Peritonitis involving the entire abdominal cavity

Introduction Peritonitis is an acute inflammatory response of the visceral and parietal peritoneum to bacterial, chemical, physical or foreign body damage. According to the cause, it can be divided into secondary suppurative peritonitis and primary peritonitis. According to the scope of involvement, it can be divided into two types: diffuse and localized peritonitis. Due to the patient's resistance, the degree of infection, and the application of treatments, the types can be transformed into each other. Timely identification of the cause, type and extent of the peritoneum, and active treatment measures to avoid serious complications and save the lives of patients.

Cause

The causes of secondary purulent peritonitis are:

1 peritoneal organ perforation. Perforation of acute appendicitis is the most common, followed by perforation of 12 groups of intestinal ulcers, and other gastric cancer, colon cancer perforation, gallbladder perforation, inflammatory bowel disease and typhoid ulcer perforation.

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

3 Abdominal blunt or penetrating injury caused by intra-abdominal organ rupture or perforation.

4 abdominal cavity contamination or anastomotic leakage after surgery.

5 mechanical strangulated intestinal obstruction and bloody intestinal obstruction, such as intestinal torsion, intussusception, closed intestinal obstruction, intestinal necrosis, mesenteric vascular embolization or thrombosis.

6 iatrogenic injury, such as colonic perforation, liver biopsy or percutaneous transhepatic cholangiography of bile fistula, abdominal intestine after abdominal puncture injury.

Endogenous cells in the gastrointestinal tract are often pathogenic bacteria of secondary peritonitis, the most common being Enterobacter, followed by Enterococcus, Streptococcus faecalis, Proteus, Pseudomonas aeruginosa and the like. Studies on anaerobic bacteria have shown that the number of aerobic and anaerobic bacteria in the ileum is roughly equal in the last few days, while the ratio of the two in the colon exceeds 3000:1. Therefore, cellular peritonitis is often a multi-bacterial mixed infection.

Primary peritonitis refers to the absence of obvious primary infections in the abdominal cavity. Peritonitis caused by pathogens through the blood, lymph or intestinal wall, and female reproductive system into the abdominal cavity is far less common than that of paroxysmal peritonitis. Often occurs in:

1 baby and child.

2 children with kidney disease syndrome.

3 patients with cirrhosis ascites.

4 patients with immunosuppression, such as kidney transplantation or blood disease patients treated with corticosteroids.

5 patients with systemic lupus erythematosus.

The main pathogens of childhood primary peritonitis are pneumococci and streptococci. May invade through the respiratory tract or the urinary tract, and spread through the bloodstream to the peritoneal cavity. In adults, it is mostly caused by endogenous bacteria in the intestines. There are many types of bacteria that are infected by the female genital tract.

an examination

Related inspection

Retroperitoneal laparoscopic laparoscopic puncture

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.

1. 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 whether there is X-ray manifestation of strangulated intestinal obstruction, such as small span which can be arranged in various forms when the intestine is twisted. Distorted intestinal fistula, 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.

2, 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.

3. If necessary, B-mode ultrasound and computed tomography can be used to understand whether there is any inflammatory change in the corresponding organs in the abdomen. After the peritoneum is stimulated by bacteria or digestive juice (gastric juice, intestinal fluid, bile, pancreatic juice), the peritoneal congestion, release of histamine and other osmotic factors by mast cells, so that the blood vessels are more attractive, oozing neutrophils, complement, A liquid that is conditioned into physicochemicals and proteins. When the bacteria bind to complement and opsonin, they are phagocytized by the phagocytic cells or enter the regional lymphatic vessels. Damage to mesothelial cells releases thromboplastin, which turns fibrinogen into cellulose. Cellulose deposits around the inflammatory condition, separating the lesion from the free abdominal cavity and impeding the absorption of bacteria and toxins. If the infection is light, the body is strong and the treatment is timely, the peritonitis can be localized, or even completely absorbed. In contrast, localized peritonitis can also develop into diffuse peritonitis. Due to the death of a large number of neutrophils, tissue necrosis, bacterial and fibrin coagulation, the exudate gradually became cloudy and purulent. E. coli infected pus is yellow-green, slightly thick, such as mixed infection with oxygen bacteria, pus smelly.

Differential diagnosis

1, secondary suppurative peritonitis:

The onset of the disease varies according to the primary disease. For example, the gastric perforation is characterized by persistent pain in the middle and upper abdomen and rapid spread to the whole abdomen. Acute appendicitis manifests as metastatic right lower abdominal pain with nausea, vomiting, and fever. The abdominal cavity or anastomotic leakage after surgery showed fever, abdominal pain, abdominal distension and intestinal paralysis. When inflammation involves the parietal membrane, peritoneal irritation occurs: abdominal pain, abdominal tenderness, rebound tenderness, and abdominal muscle tension. It is most obvious at the primary lesion and expands to the surrounding area. The extent is related to the cause, degree of disease, age and physical condition of the patient. For example, when the stomach is perforated, the abdominal muscles are plate-like and strong due to strong stimulation of stomach acid and bile. Abdominal breathing movement is weakened or even disappeared. If accompanied by a large amount of free gas in the abdominal cavity, the liver dullness circle shrinks or disappears. The bowel sounds weaken or disappear. Although the elderly and infirm have peritonitis, the signs may not be obvious, and it is easy to delay diagnosis.

After the visceral peritoneum is stimulated, it can cause nausea and vomiting. With intestinal paralysis, bloating and repeated vomiting may occur. Bacterial infection and absorption of toxins increase the patient's temperature, pulse, and white blood cell count, with an average of between 12,000 and 18,000. The proportion of neutrophils can be as high as 85 to 95%. Urine often increases in specific gravity due to concentration, and sometimes acetosterone is positive, and protein and cast type may occur.

2, in the late stage of acute diffuse peritonitis, the patient is extremely weak, the eyeball is sunken, the nose flaps, the lips are weak, often died of peripheral circulatory failure, renal function or lung failure.

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