Peritonitis – a local or diffusion inflammation of a serous cover of an abdominal cavity – a peritoneum. Belly-ache, tension of muscles of a belly wall, nausea and vomiting, a delay of a chair and gases, a hyperthermia, a serious general condition are clinical signs of peritonitis. Diagnosis of peritonitis is based on data of the anamnesis, identification of the positive peritonealny symptoms given to ultrasonography, a X-ray analysis, vaginal and rectal researches, laboratory tests. Treatment of peritonitis always surgical (a laparotomy, sanitation of an abdominal cavity) with adequate preoperative and postoperative antibacterial and dezintoksikatsionny therapy.
Peritonitis – the heavy complication of inflammatory and destructive diseases of abdominal organs which is followed by the expressed local and general symptoms, development of polyorgan insufficiency. The lethality from peritonitis in gastroenterology makes 20-30%, and at the most severe forms reaches 40-50%.
The peritoneum (peritoneum) is formed by two serous leaves passing each other - visceral and parietal, covering internals and walls of an abdominal cavity. The peritoneum is the semipermeable, actively functioning membrane performing a set of important functions: rezorbtivny (absorption of exudate, products of lysis, bacteria, necrotic fabrics); ekssudativny (release of serous liquid), barrier (mechanical and antimicrobic protection of abdominal organs), etc. The most important protective property of a peritoneum is its ability to an inflammation otgranicheniye in an abdominal cavity thanks to fibrous solderings and hems, and also cellular and humoral mechanisms.
As Etiologichesky link at peritonitis the bacterial infection in most cases presented by nonspecific microflora of digestive tract acts. It can be gramotritsatelny (an enterobakter, colibacillus, proteas, a sinegnoyny stick) and grampolozhitelny (staphylococcus, streptococci) aerobes; gramotritsatelny (fuzobakteriya, bakteroida) and grampolozhitelny (eubakteriya, klostridiya, peptokokk) anaerobe bacterias. In 60-80% of observations peritonitis is caused by association of microbes – more often colibacillus and staphylococcus. Development of peritonitis is more rare happens is caused by specific microflora – gonokokka, a hemolytic streptococcus, pneumococci, tuberculosis mikobakteriya. Therefore for the choice of rational treatment of peritonitis paramount value has bacteriological crops of contents of an abdominal cavity with definition of sensitivity of the allocated microflora to antibacterial medicines.
According to an etiology distinguish primary (idiopathic) and secondary peritonitises. Penetration of microflora into an abdominal cavity or on fallopian pipes is characteristic in the limfogenny, hematogenic way of primary peritonitises. The direct inflammation of a peritoneum can be connected with salpingita, enterokolita, tuberculosis of kidneys or genitals. Primary peritonitises meet infrequently – in 1-1,5% of cases.
In clinical practice it is necessary to face the secondary peritonitises developing owing to detsruktivno-inflammatory diseases or injuries of an abdominal cavity much more often. Most often peritonitis complicates the course of appendicitis (perforative, flegmonozny, gangrenous), probodny stomach ulcer or a 12-perstny gut, a piosalpinks, a rupture of a cyst of an ovary, intestinal impassability, infringement of hernia, sharp occlusion of mezenterialny vessels, a disease Krone, a divertikulita, flegmonozno-gangrenous cholecystitis, pancreatitis, a pankreonekroz, etc. diseases.
Post-traumatic peritonitis develops owing to the closed and open injuries of abdominal organs. As the reasons of postoperative peritonitises insolvency of anastomoz, defects of imposing of ligatures, mechanical damage of a peritoneum, intraoperative infection of an abdominal cavity, can serve at an inadequate hemostasis. Separately allocate kantseromatozny, parasitic, granulematozny, rheumatoid peritonitises.
Classification of peritonitis
On an etiology distinguish bacterial and abacterial (aseptic, toksiko-chemical) peritonitises. The last develop as a result of irritation of a peritoneum aggressive noninfectious agents (bile, blood, gastric juice, pancreatic juice, urine, hilezny liquid). Abacterial peritonitis quickly enough accepts character microbic owing to connection of infectious activators from a GIT gleam.
Depending on character of a peritonealny exudate distinguish serous, fibrinozny, hemorrhagic, bilious, purulent, kalovy, putrefactive peritonitis.
Peritonitises are divided by a clinical current on sharp and chronic. Taking into account prevalence of defeat on a surface of a peritoneum distinguish the delimited (local) and diffusion peritonitis. Carry poddiafragmalny, appendicular, subhepatic, interintestinal, pelvic abscesses to options of local peritonitis. Tell about diffusion peritonitis when the inflammation of a peritoneum does not tend to restriction and a clear boundary. On extent of defeat of a peritoneum diffusion peritonitises are subdivided on local (developing in one anatomic area, near an infection source), extended (cover several anatomic areas) and the general (at total defeat of a peritoneum).
In development of peritonitis it is accepted to allocate an early phase (till 12 o'clock), late (up to 3-5 days) and final (from 6 to 21 days from the beginning of a disease). According to pathogenetic changes distinguish jet, toxic and terminal stages of peritonitis. In a jet stage of peritonitis (24 hours from the moment of defeat of a peritoneum) giperergichesky reaction to irritation of a peritoneum is noted; in this phase local manifestations are most expressed and the general symptoms are less expressed. The toxic stage of peritonitis (from 4 to 72 hours) is characterized by increase of intoxication (endotoxic shock), strengthening and prevalence of the general reactions. In a terminal stage of peritonitis (72 hours are later) there is exhaustion of protective and compensatory mechanisms, deep violations of the vital functions of an organism develop.
In the jet period of peritonitis abdominal pains, localization and which intensity are defined by the peritoneum inflammation reason are noted. Originally pain has accurate localization in the field of an inflammation source; can irradiate in a shoulder or supraclavicular area owing to irritation of the nervous terminations of a diaphragm pyoinflammatory exudate. Gradually pains extend on all stomach, become not calming down, lose accurate localization. In the terminal period in connection with paralysis of the nervous terminations of a peritoneum the pain syndrome becomes less intensive.
Nausea and vomiting serve as characteristic symptoms of peritonitis to gastric contents which in an initial stage arise reflex. In later terms of peritonitis emetic reaction is caused by intestines paresis; in emetic masses bile impurity appears, then - intestines contents (fecal vomiting). Owing to the expressed endotoxicosis the paralytic intestinal impassability which is clinically shown a delay of a chair and a neotkhozhdeniye of gases develops.
At peritonitis, even in the earliest stage, appearance of the patient attracts attention: suffering look, adinamiya, pallor of integuments, cold sweat, . The patient adopts the compelled provision relieving pain – is more often on one side or a back with the legs which are drawn in to a stomach. Breath becomes superficial, temperature increased is noted hypotonia, tachycardia 120-140 . in min., not corresponding to a subfebrilitet.
In a terminal stage of peritonitis the condition of the patient becomes extremely heavy: consciousness is confused, euphoria is sometimes observed, features are pointed, skin and mucous pale with an icteric or tsianotichny shade, language dry, is laid over by a dark raid. The stomach is blown up, at a palpation , at an auskultation "the death silence" is listened.
Diagnosis of peritonitis
The Palpatorny research of a stomach reveals positive peritonealny symptoms: Shchetkin-Blyumberg, Voskresensky, Medel, Bernstein. Stomach percussion at peritonitis is characterized by obtusion of a sound that testifies to an exudate in a free abdominal cavity; the auskultivny picture allows to speak about decrease or lack of intestinal noise, the symptom of "death silence", "the falling drop", "splash noise" is listened. The rectal and vaginal research at peritonitis allows to suspect an inflammation of a peritoneum of a small pelvis (pelvioperitonit), availability of exudate or blood in duglasovy space.
The survey X-ray analysis of an abdominal cavity at the peritonitis caused by perforation of hollow bodies indicates availability of free gas (a symptom of "sickle") under a diaphragm dome; at intestinal impassability Kloyber's bowls are found. High standing and a limited excursion of a dome of a diaphragm, existence of an exudate in pleural sine are indirect radiological signs of peritonitis. Free liquid in an abdominal cavity can be defined at ultrasonography.
Changes in the general blood test at peritonitis (, , increase in SOE) testify to purulent intoxication. Laparotsentez (a puncture of an abdominal cavity) and a diagnostic laparoscopy are shown in cases, not clear for diagnostics, and allow to judge the reason and the nature of peritonitis.
Treatment of peritonitis
Detection of peritonitis forms the basis for the emergency surgical intervention. Medical tactics at peritonitis depends on its reason, however in all cases during operation adhere to an identical algorithm: performance of a laparotomy, carrying out isolation or removal of a source of peritonitis, implementation intra-and postoperative sanitation of an abdominal cavity, providing a decompression of a small intestine is shown.
As quick access at peritonitis serves the median laparotomy providing visualization and reach of all departments of an abdominal cavity. Elimination of a source of peritonitis can include an ushivaniye of a perforative opening, an appendektomiya, imposing of a kolostoma, a resection of the nekrotizirovanny site of a gut etc. Performance of all reconstructive interventions is transferred to later term. For intraoperative sanitation of an abdominal cavity the solutions cooled to +4-6 °C of 8-10 l are used. The decompression of a small intestine is provided by installation of the nazogastrointestinalny probe (a nazointestinalny intubation); drainage of a thick gut is carried out through an anal opening. Peritonitis operation comes to the end with installation in an abdominal cavity of chlorvinyl drainages for aspiration of exudate and intraperitonealny introduction of antibiotics.
Postoperative maintaining patients with peritonitis includes infusional and antibacterial therapy, appointment of immunoproofreaders, transfusion of leykotsitarny weight, intravenous administration of the ozonized solutions, etc. For antimicrobic therapy of peritonitis the combination of tsefalosporin, aminoglycosides and metronidazole providing impact on all range of possible activators is more often used.
In treatment of peritonitis effective use of methods of an extracorporal detoxication (haemo sorption, plasma exchange, limfosorbtion, hemodialysis, enterosorbtion, etc.), hyperbaric oxygenation, Ural federal district blood, VLOK.
For the purpose of stimulation of a vermicular movement and restoration of the GITs functions purpose of antikholinesterazny medicines (neostigmin), ganglioblokator (a dimekoloniya iodide, a benzogeksoniya), antikholinergichesky means (atropine), medicines of potassium, physiotherapy (electrostimulation of intestines, a diadinamoterapiya) is shown.
Forecast and prevention of peritonitis
Success of treatment of peritonitis in many respects depends on the term of performance of operation and completeness of volume of postoperative therapy. The lethality at the poured peritonitis reaches 40% and more; death of patients occurs from purulent intoxication and polyorgan insufficiency.
As the majority of peritonitises are secondary, their prevention demands timely detection and treatment of the main pathology - appendicitis, stomach ulcer, pancreatitis, cholecystitis, etc. The prevention of postoperative peritonitis includes an adequate hemostasis, sanitation of an abdominal cavity, check of a solvency of anastomoz at abdominal operations.