In abdominal surgery, dealing with the treatment of diseases and injuries of the organs and walls of the abdominal cavity, there are many disagreements on the interpretation of the disease, which develops in the absence of a source of inflammation of the abdominal cavity. Most surgeons take as a basis the definition formulated by G. A. Bairov, who considers acute peritonitis to be primary peritonitis, which is not a complication of inflammatory processes in the abdominal cavity. In his study, he used a generalized name, analyzed its features, and identified pathological factors contributing to its development. All this helps to find a rational approach to the choice of treatment methods and helps to consolidate the results.
Classification of peritonitis
According to the clinical course, peritonitis is divided into acute and chronic. The latter usually develops with ascites, syphilis, mycosis or tuberculosis.
Poetiology and the nature of the invasion of microorganisms into the abdominal cavity distinguish between primary, secondary and tertiary peritonitis. What it is? Primary develops as a result of microflora entering the peritoneum by the lymphogenous or hematogenous route. It can be spontaneous peritonitis in children and adults. Secondary occurs when microorganisms penetrate after the destruction of the abdominal organ or a defect in its wall. It comes in the following types:
- Perforated. Infection enters the abdominal cavity during perforation of hollow organs along with their contents.
- Infectious-inflammatory. Occurs with acute intestinal obstruction, appendicitis, pancreatitis, cholecystitis.
- Post-op. Occurs when an infection enters the peritoneum during surgery, poorly applied sutures, tissue death during ligation with vascular threads.
- Traumatic. Is the result of closed and open injuries.
Tertiary is formed immediately after secondary peritonitis. It is caused by opportunistic pathogens or fungi. According to microbiological characteristics, the disease is divided into:
- microbial – specific and non-specific;
- aseptic - it is promoted by the effect on the peritoneum of gastric juice, bile, blood;
- granulomatous;
- rheumatoid;
- parasitic;
- carcinomatous.
With peritonitis, there may be exudate in the abdominal cavity - serous-fibrinous, serous, purulent, purulent-fibrinous or pathological admixture, consisting of blood, bile or feces.
By the nature of the damage to the surface of the peritoneum, the following types of disease are distinguished:
- limited;
- unlimited;
- local - one part of the peritoneum is affected;
- diffuse - peritonitis occupies two to five areas;
- total - six or more departments affected.
The following stages of peritonitis are distinguished by the time of the course:
- Reactive - develops within a day after the onset of the disease. The pain is concentrated in a local place, the stomach is tense.
- Toxic - formed up to 72 hours. The pain subsides, but the intoxication of the body grows.
- Terminal - starts later than 72 hours, and with perforative - more than a day. The patient's state of he alth is extremely difficult, the infection spreads throughout the body.
Causes of peritonitis
Peritonitis occurs due to infection in the abdominal cavity, the reasons for this may be:
- Inflammatory processes of the abdominal organs. The most common cause is appendicitis, which occurs when an inflamed appendix ruptures.
- Hematogenous infection. Primary peritonitis occurs when pathogenic microorganisms enter the blood and lymph from an organ that is outside the peritoneum.
- Perforation of organs. During the inflammatory process, perforation of the organ located in the abdominal cavity occurs.
- Injuries. They occur when falling from a height, in traffic accidents, when the peritoneum is injured by various objects. Infection through a wound or inflammation of an organafter a bruise causes an inflammatory process in the organ.
Symptoms of peritonitis
The clinical picture of the disease is influenced by the cause of the disease and the stage of peritonitis, which are characterized by the following symptoms:
- Pain. The disease has an acute onset. Painful sensations appear at the site of inflammation, gradually spreading to the entire abdomen.
- Nausea and vomiting. There is complete emptying of the stomach.
- Tense stomach. The muscles of the abdominal wall tense up, resembling a washboard.
- Increased body temperature. It occurs due to the inflammatory process and can rise above 38 degrees.
- Tachycardia. Heart contractions increase with an increase in the general intoxication of the body.
- Lower blood pressure. This is usually observed in the terminal stage of primary peritonitis, when the body ceases to cope with the inflammatory process.
- Thirst. Drinking a lot of water does not quench your thirst. A white dry coating appears on the tongue at the beginning of the disease, which later becomes brown.
- Dry dermis. All skin and mucous membranes become dry, facial features are sharpened.
- Convulsions. They result from the loss of a large amount of fluid in the lower extremities, gradually spreading higher.
- Oliguria. The amount of urine excreted decreases, which in case of primary peritonitis leads to increased intoxication of the body.
- Imaginarywell-being. The pain stops for a short time, the patient gets better, and he can refuse medical care. After a while, the condition deteriorates sharply.
- Inhibition of intestinal motility. The contraction of the intestinal wall slows down or stops altogether.
- Confusion. It occurs with severe intoxication of the body and pain.
In the treatment of peritonitis, the symptoms and causes of the disease are important.
Diagnosis of disease
The disease can quickly lead to serious complications, so it is important to conduct a quick diagnosis, including the following:
- Collecting an anamnesis. A detailed survey of the patient is conducted with the identification of all the symptoms of the disease and the patient's complaints.
- Examination of a patient with palpation in the abdomen.
- General analysis of blood and urine to detect inflammation.
- Biochemical blood test. Gives information about the pathology of internal organs.
- Hemostasiogram. Allows you to determine the level of blood clotting.
- Ultrasound. Helps to detect the presence of exudative fluid in the peritoneum.
- X-ray. Detects areas of inflammation.
- Puncture of the abdominal cavity. Fluid taken with a thin needle from the peritoneum is examined for the presence of infection.
- Laparoscopy. It is carried out in problematic cases to establish inflammation in the peritoneum.
With a correct diagnosis of peritonitis, an accurate diagnosis is made and an operativetreatment.
Surgical treatment
It is necessary to start therapy for peritonitis immediately after an accurate diagnosis is made. Any delay can be fatal. The main task of the surgeon is to eliminate the cause that caused the disease and to sanitize the abdominal cavity. The operation is performed using the laparotomy method in order to obtain a wide operating field and quick access to the focus of inflammation.
During a peritonitis operation, the surgeon removes or sutures the damaged organ. Using antiseptic solutions, the peritoneum is washed, the edges of the incision are sutured, inserting a tube for drainage. Through it, the exudate will be released to the outside to cleanse the abdominal cavity.
Conservative treatment
Postoperative sutures are treated daily by medical personnel with antiseptic solutions, after which a sterile dressing is applied. With the help of conservative therapy, the causative agent of the infection is completely destroyed, the disturbed functions of the body are restored, and complete recovery occurs. To do this, after the operation performed in the Department of Surgery, peritonitis is treated using the following means:
- Infusion solutions. To restore water and electrolyte balance and reduce intoxication.
- Diuretic drugs. Stimulates the excretion of urine, and with it the toxins.
- Anticoagulants. They prevent rapid blood clotting and the formation of blood clots.
Sometimes the patient is given blood components, non-steroidal anti-inflammatory drugs, antipyretics andantiemetics.
Appendicitis. Complication
Appendicitis is an acute disease that causes inflammation of the process of the caecum. The reasons why the appendix becomes inflamed are not well understood. The symptoms of this disease are as follows:
- abdominal pain is often on the right side, above the inguinal crease;
- high temperature, rising to 38 degrees;
- nausea, vomiting and loose stools;
- general weakness.
The doctor makes a diagnosis using a patient survey, palpation, laboratory data and ultrasound.
Appendicitis is treated only by surgery. Often after appendicitis, peritonitis occurs as a complication after surgery. It can be called:
- poorly stitched;
- infection introduced during surgery;
- internal bleeding;
- stagnation of liquid biological substances as a result of diseases of the kidneys and liver;
- intestinal obstruction;
- necrosis of the intestinal wall.
It can be very difficult to determine peritonitis in the Department of Surgery that began after an operation to remove appendicitis. Making a diagnosis makes it much more difficult for patients to take medications that are prescribed in the postoperative period. The following symptoms are characteristic of the disease:
- There is severe pain in the lower right side of the abdomen. It increases significantly when the patient is palpated.
- Temporary is comingthe absence of painful sensations, which then reappear.
- Fever and chills begin.
- Bloating, gas retention.
- Nausea, vomiting.
- Scanty urination.
- Thirst.
- Shortness of breath and palpitations.
- Faints.
Treatment is carried out depending on the causes of the disease. In the primary form of peritonitis, antibacterial agents are used, otherwise surgical treatment is performed again. In addition, painkillers, immunomodulators and vitamin complexes are used.
Primary peritonitis in children
In this type of peritonitis, inflammation in the abdominal cavity in children develops without the occurrence of violations of the integrity of the peritoneal organs. The infection spreads by the hematogenous route from other organs. The disease in children can provoke infectious enterocolitis when staphylococci enter the abdominal cavity, as well as inflammation of the gallbladder and ovaries, ruptures and injuries of organs outside the peritoneum. The severity of the disease and symptoms depend on the age of the baby. It is especially difficult for the smallest patients to endure it due to the underdevelopment of internal organs and low immunity. The main signs by which peritonitis is determined in a child are as follows:
- deterioration of the general condition of the child;
- increase in body temperature up to 39 degrees;
- nausea and vomiting;
- the baby becomes excitable or, conversely, passive;
- torturing loose stools;
- rapid heartbeat and breathing begin;
- severe pain instomach;
- with the development of the process, the child's condition worsens;
- great thirst arises;
- skin becomes earthy;
- mucous membranes dry, tongue coated with white coating;
- the excretion of urine stops (it is the violation of the water-s alt balance that poses a great danger to the baby).
When identifying such symptoms, the patient must urgently call an ambulance. Only a doctor, after additional diagnostics using ultrasound, blood and urine tests, can make a correct diagnosis.
Treatment of disease in children
For an accurate diagnosis of the disease, the child undergoes laparoscopy, which reliably determines cryptogenic peritonitis. In this case, the need for surgical intervention is eliminated. Treatment of primary peritonitis in children is carried out by conservative methods. For this, exudate is suctioned and antibacterial agents are injected into the abdominal cavity. The child is under constant supervision of medical personnel, who closely monitors changes in heart rate and blood pressure. In addition, a systematic study of urine and blood is carried out. To relieve pain, the baby is given painkillers, therapy is prescribed to help restore the body's defenses, and a sparing diet to normalize bowel function. Parents need to be attentive to the he alth of their children and treat all infectious diseases in time.
Primary peritonitis ingirls
Cryptogenic peritonitis most often occurs in girls between the ages of three and seven. It was found that the abdominal cavity is infected through the vagina with inflammation of the mucous membranes of the fallopian tubes. With age, the disease in girls is rare. This is explained by the fact that Dederlein sticks appear in the vagina, which protect it from the ingress of pathogenic microorganisms and the development of infection. With the development of laparoscopy, it was finally confirmed that the cause of primary peritonitis in girls is an infection that has entered the peritoneum through the vagina. At the bottom of the abdominal cavity there is an accumulation of turbid mucous effusion, and most of all in the pelvic cavity. The fallopian tubes and uterus become inflamed. All these signs characterize the inflammatory process. As the disease progresses, the effusion becomes purulent. The fallopian tubes swell and become thickened.
Clinic and diagnosis of the disease
According to the clinical course of the disease, two forms of primary peritonitis in girls are distinguished:
- Toxic. It has a violent and sharp onset. Severe pain appears in the lower abdomen, the temperature rises to 39 degrees, there is repeated vomiting, loose stools. The general condition of the child is severe: he becomes restless, the skin turns pale, the tongue is dry with a white coating, there is sharp pain on palpation of the abdomen, vaginal discharge is mucopurulent, there is a high content of leukocytes in the blood.
- Local. Has an erased clinical picture. Intoxication is mild, pain is located only in the lower partabdomen or on the right, the temperature does not exceed 38 degrees, the presence of acute respiratory viral infections is noted during the examination or transferred the day before.
In both forms of peritonitis, using traditional tactics, it is difficult to exclude the diagnosis of acute appendicitis, so surgery is performed. In modern practice of pediatric surgery, primary peritonitis in girls after confirmation of the diagnosis by laparoscopy is treated with conservative therapy, suctioning off pus and using antibiotics.
Recovery period after surgery
The healing time of the abdominal wall in patients depends on the state of he alth of the patient and the individual characteristics of the organism. The first time after the operation, it is necessary to hold the stomach with your hand when coughing and laughing, carefully get out of bed, leaning on your hand, and not strain your abs. To alleviate the condition, it is recommended to use a bandage. In the early days, walking should be limited; as the recovery progresses, active movement helps prevent adhesions in the abdominal cavity. To accelerate the healing of the postoperative scar, the patient is prescribed laser therapy or UHF. In addition, dietary nutrition helps the patient recover after surgery:
- In the early days it is necessary to limit the amount of food consumed. It is advisable to eat liquid semolina porridge prepared without milk, drink plenty of water and use jelly.
- Exclude foods that promote fermentation and gas formation: cabbage, lentils, beans, peas, milk, fresh bread, kvass, chocolate.
- Do not eat fried and smoked foods,containing fat, a lot of s alt, spices.
- Gradually, the diet can be expanded to include steamed vegetables, ground dietary meat, lean fish. All foods must be steam-baked, baked or boiled.
- It is recommended to return to the usual diet no earlier than a week or two after the operation. Avoid carbonated drinks and fast food.
Following all the recommendations of the doctor, the use of physiotherapy and the right diet will help to avoid complications in the postoperative period and quickly return to normal life. In primary peritonitis, infection of the peritoneum occurs with the blood or lymph flow, therefore, for its prevention, it is necessary to treat foci of chronic infection in the body in a timely manner.
