The text is presented for informational purposes only. We urge you not to self-medicate. When the first symptoms appear, consult a doctor. Recommended reading: " Why not self-medicate?". The treatment of peritonitis is a system of measures carried out by a doctor when a patient with a diagnosis of peritonitis is admitted to him. The patient's condition with peritonitis is usually assessed as severe or moderate, and requires immediate treatment, preferably in the first hours after the onset of symptoms of the disease.
Peritonitis is a secondary inflammatory process that develops in the peritoneum due to injuries, surgeries, damage to internal organs, perforation of perforated ulcers of the stomach and intestines, as a complication of acute appendicitis or cholecystitis. The sterile abdominal cavity becomes a focus of infection, and the work of internal organs is disrupted. Sepsis, toxic shock, multiple organ failure develops.
Therapeutic tactics in this case has only one way - surgical, that is, abdominal surgery, after which the patient is prescribed appropriate medication, if necessary, procedures as part of postoperative management and recovery.
Usually the postoperative period takes place for the patient in the intensive care unit. Home treatment, the use of folk remedies and the refusal of medical intervention are categorically not allowed, since, with a high probability, they will lead to the death of the patient. Isolated conservative therapy also does not make sense, since an operation is needed to remove the source of the problem. It should be understood that without surgical procedures it is impossible to cure peritonitis.
The choice of surgical technique, as well as anesthesia, depends on the patient's condition. The operations are usually performed under general anesthesia.
The ongoing surgical treatment has several goals:
- elimination of the source of peritonitis;
- sanitation of the abdominal cavity and destruction of the infection;
- bowel probing and provision of temporary abdominal drainage to remove accumulated exudate.
If there are suspicions of diseases that can cause peritonitis, or if there are signs of an existing infection in the abdominal cavity, the patient is urgently needed deliver to the nearest hospital, providing transportation on their own, or with the participation of the ambulance team. In this case, only an urgent operation can save a person's life.
It should be noted that at the slightest suspicion of peritonitis, the use of any painkillers, including analgin, diclofenac, morphine or pantopon, is strictly prohibited, since blurring the clinical picture significantly complicates diagnosis and treatment.
Any attempt to stimulate intestinal peristalsis by enemas or medication is also not allowed, as they interfere with the delineation of inflammation, and contribute to its spread.
Manifestations of heart failure require the introduction and use of appropriate drugs - cordiamine, caffeine, water-soluble camphor, digoxin. Taking into account respiratory failure, oxygen inhalations are carried out.
Transportation of the patient is carried out with maximum convenience. Before hospitalization, the patient must be provided with bed rest in a semi-sitting state with bent knees. A cold compress is placed on the abdomen. Eating of any food is prohibited, and drinking is limited.
With regard to the use of any medications, antibiotics, infusion solutions, gastric lavage or insertion of a gastric tube, the decision on their use is made only by the emergency doctor.
Medical products (preparations, medicines, vitamins, medicines) are mentioned for informational purposes only. We do not recommend using them without a doctor's prescription. Recommended reading: " Why can't you take medications without a doctor's prescription?". Considering that peritonitis is a secondary pathology, initially its treatment aims to remove the primary source, for example, to cut off an inflamed or perforated appendix, to suture perforated ulcers of the stomach or intestines, to remove an inflamed gallbladder.
Surgery for peritonitis is a difficult procedure for the patient, despite the fact that the patient is already in a difficult condition, therefore, intensive and quick preparation is necessary before the start of surgery. The introduction of blood-substituting fluids, saline solutions, weak diuretics, albumin, antibacterial drugs is prescribed. The patient is administered:
- glucose solution at a concentration of 5 or 10%;
- Ringer's solution.
With obvious tachycardia and heart failure, the patient is added to the treatment regimen with a solution of strophanthin at a concentration of 0.05%, 0.5 ml per 500 ml of solution, twice a day. day. The appointment is carried out both before the operation and in the postoperative period.
The most common microbiological factor that plays a role in the development of peritonitis is anaerobic bacteria, E. coli, staphylococcus aureus, or several different types of microbes, so initial antibiotic therapy is prescribed based on this flora. A combination of sulfonamides, antibiotics, and antimicrobial antiseptics such as tinidazole, ornidazole, or metronidazole is commonly used. Further, the attending physician draws attention to the emerging sensitivity of the microflora, and adjusts the therapy in accordance with it.
The administered daily doses have a high concentration of active substances. The penicillin group is administered at the rate of 10-15 million units, ampioks, ampicillin and methicillin are administered at 3-5 grams. Aminoglycosides are used at 2-3 grams (monomycin and kanamycin), or 240 mg (gentamicin). The group of cephalosporins, represented by zeporin, kefzol and cefotaxime, is used at 5 grams per day. Aminoglycosides, except for gentamicin, are administered intracavitary, and the rest of the drugs are administered through intramuscular or intravenous injections.
If a patient develops hyperthermic syndrome after surgery, it is necessary to urgently begin the procedure for restoring water and electrolyte balance:
- physical cooling;
- intramuscular injections of hydrocortisone, analgin, diclofenac;
- intravenous perfalgan.
Detoxification treatment is carried out by infusion through:
- blood transfusions;
- administration of Reamberin;
- administration of rheopolyglucin and sodium chloride solution;
- prescribing antihistamines and antienzymes.
In acute peritonitis, the patient develops a state of the so-called “catabolic storm”, that is, a sharp acceleration of metabolism. To slow it down, you need to administer anabolic steroids to the patient, for example, retabolil, as well as saline solutions.
If the patient has recurrent profuse vomiting, this indicates a violation of gastrointestinal motility and electrolyte balance. To eliminate disorders, subject to the normal functioning of the kidneys, for each kilogram of the patient's weight, 40-60 ml of liquid is injected daily, as well as chloride salts of potassium, sodium, magnesium and calcium.
To prevent acute renal failure, a patient is prescribed heparin, 5,000 units. intramuscularly 3 times on the first day after surgery. The drug improves the rheological properties of blood and microcirculation.
Stimulation of the function of the gastrointestinal tract is achieved by setting hypertonic enemas, as well as intravenous administration of sodium chloride solution, intramuscular injections of nibufin, aceclidin, cerucal.
Depending on the prevalence of peritonitis, its primary source and severity, the technique of the operation may differ slightly, however, the general tactics of any surgical intervention is carried out in accordance with the specific scheme - immediately after the patient enters the hospital, they begin to prepare him for the operation. Further, as soon as possible, you need to start doing the operation itself. After its completion, the recovery period initially takes place in the intensive care unit.
Preparation for surgery
Preparation lasts no more than 3 hours, since a longer delay reduces the patient's chances of surviving during and after surgery. At this time, intensive infusion therapy is carried out. The purpose of infusion administration of drugs before surgery is to improve the basic vital functions of the body through:
- correction of water and electrolyte balance;
- increased central venous and arterial pressure;
- restore the amount of circulating blood in the bloodstream;
- decreased heart rate;
- diuresis stabilization.
If kidney function cannot be restored within three hours, the operation is still performed, but this reduces the chances of a favorable outcome for the patient.
In addition, preparation for surgery includes the placement of a catheter in the subclavian vein to control the CVP and conduct infusions. To measure hourly diuresis, bladder catheterization is performed.
The gastrointestinal tract also requires preparation measures - it is emptied using a special hollow tube, which is not removed until gastrointestinal motility is restored after surgery.
The course of the operation
Modern medicine knows several schemes for performing surgery for peritonitis:
- closed: carried out laparotomically, with elimination of the source, sanitation of the cavity without drainage, and with suturing tightly laparotomy wound;
- semi-closed: classic technique, similar to closed, but with cavity drainage;
- laparoscopy using video endoscopic technologies;
- combined: in this case, the classic semi-closed operation is performed with programmed video endoscopic sanitation of the cavity;
- semi-open: classical scheme in combination with surgical debridement and temporary closure of the postoperative wound;
- open: performed without temporary closure of the abdominal wall, with surgical debridement.
General anesthesia is given before surgery if diagnosed before surgery. If peritonitis is detected directly during laparotomy with local anesthesia, the patient is transferred to endotracheal anesthesia.
After the onset of anesthesia, it is necessary to provide access to the source of the pathology. In the presence of widespread peritonitis, a median incision is made, the location and size of which depend on the source of inflammation. During the operation, if necessary, the incision is enlarged, expanding the boundaries up or down.
If the patient has a preoperative diagnosis of peritonitis, the access is opened by an incision that is localized within the suspected source of inflammation, for example, an oblique incision is made in the hypochondrium or in the iliac zone. It is important that the length of the penetrating incision is sufficient to ensure complete and reliable sanitation of the focus of inflammation.
In the case where local peritonitis was initially suspected, and after a lateral incision a common type is found, the lateral incision is supplemented with an appropriate median one, through which debridement is carried out. Lateral remains for drainage.
After the autopsy, to minimize the trauma of the operation, the patient is injected with novocaine blockade of reflexogenic zones through the root of the mesentery of the small intestine. A solution of novocaine 0.25% in an amount of 200 ml is usually used, heated to a temperature of 37 degrees.
The course of the operation begins with a revision of the cavity to find the source of peritonitis. Exudate, which is found in the cavity, is necessarily selected for bacteriological examination. After the effusion is removed from the peritoneum with gauze napkins and electric suction, the revision of the cavity begins directly. If the operation is performed through a lateral incision, exudate is removed from it immediately after the source of peritonitis is found.
Based on the results of examination of the cavity through a lateral approach, physicians determine the presence or absence of indications for making a midline incision and performing a midline laparotomy. If the initially suspected source is not detected through the lateral incision, but the diagnosis is definitely confirmed and we are talking about peritonitis, then in the presence of a spilled form, they immediately proceed to a median laparotomy.
Revision in search of the source of inflammation is carried out strictly in order, through an incision with a length of at least 20 centimeters. Initially, the examination begins from the upper floor of the cavity, including the diaphragm and pancreas. Next, the doctor examines the lower floor, the pelvis and retroperitoneal space.
The next stage of the operation is the most important, although not always achievable. We are talking about removing the source of peritonitis. To achieve this goal , the surgeon can:
- remove a completely or partially affected organ (appendectomy, cholecystectomy, resection of part of the intestine), followed by suturing the wall;
- drain the area of inflammation.
The last two options are used if the source of inflammation cannot be removed due to danger to the patient, or due to technical difficulties. In conditions of diffuse, widespread peritonitis, the imposition of anastomoses between organs is prohibited, since the sutures in this case will be insolvent. If possible, external drainage of organs is performed.
For perforated ulcers and peritonitis, only the perforation is sutured. After resection of the intestine with diffuse fecal or purulent peritonitis, anastomoses are not superimposed, it is necessary to impose an end colostomy or ileostomy, if possible, bringing both knees of the intestine close or at a minimum distance from each other, so that in the future the restoration of intestinal continuity is easier.
Sanitation during surgery to remove a focus of local peritonitis does not require washing, as it can provoke the spread of infection further into the abdominal cavity. In this case, it is advisable to drain with suction and sterile gauze swabs. Fibrous formations tightly fixed in the peritoneum should not be removed, as this contributes to the destruction of the walls of the organs to which they are adjacent.
If we are talking about diffuse peritonitis, all parts of the abdominal cavity are already infected, so the cavity is washed with 10-12 liters of saline, and then the washings are removed by suction. Washing can be repeated several times as needed, and the last time an antiseptic solution is used, for example, dioxidine, chlorhexidine.
The duration of the operation to remove peritonitis cannot be predicted in advance, since the real picture of the state of the peritoneum is revealed to the surgeon only after a direct opening of the abdominal cavity.
In the course of surgery to remove widespread peritonitis complicated by intestinal obstruction or severe adhesions, intestinal drainage may be performed. The most sparing method for the patient is drainage with a Miller-Abbott probe according to the nasogastrointestinal method. Especially important is the drainage of the initial section of the jejunum to a length of up to 70 centimeters. Complete drainage of the stomach is achieved by leaving a separate end of the probe.
Drainage of the abdominal cavity is one of the final stages of the operation. Drains are necessary to ensure adequate outflow of exudate. Counter-openings are made in the iliac and hypochondrium regions.
Possible consequences of the operation
Penetration into the abdominal cavity during removal of the focus of peritonitis practically does not pass without consequences. Often, patients in the postoperative period develop one or more complications that are observed and treated in a hospital. So, for example, postoperative consequences caused by surgeon errors include:
- necrosis of the remaining part of the intestine, if it has undergone a destructive change: in this case, relaparotomy with resection of this area is indicated, subsequent sanitation and drainage;
- unreasonably economical resection of a section of the intestine that has undergone necrosis;
- failure of the sutures of the anastomosis: this requires relaparotomy, decompression of the intestine and the imposition of a fistula on the intestine, then the removal of the intestinal loop and drainage of the cavity.
In addition, if the requirements of asepsis are not observed during or after the operation, there is a high probability of infection in the suture. This consequence of the operation is easy to detect - the seam swells and turns red, starts to hurt, and after a day or two, pus begins to ooze from it. Against this background, signs of a violation of general well-being develop: fever, weakness, chills.
Approximately 1 patient in 100 people may develop recurrent, so-called tertiary, peritonitis. Particularly susceptible to it are people with a depleted body, an insufficiently balanced diet, weak immunity, and also after prolonged antibiotic therapy. In this case, the operation must be repeated.
Paresis of the intestine is the complete loss of its motor ability. If normally the intestine carries out the movement of food masses along its length due to its own peristalsis, then with paresis such movement becomes completely impossible. This complication often occurs after diffuse peritonitis, as well as after lengthy operations. The patient has total constipation and severe bloating.
Adhesion formation is a typical complication after surgery for peritonitis. It is provoked by any violation of the integrity of the peritoneum, since, in fact, the formation of adhesions is a protective reaction of the body. Adhesions in this case are strands of connective tissue that connect the intestinal loops, causing its complete or partial obstruction. Formation in the late postoperative period is possible. To solve the problem, most often, a second operation and surgical dissection of the adhesions are needed.
The postoperative recovery period after surgery is divided into three stages:
- early (from 3 to 5 days);
- late (2-3 weeks after intervention);
- remote (until the moment when it becomes possible to return to work, or until a disability is obtained).
Recommendations for patient care, depending on the phase, are somewhat different. In general, the management of the rehabilitation period is carried out by the doctor directly in the hospital, or, after discharge, under his periodic supervision. In the absence of positive dynamics and evidence of recovery of the body, the tactics of postoperative therapy varies according to the indications.
General principles of postoperative therapy:
- adequate pain relief;
- intensive fluid therapy;
- detoxification of the patient's body;
- antimicrobial activity;
- prevention of intestinal paresis;
- normalization of the functioning of the gastrointestinal tract system and all other systems affected by pathology.
Primary care after the operation begins immediately after its completion, and lasts until the patient fully recovers.
In the early phase, the patient is transferred to the intensive care unit on a gurney and is kept warm and comfortable in the ward. A warm heating pad is placed in the legs, and an ice pack is placed on the postoperative wound for up to half an hour. The patient should lie in bed in the Fowler position, that is, the head is raised 45 degrees, the legs are bent at the knees and bent at the hip joints. Unconscious patients are laid horizontally, without a pillow under their heads.
In the first 2-3 days, strict bed rest and hunger are observed. According to the indications, the patient is connected to the artificial lung ventilation system. On the second day, the first bandage change takes place. If the postoperative bandage has gone astray or blood has accumulated from the wound, it is changed earlier. Every hour, the pulse, respiration, urine separation and discharge through the drains are monitored. Drainages need to be washed periodically, and the doctor personally changes the dressings around the drains.
From the second day, parenteral nutrition through infusions is prescribed - the patient is injected with a 10% solution of glucose, amino acids, salt. On the first day after the operation, drinking is excluded, and then it is allowed to drink 1 teaspoon of water once an hour. If there is an establishment of intestinal motility, enteral nutrition with liquid mixtures through a nasogastric tube is allowed.
After the second day, constant bedding becomes undesirable, as it contributes to the appearance of complications. After the first day, the patient needs to start moving in bed - bend and unbend the limbs, turn around. For 2-3 days, you need to start sitting down in bed, with the help of a nurse, move around the ward.
The late phase of recovery begins when a person has a stable intestinal motility, flatulence, stool appears. Such signs are an indication for transferring the patient to self-feeding without a probe. Food is allowed in liquid and pureed form, fractional food up to 6 times a day, in small portions. In the first week, only liquid food is allowed, namely:
- vegetable soups.
By the end of the first week, the menu includes mashed low-fat cottage cheese, soft-boiled eggs, boiled meat and fish of low-fat varieties, chicken (all in the form of mashed meatballs, soufflé or cutlets), mucous soups and decoctions. Allowed oatmeal and rice porridge in a boiled state. Any indigestible foods that require special efforts from the digestive tract for processing are excluded. Cold and carbonated drinks are prohibited. A week after the operation, it is allowed to add yesterday's white bread and crackers from it, as well as a limited amount of honey and marmalade (something once a day). Short walks around the department are allowed. The sutures are removed after 8-9 days, and the drainage is removed already 4 days after the operation. On the day the sutures are removed, the patient is usually discharged.
After discharge, the regime of the operated person does not immediately return to its usual course. In the first months, he needs to comply with a list of restrictions, for example, it is forbidden to lift weights of more than 3 kilograms, to engage in physical activity. Intimate life is excluded for up to one and a half months. It is obligatory to perform therapeutic exercises, which include training of the respiratory organs, the cardiovascular system, strengthening and moderate stimulation of the abdominal muscles, and gradual restoration of working capacity. During this period, limited walking, skiing, and swimming are useful for the patient. In some cases, sanatorium treatment is prescribed.
Meals are based on the principle of fractionation, at least 5 times a day. You can't overeat, just like you can't starve. All food should be boiled or steamed, without crusts, frying and spices. Products that are irritating and difficult for the digestive tract are excluded. In the future, the use of bacon, margarine, smoked meats, sugar, pastries, jams and sweets is limited.
Features of surgery for peritonitis in children
Treatment of childhood peritonitis, similar to adult pathology, requires immediate surgical intervention. When delivering a small patient, he should not be given food and drink, it is forbidden to give enemas. Preoperative preparation takes several hours.
Diagnosing childhood peritonitis causes some difficulties, since the child behaves restlessly, he cannot objectively explain what exactly, how and in what place he has pain.
Preparation before surgery takes from 1 to 5 hours, and the question of how long it will be carried out in a particular case is decided by the doctor. As part of the preparation, the use of antibacterial drugs, cardiovascular and painkillers is prescribed. A perirenal blockade is introduced with a solution of novocaine, 10 ml of a 0.25% solution on each side. Gastric lavage is performed using a permanent probe. For newborns and young children, a gas outlet tube is installed, prozerin is prescribed. Venesection and the introduction of 25-30 ml of plasma are carried out simultaneously with the introduction of a 20% glucose solution.
Diphenhydramine, suprastin or pipolfen are also used as a drug preparation. At elevated body temperature, it is necessary to prescribe a 1% solution of amidopyrine together with a 50% solution of analgin.
The goals of surgery in children are similar to those of adult surgery:
- elimination of the source of peritonitis;
- removal of effusion;
- sanitation and drainage.
In diffuse peritonitis, intraoperative lavage and prolonged postoperative lavage are indicated. Antibiotics are prescribed intramuscularly, intravenously and inside the abdominal cavity. During the intervention, the infectious source is removed, pus and exudate are removed, antibiotics are introduced into the abdominal cavity, drainage is installed for further evacuation of the effusion and administration of drugs.
A feature of peritonitis in newborns can be called meconium peritonitis - an inflammatory process in the peritoneum, which develops as a result of meconium entering the abdominal cavity, as a rule, even while the fetus is in the womb. Pathology begins due to congenital intestinal obstruction, including its perforation, or due to meconium ileus, if the fetus has congenital cystic fibrosis.
During surgical treatment, the surgeon restores the patency of the intestine, sutures the perforation, sanitizes the cavity and injects antibiotics into it. For meconium ileus, an enterostomy is performed. To liquefy viscous meconium, 5% pancreatin is used in a volume of 10-15 ml.
Treatment of children is not limited to surgery - as in adults, they are prescribed special rules for the entire period of recovery. Etiotropic treatment with antimicrobial and anti-inflammatory drugs is carried out. Cephalosporins, metrogil, aminoglycosides can be used. According to the indications, physiotherapy is carried out. Immunocorrection is carried out using ultraviolet blood irradiation procedures, with the introduction of immunoglobulin, hyperimmune plasma and various immunomodulators.
In general, the rules of the postoperative period for children are similar to the principles of rehabilitation for adults.
Duration of treatment
The concept of duration of treatment in peritonitis can be considered in several aspects. So, for example, it is impossible to predict the duration of the operation in advance - depending on the exact diagnosis, the degree of spread of the pathology, the condition and age of the patient, it can take from several hours to a day.
Since treatment does not end at the end of surgery, the postoperative hospital stay may also be included. In the normal course of recovery, the patient can be discharged home after 9-10 days, after the stitches are removed. If, after the operation, complications begin, inflammation of the suture, repeated peritonitis or the formation of adhesions, the discharge date is postponed. Some patients stay in the hospital for several months until the final recovery occurs, when the attending physician considers it possible for the patient to be at home.
Full recovery after surgery, return to the usual routine and rhythm of life takes up to six months, in some cases from 5 to 10 months.
For the treatment of peritonitis, the patient must definitely seek medical help, and be prepared for the fact that the operation is inevitable. Only through surgical removal of the source of infection, as well as strict strict adherence to all postoperative rules, it is possible to achieve a cure for the pathology, normalization of the condition and restoration of working capacity.
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- Medicom Clinic - Peritonitis: symptoms, treatment