Peritonitises (peritoneal syndrome) Flashcards
Peritonitis
General systemic disease resulting from inflammation of the peritoneum, which manifests by severely impaired homeostasis and metabolic processes with the development of multiple organ failure.
Etiologic factors of acute inflammation of the peritoneum:
А) Microbial peritonitis:
- bacterial contamination of the peritoneum with microbal associations (aerobic, anaerobic flora).
B) Toxic-chemical (nonbacterial) peritonitis:
- peritoneal irritation by aggressive agents (bile, gastric juice, urine, pancreatic juice, blood);
- accession of bacterial flora short time after the onset of abacterial peritonitis.
C) Special forms of peritonitis:
- candidious;
- parasitic;
- tuberculous;
- rheumatoid.
Risk factors of peritonitis
А) Complications of acute inflammatory diseases of the abdominal cavity and small pelvis (acute appendicitis, cholecystitis, pancreatitis, acute obstruction of the intestines) up to 40%.
B) Perforative peritonitis (perforated ulcer, perforation of the intestine) 50%.
C) Post-traumatic peritonitis (closed and open injuries of abdominal organs) up to 5%.
D) Postoperative peritonitis (occurrence of peritonitis after surgery on abdominal organs) up to 5%.
Character of the pathogenetic changes depending on the stage of peritonitis:
А) Reactive stage (until 24 hours since the onset of peritonitis):
- peritoneal irritation by aggressive agents and microbial factors;
- pain and inflammatory manifestations, expressed near focus of peritonitis;
- tension of protective mechanisms;
- toxic, volemic, homeostasis, metabolism and organ disorders in the early stages are not expressed.
B) Toxic stage (24-72 hours since the onset of peritonitis):
- inflammatory changes spread throughout the peritoneum;
- of intoxication increases and volemic disorder;
- intensification of the metabolism;
- growing of neuroregulatory and humoral disorders;
- developent of the functional and morphological disorders in the organs and systems.
C) Terminal stage (more than 72 hours since the onset of peritonitis):
- increasing of inflammatory and toxic effects on organs and systems;
- profound morphological changes in all organs and systems;
- deep depression of the vital functions (multiple organ failure).
Clinical signs of acute peritonitis depend on:
can be diverse, complex and dynamic. It depends on:
- the area of microbial contamination of the peritoneum;
- virulence of microorganisms;
- stage of the process;
- reactivity of the organism (gender, age of the patient, the availability and nature of comorbidity, the degree of compensation).
Clinical manifestations and diagnosis in the reactive stage of acute peritonitis
(the first 24 hours from the onset of the disease) are defined by:
- the severity of the manifestations of the underlying disease;
- involvement in the inflammatory process of the peritoneum;
- initial signs of intoxication;
- exertion of reactive mechanisms of the body.
a) Complaints:
- intense constant pain in the abdomen, more pronounced in the area of inflammation focus;
- increased pain when changing body position, coughing, movements;
- if the localization of inflammation is in the upper floor of the abdominal cavity pain radiates to the shoulder girdle, if the localization of inflammation is in the pelvis it presents with a false urge to defecate, dysuric symptoms, irradiation of the pain to the sacrum and perineum;
- nausea and repeated vomiting that does not bring relief;
- general weakness.
b) History of the disease relationship to any disease, injury, surgery.
c) Objective manifestation:
- moderate condition;
- pale skin;
- body temperature above 38 °C and tachycardia;
- shortness of breath, chest breathing;
- position in the bed is forced (on the back or on the affected side with those given to the abdomen hips);
- dry tongue;
- abdomen is symmetrical; the anterior abdominal wall in the area of inflammation lags behind in the act of breathing;
- palpation: abdominal straining and sharp pain in the area of focus of inflammation;
- strongly positive pathognomonic symptoms of the underlying disease (appendicitis, cholecystitis, pancreatitis, etc.);
- locally peritoneal signs;
- percussion: dullness may be determined in sloping areas of the abdomen;
- auscultation: decreased sonority of peristaltic sounds;
- rectal finger examination: overhanging and tenderness of the front wall of the rectum.
Clinical manifestations and diagnosis in the toxic stage of acute peritonitis
(24-72 hours from the onset of the disease) are defined by:
- clinic effacement (reduction of symptoms) of the underlying disease;
- involvement in the inflammatory process throughout the peritoneum;
- intoxication (due to the action of microbial toxin, autocatalytic enzyme, gene, organic amines, metabolic toxins, etc.);
- hypoxia (respiratory, circulatory, tissue);
- violation of coagulation properties of blood (hypercoagulable state);
- metabolic disorders;
- the dynamic obstruction of the intestines;
- inhibition of reactive forces of the body;
- multi-organ failure (of varying severity).
a) Complaints:
- intensive constant nonlocalized abdominal pain;
- nausea, repeated vomiting (often - intestinal contents), regurgitation of gastric contents;
- severe weakness, fever, chills;
- constipation and gas.
b) Medical history - increase in terms of the onset of acute disease (24 to 72 hours).
c) Objective manifestation:
- severe general condition of the patient;
- facial features are sharp (facies Hyppocratica), skin pale gray, dry;
- breathlessness, chest breathing;
- blood pressure less than 100 mm Hg, pulse speeded up - to over 100 bpm;
- tongue dry, cracked;
- swelling of abdomen; it’s not involved in breathing, moderately tense and painful all over;
- symptoms of the underlying disease do not manifest; peritoneal signs dominate.
- oligoanuria (in the presence of the catheter in the bladder!)
- percussion: in sloping areas of the abdominal cavity dullness;
- auscultation: peristaltic noise is absent;
- rectal finger examination: overhang, stiffness and tenderness of the anterior wall of the rectum.
Clinical manifestations and diagnosis in the terminal stage of acute peritonitis
(more than 72 hours from the onset) are defined by:
- deepening of pathogenetic processes that have evolved in the toxic stage;
- profound inhibition of the vital functions (the central nervous, cardiovascular, respiratory, excretory, neurohormonal systems).
a) Complaints:
difficult or impossible to assess because of the confusion and inadequate patient.
b) Medical history - the time from the acute onset of the disease from 3 to 5 days.
c) Objective manifestation:
- the patient’s condition is extremely severe or terminal;
- confused consciousness, delirium, and coma intoxication;
- skin pale gray, dry, acrocyanosis;
- facial features are sharp (facies Hyppocratica), sunken eyes, and dry sclera;
- blood pressure less than 60 mm Hg, heart rate greater than 120 bpm, arrhythmias, no radial pulse;
- frequent, shallow or pathological breathing;
- frequent vomiting of smelly intestinal contents, regurgitation;
- dry tongue, cracked;
- sprawled abdomen, slightly tense and painful, and then becomes soft and painless:
- mild or absent symptoms of peritoneal irritation;
- anuria;
- retention of stool and gas;
- percussion: dull sound throughout the abdomen;
- auscultation: peristaltic sound is absent, audible splashing in balloting.
Making of preliminary diagnosis of acute peritonitis
Based on clinical data of acute peritonitis
Preliminary diagnosis is made on the basis of the patient’s complaints, history of the disease and its objective manifestations, confirmed by physical methods of research.
To confirm or clarify the diagnosis laboratory methods are used, which are characterized by the severity of the patient, in reactive and toxic stages instrumental studies aimed at identifying the source of peritonitis are applied
Diagnostic program in patients with peritonitis
Formed on the basis of the preliminary diagnosis:
A) Laboratory tests:
a) complete blood count (leukocytosis with a shift to the left , white blood cells with toxic granulation);
b) urinalysis (presence of protein, erythrocytes, casts), diastase urine;
c) blood glucose;
d) biochemistry (electrolyte shifts, hypoproteinemia, dysproteinemia, hypercoagulation , etc.).
B) Additional imaging and instrumental methods of investigation:
a) survey abdominal radiography (for signs of mechanical or dynamical obstruction of the intestines and identify pleural effusion, mostly on the left);
b) ultrasound (to assess the condition of the pancreas and parapancreatic fat tissue, the presence of fluid in the abdominal cavity, the state of the gallbladder and extrahepatic bile ducts);
c) diagnostic laparoscopy (can be used to clarify the diagnosis and causes peritonitis)
Differential diagnosis (performed depending on the stage of the pathological process reactive, toxic or terminal stage of peritonitis):
A) Differential diagnosis in the reactive stage is conducted with a group of diseases with similar pathogenic syndromes - pain, inflammation, dyspepsia:
a) surgical acute inflammatory diseases of the abdominal cavity:
- acute destructive appendicitis;
- acute destructive cholecystitis ;
- acute necrotizing pancreatitis;
- acute obstruction of the intestines;
- perforation of a hollow organ;
b) acute urological pathology:
- acute pyelonephritis;
- urolithiasis;
c) acute gynecological pathology:
- torsion of an ovarian cyst and perforation;
- purulent salpingitis;
d) acute therapeutic pathology:
- sepsis;
- myocardial infarction;
- ulcerative colitis, toxic septic type.
B) Differential diagnosis in the toxic stage performed with mesentery thrombosis.
C) Differential diagnosis of terminal stage with comas of other genesis:
- hypoglycemic coma;
- hyperglycemic coma;
- uremic coma.
Clinic statistical classification of peritonitis
CD10 Diagnosis Code K65 Acute peritonitis
Layout of the clinical diagnosis: Acute {RX} {MX} peritonitis, TX {severity}
{in FX phase}
Process prevalence:
R1 local {(BX)} (the process involves one topographic zone)
(B1) limited (the process is bounded away from the free abdominal cavity)
(B2) unlimited (inflammation may progress)
R2 diffuse {(BX)} (the process involves several topographical zones)
(B1) diffusely distributed (there are areas of the abdominal cavity that are not
covered by inflammatory process, despite the absence of obstacles to its
spreading)
(B2) general (all involved in the process of peritoneal cover)
Morphological characteristics: M1 serous M2 serofibrinous M3 fibrinous M4 fibropurulent M5 purulent M6 haemorrhagic M7 putrid
Degree of severity:
T1 1st stage of severity (mild) (peritonitis without involvement of other organs)
T2 2nd stage of severity (moderate) (peritonitis with the failure of one of the organs lungs,
kidneys, liver)
T3 3rd stage of severity (severe) (peritonitis with the failure of 23 and more organs lungs, kidneys, liver)
Stage of the process:
F1 Reactive stage
(duration of 12-24 hours, with slight intoxication, pulse 100 bpm, unexpressed hyperthermia)
F2 toxic stage
(duration 2-3 days, severe intoxication, pulse 120 bpm, hyperthermia 38-39 °C)
F3 terminal stage
(more than 72 hours duration, severe intoxication, pulse 120 bpm, reduction of blood pressure, paralysis of intestine)
Therapeutic tactics in a patient with peritonitis depends on the stage of the pathological process (treatment is complex with the obligatory use of surgical methods):
A) Principles of treatment in a reactive stage of peritonitis:
- directed to treatment of the underlying disease, which must be diagnosed.
B) Principles of treatment in the toxic stage of peritonitis:
- time should not be wasted doing a lot of complex diagnostic procedures;
- at least enough to perform laboratory tests and plain film of the abdominal cavity;
- in obscure situations (especially with closed abdominal trauma or in postoperative period) laparoscopy should be used.
a) Preoperative phase:
- intensive infusion therapy for 2-3 hours (intensive therapy) in coordination and under the supervision of an anesthesiologist, bringing to parameters: ADsyst. = 90-100 mmHg, central venous pressure (CVP) = 60-80 mm Wg, the amount of urine 30-40 ml/hour;
- nasogastric intubation;
- adminstration of broadspectrum antibiotics in therapeutic doses, from the preoperative period;
- prophylactic anticoagulant drugs corresponding to the coagulation parameters and risk factors for thromboembolic complications (low-molecular weight heparins (LMWH) -fraxiparine, pentasan, unfractionated heparins - heparin).
b) Intraoperative stage:
- general anesthesia with mechanical lung ventilation;
- in unexplained peritonitis midline laparotomy (makes it possible to expand access up and down);
- removal of exudates;
- inspection of the abdominal organs and diagnosis of the cause of peritonitis (special thoroughness necessary when adhesive obstruction, open and closed injuries of the abdomen);
- the elimination of the causes of peritonitis;
- sanitation (wash) of the abdomen (to “clean water“);
- nasointestinal intubation and decompression of the small intestine;
c) The postoperative stage:
- treatment in the ICU to support and correction of functional state of organs and systems.
- correction volemic and homeostatic disorders;
- intensive anti-inflammatory therapy;
- conducting medical and surgical methods of detoxification;
- parenteral and enteral nutrition, enteral (after elimination of peritonitis);
- syndrome treatment of multiple organ failure;
- programmed relaparotomy or laparostomy indicated.
C) Principles of treatment in the terminal stage of peritonitis:
a) Preoperative phase:
- intensive infusion therapy for 2-3 hours (intensive therapy) in coordination and under the supervision of an anesthesiologist, bringing to parameters: ADsist . = 90-100 mmHg, CVP = 60-80 mm Wg, the amount of urine 30-40 ml/hour;
- nasogastric intubation;
- administration of broadspectrum antibiotics in therapeutic doses, from the preoperative
period;
- prophylactic anticoagulant drugs corresponding to the coagulogram indicators and risk factors for thromboembolic events (LMWH-fraxiparine, clexane, unfractionated heparins heparin).
b) Intraoperative stage:
- general anesthesia with mechanical lung ventilation;
- removal of exudates;
- inspection of the abdominal organs and diagnosis of the cause of peritonitis;
- if possible the elimination of the causes of peritonitis with the formation of decompression stoma;
- sanitation (wash) of the abdomen (to “clean water“);
- drainage of the abdominal cavity through 4-6 counterpuncture lavage or peritoneal dialysis.
c) The postoperative stage:
- treatment in the ICU to support and correction of functional state of organs and systems;
- syndrome treatment of multiple organ failure;
- correction of volemic and homeostatic disorders;
- intensive antiinflammatory therapy;
- conducting medical and surgical methods of detoxification;
- parenteral nutrition;
- programmed relaparotomy or laparostomy as indicated
Definition of perforated ulcer
Characterized by the formation of a perforation at the site of the ulcer, which connects the lumen of the stomach or intestine with a free abdominal cavity.
Causes of the perforative ulcer:
А) Reasons that contribute to the development of perforations:
- exacerbation of peptic ulcer disease;
- local autoimmune process.
B) The causes which lead to the development of perforations:
- poor blood circulation in the site of ulcer;
- destruction and necrosis of the organ’s wall.
