PERITONITIS

From Big Medical Encyclopedia

PERITONITIS (peritonitis; grech, peritonaion a peritoneum + - itis) — the inflammation of a peritoneum which is followed by heavy general symptoms of a disease of an organism with disturbance of functions of vitals and systems. Usually the term «peritonitis» designate a diffusion inflammation peritoneums (see). Delimited by infiltrate and unions of accumulation of pus in this or that department of an abdominal cavity call abscess of an abdominal cavity or the delimited P.

Classification

P. distinguish on etiol, to a factor, a way of penetration and the nature of an infection, character of exudate, prevalence of an inflammation, stage of development of process and a wedge, to a current.

The item can be primary and secondary. Primary P. (idiopathic) is caused by primary defeat of a peritoneum the microorganisms getting in the hematogenous or lymphogenous way and also through fallopiyeva of a pipe; meets seldom (apprx. 1%). Secondary P. is result of spread of an infection from the vospalitel-but-changed bodies (a worm-shaped shoot, a gall bladder etc.), bodies which underwent perforation, wound or a gap at the closed damage (a stomach, a duodenum, a large and small bowel); meets often.

On a wedge, to a current distinguish P. acute, subacute, slow and chronic. Acute P. — a widespread and terrible disease.

On etiol, to a factor distinguish P. caused: colibacillus, aerobic and gnaerobny streptococcus, staphylococcus and enterococci, pyocyanic stick, Proteus, representatives of the sort Bacteroides, Klebsiella and Clostridium, Friedlander's stick, gonokokky, mycobacterium of tuberculosis, pneumococcus, beta and hemolitic streptococcus, etc. More than in 30% of cases find association 2 — 3 activators. According to character of the activator distinguish P. collibacillary, staphylococcal, streptococcal etc.

Aseptic P. — toksiko-himi-chesky (or abacterial) arises owing to hit in an abdominal cavity of blood (hemoperitoneum), chyle liquid (chyle P. — hiloperitoneum), bile, pancreatic enzymes, meconium, urine at a rupture of the bladder and also as result of aseptic necroses of internals. Aseptic P. within several hours becomes infectious owing to penetration of microbes into an abdominal cavity from a gleam of intestines in connection with a hyperpermeability of its walls at P. Kartsinomatoz of a peritoneum proceeding with an exudate call also carcinomatous (cancer) Item. Hit in an abdominal cavity of talc or starch from gloves of the surgeon causes hron, the fibroplastic Item.

Depending on character of an exudate in an abdominal cavity distinguish the serous, fibrinous, purulent, hemorrhagic and putrefactive Item.

On a distributional pattern of an inflammation on P.'s peritoneum can be diffusion (the inflammation of a peritoneum does not tend to an otgranicheniye) and delimited when thanks to early formation of friable commissures, adhesion of the inflamed peritoneum of adjacent bodies and adequate mobilization of mechanisms of protection of an organism in an abdominal cavity there is an otgranicheniye of inflammatory process. In case of accumulation of purulent contents in limited area it is accepted to use the term «abscess» (subphrenic, subhepatic, interintestinal, pelvic, paraappendi-kulyarny etc.).

On P.'s prevalence can be local (only a part or one anatomic area of a stomach is surprised); extended (several anatomic areas are surprised); the general, or poured (all departments of an abdominal cavity are surprised).

About a wedge, the points of view depending on time of emergence and rate of increase patofiziol, changes in sick P.'s organism distinguish: a reactive stage of P. (P.'s beginning), toxic (it is characteristic of the expressed P.) and terminal.

Forms P. depending on etiological, pathogenetic and other signs are given in table 1. Because P., as a rule, is secondary, in a wedge, the diagnosis on the first place write a basic disease, then P. as a complication with the indication of a version it.

Table 1. Forms of peritonitis depending on etiological, pathogenetic and other signs



A historical sketch

Before introduction of antiseptics and an asepsis to surgical practice P.'s treatment was limited only to opening or a puncture of abscesses in the bottom of a stomach (in inguinal area). In Russia the first description of P. belongs to V. Shabanov (1816). The first laparotomy concerning P. manufactured Tate (R. L. Tait, 1879), and in Russia A. I. Schmidt (1881). Messages to C. C. Reja-ra (1882), I. Mikulich (1884) and Krenleyn (R. U. Kronlein, 1885) shook the existing idea of inevitability of death at purulent or putrefactive

P. S development of methods asepsises (see) and antiseptic agents (see), and also began to be made by introduction of the general anesthesia of operation for P. with smaller risk.

According to Kirchner (M. of Kirsch-ner, 1926), have crucial importance in P.'s treatment: early operation at which delete a source of an infection; removal of exudate by washing or an osushivaniye of an abdominal cavity; postoperative removal of exudate by means of drainages. According to its data, from 1896 to 1925 the over-all mortality at P. decreased from 87,5 to 30,7%.

In the 30th years thanks to the organization of first aid, improvement of methods of the general and local anesthesia, implementation of hemotransfusion and crystalloid solutions detailed studying of a pathogeny and P.'s pathophysiology, microbic flora, changes of a hemodynamics, breath, internals, indicators of an acid-base state, protein metabolism, etc. was succeeded to improve results of prevention and P. Nachalos's treatment.

Emergence of sulfanamide drugs and antibiotics allowed to lower a lethality at diffusion to P. Ety promoted the correct selection of antibacterial drugs which is combined with surgical treatment and the adequate intensive care allowing to korrigirovat disturbances of functions of vitals and systems of an organism or to prevent their emergence.

The statistics

Primary P. (idiopathic) arises seldom, making no more than 1%. Secondary P. complicates the course of acute surgical diseases of abdominal organs, according to V. S. Savelyev (1970) and EL Fedorov (1974), in 15 — 20% of cases. P.'s incidence does not depend on gender and age of patients.

The etiology

P. can result from any disturbance of an integrity or permeability of walls of hollow bodies, an inflammation or a rupture of abdominal organs and retroperitoneal space, ruptures of cysts and diverticulums, wound of abdominal organs and their closed damage, insufficiency of seams after operations. The acute appendicitis is the most frequent reason of P. The second place is taken by diseases of a stomach and duodenum' (a perforated ulcer, wounds). Also diseases and injuries of a gall bladder and a pancreas can be an origin of P. (acute cholecystitis, acute pancreatitis, etc.); patol, processes in a small and large intestine (perforation of ulcers, tumors, necroses of intestines, diverticulites, wounds); ginekol, diseases (salpingitis, extrauterine pregnancy, endo-and parametritis, perforation of a uterus, rupture of an oothecoma, etc.); patol, processes in a liver and a spleen (damages, gaps, etc.); intraperitoneal ruptures and wounds of a bladder; damages of an initial part chest limf, channel; the inflammatory processes developing zabryushinno (a paranephritis, diseases and injuries of kidneys), in pelvic cellulose, a front abdominal wall; the complications arising after abdominal organs operation (insolvency of seams, infection of an abdominal cavity, a necrosis of the site of an epiploon and a mesentery, etc.). In P.'s emergence

the blood which got into an abdominal cavity since it at its decomposition forms the toxic products increasing aggression of bacteria is important slows down natural clarification of an abdominal cavity from microbes, interfering with influence of protective mechanisms of an organism (phagocytosis, influence of antibodies, etc.).

Primary, or idiopathic, P. is observed at children's age, especially at girls. Bacteria get into an abdominal cavity in the hematogenous, lymphogenous way or through fallopiyeva of a pipe. In 2/3 cases the activator is the hemolitic streptococcus and in V3 of cases — a pneumococcus; gonokokk meets seldom. Primary P. can be caused by also mixed flora, as a rule, in the presence in an organism of the center of an infection (quinsy, pneumonia, a respiratory infection, etc.).

Tubercular P. — a rare disease. It is observed in all age groups, women get sick more often than men. Tubercular P. is usually combined with a tuberculous focus in an organism — in lungs, intestines or in mezenterialny limf, nodes; the activator is the mycobacterium of tuberculosis (a human or bull strain).

Rheumatic P., or a so-called abdominal syndrome at rheumatism, belongs to difficult recognizable displays of rheumatism. He meets as manifestation more often polyserositis (see) at persons of young age, against the background of the repeated rheumatic attacks, a rheumatic carditis, heart diseases, a pericardis.

Cancer P. presents itself the dissimination of cancer on a peritoneum in the form of small small knots which is followed by a plentiful exudate which in the subsequent can be infected.

The pathogeny

Approximately in P.'s pathogeny can be allocated the following phases. 1. The reaction to local inflammatory process which is expressed in the nonspecific answer of system a hypophysis — bark of adrenal glands on stressorny influence and manifestation of local and general mechanisms of protection; it is characteristic of a reactive stage. 2. Reaction to receipt in blood of bacterial toxins and enzymes, the products of the proteinaceous nature which are formed in the course of disintegration of cells; it is characterized by the signs inherent to endotoxic shock and corresponds to a toxic stage. 3. Dominance of signs of septic shock and decompensation of function of vitals (liver, kidneys, heart); it is inherent to an end-stage.

The mechanism of cellular protection in development of an inflammation comes down to accumulation of granulocytes, lymphocytes and macrophages in a zone of damage of fabrics. Leukocytes and macrophages actively englobe and digest not only microorganisms, but also proteins, carry out transport of large proteinaceous molecules (slime, mucin), clearing thus an abdominal cavity. The microorganisms getting out of limits of a zone of an inflammation are late and neutralized in a liver, a spleen by cells of reticuloendothelial system.

The important role in P.'s pathogeny belongs immunol, the protection which is carried out by lymphocytes of intestines, peyerovy plaques, limf, nodes of a mesentery, cells of a mesothelium of an epiploon and a peritoneum and also immunoglobulins (see). Insufficiency of immune mechanisms of protection at P., according to Ekkert and Eykhfus-sa (P. Eckert, P. Eichfuss, 1978), can be caused by sharp reduction of formation of immunoglobulins and decrease in concentration function limf, systems of intestines in relation to them. According to Myorl and Dittmer (F. Mori, H. Dittmer, 1979), P. is followed by a heavy immunosuppression.

At the same time local mechanisms of protection in the form of hypostasis, infiltrations of bodies, adjacent to the center of an inflammation (an epiploon, a mesentery, guts), their adhesion with each other and with the struck body thanks to release of fibrin and dense sticky exudate, possessing, by data K. S. Simonyana, ability to adsorb microbes and toxins turn on. As a result the inflammatory center can be completely localized.

Localization of inflammatory process is promoted by oppression of motility of a gut adjacent to the center, differentiation of an abdominal cavity on top and bottom floors a cross colon, the considerable size and mobility of a big epiploon which shrouds the inflammatory changed body.

If mechanisms of local cellular and humoral protection are sufficient for an otgranicheniye of process, then at rational treatment the disease can be stopped, and the begun P. will be resolved by recovery. The second possible outcome — formation of abscess (the delimited P.).

Most often the otgranicheniye of exudate occurs in a small basin (see. Douglas abscess ), under a diaphragm (see. Subphrenic abscess ), under a liver, in side channels of an abdominal cavity and between loops of intestines (interintestinal abscess).

Postoperative abscesses arise usually in a zone of an operative measure. If protective mechanisms do not provide a rassasyvaniye of exudate and the remains of blood in a zone of operation, then liquid easily is infected, forms the delimited Item.

At weakness of protective forces of an organism microbic aggression accrues, the inflammation progresses, extends on a peritoneum, exudate forms, diffusion P. develops that is promoted by high virulence of an infection, intensity and duration of microbic infection, inadequate treatment.

If the invasion of microbes in an abdominal cavity occurs slowly, protective mechanisms manage to delimit inflammatory process. At sudden, bystry receipt of a significant amount of the infected material (perforation of hollow body, break of abscess) protective mechanisms do not manage to localize process and the diffusion Item develops. Its development is promoted by the respiratory movements of an abdominal wall and a peristaltics of intestines; the movements of a diaphragm creating cyclic pressure differences between top and bottom floors of an abdominal cavity; forces of gravitation moving liquid at change of position of a body. The purgatives, enemas, drugs stimulating an intestinal peristaltics, destruction of the delimiting commissures and unions in the course of operation, opening of abscess in a free abdominal cavity inadequate drainage also promote distribution of an inflammation. Inadequate treatment against the background of weakening of protective mechanisms can lead to the general P.'s development and septic shock (see. Sepsis ).

Receipt in a free abdominal cavity of microbes and toksiko-hi-micheskikh agents (bile, contents of a stomach) causes irritation of the huge receptor field and pain, on to-rye an organism the hypophysis — bark of adrenal glands, change of function of vascular, respiratory and secretory systems answers with sharp strengthening of function of system.

Disturbances of blood circulation in the early period of P. are caused by reaction of an organism to stressorny influence. Later in the mechanism of these disturbances the main role belongs to a hypovolemia owing to deposition of blood in abdominal organs and on peripheries, fluid losses in connection with formation hypostasis (see) and exudate (see). In toxic and an end-stage of P. toxicants the myocardium is surprised. In the mechanism of disturbance of blood circulation

the endotoxins representing a complex of the lipopolisakharid which are released in the course of death of gram-negative microbes are important. At receipt in blood they unite to antibodies and a complement, forming very aggressive anaphylotoxin which in turn promotes release of the catecholamines, a histamine, serotonin, kinin and other hormones causing deposition of blood in intestines and a liver. Owing to a spasm of hepatic veins venous return of blood to the right departments of heart decreases that leads to reduction of cordial emission, disturbance of blood supply of internals, falling of the ABP, reduction of volume of the circulating blood, growth of a hematocrit. Congestive develops hypoxia (see) and so-called endotoxic shock (see). At P.'s progressing disturbances of microcirculation (see) are caused preferential by development of the disseminated intravascular coagulation (see. Hemorrhagic diathesis ). It is promoted by paralysis of capillaries, dehydration, sloshing from the intravascular sector in intersticial, hypostasis and an atony of intestines.

An atony of intestines, or paralytic intestinal impassability (see. Impassability of intestines ), in an initial stage of P. arises owing to reflex synpaticotonic oppression of motility of a gut and creates premises for stretching of intestines gas and liquid contents, build-up of pressure in it. In this regard thin-walled veins in a wall of a gut are squeezed, outflow on them is at a loss, increases hypostasis, worsens microcirculation in a wall of a gut, the hypoxia accrues and permeability of capillaries and the most intestinal wall increases. The acidosis arising in muscle cells of a gut, substitution of intracellular potassium ions of sodium, decrease in electric potential, ATP level and oxidizing processes cause strengthening of an atony of intestines, loss of water, electrolytes and protein.

The liver and kidneys rather early are surprised because of reflex reduction of blood supply owing to a vasospasm and shunting of blood through an arteriovenous anastomosis. This process goes deep as a result of the increased allocation of the catecholamines strengthening catabolic processes in the cells (a glycogenolysis, education fat to - t) causing exhaustion of power products and decrease in the ATP level. Fat to - you activate coagulant system of blood, deepen disturbance of microcirculation in bodies. The hypoxia and intracellular acidosis which arose under the influence of the specified factors cause rough dystrophic changes in cells of a liver and kidneys, oppress them function.

Function of kidneys is broken owing to a reflex vasospasm of a bast layer of a kidney, shunting of blood. Development of the disseminated intravascular coagulation sharply breaks microcirculation in a bast layer of kidneys, promotes formation of fibrin in vessels of balls. Hypoxia and acidosis (see) cause dystrophy and a necrosis of an epithelium of gyrose tubules. Filtering of primary urine sharply decreases. In an end-stage of P. damage of a renal epithelium is promoted by decrease in the ABP, reduction of a minute and stroke output of heart. Acute renal or hepatonephric failure develops (see. Renal failure , Liver failure ).

Function of lungs is broken in connection with reduction of their perfusion at a circulatory disturbance. At the same time the ventilating and perfused ratio changes, the partial pressure of oxygen of blood decreases that causes developing of a hyperventilation and decrease in partial pressure of carbon dioxide gas. The strengthened allocation of catecholamines stimulates catabolic processes, increases power consumption that supports a hyperventilation, decrease in pCO 2 and O 2 . At endotoxic shock along with dysfunction of lungs in them worsens microcirculation owing to development of the disseminated intravascular coagulation, shunting of blood, hypostasis of intersticial fabric and influence of a toxic factor. The specified reasons, especially in the presence of such contributing factors as diseases of lungs, bronchial tubes, heart, promote emergence of acute respiratory insufficiency (see).

Thus, having arisen as a local inflammation of a peritoneum, P. under unfavorable conditions becomes the disease of all organism affecting vitals and systems.

Protein metabolism (see. Nitrogen metabolism ) at P. it is broken in connection with a hypermetabolism and loss by an organism of protein to 50 — 200 g a day with exudate, urine, emetic masses. Plasma protein content goes down. The hypoproteinemia and a disproteinemia are more expressed at diffusion forms P., especially ir carrying out peritoneal dialysis. Disturbance of protein metabolism is followed by the deficit of nitrogenous balance reaching 10,2 — 13,5 g a day.

At P. considerable disturbances are usually noted water salt metabolism (see). Due to strengthening of release of potassium with urine and emetic masses and its exit from intracellular space it can be observed hypopotassemia (see). In process of P.'s progressing, oppression of secretory function of kidneys, disorganization of metabolism of cells and their death the content of potassium increases in plasma, the hypopotassemia can pass in hyperpotassemia (see). Despite a reabsorption of sodium in tubules of kidneys, the expressed hypernatremia usually is not observed since a considerable part of sodium moves in cells, forcing out potassium from there. Some part it is deposited together with edematous liquid in intersticial space.

Indicators acid-base equilibrium (see) at P. are subject to considerable fluctuations. In fabrics the acidosis caused by disturbance of blood circulation in fabrics, a hypoxia and disorganization of metabolism of cells is, as a rule, noted. In response to it the compensatory buffer systems and mechanisms designed to neutralize possible shift of pH of blood towards acidosis join. One of the first the respiratory system reacts. The hyperventilation, decrease in pCO is observed 2 , respiratory alkalosis.

At the beginning of P. potassium is intensively removed by kidneys since the aldosteronovy mechanism of a reabsorption of sodium and water turns on. The deficit of potassium ions in blood which is followed alkalosis (see), it is filled at the expense of intracellular ions, at the same time instead of three potassium ions leaving a cell, two ions of sodium and a hydrogen ion enter it. Intracellular acidosis and an extracellular alkalosis results.

In a toxic stage of P. until secretory function of kidneys is much broken, in blood there can be a shift of acid-base equilibrium as towards an alkalosis (at 2/3 patients), and towards acidosis. In an end-stage of P. when function of kidneys is roughly broken, in process of development of an oliguria and even an anury in blood acid products of exchange, potassium ions, phosphorus, magnesium, nitrogenous slags begin to collect. It is followed by a hyperpotassemia and shift of acid-base equilibrium towards a metabolic and respiratory acidosis. Thus, acidosis intracellular is supplemented with extracellular.

In an end-stage of P. in connection with to lay down. both acidosis, and an alkalosis can be observed by actions and mobilization of compensatory mechanisms.

The pathological anatomy

Pathomorphologically in an initial stage of acute P. is observed standard reaction of a peritoneum, irrespective of character etiol, the agent — bacterial, chemical, fermental, mechanical, etc. This reaction is shown by destruction of a mesothelial cover, basal membrane and connective tissue structures of a peritoneum, and also emergence of the intensive exudative processes which are followed by accumulation in an abdominal cavity of a massive exudate. Scales of inflammatory process of a peritoneum and the qualitative and quantitative characteristic of exudate come to light later, in process of

P. V progressing an initial stage inflammations (see) exudate most often has serous or serofibrinous character. Gradually serous exudate becomes purulent with impurity of fibrin. From the very beginning the hemorrhagic shade of exudate is observed at a carcinomatosis of a peritoneum, hemorrhagic diathesis, after an abdominal cavity operations, etc. At a perforation of hollow body in exudate there can be an impurity of gastric or fecal contents, bile, etc.

Fig. 1 — 3. Macrodrugs of an abdominal cavity at diffusion purulent peritonitis. Fig. 1. Limited abscesses with the rubber drainages brought to them. Fig. 2. Swelling and commissures of loops of intestines (the epiploon is removed, rubber drainages are visible). Fig. 5. Massive it is purulent - fibrinous imposings and commissures of loops of intestines (the epiploon is removed). Fig. 4 — 8. Microdrugs of a parietal and visceral peritoneum at purulent peritonitis. Fig. 4. A sharp hyperemia of veins (it is specified by shooters) a parietal peritoneum; coloring according to Van-Gizona, x 80. Fig. 5. Thrombosis of expanded veins of a phrenic peritoneum (it is specified by shooters); coloring across Mallori; X 80. Fig. 6. Fibrinopurulent imposings on a peritoneum (1), desquamated cells of a mesothelium (2); coloring according to Van-Gizona; h80. Fig. 7. A hyperemia and thrombosis (are specified by shooters) superficial and deep veins of a diaphragm; coloring across Mallori; h80.

Macroscopically the peritoneum in initial phases P. dim, is a little hyperemic, covered with the sticky fibrinous plaque forming friable commissures between the inflated loops of guts. The fibrinous plaque is localized preferential in a zone of a source of P. Postepenno fibrinous films are exposed to consolidation and the organization with formation of dense commissures (see), differentiating diffusion purulent process on separate cavities, abscesses (tsvetn. fig. 1 — 3). Most often such abscesses develop under the right and left dome of a diaphragm, and also between loops of guts (interintestinal abscess).

The amount of purulent exudate in an abdominal cavity can vary from 50 ml to 3 l and more. Distribution of pus in an abdominal cavity at diffusion P., as well as localization of the delimited abscesses, to a certain extent depends on a source P. Tak, e.g., at perforated appendicitis pases-raappendikulyarnye abscesses, abscesses between loops of an ileal gut and in the right side channel with distribution under the right dome of a diaphragm develop more often.

Diffusion P.'s development proceeds differently, depending on whether the general P. developed right after infection of an abdominal cavity or at first the delimited abscess which later 2 — 3 weeks and more broke in a free abdominal cavity was formed.

If P. in the first case proceeds with formation of interintestinal abscesses, i.e. sequestration of pus the commissural process amplifying under the influence of an antibioticotherapia, then break of pus from is long the existing abscess (subhepatic, periappendikulyarny, nankreatogenny, etc.) almost always leads to the general P.'s development from the death.

Fibrinous P. with trace amount of liquid exudate (dry P.) quite often proceeds very violently that gave the grounds to some surgeons to designate this option peritoneal sepsis. However the analysis of section materials shows that such P.'s weight is explained, first, by paralytic intestinal impassability, secondly, toxic shock which can be caused not only bacterial intoxication, but also endointoxication. Pathoanatomical at the same time find a picture an angidremiya liquid state of blood in cardial cavities and vessels, signs of the disseminated intravascular coagulation in a microvascular bed of lungs, intestines, kidneys, is more rare than other internals.

So-called anaerobic P. is usually observed as a complication of a gas infection in the puerperal (postabortion) period, and also gunshot wounds of a basin. In an abdominal cavity it is possible to find a hemorrhagic exudate from which anaerobic flora is allocated, however the peritoneum always remains smooth, to the bla ~ styashchy, without any signs of an inflammation. Weight of a state in such cases is explained by a gas infection of the uterus or muscles of a small pelvis which is followed by a reactive exudate in an abdominal cavity.

Postoperative P. proceeds, as a rule, as a purulent inflammation of a peritoneum, arises most often owing to insolvency of seams of an anastomosis of hollow bodies, napr, after stomach, intestines, gall bladder operations, uric ways, and sometimes and at tight seams of an anastomosis, being a consequence of intraoperative pollution of an abdominal cavity.

The bilious P. developing at a perforation of a gall bladder or extrahepatic bilious channels differs in a peculiar kliniko-anatomic syndrome. Reaction of a peritoneum has at the same time no features in comparison with other types of acute bacterial P., however the exudate of an abdominal cavity painted by bile seldom happens purulent. If on opening do not find a perforation of bilious ways, speak about pro-sweaty bilious P., meaning a possibility of penetration of bile through the deep courses of Lushki of a gall bladder at hypertensia of bilious ways.

Microscopically in an early stage of P. desquamation of a mesothelium, a hyperemia and hypostasis of a connective tissue layer of a peritoneum, increase in permeability of a capillary bed is observed (tsvetn. fig. 4 — 7). These changes reflect processes of the accruing filtering in an abdominal cavity of the liquid which is carrying out a role of the peculiar biological dialysis fluid as if sanifying leaves of a peritoneum and reducing concentration of toxins. Further there is a destruction of a basal membrane, emigration of leukocytes, an exudate of the fibrin closing a zone of damage. Electronic microscopically activation of fibroblasts is already during the first hours noticeable, to-rye in 2 — 3 days migrate in fibrin - a leukocytic tslenka, forming in the subsequent dense fibrous commissures.

Fig. 8. Phlegmonous inflammation of a diaphragm: hypostasis, a plethora and diffusion infiltration of a stroma polymorphonuclear leukocytes (it is specified by an arrow); coloring according to Van-Gizona; h80. Fig. 9. A peritoneum and the subject cellulose at a pancreatonecrosis: massive imposings of fibrin (1), a fatty necrosis of cellulose (2), coloring according to Van-Gizona; h80.

Destruction of a peritoneum and intensity of exudative reaction are always much more expressed near P.'s source, napr, a perforated opening of body. At widespread P. especially intensive it is purulent - fibrinous imposings can be found under domes of a diaphragm (tsvetn. fig. 8).

Inflammatory process very quickly extends to all thickness of a wall of a gut, causing a picture of enteritis or colitis. Dystrophic changes are observed in nervous trunks and nodes of auerbakhovsky neuroplex; they break motility of intestines, promoting developing of paresis and paralyzes. Electronic microscopically considerable expansion of cracks between basal departments of enterocytes intestinal vorsin, pointing to processes of the increased dumping of liquid into a gleam of a gut is noted.

The described changes in a bright form are observed at bacterial P. and are much weaker at aseptic P., at irritation of a peritoneum bile, urine, juice of a pancreas (tsvetn. fig. 9) and foreign material (e.g., talc).

In parenchymatous bodies at diffusion P. the accruing dystrophic changes, depletion of a lipoidama of bark of adrenal glands, hypostatic melkoochagovy bronchial pneumonia are noted.

At tubercular P. planting of a peritoneum miliary hillocks is combined with intensive commissural process which can proceed with formation of a small amount of hemorrhagic exudate.

Cancer planting of a peritoneum quite often is followed by formation of exudate massive, rich with fibrin (ascites peritonitis).

At bad ottoke.limfa from a mesentery of a small bowel, and also at wounds large limf, channels there is an accumulation in an abdominal cavity of lacteal liquid (hilope-ritoneum). Inflammatory changes of a peritoneum at the same time are not noted.

The clinical picture

Klin, a picture P. is diverse. Complaints and objective symptoms depend on primary disease which caused P., time during which process, its prevalence and a stage of the Item developed. At the same time the wedge, P.'s symptomatology does not depend on character of the exudate which is formed in an abdominal cavity. Therefore it is necessary to tell about many-sided a wedge, a picture P., but not about its some more or less standard manifestation.

Patients usually complain of pains, character and which localization depend on a basic disease. In this regard in the anamnesis it is necessary to look for persistently subjective and objective symptoms of diseases, to-rye most often cause the Item. Along with pains patients, as a rule, note nausea, vomiting, fervescence.

In the first 24 hours (a reactive stage) the leading symptoms are the sharp constant pains amplifying at a postural change of a body, cough, the movements. The patient usually lies on spin or on one side with the legs given to a stomach, spares a stomach, avoids excess movements. At localization of a source P, in the upper floor of an abdominal cavity irradiation of pains in a back, to the area of a shoulder girdle is possible. Vomiting gastric contents usually does not give relief. Pulse is speeded up (100 — 110 blows in 1 min.), the ABP normal or is lowered. At a number of the diseases causing P. (a perforation of hollow bodies, fibrinferments and a vascular embolism of a mesentery, strangulyatsionny impassability, a pancreatonecrosis, etc.), development of shock is possible. At localization of a source of P. in a small basin false desires on a chair, dysuric symptoms, irradiation of pains to the area of a sacrum, a crotch are characteristic. The chair is normal, sometimes liquid, tenesmus are possible. At some diseases causing P. (invagination of intestines * a thromboembolism of mezenterialny vessels), fecal masses can be with impurity of blood.

The toxic stage of P. is characterized by the same symptoms, as reactive. However local signs of P. smooth out a little, pains and local morbidity decrease, a protective muscle tension (see. Muscular protection symptom ) Shchetkin's symptom — Blyumberg is weakened in connection with exhaustion of visceromotor reflexes (see. Shchetkina — Blyumberg a symptom ) becomes less expressed. Peristaltic noise of intestines disappear (a so-called symptom of death silence), the expressed abdominal distention, a delay of a chair and gases is observed.

The general manifestations of P. amplify in connection with increase of intoxication (see). Pulse sharply becomes frequent (St. 110 — 120 blows in 1 min.), the ABP decreases. Body temperature keeps on high figures (38 — 39 °), has gektichesky character. Breath becomes frequent, in lungs there are rattles, develops oliguria (see).

The end-stage is shown adynamia (see), sometimes euphoria, confusion of consciousness. Features are pointed, eyes hollow, skin pale, is covered then, cyanosis of the person, language dry with a black stain is characteristic (see. Hippocrates person ). As a rule, plentiful vomiting by congestive contents with a fecal smell is observed. Pulse is speeded sharply up (St. 140 blows in 1 min.), is lowered by the ABP, the breath which is speeded up, superficial. The stomach is blown sharply up, gases do not depart, diffuse morbidity on all stomach is noted.

The so-called immediately developing P. with bystry increase of symptomatology and intoxication is sometimes observed.

A wedge, a picture at the delimited P. not so heavy as at diffusion, also corresponds to primary disease (an acute appendicitis, acute cholecystitis, etc.). At inflammatory diseases of internal female generative organs quite often develops pelviperitonitis (see) which has the clinical features.

After removal of a source of P. or drainage of its area of pain usually abate, temperature decreases, the general state improves, the leukocytosis decreases, gradually there occurs recovery. At a part of patients recovery can also occur owing to an otgranicheniye of an inflammation and its gradual elimination. In these cases morbidity in the field of an inflammation and a protective muscle tension gradually become less. At a palpation it is possible to define inflammatory infiltrate, morbidity moderate. During the formation of abscess the condition of the patient worsens, temperature increases and accepts gektichesky character, in blood the leukocytosis accrues and the shift of a formula is observed to the left, local symptoms of abscess of an abdominal cavity appear. So, at its formation in the right ileal area or between loops of intestines local morbidity is noted, infiltrate over which the zone of obtusion is defined is sometimes palpated; in other departments the stomach remains soft. The characteristic symptomatology arises at formation of subphrenic abscess and Douglas abscess (see).

Tubercular P. begins imperceptibly — with an indisposition, loss of appetite, uncertain dull aches in a stomach, temperature increase in the evenings. In the anamnesis there can be an instruction on the pulmonary tuberculosis postponed earlier. At an objective research pallor and sometimes pastosity of integuments is noted.

At a thicket to the found exudative form of tubercular P. against the background of weight loss increase in volume of a stomach is observed, accumulation of liquid in an abdominal cavity is perkutorno defined. Morbidity of an abdominal wall is usually expressed unsharply. At a fibroznoadgezivny form in an abdominal cavity it is possible to probe tumorous masses — conglomerates of the infiltrirovanny loops of intestines and an epiploon soldered among themselves, painful at a palpation. The phenomena of partial intestinal obstruction with abdominal distention, pristupoobrazny pains, a delay of a chair and gases are sometimes observed. The knotty and tumorous form of tubercular P. arises at disintegration of conglomerates limf, nodes; it is followed by formation of abscesses with break them in a gleam of intestines or in an abdominal cavity.

Diplokokkovy P. begins suddenly, with sharp rise in temperature (39 — 40 °), vomitings, ponos, abdominal pains without a certain localization. The general condition of patients heavy, herpes labialis, tachycardia, increase of breath, dryness of mucous membranes are often noted. The stomach participates in the act of breath a little, are available the expressed protective muscle tension, a symptom. Shchetkina — Blyumberg. At widespread or general P. shock, unconsciousness can be observed.

At a favorable current dshch lokokkovy P. and adequate treatment there occurs recovery. In some cases process is delimited with formation of abscess in a small basin.

Bilious P. can hard proceed, with typical symptoms though sometimes perhaps rather safe condition of patients, despite accumulation of a significant amount of bile in an abdominal cavity. The infected bile causes typical on symptomatology, very heavy

P. P. caused by hit in an abdominal cavity during operation of talc or starch from gloves of the surgeon is shown by diffusion P.'s symptoms 10 — 20 days later after operation. To differentiate it from P. caused by an infection, extremely difficult. On operation find an exudate, a thickening of a peritoneum, an union.

Complications of peritonitis: septic shock, sepsis, shock lung, pneumonia, hepatonephric insufficiency.

The diagnosis

At survey of a stomach reveal restriction of mobility of an abdominal wall at breath, sometimes asymmetry of a stomach.

At a palpation according to a zone of a parietal peritoneum of the front abdominal wall struck with inflammatory process define a protective muscle tension. It is most sharply expressed (a stomach as a board) at sudden perforation of hollow body. Protective tension can be slight or be absent at localization of process in a small basin, a cavity of an omentulum when the parietal peritoneum of a front abdominal wall is not struck. It can be absent also at very old men, the exhausted patients, at alcoholic intoxication and shock when visceromotor reflexes are oppressed or are absent. A characteristic sign of P. is Shchetkin's symptom — Blyumberg (see Shchetkin — Blyumberg a symptom).

At a palpation it is possible to reveal the inflammatory infiltrate or abscess at the delimited P. displaced or the increased body, an intussusceptum etc.

Also strengthening of pains at cough is characteristic and at the movements. The zone of percussion morbidity is most expressed in that area from where inflammatory process began (e.g., in the right ileal area at an acute appendicitis). Perkutorno can determine accumulation of liquid in a free abdominal cavity by reduction or disappearance of hepatic dullness or availability of gas under a diaphragm (see. Stomach ).

P.'s recognition is helped by the vulval and rectal researches allowing to reveal infiltrate (abscess) in a small basin, morbidity at palpation of the inflamed peritoneum, changes in appendages, a uterus, in a rectum (see. Gynecologic research , Rectal research ).

At a blood analysis reveal a leukocytosis, shift of a formula to the left, the accelerated ROE. In an end-stage in connection with sharp intoxication and migration of leukocytes in a zone of an inflammation oppression of a leukopoiesis and decrease in number of leukocytes is possible. Increase in N and hematocrit testifies to a pachemia and dehydration. The amount of protein in blood serum in this stage of P. usually normal, however a disproteinemia already begins to be shown by reduction of albumine and increase in globulins. At a number of patients in connection with an inflammation and activation of sympathoadrenal system moderate increase in a sugar content and amylase of blood can be observed. Koagulogramma (see) usually shows signs of hypercoagulation, sometimes a consumption coagulopathy with a hemorrhagic syndrome. At defective correction sharply expressed metabolic disturbances come to light (acid-base equilibrium, proteinaceous, etc.). At development of an oliguria the content of creatinine and urea in blood, as a rule, increases. In urine find protein, cylinders.

At P.'s localization and its source in the upper floor of an abdominal cavity at a survey rentgenol, a research of a thorax restriction of mobility of a diaphragm, high standing of its dome on the party of defeat, a discal atelectasis in basal segments of a lung, reactive pleurisy in a kostodiafragmalny sine comes to light. In a toxic stage of diffusion P. slabopyatnisty blackout on both sides, testimonial of existence of an intersticial fluid lungs (a so-called water or shock lung) is sometimes observed. The centers of bronchial pneumonia are found in a number of patients.

At a survey rentgenol, a research of an abdominal cavity it is possible to find the paretichny, inflated by gas loop of a gut, adjacent to the center of an inflammation — to a source of the Item. At diffusion P. in toxic and terminal stages the picture of paralytic intestinal impassability with multiple levels and Kloyber's bowls in loops of intestines comes to light (see Impassability of intestines). At a lateroskopiya (see. Polyposition research ) the inflated loops move, holding the highest position that can serve as confirmation of the dynamic nature of impassability. At abscess of an abdominal cavity (subhepatic, subphrenic) radiological it is possible to find accumulation of gas in his cavities, shift by a number of the located bodies.

In diagnostically hard cases of P. use of a laparoscopy is reasonable (see. Peritoneoskopiya ) and laparocentesis (see). Macro - and microscopic studying, bacterial, a research of liquid, aspirirovanny of an abdominal cavity, allow to reveal the availability in it of pus or blood confirming the diagnosis of the Item.

Leukocytes can be applied to definition of the forming delimited P. marked by radionuclide. For the same purposes use a termografiya (see) and a computer tomography (see the Tomography computer). Accumulation of liquid in an abdominal cavity can be found by means of an ultrasonic ekhografiya (see. Ultrasonic diagnosis).

Differential diagnosis diffusion P. in toxic and an end-stage when it is available all typical symptoms, it is usually easy. In an early (reactive) stage it is more difficult for item to distinguish. It is differentiated with acute pancreatitis, a thromboembolism of vessels of a mesentery, acute intestinal impassability, renal and hepatic gripes, intra belly bleeding, acute inflammatory diseases of lungs and by pleurae, some forms of a myocardial infarction, etc.

At acute pancreatitis (see), thromboembolisms of vessels of a mesentery, acute impassability of intestines (see), despite existence of many similar symptoms, most often are absent the so-called peritoneal symptoms, most characteristic of P. (a protective muscle tension, Shchetkin's symptom — Blyumberg). Temperature in an onset of the illness remains normal, there are no jumps in a picture of blood. At the same time are found a wedge, and rentgenol. signs characteristic of these diseases.

At renal and hepatic (bilious) gripes (see the Nephrolithiasis, Cholelithiasis) abdominal distention, a delay of a chair and gases, nausea, vomiting, some resistance of muscles of a front abdominal wall can be observed along with pains. However the nature of pains, their localization, irradiation and independence of a postural change of a body, lack of temperature reaction and characteristic peritoneal symptoms allow to differentiate gripes from P.

Krovotecheniye in an abdominal cavity at the broken extrauterine pregnancy, a rupture of a spleen, a liver has the nek-ry signs inherent to P. Odnako into the forefront symptoms of acute blood loss act: pallor, weakness, increase of pulse, decrease in a hematocrit and volume of the circulating blood.

Pleurisy (see) and pneumonia (see) at localization in basal segments in connection with irritation of a diaphragm can simulate a picture P., especially at children the Myocardial infarction (see) sometimes is followed by the abdominal symptoms similar to P. Odnako full a wedge, a research with use of an ECG, rentgenol, researches of lungs allow to differentiate these diseases.

Uraemia (see) at an acute renal failure can be followed by symptoms of the Item. Carrying out a hemodialysis in the absence of P. sharply reduces their expressiveness that helps recognition of P. which arose against the background of a renal failure.

Treatment

Treatment shall be carried out taking into account a wedge, forms and P.'s stage, character of the activator, prevalence of an inflammation, extent of disturbance of metabolic processes and functions of vitals. General principles of treatment of P.: perhaps early elimination of the center of an infection by means of an operative measure or its otgranicheniye by means of adequate drainage; suppression of an infection in an abdominal cavity and out of it by means of antibacterial drugs and washings (lavage); fight against paralytic intestinal impassability by aspiration of contents, a decompression went. - kish. a path, use of the medicamentous means stimulating it motor eva-kuatornuyu activity; correction of disturbances of water and electrolytic balance, protein metabolism and acid-base equilibrium by means of adequate infusional therapy; correction of a functional condition of kidneys, liver, heart and lungs.

Diffusion P.'s treatment shall be carried out in chamber of an intensive care or in the intensive care unit jointly by the surgeon, a reanimator and the therapist.

At secondary P. indications to operational elimination of the center of an infection are absolute. Operation shall be made in perhaps early terms. However at widespread and general purulent P. before operation it is necessary to carry out the intensive treatment directed to elimination of a pain syndrome and water and electrolytic disturbances during 2 — 3 hours. For this purpose intravenously enter Ringer's solutions, Darrou, laktasol, 5 — 10% solutions of glucose with insulin, then Polyglucinum, Haemodesum, albumine, plasma; at a hypopotassemia of 1 — 3% solution of potassium chloride; for correction of acidosis solution of hydrosodium carbonate (2 — 4,5%) or trisamine buffer solution. Along with it enter cardiac glycosides, at decrease in the ABP Prednisolonum. For control of a condition of the patient in the course of an intensive care it is necessary to enter a catheter into a subclavial or jugular vein (for infusion of liquids, sampling of blood, measurement of the central venous pressure) and into a bladder (for measurement of an hourly diuresis), and also the probe for aspiration of contents and a decompression of an upper part went to a stomach. - kish. a path (see. Sounding of a stomach , Catheterization of veins puncture , Catheterization of uric ways ).

At operations for P. the general anesthesia allowing to carry out quickly and fully an operative measure is shown.

An operative measure at P. cannot be standard owing to a variety of the reasons causing it. Purposes of operation: removal of exudate and the infected material; elimination or otgranicheniye of a source (center) of an infection; a decompression went. - kish. path; adequate drainage of an abdominal cavity.

The most convenient quick access is median laparotomy (see) which creates the best conditions for audit of an abdominal cavity and gives the chance to expand a wound up or down depending on localization of a source of the Item. At localization of a source of diffusion P. in the upper floor of an abdominal cavity (perforation of an ulcer, acute pancreatitis, acute cholecystitis, etc.) the upper median laparotomy is shown; at localization in the first floor (a worm-shaped shoot, a blind and sigmoid gut ovaries and uterine tubes) — the lower median laparotomy; at defeat of a cross and colonic and small bowel, and also at P. with the obscure source — an average and median laparotomy from a small section which is expanded up or down depending on the nature of the found changes. Slanting cuts in right hypochondrium and in the right ileal area are admissible if P. is local when audit of all abdominal cavity and removal of exudate from areas, remote from a section, is not required.

It is preferable to do a decompression of a small and large intestine via special probes, to-rye enter through a mouth (Abbott's probe — Miller, etc.) or a rectum (see. Intubation of intestines ). At failure the enterotomy and aspiration of contents of a small bowel is shown. Elimination of a source of P. is made by full or partial removal of sick body, sewing up of defect of a wall of hollow body or its removal on a front abdominal wall. At impossibility to execute it make drainage and a tamponade of area of a source of P. for the purpose of its otgranicheniye from other departments of an abdominal cavity.

At the end of operation the abdominal cavity is washed out by 5 — 15 l of isotonic solution of sodium chloride or Ringer's solution, Furacilin, a hlorgeksidin of a biglyukonat, etc. It is reasonable to add antibiotics of a broad spectrum of activity to the last portion of solution. Intraoperative washing of an abdominal cavity at widespread purulent P. allows to remove in the mechanical way the microorganisms which are contained in exudate and on surfaces of the inflamed peritoneum, toxicants (lizosomal-ny enzymes, decomposition products of cells, etc.), the slime, foreign bodys which got from the damaged bodies. After washing of an abdominal cavity operation is finished variously, depending on character of an exudate and prevalence of inflammatory process on an abdominal cavity. During removal of a source of an infection, in an early stage of development of P., serous or seroznognoyny character of exudate the abdominal cavity is sewn up tightly or enter one or several microirrigators for introduction of antibiotics fractionally (2 — 3 times a day) or constantly drop way (into 500 — 1000 ml of isotonic solution of sodium chloride a day). The last way, according to V. D. Fedorov, allows is longer and to evenly irrigate an abdominal cavity and to constantly maintain in it high concentration of an antibiotic. The entered liquid within a day is soaked up.

At the delimited P., an inflammation of retroperitoneal cellulose, uncertainty in tightness of a seam, at liver operations, bilious ways, a pancreas the abdominal cavity is drained 1 — 2 silicone drainages to dia. 8 — 10 mm for removal of exudate (see. Drainage ).

At widespread or general purulent P. the abdominal cavity is drained 4 — 5 silicone drainages for flowing or fractional washing. Drainages to dia. 8 — 10 mm enter through separate punctures of an abdominal wall in subcostal and ileal areas, having a tube under a liver, the left dome of a diaphragm or a cross colon, in side channels, carrying out one of drainages in duglasovo space. For removal of liquid it is reasonable to put one drainage on the course of a mesentery of a small bowel. By means of postoperative washing of an abdominal cavity — peritoneal dialysis, or peritoneal lavage (see. Peritoneal dialysis ) — delete inf. material (pus, microbes) and toxicants, and also suppress an infection the antibiotics or antiseptic agents entered into an abdominal cavity. Shortcomings of a method: delay of pasting of a peritoneum in the field of seams and an anastomosis; decrease in protective mechanisms owing to washing away of macrophages, protein, polysaccharides, etc.; danger of uncontrolled absorption of medicines and water from solutions and manifestation of their side toxic effect; rather bystry termination of functioning of flowing system owing to an otgranicheniye of drainages an epiploon, the pasted loops of a gut, clots of fibrin; danger of penetration of an infection on drainages. At a flowing way through drainages enter during a day from 10 to 25 l of isotonic or slightly hypertensive solution of sodium chloride together with antibiotics or antiseptic agents. At fractional washing enter 2 — 3 l of liquid into an abdominal cavity. In 1,5 — 3 hours all drainages open for outflow. This procedure repeats several times. The same amount of liquid is during the day used, as well as at flowing lavage. It is necessary to measure amount of the flowing liquid not to allow a delay it in an abdominal cavity.

Antibacterial therapy of P. develops from local (through irrigators, drainages) uses of antiseptic agents (hlorgeksidin, to a beagle-konat, a dioxidin, an iodpolyvinylfeast-rolidon) and intravenous and intramuscular administration of antibiotics. Considering character of microflora at P., it is reasonable to appoint antibiotics of an aminoglikozidny row (gentamycin, Monomycinum, Kanamycinum) in combination with the drugs suppressing growth of anaerobic activators — lincomycin, clindamycin, metronidazole. Effectively also use of cephalosporins in combination with aminoglycosides. The dosage of drugs depends on a functional condition of kidneys. At an oliguria it is necessary to reduce doses by 2 — 3 times to avoid nephrotoxic and ototoksichesky effect of aminoglycosides.

At introduction of antibiotics in the course of lavage it is necessary to consider a possibility of cumulation them in an organism and not to exceed a therapeutic dose, especially aminoglycosides. In 6 — 7 days make replacement of drugs.

In the first days after operation the combination of intraperitoneal introduction of antibiotics with intravenous is preferable. In 4 — 5 days when drainages or microirrigators cease to function effectively, antibiotics enter preferential intravenously, intramusculary or vnutriaortalno taking into account sensitivity of microflora.

An important element of treatment of P. is fight against paralytic impassability of intestines. It shall be directed to elimination of all pathogenetic factors. Elimination of a neuroreflex synpaticotonic factor is reached perinephric novocainic blockade (see), intraoperative administration of novocaine in a mesentery of a small bowel, administration of sympatholytic drugs.

Sympatholytic drugs enter in the absence of the mechanical nature of impassability, a stable hemodynamics, lack of deficit of volume of the circulating blood. Drug convenient in this respect is aminazine which, possessing the central and peripheral action, blocks and - retsep-Torahs of an auerbakhovsky texture. The drugs having parasympathomimetic properties (prozerin, ubretid, etc.), enter after emergence of an intestinal vermicular movement, i.e. after elimination of synpaticotonic blockade. For activation of a vermicular movement appoint a cleansing, hypertensive or siphon enema (see. Enemas ).

P. Kinnaert with soavt, considers this scheme of treatment of paralytic impassability of the most effective since the peristaltics of intestines appears in 20 min. after introduction of a sympatholytic, the passage of flatus is observed in 75 min. and a chair in 90 min.

And strengthening of a vermicular movement of intestines with success also electrostimulation by the special device or pulse and diadynamic currents of Bernard is applied to recovery. Usually electrostimulation (see) is combined with introduction of a prozerin and with enemas.

Elimination of the oppressing action of toxic and inflammatory factors a fuktion went on a motor evakuatornuyu. - kish. the path is reached by adequate disintoxication therapy (see) and and nfuzionny therapy (see), administration of inhibitors of kinin system (Trasylolum, Gordoxum, Contrykal), use of an artificial diuresis, catheterization chest channel (see) with the subsequent limfosorbtion (see).,

At paralytic impassability of intestines early recovery of its microcirculation is especially important that is promoted by a decompression went. - kish. a path by aspiration of contents from a stomach and intestines probes like Abbott — Miller. It is possible to carry out introduction of such probe to a small bowel also through the gastrostomy (the so-called chrezzheludochny enterostomy offered by Yu. M. Dederer) imposed during operation. Pressure decrease in a gleam of a gut promotes improvement of outflow of a venous blood and recovery of microcirculation. For elimination of an intravascular blood coagulation appoint heparin, antiagregant (aspirin, etc.).

The great value in P.'s treatment and paralytic impassability has completion of deficit of volume of the circulating blood and vodnoelektrolitny disturbances by administration of solutions of Ringer — Locke, Darrou, Polyglucinum, Haemodesum, plasma, albumine, blood. Disturbances of acid-base equilibrium eliminate with administration of solutions of hydrosodium carbonate, a laktasol (at acidosis) and 2 — 3% of solution salt to - you (at an alkalosis). At a gipokaliyemichesky alkalosis enter solution of potassium chloride under control of an ECG and the maintenance of potassium ions into blood.

Changes of acid-base equilibrium it is closely connected with process of a catabolism, dysfunction of lungs, kidneys. Therefore sick P. need to provide full parenteral and an enteroalimentation (2500 — 3500 kcal a day). The need of an organism for proteins is satisfied with administration of solution of amino acids, proteinaceous hydrolyzates, to-rye it is necessary to enter along with glucose and insulin. A part of a metabolic cost can be filled with introduction of 20% of solution of sorbitol or alcohol.

From the first day after operation enter oryzamins, B2, B6, B12, C, PP, A.

The total quantity of liquid entered in the course of P.'s treatment reaches a day 4 — 6 l and more.

Treat P.'s complications demanding surgical treatment suppuration of a wound, eventration (see), inflammatory infiltrates and abscesses, intestinal fistulas (see).

The delimited forms P. (abscesses) are a consequence of an otgranicheniye or incomplete treatment of the diffusion Item.

Operational treatment of abscesses is made taking into account their localization. After removal of pus the abscess cavity is drained or tamponed. For treatment of inflammatory infiltrates use physiotherapeutic methods, and also radiation therapy (on 30 — 50 I am glad, only 3 — 6 procedures in a total dose 90 — 300 I am glad).

At chyle P. (hiloperitoneum) make systematic emptying of an abdominal cavity from the chyle liquid which accumulated in it by a puncture of a front abdominal wall, and also correction of disturbances proteinaceous, fatty and other types of exchange usually considerably expressed at this disease.

At all stages of treatment of P. LFK which helps to activate the patient is necessary, to improve function of the respiratory device, to prevent development of pulmonary and tromboembolic episodes.

Forecast and Prevention

Forecast depends on character of the basic disease which caused the Item. The correct treatment of P. provides an absolute recovery in case of treatment of a basic disease. At a number of patients develops adhesive desease (see).

The lethality at P. depends on character of the basic disease which served as P.'s reason, prevalence of inflammatory process on a peritoneum, age of patients, character of the activator, time which passed from an onset of the illness before an operative measure. At P. of an appendicular origin the lethality fluctuates, according to B. A. Petrov, B. M. Khromov, within 3,6 — 5,0%. The total statistics of a lethality, according to the surgeons who are not including postoperative P. makes 19,3% (V. D. Fedorov, 1974), 6,8% (B. D. Savchuk, 1979) and 12,4% (G. V. Zaritsky, 1980). According to Arbogast et al. (R. Agyo-gast, 1979), from 717 patients with acute P. 8,2%, and from 130 people with postoperative P. — 39,2% died.

Prevention: carrying out among the population systematic a dignity. - a gleam. works — an explanation of need of the early address to doctors at acute diseases of abdominal organs that promotes the prevention of development of complications, W. h peritonitis.

Features of peritonitis at children

P. at children is observed often, proceeds hard and demands an operative measure. Except secondary P. (owing to an acute appendicitis, sepsis, perforation of hollow bodies, to impassability of intestines, etc.), allocate „cryptogenic“ (essential, idiopathic, primary) allocate to P. Otdelno the so-called contact P. resulting from infection of a peritoneum from the centers located out of an abdominal cavity, but contacting to it (e.g., a paranephritis).

P.'s features at children (speed of emergence of diffuse forms, deteriorations in the general state, difficulty of early diagnosis in younger age groups) are connected with early emergence of destructive processes, existence from the very beginning of considerable transudation and exudation in an abdominal cavity, with the wide message between poles and channels of the parietal peritoneum lowered by the delimiting ability because of the small content of fibrinogen in an exudate and bystry activation of a fibrinolysis, the small delimiting role regional limf, nodes and an underdevelopment of a big epiploon. These factors along with considerably the raised resorption from an abdominal cavity cause bystry progressing of intoxication.

The most important P. in a pathogeny at children, especially early age: the acquired so-called immunological paresis (it is frequent against the background of inborn), heavy respiratory frustration (restrictive and obstructive), a dizmineralization of water spaces, bystry approach patol, phases of «centralization» of blood circulation, oppression of function of bark of adrenal glands and some factors of coagulant system of blood, neurotoxicosis with a convulsive syndrome (sometimes and a hyperthermia). At premature the anergic course of a disease is quite often observed. The brightest features a wedge, pictures and diagnoses are noted at cryptogenic and postoperative P. at newborns.

At early children's age the general symptoms prevail: high temperature, heavy toxicosis, frequent vomiting, liquid chair, colicy pains and abdominal distention. Lack of speech contact, rough reaction of the child to survey, an active muscle tension of a stomach or, on the contrary, areactivity premature and newborn with a birth trauma force to be guided by equivalents of local «peritoneal symptoms» (better against the background of superficial medication sleep). More expressed shout (groan) of the child at a careful repeated palpation of a stomach in comparison with a palpation of obviously painless body parts testifies to morbidity, napr, hips. The passive muscle tension of a stomach remains during an exhalation. At areactivity special attention is paid on very moderate, but constant tension of edges of direct muscles of a stomach, on a positive symptom of Shchetkin — Blyumberg. Existence of morbidity and hypostasis of a wall of a rectum at a rectal research matters.

Newborns and children of early age can have a septic item owing to impassability of intestines and perforation as a result of disturbances of its blood circulation. As a rule, the heavy accompanying pathology — multiple malformations, «immunological paresis», pneumonia is noted. Septic P. develops often against the background of an ulcer and necrotic septic coloenteritis with perforation of ulcers and proceeds in two waves: against the background of the torpid course of sepsis toxicosis, signs of a dizbakterioz quite suddenly amplifies, there is paresis of a stomach and intestines. For early diagnosis it is important to pay attention to a torpidnost of a course of sepsis, paresis of intestines and thrombocytopenia. The item owing to perforation of intestines as a result pre-and intranatal heavy disturbances of a hemodynamics proceeds quite violently and quickly: usually against the background of a wedge, pictures of a severe birth trauma abdominal distention accrues, the general state quickly worsens. At X-ray inspection find free gas in an abdominal cavity.

The item owing to a neprokhbdimost of intestines can begin still vnutriutrobno (fetalis P.). Pathognomonic for newborns consider mekonialny P. which arises after 4 — the 5th month of an antenatal life because of an atresia, a stenosis, torsion, diverticulums of intestines. Predictively mekonialny P. owing to a mucoviscidosis is most adverse. On a wedge, he reminds a picture mechanical Ilheus (see Impassability of intestines), but usually without the expressed phase of strengthening of a vermicular movement. At a palpation in an abdominal cavity quite often define dense conglomerates, at rentgenol, a research — calcificats, gas and horizontal fluid levels. Mekonialny P. abakterialen, if age of the child no more than 60 — 72 hour.

Cryptogenic P. (staphylococcal, pneumococcal, streptococcal, mixed, etc.) arises in a sensibilized organism usually after an aggravation of a basic disease (nasopharynxes, a respiratory organs, went. - kish. path) and decrease in barrier function of infection atriums (vagina, intestinal wall). Flora of primary center, infection atriums and peritoneal exudate are identical. Cryptogenic P. meets at girls of 6 — 12 years more often. For a wedge, pictures «the symptom of the first hours» is characteristic: from the very beginning extreme expressiveness of the general and local symptomatology of P., hypostasis of lower parts of a front abdominal wall, mucous allocations from a vagina. The erased form of a disease extremely reminds acute appendicitis (see). Cryptogenic P.'s proof on operation or at a laparoscopy is lack of primary center in an abdominal cavity, mucous, sometimes a yellowish muddy exudate (at a giperergichesky form — hemorrhagic), girls have a hypostasis of fallopian pipes and adjournment of fibrin on their fimbrias.

Postoperative P. at children arises after a large intestine operations and after appendectomy more often. It occurs at children of the first years of life by 5 — 6 times more often than at children of advanced age. Distinguish an acute current and the torpid, especially complicating diagnosis P. at children of early age. Main criteria of diagnosis: lack of positive dynamics, progressing or emergence of paresis of a stomach and intestines against the background of treatment; locally, in addition to feeling of a raspiraniye, the long time keeps (or appears again) pain in a wound. From local peritoneal symptoms only Shchetkin's symptom — Blyumberg and sometimes moderate morbidity is reliable at a deep palpation. Differentiate postoperative P. with dysbacteriosis (see), mechanical Ilheus, abscesses of an abdominal cavity. The laparoscopy or a laparotomy is often necessary for timely diagnosis.

Most often the appendicular Item meets. Difficulties in diagnosis arise only at children of a younger age group and at unreasonable purpose of antiinflammatory and symptomatic therapy. In the first case it is connected with a prevalence of somatic signs, in the second — with a stertost of local symptoms against the background of the moderated, but gradually progressing intoxication. The diagnosis is made on the basis of a positive symptom of Shchetkin — Blyumberg, a protective muscle tension of an abdominal wall and morbidity at a palpation of a stomach, and also puffiness, infiltration and morbidity of a rectum at a rectal research.

Can lead such diseases as an inflammation of a diverticulum of Mekkel, a purulent mesadenitis, perforation of a gut, destructive pancreatitis, cholecystitis, an injury of abdominal organs, foreign bodys of digestive tract, infringement of hernias to P.'s development, including phrenic.

At P.'s treatment in the preoperative and postoperative period carry out an intensive care.

Criterion of efficiency and sufficiency of preoperative preparation — elimination of dekompensirovanny disturbances of a homeostasis. At early age special attention is paid to prevention and treatment of respiratory insufficiency, paresis of intestines and immunol, insufficiency. At justification of tactics of topical treatment by the most important assessment of disturbances of blood supply of intestines, existence or lack of mechanical impassability and abscesses is. The general principles of treatment of P. at children differ from those at adults a little: elimination of primary center, recovery of a passage on intestines, careful sanitation of an abdominal cavity. In the absence of the expressed paresis of intestines the deaf seam of an abdominal wall, antibiotics intravenously are shown (intramusculary); at the expressed paresis — a microirrigator for fractional instillation of antibiotics in an abdominal cavity, in addition antibiotics intravenously; at an enteroplegia apply peritoneal dialysis and an intubation of a small bowel; at interloopback abscesses — the dosed lavage of each of them against the background of the general antibioticotherapia. At peritoneal dialysis at children up to 2 — 3 years the osmotic and oncotic pressure of the dialyzing solution shall exceed the osmotic and oncotic pressure of a blood plasma for 8 — 10% due to addition of glucose and Polyglucinum. Intravenously enter antibiotics of a broad spectrum of activity, intraperitoneally and vnutrikishechno (at an intubation of intestines) — a little soaking up antibiotics (e.g., gentamycin).

For correction immunol, disturbances against the background of disintoxication therapy (forcing of a diuresis, peritoneal dialysis, infusional therapy, an enterosorbtion, hemosorption, zamenny hemotransfusion) apply hyperimmune serums and plasmas (6 — 10 ml! kg), gamma-globulin in a double dosage; after decrease in intoxication — immunostimulators in an age dosage — levamisole (decarice), Prodigiosanum, etc.

Features of peritonitis after Cesarean section

the Major factors promoting P.'s development after Cesarean section are presurgical contamination of a vagina or a cavity of the uterus, existence of a genital or extragenital infection in childbirth, long (more than 12 hours) an anhydrous interval. The essential role belongs to also hospital infection.

The item after Cesarean section on a wedge, a picture considerably differs from surgical and gynecologic P. (see. Pelviperitonitis ) in connection with features of a pathogeny. The main difference is that at P. after Cesarean section the first (reactive) phase of process is absent or is clinically so poorly expressed that it is almost possible to speak about two-phasic development of a disease — toxic and terminal phases. 3 forms a wedge, P.'s currents after Cesarean section are observed. The early form — for the 2nd days after operation arises a characteristic symptom complex of an acute abdomen (see) — meets seldom. Its diagnosis is simple since this form is, as a rule, observed after the operations made in obviously infected conditions when the subsequent development of P. is not unexpected. Most often the erased form meets. Symptoms of a disease are shown on 2 — the 3rd days after operation. Complaints can be absent completely. The general state remains satisfactory. Body temperature usually subfebrile or normal. Peritoneal symptoms are absent or are expressed very poorly. Rare intestinal noise and a sluggish peristaltics are listened. By the end of 2 days there is a morbidity of a uterus, in blood a leukocytosis, shift of a formula to the left, the accelerated ROE. Tachycardia, short wind, the progressing paresis кишечни^, not giving in to treatment accrues. Since 3 days the palpation of a uterus becomes impossible because of the accruing abdominal distention. Perkutorno in an abdominal cavity begins to be defined liquid. On 4 — the 6th days usually there is an insufficiency of seams of a uterus which is followed by plentiful purulent discharges from a vagina. At a wavy current a wedge, a picture it is similar with above described, but with an initiation of treatment process an impression of efficiency of the held events stops as if, made; actually P. progresses, and through a nek-swarm time symptoms of intoxication amplify again. In these cases quite often P.'s diagnosis is made late.

P.'s diagnosis after Cesarean section is difficult and shall be based on ability to compare and estimate set of separate characteristic symptoms taking into account a presurgical background of a disease. A basis of diagnosis is dynamic observation in combination with active maintaining the postoperative period. If for the 3rd days after operation against the background of adequate infusional and antibacterial therapy tachycardia, short wind and paresis of intestines remain or progress, it is necessary to suspect the Item.

P.'s treatment posets, Cesarean section shall be operational — an urgent hysterectomy with pipes (see. Hysterectomy ). The decompression of intestines by means of long enteric probes like Abbott — Miller or dvukhprosvetny probes with multiple side openings is obligatory. After a decompression enter 150 — 200 ml of 0,25% of solution of novocaine into a root of a mesentery of a small and large intestine, carry out washing of an abdominal cavity by Ringer's solution — Locke £ the number of 3 — 4 l in combination with antibiotics. Adequate drainage of an abdominal cavity is obligatory. The abdominal cavity is sewn up tightly, through counteropenings enter 4 — 6 drainages on both sides of an operational wound. In the postoperative period carry out the complex treatment consisting in massive antibacterial therapy, correction of metabolic disturbances, stimulation motor evakuatornoy functions of a digestive tract. The combined antibioticotherapia with change of antibiotics in the course of treatment is reasonable. Treatment by antibiotics should be begun with intra belly introduction through irrigators of Kanamycinum and intravenous administration of semi-synthetic penicillin, napr, ampicillin, and in 4 — 5 days to pass to treatment with tetracyclines or cephalosporins. The most reasonablly intraperitoneal introduction of antibiotics to 500 — 1000 ml of solution of Ringer — Locke or novocaine. Duration of an antibioticotherapia is not less than 10 — 12 days. Motor evakuatornoy functions of a digestive tract carry out correction of metabolic disturbances by means of infusional therapy. Total quantity of the entered liquid (blood substitutes, glucose, novocaine etc.) apprx. 4 l a day. Anti-staphylococcal plasma and anti-staphylococcal gamma-globulin are highly effective, to-rye enter within 5 — 7 days. Fight against paresis went. - kish. a path has no features in comparison with other forms of peritonitis.

P.'s prevention after Cesarean section consists in sanitation of a vagina, restriction of quantity of vaginal examonations in labor, the accounting of contraindications to operation. During the performance Cesarean section (see) preferably opening of a uterus cross section in the lower segment. Careful mending of a uterine wall, its good peritonization, failure from the accompanying operations (a myomectomy, appendectomy), washing of a uterus sterile isotonic solution, a careful toilet of an abdominal cavity are necessary. In cases of absolute necessity of abdominal delivery in obviously infected conditions (the long anhydrous interval, an endometritis in labor) Cesarean section should be carried out by an ekstraperitonealny method.



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M. I. Kuzin; I. V. Burkov (it is put. hir.), N. K. Permyakov (stalemate. An.), N. V. Strizhova (academician, gin.).

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