secondary peritonitis
Introduction
Introduction to secondary peritonitis Secondary peritonitis (inflammation of the peritoneal organs, perforation, trauma, blood supply disorders, and iatrogenic trauma) caused by acute suppurative inflammation of the peritoneum, is a serious peritoneal infection, such as not early diagnosis and correct Treatment, the mortality rate is extremely high, and the perioperative period of surgery is generally secondary peritonitis. basic knowledge The proportion of illness: 0.004%-0.007% (secondary to biliary system diseases) Susceptible people: no special people Mode of infection: non-infectious Complications: anemia, edema, dehydration, electrolyte imbalance, shock, septic shock, multiple system organ failure
Cause
Cause of secondary peritonitis
(1) Causes of the disease
Cause of disease
Secondary peritonitis is caused by acute lesions of the abdominal organs. Common causes are:
(1) Acute infection: Acute infection of the abdominal organs is the most common cause of secondary suppurative peritonitis.
1 infection of the digestive tract and digestive gland: such as acute appendicitis, Meckel diverticulitis, colonic diverticulitis, necrotic enteritis, acute Crohn's disease, acute cholecystitis, acute pancreatitis, liver abscess, etc.
2 female genital ascending infection: such as gonococcal salpingitis, postpartum infection, induced abortion, acute salpingitis.
3 baby umbilical cord infection.
4 empyema can also cause peritonitis.
(2) Acute perforation of the digestive tract: When the digestive tract is perforated, the digestive juice and blood enter the abdominal cavity, and stimulate the secondary suppurative infection of the peritoneum. Among them, the acute appendicitis with perforation is the most common, followed by the stomach, duodenal ulcer, acute perforation, aphid Intestinal perforation, gangrenous cholecystitis, perforation of the small intestine and colonic diverticulum are rare, and perforation of gastric cancer and colon cancer can also cause secondary peritonitis.
(3) strangulated intestinal obstruction: such as intestinal torsion, closed intestinal obstruction, etc., intestinal mucosa due to increased permeability, bacteria in the intestinal tract through the intestinal wall to the abdominal cavity, causing infection.
(4) vascular occlusive disease: such as mesenteric vascular embolism, ischemic colitis, spleen infarction, etc., a large amount of exudate produced during ischemia, can stimulate inflammatory changes in the peritoneum.
(5) intra-abdominal hemorrhage: spontaneous spleen rupture, rupture of spleen aneurysm, rupture of liver cancer, rupture of metastatic malignant tumors (such as seminoma), rupture of ectopic pregnancy, rupture of ovarian follicles, etc.
(6) Trauma: Trauma caused by blunt instruments or sharps can cause damage to the organs in the peritoneal cavity. Cavity organs such as the stomach, small intestine, colon and bladder can cause bacterial peritonitis soon after they are worn. After rupture, urine stimulation causes chemical peritonitis, which is followed by bacterial infection, and substantial organ rupture, such as liver and spleen rupture. Although the blood stimulates the peritoneum slightly, once the infection can also cause fatal peritonitis.
(7) iatrogenicity: such as the overflow of intestinal contents during the operation, especially the overflow of the contents of the colon caused by peritoneal cavity contamination; the gastrointestinal tract anastomosis is not tight enough or the anastomotic line leaks; the foreign body remains in the abdominal cavity; Intestinal fistula, biliary fistula, pancreatic leakage, ureteral leakage caused by bile duct, pancreatic duct and ureter; recent intraperitoneal oozing or bleeding after operation.
2. Pathogens
The bacteria causing secondary peritonitis are common bacteria in the human intestines and skin surface. This is the bacteriological feature of peritoneal infection. In addition, secondary peritonitis is a mixed infection of aerobic and anaerobic bacteria. More than 58%.
Escherichia coli is the most common aerobic bacteria in infected bacteria, in addition to Klebsiella, Proteus, Streptococcus faecalis, Aeromonas aeruginosa, Pseudomonas aeruginosa, etc. Anaerobic bacteria are more See, because aerobic bacteria ingest oxygen from the environment, reduce the redox potential, so that anaerobic bacteria can grow and reproduce under anoxic environment, anaerobic bacteria can release enzymes, growth factors and host reaction inhibition Factors such as augmentation of aerobic bacteria, aerobic bacteria can provide a large amount of vitamin K required for anaerobic bacteria reproduction, the synergy between the two greatly increased virulence and pathogenicity, such as Streptococcus faecalis, Bacteroides fragilis, etc. The pathogenicity is not strong, but in the case of mixed infection, there is often a synergistic effect between each other, resulting in enhanced toxicity.
(two) pathogenesis
The peritoneum is extremely sensitive to various stimuli. After the bacteria or gastrointestinal contents enter the abdominal cavity, the body immediately responds. The degree of inflammatory reaction is related to the intensity of the stimuli. For example, the pH of the gastric juice is <3.O, which is extremely irritating to the peritoneum. Strong, acute perforation of gastric ulcer can immediately occur chemical peritonitis; some components of bile salts have strong stimulation of subperitoneal microvasculature. When biliary peritonitis occurs, there will be more exudate in the abdominal cavity, and it is easy to be complicated with anaerobic Infection of the peritoneal mesothelial cells contains plasminogen activator. When the organ or blood vessel ruptures, the peritoneal blood is not easy to coagulate. Although it is weak to the peritoneum, hemoglobin can interfere with the body's immune response and affect the bacteria. Cleared, it is easy to secondary infection.
In acute peritonitis, peritoneal congestion, edema, loss of luster, followed by a large amount of clear serous exudate to dilute the toxins in the peritoneal cavity; and the emergence of a large number of macrophages and neutrophils, as well as biologically active substances and cytokines, such as Tumor necrosis factor- (TNF-), interleukin-1 (IL-1), interleukin-6 (IL-6) and elastase were elevated in blood and peritoneal exudates; fibrinogen in exudate was The peritoneal mesothelial cells are deposited as fibrin by the released thromboplastin.
As the white blood cells continue to die, the peritoneal and visceral serosal mesothelial cells are damaged and detached, fibrin deposition and coagulation, and the exudate gradually becomes cloudy and becomes a pus.
The pathological changes of peritonitis depend on: the nature of the source of infection, the species, the quantity and virulence; the defensive ability of the whole body and the peritoneum; the time and effectiveness of the initial treatment, the development of acute peritonitis, depending on the patient's ability to resist infection, the primary The outcome of the lesion and the severity of the bacterial infection can be developed into diffuse suppurative peritonitis, which can also be localized by intestinal and omental wrapping and cellulose adhesion, or gradually absorbed and self-healing, or the formation of abscesses, diffuse Peritonitis combined with paralytic ileus, in addition to the serosal membrane of the intestine itself, that is, the visceral peritoneum also occurs congestion and edema affecting its peristaltic function, inhibition of splanchnic nerve reflex, water and electricity balance disorder, especially low potassium and digestive tract hormone The secretion disorders are related to the occurrence of paralytic ileus, extensive intestinal tube stagnation, accumulation of digestive juice, aggravation of the loss of body fluids, due to a large amount of exudation in the abdominal cavity, a large amount of fluid in the intestinal lumen leads to a sharp decrease in extracellular fluid, resulting in low formation Blood volume shock and metabolic acidosis, bloating, diaphragmatic elevation, difficulty in lung gas exchange, and more serious acidosis, due to blood volume Reduce shock and renal function is also impaired, throughout the process, such as adrenal endocrine system, we are also actively involved in the reaction, if not properly treated, the condition will worsen and can cause deaths.
Prevention
Secondary peritonitis prevention
The disease is caused by intra-abdominal lesions, the most common is acute perforation of appendicitis, followed by perforation of gastric duodenal ulcer, perforation of acute cholecystitis, acute hemorrhagic necrotizing pancreatitis, intestinal necrosis caused by intestinal obstruction; Abdominal trauma, postoperative digestive tract anastomotic leakage and female genital purulent inflammation can also cause this disease. Therefore, the key to preventing this disease is to correctly treat the primary source of peritonitis. The incidence of the disease is reduced to a minimum. When the peritonitis occurs in an unexplained cause and source, do not abuse the painkiller to prevent the condition from being covered. Stop eating, go to a qualified hospital for treatment, and if the peritonitis is seriously diagnosed, it is active. With adequate preparation, early surgery should be pursued in order to properly treat the primary lesions, and the peritoneal exudate can be cleared and drained.
Complication
Secondary peritonitis complications Complications anemia edema dehydration electrolyte disorder shock septic shock multisystem organ failure
Anemia
The peritoneum is severely congested, extensive edema and exudation of large amounts of fluid, causing dehydration and electrolyte imbalance, and plasma protein reduction aggravates anemia.
Shock
Wide mesenteric area, strong absorption, large absorption of bacterial toxins, can cause hypovolemic shock and septic shock, patients with weak pulse, lower blood pressure, irritability or apathy, cold sweat, eyeball depression, cold hands and feet, rapid breathing , shallower, body temperature does not rise and so on.
3. Multiple organ failure
Bacteria and their products (endotoxin) stimulate the patient's cellular defense mechanism and activate many cytokines such as tumor necrosis factor- (TNF-), interleukin-1 (IL-1), IL-6, etc. These cytokines have damage. The role of organs, in addition to bacterial factors, these toxic media are not eliminated, and the terminal medium NO will block the tricarboxylic acid cycle and cause hypoxia and suffocation, leading to multiple organ failure and death.
Symptom
Secondary symptoms of peritonitis Common symptoms Acute abdominal pain, abdominal pain, nausea, bowel sounds, weak abdominal muscles, intestines, intussusception, pale, sorrow, liver, dullness, narrowing or disappearing
Secondary peritonitis is the continuation and development of the primary disease, so the onset is different, the clinical manifestations are different, the duration of the disease varies, such as acute appendicitis, the development of cellulitis inflammatory appendicitis or gangrenous appendicitis combined with perforation, the course of disease needs 24h, so the early manifestations of peritonitis mainly in the right lower abdomen; ulcer disease complicated by perforation suddenly, gastric acid is very irritating to the peritoneum, so peritonitis develops rapidly, first above the abdomen, and then spread to the whole abdomen; acute intestinal obstruction The type of obstruction is different and the performance is different. The intestinal torsion is severely ischemic due to the intestinal wall. Peritonitis can occur after a few hours. However, the simple intestinal intestine does not relieve for several days, and the symptoms of peritonitis appear. The incidence of acute cholecystitis is more urgent, but 1~ After 2 days, the peritoneum was secondary to inflammatory changes.
Although the clinical symptoms of the primary disease may continue to exist, such as secondary peritonitis, there is a more consistent clinical manifestations.
Clinical symptoms
(1) Abdominal pain: Abdominal pain is the most common symptom of secondary peritonitis, and its characteristics are:
1 sudden onset, severe pain, persistent: once secondary peritonitis occurs, abdominal pain becomes persistent, because the peritoneum is dominated by somatic nerves, abdominal pain is more severe, but due to different causes, the degree of abdominal pain is also important. The abdominal pain caused by chemical peritonitis is the most severe, and the abdominal pain caused by abdominal bleeding is the lightest.
2 The initial site is consistent with the lesion of the primary disease, and it is rapidly diffused, but the abdominal pain is most severe in the primary lesion: when the peritonitis is secondary to celiac disease, the abdominal pain is aggravated, and the range can be limited to one place or diffuse to the whole abdomen, even if the secondary is diffuse. Peritonitis, the pain is also started from the original lesion, although spread to the whole abdomen, the abdominal pain is still the most severe in the original lesion.
3 coughing, turning over can be exacerbated, abdominal pain is aggravated during deep breathing or activity, so patients do not dare to take a deep breath or turn over.
In some cases, the performance of abdominal pain caused by peritonitis can be affected by some factors, such as acute perforation of ulcer disease, chemical peritonitis at the beginning due to acidic gastric juice overflow, abdominal pain is extremely severe, but when the gastric juice overflows, residual The gastric juice is reduced, or the perforation is closed, no more gastric juice overflows, the overflowed gastric juice is diluted by the exudate, the abdominal pain can be temporarily relieved, and the infection is combined after a few hours, and the abdominal pain is increased again, such as strangulated intestinal obstruction, due to ischemia Sexual pain is also extremely intense, and it is also persistent, often masking abdominal pain caused by peritonitis. Old and debilitated patients, seriously ill, physically or weakly, and postoperative patients, due to poor response, abdominal pain can be atypical.
(2) nausea, vomiting: beginning to be reflective, relatively mild, and later tend to be frequent due to infection poisoning or secondary paralytic ileus, such as peritonitis secondary to intra-abdominal infection, it may have nausea, Symptoms such as vomiting are more serious at this time. After acute peritonitis, due to weakened bowel movements, patients have no deflation or defecation, pelvic peritonitis or rectum is stimulated by exudate or pus, and patients may have a sense of falling and care. Or can only discharge a small amount of mucus, and then still feel light.
(3) body temperature, pulse: its change is related to the severity of inflammation, begins to normal, after the body temperature gradually rises, the pulse gradually accelerates, if the original lesion is inflammatory, such as appendicitis, the body temperature has increased before the occurrence of peritonitis, peritonitis occurs. After the increase, the body temperature of the elderly and frail patients may not increase, the pulse speeds up more, such as the rapid increase in body temperature, which is one of the signs of worsening the condition.
(4) symptoms of infection poisoning: patients may have high fever, pulse rate, rapid breathing, sweating, dry mouth, further development of the disease, may appear pale, weak, eye socket depression, dry skin, cold limbs, shortness of breath, lips Bun, thick tongue thick, weak pulse, sudden rise or fall in body temperature, decreased blood pressure, ambiguity or unclear, indicating severe water shortage, metabolic acidosis and shock.
2. Signs
(1) Forced position: Secondary peritonitis is severe acute abdomen. The patient's performance is acute and often has convulsions. In order to avoid the increase of abdominal pain, the slumber does not dare to move, and he likes to flex the lower limbs.
(2) Abdominal signs: obvious abdominal distension, abdominal breathing weakened or disappeared, abdominal distension is an important sign of deterioration of the condition, abdominal tenderness, abdominal muscle tension and rebound syndrome are the signs of peritonitis, especially the primary lesion The most obvious part, abdominal distension, abdominal muscle tension, the degree varies with the cause and the patient's general condition. The acute perforation of ulcer disease is strongly stimulated by the peritoneum, and the reflexive abdominal muscles are straight and "wooden-like"; Old people or extremely weak patients with abdominal muscle tension is not obvious, easy to be ignored; thin patients can show depression in the abdomen, but intestinal obstruction, especially low intestinal obstruction caused by peritonitis, abdominal swelling, abdominal tenderness.
During abdominal percussion, the flatulence of the stomach is drum sound. When the stomach and duodenum are perforated, a large amount of gas in the intestine moves to the underarm, which makes the dullness of the liver shrink or disappear. When there is more fluid in the peritoneal cavity, the mobile dullness can be seen. The bowel sounds are weakened, and the bowel sounds may disappear completely during intestinal paralysis.
(3) digital rectal examination: the rectal anterior fossa is full of tenderness, indicating that the pelvic cavity has been infected or formed a pelvic abscess, female patients can still determine the location of the primary lesion and the presence or absence of gynecological conditions according to the pain of the cervix.
Examine
Secondary peritonitis
Blood test
White blood cell counts generally increase, the wider the range of inflammation, the more severe the infection, the more obvious the increase in white blood cell count.
Serum amylase: examination can help diagnose pancreatitis, and some should be done with serum lipase and urine amylase.
2. Abdominal fluoroscopy (or plain film) The following image performance is common:
(1) acute peritonitis: plain film can show: 1 free gas abdomen sign, stomach, duodenal perforation is common to the underarms with free gas, but ileum, free gas after colon perforation is rare; 2 peritoneal thickening sign; 3 Abdominal effusion sign; 4 reflex intestinal tract levy, usually shows mild expansion of the intestine and multiple small fluid planes; 5 intestinal wall thickening and adhesion signs (by fibrin attached to the intestinal wall); The flank fat line is widened and the density is increased.
If there is intestinal torsion, it can be seen that a small span of a variety of forms of tortuous intestinal fistula, jejunum and ileum transposition; intra-abdominal fistula can be seen isolated, prominent inflated intestinal fistula, no change in position due to time, or pseudo-tumor Shaped shadows, etc.
(2) Localized peritonitis: Although the whole abdomen has certain changes, the advantage is manifested in a certain limitation (the latter is often the limitation of total peritonitis). In the plain film, due to the omental displacement and the presence of inflammatory masses Therefore, in a certain area, the density is relatively higher than other parts; the limitation of the abdominal fat line is thickened, the density is increased; the localized intestinal deposition is limited.
3.CT scan
It is easier to observe and more accurate than X-ray film. In addition to the common image showing similar performance to X-ray film, acute peritonitis caused by different causes may also show certain specific imaging features, such as from gallbladder. Stones, inflammation, perforation, the peritoneal effusion is mainly distributed in the right hepatic space, the right hepatic space and the right colonic sulcus. Gallstones can be found in the gallbladder or the aforementioned areas, generally no pneumoperitoneum; The resulting peritonitis often has reticular effusion, gas accumulation signs (Figure 3); acute appendicitis perforation caused by right lower quadrant localized peritonitis, can show the appendix thick swelling, with fecal stone or combined position outward, adjacent Adipose tissue is infiltrated by inflammation and the density is increased. Even small bubbles sign can be seen in the inflammation area. Therefore, CT examination is helpful for the diagnosis of intra-abdominal organ disease, and it is helpful to evaluate the amount of peritoneal fluid.
4.B Ultra
Guided abdominal puncture or peritoneal lavage can help diagnose.
5. Rectal examination and posterior iliac puncture
It was found that the anterior wall of the rectum was full and tender, suggesting that the pelvic cavity had been infected or formed a pelvic abscess. A married female patient could have a vaginal examination or a posterior iliac puncture.
6. Laparoscopic exploration
Laparoscopic exploration can reach the entire abdominal cavity, and the liver, gallbladder, stomach, duodenum, colon, appendix, uterus and attachments, bladder, especially for acute appendicitis, abscess around the appendix, pelvic inflammatory disease can be clearly observed under the TV. The diagnostic accuracy rate is higher.
Diagnosis
Diagnosis and diagnosis of secondary peritonitis
Diagnostic criteria
1. According to the history of abdominal pain, combined with typical signs, white blood cell count, abdominal fluoroscopy (or radiography), the diagnosis of secondary peritonitis is generally not difficult, but in the early stage of the disease (4 ~ 6h) need to be dynamically observed, in the diagnosis of acute The cause of peritonitis in the process of secondary peritonitis is an important part of the diagnosis. Most patients with secondary peritonitis have a detailed and detailed medical history, and careful physical examination can be diagnosed.
2. Abdominal puncture assisted diagnosis: For the history of the disease, the signs are not typical, the patient complains that the diagnosis is difficult, the diagnosis of abdominal puncture has a very important role, puncture the side of the lower abdomen percussion dullness, according to the puncture The color, turbidity, odor, smear microscopy, biochemical examination, bacterial culture, etc. of the obtained liquid are used to determine the cause. 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 abdominal cavity more. The situation inside.
3. Rectal examination to assist diagnosis: If the abdominal pain is mainly in the lower abdomen, a digital rectal examination should be performed. If the blood-stained substance refers to intussusception, intestinal torsion, inflammatory bowel disease or neoplastic lesion, rectal uterus or The rectal bladder lacuna is tender and full, suggesting inflammation or empyema.
4. Vaginal posterior iliac puncture assisted examination: married women can go through the vagina after the puncture puncture pus, in addition, B-ultrasound and CT can be used to understand the corresponding organs in the abdomen with or without inflammatory changes.
Differential diagnosis
The following conditions need to be identified in the diagnosis of secondary peritonitis.
Medical disease
Some systemic diseases of internal medicine, such as uremia, diabetes crisis, acute leukemia, collagen disease, and some nervous system diseases such as spinal tuberculosis crisis, sometimes acute abdominal pain, should be noted, some medical acute abdomen such as abdominal type Purpura, due to extensive hemorrhage in the serosal surface of the intestine, severe cases of a small amount of bloody exudation, as well as acute mesenteric lymphadenitis may also have inflammatory exudation, in fact there is acute peritonitis, but no surgical indications, not The scope of surgical treatment should be comprehensively considered in combination with medical history, clinical manifestations and other auxiliary examinations. In addition, there are some internal medical intestinal diseases such as intestinal typhoid, intestinal tuberculosis, ulcerative colitis, non-specific enteritis, etc. Some of them also There is a history of taking corticosteroids, which can cause perforation complication. However, many of these patients suffer from chronic illness and bed weakness, and may have systemic symptoms and irregular abdominal pain before perforation. Once perforation occurs, the patient's response is poor. There is no sudden symptoms, it is very difficult to identify whether or not perforation occurs. The development of the disease should be closely observed, paying special attention to the intestines. Whether dynamic sound disappeared, and can help abdominal puncture to confirm the diagnosis.
2. Acute intestinal obstruction
Most patients with acute intestinal obstruction have obvious paroxysmal abdominal cramps, abdominal distension, bowel sounds hyperthyroidism, and no positive tenderness and muscle tension, but intestinal obstruction can further develop into intestinal necrosis, clinical manifestations of abdominal muscle tension and other peritonitis signs .
3. Acute pancreatitis
Mild acute pancreatitis (MAP) rarely has symptoms of peritoneal irritation. In case of severe pancreatitis (SAP), it can be distinguished according to whether the abdominal puncture fluid is bloody, whether amylase is increased, and CT score can be distinguished, but severe pancreatitis Can develop into peritonitis.
4. Retroperitoneal hematoma or infection
Spinal or pelvic fractures, renal trauma, etc. may be complicated by retroperitoneal hematoma, retroperitoneal infection such as peri-renal infection, retroperitoneal appendicitis, suppurative lymphadenitis and secondary infection of hematoma can produce abdominal pain, peritoneal irritation and intestinal deposition, X The flat film can show the shadow of the psoas muscle, and there are meaningful images such as extraintestinal gas around the kidney. CT is more helpful for diagnosis. It is worth noting that some patients with trauma have confirmed retroperitoneal hematoma, how to exclude the abdominal cavity. Acute peritonitis caused by internal organ injury often has certain difficulties, and should be closely observed, if necessary, abdominal puncture or even laparotomy.
5. Primary peritonitis
Although it is also acute peritonitis, it is often based on conservative treatment and should be identified.
