Purulent peritonitis – the delimited or total inflammatory defeat of a peritoneum proceeding with participation of gnoyerodny flora. In an initial stage purulent peritonitis is shown by symptoms of the main disease (appendicitis, cholecystitis, stomach ulcer etc.), then severe pains in a stomach, a meteorizm, intestines paresis, water and electrolytic violations join. In the absence of due treatment purulent peritonitis leads to the death of the patient. It is possible to suspect peritonitis on the basis of changes in the general blood test and urine, biochemical analyses; data of an ultrasonic and radiological picture, diagnostic laparoscopy. Treatment of purulent peritonitis only surgical.
Purulent peritonitis – the infectious and nonspecific or specific inflammation of a peritoneum which arose owing to sharp surgical diseases or injuries of abdominal organs. Carry intoxication, intestines paresis, the hardest water-ion frustration to displays of purulent peritonitis. Lack of pathogenetic treatment leads to development of insufficiency of various bodies and systems: lungs, liver, kidneys, local and general blood-groove etc. It is known that peritonitis is formed at every fifth patient coming to a hospital concerning sharp surgical diseases. Most often sharp surgical pathology (85%) leads to development of purulent peritonitis, is more rare – injuries of abdominal organs (5-8%), in 5-10% of cases purulent peritonitis is a surgery complication. Approximately at two thirds of the patients who died of surgical diseases and injuries of a stomach, purulent peritonitis is a cause of death.
Reasons of purulent peritonitis
Most often development of purulent peritonitis is accompanied by violation of integrity of a wall of any abdominal organ and hit of its contents on a peritoneum. Such mechanism of developing of peritonitis can be observed at gangrenous and perforative appendicitis, perforative stomach ulcer or a duodenum, perforative cholecystitis, a rupture of an intestinal wall by a foreign matter, a rupture of a diverticulum of a stomach or intestines, germination by a tumor of a wall of a stomach or a gut with perforation development.
One more way of spread of an infection on a peritoneum is contact – the inflammation passes from the infection center to a visceral or parietal leaf of a peritoneum without violation of integrity of body. Such mechanism of development of purulent peritonitis is inherent in flegmonozny appendicitis, purulent cholecystitis, pancreatitis, inflammatory gynecologic diseases. Also the infection can get into an abdominal cavity at injuries when there is a violation of integrity of abdominal organs, in time and after operations (at inadequate observance of rules of an asepsis and antiseptics, postoperative care of the patient).
As the reason of development of purulent peritonitis one infectious agent extremely seldom can serve, however most often leads an obsemeneniye of abdominal organs to this disease of several species of bacteria at the same time. Purulent peritonitis can have various etiology: nonspecific - at infection of a stafilokokkama, streptococci, colibacillus, enterokokka, Proteus, a sinegnoyny stick, an akinetobakter, lactobacilli, klostridiya, pneumococci; specific - at hit in an abdominal cavity of mikobakteriya of tuberculosis, gonorrhea neysseriya, etc. Also purulent peritonitis can complicate the course of initially aseptic peritonitis (develops at damage of a peritoneum by the streamed blood, bile, pancreas juice, urine, gastric juice), and also special forms of an inflammation of a peritoneum (kantseromatozny, rheumatoid, parasitic, granulematozny peritonitis).
Classification of purulent peritonitis
Peritonitis is divided by the development mechanism on primary, secondary and tertiary. Primary purulent peritonitis is formed against the background of ekstraperitonealny pathology (most often it tuberculosis, is more rare - a red volchanka, damage of kidneys at children, cirrhosis, a chronic renal failure at adults). The activator at primary peritonitis gets into an abdominal cavity in the hematogenic or limfogenny way. At women perhaps also penetration of an infection into an abdominal cavity through pipe fallopiyeva. Primary purulent peritonitis meets no more than in 1% of cases. Secondary purulent peritonitis develops against the background of inflammatory diseases of abdominal organs, injuries of a stomach, the undergone operations. Makes 85-90% of all cases of pathology. Tertiary purulent peritonitis arises at the weakened patients with a heavy immunodeficiency who transferred several abdominal surgical interventions. The symptomatology erased proceeds inertly. Very often leads to development of the hardest sepsis, is a cause of death of such patients.
Because of development purulent peritonitis can be perforative, appendicular, traumatic, postoperative and cryptogene (when the reason of development of peritonitis did not manage to be revealed). On prevalence purulent peritonitis can be local (mentions less than two zones) – most often it is periappendikulyarny infiltrate or abscess; and not delimited. Not delimited peritonitis on prevalence is also divided on diffusion (from 2 to 5 zones are surprised) and poured (the inflammation in two and more floors of an abdominal cavity is noted).
Separately allocate three stages of purulent peritonitis: jet, toxic and terminal. The jet stage lasts 12-24 hours, is characterized by emergence or strengthening of belly-aches, emergence of vomiting, temperature increase of a body to febrilny figures. The toxic stage lasts about 2-3 days from an onset of the illness, emergence of unrestrained vomiting, arterial hypotension against the background of tachycardia is characteristic of it. A terminal stage – a sign of approach of irreversible changes in a peritoneum, necrosis of the nervous terminations, violation of functions of the vital functions. At perforative peritonitis development of the listed stages comes to the end much quicker, the terminal stage can begin already in a day from the beginning of a disease.
Symptoms of purulent peritonitis
The beginning of purulent peritonitis is usually characterized by symptomatology of the main disease, specific symptoms of an inflammation of a peritoneum join further. The first symptom of peritonitis is the poured belly-ache. It has no accurate localization, rather intensive, amplifies at physical activities, cough and sneezing. Intensity of pain at the beginning of a disease increases, in the subsequent can decrease, up to total disappearance. Subsiding of pain against the background of deterioration in the general condition of the patient is a bad predictive sign and speaks about a necrosis of a peritoneum and its nervous terminations.
Along with developing of pain, the patient the reflex exhausting nausea passing into ongoing vomiting at first with stomach contents, then intestinal and in a final stage – kalovy contents disturbs. It is connected with the expressed intestines paresis. Heavy vomiting leads to dehydration, an electrolytic imbalance. Because of pererazduta intestines loop paresis, are overflowed with gases, the patient is disturbed by the expressed meteorizm.
The patient holds the compelled position on one side with the knees tightened to a breast (the peritoneum tension so is less expressed, intensity of pain decreases). Integuments are dry, pale, emergence of the marble drawing, an akrotsianoz is possible. Brushes and feet cold, damp, nails blue. Mucous lips, a mouth too dry, language is laid over by a dirty-gray raid. There is an unpleasant smell from a mouth. In initial stages of a disease tachycardia and arterial hypertension gradually accrue, in a terminal stage discrepancy of pulse and pressure is noted. The patient becomes uneasy, notes sensation of fear. Breath frequency gradually increases, and in a terminal stage breaths become rare, superficial. In case of the expressed water-ion deficiency polyorgan insufficiency which is shown by gradual obscuring of consciousness up to a coma, development of spasms develops.
At a palpation the expressed protective tension of muscles of a stomach (a doskoobrazny stomach), a positive symptom of Shchetkin-Blyumberg (when pressing a belly wall morbidity which considerably amplifies at sharp otnyatiya of the palpating hand is noted) is observed. At percussion of a stomach it is noted timpanit (the ringing sound demonstrating existence of a large amount of gas), in sloping places obtusion of a sound (speaks about an exudate in an abdominal cavity). At an auskultation during the first hours of a disease perhaps some strengthening of a vermicular movement, then it gradually weakens before complete cessation. In late stages of purulent peritonitis at an auskultation splash noise, noise of the falling drop is heard. Gases and a chair do not depart. Wet because of dehydration and intoxication dark brown color is distinguished very little, it concentrated. A rectal and vaginal research are very painful.
Diagnosis of purulent peritonitis
At suspicion on development of purulent peritonitis diagnostic actions have to be carried out extremely quickly as operation in the first days guarantees recovery in 90% of cases against emergence of symptoms. To such patients performing ultrasonography of abdominal organs (reveals the reinflated intestines loops, lack of a vermicular movement, an exudate in an abdominal cavity) is shown, to a survey X-ray analysis of abdominal organs (on it intestinal arches, liquid levels, blackout in sloping places where liquid accumulates will be visible). The multislice spiral computer tomography gives the chance in more detail to consider changes of abdominal organs, to define existence of an exudate.
At doubtful results of these researches consultation of the endoscopist, carrying out a diagnostic laparoscopy can be required. During a laparoscopy inflammatory process of a peritoneum will be visible, it is purulent-fibrinozny an exudate, it is possible to find a source of development of purulent peritonitis (appendicitis, cholecystitis, a probodny ulcer). The exudate received at a laparoscopy is sent to bacteriological laboratory for definition of sensitivity of the allocated microflora to antibiotics.
In the general blood test the expressed inflammatory changes ( can reach 40109), shift of a leykoformula to the left, anemia, thrombocytopenia come to light. In biochemical blood test haemo concentration, decrease in levels of potassium, chlorine, sodium is noted (because of vomiting).
Treatment of purulent peritonitis
Rather often patients are initially hospitalized in office of gastroenterology with clinic of an exacerbation of diseases of bodies of a digestive tract. If the gastroenterologist suspects accident of an abdominal cavity, such patient is immediately transferred to intensive care unit where preoperative preparation at once begins. It includes elimination of dehydration, restoration of volume of the circulating blood, correction of electrolytic violations. Infusion of isotonic polyionic solutions, proteinaceous and colloidal medicines is for this purpose carried out. Correction of various frustration caused by toxic damage of internals, endotoxicosis, the basic and background diseases is made. Preoperative preparation has to be fully complete within 2-4 hours.
Important aspect of treatment of purulent peritonitis is the infection eradikation. Antibiotics of a broad spectrum of activity begin to enter even before operation to create their sufficient concentration in fabrics and to prevent further spread of an infection after surgery. Long introduction of antibiotics has to be followed by purpose of antifungal means.
The main method of treatment of purulent peritonitis – quick. Existence of a purulent exudate assumes carrying out an expanded laparotomy median access for providing the good review and a possibility of careful sanitation of an abdominal cavity. Audit of bodies, an intestines intubation, sanitation (suction of an exudate, washing of an abdominal cavity solutions of anti-septic tanks) and drainage of an abdominal cavity is made. If necessary search of primary center of an infection, a resection of nekrotizirovanny intestines is carried out.
In the postoperative period repeated relaparotomiya with sanitation and drainage of an abdominal cavity, division of solderings can be required. Correction of haemo dynamic, metabolic and water and electrolytic violations, antibacterial and dezintoksikatsionny therapy continues. It is necessary to provide normal gas exchange, to fill the need for nutrients and energy, to eliminate functional insufficiency of intestines. Rational anesthesia, symptomatic treatment is carried out.
Forecast and prevention of purulent peritonitis
The forecast of purulent peritonitis adverse – a lethality makes not less than 25-30%, and at development of polyorgan insufficiency reaches 90%. The forecast substantially depends on timeliness of operation. At an initiation of treatment during the first hours of a disease the favorable outcome comes in 90% of cases, when carrying out operation in the first days – in half of cases if from the beginning of a disease there passed more than three days, only 10% of patients survive. The only method of prevention of purulent peritonitis – timely treatment of diseases which can lead to this heavy complication.
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