DOUGLAS ABSCESS (synonym: abscess duglasova of space, pelvic abscess) — the delimited accumulation of pus in the most lower part of an abdominal cavity — rectovesical deepening (excavatio rectovesicalis) at men and pryamokishechnomatochny deepening (excavatio rectouterina) at women. - and. is a special case of the limited peritonitis localized in a cavity of a small pelvis.
D.'s borders - and. the peritoneum covering sidewalls and a bottom of a small pelvis, a rectum, a bladder or a uterus is.
Origins of D. - and. are similar to the reasons of development of limited peritonitises of other localization. Any disease of abdominal organs (perforated stomach ulcer or a duodenum, injury of intestines, an acute appendicitis, an extrauterine pregnancy, etc.) which is followed by formation of inflammatory exudate or outpouring of blood can lead to D.'s development - and. In the subsequent there is an infection of inflammatory exudate or the clots accumulating under the influence of gravity in the lowest site of an abdominal cavity. Cover of exudate from above intestinal loops and an epiploon conducts to its otgranicheniye and D.'s formation - and.
Promotes D.'s development - and. incomplete removal of exudate or clots from an abdominal cavity, especially from a cavity of a small pelvis, during the operations made concerning acute diseases of abdominal organs. As the most widespread surgical disease of abdominal organs is the acute appendicitis, and also owing to an anatomic arrangement of a worm-shaped shoot, destructive forms of an acute appendicitis most often lead to D.'s development - and. In addition to running off in a pelvic cavity of inflammatory exudate, a pelvic arrangement of a worm-shaped shoot with development of a periappendicitis and inflammatory infiltrate can be an origin of D. - and. before operation in case of late arrival of the patient under observation of the surgeon. Frequency of a complication of an acute appendicitis of D. - and., according to various authors, from 0,09 to 1,5% hesitate (V. I. Kolesov, 1972).
In purulent contents of D. - and. there is most often gram-negative intestinal microflora steady against penicillin that needs to be considered at an antibioticotherapia.
At long existence of D. - and. as a result of loss of fibrin and development of granulyatsionny fabric the capsule of abscess forms. The abscess can be various sizes — to contain up to 600 ml of pus and to reach the level of a navel. Existence of abscess in a cavity of a small pelvis leads to emergence of purulent intoxication and comprises risk of break of its contents in a free abdominal cavity and the next bodies. The most dangerous is the break of pus in a free abdominal cavity with development diffuse purulent peritonitis (see). Owing to distribution of pyoinflammatory process on a wall of body, adjacent to an abscess, there can be a fusion of this site proteolytic enzymes of pus and break of abscess in a gleam of a direct, blind or small bowel, a bladder, uterus.
Emptying of an abscess in a gleam of a rectum can end with self-healing, the break in a gleam of a bladder, uterus leads to development of a purulent inflammation of these bodies.
A clinical picture
the Most constant symptom of D. - and. fervescence to is 38 — 39 °, constant or gektichesky character, a cut it can be observed from the first day or in 5 — 6 days after operation with the previous period of standard temperature. - and. can develop also at not operated patient. The general condition of the patient remains satisfactory or moderately severe. Pulse corresponds to temperature. Sometimes unsharp pains in lower parts of a stomach disturb, at a palpation the stomach remains soft, painless. In suprapubic area the deep palpation can be painful. Symptoms of irritation of a peritoneum usually are absent. At disturbance of an otgranicheniye from a free abdominal cavity swelling of intestines and symptoms of irritation of a peritoneum develop.
The irritation pus of the peritoneum covering a bladder and a rectum leads to emergence of characteristic symptoms of D. - and. — a frequent urodynia, the speeded-up liquid chair with impurity of slime, tenezm. These symptoms quite often are early displays of the forming pelvic abscess. In blood the changes typical for an abscess of any localization appear: a leukocytosis, a neutrocytosis, band shift to the left a leukocytic formula, the accelerated ROE.
Wedge, D.'s current - and. at children same, as well as at adults.
Crucial importance for D.'s diagnosis - and. has a manual research of a rectum and vagina. In initial stages of formation of a pelvic abscess it is possible to note morbidity of a front wall of a rectum and a back vault of the vagina, then protrusion in a gleam of a rectum of its front wall, hypotonia or a gaping of a sphincter appears. In 2 — 3 days protrusion of a wall of a rectum gains character of dense infiltrate with a softening in the center, the mucous membrane of a rectum over it is not displaced. Similar changes are noted also in a back vault of the vagina.
The known diagnostic value at early stages of development of a disease has comparison of level of temperature at its measurement in an axillary hollow and a rectum. At the forming D. - and. the difference between them makes 1,1 — 1,4 ° instead of usual 0,2 — 0,5 °. Rentgenol, a research can instruct on D.'s presence - and. only in rare instances of gas generation in it (emergence of horizontal level of purulent liquid).
The puncture of an abscess through a rectum or a vagina as diagnostic reception shall not be made owing to risk of damage of adjacent intestinal loops and emergence of defect of a rectum.
In initial stages, before emergence of a softening of the infiltrate palpated through a rectum or a vagina appoint antibiotics of a broad spectrum of activity, a bed rest, to lay down. enemas and syringings of a vagina water with a temperature up to 38 — 40 °, disintoxication therapy. Emergence of a softening in the center of infiltrate is the unconditional indication to D.'s opening - and., carried out through a front wall of a rectum at men and children, and at women and through the back arch or a back wall of a vagina (fig., 1 and 2). It is not necessary to make opening of an abscess through a rectum in the absence of accurate data for its otgranicheniye since the defect of a rectum which is formed as a result of it significantly complicates the subsequent treatment of peritonitis and worsens the forecast.
Technology of operation
Position of the patient — as at operation on an occasion hemorrhoids (see). Anesthesia preferably general. Make manual stretching of a sphincter of a rectum then enter a rectal speculum into an anus at men. In the initial site of the greatest protrusion and a softening of a wall of a rectum strictly on the centerline a long thick needle make a puncture of a front wall of a rectum. After receiving pus, without taking a needle, on it a long scalpel make a small section of a wall: guts. After allocation of the main amount of pus through a wound it is stupidly expanded with branches of a packer or a finger. Enter the rubber drainage tube fixed by a seam to skin of a crotch into an abscess cavity. The outside end of a drainage is lowered in a vessel with antiseptic liquid or attached to system for implementation of continuous aspiration.
At women open abscess through a back vault of the vagina (see. Colpotomy ) or, as at men, through a front wall of a rectum.
After opening of abscess appoint a bed rest with the raised head end of a bed, a besshlakovy diet for a delay of a chair within 4 — 5 days for finding of a drainage in an abscess cavity; solution of antibiotics in an abscess cavity. At full emptying of an abscess and its effective drainage the condition of the patient quickly improves, temperature is normalized and there occurs recovery.
Prevention — careful removal of inflammatory exudate and clots from a cavity of a small pelvis at the operations made concerning acute surgical and ginekol, diseases (an acute appendicitis, a perforated ulcer, an extrauterine pregnancy, etc.); careful otgranicheniye of a surgery field from a free abdominal cavity. Full removal of the infected inflammatory exudate from all departments of an abdominal cavity can be provided during the performance of operation under anesthetic, at rather broad access and during the use of a suction machine.
At the destructive forms of appendicitis which are followed by common forms peritonitis (see), operation shall be made under the general anesthesia from median laparotomies (see) that allows to make careful removal of the infected exudate from all departments of an abdominal cavity and by that to provide efficient prevention of D. - and. Essential value in such situations have leaving in an abdominal cavity for 3 — 5 days of a microirrigator for local leading of antibiotics (taking into account sensitivity of the microbic flora found at crops) or carrying out peritoneal dialysis (see).
See also Duglasovo space .
Bibliography: Appendicitis, under the editorship of M. I. Kolomiychenko, etc., page 275, Kiev, 1966; Zhuravsky JI. C. Relaparotomy, M., 1974, bibliogr.; Kolesov V. I. Clinic and treatment of an acute appendicitis, L., 1972, bibliogr.; Littmann I. Belly surgery, the lane with it., Budapest, 1970; In i e r A. u. a. Chi-rurgische Operationslehre, Bd 4, T. 2, Lpz., 1975.
B. S. Pomelov.