. Correction of violations of water and electrolyte metabolism does not differ from that carried out before surgery.

The success of treatment for peritonitis largely depends on the rational use of antibiotics. Combined antibiotic therapy (based on third-generation cephalosporins or inhibitor-protected penicillins) is indicated. For children operated on again due to complications (subhepatic, subdiaphragmatic abscesses, intestinal fistulas, etc.). in patients with previous hospitalization and antibiotic therapy, as well as in postoperative peritonitis, the antibiotics of choice are carbapenems (imipenem + cilastatin, meropenem) in monotherapy or in combination with aminoglycosides. An important link in the postoperative period in patients with peritonitis is the normalization of bowel functions. In severe peritonitis, intestinal paresis often lasts for several days. To combat postoperative paresis, repeated hypertonic enemas are used, agents that stimulate peristalsis are prescribed subcutaneously (0.05% solution of neostigmine methyl sulfate, 0.1 ml per 1 year of life), hypertonic dextrose solutions are transfused intravenously (10-20 ml of a 40% solution) , 10% sodium chloride solution ~ (psG2-schgna 1 year of life) and potassium chloride solutions. The infusion of the latter is carried out in a dextrose solution drip. The safest concentration of potassium chloride is 1%. It is necessary to monitor the regularity of the stool: if it is delayed, cleansing enemas are done once every 2 days. Taking into account the possibility of formation in the postoperative period of infiltrates and abscesses in the abdominal cavity, it is necessary to control the temperature reaction and the content of peripheral blood leukocytes. For all patients, even in the absence of complaints, it is advisable to periodically conduct a digital examination of the rectum for the timely detection of pelvic infiltrate or abscess, since the use of antibiotics smooths out their clinical manifestations. Treatment of peritonitis in children, especially young children, is a task that requires an individual approach, taking into account many factors. Only massive complex therapy can be effective in this serious disease.

7.12.3. Peritonitis in newborns

Peritonitis in newborns is a formidable complication of pathological conditions of various etiologies. Among them are necrotizing enterocolitis, malformations of the gastrointestinal tract, acute appendicitis, iatrogenic perforations of hollow organs, bacterial infection of the peritoneum by contact, hematogenous and lymphogenous routes in sepsis. The most common cause of peritonitis is perforation of the gastrointestinal wall (84% of cases). Intrauterine intestinal perforations with malformations lead to aseptic adhesive peritonitis, postnatal - to diffuse fibrinous-purulent, fecal peritonitis. With necrotizing enterocolitis against the background of intensive therapy, the development of delimited peritonitis is possible. Non-perforative fibrinous-purulent peritonitis, which develops in utero with hematogenous, lymphogenous and transplacental infection, is now rarely observed. In the postnatal period, infection of the peritoneum occurs by contact with purulent periarteritis and periphlebitis of the umbilical vessels, liver abscesses, purulent diseases of the retroperitoneal space, phlegmon of the anterior abdominal wall. These forms also rarely occur now.

Classification. Peritonitis in newborns is classified as follows.

On an etiological basis. Perforated : necrotizing enterocolitis (posthypoxic, septic); malformations of the gastrointestinal tract (segmental defect of the muscular layer of the wall of a hollow organ, complications with atresia, intestinal volvulus, meconium ileus, Hirschsprung disease); acute appendicitis; destructive cholecystitis and cholangitis; iatrogenic perforations of hollow organs. non-perforative peritonitis: hematogenous, lymphogenous infection of the peritoneum; contact infection of the peritoneum.

By time of occurrence: prenatal; postnatal.

According to the degree of distribution in the abdominal cavity: spilled; limited.

By the nature of the effusion in the abdominal cavity: fibroadhesive; fibrinous-purulent; fibrinous-purulent, fecal.

Clinical picture postnatal perforative peritonitis in newborns with intestinal wall defects is manifested by acute symptoms of peritoneal shock on the 2nd-3rd day of life. The child is lethargic, groans. The skin is pale gray, acrocyanosis. Breathing is frequent, superficial due to the high standing of the dome of the diaphragm. Heart sounds are muffled. Pay attention to a sharp swelling, tension and soreness of the abdomen, expansion of the subcutaneous venous network. With peritonitis in newborns, hyperemia of the skin in the lower abdomen and on the genitals is often observed. Intestinal peristalsis is not heard. Percussion above the liver reveals a box sound - a symptom of the disappearance of hepatic dullness. They note constant vomiting of intestinal contents, stools and gases do not go away.

Diagnosis The diagnosis is confirmed by a survey radiograph of the abdominal organs. Under the dome of the diaphragm, a significant pneumoperitoneum is detected (Fig. 7-17).

Treatment Treatment is surgical only. After a puncture of the abdominal cavity and a decrease in intra-abdominal pressure for 2-3 hours, a comprehensive preoperative preparation is carried out, aimed at eliminating the symptoms of centralization of blood circulation. Preference is given to upper transverse laparotomy, which allows for a complete revision of the abdominal organs. An intestinal loop with a perforated area is sutured to the abdominal wall in the form of an intestinal fistula. After that, the abdominal cavity is washed with antiseptic solutions and sutured leaving drainage.

Prevention Currently, special attention is paid to the prevention of peritonitis in newborns. Early diagnosis of malformations and diseases leading to peritonitis can significantly reduce its incidence and improve treatment outcomes.

7.12.4. Necrotizing enterocolitis

One of the most common causes of postnatal perforative peritonitis (60% of all perforations) is hemorrhagic or septic infarction, which develops as a result of circulatory disorders in the gastrointestinal wall. Among children of the adaptation period, necrotizing enterocolitis occurs in 0.25%, and among children requiring intensive care in the neonatal period - in 4%. Necrotizing enterocolitis is a polyetiological disease. In the early neonatal period, the disease develops in children who have undergone severe neonatal hypoxia and asphyxia; it can also be a complication of infusion therapy and exchange transfusion through the umbilical vein, it can develop with decompensation of severe congenital heart disease and decompensated form of Hirschsprung's disease. Irrational use of antibiotics also contributes to the development of enterocolitis. Along with the direct damaging effect of some antibiotics (ampicillin, tetracycline) on the intestinal mucosa, the suppression of colonization resistance of the saprophytic flora with the development of severe dysbacteriosis is essential. Despite the variety of etiological factors in the pathogenesis of necrotizing enterocolitis, there are severe microcirculatory disorders in the wall of the gastrointestinal tract. There is a centralization of blood circulation with a spasm of mesenteric vessels (up to a complete stop of blood circulation), which is resolved by intestinal paresis with hemorrhages. Morphologically, large or small infarcts of the intestinal wall are detected. More frequent damage to premature babies is explained by the low resistance of their capillaries to pressure drops in the vascular bed. Mostly there is a lesion of the distal ileum and the corners of the colon (ileocecal, hepatic, splenic, sigmoid). The process begins with necrosis of the mucosa, and then spreads to the submucosal, muscular and serous layers, ending with perforation (Fig. 7-18).

Clinical picture and diagnosis In the clinical picture of necrotizing enterocolitis in children who have undergone chronic perinatal hypoxia and infection, a clear staging of the course of the disease is noted.

Stage I can be regarded as prodromal. The condition of children at risk who have undergone perinatal hypoxia and infection is closer to severe due to neurological disorders, respiratory disorders and cardiovascular activity. From the gastrointestinal tract, symptoms of dyskinesia are detected. Sluggish intermittent sucking, regurgitation during and after feeding milk, occasionally bile, malnutrition, aerophagia, bloating, anxiety of the child during stroking the abdomen in the absence of symptoms of peritoneal irritation, delayed discharge of meconium stool, rapid loss of body weight are clearly expressed. Radiologically, an increased uniform gas filling of all parts of the gastrointestinal tract with a slight thickening of the intestinal walls is noted.

Stage II is characterized by clinical manifestations of necrotizing enterocolitis. In newborns on the 5-9th day of life, the condition worsens, the symptoms of dynamic intestinal obstruction increase, the body weight deficit is 10-15% due to dehydration. The child sucks poorly, burps with an admixture of bile, bloating increases, local pain appears, more often in the right iliac region. The discharge of feces is accelerated, occurs in meager portions, with an admixture of mucus and greenery. The color of the stool is determined by the nature of the pathological intestinal microflora. So, for staphylococcal dysbacteriosis, a pronounced general toxicosis is characteristic, and in a liquid foamy stool - mucus and greens. For gram-negative infection, severe dehydration, scanty, porous, pale yellow stools with mucus and a large water spot are more characteristic. On the survey radiograph of the abdominal organs, an increased uneven gas filling of the gastrointestinal tract with a shading zone corresponding to the area of ​​maximum intestinal damage is noted. The stomach is swollen, with a level of liquid. Thickening of the shadows of the intestinal walls due to their edema, inflammation and interloop effusion is characteristic. The rigidity of the intestinal walls leads to the straightening of their contours. Submucosal cystic pneumatosis of the intestinal wall appears (Fig. 7-19). In severe cases, gas is detected in the portal system of the liver (Fig. 7-20). Progressive dehydration and weight loss further disrupt the microcirculation of the intestinal wall and contribute to the progression of the necrotic process. Violations of the barrier function of the intestinal wall are accompanied by severe infectious toxicosis.

Stage III - (pre-perforation) paresis of the intestine is expressed. The duration of the stage is not more than 12-24 hours. The condition is very serious, symptoms of toxicosis and exicosis are expressed, persistent vomiting of bile and "feces", sharp swelling, soreness and tension throughout the abdomen are characteristic. Peristalsis is sluggish, but auscultated. Feces and gases do not depart. Anus closed. During rectal examination (finger, probe), scarlet blood is released. Radiologically, due to the hydroperitoneum, the shading of the abdominal cavity increases, the outer contours of the intestinal loops lose their clarity of outline (Fig. 7-21).

Stage IV - (diffuse perforative peritonitis) is characterized by symptoms of peritoneal shock and intestinal paralysis. The peculiarity of perforative peritonitis in necrotizing enterocolitis is a significant area of ​​intestinal damage, the severity of the adhesive-inflammatory process in the abdominal cavity, and moderate pneumoperitoneum (Fig. 7-22).

A more favorable complication of necrotizing enterocolitis is delimited peritonitis, observed in a third of cases against the background of ongoing treatment. A child with clinical symptoms of enterocolitis in the abdominal cavity (more often in the iliac region) develops a dense infiltrate with clear contours, moderately painful. Against the background of ongoing conservative therapy, both complete resorption of the infiltrate and its abscess formation with the formation of an intestinal fistula on the anterior abdominal wall are possible. When conducting differential diagnosis, great difficulties arise, since the clinical manifestations are similar to acute appendicitis.