Acute diffuse peritonitis

Introduction to acute diffuse peritonitis Acute diffuse peritonitis is a serious disease commonly caused by bacterial infection, chemical stimulation or injury. Most are secondary peritonitis, original organ infections in the abdominal cavity, necrotic perforation, trauma and so on. The main clinical manifestations are abdominal pain, abdominal tenderness, abdominal muscle tension, as well as nausea, vomiting, fever, elevated white blood cells, severe blood pressure drop and systemic toxicity, if not treated promptly, can die of toxic shock. Some patients may have pelvic abscess, intestinal abscess, and underarm abscess, axillary abscess, and adhesive intestinal obstruction. Peritonitis is inflammation of the peritoneal and peritoneal membranes of the abdominal cavity, which can be caused by bacterial infection, chemical or physical damage. According to the cause can be divided into two categories: bacterial and non-bacterial; according to clinical experience can be divided into acute, subacute and chronic; according to the release mechanism can be divided into primary and secondary categories; according to the scope can be divided into diffuse Sex and limitations. Because acute suppurative peritonitis often involves the entire abdominal cavity, it is called acute diffuse peritonitis. basic knowledge The proportion of illness: the incidence rate is about 0.003% - 0.006% Susceptible people: no special people Mode of infection: non-infectious Complications: edema shock metabolic acidosis

Causes of acute diffuse peritonitis

Cause

Peritoneal organ perforation (25%):

Perforation of acute appendicitis is the most common, followed by perforation of gastroduodenal ulcer, and other gastric cancer, colon cancer perforation, gallbladder perforation, inflammatory bowel disease and perforation of typhoid ulcer.

Abdominal inflammation (25%):

Intestinal and intra-abdominal inflammation, such as appendicitis, diverticulitis, necrotic enteritis, Chron's disease, cholecystitis, pancreatitis, and purulent inflammation of the female reproductive organs.

Trauma (10%):

Abdominal blunt or penetrating injury causes rupture or perforation of the intra-abdominal organs. Abdominal contamination or anastomotic leakage after surgery.

Intestinal obstruction (20%):

Mechanical strangulated intestinal obstruction and blood transport intestinal obstruction, such as intestinal torsion, intussusception, closed intestinal obstruction, intestinal necrosis, mesenteric vascular embolization or thrombosis.

Iatrogenic injury (10%):

Such as colonoscopy, colonic perforation, liver biopsy or percutaneous transhepatic cholangiography of biliary fistula, intestinal perforation after small bowel injury.

Acute diffuse peritonitis prevention

Most of the surgical incisions in patients with peritonitis have a suture. If the incision is more serious, the peritoneum can be sutured with the absorbable gut. The nylon suture is placed in the whole layer of the incision. The saline gauze is blocked in the incision, the outer cover is disinfected and the gauze is changed every day. After 4 to 5 days, the secretions are reduced and there is healthy granulation tissue growth, and then the incision is sutured, which can often avoid serious infection of the incision.

After the operation, the semi-sitting position should be taken to make the pus flow to the pelvic cavity. Since the absorption capacity of the pelvic peritoneum is worse than that of the upper abdomen, the absorption of toxins can be reduced. Even if an abscess is formed, it can be drained through the rectum or the vagina.

Acute diffuse peritonitis complications Complications, edema, shock, metabolic acidosis

The intestine is soaked in the pus, which can cause intestinal paralysis, a large amount of air and liquid accumulate in the intestine, dilatation of the intestine, effusion in the intestine, a large amount of inflammatory exudate in the abdominal cavity, peritoneal and intestinal wall, and mesenteric edema. Water, electrolytes and protein are lost in the third gap, the amount of extracellular fluid drops sharply, and bacteria and toxins inhale blood, leading to low blood volume and toxic shock, causing endocrine, kidney, lung, heart, brain metabolism, etc. Changes, most commonly occurring are metabolic acidosis, acute renal failure and adult respiratory distress syndrome, which ultimately leads to irreversible shock and death.

Acute diffuse peritonitis symptoms Common symptoms Abdominal pain Plate-like abdominal congestion Intestinal perforation Shock Peritoneal irritation Intussusception edema Peritonitis Paralysis

Due to the different causes of the disease, peritonitis can occur suddenly or gradually. For example: peritonitis caused by acute perforation of gastroduodenal ulcer or rupture of hollow organ injury, often occurs suddenly, and acute stagnation inflammation, etc., firstly have symptoms of primary disease, and then gradually appear Peritonitis signs.

The main clinical manifestations of acute peritonitis, early symptoms of peritoneal irritation such as (abdominal pain, tenderness, abdominal muscle tension and rebound tenderness). Due to infection and toxin absorption in the later stage, it is mainly manifested as symptoms of systemic infection.

(1) Abdominal pain:

This is the main symptom of peritonitis. The degree of pain varies with the degree of inflammation. But they are generally very intense, unbearable, and persistent. Deep breathing, coughing, and pain can be exacerbated when you turn your body. Therefore, regardless of the change of position, the patient started from the original lesion, and the inflammation spread and spread throughout the abdomen, but the original lesion was more prominent.

(2) nausea and vomiting:

This is a common symptom that occurs early. At the beginning, reflex nausea and vomiting is caused by stimulation of the peritoneum, and the vomit is the stomach contents. In the later stage of paralytic ileus, the vomit turned into a yellow-green bile juice, or even a tan fecal-like intestinal contents. Frequent dehydration and electrolyte imbalance can occur due to frequent vomiting.

(3) Fever:

Sudden onset of peritonitis, the body temperature can be normal at the beginning, and then gradually increased. In elderly patients with debilitation, body temperature does not necessarily increase as the condition worsens. The pulse usually speeds up as the body temperature increases. If the pulse increases and the body temperature falls, it is mostly a sign of worsening the condition, and effective measures must be taken as soon as possible.

(4) Infection poisoning :

When peritonitis enters a serious stage, there are often high-grade fever, dry sweat, dry mouth, fast pulse, and shortness of breath and other systemic poisoning. In the later stage, due to the absorption of a large amount of toxins, the patient was indifferent expression, face sputum, eye socket depression, lips cyanosis, cold limbs, dry yellow tongue, dry skin, shortness of breath, weak pulse, soaring or falling body temperature, blood pressure drop shock, acidosis. If the condition continues to worsen, it will eventually die due to liver and kidney dysfunction and respiratory and circulatory failure.

(5) Abdominal signs:

It is manifested as abdominal weakening or disappearance, accompanied by significant abdominal distension. Aggravation of abdominal distension is often an important indicator of the development of the disease. The tenderness and rebound tenderness are the main signs of peritonitis, which are always present, usually throughout the abdomen and most prominent in the primary lesion. The degree of abdominal muscle tension varies depending on the cause and the general condition of the patient. Sudden and intense stimulation, the chemical stimulation of stomach acid and bile can cause strong abdominal muscle tension, and even "wooden-like" rigidity, clinically called "plate-like abdomen." In the elderly, young children, or extremely weak patients, abdominal muscle tension can be neglected slightly. When the total abdominal tenderness is severe and it is not easy to use the method of percussion to identify the primary lesion site, it is often found that the primary lesion has a significant slamming pain in the entire abdomen, which is helpful for localization diagnosis. Abdominal percussion can be drum sounded due to flatulence. When the gastrointestinal tract is perforated, it is often found that the dullness of the liver is reduced or disappeared due to the presence of a large amount of free gas in the peritoneal cavity. When the effusion in the peritoneal cavity is long, the mobile voiced sound can be extracted, and it can also be used to locate the necessary abdominal puncture. Auscultation often finds that the bowel sounds weaken or disappear. In the rectal examination, if the rectal anterior fossa is full and tender, it indicates the presence of a pelvic infection.

(6) Laboratory tests and X-ray examinations :

White blood cell counts are increased, but when the condition is severe or the body's response is low, the white blood cell count is not high, only the proportion of neutrophils is elevated or toxic particles appear. X-ray examination of the abdomen showed that the intestine was generally flatulent and had multiple signs of intestinal paralysis such as small gas and liquid surface. When the gastrointestinal perforation was observed, most of the free gas in the axillary area was present (should be in perspective). This is of great significance in diagnosis. A patient with a weak constitution, or a patient who is unable to stand for fluoroscopy due to shock, can also show the presence or absence of free gas in the lateral film.

Examination of acute diffuse peritonitis

X-ray plain film in the abdominal vertical position can observe the presence or absence of free gas under the armpit caused by gastrointestinal perforation, and the X-ray manifestations of strangulated intestinal obstruction, such as small-span tortuous intestines arranged in various forms during intestinal torsion Transposition of sputum, jejunum and ileum. In the intra-abdominal stenosis, the isolated and prominent intestines can be seen, and the position is not changed due to time, or there is a pseudo-tumor shadow. Peripheral fat line blur or disappear directly to suggest peritoneal inflammation.

Diagnostic abdominal puncture has a very important role. If you take a purulent liquid, even a drop of liquid can be diagnosed by observing a large number of white blood cells or pus cells under high magnification. If necessary, the needle can be punctured with a fine needle under different anesthesia in different parts of the abdominal cavity, and the pumped liquid can reflect the condition in the abdominal cavity.

Diagnosis and diagnosis of acute diffuse peritonitis

diagnosis

According to the medical history and the occurrence of peritoneal irritation, the diagnosis of secondary peritonitis is mostly difficult. However, in some patients, it is difficult to determine the cause and judge whether or not surgery is performed immediately. This requires close observation of the evolution of the disease and necessary examination.

X-ray plain film in the abdominal vertical position can observe the presence or absence of free gas under the armpit caused by gastrointestinal perforation, and the X-ray manifestations of strangulated intestinal obstruction, such as small-span tortuous intestines arranged in various forms during intestinal torsion Transposition of sputum, jejunum and ileum. In the intra-abdominal stenosis, the isolated and prominent intestines can be seen, and the position is not changed due to time, or there is a pseudo-tumor shadow. Peripheral fat line blur or disappear directly to suggest peritoneal inflammation.

Diagnostic abdominal puncture has a very important role. If you take a purulent liquid, even a drop of liquid can be diagnosed by observing a large number of white blood cells or pus cells under high magnification. If necessary, the needle can be punctured with a fine needle under different anesthesia in different parts of the abdominal cavity, and the pumped liquid can reflect the condition in the abdominal cavity.

If the abdominal pain is mainly in the middle and lower abdomen, a digital rectal examination should be performed. If the blood-stained substance refers to intussusception, intestinal torsion, inflammatory bowel disease or neoplastic lesions. The rectal uterus or rectal bladder sag has tenderness and fullness, suggesting inflammation or empyema. Married women can still puncture through the vagina.

If necessary, B-mode ultrasound and computed tomography scans can be used to understand whether there is an inflammatory change in the corresponding organs in the abdomen.

Differential diagnosis

The disease should be differentiated from the following diseases:

(1) Medical diseases: There are many medical diseases with clinical manifestations similar to peritonitis, which must be strictly differentiated to avoid wrong treatment. Pneumonia, pleurisy, pericarditis, coronary heart disease, etc. can cause reflex abdominal pain, and pain can be aggravated by respiratory activity. Therefore, shortness of breath, rapid pulse, and sometimes abdominal muscles in the upper abdomen are mistaken for peritonitis. However, in detail, the pain is checked, the chest is carefully examined, and the lack of obvious and affirmative tenderness and rebound pain in the abdomen can be judged. Acute gastroenteritis, dysentery, etc. also have acute abdominal pain, nausea, vomiting, high fever, abdominal tenderness, etc., easily mistaken for peritonitis. However, the history of improper diet, abdominal tenderness, no abdominal muscle tension, and auscultation of bowel sounds are all helpful in eliminating the presence of peritonitis. Others, such as acute pyelonephritis, diabetic ketotoxicity, uremia, etc. can also have different degrees of acute abdominal pain, nausea, vomiting and other symptoms, and no typical signs of peritonitis, as long as the analysis, should be able to identify.

(B) acute intestinal obstruction: most acute intestinal obstruction has obvious paroxysmal abdominal cramps, bowel sounds hyperthyroidism, abdominal distension, and no positive tenderness and abdominal muscle tension, easy to identify with peritonitis. However, if the obstruction is not relieved, the intestinal wall edema and stagnation, the bowel movements will change from hyperthyroidism to paralysis, and the clinical sounds may be weakened or disappeared, which may be confused with intestinal paralysis caused by peritonitis. In addition to careful analysis of symptoms and signs, and to distinguish by abdominal X-ray and close observation, if necessary, laparotomy should be performed to be clear.

(C) acute pancreatitis: edematous or hemorrhagic necrotizing pancreatitis have different symptoms and signs of peritoneal irritation, but not peritoneal infection; in the identification, serum or urinary amylase elevation is important, from abdominal puncture Determination of the amylase value in the liquid can sometimes confirm the diagnosis.

(4) intra-abdominal or retroperitoneal hemorrhage: various causes of intra-abdominal or retroperitoneal hemorrhage, can appear abdominal pain, abdominal distension, weakened bowel sounds and other clinical phenomena, but lack of tenderness, rebound tenderness, abdominal muscle tension and other signs . Abdominal X-ray, abdominal puncture and observation can often confirm the diagnosis.

(5) Others: Urinary calculi, retroperitoneal inflammation, etc., all have their own characteristics, as long as the analysis is fine, the diagnosis is not difficult.

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