Bilious peritonitis - the serious inflammatory illness of a peritoneum caused by intake of bile in a stomach cavity. Clinical manifestations develop promptly: there is acute intensive pain in the left podreberye, vomiting, an abdominal distension, hypotonia and tachycardia, accrue intoxication symptoms. The general condition of the patient worsens up to consciousness violation (a sopor, a stupor). Diagnostics consists in carrying out surgical survey, laboratory analyses, ultrasonography, a survey X-ray analysis and MSKT of an abdominal cavity. The treatment combined. In the emergency order carry out surgical intervention with elimination of a source of peritonitis, appoint antibiotics, anesthetics and antishock medicines, parenteral solutions.
Bilious peritonitis - the complication of inflammatory and destructive diseases of bodies of biliarny system caused izlitiy bile in an abdominal cavity. Prevalence of pathology makes 10-12% of all peritonitises. The disease belongs to zhizneugrozhayushchy states, meets in practice of doctors of various specialties: gastroenterologists, abdominal surgeons, resuscitators. Close attention to this pathology is connected with high death rate, serious condition of patients and complexity of early diagnostics. Despite rapid development of surgery, a lethality remains high, varies from 20 to 35% depending on the reasons of development of peritonitis. At men the disease is registered by 2-2,5 times more often than at women.
Reasons of bilious peritonitis
Distinguish from the contributing factors increasing risk of development of destructive pathology of a gall bladder and biliary tract: long course of diabetes, atherosclerosis of vessels, anemia, advanced and senile age, system and autoimmune diseases, frequent exacerbations of chronic pancreatitis. Carry to immediate causes of formation of biliarny peritonitis:
- Diseases of a gall bladder. In time not diagnosed flegmonozny and gangrenous cholecystitis leads to a perforation of a gall bladder and a contents izlitiya in an abdominal cavity. This state meets frequency of 6-7%.
- Surgical interventions on the bilious ways. Reconstructive operations and interventions with imposing of anastomoz can lead to violation of tightness of bilious channels because of insolvency of seams, leaky clamped clip. In this case there is a dribble of bile and development of peritonitis. This complication can arise at violation of the technology of performance of a punktsionny biopsy of a liver or chrezpechenochny drainage of biliarny channels.
- Injuries of a liver or biliary tract. As a result of traumatic damage of various genesis (a knife, gunshot wound) integrity of a wall of a gall bladder, a holedokh with the expiration of bile in a stomach is broken.
- Cholelithiasis. Long finding of concrements in a holedokha leads to formation of decubituses and perforation of a bilious channel with izlitiy bile.
Extremely seldom the disease develops without a certain reason as a result of increase in pressure and microtears in bilious channels against the background of a heavy inflammation of a pancreas, a spasm of a sphincter of Oddi, an embolism of vessels, krovosnabzhayushchy a gall bladder and .
Bile is formed in cells of a liver and on a puzyrny channel comes to a gall bladder. Bilious acids, pigments (bilirubin, lecithin, etc.), a small amount of enzymes (amylase, a lipase), amino acids and inorganic substances are its part (sodium, potassium, etc.). Bile has hostile alkaline environment. At hit in an abdominal cavity causes irritation and an inflammation of a peritoneum, and then and a necrosis of walls of an abdominal cavity, parenchymatous bodies in the beginning. Further influence of bile leads to absorption of its components in blood and to development of intoxication. In a liver and kidneys degenerate processes are formed: there is hypostasis, proteinaceous and fatty dystrophies from the outcome in a necrosis.
Bilious peritonitis can be probodny and pro-sweaty. In the latter case the disease develops owing to a bile filtration through a wall of a gall bladder in an abdominal cavity. Allocate a sharp, subsharp and chronic form of a disease. Proceeding from prevalence of pathological process, distinguish:
- The delimited (local) peritonitis. This state is meant as a congestion of bilious contents in pockets of a peritoneum or formation of the delimited education (infiltrate, abscess).
- Poured (widespread) peritonitis. More than 2 anatomic areas of an abdominal cavity are involved in pathological process. This option is the most dangerous and more often leads to serious complications.
Symptoms of bilious peritonitis
The clinical picture of a disease depends on the speed of penetration and amount of the bile which came to an abdominal cavity, the area of defeat. Slow izlity biliarny contents leads to development of chronic and subsharp peritonitis with ill-defined symptoms. Bystry penetration of bile into peritonealny space leads to pronounced symptomatology with sharp deterioration in a condition of the patient. During a disease allocate several stages.
1 stage (initial) demonstrates in several hours after a bile exit from bilious ways. Inflammatory changes of a peritoneum develop in this period, it is formed serous or serous an exudate. There are sharp cutting or pricking pains in the right podreberye irradiating in a right shoulder-blade, a clavicle. Reflex vomiting, an eructation, heartburn is noted. The condition of the patient sharply worsens: the patient adopts the compelled provision on the right side with the legs given to a stomach, a pale face, cold sweat acts, ChSS raises, short wind develops. Body temperature can remain normal or slightly raised. At a palpation the stomach painful in all departments, comes to light tension of muscles. The dispepsichesky phenomena are noted: abdominal distension, lock.
2 stage (toxic) develop in 1-2 days after an onset of the illness. Intoxication accrues, inflammatory process gets a generalized form. The general condition of the patient worsens: consciousness level - a stupor-sopor with the excitement periods, arises frequent vomiting, dryness in a mouth. Emetic masses has brown color and an unpleasant smell. Skin damp and pale, is noted . Breath becomes superficial, frequent. Hypotonia, moderate tachycardia is noted. Body temperature to 39-40 °C, language dry with a brown raid increases. The stomach at a palpation is intense, sharply positive symptoms of Shchetkin — Blyumberg, Kerr, Ortnera-Grekov, Myussi, etc. The chair is absent, gases do not depart, the oliguriya appears.
3 stage (terminal) of bilious peritonitis are formed for 2-3 days. It is characterized by critical condition. The patient in a sopor, periodically screams, the person of earthy color, an eye hollow, lines are pointed. Breath is arrhythmic, superficial, pulse threadlike, the expressed hypotonia. The stomach is blown up, the patient does not react to a palpation, at an auskultation the vermicular movement is absent, the anury develops.
The long course of bilious peritonitis leads to penetration of bilious acids into blood, emergence of a holemiya. Spread of an infection and generalization of inflammatory process leads to formation of sepsis and infectious and toxic shock. Biliarny peritonitis causes violation of work of kidneys and a liver with development of a kidney liver failure.
Statement of the correct diagnosis often causes difficulties because of rapid development of symptoms of a disease and lack of a specific clinical picture. The disease belongs to urgent pathology, demands performing bystry rational diagnostics and the emergency treatment. Diagnosis of bilious peritonitis consists of several stages:
- Survey of the abdominal surgeon. The expert conducts the patient's survey regarding diseases of a gall bladder, operations in the anamnesis, etc. Then carries out fizikalny survey (a palpation, percussion and an auskultation of a stomach) and appoints tool and laboratory researches.
- Ultrasonography of an abdominal cavity. Allows to reveal liquid in an abdominal cavity, existence of alien education (abscess, a cyst), stones of a holedokh, change of a form and configuration of a gall bladder.
- Survey X-ray analysis of an abdominal cavity. Reveals the changes caused by perforation of a gall bladder or a holedokh, defines free gas, intestinal impassability. The limited excursion of a diaphragm and existence of an exudate in pleural sine are indirect signs of peritonitis.
- MSKT of abdominal organs. In the best way visualizes pathological changes from biliary tract and a gall bladder.
- Laboratory researches. In OAK increase in SOE, anemia is noted . In biochemical blood test the ALT, nuclear Heating Plant level, bilirubin, ShchF, amylase, etc. increases.
Differential diagnostics is carried out with the peritonitis caused pankreonekrozy, a probodny ulcer of a 12-perstny gut and a stomach, etc. Often the reason of development of peritonitis manages to be found only intraoperatsionno. Belly-aches often differentiate with an acute appendicitis, cholecystitis, right-hand paranephrite and cholelithic colic.
Treatment of bilious peritonitis
Tactics of treatment depends on an initial disease, volume of defeat and the general condition of the patient. At all stages of a disease carry out the emergency surgical intervention directed to disposal of the pathology which led to development of peritonitis (a perforation of a gall bladder, insolvency of operational seams, etc.). At damages of biliary tract carry out a holetsistektomiya or a holedokhotomiya, drainage of a biliarny channel, imposing of a repeated anastomoz, obligatory drainage and audit of an abdominal cavity. At an idiopathic form of a disease are limited to sanitation and drainage of an abdominal cavity. Along with operation performing the dezintoksikatsionny, combined antibacterial, anti-inflammatory and anesthetizing therapy is shown to the patient. Patients have to be in conditions of intensive care unit.
Forecast and prevention
The forecast of bilious peritonitis depends on prevalence and neglect of pathological process. When performing operation at the initial stage of a disease the forecast is more often favorable. Formation of the poured peritonitis with development of sepsis can lead to a lethal outcome even after the carried-out intervention. Prevention of biliarny peritonitis consists in timely diagnostics and treatment of chronic diseases of biliary tract, careful observation of patients, carrying out ultrasonography control during rehabilitation after an abdominal cavity operations.