Pediatric secondary peritonitis
Introduction
Introduction to secondary peritonitis in children Secondary peritonitis refers to the acute inflammation of the peritoneum caused by perforation of the intraperitoneal organs, damage, rupture of the blood, blood circulation disorder, necrosis or surgical contamination. It is the most common acute peritonitis in the clinic and may be associated with many congenital and acquired gastrointestinal diseases, including the most common cause of inflammation, ischemia or perforation secondary peritonitis. Health search is in infants and older children. Appendicitis; neonatal is necrotizing enterocolitis; in patients undergoing peritoneal dialysis, an average of 1 or 2 peritonitis occurs in 1 year. basic knowledge The proportion of illness: 0.025% Susceptible people: children Mode of infection: non-infectious Complications: septic shock sepsis
Cause
The cause of secondary peritonitis in children
First, the cause of the disease
1. Invasive peritonitis:
Such as the spread of acute appendicitis or other organ purulent lesions.
2, perforated peritonitis:
Such as peptic ulcer perforation, acute suppurative cholecystitis perforated intestinal typhoid perforation, traumatic intestinal perforation.
3. Necrotic peritonitis:
Secondary to strangulated intestinal obstruction and necrosis. The most common pathogen is Escherichia coli or mixed multiple infections.
4. There are also peritonitis associated with dialysis:
Peritoneal catheters are mainly used for peritoneal dialysis of renal failure. It is often used instead of hemodialysis, but its infection rate is often high. During the dialysis process, the patient's protein loss (including immunoglobulin and complement) may cause damage to the body's defense function. The low pH of the dialysate can also inhibit the body's body. immune system.
Bacteria can enter the abdominal cavity when the catheter is placed or pass through the dialysate and the tip of the catheter to penetrate the intestinal wall to bring the bacteria into, causing common bacteria in the peritoneal infection. The bacteria are mostly single, mostly Staphylococcus aureus, followed by Gram-negative Escherichia coli, Pseudomonas aeruginosa, mycoplasma or fungi.
Second, the pathogenesis
The pathological changes of secondary peritonitis often differ significantly depending on the source and mode of infection, the virulence and quantity of the pathogen, and the immunity of the child. After the peritoneum is stimulated by the contents of bacteria, bile or gastrointestinal tract, congestion, edema, and exudation occur due to neutrophil enlargement, tissue necrosis, coagulation and exudation of bacteria and fibrin, into opacity, and adhesion formation around the primary lesion. .
Peritonitis develops into localized or diffuse peritonitis based on the treatment of the primary lesion and the severity of the peritoneal infection.
The former tends to self-heal or form a localized abscess around the primary lesion.
In the latter case, if the treatment is unfavorable, the infection is more spread, the poisoning is aggravated, and sometimes the development of sepsis sepsis diffuse peritonitis can lead to death.
Prevention
Secondary peritonitis prevention in children
1. Early and appropriate treatment of intra-abdominal inflammatory diseases that may cause peritonitis is a fundamental measure to prevent peritonitis.
2, prevention of trauma and early diagnosis and treatment of acute appendicitis, can prevent the occurrence of secondary peritonitis.
3, any abdominal surgery or even abdominal puncture should be strictly performed aseptic operation.
4, before the intestinal surgery should be given antibacterial drugs orally and the use of appropriate treatment catheter technology, can reduce and reduce the incidence of peritonitis related peritonitis.
5, regular physical examination: to achieve early detection, early diagnosis, early treatment.
6, do a good job of follow-up: to prevent the disease from getting worse.
7, enhance physical fitness, improve their own immunity: pay attention to work and rest, more to participate in physical exercise, eat more fresh fruits and vegetables rich in vitamins.
Complication
Secondary peritonitis complications in children Complications , septic shock, sepsis
Often complicated by dehydration, acidosis, localized abscess, severe cases can be complicated by septic shock, develop into sepsis sepsis, multiple organ failure.
First, septic shock:
Also known as septic shock, it refers to sepsis syndrome caused by products such as microorganisms and their toxins.
Microorganisms, their toxins, and cell wall products in the infected area invade the blood circulation, activate various cellular and humoral systems of the host; produce cytokines and endogenous mediators, affect various organs and systems of the body, affect their perfusion, and cause tissue Cellular ischemia and hypoxia, metabolic disorders, dysfunction, and even multiple organ failure.
Therefore, septic shock is the result of the interaction between microbial factors and the body's defense mechanism. The amount of virulence of the microorganisms and the internal environment and response of the organism are important factors in determining the development of septic shock.
Second, the complications and consequences of peritonitis can be divided into early and late according to the onset time:
1. Acute phase (early period):
There is often bacteremia in the acute phase, which is related to aerobic or anaerobic bacteria. Hematogenous infections can cause shock and DIC, mostly due to bacterial and endotoxin effects, and this combination of shock and multiple organ system failure is associated with early mortality.
2. Late:
The late consequence is abscess formation.
Purulent substances can form abscesses, such as pelvic and underarm areas, depending on the anatomical area. Adhesion can also occur, causing hemodynamic or nerve compression and obstruction. Partial anastomotic rupture occurred and the fistula was formed.
1. Acute phase (early) In the acute phase, there is often bacteremia, which is related to aerobic or anaerobic bacteria. Blood infection can lead to shock and DIC, most of which are caused by bacteria and endotoxin. This shock and multiple organs The combined effects of systemic failure are associated with early mortality.
2. Late stage consequences are abscess formation, purulent substances can form abscesses according to the anatomical area, such as pelvic and infraorbital areas, adhesions can also occur, causing hemodynamics or nerve compression and obstruction, part of the anastomotic rupture, fistula form.
Symptom
Secondary peritonitis symptoms in children Common symptoms Abdominal pain Abdominal tenderness Abdominal muscle tension High fever Abdominal skin Dry expression Apathy Disgusting Dehydration
Due to different causes, the incidence of secondary peritonitis can be sudden or gradually transformed. Generally, those caused by gastrointestinal perforation are sudden outbreaks. Abdominal fluoroscopy has pneumoperitoneum, and acute inflammation spreads such as acute appendicitis. Acute pancreatitis, caused by perforation of acute cholecystitis, first symptoms of primary disease, recurrence of peritonitis, and most obvious tenderness and muscle tension in the lesion site. Intestinal obstruction and necrosis peritonitis first history of intestinal obstruction, X-ray Enema can be seen in the open space of the colon, the small intestine has a liquid surface, the main clinical manifestations of acute secondary peritonitis, early peritoneal irritation such as abdominal pain, tenderness, abdominal muscle tension and rebound tenderness, etc., due to infection and toxin absorption, mainly Symptoms of systemic infection.
Symptom
(1) Abdominal pain: This is the most common symptom of peritonitis. The degree of pain varies with the degree of inflammation, but it is generally severe and unbearable, and it is persistent, deep breathing, coughing, and can cause pain when turning the body. The sick child is reluctant to change his position. The pain starts from the original lesion, and the inflammation spreads to the whole abdomen, but the original lesion is still more prominent.
(2) nausea, vomiting: This is a common early symptom. At the beginning, reflex nausea and vomiting caused by peritoneal stimulation, vomit is stomach content, and when paralyzed intestinal obstruction occurs later, vomit turns yellow-green. Containing bile juice, even tan feces-like intestinal contents, can cause severe dehydration and electrolyte imbalance due to frequent vomiting.
(3) Fever: Sudden onset of peritonitis, the body temperature can be normal at the beginning, then gradually increase, the body of the weak, the body temperature does not necessarily increase with the severity of the disease, the pulse usually accelerates with the increase of body temperature, if the pulse increases As soon as the body temperature drops, it is mostly a sign of worsening the condition, and effective measures must be taken as soon as possible.
(4) Infection poisoning: When peritonitis enters a serious stage, it often shows high heat, sweating, dry mouth, fast pulse, shallow breathing and other systemic poisoning. Later, due to the absorption of a large amount of toxins, the patient is indifferent, face, eye socket. Depression, lips cyanosis, limbs cold, dry tongue, dry skin, shortness of breath, weak pulse, sudden rise or fall in body temperature, decreased blood pressure, shock and acidosis, if the condition continues to deteriorate, eventually due to liver and kidney dysfunction and respiratory and circulatory failure And die.
2. Abdominal signs
(1) Visual inspection: manifested as abdominal weakening or disappearance, accompanied by obvious abdominal distension, and increased abdominal distension is often an important indicator for judging the development of the disease.
(2) palpation: tenderness, rebound tenderness is the main sign of peritonitis, always exists, usually throughout the abdomen and the most significant part of the original lesion, the degree of abdominal muscle tension varies with the cause and the patient's general condition Inconsistent, sudden and intense stimulation, such as chemical stimulation caused by stomach acid and bile, can cause strong abdominal muscle tension, and even "wooden-like" rigidity, clinically called "plate-like abdomen", but young children or extreme In a weak child, abdominal muscle tension can be neglected slightly.
(3) Percussion: When the whole abdominal tenderness is severe and it is not easy to use the method of percussion to identify the original lesion site, it is often found that the primary lesion has a significant slamming pain in the whole abdomen. Help, abdominal percussion can be due to flatulence and drum sound, when the gastrointestinal tract perforation, due to a large amount of free gas in the abdominal cavity, supine position percussion often found that the liver dullness circle shrinks or disappears, the intra-abdominal effusion for a long time, you can pull out Movable voiced sound can also be used to locate the necessary abdominal puncture.
(4) Auscultation: It is often found that the bowel sounds are weakened or disappeared.
(5) digital rectal examination: If the rectal anterior fossa is full and tender, it indicates the presence of pelvic infection.
Examine
Examination of secondary peritonitis in children
First, the surrounding blood:
1. General situation:
Both white blood cell count and neutrophil ratio were significantly increased.
2. When the condition is serious or the body's response is low:
The white blood cell count is not high, only the proportion of neutrophils is elevated or the left nucleus and poisoning particles appear.
Second, blood biochemical examination:
Acidosis and electrolyte disturbances can be found.
Third, urine test:
Protein and tube type, urinary ketone can be positive.
Fourth, abdominal puncture:
Abdominal exudate culture often obtain pathogenic bacteria.
Fifth, abdominal X-ray examination:
It can be seen that the intestinal lumen is generally flatulent, and there are multiple signs of intestinal paralysis such as small gas level.
In the case of gastrointestinal perforation, most of the free gas in the underarm is visible (should be in perspective). This is of great significance in diagnosis.
Imaging examination can be observed by X-ray or under laparoscopy. X-ray films show free gas, mostly gastrointestinal perforation.
Six, barium enema:
X-ray barium enema can be seen in the open space of the colon and the small intestine. It is helpful for the diagnosis of appendicitis and intussusception, but if the expectorant leaks through the hole to the infected abdominal cavity, the infection can be aggravated.
Seven, ultrasound and CT:
Not only helps to check the fluid and gas in the extra-abdominal cavity, but also to detect primary diseases such as appendicitis or intussusception.
Eight, percussion:
When the total abdominal tenderness is severe and it is not easy to use the method of percussion to identify the primary lesion site, it is often found that the primary lesion has a significant slamming pain in the entire abdomen, which is helpful for localization diagnosis.
Abdominal percussion can be drum sounded due to flatulence. When the gastrointestinal tract is perforated, due to the large amount of free gas in the abdominal cavity, the hepatic dullness is often reduced or disappeared in the supine position. When the effusion in the peritoneal cavity is long, the mobile voiced sound can be extracted, and it can also be used to locate the necessary abdominal puncture.
Nine, auscultation:
It is often found that the bowel sounds are weakened or disappear.
X. Digital rectal examination:
If the rectal anterior fossa is full and tender, it indicates the presence of a pelvic infection.
Diagnosis
Diagnosis and diagnosis of secondary peritonitis in children
diagnosis
According to medical history, clinical features and laboratory, auxiliary examination is helpful for diagnosis. The location of abdominal tenderness helps to determine whether it is localized peritonitis (such as unperforated appendicitis, Yersinia mesenteric lymphadenitis) or diffuse peritonitis; abdominal wall Erythema is common in necrotizing enterocolitis with peritonitis; fever is usually the initial and main symptoms of primary peritonitis, and fever in the peritonitis associated with the intestine is secondary, and about 1 in children with peritonitis associated with dialysis. /3 only has fever.
Differential diagnosis
It should be differentiated from the following conditions:
First, pneumonia, pleurisy:
1, the same place:
Both can cause reflex abdominal pain, and pain can be aggravated by respiratory activity. Shortness of breath, rapid pulse, and sometimes abdominal muscles in the upper abdomen are mistaken for peritonitis.
2. Identification Department:
In detail, ask the pain, check the chest carefully, and make a judgment on the lack of obvious and affirmative tenderness and rebound pain in the abdomen.
Second, acute gastroenteritis, dysentery:
Dysentery:
It is one of the acute intestinal infectious diseases. Clinically, fever, abdominal pain, urgency, and stool pus and blood are the main symptoms. If the epidemic is infected, the incidence is sharp, accompanied by sudden high fever, dizziness, convulsions, and plague. At the beginning of dysentery, I saw abdominal pain first, followed by squatting, ranging from several times to dozens of times. It occurs mostly in the summer and autumn seasons. It is caused by the evil of dampness and heat, internal injury to the spleen and stomach, spleen and loss of health, and loss of stomach and stagnation.
1, the same place:
There are also acute abdominal pain, nausea, vomiting, high fever and abdominal tenderness, etc., easy to mistaken for peritonitis.
2. Identification Department:
Improper eating history, abdominal tenderness, no abdominal muscle tension, and auscultation of bowel sounds are all helpful in eliminating the presence of peritonitis.
Third, acute pyelonephritis, diabetic ketoacidosis, uremia, etc.:
Diabetic ketoacidosis (DKA):
It is an acute complication of diabetes. Acidosis caused by a severe deficiency of insulin caused by a sharp rise in blood sugar.
Uremic disease:
In fact, it means that the human body can not produce urine through the kidneys, excreting wastes and excess water from the body, such as glucose, protein, amino acids, sodium ions, potassium ions, sodium bicarbonate, acid-base balance disorders, etc. There are endocrine functions of the kidney such as: renin, erythropoietin, active vitamin D3, prostaglandins, etc., and the deterioration of the kidney is caused by metabolic disorders caused by the progression of the disease.
1, the same place:
Can have different degrees of acute abdominal pain, nausea, vomiting and other symptoms.
2. Identification Department:
Typical signs of no peritonitis can be identified by analysis.
Fourth, acute intestinal obstruction:
Intestinal obstruction is blocked by the operation of the intestinal contents of any part of the intestine from the beginning of the jejunum to the rectum. It manifests as dilatation of the intestine above the blocked site, accumulation of intestinal contents and dysfunction of peristalsis, and symptoms such as abdominal pain, bloating, vomiting, inability to vent and defecation.
1, the same place:
If the obstruction is not relieved, the intestinal wall edema and blood stasis, intestinal peristalsis from hyperthyroidism to paralysis, clinical bowel sounds may be weakened or disappeared, easily confused with peritonitis caused intestinal paralysis.
2. Identification Department:
Most acute intestinal obstruction has obvious paroxysmal abdominal cramps, hyperactivity of bowel sounds, abdominal distension, and no positive tenderness and abdominal muscle tension, easy to distinguish with peritonitis.
In addition to careful analysis of symptoms and signs, and to distinguish by abdominal X-ray and close observation, if necessary, laparotomy should be performed to be clear.
Fifth, acute pancreatitis:
Edema or hemorrhagic necrotizing pancreatitis have mild and severe peritoneal irritation symptoms and signs, but not peritoneal infection; in the identification, serum or urinary amylase elevation is important.
Sixth, other:
For example, urinary calculi, retroperitoneal inflammation, etc., have their own characteristics, as long as the analysis is fine, the diagnosis is not difficult.
