In the article, we consider the stages of development of peritonitis. This pathology is diffuse or local inflammation of the serous cover of the peritoneum. The main signs of the pathology are abdominal pain, muscle tension, nausea and vomiting, gas retention, fever, severe 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 reaches 50%.
The peritoneum is formed by two serous leaves - parietal and visceral, which cover the internal organs and walls of the cavity. It is a semipermeable, active membrane that performs many functions: absorption of exudate, bacteria, lysis products, excretion 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 humoral and 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, aerobes, eubacteria, peptococcus, clostridia. In 80% of cases, peritonitis is provoked by the association of pathogenic microbes. More rarely, the occurrence of this process is due to a specific microflora - mycobacteria of tuberculosis, hemolytic streptococcus, gonococcus, pneumococcus. Therefore, when choosing a rational therapy for peritonitis, the main role is played by bacteriological culture with the determination of sensitivity to antibacterial drugs.
The stages of peritonitis will be discussed below.
Taking into account the etiology, primary and secondary peritonitis are distinguished. Primary bacteria are characterized by the penetration of bacteria into the abdominal cavity through the hematogenous or lymphogenous route or through the fallopian tubes. Inflammation of the peritoneum can be associated with enterocolitis, salpingitis, genital or renal tuberculosis. Primary peritonitis is observed infrequently.
The last stage of peritonitis is very dangerous.
In medical practice, they are more often faced with secondary peritonitis, which develops as a result of a destructive inflammatory process or injuries. Most often, peritonitis occurs after appendicitis (phlegmonous, perforating, gangrenous), perforated gastric ulcer, pyosalpinx, ovarian rupture, intestinal obstruction, occlusion of mesenteric vessels, with Crohn’s disease, phlegmonous-gangrenous cholecystitis, pancreatic ulcer disease, and pulmonitis.
Post-traumatic peritonitis can occur due to open or closed organ damage. 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 stage of the course are presented below.
Classification
In clinical medicine, abacterial (toxic-chemical, aseptic) and bacterial peritonitis are distinguished. The former develop due to irritation of the peritoneum with non-infectious agents (blood, bile, gastric or pancreatic juice, urine). Such peritonitis quickly assumes the character of a bacterial as a result of the attachment of an infection from the gastrointestinal tract.
Given the nature of peritoneal effusion, serous, hemorrhagic, fibrinous, biliary, fecal, purulent, putrefactive peritonitis are distinguished.
Depending on the course of the course, this pathology is divided into acute and chronic peritonitis. Given the prevalence of lesions along the peritoneum, local (pelvic, subphrenic, subhepatic, appendicular, interintestinal) and diffuse are distinguished. You can talk about diffuse peritonitis when inflammation does not have limitations 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 legs bent to the stomach. The pain extends to the entire abdominal cavity.
The surgeon at the reactive stage of peritonitis examines the patient and reveals the following signs of inflammation of the peritoneum:
- Symptoms of Blumberg-Shchetkin - the doctor presses on the stomach, fixing his fingers in the front wall for 2 seconds. A sharp jerking of the arm provokes severe pain in a patient with peritonitis.
- Symptoms of Mendel - tapping the abdomen, which with 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 symptom is characterized by irritation of the phrenic nerve, which occurs during acute processes in the peritoneum, even in the first stage of peritonitis.
- Symptoms of Voskresensky - when the patient exhales, the specialist passes his fingers from the ribs towards the ilium. An increase in soreness at the same time indicates irritation of the abdominal cavity.
At this stage, vomiting, nausea, hyperthermia, increased pressure, increased heart rate appear.
Stage II peritonitis is toxic, which lasts about 2-3 days. Increased intoxication pushes local symptoms to the background. Abdominal pain and symptoms that indicate irritation of the peritoneum become less pronounced. What are the symptoms identified in the toxic stage of peritonitis?
In the clinical picture, intestinal paresis and flatulence with constipation prevail, and vomitus acquire a fetid odor. The pulse is significantly increased, the pressure drops.
III stage of peritonitis - terminal, which occurs in three days. Intoxication causes severe dehydration. Tissue ischemia, acidosis and increased blood coagulation develop, which leads to multiple organ failure. The patient's breathing becomes frequent and shallow, his pressure drops to critical levels. At the terminal stage of peritonitis with vomiting, the contents of the intestines are evacuated , the abdomen is greatly swollen, peristalsis cannot be determined even when listening with a phonendoscope. The nervous system responds to intoxication with adynamia. The patient may be in euphoria without feeling pain. He has confusion, delirium.
At the most complex, terminal stage of development of peritonitis, the patient's condition becomes extremely difficult: the skin and mucous membranes acquire an unhealthy cyanotic, pale or yellowish hue, the tongue is overdried, and a dark thick coating appears on its surface. There is also a pronounced swelling of the internal organs, as a result of which the urine excretion process is disturbed, shortness of breath develops, the heartbeat intensifies to critical values, and the patient periodically loses consciousness. This stage is considered extremely dangerous and at the same time forecasts are given very disappointing. If untreated, the patient dies within 24 hours. Below we consider urinary peritonitis, stages of development and the clinic.
Urinary Peritonitis
Damage to the ureters, perforation of the bladder can cause the development of the so-called "urinary" peritonitis, which is characterized by the outflow of urine into the abdominal cavity. Nevertheless, such phenomena often remain unrecognized during surgical interventions - only in 4 out of 23 women the injuries of the ureters were identified intraoperatively, in 16 patients with genitourinary fistulas - they were formed as a result of an unidentified urinary tract injury. Their damage is indicated by the expiration of urine after different periods of time after surgery.
Complete separation of the ureters ends, as a rule, with non-healing scar stenoses and fistulas that cause hydronephrotic changes and urinary peritonitis.
When urine is poured into the ureteric space, it can be encapsulated with a fibrous capsule, thus forming urinoma, which often occupies the entire retroperitoneal space and can fall into the pelvic area. In this case, malaise develops, pain in the corresponding part of the abdomen, and sometimes symptoms of an acute abdomen. A similar formation that occurred during injuries of the ureter, in almost every second patient causes serious destructive changes in the kidneys and urinary tract.
At the stage of development of urinary peritonitis, surgical treatment is lumbotomy, accompanied by emptying of urinoma.
The actions of surgeons are the same as with any other, the only difference is in the symptoms 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 effusion in the free peritoneum; the auscultatory picture indicates a decrease or complete absence of any intestinal noise, the symptoms of "deathly silence", "splashing noise" are heard. Vaginal and rectal examination for this pathology allows you to suspect an inflammatory process in the pelvis (pelvioperitonitis), the presence of exudate in the douglas space or blood.
Survey radiography of the peritoneum with peritonitis, which is caused by organ perforation, may indicate the presence of free gas (symptom of "sickle") under the diaphragm; with intestinal obstruction, Kloiber's cups are observed . An indirect radiological 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 should be determined by ultrasound.
Changes in laboratory blood tests for peritonitis (leukocytosis, an increase in 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. This technique for diagnosing peritonitis is shown in cases of uncertainty and allows you to identify the cause and nature of the pathological process.
Peritonitis treatment - methods and drugs
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 detected). In case of doubtful diagnostic data, the surgeon should perform a puncture and laparoscopy.
Operation stages
Treatment of purulent peritonitis is, as a rule, reduced to an early surgical intervention. The operation consists of the following steps:
- Preparation in which anesthesia and bowel cleansing are performed.
- Elimination of the main reason for the development of peritonitis, which can be a resection of an ulcer, excision of the appendix, etc.
- Removal of exudate from the peritoneum and rinsing with antiseptic agents.
- Installation of drainage for the subsequent outflow of accumulating fluid.
- In addition to surgical intervention, the patient is prescribed drug therapy.
- The fight against infectious infection includes the use of antibacterial agents (Ampicillin, Ceftriaxone, Gentamicin).
- Detoxification, which is an infusion of intravenous calcium chloride, hemodesis, a solution of ringer or glucose. If necessary, plasmapheresis and hemosorption are performed.
- Recovery measures to normalize the composition of the blood, in which protein preparations are prescribed for 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 the use of antiemetic drugs (Cerucal), non-steroidal drugs (Ibuprofen), elimination of intestinal paresis (Proserinum).
In cases of diffuse peritonitis , several surgical interventions are often performed until complete suppression of exudation. And although medical science and practice has reached a fairly high level today, the total inflammatory process in the peritoneum provokes a fatal outcome in almost 50% of cases. With delimited, local peritonitis, death is observed only in 5% of cases, mainly in patients with immunity failure and severe exhaustion.
Postoperative recovery of patients includes antibacterial and infusion therapy, the introduction of immunocorrections, 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 due to severe purulent intoxication and insufficiency of all organs.
Since the bulk of peritonitis is secondary, their prevention requires immediate diagnosis and treatment of the main pathology - stomach ulcers, appendicitis, cholecystitis, pancreatitis, etc. Prevention of postoperative peritonitis should include adequate hemostasis, sanitation of the peritoneum, and assessment of the viability of anastomoses.