Treatment of peritonitis is a system of activities carried out by a doctor when a patient is diagnosed with peritonitis. The patient's condition in peritonitis is usually rated as severe or moderate, and requires immediate treatment, preferably in the first hours after the onset of symptoms.
Peritonitis is a secondary inflammatory process that develops in the peritoneum, due to injuries, operations performed, due to damage to internal organs, perforation of perforated gastric and intestinal ulcers, as a complication of acute appendicitis or cholecystitis. The sterile abdominal cavity becomes a focus of infection, and the work of the internal organs is impaired. Sepsis, toxic shock, multiple organ failure develops.
The medical tactic in this case has only one way - surgical, that is, performing abdominal surgery, after which the patient is prescribed the appropriate drug treatment, if necessary, the procedure as part of postoperative management and recovery.
Usually, the postoperative period passes for the patient in the intensive care unit. Home treatment, use of folk remedies and refusal of medical intervention are categorically not allowed, because, with great probability, will lead to the death of the patient. Isolated conservative therapy also does not make sense, since surgery 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 methods of operation, as well as anesthesia depends on the patient's condition. Usually operations are performed under general anesthesia.
Surgical treatment has several goals:
- elimination of the source of peritonitis;
- rehabilitation of the abdomen and the destruction of infection;
- intubation and provision of temporary drainage of the abdominal cavity so that the accumulated exudate can exit.
If there are suspicions of diseases that can cause peritonitis, or if there are signs of an already existing infection of the abdominal cavity, the patient should be urgently transported to the nearest hospital, having provided transportation independently, or with the participation of the ambulance team. In this case, only an emergency operation can save a person’s life.
It should be noted that with the slightest suspicion of peritonitis, the use of any painkillers, including analgin, diclofenac, morphine or pantopon, is strictly forbidden, since smearing the clinical picture makes diagnosis and treatment much more difficult.
Any attempt to stimulate intestinal motility by enemas or medication is also not allowed, as they prevent the inflammation from being limited, 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 conducted.
Patient transportation is carried out with maximum comfort. Before hospitalization, the patient must be provided with bed rest in a half-sitting state with bent knees. Put a cold compress on your stomach. Eating any food is prohibited, and drinking is limited.
Regarding the use of any medications, antibiotics, solutions for infusions, gastric lavage or the introduction of a gastric probe, the decision on their use is taken only by the ambulance doctor.
Considering that peritonitis is a secondary pathology, initially its treatment aims to remove the original source, for example, cut off an inflamed or perforated appendix, suture perforated gastric or intestinal ulcers, remove the inflamed gallbladder.
The operation for peritonitis is a difficult procedure for the patient, despite the fact that the patient is already in a difficult condition, so it is necessary to conduct intensive and quick preparation before the start of the surgical intervention. Administration of blood-substituting liquids, 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, a 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. The appointment is carried out 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 or several different types of microbes, therefore, primary antibiotic therapy is prescribed for this flora. A combination of sulfonamides, antibiotics, and antimicrobial antiseptics, such as tinidazole, ornidazole, or metronidazole, is commonly used. Next, the attending physician draws attention to the manifesting sensitivity of microflora, and adjusts therapy in accordance with it.
Introduced daily doses have a greater concentration of active substances. A group of penicillins is administered at the rate of 10-15 million units, ampioks, ampicillin and methicillin are injected in 3-5 grams. Aminoglycosides are applied by 2-3 grams (monomitsin and kanamycin), or by 240 mg (gentamicin). The group of cephalosporins represented by ceporin, kefzol and cefotaxime is used 5 grams per day. Aminoglycosides, except for gentamicin, are injected intracavitary, and the remaining drugs - through intramuscular or intravenous injections.
If a patient has hyperthermic syndrome after the operation, it is urgent to begin the procedure of restoring the water-electrolyte balance:
- physical cooling;
- intramuscular injections of hydrocortisone, analgin, diclofenac;
- intravenous perfalgana.
Detoxification treatment is carried out by infusion through:
- blood transfusions;
- reambirin prescriptions;
- the introduction of reopolyglukine and sodium chloride solution;
- administration of antihistamines and anti-enzymes.
In case of acute peritonitis, the patient forms a state of the so-called “catabolic storm,” that is, a sharp acceleration of metabolism. To slow it down, anabolic steroids should be administered to the patient, for example, retabolil, including saline solutions.
If the patient has repeated abundant vomiting, this indicates a violation of gastrointestinal motility and electrolyte balance. In order to eliminate the disorders, provided the kidneys function normally, 40-60 ml of fluid is injected per day for each kilogram of the patient’s daily, as well as potassium, sodium, magnesium and calcium chloride salts.
For the prevention of acute renal failure, the patient is prescribed heparin of 5 thousand units. intramuscularly 3 times the first day after surgery. The drug improves the rheological properties of blood microcirculation.
Stimulation of the function of the gastrointestinal tract is achieved by installing hypertonic enemas, as well as intravenous administration of sodium chloride solution, intramuscular injections of nibuphine, aceclidine, cerucal.
Depending on the prevalence of peritonitis, its source and degree of severity, the technique of the operation may differ slightly, but the general tactics of any surgical intervention is carried out in accordance with a specific scheme - immediately after the patient enters the hospital, they begin to prepare for the operation. Further, as soon as possible, you need to start doing the operation itself. After its completion, the recovery period initially goes to the intensive care unit.
Preparation for surgery
Preparation lasts no more than 3 hours, as a longer delay reduces the patient's chances of survival during and after surgery. At this time, an intensive infusion therapy. The purpose of the infusion of drugs before the operation is to improve the basic vital functions of the body through:
- correction of water and electrolyte balance;
- increase central venous and blood pressure;
- restore the amount of circulating blood in the bloodstream;
- pulse reduction;
- diuresis stabilization.
If the kidneys fail to recover in three hours, the operation is still carried out, but this reduces the chances of a favorable outcome for the patient.
In addition, the preparation for the operation includes the installation of a catheter in the subclavian vein to monitor the CVP and infusion. To measure hourly diuresis, catheterization of the bladder is performed.
The gastrointestinal tract also requires preparation measures - it is emptied using a special hollow probe, which is not removed until gastrointestinal motility is restored after surgery.
Course of operation
Modern medicine knows several schemes for the operation in peritonitis:
- closed: held laparotomically, with the elimination of the source, the rehabilitation of the cavity without drainage, and with the closure of a tightly laparotomic wound;
- semi-closed: classical method, similar to closed, but with drainage cavity;
- laparoscopy using video endoscopic techniques;
- combined: in this case, the classical semi-closed operation is carried out with programmed video endoscopic sanation of the cavity;
- half-open: classical scheme in combination with surgical debridement and temporary closure of a postoperative wound;
- open: it is performed without temporary closure of the abdominal wall, with surgical rehabilitation.
Before the operation, general anesthesia is performed if the diagnosis is made before the operation. If peritonitis is detected directly during laparotomy with local anesthesia, the patient is transferred to endotracheal anesthesia.
After the start of the anesthesia, it is necessary to provide access to the pathology source. In the presence of widespread peritonitis, a midline incision is made, the location and size of which depend on the source of inflammation. In the course of the operation, if the need arises, the incision is increased, expanding the boundaries up or down.
If a preoperative diagnosis of “peritonitis” is made in a patient, access is opened by a slit that is localized within the intended source of inflammation, for example, an oblique incision is made in the hypochondrium or in the iliac area. It is important that the length of the penetrating incision is sufficient to ensure complete and reliable rehabilitation of the inflammatory focus.
In the case when local peritonitis was initially suspected, and after a lateral incision, a common type was found, the lateral incision is supplemented with a corresponding median, through which rehabilitation is carried out. The side remains for drainage.
After the autopsy is performed, to minimize the morbidity of the operation, the patient is given a novocainic blockade of the reflexogenic zones through the mesentery root of the small intestine. A commonly used solution of novocaine 0.25% in an amount of 200 ml, heated to a temperature of 37 degrees.
The course of the operation begins with the revision of the cavity to detect the source of peritonitis. Exudate, which is found in the cavity, must be selected for bacteriological examination. After the effusion is removed from the peritoneum with gauze napkins and an electric suction pump, the cavity revision begins directly. If the operation is performed through a lateral incision, effusion is removed from it immediately after the discovery of the source of peritonitis.
According to the results of the examination of the cavity through the lateral access, physicians determine the presence or absence of indications for the application of a midline incision and a midline laparotomy. If the initially suspected source is not detected through a side incision, but the diagnosis is accurately confirmed and we are talking about peritonitis, then in the presence of a diffuse form, they immediately go to the midline laparotomy.
The audit in search of a source of inflammation is strictly in order, through an incision with a length of at least 20 centimeters. Initially, the inspection starts from the upper floor of the cavity, including, checked diaphragm and pancreas. Next, the doctor examines the lower floor, small 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 fully or partially affected organ (to conduct appendectomy, cholecystectomy, resection of part of the intestine), followed by closure of the wall;
- impose fistulas;
- 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 the conditions of diffuse, widespread peritonitis, the imposition of anamostosis between organs is prohibited, since the stitches in this case will be untenable. If possible, external drainage of organs is performed.
In case of perforated ulcer and peritonitis, only the perforation hole is sutured. After resection of the intestine with diffuse fecal or purulent peritonitis, the anastomoses do not overlap, it is necessary to overlay the terminal colostomy or ileostomy, possibly removing both intestinal knees near or at a minimum distance from each other, so that later the restoration of intestinal continuity is easier.
Sanitation during an operation to remove a local peritonitis focus does not require rinsing, since it may provoke a separation of infection further along the abdominal cavity. In this case, it is advisable to drain with suction and gauze sterile tampons. 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 lie.
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 removal of wash liquids with suction. Washing can be repeated several times as necessary, and the last time an antiseptic solution, for example, dioxidine, chlorhexidine, is necessarily used.
The duration of the operation to remove peritonitis is impossible to predict in advance, since the real picture of the state of the peritoneum is opened to the surgeon only after the immediate opening of the abdominal cavity.
During the operation to remove the common peritonitis, complicated by intestinal obstruction or pronounced adhesive process, bowel drainage can be performed. The most gentle for the patient method of conducting - drainage probe Millsra-Abbott nasogastrointestinal method. Especially important is the drainage of the initial jejunum to a length of 70 centimeters. Full drainage of the stomach is achieved by leaving a separate end of the probe in it.
Drainage of the abdominal cavity is one of the final stages of the operation. Drains are necessary to ensure adequate exudate outflow. Contraperties are made in the ileum and subbarine regions.
Possible consequences of the operation
Penetration into the abdominal cavity when removing the focus of peritonitis practically does not go without consequences.Often, patients in the postoperative period develop one or more complications that are observed and treated in the hospital. For example, the postoperative effects caused by the surgeon’s errors include:
- necrosis of the left part of the intestine, if it has undergone a destructive change: it shows a relaparotomy with resection of this area, followed by rehabilitation and drainage;
- unreasonably economical resection of the area of the intestine subjected to necrosis;
- the failure of the stitches of the anostomosis: this requires relaparotomy, intestinal decompression and fistula imposition on the intestine, then - the release of a bowel loop and drainage of the cavity.
In addition, if non-compliance with the requirements of asepsis during or after surgery, there is a high probability of infection in the seam. This consequence of the operation is easy to detect - the seam swells and turns red, starts to ache, and after a day or two of it pus begins to ooze. Against this background, signs of impaired general well-being develop: fever, weakness, chills.
Approximately 1 patient out of 100 people may develop repeated, so-called tertiary, peritonitis. People with a depleted body, an insufficiently balanced diet, a weak immune system, and also after prolonged antibiotic therapy are especially susceptible to it. In this case, be sure to carry out the operation again.
Paresis of the intestine is called a complete loss of their motor ability. If normally the intestine moves the food mass along its length due to its own motility, then with paresis such movement becomes completely impossible. This complication often occurs after diffuse peritonitis, as well as after long operations. The patient has total constipation and severe flatulence.
The formation of adhesions is a typical complication after peritonitis operations. It provokes 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. Possible formation in the late postoperative period. To solve the problem, most often, reoperation and surgical dissection of adhesions is needed.
The postoperative recovery period after surgery is divided into three stages:
- early (from 3 to 5 days);
- late (2-3 weeks after the intervention);
- remote (until the moment when it becomes possible to go to work, or before receiving disability).
Recommendations for patient care, depending on the phase, are somewhat different. In general, the rehabilitation period is managed 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 indications.
General principles of treatment after surgery:
- adequate pain relief;
- intensive infusion therapy;
- detoxification of the patient;
- antimicrobial effect;
- prevention of intestinal paresis;
- normalization of the system of the digestive tract and all other systems affected by the pathology.
Primary care after surgery begins immediately after its completion, and lasts until the patient is fully able to work.
In the early phase of the patient on a gurney, they are transferred to the intensive care unit, providing him with warmth and comfort in the ward. A warm water bottle is placed in the legs, and a bubble with ice for a period of up to half an hour is applied to the postoperative wound. The patient should lie in bed in the Fowler position, that is, the head end is raised by 45 degrees, the legs bend at the knees, and bend at the hip joints. Unconscious patients are laid horizontally, without a pillow under their heads.
In the first 2-3 days there is a strict bed rest and hunger. According to the testimony of the patient is connected to the system of artificial ventilation of the lungs. On the second day, the first dressing change takes place. If the postoperative dressing got off or got blood from the wound, they change it earlier. Every hour, control of the pulse, respiration, urine separation and discharge through the drains is carried out. Drains need to be periodically washed, and the dressings around the drains are changed personally by the doctor.
From the second day parenteral nutrition is prescribed via infusion - a 10% glucose solution, amino acids, salts are administered to the patient. 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 intestinal peristalsis is observed, enteral feeding with liquid mixtures via a nasogastric tube is permitted.
After the second day, being in bed permanently becomes undesirable, since it contributes to the appearance of complications. After the first day, the patient needs to start moving in bed - bending and unbending limbs, turning. For 2-3 days you need to start sitting down in bed, with the help of a nurse to move around the ward.
The late phase of recovery begins when a person is established stable intestinal motility, there is a discharge of gases, stool. Such signs are indications for transferring the patient to independent feeding without a probe. Food is allowed in liquid and ground form, food fractional 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 grinded low-fat cottage cheese, soft-boiled eggs, boiled meat and fish of low-fat varieties, chicken (all in the form of ground meatballs, souffle or meatballs), slimy soups and broths. Oatmeal and rice porridge in the boiled state is allowed. Any hard-to-digest products 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 in the department are allowed. The stitches are removed after 8-9 days, and the drainage is removed already 4 days after the operation. On the day of suturing, the patient is usually discharged.
After discharge, the mode of the operated does not immediately return to the usual direction. In the first months he needs to comply with the list of restrictions, for example, it is forbidden to lift weights more than 3 kilograms, to engage in physical activities. Intimate life is excluded for up to one and a half months. It is necessary to perform therapeutic gymnastics, which includes training of the respiratory organs, cardiovascular system, strengthening and moderate stimulation of the abdominal muscles, gradual restoration of working ability. During this period, limited walking, skiing and swimming are beneficial for the patient. In some cases, sanatorium treatment is prescribed.
Meals are based on the principle of fragmentation, at least 5 times a day. Overeat, like starving, it is impossible. All food should be boiled or steamed, without crusts, zazharki and spices. Annoying and heavy for the digestive tract products are excluded. In the future, the use of lard, margarine, smoked meats, sugar, pastry, jams and sweets is limited.
Features of surgery for peritonitis in children
Treatment of pediatric peritonitis, similarly to adult pathology, requires immediate surgical intervention. When delivering a small patient, he should not be given food and drink, it is forbidden to put enemas. Preoperative preparation takes several hours.
Diagnosing children's peritonitis causes some difficulties, since the child behaves restlessly, he cannot objectively explain what it is, how, and in what place he has a pain.
Preparation before surgery takes from 1 to 5 hours, and the question of how long it will be spent in a particular case is decided by the doctor. As part of the preparation, the use of antibacterial drugs, cardiovascular and painkillers is prescribed. Intrarenal blockade with novocaine solution, 10 ml of 0.25% solution on each side is injected. Gastric lavage is carried out using a constant probe. Newborn and younger children are installed gas vent, appointed by proserin. There is a venesection and the introduction of 25-30 ml of plasma simultaneously with the introduction of a 20% glucose solution.
Dimedrol, suprastin or pipolfen is also used as a medication preparation. At elevated body temperature, it is necessary to prescribe a 1% solution of amidopyrine together with a 50% solution of analgin.
The objectives of the operation in children are similar to the tasks of adult surgery:
- elimination of the source of peritonitis;
- removal of effusion;
- sanitation and drainage.
If the peritonitis is diffuse, it is shown washing during surgery, as well as prolonged washing in the period after surgery. 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 that 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, includes its perforation, or because of meconial obstruction, if congenital cystic fibrosis is present in the fetus.
During the surgical treatment, the surgeon restores the permeability of the intestinal sections, sutures the perforation hole, conducts the rehabilitation of the cavity and introduces antibiotics there. In case of meconial obstruction, 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 the operation - as in adults, they are prescribed special rules for the entire recovery period. Conducted etiotropic treatment with antimicrobial and anti-inflammatory drugs. Cephalosporins, metrogyl, aminoglycosides can be used. According to the testimony of physiotherapy. Immunocorrection is performed 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 the duration of therapeutic measures for peritonitis can be viewed in several aspects. For example, it is impossible to predict the duration of the operation in advance - depending on the exact diagnosis, the extent of the pathology, the condition and the age of the patient, it can take from several hours to a day.
Since the treatment does not end at the end of the surgical intervention, it can also include the postoperative period of inpatient stay. During the normal course of recovery, the patient can be discharged home after 9-10 days, after removing the stitches. If after the operation, complications, inflammation of the suture, re-peritonitis or the formation of adhesions begin, the discharge dates are postponed. Some patients remain in the hospital for several months until a final recovery occurs, when the attending physician considers it possible to find the patient at home.
Full recovery after surgery, return to the usual mode 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 necessarily seek medical help, and be prepared for the fact that the operation is inevitable. Only through the surgical removal of the source of infection, as well as the strict observance of all postoperative rules, can pathology, normalization and restoration of working ability be achieved.
Specialty: infectious diseases specialist, gastroenterologist, pulmonologist.
Total experience: 35 years.
Education: 1975-1982, 1MMI, San gig, high qualification, infectious diseases doctor.
Science degree: doctor of the highest category, PhD.
- Infectious diseases.
- Parasitic diseases.
- Emergency conditions.