Sharp peritonitis – one of kinds of a surgical infection of a peritoneum which is followed by the expressed local changes and the general functional frustration in an organism. In a clinical picture the phenomena of shock, paresis of intestines, belly-ache, nausea, vomiting, tension of a forward belly wall, dehydration prevail. Diagnosis of sharp peritonitis provides carrying out a survey X-ray analysis of OBP, ultrasonography and MSKT of abdominal organs, elektroenterografiya, a laparotsentez or a diagnostic laparoscopy, clinical and biochemical blood tests. Treatment is complex, includes both conservative, and surgical actions.
Sharp peritonitis is one of the most important problems of urgentny surgical service. Patients with inflammatory processes of a peritoneum make about 20% of all patients demanding the emergency surgical aid concerning sharp diseases and injuries of an abdominal cavity. In structure of the reasons of peritonitises destructive appenditsita and other pathology of a large intestine (every second case), diseases of a small intestine (every tenth case) prevail perforation of various departments of a digestive tract (a third of patients). The separate group is made by patients with the getting wounds of abdominal organs, postoperative complications. Development of peritonitis is closely connected with the late request for medical care, and respectively, with late surgery.
Reasons of sharp peritonitis
In most cases a source of sharp peritonitis is nonspecific inflammatory process. As an immediate cause at the same time appendicitis (to 65%), probodny stomach ulcer or DPK (to 15%), purulent or kalkulezny cholecystitis and purulent pancreatitis (to 10%), a necrosis of internals (intestinal impassability, infringement of hernia, thrombosis of mezenterialny vessels) – to 5%, inflammatory processes of a small pelvis (to 12%), a trauma, postoperative complications can act.
Allocate three phases of a course of peritonitis. In a jet phase there is an activation of protective mechanisms of an organism in response to penetration of microorganisms into an abdominal cavity; at perforation of hollow body lasts till 12 o'clock, at inflammatory diseases – about one days. Further the toxic phase follows - progressing of infectious process leads to disorders of functioning of internals, within 12-24 hours at perforation of hollow body and one-two days at inflammatory pathology. The terminal phase is characterized by the hardest polyorgan insufficiency developing within 24-36 hours at perforation and 48-72 hours at an inflammation of internals.
The jet phase is optimum for treatment – at implementation of surgery at this stage progressing of sharp peritonitis stops, a lethality very low. In a toxic phase every fifth patient perishes. The terminal phase develops in the absence of timely treatment and at nine patients from ten leads to a lethal outcome.
Classification of sharp peritonitis
In domestic abdominal surgery of uniform classification of sharp peritonitises does not exist. According to classification of 2009, division according to such criteria is accepted:
- On an etiology – primary (a tubercular etiology, spontaneous) in one case from 100; secondary (connected with an inflammation and perforation of internals, postoperative complications, injuries and wounds) in 95% of observations; tertiary (slow and persistiruyushchy) no more than 5% of patients.
- On prevalence – delimited (abscesses and infiltrates of an abdominal cavity), not delimited (local extends no more than to three anatomic regions; extended - more than on three).
- On properties of an exudate in an abdominal cavity – serous, fibrinozny, purulent, hemorrhagic, kalovy, chemical, mixed.
- According to characteristics of the activator – aerobic and anaerobic, grampolozhitelny and gramotritsatelny, specific.
- On weight of a current – with absence or existence of symptoms of sepsis, infectious and toxic shock.
- On character of complications – with intra belly complications, an angiogenny infection, secondary infection of airways, an urinogenital path, etc.
Symptoms of sharp peritonitis
In a jet phase of sharp peritonitis the patient shows complaints to intensive belly-ache, nausea, lack of an otkhozhdeniye of gases and a chair, emergence of tension of a forward belly wall and symptoms of tension of a peritoneum. The phenomena of intoxication are expressed in high fever, dryness and an oblozhennost of language, tachycardia.
Approximately on the second - third day from the beginning of sharp peritonitis the condition of the patient worsens due to increase of organ dysfunction. Initial changes of mentality are noted, the patient becomes uneasy. There is short wind, the abdominal distension accrues. Tension of a forward belly wall decreases, but symptoms of irritation of a peritoneum remain. The vermicular movement of intestines is absent, vomiting a coffee thick develops. In analyses inflammatory changes, signs of insufficiency of functions of a liver, kidneys are registered.
For the third or fourth days the terminal stage during which imaginary improvement of a condition of the patient at the expense of an otgranicheniye of inflammatory process is noted develops. Belly-aches weaken, but points to progressing of intoxication that features are pointed and accept suffering expression. The patient becomes indifferent, not movably lies in a bed. Breath superficial and frequent, a forward belly wall does not participate in the act of breath. Tachycardia is noted, pulse is weakened. Vomiting accepts kalovy character.
It is necessary to differentiate sharp peritonitis with a sharp myocardial infarction, pregnancy complications, a sharp stomach without peritonitis. Sharp peritonitis can be complicated by infection of edges of a wound, formation of intestinal fistulas and a kompartment-syndrome (critical increase intra belly pressure leading to polyorgan dysfunction and the death of the patient), sepsis and the DVS-syndrome, a distress syndrome of adult type, polyorgan insufficiency, intestinal malabsorption.
Diagnosis of sharp peritonitis
At suspicion of sharp peritonitis consultation of the gastroenterologist, endoscopist, surgeon is required. Lack of a vermicular movement of intestines and a resorption of liquid a peritoneum against the background of sharp peritonitis leads to heavy water and electrolytic violations. Insufficiency of work of a liver and kidneys is shown by a considerable gipoproteinemiya, increase in level of nitrogenous slags, anemia. Nonspecific symptoms of peritonealny sepsis are with shift of a leykotsitarny formula, increase in level of a pro-calcitonin and S-jet peptide to the left.
From tool methods of diagnostics by the most informative the survey X-ray analysis and MSKT of abdominal organs are. Carrying out a computer tomography usually demands considerable time and financial expenditure therefore it is practically not applied to diagnosis of sharp peritonitis. On a survey X-ray analysis of OBP the reinflated loops of intestines, Kloyber's bowl, free gas in an abdominal cavity, a relaxation or restriction of mobility of domes of a diaphragm are visualized.
Performing ultrasonography of abdominal organs can be complicated because of intestines paresis, however at sharp peritonitis helps to reveal an exudate in an abdominal cavity, primary center; it can be used for differential diagnostics. Also the elektroenterografiya has auxiliary value. At difficulties of diagnosis it is carried out or a diagnostic laparoscopy.
Treatment of sharp peritonitis
Patients with sharp peritonitis demand urgentny hospitalization in intensive care unit for preoperative preparation. After expeditious treatment recovery therapy can be carried out in office of surgery or gastroenterology.
Treatment of sharp peritonitis has to be complex, include conservative and surgical actions. The purposes of treatment of sharp peritonitis are: control of infectious process, eradikation of bacteria and elimination of their toxins, restoration of functions of internals. Conservative actions include introduction of antibiotics of a broad spectrum of activity, intensive infusional therapy, respiratory and haemo dynamic support, actions for replacement of function of kidneys, efferent methods of a detoxication, parenteral food etc.
Surgical tactics can also be conservative and quick. Conservative surgical tactics includes chreskozhny drainage of abscess of an abdominal cavity. Peritonitis operation is carried out in several steps: section of a forward belly wall, novokainovy blockade, elimination of a source of sharp peritonitis, careful sanitation of all abdominal cavity, decompression of an intestinal tube, imposing of drainages of an abdominal cavity and ushivany operational wound. Antibacterial therapy continues also after operation, the course has to be rather long for an eradikation of microbic agents and full regress of inflammatory process.
Forecast and prevention of sharp peritonitis
To make the individual forecast at sharp peritonitis rather difficult as it depends on many factors. As predictive symptoms of sharp peritonitis use such indicators: rectal temperature, average arterial pressure and frequency of reductions of heart, breath frequency, blood, the level of electrolytes, a gematokrita, leukocytes, creatinine, age of the patient, disease duration from emergence of the first symptoms to the appeal to clinic, etc. Prevention of sharp peritonitis is secondary and consists in timely detection and treatment of diseases which can lead to this state.