In the article we will consider the stages of development of peritonitis. This pathology is a diffuse or local inflammation of the serous cover of the peritoneum. The main signs of pathology are abdominal pain, muscle tension, nausea and vomiting, gas retention, fever, serious condition.
Description
The process of peritonitis is accompanied by severe symptoms, the development of organ failure. Mortality in this case is approximately 20-30%, and in severe forms it reaches 50%.
The peritoneum is formed by two serous sheets - parietal and visceral, which cover the internal organs and walls of the cavity. It is a semi-permeable, active membrane that performs many functions: absorption of exudate, bacteria, lysis products, secretion of serous fluid, mechanical and antimicrobial protection of organs, etc. An important protective property is the ability of the peritoneum to delimit inflammation due to adhesions and scars, as well as humoraland cellular mechanisms.
Before considering the stages of peritonitis, let's talk about the causes of the disease.
Causes of peritonitis
The main cause of peritonitis is a bacterial infection represented by nonspecific microflora of the digestive tract. It can be Enterobacter, Pseudomonas aeruginosa or Escherichia coli, Proteus, Staphylococcus aureus, aerobes, eubacteria, Peptococcus, Clostridia. In 80% of observations, peritonitis is provoked by the association of pathogenic microbes. Less commonly, the occurrence of this process is due to a specific microflora - Mycobacterium tuberculosis, hemolytic streptococcus, gonococci, pneumococci. Therefore, when choosing a rational therapy for peritonitis, bacteriological culture with the determination of sensitivity to antibacterial drugs plays the main role.
The stages of the course of peritonitis will be considered below.
Taking into account the etiology, primary and secondary peritonitis is distinguished. Primary bacteria are characterized by the penetration of bacteria into the abdominal cavity by the hematogenous or lymphogenous route or through the fallopian tubes. Inflammation of the peritoneum may be associated with enterocolitis, salpingitis, tuberculosis of the genitals or kidneys. Primary peritonitis is rare.
The last stage of peritonitis is very dangerous.
In medical practice, more often they encounter secondary peritonitis, which develops as a result of a destructive-inflammatory process or injuries. Most often, peritonitis occurs after appendicitis (phlegmonous, perforative, gangrenous), perforated ulcerstomach, pyosalpinx, ovarian ruptures, intestinal obstruction, occlusions of mesenteric vessels, Crohn's disease, phlegmonous-gangrenous cholecystitis, diverticulitis, pancreatitis, pancreatic necrosis and other pathologies.
Post-traumatic peritonitis can occur due to open or closed injuries of organs. The cause of postoperative peritonitis may be a defect in the application of ligatures, damage to the peritoneum, infection of the cavity, etc.
Classification of peritonitis and stages of the course are presented below.
Classification
In clinical medicine, abacterial (toxic-chemical, aseptic) and bacterial peritonitis are distinguished. The former develop as a result of irritation of the peritoneum by non-infectious agents (blood, bile, gastric or pancreatic juice, urine). Such peritonitis quickly takes on the character of a bacterial infection as a result of the addition of an infection from the lumen of the gastrointestinal tract.
Taking into account the nature of the peritoneal effusion, serous, hemorrhagic, fibrinous, bilious, fecal, purulent, putrefactive peritonitis is isolated.
Depending on the course of the disease, this pathology is divided into acute and chronic peritonitis. Taking into account the prevalence of lesions in the peritoneum, local (pelvic, subdiaphragmatic, subhepatic, appendicular, interintestinal) and diffuse are distinguished. We can talk about diffuse peritonitis when inflammation has no limits and clear boundaries.
Stages of peritonitis
How does this pathology proceed?
The first stage of peritonitis is reactive, which lasts no more than 24 hours. It is characterized by severe pain in the abdomen, forcing the patient to take a forced position - on his side with his legs bent to his stomach. The pain extends to the entire abdominal cavity.
A surgeon at the reactive stage of peritonitis examines a patient and identifies the following signs of peritoneal inflammation:
- Blumberg-Shchetkin symptoms - the doctor presses on the stomach, fixing his fingers in the front wall for 2 seconds. A sharp jerk of the hand provokes severe pain in a patient with peritonitis.
- Mendel's symptoms - tapping of the abdomen, which in this pathology causes an increase in pain and helps to establish the localization of the process.
- Frenicus-symptom - pressure in the supraclavicular region. A similar sign is characterized by irritation of the phrenic nerve, which occurs during acute processes in the peritoneum, even at the first stage of peritonitis.
- Symptoms of Resurrection - when the patient exhales, the specialist runs his fingers from the ribs towards the ilium. Increased soreness indicates irritation of the abdominal cavity.
At this stage, vomiting, nausea, hyperthermia, increased pressure, increased heart rate appear.
II stage of peritonitis - toxic, which lasts about 2-3 days. Increasing intoxication pushes local symptoms into the background. Abdominal pain and symptoms that indicate irritation of the peritoneum become less pronounced. What are the symptoms of the toxic stage of peritonitis?
In the clinic althe picture is dominated by intestinal paresis and flatulence with constipation, and the vomit acquires a fetid odor. The pulse increases significantly, the pressure drops.
III stage of peritonitis - terminal, which occurs in three days. Intoxication causes severe dehydration. Tissue ischemia, acidosis and an increase in blood clotting develop, which leads to multiple organ failure. The patient's breathing becomes frequent and superficial, his pressure drops to critical levels. At the terminal stage of peritonitis, vomiting evacuates the contents of the intestine, the abdomen is strongly swollen, it is impossible to determine peristalsis even when listening with a phonendoscope. The nervous system reacts to adynamia intoxication. At the same time, the patient can be in euphoria without feeling pain. He has confusion, delirium.
At the most difficult, terminal stage of the development of peritonitis, the patient's condition becomes extremely difficult: the skin and mucous membranes become unhe althy bluish, pale or yellowish, the tongue is dry, a dark thick coating appears on its surface. There is also a pronounced swelling of the internal organs, as a result of which the process of excretion of urine is disturbed, shortness of breath develops, the heartbeat increases to critical levels, and the patient periodically loses consciousness. This stage is considered extremely dangerous and at the same time the forecasts are very disappointing. If untreated, the patient dies within a day. Below we consider urinary peritonitis, stages of development andclinic.
Urinary peritonitis
Injuries to the ureters, perforation of the bladder can cause the development of the so-called "urinary" peritonitis, which is characterized by the outpouring of urine into the abdominal cavity. However, such phenomena often remain unrecognized during surgical interventions - only in 4 out of 23 women, ureteral injuries were identified intraoperatively, in 16 patients with urogenital fistulas - they were formed as a result of an injury to the urinary organs that was not identified during surgery. Their damage is evidenced by the outflow of urine at various times after operations.
Complete divisions of the ureters usually end in non-healing cicatricial stenoses and fistulas that cause hydronephrotic changes and urinary peritonitis.
When urine spills into the periureteral space, it can become encapsulated by a fibrous capsule, thus forming a urinoma that often occupies the entire retroperitoneal space and may descend into the pelvic area. At the same time, malaise develops, pain in the corresponding part of the abdomen, and sometimes symptoms of an acute abdomen. A similar formation, which has arisen due to injuries of the ureter, causes serious destructive changes in the kidneys and urinary tract in almost every second patient.
At the stage of development of urinary peritonitis, surgical treatment is lumbotomy, accompanied by emptying of the urinoma.
The actions of surgeons are the same as with any other, the only difference issymptoms and duration of the pathological process.
Diagnosis of peritonitis
Palpation of the abdomen helps to identify positive peritoneal symptoms: Shchetkin-Blumberg, Medel, Voskresensky, Bernstein. Tapping on it is characterized by dullness of sound sensations, which indicates an effusion in the free peritoneum; auscultatory picture indicates a decrease or complete absence of any intestinal noise, symptoms of "deathly silence", "splash noise" are heard. Vaginal and rectal examination in this pathology allows us to suspect an inflammatory process in the small pelvis (pelvioperitonitis), the presence of exudate in the Douglas space or blood.
Peritoneal radiography in peritonitis due to organ perforation may indicate the presence of free gas (sickle symptom) under the diaphragm; with intestinal obstruction, Kloiber bowls are observed. An indirect x-ray sign of peritonitis is a limited excursion of the diaphragm, its high standing and the presence of effusion in the pleural sinus. Free fluid in the peritoneum to be determined by ultrasound.
Changes in laboratory blood tests for peritonitis (leukocytosis, increased ESR, neutrophilia) indicate purulent intoxication.
Laparocentesis
In addition, when diagnosing this pathology, laparocentesis is performed, which is a puncture of the abdominal cavity, as well as diagnostic laparoscopy. These methods of diagnosing peritonitis are indicated in cases of uncertainty and allow to identify the causeand the nature of the pathological process.
Treatment of peritonitis - methods and medicines
When diagnosing peritonitis, not only the symptoms of the disease should be taken into account. The diagnosis is made on the basis of laboratory blood tests (significant leukocytosis), ultrasound and x-ray of the peritoneum (the area of accumulated exudates is revealed). With doubtful diagnostic data, the surgeon should perform a puncture and laparoscopy.
Steps of operation
Treatment of purulent peritonitis is usually reduced to an early surgical intervention. The operation consists of the following steps:
- Preparation in which anesthesia is administered and bowel cleansing.
- Remove the main cause of peritonitis, which can be ulcer resection, appendix excision, etc.
- Removal of exudate from the peritoneum and washing with antiseptic agents.
- Installation of drainage for subsequent outflow of accumulated fluid.
- In addition to surgery, the patient is prescribed drug therapy.
- The fight against infection includes taking antibacterial agents (Ampicillin, Ceftriaxone, Gentamicin).
- Detoxification, which is an intravenous infusion of calcium chloride, gemodez, Ringer's solution or glucose. If necessary, plasmapheresis and hemosorption are performed.
- Restorative measures to normalize blood composition, in which protein preparations are prescribed to the patient(Hydrolysin, Albumin), Plasma, Vitamin K.
- Prevention of further accumulation of excess fluid in the abdominal cavity. In this case, the patient is prescribed diuretics (Furosemide, Lasix).
- Symptomatic treatment, which includes taking antiemetic drugs ("Cerucal"), non-steroidal drugs ("Ibuprofen"), elimination of intestinal paresis ("Prozerin").
In cases of diffuse peritonitis, several surgical interventions are often performed until the exudation is completely suppressed. And although medical science and practice has reached a fairly high level today, a total inflammatory process in the peritoneum provokes a fatal outcome in almost 50% of cases. With limited, localized peritonitis, death occurs in only 5% of cases, mainly in patients with immune failure and severe malnutrition.
Postoperative recovery of patients includes antibacterial and infusion therapy, the introduction of immunocorrectors, ozonated solutions and transfusion of leukocyte mass. For antimicrobial therapy, a combination of aminoglycosides, cephalosporins and metronidazole is used, which provides an effect on the entire spectrum of potential pathogens.
Prevention and prognosis of peritonitis
The success of the treatment of this pathological condition largely depends on the timing of the surgical intervention and the completeness of the volume of postoperative treatment. Mortality in cases of extensive peritonitis is extremely high - almost every second patient dies,and death occurs from severe purulent intoxication and failure of all organs.
Since the bulk of peritonitis are secondary, their prevention requires immediate diagnosis and treatment of the underlying pathology - stomach ulcers, appendicitis, cholecystitis, pancreatitis, etc. Prevention of postoperative peritonitis should include adequate hemostasis, sanitation of the peritoneum, assessment of the viability of anastomoses.
