Reliable symptom of peritonitis. Causes of peritonitis of the abdominal cavity. Complementary and Alternative Treatments at Home

Peritonitis is an inflammation of the peritoneum, the thin membrane that covers organs. abdominal cavity. Peritonitis is considered a life-threatening condition and is a medical emergency.

Usually signs of peritonitis appear suddenly. The main ones are: sudden onset, intense abdominal pain, nausea, a temperature of 38 ºC or higher. Peritonitis is associated with a bacterial or fungal infection that enters the abdominal cavity from outside or from another part of the body. Most often, peritonitis occurs as a result of infection or injury to the abdominal organs.

Peritonitis is a dangerous disease that must be recognized as early as possible and urgently treated to avoid fatal complications. Therefore, suspicion of peritonitis is an indication for urgent hospitalization in hospital. Infection causing peritonitis is treated with injections of antibiotics or antifungals, depending on the type of pathogen. In some cases, surgery may be required.

Peritonitis can lead to death, despite the best efforts of doctors. The danger of this disease is due to the fact that the infection can quickly spread through the blood to the vital important bodies(sepsis). According to statistics, about one in ten cases of peritonitis caused by a perforation (hole) in the intestinal wall is fatal, although this largely depends on the cause of the disease, age and general condition human health. Peritonitis associated with cirrhosis and kidney dialysis is less likely to cause death, but it still poses a health risk.

Symptoms of peritonitis

One of the main symptoms of peritonitis is pain in the abdomen. Often the pain is sudden, sharp and its intensity is constantly increasing. Other possible symptoms peritonitis:

  • nausea;
  • vomit;
  • lack of appetite;
  • chills;
  • temperature 38ºC or higher;
  • cardiopalmus;
  • inability to urinate or decreased amount of urine;
  • bloating.

If you are having peritoneal dialysis for kidney failure, the fluid that comes into the collection bag will likely be cloudier than usual and may contain white flakes or lumps. If the peritonitis is caused by cirrhosis, there may be no abdominal pain at all. Instead, there is a general bad feeling, as well as the development of complications from the liver: an increase in the size of the abdomen due to the accumulation of fluid in it, as well as confusion.

Causes of peritonitis

Peritonitis occurs when the peritoneum becomes infected with bacteria or fungi. The peritoneum is a thin layer of tissue within the abdominal cavity.

Secondary peritonitis- the most common type of inflammation of the peritoneum. The cause of secondary peritonitis is the spread of infection from any organ of the abdominal cavity or another part of the body. Common causes of secondary peritonitis:

  • perforation of a stomach ulcer (rupture of the stomach wall);
  • acute pancreatitis (inflammation of the pancreas);
  • severe trauma to the peritoneum, such as stabbing or bullet wound;
  • diseases digestive system such as Crohn's disease or diverticulitis.

Both Crohn's disease and diverticulitis can cause inflammation of the colon. If the inflammation is particularly severe, the wall of the large intestine becomes damaged and the bacteria-rich contents enter the abdominal cavity, causing infection.

Less commonly, peritonitis results from direct infection peritoneum - primary (spontaneous) peritonitis. Usually, primary peritonitis is associated with the accumulation of infected fluid in the abdominal cavity in cirrhosis of the liver or peritoneal dialysis in renal failure.

Damage to the liver can cause scarring of the liver, known as cirrhosis. The most common causes of cirrhosis are alcohol abuse, hepatitis C, or fatty liver (fatty liver).

Cirrhosis can cause a buildup of fluid in the abdomen (ascites). This fluid is particularly susceptible to contamination and is favorable environment for the growth and reproduction of bacteria and fungi. This accumulation of fluid occurs in half of people with cirrhosis, usually many years after they were diagnosed. Approximately 20% of people with ascites due to cirrhosis develop peritonitis.

People with kidney failure undergoing peritoneal dialysis have an increased risk of developing peritonitis. Dialysis is a way of cleaning the blood of unnecessary metabolic products. Dialysis replaces the work of the kidneys in patients.

In peritoneal dialysis, the peritoneum plays the role of the kidneys - a filter that purifies the blood of waste products. A small tube called a catheter is inserted into the abdomen and waste is removed through it. In rare cases, peritonitis can be caused by the fact that an infection is introduced into the body with the equipment.

Diagnosis of peritonitis

For the diagnosis of peritonitis, an examination is necessary, as well as a number of tests and studies. Your GP will ask you about your symptoms and recent medical conditions, as well as perform a detailed physical examination. If you have peritonitis, when you press on the abdominal wall, there is a sharp pain. Examination will help rule out other diseases with similar symptoms, such as a hernia. The risk of complications from peritonitis is high, so if your GP suspects you have peritoneal inflammation, you will most likely be referred to the hospital right away for evaluation and treatment.

Blood and urine tests help confirm the diagnosis of peritonitis. If you have fluid in your stomach, your doctor may use a thin needle to take a sample of the fluid to test for infections.

  • X-ray - using x-rays a picture is taken on which you can find a sign of rupture of internal organs - air in the abdominal cavity;
  • ultrasound procedure(ultrasound) - with the help of sound waves, an image of your abdominal cavity is obtained;
  • computed tomography (CT) - a series is being done x-rays, which are assembled by a computer into a detailed 3D representation of your abdominal organs.

These types of examinations help identify damage to internal organs, such as a ruptured appendix, perforation (rupture) of a stomach ulcer, or extensive inflammation of the colon.

Treatment of peritonitis

If you are diagnosed with peritonitis, you will most likely be referred to a hospital so that doctors can monitor your health.

This is associated with the risk of dangerous complications peritonitis, such as blood poisoning.

The first step in the treatment of peritonitis will be injections of antibiotics or antifungal drugs. Usually the course of treatment lasts 10-14 days. If the peritonitis was caused by peritoneal dialysis, antibiotics may be given directly into the abdomen. Research shows that this is more effective than intravenous antibiotics.

You will need to perform dialysis in another way, such as hemodialysis (where the blood passes through a special filtering machine), until the peritonitis is cured. Painkillers are prescribed to relieve pain.

Many people with peritonitis have trouble digesting and absorbing food, so tube feeding may be necessary. It is inserted into the stomach either through the nose (nasogastric tube) or surgically through the anterior wall of the abdomen. If these options cannot be used, nutrients may be given directly into your vein (parenteral nutrition).

If the infection has damaged internal organs may need to be removed surgically. In some cases, abscesses (cavities filled with pus) appear in the abdominal cavity, from which it is necessary to pump out pus by puncturing them with a needle. The operation is performed with the help of ultrasound, which helps to guide the needle to the abscess. As a rule, the procedure is performed under local anesthesia, so you should not feel pain.

In addition, surgery is required to eliminate the cause of peritonitis if it is associated with damage to internal organs, such as a ruptured appendix.

Complications of peritonitis

With peritonitis, the infection can enter the bloodstream and spread throughout the body, which is called sepsis. severe sepsis often accompanied by infection of several organs and a sharp drop in blood pressure, which disrupts the blood supply to vital organs.

Usually the symptoms of sepsis appear suddenly. They include:

  • high temperature (above 38ºC);
  • chills;
  • cardiopalmus;
  • rapid breathing.

Sepsis is treated with intravenous fluids and antibiotics. If sepsis is not treated promptly, it can cause septic shock.

Septic shock- this is sharp drop blood pressure. As a result, symptoms of shock appear, such as cold skin and palpitations. Sepsis affects many vital important processes: blood pressure, respiration and organ function, which can lead to death. Treatment is usually carried out in the intensive care unit and intensive care where there is room to maintain vital functions body during treatment.

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

Complaints.

As a rule, rather intense, dull constant pains in the abdomen approximately correspond to the prevalence of the process, aggravated by breathing and movement. Irradiation to the shoulder girdle is possible with irritation of the diaphragm. Feeling unwell. There is often nausea. The chair is delayed.

Anamnesis.

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

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

General inspection.

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

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

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

Tachycardia 100-120 in 1 min and above, blood pressure is normal or with a tendency to decrease, shortness of breath 20-24 in 1 min.

The manifestation of toxic encephalopathy is possible as lethargy, and excitation or delirium.

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

Special inspection.

The abdomen is usually symmetrical, somewhat swollen, does not participate in breathing. Palpation is determined by severe diffuse soreness, tension and symptoms of Mendel and Shchetkin-Blumberg. Usually there is a sharp weakening or absence of peristaltic noises.

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

Rectal and vaginal examination may reveal overhanging arches and tenderness due to accumulation of inflammatory exudate.

AT general analysis blood - pronounced leukocytosis, a pronounced shift to the left to the young. Biochemical analysis reveals normo- or hyperglycemia, a moderate increase in urea, creatinine, ALAT, ASAT, alkaline phosphatase, signs of DIC.

Laboratory examination.

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

Normally = 1 0.6.

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

A biochemical examination may reveal an increase in hematocrit, urea, creatinine, transaminases, bilirubin, glucose, lactate, coagulation disorders, a shift in acid-base balance, an increase in pCO 2, a decrease in pO 2 - evidence of dysfunction of various organs and systems.

Additional research.

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

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

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

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

In reactive and terminal phases the clinical manifestations of peritonitis vary considerably.

Predominant in the reactive phase pain syndrome. Often the area of ​​greatest pain is identified, corresponding to the primary focus of inflammation. Expressed muscle tension abdominal wall. A sharply tense abdomen looks somewhat drawn in - "navicular", this is especially characteristic of peritonitis with perforation of hollow organs. The symptoms of Mendel and Shchetkin-Blumberg are distinct. The peristalsis is usually sharply weakened.

There are no obvious signs of dehydration. Tachycardia reaches 90 - 100 in 1 min, shortness of breath is rare. It is possible to identify some elements of the erectile phase of shock - arousal, increased blood pressure.

Neutrophilic lecocytosis 12-18x10 9 /l, lypho- and monocytopenia, aneosinophilia. No significant deviations were found in biochemical analyzes.

In the terminal phase, it can be very difficult to establish a diagnosis of peritonitis if there is no way to find out the history of the disease from relatives.

Several times a day, mild vomiting of stagnant contents is repeated. Stool independent, or after an enema, usually scanty, often offensive (septic).

An adynamic, lethargic, severely dehydrated patient with sunken eyes, sharpened facial features, breathes superficially rapidly, often with a quiet groan. Dry "like a brush" tongue, he cannot stick out, as the inner surfaces of the cheeks are also dry.

The abdomen is significantly swollen, unevenly weakly painful. The symptoms of Mendel and Shchetkin-Blumberg are doubtful. Percussion sound uneven. You can detect a symptom of "deathly silence" - when instead of intestinal noises, respiratory and vascular noises are heard. When shaking the abdominal wall with a hand, a “splashing noise” can be heard.

Plain radiographs revealed multiple Kloiber cups.

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

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

In the biochemical analysis, pronounced signs of PON.

General principles of treatment.

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

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

The subclavian vein is always catheterized. This provides a high rate of infusion, the ability to control CVP.

Suitable for catheterization Bladder to measure hourly urine output as an objective performance measure infusion therapy.

Preparation of the gastrointestinal tract. Emptying the stomach with a probe is obligatory. When running processes, the probe must be in the stomach constantly, during the entire preoperative period, during the operation and for some time after it. Before the resumption of intestinal motility.

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

Operative treatment. The operation consists of seven successive stages.

Peritonitis is an inflammatory, bacterial, aseptic process of local or diffuse character that develops in the abdominal cavity. This process is a serious complication of destructive-inflammatory diseases of the peritoneal organs.

Inflammation occurs in peritonitis serous membrane abdominal cavity, also called the peritoneum. The inflammatory process belongs to the category of dangerous surgical conditions under common name"sharp belly"

The development of the disease is characterized by intense pain in the abdomen, tension in the muscle tissues of the abdominal cavity, and a rapid deterioration in the condition and well-being of the patient.

Peritonitis of the abdominal cavity is one of the most common diseases with high level lethal outcomes. To date, the mortality rate from inflammation of the peritoneum is 15–20%, although until recently this figure was much higher and varied between 60–72%.

Causes of the disease

The causes of peritonitis can be very diverse and primarily depend on the type and characteristics of the inflammatory process, which can be primary or secondary.

Primary type of peritonitis - develops as independent disease as a result of the entry of a bacterial infection and pathogens into the abdominal cavity through the bloodstream, lymphatic system. It is extremely rare - no more than 2% of all cases of the disease.

Bacteriological infections that can cause the development of inflammation of the peritoneum include both gram-positive and gram-negative bacteria, among which enterobacter, Pseudomonas aeruginosa, Proteus, Escherichia coli, streptococci, staphylococci can be distinguished.

In some cases, the occurrence of an inflammatory process may be associated with the penetration into the abdominal cavity of specific microflora - gonococci, pneumococci, Mycobacterium tuberculosis and hemolytic streptococci.

Secondary type - the inflammatory process develops against the background of damage to the abdominal organs or gastroenterological diseases.

It is possible to identify the main factors that can provoke the development of inflammation of the abdominal cavity:

  • Surgical intervention on the organs of the peritoneum.
  • Damage to the internal organs located in the abdominal cavity, violation of their integrity.
  • Various internal processes inflammatory nature- salpingitis, appendicitis, cholecystitis. Found that in more than 50% of cases the main cause of secondary inflammation.
  • Inflammations that do not have a direct connection with the abdominal cavity - phlegmon and purulent processes.
  • In women, peritonitis of the peritoneum can be triggered by inflammatory processes in the pelvic organs.

In the majority of cases, peritonitis acts as a complication of various injuries and diseases of a destructive-inflammatory nature - appendicitis, pyosalpinx, perforated ulcer stomach or duodenum, pancreatitis, pancreatic necrosis, intestinal obstruction, ovarian cyst rupture.

Varieties of peritonitis

Peritonitis is classified according to several parameters - such as the etiology of the disease, the extent of inflammation. Depending on the characteristics of the course, inflammation can be acute or chronic. Chronic peritonitis often develops against the background of a systemic infection of the body - tuberculosis, syphilis. acute form peritonitis is characterized by rapid development and rapid manifestation of clinical symptoms.

Depending on the characteristics of the etiology, the inflammatory process in the peritoneum can be bacterial, developing as a result of infection entering the abdominal cavity, as well as abacterial, that is, provoked by aggressive agents. non-infectious origin. Such non-infectious pathogens include blood, bile, gastric juice, pancreatic juice, urine.

Depending on the area and extent of the lesion, the disease is divided into several forms:

  1. Local - only one anatomical element of the peritoneum is involved in the inflammatory process.
  2. Widespread or diffuse - inflammation spreads to several parts of the abdominal cavity.
  3. Total type - characterized by an extensive lesion of all parts of the peritoneal cavity.

Due to occurrence:

  • Traumatic type of peritonitis.
  • Infectious.
  • Postoperative.
  • Probodnaya.

Depending on the presence of exudate, inflammation of the peritoneum is divided into dry and exudative (wet) type of peritonitis.

Depending on the features and nature of the exudate:

  • Purulent.
  • Serous.
  • Gallic.
  • Fecal.
  • fibrinous.
  • Hemorrhagic.

According to the type of infectious agent, peritonitis is divided into tuberculous, streptococcal, gonococcal, clostridial.

Depending on the severity and severity of pathogenetic changes, several stages of the inflammatory process are distinguished, each of which has its own characteristics and symptoms.

The reactive stage of peritonitis is the initial stage of the disease, the symptoms of which appear during the first day after the infection enters the abdominal cavity. The reactive stage is characterized by swelling of the peritoneum, the appearance of exudate and severe local reactions.

Toxic stage - occurs within 48-72 hours from the moment of injury. This stage is characterized by the intensive development of signs of intoxication.

The terminal stage is characterized by a general deterioration of the body and a weakening of the vital important functions organism, the functioning of the protective-compensatory system is reduced to a minimum.

Symptoms and signs

The main signs of peritonitis can be divided into general and local. local signs represent a response of the body to irritation of the abdominal cavity with exudative fluid, bile or blood. To the main local symptoms peritonitis refers to a strong tension of the anterior wall of the abdominal cavity, pain in the abdomen, irritation of the peritoneal cavity, identified during the medical examination.

First and most severe symptom initial stage inflammation of the peritoneum is considered pain, which may have varying degrees expression and intensity. The most severe is the pain syndrome that accompanies peritonitis with perforation of the internal organs located in the abdominal cavity. Such pain is described in the medical literature as "dagger" - sharp, sharp and penetrating.

At the initial stage of peritonitis, pain is localized exclusively around the immediate lesion. But after a while, the pain becomes diffuse, generalized, which is associated with the spread of inflamed exudate throughout the internal organs.

In some cases, pain can move and be localized in another area of ​​the abdominal cavity. This does not mean that the inflammatory process has decreased or stopped - this is how another internal organ is affected. Sometimes the pain can disappear completely - that's enough danger sign, which may indicate or accumulation of an excessive amount of inflammatory fluid.

characteristic general symptoms peritonitis - severe nausea, heartburn, vomiting with an admixture of gastric contents and bile. Vomiting accompanies the entire period of the disease; in the later stages of the disease, the so-called "fecal" vomiting occurs with an admixture of intestinal contents.

As a result general intoxication the body develops intestinal obstruction, which can be expressed in the form of flatulence, gas delay or stool disorders.

Other common symptoms of peritonitis:

  • Increased body temperature, chills.
  • Significant deterioration general well-being- weakness, apathy.
  • Rapid Leaps blood pressure up to 130-140 beats per minute.
  • Changes dramatically appearance a person - facial features become more pointed, the skin turns pale, there is cold sweat, facial expression becomes twisted, suffering.
  • A person cannot fully sleep, he is tormented by sleep disorders - insomnia or constant drowsiness. In addition, the patient cannot lie down due to acute pain, he tries to take the most comfortable position for himself - most often on his side, with his legs pulled up to his stomach.
  • On the advanced stages peritonitis, a person has a confused consciousness, he cannot normally, adequately assess what is happening.

With the development of the most complex, terminal stage peritonitis, the patient's condition becomes extremely severe: the skin and mucous membranes acquire an unhealthy pale, bluish or yellowish tint, the mucous membrane of the tongue is overdried, a thick coating of dark color appears on its surface. Psycho-emotional mood is characterized by instability, apathy is quickly replaced by a state of euphoria.

Symptoms of the disease differ significantly depending on the stage of the inflammatory process. Each of them has its own characteristics and features.

The reactive stage, which is the initial one, is accompanied by the appearance of spasms and pains in the peritoneum, tension of the anterior wall of the abdomen, fever, weakness and apathy.

The toxic stage is manifested by some improvement in the patient's condition, which, however, is imaginary. This period is characterized by intense intoxication of the body, which is expressed in severe nausea and debilitating vomiting. The appearance of a person also leaves much to be desired - pale skin, dark circles under the eyes, sunken cheeks. As medical statistics show, approximately 20% of all cases of peritonitis end in death at the toxic stage.

The terminal stage is considered the most difficult and dangerous not only for health, but also for human life. At this stage, the level of the body's defenses decreases to a minimum level, and the person's well-being becomes much worse. The abdomen swells sharply, the slightest touch to its surface causes an intense attack of pain.

At the terminal stage of peritonitis, the patient has severe swelling internal organs, resulting in impaired excretion of urine from the body, shortness of breath, increased heart rate, confused consciousness. As medical practice shows, even after surgical intervention only one in ten patients survive.

Symptoms of chronic peritonitis look a little different - they are not as pronounced as signs of acute inflammation and are more "blurred". The patient is not disturbed by debilitating vomiting, nausea, stool disorders, or painful spasms in the abdominal region. And therefore, for a long time, the chronic form of the disease can proceed completely unnoticed by a person.

In the same time prolonged intoxication The body cannot be completely asymptomatic, most often the presence of chronic peritonitis can be determined by the following signs:

  • Body weight is rapidly decreasing, while the diet remains the same.
  • For a long time, a person has an elevated body temperature.
  • Constipation occurs from time to time.
  • Increased sweating of the body.
  • Periodic pain in the abdomen.

As the disease progresses, the symptoms become more pronounced and frequent.

Diagnosis of peritonitis

Timely diagnosis of peritonitis is the key to successful and effective treatment. Required for diagnosis clinical analysis blood, on the basis of which the level of leukocytosis is examined.

also in without fail ultrasound and x-ray examination abdominal organs, during which experts study the presence of exudate in the abdomen - there is an accumulated inflammatory fluid.

One of diagnostic measures is to conduct a vaginal and rectal examination, which allows you to identify soreness and tension of the vaginal fornix and the wall of the rectum. This indicates inflammation of the peritoneum and negative impact accumulated exudate.

In order to eliminate any doubts about the diagnosis, a puncture is taken from the peritoneum, thanks to which it is possible to examine the nature of its contents. In some cases, laparoscopy is recommended. This is a painless, non-invasive diagnostic method that is carried out using special device- laparoscope. As a result of the laparoscopy performed, the doctor receives a complete clinical picture diseases and is able to make a correct diagnosis.

Treatment

To date, the only effective method treatment of peritonitis of the abdominal cavity remains surgical treatment. Despite the progress modern medicine the death rate remains high. It is for this reason that the treatment of peritonitis should be given maximum attention. The most effective is a complex method of treatment that combines surgical and drug therapy.

Simultaneously with surgery, drug treatment, the main purpose of which is to eliminate the infection, as well as to prevent the development of possible complications.

The most commonly prescribed medications are:

  1. Antibiotics a wide range actions - Ampicillin, Methicillin, Benzylpenicillin, Gentamicin, Oletetrin, Kanamycin.
  2. Infusion solutions - such drugs are used to restore lost fluid and prevent possible dehydration organism. Such solutions include Perftoran and Refortan.
  3. Sorbents and detoxification preparations, the action of which is aimed at preventing toxic shock, removing toxins and toxins from the body. The most commonly used solution is calcium chloride 10%.
  4. Diuretic drugs are used to eliminate violations of the excretion of urine from the body.
  5. If peritonitis of the peritoneum is accompanied by an increase in body temperature, antipyretic drugs are prescribed.

Antiemetics such as metoclopramide are often used to control vomiting and nausea. In the event that tuberculosis-type peritonitis has been diagnosed, treatment is carried out with the help of anti-tuberculosis medicines- Trichopolum, Gentomycin, Lincomycin.

Main task surgical treatment is the elimination of the root cause, which provoked the inflammatory process of the peritoneum, as well as carrying out with peritonitis. Preoperative preparation is complete cleansing gastrointestinal tract from the contents, intravenous administration of the necessary drugs, as well as anesthesia.

Surgery is performed by laparotomy, that is, by direct penetration into the abdominal cavity. After that, the surgeon removes the focus of inflammation, as well as complete reorganization peritoneal cavity. This means that if an organ became the cause of peritonitis, after the removal of which it is possible complete cure, resection this body. Most often we are talking about gallbladder or appendix.

Abdominal lavage is performed using special antiseptic solutions, which contributes effective elimination infections and a decrease in the amount of exudate released. The next step is bowel decompression. This is the name of the procedure for removing accumulated gases and liquids from the intestines. To do this, a thin probe is inserted through the rectum or oral cavity, through which fluid is suctioned from the abdominal cavity.

Drainage of the peritoneum is performed using special hollow drainage tubes, which are inserted in several places - under the liver, on both sides of the diaphragm and in the pelvic area. The final stage of surgery is suturing. Sutures can be applied with or without drainage, depending on the severity of the disease.

With simple forms of peritonitis, a continuous suture is applied, without drainage tubes. In the case of more severe purulent forms inflammation, suturing is carried out simultaneously with the introduction of drainage tubes, through which exudate is removed.

Treatment of peritonitis is carried out only in stationary conditions, self-treatment is not allowed. It is important to remember that no more than 72 hours pass from the moment the peritoneum is damaged to the development of the most severe, terminal stage. Therefore, any delay in applying for a qualified medical assistance and the operation is fraught with the most adverse consequences for human health and life.

- local or diffuse inflammation of the serous cover of the abdominal cavity - the peritoneum. Clinical signs of peritonitis are abdominal pain, abdominal wall muscle tension, nausea and vomiting, stool and gas retention, hyperthermia, and a severe general condition. Diagnosis of peritonitis is based on anamnesis, identification of positive peritoneal symptoms, ultrasound data, radiography, vaginal and rectal examination, laboratory tests. Treatment of peritonitis is always surgical (laparotomy, sanitation of the abdominal cavity) with adequate preoperative and postoperative antibacterial and detoxification therapy.

ICD-10

K65

General information

Peritonitis is a severe complication of inflammatory and destructive diseases of the abdominal organs, accompanied by severe local and general symptoms, the development of multiple organ failure. Mortality from peritonitis in gastroenterology is 20-30%, and in the most severe forms it reaches 40-50%.

The peritoneum (peritoneum) is formed by two serous sheets passing into each other - visceral and parietal, covering the internal organs and walls of the abdominal cavity. The peritoneum is a semi-permeable, actively functioning membrane that performs many important functions: resorptive (absorption of exudate, lysis products, bacteria, necrotic tissues); exudative (discharge serous fluid), barrier (mechanical and antimicrobial protection of the abdominal organs), etc. The most important protective property of the peritoneum is its ability to delimit inflammation in the abdominal cavity due to fibrous adhesions and scars, as well as cellular and humoral mechanisms.

Causes of peritonitis

The etiological link in peritonitis is bacterial infection, in most cases represented by nonspecific microflora of the gastrointestinal tract. It can be gram-negative (Enterobacter, Escherichia coli, Proteus, Pseudomonas aeruginosa) and gram-positive (staphylococci, streptococci) aerobes; gram-negative (fusobacteria, bacteroids) and gram-positive (eubacteria, clostridia, peptococci) anaerobes. In 60-80% of cases, peritonitis is caused by the association of microbes - more often coli and staphylococcus. Less commonly, the development of peritonitis is due to specific microflora - gonococci, hemolytic streptococcus, pneumococci, Mycobacterium tuberculosis. Therefore, to select rational treatment peritonitis is paramount bacteriological culture contents of the abdominal cavity with the determination of the sensitivity of the isolated microflora to antibacterial drugs.

In accordance with the etiology, primary (idiopathic) and secondary peritonitis are distinguished. Primary peritonitis is characterized by the penetration of microflora into the abdominal cavity by the lymphogenous, hematogenous route or through the fallopian tubes. Direct inflammation of the peritoneum may be associated with salpingitis, enterocolitis, tuberculosis of the kidneys or genitals. Primary peritonitis meet infrequently - in 1-1.5% of cases.

AT clinical practice much more often one has to deal with secondary peritonitis, which develops as a result of destructive-inflammatory diseases or injuries of the abdominal cavity. Most often, peritonitis complicates the course of appendicitis (perforative, phlegmonous, gangrenous), perforated ulcer of the stomach or duodenum, pyosalpinx, ovarian cyst rupture, intestinal obstruction, strangulated hernia, acute occlusion of mesenteric vessels, Crohn's disease, diverticulitis, phlegmonous-gangrenous cholecystitis, pancreatitis, pancreatic necrosis and other diseases.

According to etiology, bacterial and abacterial (aseptic, toxic-chemical) peritonitis are distinguished. The latter develop as a result of irritation of the peritoneum by aggressive non-infectious agents (bile, blood, gastric juice, pancreatic juice, urine, chylous fluid). Abacterial peritonitis rather quickly takes on the character of a microbial due to the addition infectious agents from the lumen of the gastrointestinal tract.

Depending on the nature of the peritoneal effusion, serous, fibrinous, hemorrhagic, bilious, purulent, fecal, putrefactive peritonitis are distinguished.

According to the clinical course, peritonitis is divided into acute and chronic. Given the prevalence of the lesion on the surface of the peritoneum, there are delimited (local) and diffuse peritonitis. Variants of local peritonitis include subdiaphragmatic, appendicular, subhepatic, interintestinal, pelvic abscesses. They say about diffuse peritonitis when the inflammation of the peritoneum does not tend to be limited and has clear boundaries. According to the degree of damage to the peritoneum, diffuse peritonitis is divided into local (developing in one anatomical region, close to the source of infection), widespread (covering several anatomical regions) and general (with total damage to the peritoneum).

In the development of peritonitis, it is customary to allocate early phase(up to 12 hours), late (up to 3-5 days) and final (from 6 to 21 days from the onset of the disease). In accordance with pathogenetic changes, reactive, toxic and terminal stages of peritonitis are distinguished. In the reactive stage of peritonitis (24 hours from the moment of peritoneal injury), a hyperergic reaction to irritation of the peritoneum is noted; in this phase, local manifestations are most pronounced and general symptoms are less pronounced. The toxic stage of peritonitis (from 4 to 72 hours) is characterized by an increase in intoxication (endotoxic shock), an increase and a predominance of general reactions. In the terminal stage of peritonitis (after 72 hours), the protective and compensatory mechanisms are depleted, deep violations of the vital functions of the body develop.

Symptoms of peritonitis

In the reactive period of peritonitis, abdominal pains are noted, the localization and intensity of which are determined by the cause of inflammation of the peritoneum. Initially, the pain has a clear localization in the area of ​​​​the source of inflammation; may radiate to the shoulder or supraclavicular region due to irritation nerve endings diaphragm with purulent-inflammatory exudate. Gradually, the pains spread throughout the abdomen, become persistent, lose their clear localization. In the terminal period, due to paralysis of the nerve endings of the peritoneum, the pain syndrome becomes less intense.

The characteristic symptoms of peritonitis are nausea and vomiting of gastric contents, which in the initial stage occur reflexively. In the later periods of peritonitis, the emetic reaction is due to intestinal paresis; an admixture of bile appears in the vomit, then the contents of the intestine (fecal vomiting). Due to severe endotoxicosis, paralytic ileus develops, clinically manifested by stool retention and non-excretion of gases.

With peritonitis, even in the most early stage, the appearance of the patient attracts attention: a suffering expression, weakness, pallor skin, cold sweat, acrocyanosis. The patient takes a forced position that relieves pain - more often on the side or back with legs tucked up to the stomach. Breathing becomes superficial, the temperature is elevated, hypotension, tachycardia 120-140 beats. per minute, not corresponding to subfebrile condition.

In the terminal stage of peritonitis, the patient's condition becomes extremely difficult: consciousness is confused, euphoria is sometimes observed, facial features are sharpened, the skin and mucous membranes are pale with an icteric or cyanotic tint, the tongue is dry, covered with a dark coating. The abdomen is swollen, with little pain on palpation, "deathly silence" is heard during auscultation.

Diagnostics

Palpation examination of the abdomen reveals positive peritoneal symptoms: Shchetkin-Blumberg, Voskresensky, Medel, Bernstein. Percussion of the abdomen with peritonitis is characterized by dullness of sound, which indicates an effusion in the free abdominal cavity; the auscultatory picture allows us to talk about a decrease or absence of intestinal noises, a symptom of "deathly silence", "falling drop", "splash noise" is auscultated. Rectal and vaginal examination with peritonitis allows us to suspect inflammation of the peritoneum of the small pelvis (pelvioperitonitis), the presence of exudate or blood in the Douglas space.

Changes in the general blood test with peritonitis (leukocytosis, neutrophilia, increased ESR) indicate purulent intoxication. Laparocentesis (abdominal puncture) and diagnostic laparoscopy are indicated in cases that are unclear for diagnosis and allow us to judge the cause and nature of peritonitis.

Treatment of peritonitis

Identification of peritonitis is the basis for emergency surgical intervention. Medical tactics with peritonitis depends on its cause, however, in all cases during the operation, the same algorithm is followed: laparotomy is indicated, isolation or removal of the source of peritonitis, intra- and postoperative sanitation of the abdominal cavity, and decompression of the small intestine.

Operative access for peritonitis is median laparotomy, which provides visualization and reach of all parts of the abdominal cavity. Elimination of the source of peritonitis may include suturing the perforation, appendectomy, colostomy, resection of the necrotic portion of the intestine, etc. All reconstructive interventions are transferred to more late deadline. For intraoperative sanitation of the abdominal cavity, solutions cooled to +4-6°C are used in a volume of 8-10 liters. Decompression of the small intestine is provided by installing a nasogastrointestinal probe (nasointestinal intubation); drainage of the colon is performed through the anus. The operation for peritonitis ends with the installation of PVC drains into the abdominal cavity for aspiration of exudate and intraperitoneal administration of antibiotics.

Postoperative management of patients with peritonitis includes infusion and antibiotic therapy, the appointment of immunocorrectors, transfusion of leukocyte mass, intravenous administration ozonated solutions, etc. For antimicrobial therapy of peritonitis, a combination of cephalosporins, aminoglycosides and metronidazole is more often used, providing an impact on the entire spectrum of possible pathogens.

In the treatment of peritonitis, the use of extracorporeal detoxification methods (hemosorption, lymphosorption, hemodialysis, enterosorption, etc.), hyperbaric oxygenation, blood ultraviolet irradiation, ILBI is effective.

In order to stimulate peristalsis and restore the functions of the gastrointestinal tract, the appointment of anticholinesterase drugs (neostigmine), ganglioblockers (dimecolonium iodide, benzohexonium), anticholinergics (atropine), potassium preparations, physiotherapy (electrical stimulation of the intestine

ICD-10 code

- this is inflammation (irritation) of the peritoneum, a thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs, caused by a bacterial or fungal infection and accompanied by a severe general condition of the body.

An alternative name for peritonitis is "acute abdomen".

According to the nature of infection, primary or acute and secondary peritonitis are distinguished.

Causes and Risk Factors of Peritonitis

Peritonitis is caused by hemorrhage, congestion biological fluids, or intra-abdominal abscess with the formation of pus in the abdominal cavity.

The most common risk factors for primary acute peritonitis are:

Liver disease, including cirrhosis of the liver. Such diseases often lead to an accumulation of abdominal fluid (ascites), which can become infected.
- Kidney failure and receiving peritoneal dialysis to remove waste from the blood of patients with kidney failure. It's connected with increased risk development of peritonitis as a result of accidental infection of the peritoneum through the catheter.

The most common causes of secondary peritonitis are considered to be:

ruptured appendix, diverticulum
- Perforated stomach or intestinal ulcers
- Diseases digestive tract such as Crohn's disease and diverticulitis
- Pancreatitis
- Inflammation of the pelvic organs
- Perforation of the stomach, intestines, gallbladder
- Surgical operations and abdominal procedures
- Injuries to the abdomen, such as stabbing or gunshot wound
- Gynecological infections of the upper genital tract
- Complications after childbirth and abortion
- Acute obstruction intestines and rupture
- History of peritonitis. After suffering peritonitis, the risk of developing it again is higher than in those who have never had peritonitis.

Non-infectious causes of peritonitis are caused by irritants such as bile, blood, or foreign matter in the abdomen, such as barium.

Symptoms of peritonitis

Peritonitis begins with acute pain at the site of damage to the organ, which quickly intensifies, especially when moving or pressing on this place. With peritonitis, the so-called symptom of "imaginary well-being" can be observed when the patient feels severe pain, which then subsides. At this point, the patient calms down, and this is a very dangerous moment. The fact is that the receptors on the peritoneum adapt, but soon, after 1-2 hours, the pain appears with new force, as inflammation of the peritoneum develops.

Other symptoms of peritonitis may include:

- Fever and chills
- Fluid in the abdomen
- Symptom of Shchetkin - Blumberg, when the pain of the abdomen sharply increases at the moment of rapid removal of the palpating hand from the anterior abdominal wall after pressing with deep palpation belly
- Bloating or bloating in the abdomen
- Tension of the muscles of the anterior abdominal wall
- Difficulty with defecation
- Poor gas
- Excessive fatigue
- Difficult and scanty urination
- Nausea and vomiting that does not bring relief
- Cardiopalmus
- shortness of breath
- Loss of appetite
- Diarrhea
- Thirst

If you are receiving peritoneal dialysis, symptoms of peritonitis also include:

Cloudiness of the dialysis fluid
- White threads or clots (fibrin) in dialysis fluid
- Unusual smell of dialysis fluid
- Redness soreness of the area around the catheter.

Diagnosis of peritonitis


Because peritonitis can quickly lead to potentially fatal complications such as sepsis and septic shock, which causes a sharp decline blood pressure, organ damage and death, it is very important to get fast diagnostics and appropriate treatment on the first day.


Diagnosis of peritonitis begins with a thorough history of symptoms and medical history, and requires a thorough physical examination, including an assessment of tension and tenderness in the abdomen. Patients with peritonitis usually lie curled up or do not allow anyone to touch the abdomen.


Diagnostic tests for peritonitis may include:

Blood and urine tests
- Abdominal ultrasound
- Radiography of the abdominal cavity
- Computed tomography (CT) of the abdominal cavity (for the diagnosis of chronic peritonitis)
Abdominal puncture, a procedure in which fluid is removed from the abdominal cavity through a fine needle and examined for infection, primary acute peritonitis, and secondary peritonitis due to pancreatitis.

Treatment of peritonitis


Treatment of peritonitis will depend on the causes of its causes and on the characteristics of its course. In any case, treatment should be urgent and carried out in a hospital.


Intravenous antibiotics or antifungals are usually given immediately to treat the infection. If necessary, treatment may include intravenous fluids and nutrition, drugs to maintain blood pressure. After a few days, the intestinal musculature is stimulated, which can be significantly weakened.

In acute peritonitis, which was caused by a ruptured appendicitis, perforation of a gastric ulcer, or diverticulitis, emergency surgery and immediate transfer of the patient to the intensive care unit are necessary. They try to prepare the patient for the operation in order to avoid complications, but this is not always possible.
During the operation, pus is removed, general sanitation of the abdominal cavity is carried out, the cause of peritonitis is eliminated - tears are stitched and sealed, abscesses are excised. For the discharge of the newly formed pus, a percutaneous drainage is installed for some time. After the operation, drug treatment of peritonitis is continued, with the help of active antibiotic therapy, as well as prescribed therapy aimed at maintaining the vital functions of the body.

Prognosis of peritonitis

The outcome of the disease depends on the cause, the duration of symptoms before treatment, and the general health of the patient. Results may vary from full recovery to death, depending on these factors.

Complications of peritonitis

Hepatic encephalopathy
- Hepatorenal syndrome
- Sepsis
- Abscess
- Gangrene of the intestine
- Intraperitoneal adhesions
- Septic shock

Prevention of peritonitis

Although peritonitis can be a complication of peritoneal dialysis, it is much less common than it used to be due to improvements.

If you are on peritoneal dialysis, you can lower your risk of peritonitis by:

Wash your hands thoroughly, including between the fingers and under the nails, before touching the catheter.
- Compliance with proper sterility during the procedure.
- Apply an antiseptic cream at the site of the catheter every day.
- Report any changes to your dialysis fluid immediately.

Acute peritonitis is an acute inflammation of the peritoneum that requires emergency medical care, otherwise it can lead to lethal outcome.

Acute peritonitis is usually caused purulent infection that got into the abdominal cavity as a result of acute purulent appendicitis, perforation of gastric and duodenal ulcers, acute purulent cholecystitis, acute pancreatitis, acute purulent inflammation pelvic organs, rupture of the stomach, intestines, ascites and accumulation of fluid in the abdominal cavity.

Acute purulent peritonitis also occurs in patients who are on peritoneal dialysis for renal failure.

Symptoms of purulent peritonitis grow rapidly and have several phases of development:

The reactive phase, lasting from 12 to 24 hours, is accompanied by acute pain that spreads to the entire abdomen, with a peak of tenderness in the area primary focus. The abdomen is tense, there is a symptom of Shchetkin-Blumberg. The patient lies in the "fetal position" on his side with the legs brought to the stomach, any attempt to change the position increases the pain. This condition is accompanied by fever and chills.

The toxic phase, lasting from 12 to 72 hours, is dangerous in that an apparent improvement occurs. The pain subsides, the abdomen ceases to be tense, the patient enters a state of lethargy or euphoria. His facial features are sharpened, pallor appears, nausea and vomiting are observed, which takes on a painful, debilitating character and does not bring relief. Decreased urination and intestinal peristalsis, when listening to the usual intestinal noises are not heard. The first symptoms of dehydration begin to appear, such as dry mouth, but fluid intake is difficult due to lethargy or vomiting. About 20% of patients die at this stage.

The terminal phase, occurring 24 to 72 hours after the onset of the disease and lasting several hours. At this stage, there is a deep disorder of the functions of all body systems, the body's defenses are depleted. The patient is in prostration, indifferent to what is happening. The face acquires an earthy tint, the eyes and cheeks sink, the so-called “Hippocratic mask” is observed, cold sweat appears. Possible profuse vomiting of putrefactive contents small intestine. Shortness of breath and tachycardia appear, body temperature drops rapidly, and in the terminal stage it often turns out to be below 36 C. The abdomen is swollen, painful, but there is no protective muscle tension. In the terminal stage, about 90% of patients die.

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

Treatment of acute purulent peritonitis

Purulent peritonitis is an absolute indication for surgery aimed at eliminating the focus of infection or delimiting it with adequate drainage.

removed during the operation. damaged tissue, the abdominal cavity is flushed with antibacterial drugs. The next stage of treatment is the fight against paralytic intestinal obstruction, correction of violations of water and electrolyte balance, protein metabolism with the help of infusion therapy, as well as correction and normalization of the activity of the kidneys, liver, heart and lungs.

The success of treatment in acute purulent peritonitis directly depends on the speed of treatment for medical care and prompt treatment.

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