The disease is peritonitis. Signs of peritonitis: main symptoms for acute and chronic inflammation

Diagnosis of peritonitis, like all acute human diseases, is based on a comprehensive assessment of medical history, local symptoms, signs of inflammation and intoxication, and characteristic complications.

Complaints.

As a rule, rather intense, dull, constant pain in the abdomen approximately corresponds to the extent of the process, intensifying with breathing and movement. Irradiation to the shoulder girdle is possible due to irritation of the diaphragm. Feeling unwell. There is often nausea. The chair is delayed.

Anamnesis.

It is necessary to find out the duration of the disease, changes in the nature and location of pain, the dynamics of toxic manifestations, and signs of complications.

In a large number of cases, it is possible to identify signs of a previous disease (appendicitis, cholecystitis, exacerbation of peptic ulcer), a typical complication of which is peritonitis. Often, against the background of some improvement in well-being and a decrease in previous abdominal pain, they suddenly intensify and become widespread. From this moment on, your health deteriorates sharply, dry mouth and thirst appear, and your heart rate increases.

General inspection.

The patient, as a rule, lies on his back or on his side with his hips adducted to the stomach; he does not change his position, since any movement or attempt to stand up leads to increased pain. If the patient was sitting, then when trying to lie down, increased pain in the abdomen or the appearance of pain in the shoulder girdle (a symptom of irritation of the phrenic nerve) force him to return to a sitting position. This is the so-called “Vanka-Vstanka” symptom.

Speech is quiet. If the patient is not addressed, he will not scream, demanding attention. Such behavior of the patient, especially his quiet groan while breathing, should always cause special concern to the doctor.

It is necessary to pay attention to the severity of all parts of the infectious process and intoxication - temperature, tachycardia, frequency and depth of breathing, the state of consciousness, the violation of which is the most striking reflection of severe intoxication, blood pressure, dryness of the mucous membranes of the tongue and the inner surface of the cheeks.

Tachycardia 100-120 per minute and above, blood pressure is normal or with a tendency to decrease, shortness of breath 20-24 per minute.

Toxic encephalopathy may manifest itself as lethargy, agitation or delirium.

Paleness, especially marbling of the skin, reflects a deep violation of microcirculation.

Special inspection.

The abdomen is usually symmetrical, somewhat swollen, and does not participate in breathing. By palpation, severe diffuse pain, tension and Mendelian and Shchetkin-Blumberg symptoms are determined. Usually there is a sharp weakening or absence of peristaltic noise.

It is necessary to check the presence of free gas by the disappearance of hepatic dullness and free fluid by the presence of dullness of percussion sound in the lateral regions, which disappears when turning on the side.

Rectal and vaginal examination may reveal sagging of the fornix and pain due to the accumulation of inflammatory exudate.

In the general blood test - pronounced leukocytosis, a pronounced shift to the left to young. Biochemical analysis reveals normo- or hyperglycemia, a moderate increase in urea, creatinine, ALAT, ASAT, alkaline phosphatase, and signs of disseminated intravascular coagulation syndrome.

Laboratory examination.

Laboratory examination reveals pronounced leukocytosis (14-20x10 9 /l), usually with a shift in the leukocyte formula to the left, lympho- and monocytopenia, aneosinophilia, thrombocytopenia. To objectify the assessment of the degree of intoxication, the Kalf-Kalif Leukocyte Intoxication Index (LII) is used.

Normal = 1 0.6.

In the reactive phase, as a rule, it reaches 4, in the toxic phase – 8, in the terminal phase – it can reach values ​​of 12 – 18.

During a biochemical examination, it is possible to detect an increase in hematocrit, urea, creatinine, transaminases, bilirubin, glucose, lactate, a violation of the coagulation system, a shift in acid-base balance, an increase in pCO 2, a decrease in pO 2 - evidence of dysfunction of various organs and systems.

Additional research.

The presence of free gas and liquid can be confirmed by ultrasound examination.

An X-ray examination can reveal free gas, Kloiber cups, high standing domes of the diaphragm, limitation of their mobility due to swelling or muscle tension. In severe cases, signs of ARDS are found in the lungs.

If there is doubt about the diagnosis, laparoscopy is performed, during which the source, extent and nature of peritonitis can be established.

The presence of peritonitis can be confirmed by laparocentesis if characteristic exudate is obtained.

In reactive and terminal phases The clinical manifestations of peritonitis vary significantly.

In the reactive phase, pain prevails. An area of ​​greatest pain is often identified, corresponding to the primary focus of inflammation. The tension of the abdominal wall muscles is pronounced. A sharply tense abdomen looks somewhat retracted - “scaphoid”, this is especially characteristic of peritonitis with perforation of hollow organs. The symptoms of Mendel and Shchetkin-Blumberg are distinct. Peristalsis is usually sharply weakened.

There are no obvious signs of dehydration. Tachycardia reaches 90 - 100 per minute, shortness of breath is rare. It is possible to identify some elements of the erectile phase of shock - arousal, increased blood pressure.

Neutrophilic lekocytosis 12-18x10 9 /l, lymphocytopenia and monocytopenia, aneosinophilia. Biochemical tests do not reveal any significant deviations.

In the terminal phase, it can be very difficult to establish a diagnosis of peritonitis if it is not possible to find out the history of the disease from relatives.

Mild vomiting of stagnant contents is repeated several times a day. Stool on its own, or after an enema, is usually scanty, often foul-smelling (septic).

An adynamic, lethargic, severely dehydrated patient with sunken eyes, sharpened facial features, breathes shallowly quickly, often with a quiet groan. He cannot stick out his dry “brush-like” tongue, since the inner surfaces of his cheeks are also dry.

The abdomen is significantly distended and unevenly slightly painful. Mendel's and Shchetkin-Blumberg's symptoms are questionable. Percussion sound is uneven. You can detect a symptom of “deathly silence” - when instead of intestinal sounds, respiratory and vascular sounds are heard. When you shake the abdominal wall with your hand, a “splashing noise” may be heard.

Plain radiographs reveal multiple Kloiber cups.

Tachycardia is above 120, blood pressure is reduced, especially after transportation, it is maintained close to normal only against the background of intensive infusion. Shortness of breath is about 30, blood oxygen saturation is often reduced (StO 2). In the lungs there are spherical shadows of different sizes, characteristic of ARDS, hydrothorax.

In the blood test, normocytosis is sometimes leukopenia, a sharp shift to the left, to young, sometimes plasma cells.

Biochemical analysis showed pronounced signs of MODS.

General principles of treatment.

Based on materials from the 31st All-Union Congress of Surgeons (1986) and the 1st International Congress in Moscow (1995), the general principles of treatment of peritonitis contain 4 points:

Preoperative preparation. It is impossible to completely correct homeostasis disorders before surgery. But it is always better to postpone the operation for 2-3 hours for targeted preparation. It is enough to achieve stabilization of blood pressure and central venous pressure, diuresis of 25 ml/hour. The total volume of infusion before surgery is 1.5-2.0 l over 2 hours. In advanced processes, when hemodynamic disturbances are pronounced (fluid loss of more than 10% of body weight), the infusion volume increases to 3-4 l over 2-3 h.

The subclavian vein is always catheterized. This provides a higher infusion rate and the ability to control central venous pressure.

Bladder catheterization is advisable to measure hourly diuresis as an objective criterion for the effectiveness of infusion therapy.

Preparation of the gastrointestinal tract. Emptying the stomach with a tube is mandatory. In case of advanced processes, the probe must be in the stomach constantly, during the entire preoperative period, during the operation and for some time after it. Until intestinal motility resumes.

Anesthesia. The main method of pain relief during operations for peritonitis is multicomponent anesthesia with the use of mechanical ventilation.

Surgical treatment. The operation consists of seven sequential stages.

What it is?

Peritonitis is inflammation of the peritoneum. The victim has a stomach ache, stool and gas retention, vomiting and tension in the abdominal muscles. He is in a serious physiological condition, suffering from an excess of heat in the body, which leads to a rapid increase in temperature.

Peritonitis of the abdominal cavity is treated only surgically.

The peritoneum is a serous covering that protects the gastrointestinal tract. The peritoneum is parietal and visceral.

The first type of membrane protects the inner wall of the abdomen. Visceral covers the surface of the organs located inside the parietal layer.

Causes of peritonitis

Infectious peritonitis is caused by bacteria and germs. The following microorganisms provoke the disease:

• fusobacterium;
• enterobacter;
• Proteus;
• streptococcus;
• eubacteria;
• peptococcus;
• Pseudomonas aeruginosa;

In most cases, viral peritonitis is caused by Escherichia coli and staphylococci.

In addition to microbes, there are other causes of the disease:

• inflammatory processes occurring in the peritoneum ( , );
• defect of the digestive system;
• the appearance of through holes in the abdominal organs (or stomach during ulcers, appendix, colon);
• surgical interventions in the abdominal organs;
• inflammation of the phlegmon of the abdominal covering of the abdomen, processes of decay in the retroperitoneal tissue.

Symptoms

There are 3 stages of the disease. Therefore, everyone has their own symptoms. The main signs of peritonitis:

• increased temperature and blood pressure;
• nausea with vomiting;
• dry mouth;
• cardiopalmus.

Peritonitis in children has the same symptoms as symptoms in adults

Symptoms of the first stage of the disease

This is long-term abdominal pain that gets worse with changes in body position. The patient lies and tries not to make movements. The Shchetkin-Blumberg symptom allows you to detect this disease.

It is necessary to slowly press on the abdominal wall, hold your hand for 3-6 seconds and sharply remove it. The occurrence of sharp pain indicates that the person is suffering from peritonitis.

The disease can also be identified using Mendel's symptom. You need to tap over the entire abdominal area. If the pain intensifies, the person is sick. This method determines the location of the pathology.

Symptoms of the second stage of peritonitis

The pain in her stomach and the tension in her muscles are subsiding. Stool retention begins to appear, frequent vomiting with an unpleasant odor.

The heartbeat also accelerates (more than 115 beats per minute), blood pressure decreases, and body temperature increases. Intoxication symptoms occur.

Symptoms of the third stage of the disease

Due to lack of water, the patient’s skin becomes pale and facial features become sharp. There is a rapid heartbeat, low blood pressure, incomplete breathing, and bloating.

There is no peristalsis - wave-like contractions of the walls of the gastrointestinal tract, leading to the movement of food.

The patient's psychological state changes dramatically due to intoxication (poisoning): from adynamia (loss of strength) to euphoria (state of bliss). In rare cases, delirium and confusion of consciousness appear.

Types and stages of peritonitis

Acute peritonitis is classified into three stages:

• First stage intestinal peritonitis(reactive, duration – half a day). The body begins to fight the infection that has entered the peritoneum. This leads to localized inflammation in the form of edema, hyperemia (overflow of blood vessels in the body area), and accumulation of exudate.

Exudate is a liquid that is released in organ tissues due to blood vessels during the inflammatory process. At first it is serous, later, due to an increase in the number of bacteria and leukocytes, it becomes purulent.

The peritoneum limits the problem area from healthy parts of the body. Therefore, this stage is characterized by the formation of adhesions in the peritoneum and nearby organs.

Swelling and infiltration may appear near the located organs. The latter is the penetration into tissues of substances that are not their normal constituents.

• Stage 2 peritonitis(toxic, duration from 3 to 5 days). The body's immune response to inflammation is enhanced. Microorganisms, their waste products (endotoxins) and proteins (polypeptides, proteases) enter the bloodstream and lymphatic system. Signs of stage 2 peritonitis: suppression of intestinal contractile function, degeneration of the digestive organs, hemodynamic disorders (low blood pressure), blood clotting failure. Purulent peritonitis can lead to disruption of the cardiovascular system ( , , endocarditis).
• Stage 3 intestinal peritonitis(terminal, duration – 1-3 weeks). There is an abrupt change in body temperature, chills, rapid pulse, decreased blood pressure, and pallor of the epidermal membranes (skin). There is also nausea accompanied by vomiting, rapid weight loss, acute abdominal pain, and diarrhea. The work of creating protein gets worse. The amount of ammonium and glycol in the blood increases. Brain cells swell, the volume of spinal cord substance increases.

Based on their occurrence, medicine distinguishes the following types of disease:

• Idiopathic abdominal peritonitis. Appears due to the entry of bacteria along with the outflow of lymph, blood or through the tubes of the uterus with enterocolitis , , tuberculosis of the genital organs. Another name is viral peritonitis.
• Secondary intestinal peritonitis. Occurs due to injuries and inflammatory diseases of organs. Observed when:
  • appendicitis;
  • peptic ulcer of the stomach or duodenum;
  • disease "";
  • pancreatic necrosis (impaired pancreatic function);
  • (severe chronic disease of the Gastrointestinal tract);
  • with inflammation of the gallbladder;
  • occlusion of mesenteric vessels (impaired blood circulation of the vessels supplying the mesentery);
  • (inflammation of the inner lining of the large intestine).

Secondary peritonitis is more common than primary peritonitis, occurring in 2% of victims.

For microbial reasons it happens:

• infectious peritonitis. Appears due to aggressive substances trapped in the abdominal cavity. They cause an inflammatory process;
• viral peritonitis. It is provoked by inflammation caused by microorganisms.

Peritonitis resulting from trauma is divided into:

• appearing due to open or closed injuries causing defects of the peritoneal organs;
• arising from surgical operations. They are accompanied by a violation of the position of the sutures, failure of the junction of individual elements of the network and accumulation of blood.

There are special types of peritonitis:

Based on the composition of the substance accumulating in the abdominal cavity, they are distinguished:

• purulent (purulent peritonitis has a high mortality rate);
• hemorrhagic (blood mixed with exudate);
• serous (effusion consists of fluid with a low concentration of protein elements);
• mixed (serous-fibrinous);
• fecal (appears with abdominal injuries);
• gall (bile flows into a vulnerable spot);
• fibrinous (fibrinogen fibers cover the peritoneum, forming adhesions).

Based on the form of peritoneal lesions, there are:

• unlimited. The zone of inflammation is diffuse, without precise boundaries;
• limited. In the problem area, an accumulation of pus appears in the organs and compaction of cells in the tissues of the body.

By area of ​​damage it happens:

• Local. Damage is caused to one anatomical area of ​​the abdominal cavity;
• Common. 2-5 zones are affected;
• General. Inflamed in 6 or more areas.

Peritonitis can be acute or chronic. The acute form of the disease occurs in three stages, described above. Chronic peritonitis occurs when , .

Peritonitis in children

Acute peritonitis often occurs in children. They are vulnerable to disease because... their immunity is just beginning to adapt to the environment. It is more difficult for children to get a correct diagnosis because of the difficulty in describing symptoms. Acute peritonitis poses a threat to the child's life.

Peritonitis in adults

Infectious peritonitis is practically not a concern for adults. They are more affected by chronic or purulent peritonitis. It is more difficult to detect due to the lack of significant symptoms.

First, the body copes with microbes. Later, weight loss appears, body temperature rises to 37.5 °C, drowsiness, and heaviness.

Diagnostics

The initial stage includes examining the patient and identifying symptoms:

• Medel;
• Bernstein;
• Voskresensky;
• Shchetkin-Blumberg.

The patient undergoes research:

• Radiography. A “sickle” symptom is established under the diaphragm. In case of intestinal obstruction, a Kloiber cup is determined.
• Blood analysis. An increase in the number of leukocytes is also detected;
• Ultrasound of the peritoneum.

In rare cases, laparoscopy is prescribed.

Treatment

Once peritonitis is identified, the patient is scheduled for surgery. It is aimed at eliminating the root cause. The disease cannot be cured in any other way.

Surgery

The patient is hospitalized and preoperative measures aimed at treating peritonitis are carried out:

• relieve pain shock - anesthesia is administered;
• bring the pressure back to normal by introducing food, fluids, and medications.

It also helps normalize the amount of water in the human body and destroy infections.

During surgery, a laparotomy is performed, treating all the contents with a special antibacterial agent. The abdominal wall is cut to identify through holes in the stomach or intestines. The perforations are sutured, the pus along with part of the hollow organs is cut off and removed.

During an emergency operation, when peritonitis progresses in the final stages, the surgeon eliminates exclusively the cause of the disease. The remaining measures are scheduled for the next term, because purulent inflammation prevents their implementation.

Decompression of the small intestine is carried out by nasointestinal intubation. This is the insertion of a hose through the mouth or nostril cavity. It is also used for the purpose of evacuation of intestinal contents and artificial supply of nutrients.

Drainage - removal of fluid using rubber tubes - of the large intestine is carried out to eliminate peritonitis through the anus. The event includes the removal of exudate and the introduction of antimicrobial solutions to destroy harmful microorganisms.

Treatment after surgery

Peritonitis after surgery requires special treatment. It involves taking medications that destroy pathogenic microflora, restore the activity of the gastrointestinal tract and normalize the immune system.

The patient is also prescribed a diet that he must adhere to for a week. Peritonitis in children is treated in the same way as in adults.

Drug treatment

The following types of medications are prescribed:

• antibiotics. Penicillin-Teva, benzylpenicillin, ceftriaxone, gentamicin and others;
• diuretics, the active ingredients of which are Indapamide (trade name - "Arifon"), Spironolactone ("Veroshpiron"), Torasemide ("Trigrim");
• means aimed at removing toxic substances from the body. These include “Calcium gluconate”, “Splenin”, “Unitiol”, etc.;
• infusion solutions (“Hemodez”, “Gelatinol”, “Reopoliglyukin”);
• blood products – “Albumin” (5% and 20% solutions), “protein”, “fibrinogen”;
• non-steroidal anti-inflammatory drugs - Ketoprofen, Arcoxia, Indomethacin;
• anti-vomiting agents. Contains ondansetron (Emeset), domperidone (Motilium);
• drugs aimed at preventing the development of intestinal paresis. These are "Neostigmine", "Physostigmine".

Also used:

• ultraviolet irradiation of blood;
• plasmapheresis (purification and return of blood back to part of the circulatory system);
• intravenous laser irradiation of blood;
• hemodialysis;
• cleansing lymph from toxic substances;
• hyperbaric oxygenation (a method of using oxygen at high pressure).

Important! If you experience abdominal pain, you should never take painkillers. This may lead to a reduction in symptoms. Then it will be more difficult for the doctor to recognize the disease.

Diet after surgery

The patient needs to take fluid in the proportion of 50-60 milliliters per kilogram of body weight per day.

After normalization of the digestive system, administration of vitamin mixtures is prescribed using a probe through the mouth or nose. During recovery, dietary nutrition is prescribed for a long time.

The composition of the diet is as follows:

• low-fat broths;
• vegetable puree;
• fruits, jelly, berry compotes.

Gradually increase calorie content by adding boiled and steamed meat, chicken eggs, and dairy products to the diet.

Do not eat:

• fatty meats;
• smoked;
• chocolate and confectionery products;
• spices;
• coffee and carbonated drinks;
• legumes

​Complementary and alternative treatments at home

Before specialists arrive, you need to provide first aid using folk remedies. Otherwise, the risk of death increases.

• Ice. You need to wrap ice in a cloth and lightly apply it to your stomach. This will reduce pain.
• Turpentine. It is necessary to prepare a compress from purified turpentine and vegetable oil in a ratio of 1 to 2, respectively. Apply to belly.

Prevention

Purulent peritonitis can be avoided by observing the following rules:

• do not delay the treatment of diseases that can lead to serious complications (appendicitis, etc.);
• get 50%-60% of all energy per day from fruits, vegetables and other foods rich in vitamins and chemical elements;
• give up unhealthy foods (fast food, sweet carbonated drinks, etc.);
• avoid body hypothermia;
• avoid stress;
• do not take medications without consulting a doctor;
• get enough sleep, don’t forget to rest after work;
• Wash fruits, vegetables, berries and hands thoroughly before eating.

Forecast

30% of patients with peritonitis die, and with multiple organ failure, the fatal outcome is 90%. Peritonitis in children is even more dangerous due to their weak immune system.

It all depends on the type, degree of the disease and on timely contacting an ambulance.

Treatment of peritonitis in the first hours allows saving 90% of those operated on. After one day this figure reaches 50%, after three – 10%.

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Interesting

The belly is what the common people called one of the important parts of the body. Usually a person does not pay attention to the state of his belly. However, it is this department that performs one of the important functions - bactericidal. The peritoneum has a fairly simple structure - two petals that are not interrupted, pass into one another, create a sealed space and fix the internal organs. But if for some reason, then this leads to undesirable consequences..

What is peritonitis?

No organ is deprived of the possibility of being inflamed. Most often, the infection even penetrates into areas that a person does not know about. What is peritonitis? This is an inflammation of the serous lining of the abdominal cavity, which is called the peritoneum. There is another name for this disease - “”.

Kinds

There are several types of peritonitis, according to different classifications:

The most important cause of peritoneal peritonitis is an infection that rarely penetrates through the blood or lymph (in 2% of cases), and most often occurs due to a violation of the integrity of the pelvic organs or abdominal cavity. Often the disease occurs as a secondary disease, that is, against the background of some damage that is already observed in the patient. The main factors provoking peritoneal peritonitis are:

• – the cause of 50% of all peritonitis.
• Perforation of the duodenum or gastric ulcer is the cause of 15% of all peritonitis.
• Biliary or intestinal disorders are the cause of 10% of all cases of peritonitis. What diseases are identified here as provocateurs of peritoneal inflammation? Intestinal obstruction, perforation of ulcers in colitis, enterocolitis, cholelithiasis, diverticulitis, perforation of ulcers in Crohn's disease.
• Inflammation of the female reproductive system is the cause of 10% of all peritonitis. What diseases cause inflammation of the peritoneum? Salpingitis, rupture of an ovarian cyst or fallopian tube, pyosalpinx.
• Abdominal injuries.

This also includes isolated cases associated with diseases of the pancreas, bladder and spleen.

Separately, there is aseptic peritonitis, which occurs not due to infection entering the abdominal cavity, but due to the aggressive effects of blood, urine, and pancreatic juice. This type of cause is called toxic-chemical, since the liquid has a toxic effect on the abdominal cavity. Everything would be fine if, after a few hours, bacteria did not attach to the affected area and turn aseptic peritonitis into bacterial.

A separate type of aseptic peritonitis is barium peritonitis, when the substance leaves the gastrointestinal tract and fills the abdominal cavity. Such situations happen rarely, but the mortality rate is more than 50%.

Symptoms and signs

Signs of inflammation of the peritoneum are divided into local and general. Local symptoms include the following:

• Pain is the most important symptom of any peritonitis, which is first localized (in the affected area), and then becomes widespread;
• Peritoneal irritation;
• Tension of the abdominal muscles occurs involuntarily as a reflex reaction of the body. Can be local or general.

Common symptoms of peritoneal inflammation include:

1. Temperature;
2. Low pressure;
3. Confusion;
4. Repeated vomiting;
5. Decreased diuresis;
6. Increased acidity (acidosis);
7. Frequent heartbeat;
8. Dry skin, sharp facial features.

The symptoms of tuberculous peritonitis are similar to the symptoms of ordinary tuberculosis in respiratory diseases:

• Weight loss;
• Intermittent cough;
• Fever that doesn't go away;
• Increased sweating.

In practice, doctors distinguish symptoms according to the stages of the disease:

1. Reactive (initial):
   • Symptoms begin with local signs and develop to general ones over one or several days.
   • The patient lies on his back, legs bent to his stomach.
   • Temperature and rapid heartbeat occur.
   • A gag reflex and nausea occur.
   • The tongue becomes dry and coated.
   • Shallow breathing appears.
   • The more acute the disease, the more confused the consciousness becomes.
   • Signs of the Shchetkin-Blumberg symptom appear.
2. Toxic:

• General symptoms with general intoxication appear. Develops up to 3 days after the onset of the disease.
• Water-electrolyte metabolism and metabolism are disrupted.
• Breathing becomes frequent, shallow, intermittent.
• I suffer from vomiting, in which the waste material has a foul odor.
• Dehydration and thirst occur, which cannot be eliminated by drinking. Over time, the amount of urine becomes scanty.
• The tongue is covered with a brown coating.
• Convulsions or arrhythmia appear due to the loss of salts by the body.
• Muscle tension leads to bloating.

1. Terminal:

• Occurs on the 4th day after the onset of the disease.
• There is dehydration and a precomatous state.
• The face changes: the features become pointed, the eyes and cheeks recede, the skin takes on an earthy color, the skin is so dry and tight that the temples are hollow.
• Abdominal pain occurs on palpation.
• The patient usually lies motionless.
• His consciousness is confused.
• The belly is very distended.
• Breathing becomes intermittent and the pulse becomes thready.

The chronic form of peritonitis, as with other inflammatory diseases (for example, colitis or gastritis), is asymptomatic. Has the following signs:

1. Increased sweating;
2. Anorexia;
3. Temporary constipation;
4. Low temperature;
5. Temporary abdominal pain.

Peritonitis in a child

It is peritonitis that can become a serious cause for concern for parents if it appears in a child. This disease is quite rare, but if it does appear, it brings many problems. In 70% of cases it leads to death, so you should act immediately and seek medical help. Fortunately, modern medicine can reduce the mortality rate by up to 20%. The most common type is tuberculous peritonitis.

Since children often get sick with various bacterial diseases, the risk of inflammation of the peritoneum is high. The infection penetrates through the blood into weak areas of the body and begins to multiply. Therefore, here parents should not wait for the child to recover on his own, but start treating him in the early stages so that sepsis does not develop.

Peritonitis in adults

In adults, various types of peritonitis occur. If we talk about the tuberculosis form, it often occurs in women due to the transfer of mycobacteria from the genitals. The disease occurs 9 times more often in women than in men.

Diagnostics

Diagnosis of inflammation of the peritoneum begins with asking the patient about what symptoms are bothering him and what he was previously ill with or is currently ill with. Conclusions are drawn through a general examination (measurement of pulse, respiration and pressure). To clarify the diagnosis, additional procedures are performed:

• Laparoscopy.
• Ultrasound of the peritoneum.
• Hemogram (blood test).
• CT and MRI of the peritoneum.
• X-ray of the abdominal cavity.
• Analysis of stool, urine and vomit.
• Puncture of the inflamed area.

Treatment

Treatment of peritonitis is divided into hospital and out-of-hospital forms. Since “acute abdomen” has a high mortality rate, the disease begins its treatment in hospital form. The secondary nature of nature forces us to first eliminate the root cause: remove the appendix, purulent gall bladder, and suturing a perforated ulcer. That is, surgical treatment is carried out, after which they begin to eliminate peritonitis.

How to treat inflammation of the peritoneum? Medicines:

• Antibiotics (pecillin, aminoglycosides, macrolides).
• Glucose infusion solutions.
• Detoxification medications and sorbents (hemodez, 10% calcium chloride).
• Diuretics (furosemide).
• Antipyretics (ibuprofen, paracetamol).
• Antiemetic drugs (metoclopramide).
• Anticholinesterase drugs (prozerin, ubretide).
• Anticoagulants (heparin).
• Anabolic drugs (retabolil, insulin and glucose).

Painkillers are not prescribed because they blur the clinical picture, which shows how the disease progresses. As for surgery, it is a mandatory procedure. Its purpose is to remove exudate, isolate the source of bacteria, resection, free the gastrointestinal tract from liquid and gases, and sanitize the peritoneum.

Is it possible to treat peritonitis at home?

Peritonitis cannot be cured at home, so the disease cannot be treated at home. Immediately at the first symptoms, hospitalization of the patient is required, since in the absence of treatment there is a high probability of death. Home care is possible only after the patient is cured, but even here it is necessary to periodically visit the surgeon to be examined.

Diet

During the treatment period, diet becomes very important, which is divided into three stages:

1. Early - lasts up to 5 days - here the patient does not eat food, and all the necessary microelements are administered intravenously.
2. The second - duration up to 3 weeks - gradual introduction of natural food: jelly and jelly, soft-boiled eggs, meat broth, juices from fruits and berries, pureed vegetables.
3. Long-term - until full recovery of working capacity - coarser products are introduced gradually. Sweet and fried foods, seasonings, spices and heavy foods are still excluded.

Lifespan

How long do people live with peritonitis? This forecast is unpredictable. The mortality rate is very high, so life expectancy decreases as the disease progresses (lasts up to 6 days if untreated). If treatment is delayed, then the patient dies. The main complications of this disease are:

• Sepsis,
• Hepatic encephalopathy,
• Intestinal gangrene,
• Hepatorenal syndrome,
• Adhesions inside the peritoneum,
• Abscess,
• Septic shock
• Pulmonary complications
• Dehydration.

The only preventive measure is timely consultation with a doctor. At the same time, it is important to eat a healthy diet and cure other infectious diseases of the body.

A slightly different mechanism is observed in cholecystitis and cholelithiasis. In this case, sweaty biliary peritonitis develops. In this case, there is no destruction or rupture of the gallbladder. The main mechanism is the slow leakage of bile into the peritoneal cavity. In this case, the reaction of the peritoneum to the aggressive action of bile ( bile contains bile acids) is proportional to its quantity. Since bile does not pour out immediately, but slowly sweats, its amount may initially be insignificant. The clinical picture in this period is blurred, and classic symptoms may be absent. However, as you gradually sweat, the volume of bile increases. When a large volume of bile irritates the peritoneum, a classic picture of peritonitis appears.

With a simultaneous massive outflow of bile, for example, with a rupture of the gallbladder, peritonitis develops quickly with the phenomenon of abdominal shock. The degree of the reactive process is influenced not only by the amount of bile and the rate of its outflow, but also by the nature of the bile.

Abdominal injuries

As a result of open and closed injuries, post-traumatic peritonitis develops. With open injuries to the abdominal cavity, direct infection of the peritoneum occurs. Thus, through a defect in the abdominal wall, direct contact of the non-sterile environment with the peritoneal cavity occurs. Bacteria penetrated from the air become a source of inflammation. With closed injuries, the mechanism of development of peritonitis is due to a violation of the integrity of the internal organs. Thus, closed abdominal injuries may be accompanied by rupture of the spleen and other internal organs. In this case, their contents, poured into the peritoneal cavity, become the cause of peritonitis.

In addition, pathologies of the pancreas can be the cause of peritonitis ( in one percent of cases), spleen and bladder.

Causative agents of bacterial peritonitis

The cause of infection in peritonitis can be a variety of bacteria. This can be either a specific microbial flora or a nonspecific microflora of the intestinal tract.

Microorganisms that can cause peritonitis

Specific flora	Nonspecific flora
hemolytic streptococcus; gonococci; pneumococci; Mycobacterium tuberculosis.	aerobic microorganisms ( those that use oxygen in the process of their life).	anaerobic microorganisms ( those that do not use oxygen in the process of their life activity).
	coli ( in 60 percent of cases); proteus; Klebsiella; enterobacter; staphylococcus and streptococcus ( 20 percent or more of cases).	clostridia; bacteroides; fusobacteria; peptococci and peptostreptococci.
In 50–60 percent of cases of peritonitis, microbial associations are observed. They are presented simultaneously by 2 or 3 pathogens. Most often these are Escherichia coli and staphylococcus, as well as anaerobic non-clostridial flora.

Causes of aseptic peritonitis

In aseptic peritonitis, the peritoneum is irritated not by bacterial flora, but by aggressive agents such as blood, urine, gastric juice or pancreatic juice. This type of peritonitis is also called toxic-chemical, because the action of enzymes and acids contained in the blood or pancreatic juice is similar to a chemical burn. It is worth noting that aseptic peritonitis itself does not exist for long. Within 6–8 hours, bacterial flora joins it, and it becomes bacterial.

A special type of aseptic peritonitis is barium peritonitis. This type of peritonitis is extremely rare, but its mortality rate exceeds 50 percent. It develops as a result of barium leaving the gastrointestinal tract. This occurs when performing X-ray diagnostic methods with barium contrast ( for example, during irrigoscopy).

Types of peritonitis

There are many types of peritonitis, which are classified according to different criteria.

Criterion	Type of peritonitis
Because of	traumatic; perforated ( or perforated); postoperative; infectious.
By traumatic factor	bacterial; aseptic.
According to the mechanism of infection	primary; secondary.
By degree of distribution	local ( or local); diffuse; total.
According to the nature of the inflammatory content	purulent; serous; hemorrhagic; fibrinous.
By the presence of exudate	exudative ( he's wet); dry.
By type of infectious agent	streptococcal; tuberculous; clostridial; gonococcal.

From a clinical point of view, the most important and informative classification is according to the degree of distribution and the nature of the inflammatory content. Distinguishing peritonitis by type of infectious agent is very important for prognosis of the disease. Knowing the type of microorganism, you can select the treatment as accurately as possible. However, in practice, identifying the etiological factor ( that is, the causative agent of peritonitis) very hard.

Exudative peritonitis

Exudative peritonitis is one in which inflammatory fluid accumulates in the peritoneal cavity. Normally, a small amount of fluid is present in the cavity, which ensures the absence of friction between the visceral and parietal layers of the peritoneum. This liquid is aseptic, meaning it does not contain bacteria.

When, as a result of various mechanisms, an infection enters the cavity, destruction of the surface layer of the peritoneum occurs. This leads to intense exudative processes, which are accompanied by the accumulation of inflammatory fluid. Initially, the volume of fluid that accumulates in the peritoneal cavity is small. However, as the pathological process progresses, it increases. The amount of liquid can vary from several tens of milliliters ( 50 - 70 ) up to several liters ( 1 – 2 ). The main key point in the development of the disease is intoxication. It is known that the total area of ​​the abdominal covering is equal to the total area of ​​the skin, that is, approximately 2 square meters. All toxins that accumulate in the cavity penetrate the blood and very quickly lead to intoxication of the body. Together with the bloodstream, bacteria and their toxins are carried to the organs, affecting them. As a result of such generalized dissemination of infection, multiple organ failure develops.

A feature of exudative peritonitis is that simultaneously with the accumulation of fluid in the peritoneal cavity, the body loses water. It is known that all water in the body is divided into intracellular and extracellular fluid. Intracellular fluid refers to the fluid contained in tissue cells. Extracellular fluid includes interstitial fluid ( fluid between cells) and intravascular ( blood plasma) liquid.

In a healthy body, the intracellular volume of fluid accounts for 60 - 65 percent, and the extracellular part - 40 - 35. However, with peritonitis, a pathological third space is formed. This space is nothing more than the peritoneal cavity. In it, due to hemodynamic disturbances ( impaired vascular tone, increased permeability of the vascular wall) fluid accumulates both from the vascular bed and from the tissues. Thus, the body loses water and experiences dehydration. This condition is complicated by vomiting, which also results in loss of fluid and electrolytes.

Depending on the nature of the inflammatory fluid, serous, purulent, hemorrhagic or fibrinous peritonitis is distinguished.

Serous peritonitis
With serous peritonitis, fluid accumulates in the peritoneal cavity, which is poor in protein and cellular elements. Such inflammation is observed in the first 2–3 days of the disease. After this, the fibrin in it heats up and it becomes serous-fibrinous. If the purulent flora is activated, then serous peritonitis evolves into purulent peritonitis.

Fibrinous peritonitis
With fibrinous peritonitis, a large amount of fibrin accumulates in the inflammatory fluid. This leads to the formation of fibrin films that cover the layers of the peritoneum. This type of peritonitis can develop into adhesive peritonitis.

Hemorrhagic peritonitis
This form of peritonitis occurs when blood that has penetrated into the peritoneal cavity is mixed with the fluid. This blood can form during injuries ( traumatic peritonitis) or pour out when organs are perforated.

Dry peritonitis

With dry peritonitis, a small amount of fluid is observed in the peritoneal cavity. The difference between this liquid is the high content of fibrinogen in it. Fibrinogen is a protein that forms the basis of a blood clot during clotting. Its concentration increases during inflammatory reactions, as well as during epithelial injuries. Upon contact with the sheets of inflamed peritoneum, fibrinogen is converted into fibrin. Fibrin thickens the inflammatory fluid, making it thicker, due to its physicochemical properties. It also falls out on the surface of the peritoneum in the form of threads and villi, and forms films on the surface of the internal organs. These fibrin structures subsequently stick together. For this reason, dry peritonitis is also called adhesive peritonitis.

On the one hand, this process is carried out by the body for a protective purpose. Indeed, with the formation of adhesive fibrin structures, the site of inflammation is delimited. Dry peritonitis is less likely to be diffuse. However, at the same time, due to the massive adhesive process, adhesions are formed between the peritoneum and the intestines. This type of peritonitis often occurs violently. Despite the absence of a large effusion in the peritoneal cavity and the limited nature of the process, it occurs with severe hypovolemia ( decreased blood volume).

Dry peritonitis is often observed with tuberculous etiology of this disease. In this case, the layers of the peritoneum swell sharply, and tuberculous tubercles form on their surface. In this case, there is practically no liquid in the peritoneal cavity, or it is contained in small quantities. As the bumps progress, they begin to spread to the intestines and other organs. Sometimes they become so thick and compacted that they deform the organ.
With dry peritonitis, disseminated intravascular coagulation syndrome often develops.

Purulent peritonitis

This type of peritonitis is caused by putrefactive flora such as staphylococci, gonococci, E. coli, and most often by an association of these microorganisms. As a rule, purulent peritonitis occurs in an exudative form. But there is also a purulent-caseous form, in which multiple localized ulcers form in the peritoneal cavity. Most often, purulent peritonitis develops as a result of perforation of purulent appendicitis or other organs.

Purulent peritonitis occurs very quickly and is characterized by a pronounced intoxication syndrome. Many representatives of purulent flora produce toxins that are tropic ( more preferable) to various types of fabrics. Some toxins are particularly selective for the epithelium of the vascular wall. Penetrating into the bloodstream, they cause swelling and dilation of blood vessels, leading to numerous hemorrhages in the organs. The phases of peritonitis in its purulent form are sharply expressed, and no clinical manifestations are observed. Symptoms of general intoxication and disturbances of water and electrolyte metabolism prevail. Often, especially with streptococcal peritonitis, confusion and delirium are observed. Purulent peritonitis is characterized by its high mortality rate. Chronic and sluggish forms of purulent peritonitis are extremely rare.

Tuberculous peritonitis

Peritonitis caused by Mycobacterium tuberculosis is called tuberculosis. This is the most common form of chronic peritonitis. Tuberculous peritonitis primarily affects children. However, this is a common occurrence among adults. In 99.9 percent of cases, this is secondary peritonitis, which developed during dissemination of the pathogen from the primary focus. In children, such sites are the lungs and lymph nodes. Among women ( The ratio of men to women with this pathology is 1 to 9) are the internal genital organs. This ratio of men and women is explained by the fact that in women the uterus communicates with the peritoneal cavity through the fallopian tubes. This message ensures the rapid spread of mycobacteria into the peritoneal cavity during tuberculosis of the internal genital organs.

Tuberculous peritonitis can occur in both dry and exudative forms. The peculiarity of this type of peritonitis is that it can occur in blurred clinical forms without clearly defined phases. Symptoms of intoxication ( fever, weakness) can exist for weeks and even months. Such a sluggish course of peritonitis is accompanied by a violation of metabolic, endocrine and other functions of the body. To the characteristic symptoms of peritonitis are added the symptoms of the underlying disease, that is, tuberculosis. The main symptoms are weight loss, prolonged fever, increased sweating, periodic cough and others. The acute course of tuberculous peritonitis is observed relatively less frequently.

In addition to these forms of peritonitis, there is so-called anaerobic peritonitis, which is caused by anaerobic flora. It develops as a result of gunshot wounds or as a complication of childbirth or abortion. The inflammatory fluid has a fetid odor, and multiple abscesses develop in the peritoneal cavity. A distinctive feature of biliary peritonitis is mild irritation of the peritoneum. Despite the general signs of intoxication, classic local symptoms ( “board belly”, muscle tension) are not expressed.

Local and general symptoms of peritonitis

Symptoms of peritonitis are divided into local and general. Local symptoms include those that develop in response to irritation of the peritoneum ( inflammatory exudate, blood, bile). These symptoms develop as a protective mechanism, and the area of ​​their localization depends on the area and location of the pathological focus.

Local symptoms of peritonitis are:

• pain;
• abdominal muscle tension;
• symptoms of peritoneal irritation detected during examination.

Pain

Pain is the very first symptom of peritonitis. Its nature and intensity depend on the cause of peritonitis. The most vivid and intense pain is observed with perforation of internal organs, for example, the stomach or duodenum. In this case, it appears sharply, suddenly, and in strength resembles a blow with a dagger ( described in medical literature as a dagger-like pain). The intensity of the pain syndrome is also influenced by the composition of the irritating substance. Thus, the most intense pain is observed with pancreatic necrosis or acute pancreatitis. Enzymes contained in pancreatic juice have a maximum irritating effect on the peritoneum, comparable to a burn. Severe pain can lead to painful shock and loss of consciousness. Sometimes the patient may become agitated. However, most often the pain limits the patient’s movements, forcing him to take a certain position. Abdominal breathing becomes difficult, infrequent and superficial.

The pain that appears is first localized and limited to the area where the pathological focus is located. However, after a couple of hours the pain becomes widespread. This is due to the spread of pathological contents throughout the abdominal cavity. At the same time, the opposite can also be observed. Initially diffuse pain can be localized.

Pain during peritonitis is caused by irritation of the peritoneum. After all, the peritoneum has rich innervation and is sensitive to any type of irritant. The transition from localized pain to diffuse pain is also explained by the transition of inflammation from the parietal layer of the peritoneum to the visceral one. The parietal layer of the peritoneum, which covers the walls, receives innervation from the corresponding abdominal walls. For example, the leaf covering the anterior abdominal wall is innervated by intercostal nerves. Therefore, the pain that arises in this case has a clear localization. At the same time, the visceral layer of the peritoneum is innervated by the autonomic nervous system. The pain that occurs when the visceral peritoneum is irritated does not have a clear localization, but is diffuse in nature.

Sometimes the pain can simply change location, which also means the transition of the inflammatory process. But in this case, the inflammatory process is not diffuse, but localized. For example, pain may be relieved for a while and intensified when urinating. This means that the pathological process has moved to the peritoneum covering the bladder. In diagnosis, it is important to find out the primary location of pain.
The disappearance of pain is an unfavorable sign of peritonitis. This may be due to the accumulation of large amounts of fluid in the abdominal cavity or paresis ( lack of peristalsis) intestines.

Abdominal muscle tension

Abdominal muscle tension, or muscle guarding, occurs almost simultaneously with pain. The appearance of this symptom is due to a reflex contraction of the abdominal muscles. Muscle tension also corresponds to the zone of innervation. Maximum muscle tension with the disappearance of all abdominal reflexes is observed when the ulcer is perforated. Such a belly is also called “board-shaped” in the medical literature. In this case, muscle tension is visible visually, even before palpation.

The voltage can also be local. For example, with effusion biliary peritonitis, the abdominal wall thickens in the area of ​​​​the gallbladder projection.
Muscle guarding is an early local symptom. At the same time, as intestinal paresis develops and exudate accumulates, it disappears. The absence of muscle tension can be observed in weakened patients, usually in the elderly.

Symptoms of peritoneal irritation revealed during examination

The classic objective symptom of peritoneal irritation is the Shchetkin-Blumberg symptom. The symptom reveals the presence of inflammation and irritation in the peritoneum.

Methodology
The patient is in a supine position with his knees bent ( for maximum relaxation of the abdominal wall). The doctor slowly presses his hand on the area of ​​the anterior abdominal wall, where the inflammatory process is suspected. In this case, the patient notes pain. When the hand is suddenly removed, the pain increases sharply. This symptom is considered positive. If, when the hand is removed, the pain does not change its intensity, then the symptom is considered negative.

With pronounced muscle tension, the symptom is difficult to determine. Diagnosis is also difficult in cases where intestinal paresis has developed.

General symptoms of peritonitis are of great diagnostic importance. They are caused by the penetration of toxins into the blood and general intoxication.

Common symptoms of peritonitis are:

• temperature;
• repeated vomiting;
• cardiopalmus;
• low pressure;
• decreased diuresis;
• dry skin and pointed facial features;
• signs of acidosis ( increase in acidity);
• confusion.

In the clinic of peritonitis, it is customary to identify several stages, which are characterized by their own symptoms.

Symptoms of peritonitis by stage

Reactive stage

The reactive or initial phase is characterized by the predominance of local symptoms and the initial development of general ones. Its duration ranges from several hours to several days. In acute purulent peritonitis, its duration is limited to 24 hours.

At this stage, the patient is in a forced position, usually lying on his back with his legs brought to his stomach. General symptoms such as fever and rapid heartbeat appear. The temperature is caused by the activity of bacteria and their penetration into the blood. The degree of temperature rise is directly proportional to the pathogenicity of microorganisms. So, with streptococcal and staphylococcal peritonitis, the temperature rises to 39 - 40 degrees Celsius. For tuberculosis - 38 degrees. Along with the rise in temperature, the number of heart beats increases. At this stage of the disease, this is associated with elevated temperature. It is known that for every degree raised, the heart increases the number of its contractions by 8 beats per minute.

Nausea and vomiting also occur at this stage. The patient's tongue becomes coated and dry. When examining the patient, shallow, gentle breathing is revealed. With moderate pain syndrome, consciousness is clear, with painful shock it is confused. Also at this stage, objective symptoms of peritoneal irritation, such as the Shchetkin-Blumberg symptom, are revealed.

Toxic stage

This stage lasts from 24 to 72 hours. General symptoms begin to prevail in it, which are caused by general intoxication, disturbances of water-electrolyte metabolism and metabolic disorders.
Toxins are carried throughout the body through the blood and lymph. They reach the liver and lungs first, resulting in liver failure and pulmonary distress. Breathing becomes frequent, shallow, and sometimes intermittent. The patient continues to vomit, and the vomit becomes foul-smelling.

The main complications at this stage are associated with dehydration and water-electrolyte disturbances. Due to disturbances in vascular tone and changes in the permeability of the vascular wall ( everything is caused by toxins) fluid seeps into the peritoneal cavity. A state of anhydremia develops, which is characterized by a decrease in fluid levels in the body. The patient is thirsty, which does not go away with drinking. The tongue becomes dry, coated with a brown coating. Blood pressure drops, and the heart rate compensatory increases to 140 beats per minute. At the same time, due to hypovolemia ( low blood pressure) heart sounds become dull and weak.
Frequent vomiting leads to the loss of not only water, but also body salts. Due to hypokalemia and hyponatremia, seizures or arrhythmia may occur.

The patient's condition worsens further when oliguria develops. At the same time, the daily volume of urine decreases from the norm of 800–1500 to 500 ml. It is known that all metabolic products are removed from the body with urine. These include urea, uric acid, indican. However, with oliguria they are not excreted, but remain in the body. This leads to even greater intoxication of the body.

At the same time, local symptoms of peritonitis become erased. Muscle tension disappears, and it is replaced by bloating. At this stage, intestinal paresis develops, which is characterized by the absence of peristalsis. The pain also subsides or completely disappears, which is associated with the accumulation of exudate in the peritoneal cavity.

If emergency measures are not taken, this stage may progress to the terminal stage.

Terminal stage

This stage develops 72 hours or more from the onset of the disease. It is characterized by dehydration and the development of a precomatous state. The patient's face at this stage corresponds to the descriptions of Hippocrates ( facies Hippocratica). The features of such a face become sharper, the eyes and cheeks are sunken, and the complexion acquires an earthy tint. The skin becomes very dry and tight to such an extent that the temples are pressed in. Consciousness is confused, the patient most often lies motionless. The abdomen is strongly inflated, its palpation is painless. The patient's pulse is threadlike, breathing is intermittent.
Today, the terminal stage is, of course, extremely rare.

The severity of local and general symptoms of peritonitis depends on the extent of its spread and the cause of the disease. The classic staged course is observed with diffuse peritonitis. In localized forms, the symptoms are not so pronounced.

Symptoms of chronic peritonitis

The classic symptoms of peritonitis in its chronic form are usually erased and not expressed. The patient does not complain of acute pain, vomiting or muscle tension. Therefore, for a long time this type of peritonitis can proceed unnoticed.
At the same time, the main symptoms are associated with long-term, chronic intoxication of the body.

Symptoms of chronic peritonitis are:

• weight loss;
• increased sweating;
• prolonged low-grade fever;
• periodic constipation;
• periodic abdominal pain.

Loss of body weight and increased sweating are constant symptoms in chronic tuberculous peritonitis ( the most common form of chronic peritonitis). These symptoms are caused by intoxication of the body with decay products of mycobacteria.

Other symptoms of chronic peritonitis are caused by adhesions. Thus, chronic peritonitis most often occurs in a dry form, which is characterized by an adhesive process. The adhesions that form in this case tighten the intestinal loops and disrupt its motor activity. Thus, periodic intestinal obstruction syndrome develops. The patient suffers from periodic constipation, which becomes more frequent as the disease progresses. Pain in the abdomen and periodic bloating also appear. As the adhesive process spreads, symptoms become more frequent and severe.

Diagnosis of peritonitis

Diagnosis of peritonitis is based on anamnestic data and clinical picture. History data ( medical history) are especially important in chronic forms of peritonitis. Knowing what the patient was sick with before or what he is sick with now, we can most accurately predict the location of the primary infection. In chronic peritonitis, objective data revealed during the examination are scarce and therefore the doctor may resort to additional examination methods. One such examination is diagnostic laparoscopy. This diagnostic method allows you to visually examine the peritoneal cavity without making large incisions on the abdomen, as during surgery. During this manipulation, the doctor examines the layers of the peritoneum through a tube combined with a lens and assesses their condition. As a rule, in chronic peritonitis, the peritoneum is covered with fibrin films, and adhesions form between its layers.

In acute and diffuse peritonitis, diagnosis is not difficult. As a rule, the patient's complaints and objective data revealed during examination are sufficient for diagnosis. The main symptoms that the doctor identifies during examination are associated with irritation of the peritoneum. These symptoms are muscle tension, a positive Shchetkin-Blumberg symptom.

Treatment of peritonitis with medications

The mortality rate of peritonitis today is still high, so the problem of treatment is very urgent. Since peritonitis in 99 percent of cases is a secondary disease, its treatment should begin with eliminating the root cause. As a rule, it consists of surgery to remove a burst appendix, suturing a perforated ulcer, or removing a purulent gallbladder. At the same time, drug treatment is carried out aimed at correcting all those disorders that develop during peritonitis. Thus, the treatment of peritonitis should be comprehensive and combine various methods.

Treatment of peritonitis with medications is aimed at eliminating the infection ( causing peritonitis), to correct metabolic disorders, as well as to prevent the development of complications.

Group of drugs	Representatives	Mechanism of action	How to use
Antibiotics Antibacterial therapy is the mainstay in the treatment of bacterial peritonitis. Since the most common cause of peritonitis is a microbial association of 2 or 3 organisms, it is advisable to prescribe broad-spectrum antibiotics.	From the penicillin group: benzylpenicillin; ampicillin; methicillin. From the group of aminoglycosides: kanamycin; gentamicin. From the group of macrolides: sigmamycin; oletethrin.	They disrupt the synthesis of cell wall components, thus preventing further proliferation of bacteria in the peritoneal cavity. Antibiotics from the aminoglycoside group block the synthesis of proteins necessary for bacteria to function.	For moderate peritonitis, antibiotics are mainly prescribed intramuscularly. As a rule, loading doses of antibiotics are prescribed. Benzylpenicillin - 15,000,000 units each ( units of action) per day, ampicillin and methicillin - 3 to 4 grams, gentamicin - from 2 to 3 mg per kg of body weight. The daily dose is divided into 2–4 doses. In severe cases and in cases of septic shock, antibiotics are prescribed intravenously.
Infusion solutions They are used to restore lost fluid, as well as to prevent dehydration and hyperthermia.	5 and 25 percent glucose solution: refortan; perftoran.	Due to their high osmolarity, these solutions retain fluid in the vascular bed. Replenish lost water and salts of the body.	All these drugs are prescribed intravenously ( extremely rarely - intermittently). The volume of the prescribed solution is determined individually based on the amount of fluid lost by the body.
Detoxification agents and sorbents This group of drugs is used to remove toxins and bacteria from the body. Drugs are necessary to prevent the development of toxic shock and other complications.	hemodesis.	Binds toxins that have entered the blood from the peritoneal cavity and removes them.	The volume of the solution depends on the age and condition of the patient. On average, 200 to 500 ml are administered intravenously.
	10 percent calcium chloride solution.	Normalizes the permeability of the vascular wall ( which is impaired during peritonitis), thereby preventing toxins from penetrating through it.	10 ml of a 10 percent solution is diluted in 200 ml of isotonic solution and administered intravenously.
Diuretics This category of drugs is used for forced diuresis. The method of forced diuresis is prescribed together with detoxification drugs and hypertonic solutions to quickly remove toxins from the body.	furosemide This drug is prescribed with caution, especially in cases of severe water and electrolyte disturbances.	Blocks sodium reabsorption, thereby increasing urine volume. It has a quick but short-term effect.	One or two ampoules of the drug are administered intravenously after the hypertonic solution has been administered. For example, at the end of a drip with 400 ml of 20 percent glucose or mannitol solution, inject 4 ml ( 40 mg) furosemide.
Antipyretics To eliminate fever.		They block the synthesis of substances that are involved in inflammation and increase the temperature.	Paracetamol – 500 mg ( one tablet) 4 times a day. Ibuprofen - 400 mg each ( one tablet) 2 – 3 times a day.
Antiemetic drugs Used in the treatment of peritonitis to eliminate symptoms such as nausea and vomiting.	metoclopramide.	It has a tonic effect on the muscles of the gastrointestinal tract. Blocks receptors of the vomiting center and, thereby, has an antiemetic effect.	Administer intravenously or intramuscularly at 10 mg ( 2 ampoules) two or three times a day. The maximum daily dose is 60 mg.
Anticholinesterase drugs Used to restore intestinal motor function and prevent paresis.	ubretid; Prozerin.	They increase the tone of the intestinal muscles and enhance peristalsis, preventing the development of paresis.	Ubretide is administered intramuscularly, once at a dose of 0.5 mg ( one ampoule). A second injection is given only after 24 hours. Prozerin is administered subcutaneously in a dose of 1 ml of a 0.05 percent solution twice a day.
Anticoagulants Used to prevent thrombosis, which is characteristic of purulent peritonitis.	heparin.	Reduces platelet aggregation, preventing the formation of blood clots. It also reduces the permeability of the vascular wall.	Can be used both intravenously and subcutaneously. It is also prescribed after surgery. The dose ranges from 25,000 to 50,000 units per day.
Anabolic drugs In patients with peritonitis, the rate of catabolic ( decay process) reactions are maximally increased. Therefore, drugs are prescribed that reduce this process.	In order to activate anabolic processes, anabolic steroids are prescribed: retabolil; insulin along with glucose.	Retabolil activates anabolic processes, mainly due to the synthesis of proteins in the body. Insulin increases energy processes in the body.	Retabolil is administered intramuscularly at 100–200 mg for men, 50–100 mg for women once a week. Based on the calculation that one unit of insulin is per 5 mg of glucose, 250 to 500 ml of a 10 percent glucose solution is administered intravenously along with insulin.

Treatment of peritonitis should be individualized. It is necessary to take into account the peculiarities of the course of the pathological process, the form of peritonitis ( dry or wet), as well as an etiological factor. The latter plays a decisive role in the effectiveness of treatment. So, for tuberculous peritonitis, anti-tuberculosis drugs are prescribed - isoniazid, rifampicin, ethambutol. If anaerobic flora is suspected, lincomycin, trichopolum, gentamicin are used, and hyperbaric oxygenation is also performed ( high pressure oxygen supply). For aseptic peritonitis caused by acute pancreatitis, antienzymes are prescribed - contrical. For diffuse forms of peritonitis, the technique of washing the peritoneum is used ( peritoneal dialysis).

It should be noted that the use of painkillers for peritonitis is contraindicated. Firstly, painkillers blur the clinical picture, which is especially dangerous in the acute period of the disease. And this applies to all pathologies related to the “acute abdomen” section in surgery. Secondly, most painkillers weaken intestinal motility, thereby accelerating the development of intestinal paresis. It is also not allowed to administer laxatives, which contribute to the spread of the pathological process.

Surgery for peritonitis

When is surgery needed for peritonitis?

Detection of peritonitis is an absolute indication for emergency surgery. The course of the procedure depends on the cause that provoked the inflammation of the peritoneum, but in all cases the operation pursues the same goals and is carried out according to a certain algorithm.

The goals of surgical intervention for peritonitis are:

• elimination of exudate ( fluid released from blood vessels during inflammation) and infected tissues;
• resection or isolation of the source of infection;
• decompression ( release from liquids and gases) gastrointestinal tract;
• sanitation of the abdominal cavity.

The stages of surgery for inflammation of the serous covering of the peritoneum are:

• preoperative preparation;
• providing access;
• elimination or delimitation of the source of infection;
• abdominal lavage;
• intestinal decompression;
• drainage ( creating conditions for a constant outflow of content) abdominal cavity;
• suturing the wound.

Preparing for surgery

The main task of preoperative preparation is to correct impaired body functions.

The stages of preparatory therapy for the patient are:

• intravenous infusion of drugs;
• emptying the gastrointestinal tract;
• anesthesia.

Medication preparation of the patient
The nature of infusion therapy depends on the age and weight of the patient and the presence of concomitant diseases. In some cases, venous catheterization is advisable, which allows you to increase the speed of infusions and better control the process.

The goals of intravenous influence are:

• Replenishment of circulating blood volume.
• Correction of central and peripheral circulatory disorders.
• Ensuring the necessary concentration of antibiotics in tissues to reduce the spread of infection and prevent septic shock. In case of severe multiple organ failure syndrome and unstable blood circulation, the patient is given artificial ventilation.

Cleansing the gastrointestinal tract
If peritonitis is diagnosed at an early stage, a single gastric emptying is performed using a tube. For more advanced processes, the probe is left in place for the entire recovery period after surgery. Cleansing the lower intestines is carried out using enemas.

Anesthesia
Anesthesia during surgical treatment of peritonitis is carried out on the basis of multicomponent anesthesia and the use of muscle relaxants. Spinal anesthesia has recently been widely used. A mandatory step in pain relief is novocaine blockade. This procedure reduces the need for narcotic analgesics. Novocaine also helps improve tissue trophism and eliminate reflex vascular spasm, which ensures earlier restoration of the functionality of the gastrointestinal tract.

Incision during surgery
Surgical intervention for inflammation of the serous membrane of the peritoneum is performed using a median laparotomy ( an incision is made along the linea alba of the abdomen, from the lower end of the sternum to the pubis). This type of laparotomy provides access to all areas of the abdominal cavity. Depending on the location of the source of infection, the incision made can be expanded in the required direction. Correction of an abdominal wound using special retractors provides the opportunity to quickly and with a minimal level of injury gain access to any part of the abdominal cavity. In cases where widespread purulent peritonitis is diagnosed only during an operation that is performed from another incision, the doctor switches to a median laparotomy.

Removing or delimiting the cause of peritonitis
Elimination of the source of peritonitis is the main goal of the operation. The doctor’s actions at this stage of the operation depend on which organ is the source of the infection. If the cause of inflammation is an organ, the removal of which is possible ( appendix or gallbladder), then resection of this organ is performed. If peritonitis causes perforation of a hollow organ, it is sutured. The affected area of ​​the gastrointestinal tract can also be removed with a colostomy or enterostomy ( methods of removing the small intestine or colon) or isolation of the source of infection. For peritonitis that occurs after intestinal surgery due to failure of the anastomotic sutures ( connection of two hollow organs) in some cases non-radical operations are performed. Such manipulations include suctioning out purulent contents using drainage tubes, isolating the source of peritonitis using tamponing, and removing the intestinal anastomosis to the outside.

Abdominal cleansing
Rinsing the abdominal cavity with special solutions reduces the number of pathogens in the exudate and helps eliminate the infection more effectively. In order to maintain the integrity of the serous layer, the use of gauze pads to remove pus is avoided. Also, due to the risk of disruption of the serous cover, dense deposits of fibrin are not eliminated ( substance that is formed when blood clots). The compositions that are used for washing are pre-cooled to a temperature that varies from +4 to –6 degrees. This procedure allows you to achieve vasoconstriction and reduce the intensity of metabolic processes, the level of which increases sharply in this disease.

Bowel decompression
To remove accumulated fluid and gases from the intestines, a long probe with a large number of holes is passed into the small intestine through the oral cavity. The probe can also be passed through the rectum. If suction of the contents is not effective, the doctor performs an ileostomy ( passage of part of the small intestine out through an opening in the abdominal wall). The colon, if necessary, is drained through the anus. In rare situations, a stoma is performed to install the probe ( a hole created artificially and brought to the anterior wall of the abdominal region) on the stomach or appendix.

Abdominal cleansing
Special hollow tubes are used to drain the abdominal cavity. Drains are inserted into the right and left pelvic area, on both sides of the diaphragm and under the liver. If during the operation purulent peritonitis was detected and the cause of the infection was eliminated, then peritoneal lavage is performed ( introduction of special drugs into the abdominal cavity through a catheter and its removal after some time). This procedure allows you to effectively clean the abdominal cavity.

Suturing a surgical wound
The method of completion of the operation depends on how the residual infection is treated.

Options for suturing the surgical incision are:

• Application of a continuous suture without drainage– this method is used when the level of infection is low, when there is no risk of abscesses. In such cases, the expectation is that the body can independently cope with the infectious process with the help of antibiotics.
• Closing the incision with passive drainage– drainages are used to drain exudate and administer antibiotics.
• Bringing the edges of the wound closer together– used when installing drains near the abdominal wall to wash the peritoneum and remove pus.
• Open way– used in the presence of a large amount of pus or extensive inflammation of the tissues of the abdominal wall. With this method, exudate is removed through an open wound, which is covered with tampons.

Postoperative period

The patient's condition after surgery for peritonitis requires close attention, since inflammation is associated with factors such as anesthesia, surgical trauma and malnutrition.

The areas of postoperative therapy are:

• taking antibiotics to reduce the number of harmful microbes in the body;
• carrying out therapeutic measures aimed at detoxifying the body;
• correction of metabolic disorders;
• restoration of intestinal functionality.

Is hospitalization necessary to treat peritonitis?

Treatment of peritonitis requires hospitalization. Outpatient ( at home) treatment of peritonitis in any form is unacceptable. Peritonitis is an acute surgical pathology with an unpredictable course, the mortality rate of which is very high. At any stage of this disease, complications may arise that will endanger the patient's life. Therefore, at the slightest suspicion of peritonitis, emergency hospitalization is necessary. After complex treatment in a hospital, long-term observation by a surgeon is necessary.

Nutrition for peritonitis

Diet therapy is an important part of postoperative rehabilitation after peritonitis. Surgery causes a disruption in the functionality of the body, so the reserves of proteins, fats and carbohydrates are depleted. Therefore, the patient’s diet after peritonitis must be balanced and include all elements to normalize energy metabolism. Determination of the final diet ( composition, duration) depends on the cause that caused peritonitis. The postoperative period is divided into several stages, which determine the patient’s nutritional pattern.

The phases of the recovery period are:

• first ( early) – lasts from 3 to 5 days;
• second – duration from 2 to 3 weeks;
• third ( distant) – ends when the patient’s ability to work is fully restored.

Nutrition at the first stage

It is possible to provide full support to the patient after surgery with the necessary nutritional ingredients only with the help of artificial nutrition. To meet the body's protein needs and prevent complications, the patient is given parenteral feeding ( administration of nutrients intravenously). When intestinal peristalsis occurs, the patient is transferred to enteral nutrition ( administration of mixtures using a probe through the mouth, nose or a special hole in the abdominal wall). The composition of the diet and duration are determined by the physician depending on the general condition of the patient. Parenteral and enteral feeding can reduce the likelihood of complications and shorten the recovery period after peritonitis surgery.

Nutrition in the second stage

When stool appears and the body’s condition improves, the patient is transferred to natural nutrition. The main rule of feeding is the gradual introduction of new products and constant monitoring of the patient’s well-being.
For some period ( from 2 to 5 days) after completion of artificial feeding, the patient is prescribed a special diet with low energy value ( up to 1000 kilocalories per day). The patient needs to consume approximately 20 grams of proteins and fats and 200 grams of carbohydrates per day. The amount of table salt consumed should be limited to a minimum, and fluid intake should be at least 2 liters per day. The consistency of the dishes should be liquid or semi-liquid.

• jelly, jelly ( vegetable, fruit, meat);
• weak meat broth;
• boiled eggs ( soft-boiled);
• homemade fruit and berry juices;
• vegetable puree with butter.

If this diet is well tolerated and there is no loose stool, the patient is transferred to a more varied diet, which is followed throughout the entire period of treatment in the hospital.

The main diet of the second phase of rehabilitation after surgical treatment of peritonitis
The diet must satisfy all the patient’s nutritional needs and promote the healing of organs affected during surgery. Also, one of the key goals of the diet is to restore the functionality of the gastrointestinal tract.

Principles of creating a menu for a patient after treatment of peritonitis
High protein content – ​​sufficient amounts are included in the following products:

• eggs;
• meat ( lamb, beef, turkey, rabbit);
• fish ( saury, salmon, sardine);
• fish products ( caviar, cod liver);
• dairy ( hard and semi-hard cheeses, sour cream, cream).

Minimum dose of easily digestible carbohydrates - it is necessary to reduce the consumption of foods such as:

• sugar;
• marmalade;
• jam;
• butter and other products made from wheat flour;
• sugar substitutes.

A sufficient amount of complex carbohydrates - products that contain the required norm of these elements are:

• brown rice;
• carrot;
• eggplant;
• potato;
• legumes;
• dried apricots;
• prunes.

Balanced fat intake – recommended sources of fat after peritonitis are:

• vegetable oil ( corn, sunflower, olive);
• butter;
• sour cream, cream, milk, cottage cheese;
• medium fat fish.

Also, nutrition in the postoperative period should help increase the body's resistance to infections and healing of the postoperative wound.

The rules of the basic diet are:

• Diet– should consist of 5 – 6 meals.
• Pauses between meals– no more than 4 hours. Dinner – 1 – 2 hours before going to bed.
• Food temperature– average. Excessively hot or cold food is excluded.
• Food consistency– liquid, mushy. When boiled, food may have a denser structure than porridge, but should be served pureed.
• Recommended heat treatment– boiling or steaming. The use of an oven is also allowed, but without forming a crust on the products.
• Rest after meals– if possible, especially during lunch hours, after eating, you should take a horizontal position for 15–30 minutes.
• Fluid intake– tea, milk and other drinks should be consumed 20–30 minutes after meals. The amount of liquid taken at one time should not exceed 1 glass.

To ensure that the food you eat does not have an aggressive effect on the organs of the digestive system, it is necessary to exclude foods that are strong stimulants of secretion.

Products that provoke increased secretory activity of the stomach include:

• rich meat and vegetable broths;
• smoked, dried sausages;
• salted, marinated fish;
• industrial canned food;
• baked goods;
• tomato sauce, ketchup, soy sauce, mustard, horseradish;
• salted, pickled vegetables;
• sour, salty, spicy dressings for dishes;
• insufficiently ripe or sour fruits;
• stale vegetable and animal edible fats;
• chocolate;
• coffee, cocoa;
• drinks containing carbonic acid.

Products whose consumption should be minimal in the main diet include:

• whole grain products– bread made from coarsely ground flour, durum pasta, whole grain porridge;
• vegetables– white cabbage, broccoli, peas, green beans, spinach, dried mushrooms;
• fruits– dates, gooseberries, currants, apples, bananas, grapefruits, oranges, avocados.

You should also consume foods that contain stringy meat or rough connective tissue of animal origin in minimal quantities ( skin, cartilage, tendons).

The daily norms for the chemical composition of the basic diet are:

• squirrels- 100g ( 60 percent animal origin);
• fats– from 90 to 100 grams ( 30 percent plant-based);
• carbohydrates– 400 grams;
• calorie content– from 2800 to 2900 kilocalories.

The amount of table salt consumed by the patient per day should not exceed 6 grams.

The diet of a patient with peritonitis should be rich in vitamins and microelements, the deficiency of which can be compensated with the help of vitamin and mineral supplements. The main indicator that you should focus on when drawing up a menu is the patient’s well-being. If, when eating certain foods, the patient experiences discomfort in the epigastric region, nausea or vomiting, such foods or products should be discarded.

• Bread– wheat products baked yesterday or dried in the oven.
• Soups– prepared with potato or carrot broth. Products such as cereals can be added ( needs to be boiled well), vegetables ( should be wiped), milk. You can season first courses with butter.
• Meat– cutlets ( steamed, boiled), casseroles, soufflés. Recommended beef, lamb ( low-fat), pork ( circumcised), chicken, turkey.
• Fish– use low-fat varieties for boiling or steaming in one piece. The skin is first removed. Also possible are cutlets or meatballs made from fish fillets, aspic.
• Dairy– milk, low-fat cream, low-fat kefir, cottage cheese, yogurt, fermented baked milk. The products can be consumed independently or used to prepare casseroles, mousses, and creams.
• Eggs– soft-boiled, steam omelettes.
• Porridge– boiled in water or milk from cereals such as buckwheat, semolina, rice.
• Vegetables– potatoes, carrots, beets. You can simply boil vegetables, make puree or pancakes from them ( steam), cutlets ( steam), soufflé.
• Finished goods– milk sausage, unsalted low-fat ham, children’s sausages, curd cheeses.
• Dessert– jelly, jelly, unsweetened compote.
• Beverages– juices from sweet berries diluted with water, weak tea, rosehip decoction.

Sample menu dishes for 1 day are:

• Breakfast– 1 soft-boiled egg, rice porridge with milk, tea.
• Late breakfast– granular ( non-acidic) cottage cheese, rosehip decoction.
• Dinner– potato soup without meat, steamed chicken cutlets and carrot puree, dried fruit compote.
• Afternoon snack– a decoction of wheat bran with dried bread.
• Dinner– boiled fish, boiled vegetable salad, tea with milk.
• 1 – 2 hours before bedtime– 1 glass of milk.

Nutrition in the third stage

In most cases, the third phase of the postoperative period coincides with discharge from the hospital and transfer to outpatient treatment. Gradually, new foods are introduced into the patient’s diet, while monitoring the body’s reaction.

The rules according to which the transition to a more varied diet is carried out are:

• reducing restrictions on the types of heat treatments used;
• gradual increase in caloric intake;
• replacing pureed food with solid foods.

Restrictions that must be observed until full recovery are:

• reduced sugar intake;
• minimal use of hot herbs and spices;
• reducing the amount of hard-to-digest food ( animal fats, legumes, fatty meats, highly fried foods).

It is necessary to continue to follow the principles of fractional nutrition, distributing the daily calorie intake ( from 2300 to 2500) in accordance with the rules of a healthy diet.

The principles of distribution of daily calorie content are (data are indicated as a percentage of the total food):

• breakfast – 20;
• late breakfast – 10;
• lunch – 35;
• afternoon snack – 10;
• dinner – 20;
• late dinner – 5.

Prevention of dysbacteriosis after peritonitis

Prevention of dysbacteriosis is of great importance when recovering from peritonitis ( decrease in beneficial and increase in harmful bacteria in the intestines).

Nutritional rules that will help restore intestinal microflora are:

• Refusal or reduction in consumption of all types of sugar and its substitutes ( honey, maple syrup, corn syrup, glucose, fructose, maltose, sorbitol, sucrose).
• Avoiding foods prepared using fermentation processes ( beer, wine, cider, ginger ale).
• Minimum consumption of foods that may contain yeast and mold ( cheeses, vinegar, marinades, baked goods, raisins, kvass).
• Avoid foods that contain dyes, flavors, or flavor enhancers. A large concentration of these elements is found in fast food.
• Eating stewed carrots and beets. These vegetables contain pectin, a substance that has a sorbent ( suction) property and promotes the removal of toxins from the body.
• Inclusion of dairy and lactic acid products in the menu ( kefir, cottage cheese, yogurt, kumiss, milk). It should be noted that fermented milk products, the duration of which does not exceed 1 day, bring benefits to the body in the fight against dysbiosis. After 24 hours, saprophytic bacteria develop in kefir and cottage cheese, which inhibit intestinal function and can cause constipation.
• Consumption of foods enriched with lactobacilli and bifidobacteria. Fermented milk products such as bifidok, biokefir, and fermented milk lactobacterin are enriched with such elements.
• Introducing slimy soups and porridges made from buckwheat or oatmeal to the menu. These dishes improve intestinal function and prevent diarrhea.

Is it possible to treat peritonitis at home?

Peritonitis is a disease that requires immediate medical attention. From the onset of the development of the disease to the terminal phase, a short period of time passes, the duration of which does not exceed 3 days. Therefore, untimely diagnosis and surgery can cause the patient’s death.

With peritonitis, blood, urine, bile, feces, and stomach contents enter the abdominal cavity, causing the body to experience severe intoxication. It is possible to remove the source of infection and eliminate the consequences of peritonitis only in special clinical conditions using medical equipment and a wide range of medications. In the hospital, the patient is provided with adequate preoperative preparation, which makes it easier to endure surgery. After completion of the operation, the patient undergoes multi-level postoperative therapy to prevent complications. It is impossible to implement all stages of treatment of peritonitis at the appropriate level at home.

Consequences of peritonitis

The consequences of peritonitis include the development of numerous complications both during the illness itself and during the recovery period.

Complications of peritonitis in the acute period of the disease are:

• acute renal failure;
• pulmonary complications;
• toxic shock;
• dehydration of the body.

Acute renal failure

Acute renal failure is a severe consequence of peritonitis, which is characterized by a sharp decrease in kidney function. It is known that the main function of the kidneys is to remove toxic metabolic products from the body. Due to damage to the kidneys by bacterial toxins that spread through the bloodstream from the peritoneal cavity throughout the body, this function declines sharply. The result of this is the retention of these products in the human body.

The most dangerous waste product in our body is urea. Its increased content in the blood is called uremia. The danger of this condition lies in the fact that, being an osmotically active substance, it carries water with it. Easily passing through cell membranes, urea, penetrating into the cell, leads to cellular hyperhydration. In this case, the cell becomes swollen and swollen, and its functions are lost.

Also, urea can fall out and form crystals, which will subsequently be deposited in the organs. With renal failure, nitrogen bases are also retained in the body. The greatest danger is ammonia, which, due to its lipophilicity, easily penetrates brain tissue, damaging it.

Unfortunately, damage to kidney tissue is often irreversible. Therefore, acute renal failure can often develop into a chronic form. Morphological examination of people who died from peritonitis reveals numerous necrosis in the kidneys ( areas of necrosis) and hemorrhages.

Pulmonary complications

Pulmonary complications develop in the toxic stage of peritonitis, when toxins and bacteria from the peritoneal cavity are carried through the bloodstream throughout the body. Once in the lungs, they cause blood stagnation, disrupting the process of oxygen transfer into them. The main mechanism of damage is a decrease in surfactant synthesis ( a substance that prevents the lungs from collapsing). The result is acute distress syndrome, which is characterized by severe shortness of breath, cough and chest pain. Its severity is proportional to the severity of peritonitis. The further the underlying disease progresses, the more respiratory failure increases. The patient becomes cyanotic ( skin color turns blue), he has rapid and shallow breathing and a strong heartbeat. Without correction of respiratory disorders, distress syndrome develops into pulmonary edema. Pulmonary edema is one of the most severe complications that can be fatal. This condition is characterized by the fact that the pulmonary alveoli fill with fluid instead of air. As a result, the patient begins to choke because he does not have enough air.

Toxic shock

Toxic shock is one of the causes of death in peritonitis. It develops in the toxic stage, when toxins spread from the source of inflammation throughout the body. It is known that one of the pathogenetic links in peritonitis is increased vascular permeability. Bacteria and their toxins easily enter the bloodstream through the damaged wall. Together with the blood, they spread throughout the body, causing multiple organ failure. First they enter the liver, then the lungs, heart and kidneys. At the same time, water rushes from the vessels into the peritoneal cavity, causing blood pressure to drop. If a very large amount of toxins enters the blood at the same time, then all these stages occur very quickly. The temperature rises sharply, the pressure drops, and the patient becomes confused. Simultaneous development of multiple organ failure progresses very quickly. Toxic shock has a very high mortality rate, which can develop within a few hours.

Dehydration

Dehydration or exicosis is characterized by a loss of fluid from the body of 5 percent of normal or more. With exicosis, there is a lack of water not only in the bloodstream, but also in all cells of the body. Since water is the source of life, it participates in all metabolic processes in the human body. Its deficiency affects the functioning of all organs and systems. Tissues that have lost water lose their functions. Severe damage to the brain, kidneys and liver develops.

Complications of peritonitis in the postoperative period of the disease are:

• infection of the postoperative suture;
• repeated peritonitis;
• intestinal paresis;
• adhesions.

These complications are the most common in the list of numerous consequences of peritonitis. Repeated peritonitis develops in one case out of a hundred. This complication necessitates repeat surgery. It can develop due to insufficient drainage of the operated cavity, inadequate antibiotic therapy, or for a number of other reasons. As a rule, repeated peritonitis is more severe and even more difficult to treat.

Infection of the surgical suture is also a common complication. The risk of its development is greatest in people who are overweight or have diabetes. Supuration of the suture is observed in the early postoperative period. The seam becomes red, swollen and painful. After a couple of days, pus begins to flow out of it. At the same time, the patient develops fever, chills, and general health worsens.

Intestinal paresis is manifested by a lack of intestinal motor activity. It is a serious complication because it is difficult to correct. Most often it develops with diffuse peritonitis or as a result of prolonged operations. In this case, the patient suffers from painful bloating and prolonged constipation. Intestinal paresis can also develop during the period of the disease itself. In this case, it complicates the diagnosis of peritonitis, since it does not give the classic symptoms of peritoneal irritation and muscle tension.

The adhesive process is almost inevitable with peritonitis. Any violation of the integrity of the peritoneum, including its inflammation, is accompanied by the development of adhesions. As a result, connective tissue cords are formed that connect the intestinal loops. The adhesive process develops in the late postoperative period. Adhesions can initially cause partial and then complete intestinal obstruction. Their manifestation is prolonged pain in the abdomen and constipation. The complexity of the adhesive process lies in the fact that in most cases it is necessary to re-open the abdominal cavity and remove adhesions. This is necessary in order to restore intestinal obstruction, since an advanced adhesive process tightens the intestinal loops so much that it blocks its obstruction.

The consequence of peritonitis is also prolonged exhaustion of the patient. His recovery continues for months. Patients may lose a significant portion of their body weight. This happens because with peritonitis there is an increased breakdown of all the building substances of our body ( proteins, fats, carbohydrates). This phenomenon is also called a “catabolic storm.” Therefore, patients who have suffered peritonitis are as exhausted and weakened as possible.

The mortality rate of peritonitis is still high. With purulent and diffuse peritonitis, according to various sources, it accounts for 10–15 percent of cases. The outcome largely depends on timely hospitalization. A favorable outcome of the disease is possible in 90 percent of cases with surgery performed within a few hours after gastric or intestinal contents enter the abdominal cavity. If surgery is performed during the day, the chance of a favorable outcome is reduced to 50 percent. When surgical treatment is performed after the third day, the patient’s positive chances do not exceed 10 percent.

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Peritonitis is an acute inflammation associated with the entry of contents into the abdominal cavity:

• stomach;
• intestines;
• Bladder;
• blood.

Timely identification of symptoms and signs of peritonitis and immediate surgical treatment help not only to avoid complications, but also to save lives.

General concept of the disease

This inflammation is characterized by:

• general serious condition;
• severe pain;
• muscle tension in the abdominal area.

The danger of the disease does not decrease over time, since a favorable outcome is influenced not only by high-quality medical care, but also by the speed of providing such care.

Causes of inflammation

Normally, the abdominal cavity has the ability to secrete and absorb fluid.

This is due to the special structure of the peritoneum. During normal functioning of the body, the processes of excretion and absorption are balanced, so the abdominal cavity does not contain a large amount of fluid. But, if pathology occurs, the excretion processes are activated, and the following occurs:

• fluid accumulation;
• formation of inflammatory processes.

The occurrence of inflammation peritonitis

The following variants of the occurrence of inflammatory processes are distinguished:

• bacterial;
• aseptic.

Let's look at each of them in more detail.

Bacterial

The development of inflammatory processes occurs due to the presence of microorganisms in the abdominal cavity. As a rule, the disease develops due to perforation of the intestines or stomach and the entry of their contents into the abdominal organs. Such perforation can result from:

• inflammation of the cecum;
• rupture of gastric tissues altered by ulcerative processes;
• mechanical damage to the intestines;
• rupture of a malignant neoplasm;
• intestinal rupture due to intestinal obstruction.

Aseptic

Occurs due to entry into the abdominal cavity:

• bile;
• urine;
• blood.

This may happen due to:

• intra-abdominal bleeding;
• inflammation of the abdominal organs.

Aseptic peritonitis turns into bacterial peritonitis after a few hours.

Differences in inflammation by causes

1. Primary peritonitis. Inflammatory agents enter the abdominal cavity through the blood or lymph.
2. Secondary peritonitis. The contents of damaged organs enter the abdominal cavity.

Course of the disease

Peritonitis develops rapidly. There are three stages.

1. Reactive stage. It is characterized by acute pain, swelling of the abdominal cavity and exudation of fibrin. The condition persists in the first days of the disease.
2. Toxic stage. The inflammatory process increases and intoxication of the body begins. Symptoms of general intoxication of the body appear. The condition is noticeably worsening.
3. Terminal stage. It is characterized by an extremely acute course of the disease. The inflammation is progressing. The infection affects all organs and systems. Occurs on the fifth or sixth day and, as a rule, ends in death.

Peritonitis is distinguished by its content:

• serous (associated with the accumulation of serum blood in the peritoneum);
• fibrinous (accumulation of fibrin in the cavity);
• purulent (stagnation of purulent discharge).

By localization:

• local;
• common.

Local peritonitis, in turn, can be limited or not limited. Commonly divided into:

• diffuse;
• spilled;
• general.

The classification of peritonitis according to ICD-10 is quite complex, but is necessary to clarify the current condition and prescribe adequate treatment.

Peritonitis (K65)

Excluded: peritonitis:

• aseptic (T81.6);
• benign paroxysmal (E85.0);
• chemical (T81.6);
• caused by talc or other foreign substance (T81.6);
• neonatal (P78.0-P78.1);
• pelvic (in women) (N73.3-N73.5);
• periodic family (E85.0);
• postpartum O85;
• in combination with or occurring after:
  • abortion, ectopic or molar pregnancy (O00-O07, O08.0);
  • appendicitis (K35.-);
  • with diverticular disease of the intestine (K57.-).

Why is peritonitis dangerous?

The main danger of this disease is the rapid and acute development of the disease. In the second and third stages of the disease, all organs and systems suffer due to intoxication. High risk of death.

Photo: Pathogenesis

Peritonitis during pregnancy

Peritonitis during pregnancy is very dangerous. Characterized by rapidity, a huge risk for both mother and fetus. The operation begins with a caesarean section. In most cases, the uterus is removed. If inflammation can be diagnosed at the initial stage, there is a chance of a favorable outcome and subsequent natural birth.

Symptoms and signs of peritonitis

What symptoms should you pay attention to immediately:

1. Sharp pain in the abdomen, which becomes hard and painful.
2. Nausea and vomiting .
3. Heat.
4. Weakness.
5. Confusion.
6. Rapid pulse.
7. Low pressure.
8. Pain when pressing in the diaphragmatic area.
9. Pain when tapping on the anterior abdominal wall.
10. Pain when pressing slowly on the abdominal wall and quickly removing it.

Methods for diagnosing peritonitis

To obtain a complete picture of the patient’s condition in the hospital, it is necessary to carry out laboratory blood tests. It is also necessary to:

• ultrasound diagnosis of peritonitis (ultrasound);
• X-ray of the abdominal cavity.

A more accurate result will be given:

• laparoscopy;
• laparotomy.

You should not neglect examinations, since the most accurately determined degree of damage will help you choose the right tactics for surgical intervention. Using the Mannheim Peritonitis Index, the condition is assessed on a scale from 0 to 47. Values ​​of 26 points and above are very dangerous.

Treatment of the disease

Treatment of peritonitis in adults can only be surgical and includes a number of stages:

• preparation for surgery (bowel emptying, anesthesia);
• performing a laparotomy to remove the source of infection;
• treatment of the abdominal cavity with sanitizing solutions;
• installation of drainage;
• suturing the wound.

In order to avoid complications after peritonitis, drug treatment is carried out in the postoperative period. The prognosis is favorable only in case of immediate surgical intervention.

It should be remembered that self-treatment with painkillers will not help with peritonitis, but will only complicate the diagnosis.

Diet and nutrition

One day after the operation, intravenous administration of a nutrient solution in small volumes is carried out.

If the dynamics are positive, intravenous nutrition is replaced by feeding through a tube. Special nutritional mixtures are administered at a certain time in strict dosages under the supervision of medical personnel.

Allowed foods

If the restoration of the digestive system occurs according to plan, then after four days, on the fifth, it is possible to switch to the diet recommended for peritonitis. The patient's diet consists mainly of:

• broth with a low fat content;
• mashed boiled vegetables.

Possible drinks:

• herbal teas;
• jelly.

Prohibited foods, pancreatitis and others, as this is the most effective prevention of peritonitis. You also need to pay attention to the symptoms and seek qualified medical help.

Project consultant, co-author of the article: Ovchinnikova Natalya Ivanovna| Gastroenterologist, Hepatologist, Infectious disease specialist
30 years of experience / Doctor of the highest category, Candidate of Medical Sciences

Education:
Diploma in General Medicine, Novosibirsk State Medical Institute (1988), Residency in Gastroenterology, Russian Medical Academy of Postgraduate Education (1997)