Primary peritonitis in children

Introduction to primary peritonitis in children Primary peritonitis (primary peritonitis) includes spontaneous bacterial peritonitis (ascites infection, often associated with chronic liver disease or nephrotic syndrome) and peritonitis associated with Mycobacterium tuberculosis, pneumococcal and Neisseria infection (the latter is prone to occur) In pre-puberty girls, it refers to the absence of obvious primary infections in the abdominal cavity, the pathogens through the blood, lymph or intestinal wall, female reproductive system into the abdominal cavity caused by acute suppurative infection. Since the widespread use of antibiotics, the incidence of the disease has been significantly reduced, and due to the improvement of the diagnostic level, many cases can be treated promptly, and the prognosis has been greatly improved. basic knowledge The proportion of illness: the incidence rate is about 0.004%-0.008% Susceptible people: children Mode of infection: non-infectious Complications: dehydration, diarrhea, shock

Causes of primary peritonitis in children

(1) Causes of the disease

Most of the primary peritonitis is because the bacteria in other parts of the body pass through the blood circulation into the abdominal cavity, and a small number of children can also go up through the lymphatic system, the gastrointestinal tract and the female genitalia (the local pH and mucous membranes are suitable for bacterial growth in prepuberty). Infection into the abdominal cavity, kidney disease, liver disease, a large amount of ascites in the abdominal cavity, often due to its low immune function, lack of complement and peritoneal infection, the most common pathogens of this disease are group A streptococci, pneumonia, intestinal Cocci, Staphylococcus and Escherichia coli.

(two) pathogenesis

After the bacteria enter the abdominal cavity, it causes peritoneal congestion, edema and exudation. The exudate contains a large amount of neutrophils, necrotic tissue, bacteria and coagulated fibrin, which are generally turbid exudate or thin purulent liquid due to the amount of exudate. Large and fibrin content is less, less localized abscesses are formed, streptococci are sparse, and fibrin-like adhesions are rarely produced. Staphylococcus, Escherichia coli and pneumococcus cause thicker pus and more adhesions. After the infection is controlled, the pus is absorbed, and the fibrin glue in the peritoneal cavity is also absorbed within 1 week. Some of the children have serosal destruction or necrotic tissue in the abdomen, which will leave extensive and stubborn intestinal adhesions, causing adhesions. The potential factor of intestinal obstruction, due to exudate-stimulated intestinal wall edema, inhibition of intestinal peristalsis, intestinal swelling, paralysis; a large number of extracellular fluid exudation causes dehydration, electrolyte imbalance, severe circulating blood loss, leading to circulatory failure At the same time, a large number of bacteria and toxins are absorbed by the peritoneum, which can produce toxemia, sepsis or toxic shock.

Primary peritonitis prevention in children

Adults can use either norfloxacin or TMP-SMZ to prevent primary peritonitis, but it is not recommended for children with ascites to prevent this disease with antibiotics. Children under 2 years old and older children with nephrotic syndrome or chronic renal failure (and with ascites may Chronic liver disease) need to replant pneumococcal vaccine.

Pediatric primary peritonitis complications Complications dehydration diarrhea shock

Most of them have severe dehydration and poisoning. They often have diarrhea and frequent urination. In severe cases, toxic shock and multiple organ failure may occur.

Primary symptoms of primary peritonitis in children Common symptoms Abdominal tenderness, abdominal distension, mobility, dullness, abdominal muscle tension, intestinal paralysis, abdominal pain, slow response, high fever, pale abdominal wall, venous anger

Typical primary peritonitis has a rapid onset, with high fever as the initial main symptom, followed by vomiting, abdominal pain and bloating.

1. Symptoms of poisoning are serious: the symptoms of systemic poisoning are severe, pale, irritated or wilting, and the response to the outside world is slow. The examination reveals that the sick child is confused, the body temperature can be as high as 40 ° C, the pulse is fast and weak, and the baby's body temperature can be normal. Only abdominal distension, bowel sounds disappeared as an important sign, children with severe dehydration and poisoning symptoms, but no secondary peritonitis is obvious, advanced cases are generally poor, semi-conscious, with proverbs, face, breathing Difficulties, herpes on the lips, dry skin, severe dehydration, but in the early treatment with antibiotics, the symptoms are mild, generally better, nephrotic syndrome complicated by peritonitis, more common in school-age children, the general condition is more moderate, the symptoms of poisoning Also lighter.

2. Digestive symptoms: abdominal pain is often more intense, throughout the abdomen, often the lower abdomen is heavy, vomiting frequently, spit out food residue and bile, occasionally diarrhea at the beginning, and later due to abdominal distension and intestinal paralysis, more constipation or not exhaust Some cases have diarrhea or frequent urination due to irritation of the intestinal wall or pelvic cavity, and sometimes even mucus and blood.

3. Signs: abdominal distension, no intestinal type, tenderness and muscle tension in the whole abdomen, but the abdominal muscle tension in infants is often not obvious, abdominal tenderness, rebound tenderness and abdominal muscle tension are not as obvious as secondary peritonitis, percussion Most of them can be drum sounds and have mobile dullness. Most of the ascites have a peritoneal effusion sign, that is, tremor conduction sign. The early bowel sounds can be normal after auscultation, and the bowel sounds are weakened or disappeared. Nephrotic syndrome is accompanied by peritonitis. Abdominal pain with fever, abdominal wall and scrotal edema aggravated, liver disease complicated with peritonitis can be seen abdominal wall venous engorgement, and common umbilical lower abdominal wall redness, tenderness, often suspected female genital tract infection, abdominal pain and abdominal signs below the abdomen most significant, Rectal examination, tenderness in the rectal bladder depression or rectal uterus depression.

Examination of primary peritonitis in children

1. Blood routine: peripheral blood leukocytes are much higher than general peritonitis, up to (20 ~ 40) × 10 ⁹ / L (20,000 to 40,000 / mm9), neutrophils can be increased to more than 90%.

2. Abdominal puncture fluid: puncture ascites turbidity, can extract thin pus, microscopic examination of a lot of pus, smear by Gram stain, often can find dicocci or cocci; ascites culture positive, if necessary, gynecological examination and transvaginal Qianlong puncture and pus, should be used for B-ultrasound and X-ray examination, X-ray abdominal plain film can be seen in intestinal paralysis (colon simultaneous flatulence) and most scattered low-tension liquid level, while seeing ascites phenomenon, pay attention to the presence or absence of free gas, if necessary Do other tests such as CT to confirm the diagnosis.

Diagnosis and diagnosis of primary peritonitis in children

diagnosis

Children with severe abdominal pain, vomiting, accompanied by high fever or change of consciousness, rapid appearance of total abdominal tenderness and muscle tension and bowel sounds disappear, should consider primary peritonitis, for the diagnosis can be considered for abdominal puncture, such as pumping out thin pus, painted Gram staining can be confirmed by finding a bacillus or cocci, and if the diagnosis is still difficult, laparoscopic or exploratory laparotomy.

Differential diagnosis

1. Secondary peritonitis: the symptoms of primary peritonitis, signs similar to secondary peritonitis, laboratory results are also the same, but only non-surgical treatment is different from secondary peritonitis, so should pay attention to identification, The main points of identification of primary peritonitis and secondary peritonitis are as follows:

(1) Primary peritonitis is mainly seen in cirrhotic ascites, nephrotic syndrome and other immune dysfunction, especially in girls under 10 years of age, while secondary peritonitis mostly has no such limitations.

(2) Primary peritonitis occurs in patients with cirrhosis and ascites. The "peritonitis triad" in abdominal signs is often not obvious. The incidence of primary peritonitis occurs in infants and young children. "Peritonitis triple The levy is also less than secondary peritonitis.

(3) There is no primary infection in the abdominal cavity is the key to distinguish between primary peritonitis and secondary peritonitis. X-ray examination found that underarm free gas is evidence of secondary peritonitis.

(4) abdominal puncture, ascites or peritoneal exudate for bacterial smear and culture examination, primary peritonitis is mostly a single bacterial infection and secondary peritonitis is almost a mixed bacterial infection, such as perforation perforation peritonitis, which is The most important disease in differential diagnosis, the disease has no sudden onset of primary peritonitis, the changes in body temperature, pulse, and consciousness are relatively mild, and the number of vomiting is relatively small. Abdominal pain and abdominal muscle tension in appendicitis are significant in the right lower quadrant. Peripheral peritonitis begins with extensive bloating, muscle tension and tenderness, and appendicitis has less leukocytosis than primary peritonitis.

2. Acute appendicitis complicated with peritonitis: the course of the disease is slow, the symptoms of poisoning appear in patients with advanced disease, abdominal tenderness, muscle tension is most prominent in the right lower quadrant, and white blood cells are mostly (15 ~ 20) × 10 ^{9 /} L (15,000 ~ 20,000 / mm9) .

3. Acute necrotizing enterocolitis: rapid onset, toxic shock can also occur in the early stage, however, most of the stool is washed bloody bloody stool, accompanied by odor, abdominal X-ray photographs have special signs, such as intestinal gap widening , portal vein gas and so on.

4. Pneumonia: early pneumonia in children, when the chest symptoms are not obvious, such as high fever, abdominal pain, vomiting, abdominal distension and muscle tension, etc., similar to the phenomenon of primary peritonitis, should be carefully observed, as the disease progresses, the child may have breathing Shortness, nose flapping, chest X-ray can be clearly diagnosed.

5. Neonatal sepsis or umbilical infection: caused by peritonitis, clinical manifestations of sudden vomiting, bloating, constipation.

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