In abdominal surgery, which deals with the treatment of diseases and injuries of organs and walls of the abdominal cavity, there are many disagreements on the treatment of the disease, which develops in the absence of a source of inflammation of the abdominal cavity. Most surgeons take as their 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 generic name, analyzed its features, identified pathological factors that contribute 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.
According to the etiology and nature of the invasion of microorganisms into the abdominal cavity, primary, secondary and tertiary peritonitis are distinguished. What it is? Primary develops as a result of the ingress of microflora into 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 defect in its wall. It is of the following types:
- Perforated. Infection in the abdominal cavity penetrates during perforation of the hollow organs together with their contents.
- Infectious and inflammatory. It occurs with acute intestinal obstruction, appendicitis, pancreatitis, cholecystitis.
- Postoperative. Occurs when an infection gets into the peritoneum during an operation, poorly stitched sutures, tissue dies when the vessels are ligated.
- Traumatic. It is the result of closed and open injuries.
Tertiary is formed immediately after secondary peritonitis. It is caused by opportunistic microorganisms or fungi. According to microbiological characteristics, the disease is divided into:
- microbial - specific and non-specific;
- aseptic - it contributes to the effect on the peritoneum of gastric juice, bile, blood;
- granulomatous;
- rheumatoid;
- parasitic;
- carcinomatous.
With peritonitis in the abdominal cavity, there may be exudate - serous-fibrinous, serous, purulent, purulent-fibrinous or pathological impurity, consisting of blood, bile or feces.
By the nature of the damage to the surface of the peritoneum, these types of ailment are distinguished:
- delimited;
- unlimited;
- local - one section of the peritoneum is affected;
- diffuse - peritonitis takes from two to five areas;
- total - six or more departments are 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 - forms up to 72 hours. The pain subsides, but the intoxication of the body increases.
- Terminal - starts later than 72 hours, and with perforation - more than a day. The patient's health 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 cavity. The most common cause is appendicitis, which occurs when the inflamed process 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. In the inflammatory process, perforation of an organ located in the abdominal cavity occurs.
- Injuries. Occur when falling from a height, in traffic accidents, when the peritoneum is wounded by various objects. Infection through a wound or inflammation of an organ after 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 a complete emptying of the stomach.
- Tense belly. The muscles of the abdominal wall tighten, resembling a washboard.
- Elevated body temperature. It occurs due to the inflammatory process and can rise above 38 degrees.
- Tachycardia. Heart contractions increase with an increase in general intoxication of the body.
- Lowering blood pressure. This is usually observed at the terminal stage of primary peritonitis, when the body ceases to cope with the inflammatory process.
- Thirst. Drinking plenty of water does not quench your thirst. On the tongue at the beginning of the disease, a white dry coating appears, which subsequently becomes brown.
- Dry dermis. All skin integuments and mucous membranes become dry, facial features are sharpened.
- Cramps. They arise as a result of the loss of a large amount of fluid in the lower extremities, gradually spreading higher.
- Oliguria. The amount of urine excreted is reduced, which with primary peritonitis leads to increased intoxication of the body.
- Imaginary well-being. The pain stops for a short time, the patient becomes better, and he can refuse medical care. After a while, the condition worsens sharply.
- Inhibition of intestinal motility. The contraction of the intestinal wall slows down or completely stops.
- 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 the disease
A disease can quickly lead to serious complications, so it is important to conduct a quick diagnosis, including the following measures:
- History taking. A detailed survey of the patient is carried out with the identification of all the symptoms of the disease and patient complaints.
- Examination of the patient with palpation in the abdomen.
- General analysis of blood and urine to identify the inflammatory process.
- Blood chemistry. Gives information about the pathology of internal organs.
- Hemostasiogram. Allows you to determine the level of blood coagulability.
- Ultrasonography. Helps detect the presence of exudative fluid in the peritoneum.
- Roentgenography. Detects inflammation sites.
- Puncture of the abdominal cavity. A 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 the correct diagnosis of peritonitis, an accurate diagnosis is made and surgical treatment is prescribed.
Surgical treatment
The therapy of peritonitis should be started immediately after the diagnosis is clearly identified. Any delay can be fatal. The main task of the surgeon is to eliminate the cause of the disease, and to carry out rehabilitation of the abdominal cavity. The operation is performed by laparotomy to get a wide surgical field and quick access to the site of inflammation.
During peritonitis surgery, the surgeon removes or sutures the damaged organ. Using antiseptic solutions, the peritoneum is washed, the edges of the incision are sutured by inserting a drainage tube. On it, exudate will be released outside to cleanse the abdominal cavity.
Conservative treatment
Postoperative sutures are daily treated 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, impaired body functions are restored, and full recovery occurs. For this, after an operation performed in the Department of Surgery, peritonitis is treated using the following means:
- Infusion solutions. To restore water-electrolyte balance and reduce intoxication.
- Diuretic drugs. Stimulate the excretion of urine, and with it, toxins.
- Anticoagulants. Prevent rapid coagulation and blood clots.
Sometimes the patient is administered blood components, non-steroidal anti-inflammatory drugs, give antipyretic and antiemetic drugs.
Appendicitis. Complication
Appendicitis is an acute disease that causes inflammation of the process of the cecum. The reasons why the appendix is inflamed are not well understood. Symptoms of this disease are as follows:
- abdominal pain is often on the right side, above the inguinal fold;
- fever, rises to 38 degrees;
- nausea, vomiting, and loose stools;
- general weakness.
The doctor makes a diagnosis using a patient survey, palpating, receiving laboratory data and ultrasound.
Appendicitis is treated only by surgery. Often after appendicitis, peritonitis occurs as a complication after surgery. It can be caused by:
- poorly stitched seams;
- infection introduced during surgery;
- internal bleeding;
- stagnation of liquid biological substances as a result of diseases of the kidneys and liver;
- bowel obstruction;
- necrosis of the intestinal wall.
It is very difficult to determine peritonitis in the surgery department that began after an operation to remove appendicitis. The diagnosis makes it very 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 abdomen. It is significantly enhanced when the patient begins to palpate.
- There is a temporary absence of pain, which then reappears.
- Fever and chills begin.
- Bloating, gas retention.
- Nausea, vomiting.
- Scanty urination.
- Thirst.
- Dyspnea and palpitations.
- Fainting.
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 again carried out. 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 through the hematogenous route from other organs. The disease in children can provoke infectious enterocolitis when staphylococci enters the abdominal cavity, as well as inflammation of the gallbladder and ovaries, ruptures and injuries of organs outside the peritoneum. The severity of the course of the disease and symptoms depends on the age of the baby. It is especially difficult for the smallest patients to tolerate it due to the underdevelopment of internal organs and low immunity. The main signs by which peritonitis in a child is determined are as follows:
- deterioration in the general condition of the child;
- increase in body temperature up to 39 degrees;
- nausea and vomiting;
- the baby becomes excitable or, conversely, passive;
- tormented by loose stools;
- frequent heartbeat and breathing begin;
- severe abdominal pain;
- with the development of the process, the condition of the child worsens;
- there is a strong thirst;
- integuments become earthy;
- mucous membranes are overdried, the tongue is coated with a white coating;
- urine production stops (it is the violation of the water-salt balance that poses a great danger to the baby).
If such symptoms are identified, the patient urgently needs to call an ambulance. Only a doctor, after additional diagnostics using ultrasound, blood and urine tests, can make the correct diagnosis.
Treatment of the disease in children
For an accurate diagnosis of the disease, a child undergoes laparoscopy, with the help of which cryptogenic peritonitis is reliably determined. In this case, the need for surgical intervention disappears. Treatment of primary peritonitis in children is carried out by conservative methods. For this, exudate is suctioned and antibacterial agents are introduced into the abdominal cavity. The child is constantly monitored by medical personnel who closely monitor changes in heart rate and blood pressure. In addition, urine and blood tests are systematically performed. To relieve pain, the baby is given painkillers, therapy is prescribed to help restore the body's defenses, and a sparing diet to normalize the intestines. Parents need to be careful about the health status of their children and treat all infectious diseases on time.
Primary peritonitis in girls
Cryptogenic peritonitis most often occurs in girls, whose age is from three to seven years. 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 is rare in girls. 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 it in the pelvic cavity. The fallopian tubes and uterus become inflamed. All these signs characterize the inflammatory process. With the progression of the disease, 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 turbulent and acute onset. Severe pain appears in the lower abdomen, the temperature rises to 39 degrees, repeated vomiting, loose stools occur. The general condition of the child is severe: it becomes restless, the skin turns pale, the tongue is dry with a white bloom, palpation of the abdomen shows sharp pain, vaginal discharge is mucopurulent, and there is a high white blood cell count in the blood.
- Local Has an erased clinical picture. Intoxication is poorly expressed, painful sensations are located only in the lower abdomen or on the right, the temperature does not exceed 38 degrees, the presence of acute respiratory viral infections during examination or the previous day is noted.
In both forms of peritonitis, using the traditional tactics, it is difficult to exclude the diagnosis of acute appendicitis, therefore, surgery is performed. In the modern practice of pediatric surgery, primary peritonitis in girls, after confirming the diagnosis with laparoscopy, is treated using conservative therapy, sucking pus and using antibiotics.
Recovery period after surgery
The healing time of the abdominal wall in patients depends on the state of health of the patient and the individual characteristics of the body. The first time after the operation, you need to hold the stomach with your hand when coughing and laughing, gently rise from the bed, resting on your hand, and not strain the abs. To alleviate the condition, it is recommended to use a bandage. In the early days, walking should be limited, as recovery is 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 strength after surgery:
- In the early days, you need to limit the amount of food consumed. It is advisable to eat liquid semolina made without milk, drink plenty of water and consume jelly.
- Exclude products that promote fermentation and gas formation: cabbage, lentils, beans, peas, milk, fresh bread, kvass, chocolate.
- Do not eat foods fried and smoked, containing fat, a lot of salt, spices.
- Gradually, the diet can be expanded to include steamed vegetables, ground diet meat, and low-fat fish. All products must be cooked in a steam bath, baked or boiled.
- It is recommended to return to the usual diet no earlier than a week or two after the operation. Carbonated drinks and fast food are best avoided.
The implementation of 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. With primary peritonitis, infection of the peritoneum occurs with a blood or lymph flow, therefore, for its prevention, it is necessary to timely treat the foci of chronic infection in the body.