primary peritonitis
Introduction
Introduction to primary peritonitis Primary peritonitis (Spontaneous bacterial peritonitis (SBP) refers to the acute bacterial infection of the peritoneum in the peritoneal cavity of the patient. It is more common in the decompensated period of cirrhosis caused by various causes, after hepatitis. Active cirrhosis and subacute severe or chronic severe hepatitis. basic knowledge The proportion of the disease: the probability of the population is 0.21% Susceptible people: no special people Mode of infection: non-infectious Complications: hepatic encephalopathy
Cause
Cause of primary peritonitis
Bacterial infection (30%):
The cause of primary peritonitis is mainly bacterial infection, so the cause is easy to find. The main pathogens are Gram-negative bacteria, and Escherichia coli, pneumococci, streptococcus, and Klebsiella pneumoniae are more common. A few are Staphylococcus aureus and anaerobic bacteria.
The route of transmission of bacteria:
1. Blood-borne infections: the majority, of which streptococcus and pneumococci may be derived from the blood-borne transmission of respiratory or urinary tract infections.
2. Ascending infection: For example, female genital inflammation can spread directly to the abdominal cavity through the fallopian tube.
3. Direct spread of infection in adjacent tissues or organs: When the lungs, pancreas or urinary tract infections, bacteria can spread through the visceral peritoneum to the peritoneal cavity.
4. Gut bacteria spread through the intestinal wall to the abdominal cavity.
Low immune status (20%):
The causes and mechanisms of SBP in patients with cirrhosis and ascites are as follows.
1. Liver dysfunction in patients with cirrhosis, weakened defense mechanism, making invasive bacteria prone to disease, manifested as:
(1) The function of the liver reticuloendothelial system is low and the phagocytic activity is reduced.
(2) Low immune status, dysregulation, decreased blood levels of complement, fibronectin and other opsonins, and decreased concentrations of IgG, IgM and complement in ascites.
(3) weakened abdominal defense mechanism: patients with cirrhosis and ascites have low protein content in ascites and less opsonization. A large amount of ascites also reduces the chance of contact between phagocytic cells and bacteria, and the ability to kill bacteria is reduced.
(4) The formation of ascites, the diaphragm muscle movement is limited, and the elimination ability is reduced.
2. Patients with cirrhosis due to portal hypertension, collateral circulation, portal shunt, blood bacteria can not go through the liver, not eliminated by the reticuloendothelial system and directly into the systemic circulation.
3. Patients with cirrhosis due to portal hypertension, intestinal mucosal congestion, edema caused by portal hypertension, intestinal mucosal barrier is destroyed, permeability increases, and bacteria in the small intestine overproduce and move up, causing bacteria easily from the intestine Mucosal infiltration into the abdominal cavity, or through the submucosal lymphatics into the peritoneal lymph nodes and blood circulation, this intestinal infection is currently considered to be the most important bacterial source of SBP.
Other factors (15%):
Such as cirrhosis patients with esophageal variceal hemorrhage, portal hypertensive gastropathy, use of gastroscope emergency examination, etc. have increased the chance of bacterial infection.
Primary peritonitis has a wide range of abdominal infections, which can affect the whole abdomen. The pus can be scattered between the intestines and the intestines. The intestinal wall is edematous and edgy. The disease is long. The upper part of the disease can be found on the intestinal wall. Staphylococcus aureus or large intestine. Infected with Escherichia coli, abdominal inflammation has a limited tendency, pus thick, yellow, no odor, hemolytic streptococcus infection in the intestines without cellulose formation, pus thin, no odor, pneumococcal infection It is characterized by the formation of cellulose between the intestines, and more, the pus is thick, yellowish green, leaving intestinal adhesion after healing.
Prevention
Primary peritonitis prevention
Because of the high incidence, mortality and recurrence rate, prevention is particularly important. Active treatment of underlying diseases and maintaining good liver function are important steps in the prevention of SBP. Various traumatic examinations and treatments should be avoided to reduce bacteremia. The occurrence of traumatic surgery must be performed to prevent the use of antibiotics. Ascites is an important condition for infection. The low protein concentration of ascites is conducive to the occurrence and recurrence of this disease. Therefore, reducing or eliminating ascites and increasing ascites protein concentration are important measures for prevention.
High-risk patients, such as insensitive to diuretics or total ascites protein <10g / L, should be used for preventive antibacterial treatment, antibiotic prevention aims to interfere with intestinal bacterial localization and metastasis, prevent bacteremia and ascites infection, preventive application of antibiotics Should have:
1. It can effectively deal with the infection of Gram-negative bacilli from the normal intestinal flora, and does not produce drug resistance during the treatment.
2. The effect on intestinal anaerobic flora is small, and the normal flora is maintained as much as possible to prevent intestinal pathogenic microorganisms from being implanted.
3. The drug has the lowest toxic effect.
4. Cost-effective, in the past used oral antibiotics (vancomycin, colistin, nystatin, neomycin, etc.) and compound synergistic sulfonamides, but these drugs have poor tolerance and resistance Sexual problems, it has recently been reported that quinolone antibiotics such as FPA, due to its good tolerance and selective removal of aerobic Gram-negative bacilli, do not damage normal intestinal anaerobic bacteria, and can significantly increase cirrhosis ascites Patients with ascites total protein and complement C3 and serum complement C3 concentration, increased ascites bactericidal ability, etc., have been widely used in clinical, but long-term use of FPA will also cause bacterial ecological disorders, it is believed that cirrhosis patients with ascites should not be digested for a long time Antibacterial treatment, for patients with high-risk SBP with severe disease and low resistance in chronic liver disease, oral antibiotics (such as FPA, ciprofloxacin, etc.) are important for preventing the occurrence of SBP, in order to prevent interference with the intestinal tract. The normal flora can be taken intermittently, such as taking 5 to 7 days, stopping for 3 to 5 days, and so on.
Complication
Primary peritonitis complications Complications, hepatic encephalopathy
Some patients may have worsening liver function, hepatic encephalopathy, and even death.
Symptom
Primary symptoms of peritonitis Common symptoms Forced supine abdominal distension Abdominal pain Abdominal tenderness Diarrhea Abdominal muscle tension Fiber membrane Wrap Peritoneal irritation Gut sound disappears Relaxation heat
The main symptoms are sudden acute abdominal pain and the site is uncertain. Because women come from the genitals due to bacteria, they often have lower abdominal pain and generally spread faster. Some can reach the whole abdomen, and there are always restrictions on the lower abdomen. The pain is generally acceptable. Often accompanied by gastrointestinal irritation, such as nausea, vomiting, but also intestinal paralysis, but the bowel sounds do not completely disappear. Examination can be found that there is an increase in body temperature, pulse rate, and the symptoms of poisoning are generally not very serious. Abdominal often have flatulence, abdominal muscle tension, but not plate-like, tenderness, rebound tenderness is often very significant, most of the percussion can be ascites. The number of white blood cells is elevated, and the percentage of neutrophils is almost increased.
Clinical features
The disease is characterized by fever, abdominal pain, peritoneal irritation and elevated white blood cells, but about half of the patients have clinical manifestations. Some patients with cirrhosis have a sudden increase in ascites in a short period of time, antidiabetic against diuretics, and hepatorenal syndrome. Hepatic encephalopathy and the like are early manifestations and should be noted.
1. There is often an upper respiratory tract infection before the onset of the disease, or occurs in kidney disease, scarlet fever, cirrhosis ascites and low immune function;
2. The main symptom is sudden onset of acute abdominal pain, the beginning of the site is not clear, and soon diffuse to the whole abdomen;
3. With nausea and vomiting, fever, pulse fast systemic symptoms;
4. bloating, total abdominal muscle tension, tenderness and rebound pain, bowel sounds weakened or disappeared.
2. Clinical classification
(1) According to the severity of the disease, it is divided into mild and severe type. The mild condition progresses slowly, the abdominal pain is mild, the body temperature is 37.5~38.5°C, there is no obvious poisoning performance, the abdominal muscles are mildly tense, mild abdominal distension, tenderness, and bowel sounds. Attenuated, white blood cells 12 × 109 ~ 20 × 109 / L, severe cases of onset acute, body temperature above 39 ° C, full abdominal bulging, obvious tenderness and rebound pain, white blood cells 20 × 109 ~ 60 × 109 / L, the body poisoning is obvious, can Lead to death.
(2) Another classification method, according to the pathological changes and clinical manifestations of primary peritonitis, is divided into five types: common type, shock type, hepatic encephalopathy type, refractory ascites type and asymptomatic type.
1 common type: mild perfusion of the peritoneum and intestinal wall, edema, no obvious pus, a small amount of pale yellow in the abdominal cavity, no odorous thin pus, mild abdominal pain, body temperature 37.5 ~ 38.5 ° C, physical examination of abdominal muscles mild Tension, tenderness is mostly confined to the lower abdomen or right lower abdomen, the bowel sounds are weakened, the white blood cell count is 10×10920×109/L, the disease progresses slowly, and there is no obvious poisoning performance, which is equivalent to mild type.
2 shock type: acute onset, body temperature above 39 ° C, severe abdominal pain, abdominal muscle tension, tenderness, extensive rebound tenderness, disappearance of bowel sounds, obvious symptoms of poisoning, most patients occur within a few hours to 1 day of abdominal pain or fever Infectious shock, and difficult to correct, can cause death.
3 hepatic encephalopathy type: more common in patients with advanced cirrhosis with primary peritonitis, this type of fever, abdominal pain is not very obvious, but deep jaundice, severe liver damage, high blood ammonia, early emergence of Shenzhi and other liver coma Symptoms, gradually entering a coma.
4 refractory ascites type: This type occurs in patients with decompensated cirrhosis, the original chronic ascites, diuretics can improve symptoms, combined with primary peritonitis, further impaired renal function, increased retention of sodium water, resulting in refractory ascites Formation, poor therapeutic effect, can not tolerate sodium and water, no diuretic effect, poor prognosis.
5 asymptomatic type: about 7%, clinical symptoms are not obvious, and more often diagnosed in routine abdominal experimental puncture.
In addition, atypical cases of primary peritonitis accounted for about 35.5%, only low fever and mild bloating, and no abdominal symptoms and signs.
Examine
Examination of primary peritonitis
Ascites examination
The ascites was exudative, the grass was yellow, and the appearance was turbid. Li Fan was positive, but the specific gravity was rarely <1.018. The specific gravity of ascites, protein and glucose were not meaningful for diagnosis. The positive rate of ascites culture was before antibiotics. 82.7%, 10% to 49% after antibiotics, >500×106/L for ascites, >50% or >250×106/L for neutrophils, with diagnostic significance, sensitivity 100%, specificity 96 %, in addition, ascites is acidic, pH (7.25 ± 0.06), lower than simple cirrhosis ascites, pH is negatively correlated with white blood cells and neutrophils.
2. Blood culture
The positive rate is about 40% to 60%.
3. Other laboratory inspections
(1) White blood cells>10×109/L, neutrophils are elevated, white blood cells of severe spleen hyperfunction can be normal or below normal, platelets and red blood cells are also lower than normal.
(2) Hepatic dysfunction: further decline on the basis of the original albumin, the white/ball ratio is inverted, and the severity depends on the severity of the original liver function and the severity of the abdominal infection.
(3) Alanine and aspartate aminotransferase increased, lactate dehydrogenase, alkaline phosphatase, glutamyl transpeptidase also increased, and those with biliary obstruction or cholestasis were higher.
(4) elevated bilirubin is seen in patients with biliary obstruction, cholecystitis, cholelithiasis, direct bilirubin increased significantly.
(5) Blood urea nitrogen, elevated creatinine is seen in patients with oliguria, suggesting renal function involvement or the possibility of hepatorenal syndrome.
(6) Most patients with blood ammonia can cause elevation after abdominal infection, suggesting that hepatic encephalopathy should be prevented.
(7) water, electrolyte disorders, some patients have low sodium, low potassium or metabolic acid, laboratory indicators of alkalosis.
(8) Patients with hepatic diabetes have elevated blood glucose or abnormal glucose tolerance.
(9) The positive tester indicates that the infection is heavier and the possibility of infection with Gram-negative bacteria is high.
(10) The alpha-fetoprotein can be positive and quantitative, but it is mostly transient, and it is low, suggesting that the liver cells are necrotic and regenerating.
B-ultrasound, CT, MRI and other imaging examinations showed the imaging characteristics of cirrhosis, abdominal inflammation caused by flatulence, intestinal paralysis X-ray abdominal fluoroscopy showed small intestine dilatation, and sometimes the colon was also flatulent.
Diagnosis
Diagnosis and diagnosis of primary peritonitis
Diagnostic criteria
The diagnosis of this disease is not difficult, patients with cirrhosis and ascites, such as fever, abdominal pain, abdominal tenderness or abdominal muscle tension; ascites in line with acute inflammation, white blood cells > 500 × 106 / L, neutrophils > 50% (or > 250 × 106/L) or with ascites culture positive can be diagnosed, in order to strive for early diagnosis, should pay attention to:
1. Unexplained or varying degrees of abdominal pain.
2. Progressive or refractory ascites.
3. Sudden shock.
4. Hepatic encephalopathy or short-term deepening of jaundice should be suspected and combined with primary peritonitis, non-cirrhosis combined with primary peritonitis should pay attention to symptoms of fever and abdominal pain.
Differential diagnosis
The diagnosis should be mainly differentiated from tuberculous peritonitis and secondary peritonitis, and it is reported that up to 50% can be misdiagnosed as secondary peritonitis.
1. Characteristics of tuberculous peritonitis
(1) The abdominal wall is soft or soft.
(2) Leukocytosis in ascites, mainly lymphocytes, more than 50%.
(3) Tuberculosis may be found throughout the body.
(4) There may be signs of tuberculosis poisoning such as low fever in the afternoon, flushing of cheeks, night sweats, and increased erythrocyte sedimentation rate.
(5) Anti-tuberculosis treatment is effective, and the effect of adding hormones is even more.
(6) Ascites culture or animal inoculation of tuberculosis can be positive.
2. Characteristics of secondary peritonitis
(1) There are primary lesions in the abdominal cavity, especially gastrointestinal perforation, perforation of the appendix, etc. The abdominal pain is mostly confined to the upper abdomen or the lower right abdomen, with localized tenderness, after the whole abdomen, total abdominal muscle tension or plate. Hard, broad and obvious rebound pain.
(2) Ascites total protein and lactate dehydrogenase increased significantly, sugar content decreased, if the acute ascites caused by acute pancreatitis is mostly reddish blood, ascites amylase increased, and higher than blood, urine amylase.
(3) Ascites is mostly mixed infection, and 78% to 88% of primary infections are single bacterial infections.
(4) If there is pneumoperitoneum, it is highly suggestive of secondary peritonitis.
(5) Acute inflammation is more pronounced in patients with fever and elevated white blood cells.
3. Other
If the rapidly increasing ascites or ascites is full blood, people should pay attention to the possibility of cancerous ascites. For liver cancer, special attention should be paid to the possibility of primary liver cancer rupture.
