secondary suppurative peritonitis
Introduction
Introduction to secondary suppurative peritonitis Secondary purulent peritonitis (secondary purulent peritonitis) is often caused by acute inflammation of the abdominal organs, acute perforation, visceral rupture, surgical contamination and other factors. The bacteria causing peritonitis are the resident bacteria of the digestive tract, the most common being Escherichia coli, followed by Streptococcus faecalis, Enterococcus, Proteus, Pseudomonas aeruginosa and anaerobic bacteria. Staphylococcus is the main pathogen causing peritonitis caused by surgical contamination. In the early stage of peritonitis, peritoneal bacterial invasion or digestive juice stimulation, on the one hand mobilize the body's defense function, began to antagonize bacteria and their toxins; on the other hand, gastric juice, bile, ruptured blood of the gastrointestinal tract perforation And necrotic organ tissues play a supporting role in bacterial infection. basic knowledge The proportion of illness: 0.0013% Susceptible people: no special people Mode of infection: non-infectious Complications: hypokalemia, shock, intestinal obstruction, acute renal failure, adult respiratory distress syndrome, sepsis, abscess, bacteremia
Cause
The cause of secondary suppurative peritonitis
(1) Causes of the disease
Common causes of secondary peritonitis include: acute inflammation of the abdominal organs, such as acute appendicitis, acute cholecystitis, purulent inflammation or postpartum infection in women's reproductive organs, strangulated intestinal obstruction, intestinal necrosis caused by mesenteric vascular thrombosis, acute hemorrhagic Chemical peritonitis caused by necrotizing pancreatitis secondary infection, among which acute appendicitis is the most common, accounting for about 40%.
Acute perforation (45%):
On the basis of the original lesions, acute hollow organ perforation occurs, such as gastroduodenal ulcer, appendicitis, cholecystitis, typhoid fever, hemorrhagic necrotic enteritis, intestinal amebiasis, ulcerative colitis, Meckel's diverticulum And gastrointestinal tumor necrosis and perforation.
Visceral rupture (25%):
Abdominal blunt or penetrating trauma can cause gastrointestinal tract, biliary tract and bladder rupture. Gastric juice, bile or urine leakage is a chemical stimulus to the peritoneum, which can be followed by secondary infection; leakage of fecal fluid, contaminating the abdominal cavity, leading to serious Suppurative peritonitis.
Surgical contamination (23%):
Often caused by inadvertent operation, the original intra-abdominal infection spread, or intestinal, biliary, pancreatic or ureteral injury, content spillover, or postoperative intestinal fistula, anastomotic leakage, biliary pancreatic fistula and cholecystectomy Caused by accidental injury to the extrahepatic bile duct.
(two) pathogenesis
The bacteria causing peritonitis are the resident bacteria of the digestive tract, the most common being Escherichia coli, followed by Streptococcus faecalis, Enterococcus, Proteus, Pseudomonas aeruginosa and anaerobic bacteria, so many mixed infections, Staphylococcus is the main pathogen causing peritonitis caused by surgical contamination.
In the early stage of peritonitis, after the peritoneum is stimulated by bacteria or digestive juice, it mobilizes the body's defense function and antagonizes bacteria and its toxins. A large amount of serous exudate can dilute the endotoxin, which is phagocytic, neutral. Granulocytes and complement can produce bactericidal effects, while fibrin deposition in the exudate adheres to surrounding organs and omentum to prevent the spread of infection; on the other hand, gastric juice, bile, and parenchymal rupture of gastrointestinal perforation The blood and necrotic organ tissues play an auxiliary role in bacterial infection. As the inflammatory response increases, a large number of neutrophils die, tissue necrosis, bacterial and fibrin coagulation, and the exudate gradually becomes cloudy or pus Sex, the characteristics of pus and the type of bacteria, Escherichia coli and anaerobic fragile bacilli mixed infection, pus mostly yellow-green, thick; if there is a special odor of fecal sample, anaerobic infection feature.
Young and strong, strong disease resistance, such as weak pathogenic bacteria, lesions can be limited to become localized peritonitis; old and frail, serious lesions, more bacteria or gastrointestinal fluid into the abdominal cavity or treatment Improper, infection can rapidly spread in the case of low disease resistance, resulting in the formation of persistent diffuse peritonitis, the former tends to self-heal or form a localized abscess, can be removed by surgical drainage, antibiotics, etc., or through the body During the repair process, it is absorbed and replaced by fibrosis, which eventually causes adhesion between the wall peritoneum, intestinal fistula, and omentum, which may have the aftereffect of mechanical intestinal obstruction; the latter tends to deteriorate, and continues to produce a large amount of pus, and the intestine is immersed in In purulent exudate, it is congested and edema, and the peristalsis is reduced or even stopped, and paralytic intestinal obstruction is formed. The toxin produced by the bacteria is absorbed by the peritoneum to cause toxemia. The bacteria enters the blood circulation and produces sepsis. At this time, the peritoneum is severely congested and extensively edematous. A large amount of fluid is exuded, and a part of the peri-infiltration of the peritoneum includes the mesentery; a part of it permeates into the free abdominal cavity, and the amount thereof can reach 4 to 6 L per day, causing a large amount of water for the patient. Detoxification and protein loss, resulting in significant hypovolemia, peritonitis caused by fever, vomiting, intestinal paralysis, intestinal fluid, etc., more severe patient's hypovolemia, affecting normal blood circulation and respiratory gas exchange, become clinical Fast heart rate, low blood pressure, fast breathing, low blood oxygen partial pressure and acidosis, acute peritonitis due to a large amount of peritoneal exudate and endotoxemia in a short period of time, hypovolemia and visceral vasoconstriction cause intestinal ischemia and intestine Mucosal damage, reduced hepatic blood flow affects Kupffer cell function, leading to intestinal bacterial and endotoxin translocation, is the root and foundation of multiple organ system failure.
Prevention
Secondary suppurative peritonitis prevention
The best treatment is prevention. Since most of the acute diffuse peritonitis is secondary, if the primary lesion causing peritonitis can be treated correctly in time, the number of cases of acute peritonitis can be minimized. For example, in the early stage of acute appendicitis or acute cholecystitis, the lesion is removed, and the intestinal obstruction is removed early. If the gastrointestinal perforation is repaired as soon as possible, the chance of peritonitis can be greatly reduced. When performing gastrointestinal surgery, Efforts should be made to avoid spillage of the contents and to prevent leakage of the gastrointestinal suture to minimize or prevent postoperative peritonitis.
Complication
Secondary suppurative peritonitis complications Complications hypokalemia shock intestinal obstruction acute renal failure adult respiratory distress syndrome sepsis abscess bacteremia
Complications of acute peritonitis can be divided according to the time of its occurrence.
Early complications
Metabolic/multiple system changes, hypokalemia, shock, DIC, intestinal obstruction, acute renal failure, adult respiratory distress syndrome, pulmonary failure, sepsis.
2. Late complications
Abdominal abscess formation, (intrapelvic, subgingival space, mesenteric, etc.), fistula formation, anastomotic rupture, adhesion.
Antibiotic treatment can cover or delay the performance of local signs of abscess.
In the early stage of peritonitis, due to metabolic changes and leakage of fluid into the abdominal cavity, water and electrolyte disturbances may occur, and intestinal obstruction also increases the flow of liquid into the intestinal lumen. The above changes cause the intracellular potassium to enter the extracellular fluid in a large amount, and the sodium moves toward the extracellular fluid. Intracellular, hypokalemia, serum glucocorticoids, aldosterone and catecholamine levels are often elevated, elevated levels of catecholamines can cause peripheral vasoconstriction and decreased perfusion of vital organs, causing renal function, cardiac dysfunction, intestinal obstruction Progressive elevation of the diaphragm can interfere with ventilation and breathing exchange.
In peritonitis, aerobic bacteria and anaerobic bacteremia often occur, which can lead to shock, DIC, shock and MOSF by bacterial endotoxin. The early mortality rate is as high as 50% to 70%. .
The main complication of late peritonitis is abscess formation. The most common areas of abscess include underarm, perihepatic, mesentery, pelvis, etc., but in fact, abscess can form in any part of the abdominal cavity. Adhesion can also occur, often causing intestinal tube, circulation. Vascular, nerve compression and obstruction, causing corresponding clinical manifestations.
Symptom
Secondary suppurative peritonitis symptoms Common symptoms Abdominal pain Bloating Acute abdominal pain Painful blunt pain Cold war Peritoneal stimulation Blood pressure drop Mobility Voiced dry skin
Symptom
(1) abdominal pain, bloating: is the most important and most common symptoms, can be severe localized or diffuse abdominal pain, the location of abdominal pain and the cause and course of the primary disease, inflammation is limited or diffuse and the patient's Responsive, mostly sudden, persistent, deep breathing, coughing, increased pain when turning position, patients who prefer to flex position, refuse to move, localized bacterial peritonitis (such as uncomplicated acute appendicitis, cholecystitis, etc.) The pain is first confined to the inflammation site of the primary lesion, and the onset is slow, and it is painful or dull. As the lesion progresses, the inflammation spreads and spreads to the whole abdomen. The pain gradually increases and spreads from the lesion area to the whole abdomen. When peritonitis (such as peptic ulcer, gallbladder and other acute perforation), the contents of the gastrointestinal tract suddenly leak into the abdominal cavity, irritating the peritoneum, causing sudden onset of severe abdominal pain, in the treatment of steroids, spontaneous bacterial Peritonitis, the elderly, the extremely debilitated patients, the pain may be masked and become inconspicuous and absent, in the early stage of acute peritonitis, accompanied by paralytic ileus Or ascites, there may be different degrees of abdominal distension, with the increase of intestinal obstruction, abdominal distension will be more obvious, abdominal distension is an important indicator of exacerbation.
(2) nausea, vomiting: is the first common symptom, due to stimulation of the peritoneum, causing reflex nausea, vomiting, vomiting is mostly stomach contents, duration is different, when paralyzed intestinal obstruction occurs, vomit often Accompanied by yellow-green bile, even brown-yellow stool content, accompanied by stench.
(3) body temperature, pulse: in the early stage of acute peritonitis, patients often have collapse phenomenon, body temperature can be normal or low, gradually increase later, body temperature is often increased with breathing, pulse parallel growth, and can be accompanied by chills, this more For the signs of sepsis, the temperature of the elderly and frail patients may not rise, and the pulse speeds up more, such as the rapid increase in body temperature, which is one of the signs of worsening the condition.
(4) Others: When acute peritonitis occurs, there may be symptoms such as anorexia and constipation. As the disease progresses, there may be more sweat, dry mouth, sunken eyes, dry skin, less urine and other dehydration symptoms. Breathing is shallow and quick. The sputum is stimulated to restrict its movement, and may be accompanied by hiccups and shoulder pain. In addition, other clinical manifestations related to the cause may occur in the onset of acute peritonitis.
2. Signs
Patients are often forced to position, painful expression, gray complexion, pulse breakdown or unclear, blood pressure drop, obvious abdominal distension, abdominal breathing weakened or disappeared, abdominal tenderness, abdominal wall muscle tension and rebound tenderness are typical signs of peritonitis, abdomen Muscle tension, the degree varies with the cause and the patient's general condition, abdominal tenderness and rebound tenderness almost always exist, usually throughout the abdomen, often suggesting the presence of diffuse peritonitis, if localized peritonitis, abdominal tenderness, The rebound tenderness and abdominal muscle tension can be confined to one part of the abdomen, often the most obvious in the primary lesion. The mild snoring pain in the primary lesion is often characterized by its location, which helps to locate the diagnosis. In the late stage of peritonitis, it is severely toxic. In patients with blood, loose or obese abdominal wall, abdominal muscle rigidity is often weakened or lacking. Abdominal due to flatulence may cause drum sound during percussion. When the gastrointestinal tract is perforated, the liver dullness boundary shrinks or disappears. When the peritoneal fluid accumulates, movement may occur. Dull voice, in the early stage of acute peritonitis can hear the bowel sounds, with the development of the disease gradually weakened, the emergence of diffuse peritonitis or intestinal paralysis The vocalization disappears. The pelvic peritonitis is often accompanied by tenderness of the rectum and vagina. The rectal anterior fossa is full and tender, indicating that the pelvic cavity has been infected or forms a pelvic abscess. When the inflammation in the abdominal cavity is limited, an abscess or inflammatory mass can be formed. Unclear lumps.
The diagnosis of peritonitis often requires careful examination of the medical history, careful physical examination and relying on laboratory examinations, imaging examinations, etc. to make a comprehensive judgment.
Examine
Secondary suppurative peritonitis
1. The total number of white blood cells and neutrophils are obviously increased. In severe infection, neutrophils contain poisonous particles and the left side of the nucleus. The urine often increases in specific gravity and sometimes the urine ketone body is positive. When abnormal, protein and cast type may appear.
2. abdominal puncture or posterior iliac puncture
It is still recognized as one of the most valuable diagnostic methods for peritonitis. It can understand the appearance, odor, and cell count of smear, smear and bacterial culture, and determine the amylase content if necessary, which is of great help to the diagnosis.
3. Laboratory tests and other auxiliary inspections.
4. Abdominal X-ray examination: check for free gas, focus on the underarm area, or observe the shape of the intestines and liquid level. If there is free gas under the armpit or gas outside the gastrointestinal tract, it is often suggested that there is gastrointestinal perforation.
5.B-ultrasound examination: Abdominal abscess is shown as a hypoechoic area on the B-ultrasound. It can still be puncture and drainage through the positioning and guidance of B-ultrasound. When suffering from acute peritonitis, due to intestinal flatulence, it affects the ultrasound display. The diagnosis of intra-abdominal intestinal abscess is of little value.
6. Rectal examination or pelvic examination: pelvic peritonitis rectal examination or pelvic examination can be found in the rectum, uterus or bladder depression has obvious tenderness, and sometimes can detect bulging, induration or fluctuating, indicating inflammation or pus accumulation.
7. Laparoscopy: For patients with atypical clinical symptoms and undiagnosed peritonitis, laparoscopic examination can be used to assist diagnosis. Laparoscopy should not be used for those with emergency surgical exploration.
Diagnosis
Diagnosis and diagnosis of secondary suppurative peritonitis
Diagnostic criteria
History
By carefully asking about your medical history, you can get an idea of the source of the bacteria that cause peritonitis.
2. Have acute abdominal pain and peritoneal irritation
It is worth noting that in children because the abdominal muscles are not fully developed, the abdominal muscles of the elderly have shrunk, so abdominal muscle tension is not as significant as young adults; in some diseases, such as intestinal typhoid perforation or application of corticosteroids, the peritoneal irritation sign is reduced.
Differential diagnosis
Intraperitoneal disease
(1) acute gastroenteritis, toxic dysentery, intestinal typhoid, etc.: These diseases can have abdominal pain, nausea, vomiting, but mostly paroxysmal, the important point is that these diseases often have high fever before abdominal pain, abdominal examination full belly Although tender, but muscle tension is not obvious, abdominal puncture is negative.
(2) acute pancreatitis: elevated serum amylase is important, secondary acute peritonitis can sometimes have elevated serum amylase, but generally does not exceed 500U, far less than pancreatitis, liquid examination obtained by abdominal puncture has To identify the value, pancreatitis should be free of bacteria, but amylase is significantly increased.
(3) Primary peritonitis: sometimes difficult to identify, patients with primary peritonitis have severe liver and kidney disease, no abdominal lesions, puncture fluid examination and bacterial culture are helpful for diagnosis.
(4) retroperitoneal inflammation: peri-renal inflammation, peri-colonitis or retroperitoneal appendicitis, the tenderness and muscle tension of the front abdominal wall of these diseases are relatively light, often with lumbar muscle stimulation and obvious snoring pain in the lower back.
2. Extra-abdominal disease
(1) lobar pneumonia, pleurisy: the abdominal pain caused by it is the nature of nerve reflex, the chest has positive signs during physical examination, abdominal tenderness and abdominal muscle tension are not obvious, and the symptoms and signs are limited to one side, not exceeding the midline.
(2) angina pectoris and acute coronary embolism: can cause severe sub-surgical and upper abdominal pain, similar to acute cholecystitis or perforation of ulcer disease, depending on the nature of the pain, duration, accompanying symptoms supplemented with ECG and corresponding imaging examinations Identification.
(3) Spinal and spinal cord lesions: such as spinal tuberculosis, spinal cord spasm and other stimuli, compression of the spinal nerve causes abdominal pain, but no muscle tension or bowel sounds disappear, and lack of symptoms of acute systemic infection.
