The peritoneum is the serous membrane that lines the inner surface of the abdomen and pelvis, and also covers the internal organs inside. Peritonitis is a medical emergency and requires immediate surgical intervention. What are the causes and symptoms of peritonitis? How is the treatment going? What are the complications?

Peritoneumphysiologically it is a sterile environment when bacteria from the digestive tract, irritants, foreign bodies or physiological fluids such as blood, urine, bile or juice enter it pancreatic inflammation,peritonitismay develop, which is a direct threat to human life and requires urgent medical intervention.

Otrzewna: construction

In the human body, the peritoneum consists of two plaques. The first is the parietal peritoneum (which covers the abdominal wall from the inside), the second is the visceral peritoneum (covers the organs in the abdominal cavity and pelvis).

The place where the parietal peritoneum connects with the visceral peritoneum is the mesentery.

The peritoneal cavity is a natural space between the laminae of the peritoneum and is filled with a small amount of fluid.

A condition involving the production and accumulation of excessive amounts of ascites is ascites.

Peritoneal: puncture of the peritoneal cavity

Paracentesis , i.e. puncture of the peritoneal cavity, is a diagnostic test involving the collection of ascites fluid for examination. It can also be performed to reduce the tension of the integuments and alleviate the discomfort of a patient suffering from ascites.

Before starting the procedure, palpate the patient's abdomen, determine the limits of fluid presence and determine the puncture site.

In case of difficulties, it is recommended to perform an ultrasound of the abdominal cavity with radiology marking the place where the needle should be inserted.

Before the procedure, you should thoroughly wash and disinfect your hands, wear sterile gloves, and disinfect the puncture site.

The use of a local anesthetic is not necessary, but it increases the patient's comfort during the procedure.

The puncture is made with the needle perpendicular to the skin surface, usually 1/3 distance awaybetween the left or right upper iliac spine and the navel.

The collected ascites fluid should be submitted to the laboratory for basic tests and the culture of the fluid on aerobic and anaerobic media.

In the case of ascites fluid discharge in the course of ascites, write down the exact amount of fluid obtained and decide on the possible albumin transfusion.

Peritoneum: intra- and extra-peritoneal organs

The organs in the abdominal cavity of humans are divided according to their position in relation to the peritoneum, into the intra- and extra-peritoneal organs.

The intraperitoneal organs include part of the esophagus, stomach, part of the duodenum, small intestine (jejunum and ileum), liver and gallbladder, appendix, part of the large intestine (caecum, transverse, sigmoid colon), spleen, uterus and ovaries and fallopian tubes. They are completely covered by the visceral peritoneal lamina.

On the other hand, the extraperitoneal organs include the urinary bladder, kidneys and ureters, adrenal glands, pancreas, part of the duodenum and a fragment of the large intestine (ascending colon, descending colon, part of the rectum).

Peritonitis

Peritonitis is a common cause of an acute abdomen. It is most often caused by the presence of infected fluid in the peritoneal cavity or the ingress of pathogens and irritants.

There are several divisions of peritonitis, the most popular of which are primary and secondary, acute and chronic, limited and diffuse, as well as infectious and chemical.

By far the most common is acute secondary purulent peritonitis.

The clinical symptoms presented by patients include:

  • continuous, severe abdominal pain
  • increased abdominal muscle tone
  • flatulence
  • abolition of intestinal peristalsis
  • stool passage disorder
  • nausea
  • vomiting
  • fever
  • chills

Patients are most often restless, pale and sweaty. They breathe frequently, have a fast heartbeat and low blood pressure.

Abdominal pain worsens during movement, so it is typical for patients with peritonitis to lie on their side with bent lower limbs.

Peritonitis: causes

The most common causes of peritonitis are disruption of the gastrointestinal tract, complicated by the pouring out of the gastric contents into the peritoneal cavity, usually in the course of acute appendicitis, gastric ulcer perforation orduodenum, intestinal necrosis caused by embolism or thrombus of the mesenteric vessels, trauma or surgery.

Peritonitis can also be caused by inflammation of the appendages, diseases of the bile ducts, as well as diseases of the pancreas. It happens that peritonitis occurs without a clear break in the continuity of the digestive tract and a clear source of infection - then it is called spontaneous peritonitis.

Peritoneal symptoms

Peritoneal symptoms are presented by patients who develop irritation or inflammation of the peritoneum. They should be examined in every patient who comes to a doctor because of severe abdominal pain, which is often accompanied by gas and stool disorders, nausea, vomiting, and increased muscle tone of the anterior abdominal wall (called a board-like abdomen). The symptom of Blumberg, Rovsing and Jaworski stands out among the peritoneal symptoms.

  • Blumberg's symptom

The study of the Blumberg symptom is performed with the patient lying on his back. It consists in pressing deeply the abdominal wall of the patient with the fingertips and quickly tearing them upwards. A positive symptom is described when pain occurs when the pressure on the fingers is suddenly released.

  • Rovsing symptom

The Rovsing symptom is tested with a patient lying on his back. It consists in slowly compressing the abdominal wall of the patient with the fingertips, moving them from the left iliac fossa to the area of ​​the left hypochondrium. The purpose of the test is to increase the pressure of gases present in the large intestine and to stretch it.

Positive Rovsing symptom is described as the occurrence of severe pain in the area of ​​the right iliac fossa, which may indicate appendicitis and requires further diagnosis of abdominal pain in this direction.

  • Jaworski's symptom

The examination of the Jaworski symptom is carried out on a patient lying on his back. It consists in lifting the right lower limb straightened in the knee joint, pressing the abdominal wall of the patient in the area of ​​the right iliac fossa and gradually, slowly lowering the limb.

A positive symptom of Jaworski is described when pain appears while lowering the straightened limb. It may indicate appendicitis, and a patient presenting such a symptom requires further diagnosis of abdominal pain in this direction.

Peritonitis: causes

The digestive content released from the gastrointestinal tract irritates the peritoneum and causes a reactioninflammatory. In the peritoneal cavity, a protein-rich, exudative fluid begins to accumulate.

Depending on the he alth of the patient and the efficiency of his immune system, the inflammatory process may be limited to the peritoneum (limited peritonitis develops) or spread (then we are talking about diffuse purulent peritonitis) and involve distant organs through the spread of bacteria through blood vessels, leading to sepsis and multi-organ failure syndrome.

Peritonitis: complications

Peritonitis is a state of immediate life-threatening condition and carries many serious complications, which is why it is so important to quickly, accurately diagnose and implement effective treatment, usually surgical.

The most common complications of peritonitis include local complications such as intraperitoneal abscesses and adhesions (which may lead to the development of intestinal obstruction) and sepsis, as well as multi-organ failure syndrome, which can lead to death.

Diffuse Peritonitis

  • symptoms

The symptoms most often presented by patients with diffuse peritonitis include nausea, vomiting, and abdominal pain. As time passes, gas and stools stop, the abdomen becomes more painful, bloated and tense, and the peristalsis becomes harder and harder to hear.

Due to the increasing pain, patients lie on the beds in one position, with the lower limbs bent at the hip and knee joints, which reduces the abdominal muscle tension. Peritoneal symptoms appear and the abdomen becomes plank.

The patient should be hospitalized and thoroughly examined, because without medical intervention and appropriate treatment, the patient's he alth may deteriorate quickly, dehydrate, decrease blood pressure, tachycardia, and heart rhythm disturbances may occur.

Improperly diagnosed and untreated diffuse peritonitis can lead to septic shock, which is a medical emergency.

  • diagnostics

Each patient in whom the doctor suspects diffuse peritonitis should have a laboratory blood test performed as soon as possible.

Correct diagnosis should be indicated by increased parameters of inflammation (leukocytosis, CRP, procalcitonin) and disturbances in the water and electrolyte balance (especially abnormal levels of sodium and potassium in the blood).

For the necessary imaging studies thatshould be performed in every patient with severe abdominal pain, include X-ray and ultrasound of the abdominal cavity.

They confirm the presence or exclusion of gastrointestinal perforation (gas under the diaphragm domes), gastrointestinal obstruction (multiple levels of fluid in the intestines visible), or acute pancreatitis or acute cholecystitis as a source of peritonitis.

  • differentiation

The diagnosis of diffuse peritonitis is not easy even for an experienced doctor. Severe abdominal pain should always be differentiated from acute abdominal diseases, appendicitis, as well as gynecological conditions such as ovarian cyst torsion or rupture or ectopic pregnancy.

Abdominal pain, nausea, vomiting and peristalsis may also occur in the course of acute pancreatitis or acute cholecystitis. You should remember about the elderly, especially those with diabetes, whose peritonitis may be mildly symptomatic.

  • treatment

Treatment of diffuse peritonitis depends on the underlying cause. Most often it is a surgical procedure due to the occurrence of gastrointestinal perforation and leakage of food contents into the peritoneal cavity, supported by antibiotic therapy with a broad spectrum of activity.

Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is a rare condition caused by bacterial infection of the ascites fluid accumulating in the peritoneal cavity.

It is a complication often occurring in people suffering from ascites, usually caused by bacteria from the human digestive tract:E. coli , gram-positive cocci ( Enterococcus faecalis ),Serratiaand pathogens of the generaKlebsiella,ProteusiPseudomonas .

  • recognition

The most common symptoms presented by patients with idiopathic bacterial peritonitis include fever, chills, lack of appetite and abdominal pain.

It is important to perform imaging tests and check if there is a visible source of infection within the abdominal cavity, which is a condition for the diagnosis of spontaneous inflammation (in the presence of perforation or peritoneal abscess, it is called secondary peritonitis).

During the physical examination, the doctor determines the presence of peritoneal symptoms. To establishin the diagnosis, it is necessary to collect ascites fluid for laboratory testing and to perform aerobic and anaerobic culture of the material.

The presence of more than 250 neutrophils (neutrophils) in 1 mm3fluid confirms initial suspicions.

  • treatment

The most effective treatment for idiopathic bacterial peritonitis is broad-spectrum antibiotic therapy. Hospitalization and intravenous drug administration are the most common requirements. The therapy uses 3rd generation cephalosporins (e.g. cefotaxime) or fluoroquinolone antibiotics (e.g. ciprofloxacin)

  • prognosis

The occurrence of spontaneous bacterial peritonitis significantly worsens the prognosis of patients with ascites. Differentiation of spontaneous and secondary bacterial peritonitis based on the results of laboratory examination of ascites fluid ("Interna Szczeklik. Handbook of internal diseases")

SPONITIC BACTERIAL ITitisSECONDARY BACTERIAL PERICONITIS
Neutrophils (in mm3 )250-1200>1200
Ph>7 <7
Glucose (mg / dL)>60 <60
LDH<600>600
Protein (g / dl)<3,0>3,0
BacteriaAerobic (usually 1 pathogen)Aerobic and anaerobic (mixed flora)

Tuberculous peritonitis

Tuberculous peritonitis is a very rare disease. It usually affects not only the peritoneum, but also other organs of the digestive tract and is difficult to diagnose even for an experienced physician.

The literature does not describe the characteristic symptoms of tuberculosis of the gastrointestinal tract. Patients may experience unintentional weight loss, loss of appetite, diarrhea, abdominal pain, as well as fever and ascites.

Aseptic (chemical) peritonitis

Chemical peritonitis is caused by the irritating effect of a substance on the serosa with the accompanying development of an inflammatory reaction in the body.

The most common causes of this condition include leakage of bile (biliary peritonitis), gastric juice, pancreatic juice, urine, stools, or blood into the sterile peritoneal cavity as a result of disruption of the gastrointestinal tract, digestive tracts, or blood vessels.

Don't do that

Peritonitis - don't takepain medications

As soon as symptoms of peritonitis appear, call an ambulance as soon as possible. Until a medical consultation, you should not take any medications (painkillers or diastolic drugs) on your own, as they may blur the image of the disease, and thus delay the proper diagnosis and treatment.

Category:

Gastrology