What Is Acute Peritonitis?

Acute peritonitis can be classified from the following different perspectives:

Chen Jie	(Chief physician)	Beijing Chaoyang Hospital General Surgery
Wang Minggang	(Attending physician)	Hernia and abdominal wall surgery at Beijing Chaoyang Hospital

Acute peritonitis is a common surgical acute abdomen. Its pathological basis is that the peritoneal wall layer and / or visceral layer are stimulated or damaged for various reasons and have an acute inflammatory reaction. Most of them are caused by bacterial infection, chemical stimulation or physical Caused by damage. Most of them are secondary peritonitis, which originate from organ infections in the abdominal cavity, perforation of necrosis, and trauma. Its typical clinical manifestations are the triad of peritonitis-abdominal tenderness, abdominal muscle tension and rebound pain, as well as abdominal pain, nausea, vomiting, fever, elevated white blood cells, etc., which can cause blood pressure drop and systemic toxic reactions in severe cases. Treatment can die from toxic shock. Some patients may have complications such as pelvic abscess, intestinal abscess, sub-diaphragmatic abscess, popliteal abscess, and adhesive intestinal obstruction.

Western Medicine Name: Acute peritonitis
English name: acute peritonitis
Affiliated Department: surgical-
Disease site: peritoneum

The main symptoms: Abdominal tenderness, abdominal muscle tension and rebound pain, abdominal pain, nausea, vomiting, fever, etc.
Main cause: Bacterial infection, chemical stimulation, physical damage, etc.
Contagious: Non-contagious

Acute peritonitis disease classification

Acute peritonitis can be classified from the following different perspectives:

According to the cause can be divided into bacterial peritonitis and non-bacterial peritonitis. Non-bacterial peritonitis is often caused by gastric, intestinal, pancreatic juice leaking into the abdominal cavity caused by gastric, duodenal acute perforation, acute pancreatitis, etc. However, if the lesions do not heal, bacterial infections are more common after 2 to 3 days, which is no different from bacterial peritonitis.

According to clinical experience, it can be divided into three categories: acute, subacute and chronic.

According to the scope of inflammation, it can be divided into diffuse peritonitis and localized peritonitis.

According to the pathogenesis, it can be divided into secondary peritonitis and primary peritonitis. The vast majority of peritonitis is secondary peritonitis. Primary peritonitis is rare, and there is no original disease in the abdominal cavity. Pathogens infect the peritoneum by blood or lymphatic spread from extra-abdominal lesions. It is more common in immunocompromised liver cirrhosis, nephrotic syndrome, and infants and young children.

Causes of acute peritonitis

(A) secondary peritonitis

Acute perforation and rupture of abdominal organs: the most common cause of acute secondary peritonitis [1]. Cavity organ perforations often occur suddenly due to the progression of ulcers or gangrene lesions, such as acute appendicitis, peptic ulcer, acute cholecystitis, typhoid ulcer, gastric or colon cancer, ulcerative colitis, ulcerative intestinal tuberculosis, amoebic Bowel disease, diverticulitis and other perforations cause acute peritonitis. Parenchymal organs such as the liver and spleen can also rupture due to abscesses or cancers.

The spread of acute infections of the abdominal viscera: for example, acute appendicitis, cholecystitis, pancreatitis, diverticulitis, ascending infections of the female genital tract (such as puerperal fever, salpingitis), etc., can spread to the peritoneum and cause acute inflammation.

Acute intestinal obstruction: Intussusception, intestinal torsion, incarcerated hernia, mesenteric vascular embolism or thrombosis caused by strangulated intestinal obstruction, due to intestinal wall damage, lose the normal barrier function, intestinal bacteria can pass through the intestinal wall Invades the abdominal cavity and produces peritonitis.

Abdominal surgery: When sharp weapons and bullets penetrate the abdominal wall, they can pierce hollow organs or introduce external bacteria into the abdominal cavity. Abdominal injuries can sometimes rupture internal organs and produce acute peritonitis. During abdominal surgery, external bacteria can be brought to the abdominal cavity due to inadequate disinfection. It can also cause local infection to spread due to careless surgery, or leakage of sutures in the stomach, intestine, gallbladder, and pancreas. Sometimes due to abdominal puncture. Liquid or neglecting aseptic operation during peritoneal dialysis can cause the consequences of acute peritonitis.

(Two) primary peritonitis

Primary peritonitis is also called spontaneous peritonitis, and there is no primary lesion in the abdominal cavity. The pathogenic bacteria are mostly hemolytic streptococcus, pneumococcus or E. coli.

The way of bacterial invasion is generally: bloodstream spread, pathogenic bacteria spread from the respiratory tract or infection to the peritoneum through bloodstream. Primary peritonitis of infants and children mostly belongs to this category; Ascending infection, bacteria from female reproductive tract Direct diffusion through the fallopian tube to the peritoneal cavity, such as gonorrheic peritonitis; Direct diffusion, when urinary tract infections, bacteria can spread directly to the peritoneal cavity through the peritoneal layer; When the body's resistance such as scarlet fever or malnutrition is reduced, bacteria in the intestinal cavity can enter the abdominal cavity through the intestinal wall, causing peritonitis.

Pathogenesis and pathophysiology of acute peritonitis

The pathological changes of acute peritonitis often differ significantly due to the source and mode of infection, the virulence and quantity of pathogenic bacteria, and the patient's immunity.

Once the infection enters the abdominal cavity, the peritoneum immediately becomes inflammatory, manifested as congestion, edema, and exudate. Fibrin in the exudate can promote intestinal loops, the greater omentum, and other viscera to adhere to the peritoneal inflammation zone and limit the expansion of inflammation. However, if the infection is not removed, the perforated viscera is repaired, or abdominal drainage is performed, or the bacterial toxicity is too strong or excessive, or the patient's immune function is low, the infection spreads to form diffuse peritonitis.

After treatment of peritonitis, the inflammation can be gradually absorbed, and the exuding fibrin can be mechanized, causing adhesions between the peritoneum, intestinal loops, and omentum, and may be caused by mechanical intestinal obstruction.

After the formation of peritonitis, a large amount of bacteria and toxins in the peritoneal exudate are absorbed through the peritoneum and enter the blood through the lymphatic vessels, resulting in a series of symptoms of sepsis.

In the early stages of peritonitis, bowel movements increase and then weaken. Development of intestinal paralysis. Intestinal secretion increases after intestinal paralysis occurs. Absorption is reduced, and a large amount of gas and fluid accumulate in the intestinal cavity. The intestinal wall, peritoneum, and mesentery are edema and a large number of inflammatory exudates enter the abdominal cavity, causing a large amount of water, electrolytes and proteins to be lost. Reduces blood volume sharply. Some people estimate that the amount of fluid loss in patients with diffuse peritonitis can reach 4-6 liters within 24 hours.

Under the combined effect of reduced blood volume and toxemia, the adrenal cortex secretes a large amount of catecholamines, which leads to an accelerated heart rate and vasoconstriction. Increased secretion of antidiuretic hormones and aldosterone leads to water and sodium retention, which causes hyponatremia because water retention exceeds sodium retention. Decreased extracellular fluid and acidosis reduce cardiac output and impair cardiac contractility. Abdominal distension and diaphragmatic muscle uplift reduce the patient's ventilation and shortness of breath, leading to tissue hypoxemia. Under the combined effects of low blood volume, low cardiac output, and increased antidiuretic hormone and aldosterone, the glomerular filtration rate decreased and urine output decreased. Due to the increased metabolic rate and insufficient tissue perfusion and tissue hypoxia metabolism, lactic acidemia occurs. All of these can cause disturbances in body fluids, electrolytes, acid-base balance, and damage to important organ functions such as the heart, lungs, and kidneys, leading to death of patients without effective treatment.

Clinical manifestations of acute peritonitis

The main clinical manifestations of acute peritonitis include abdominal pain, abdominal tenderness, abdominal muscle tension and rebound pain, often accompanied by poisoning such as nausea, vomiting, abdominal distension, fever, hypotension, fast pulse, shortness of breath, and leukocytosis. Because this disease is mostly a complication of a certain disease in the abdominal cavity, there are often primary symptoms before and after onset.

(A) clinical symptoms

1. Abdominal pain Abdominal pain is the most common and most common symptom, most of which occur suddenly, persist, and rapidly expand. Its nature depends on the type of peritonitis (chemical or bacterial), the extent of inflammation and the patient's response. When diffuse peritonitis is caused by acute puncture of the stomach, duodenum, gallbladder and other organs, the digestive fluid irritates the peritoneum, and suddenly produces severe abdominal pain, and even produces so-called peritoneal shock. In a few cases before the secondary bacterial infection, a large amount of fluid can be leaked from the peritoneum and the irritants are diluted, and the symptoms of temporary relief of abdominal pain and peritoneal irritation symptoms appear to improve. When the secondary bacterial infection occurs, the abdominal pain is aggravated again. Peritonitis caused by bacterial infection usually has local pain of the original lesions (such as appendicitis, cholecystitis, etc.). The abdominal pain is relatively mild during perforation, and it is swollen or dull. It is not as severe as the acute puncture of the stomach and gallbladder, and pain. Gradually increased and spread from the lesion area to the whole abdomen. The degree of abdominal pain varies from person to person, some patients report abnormally intense persistent pain, and others only describe dull pain or discomfort.

2. Nausea and vomiting Due to the peritoneal irritation, reflex nausea and vomiting are caused. The discharge is stomach contents, sometimes with bile. Later, due to paralytic intestinal obstruction, vomiting becomes persistent without nausea. The discharge can be yellow. Green bile and even tan feces-like contents.

3. Other symptoms In the case of peritonitis due to acute perforation of the cavity organs, collapse is common due to peritoneal shock or toxemia. At this time, the body temperature is mostly lower than or near normal; when the collapse improves and the peritonitis continues to develop, the body temperature begins to gradually Increase. If the primary disease is an acute infection (such as acute appendicitis and acute cholecystitis), the body temperature is often higher than the original when acute peritonitis occurs. In the case of acute diffuse peritonitis, due to a large amount of fluid exuding from the peritoneum, high congestion and edema in the peritoneum and intestinal wall, a large amount of fluid accumulating in the paralyzed intestinal cavity, coupled with vomiting and dehydration, the effective circulating blood volume and total blood potassium were significantly reduced. . In addition, due to decreased renal blood flow, worsened toxemia, impaired heart, kidney, and peripheral blood vessel function, patients often have hypotension and shock, and the pulse rate may not be reached, and they may also have thirst, oliguria, or anuria. , Abdominal distension, no anal exhaust. Sometimes there are frequent hiccups, and the reason may be that the inflammation has spread to the diaphragm.

(Two) signs

Patients with peritonitis often have painful expressions. Coughing, breathing, and turning your body can make your abdominal pain worse. The patient was forced to take a supine position with flexion of both lower extremities and shallow frequency of breathing. In the later stage of toxemia, due to high fever, no diet, dehydration, acidosis, etc., the central nervous system and various important organs are in a state of inhibition. At this time, the patient is showing depression, general coldness, gray complexion, dry skin, Eyes and cheeks are sunken, nose is sharp, and forehead is sweaty.

Abdominal examination reveals a typical triad of peritonitis: abdominal tenderness, abdominal muscle tension, and rebound pain. In localized peritonitis, the three are confined to one part of the abdomen, while in diffuse peritonitis, the whole abdomen is seen, and abdominal breathing becomes shallow, abdominal wall reflexes disappear, and bowel sounds decrease or disappear. Tenderness and rebound pain are almost always present, and the degree of abdominal muscle tension varies with the patient's overall condition. Generally in the acute perforation of peptic ulcer, the abdominal wall muscles are plank-like rigidity, and in the case of extremely debilitating cases such as typhoid perforation or advanced toxemia, the signs of abdominal muscle spasm or tonicity may be mild or absent. When there is a large amount of exudate in the abdominal cavity, mobile dullness can be detected. When the gastrointestinal puncture caused the gas to dissipate in the abdominal cavity, the liver dullness area in about 55 to 60% of the cases shrank or disappeared. When the inflammation is localized, a localized abscess or inflammatory mass is formed, and the abdominal wall may swell, the mass may be blurred. Masses or abscesses in the pelvis can sometimes be reached by digital rectal examination.

Diagnosis of acute peritonitis

According to typical symptoms and signs, white blood cell count and classification, abdominal X-ray examination, B-ultrasound and CT examination, the diagnosis of acute peritonitis is generally not difficult.

Auxiliary examination of acute peritonitis

Abdominal puncture: It is a simple, easy and economical inspection method. If the fluid in the abdominal cavity can be obtained, the naked eye can generally determine whether there is peritonitis and what type of peritonitis, plus microscopy, bacterial smear and necessary Biochemical tests (such as amylase assays) have higher diagnostic value.

Tuberculous peritonitis is grass-green transparent ascites; the extracted fluid is yellow, turbid, bile, and odorless during acute perforation of the gastroduodenum; food residues may be contained during perforation after satiety; the extracted fluid is bloody during acute severe pancreatitis The pancreatic amylase content is high; the extraction fluid during perforation of acute appendicitis is purulent and slightly odorous; the extraction fluid for narrower intestinal obstruction is bloody and heavy odor; if the abdominal puncture is completely fresh and not coagulated, it is considered to be in the abdominal cavity For substantial organ damage, it is also necessary to exclude whether the organ or blood vessel is punctured.

For secondary peritonitis, the location of the primary lesion should be determined for further treatment. But sometimes it is not easy when the signs of peritonitis are obvious. Generally speaking, X-ray examination indicates gastrointestinal perforation when free gas is present below the diaphragm. If the symptoms do not improve after gastrointestinal decompression and initial treatment, the possibility of gallbladder puncture should be considered. Female patients should consider salpingitis and ovarian inflammation, and elderly patients should consider the possibility of colon cancer or diverticulum perforation.

Pleuritis and pneumonia can cause fever, epigastric pain, and acute myocardial infarction. Acute pancreatitis, perirenal abscesses, and even shingles can cause fever and abdominal pain. However, it is not difficult to identify according to the medical history, physical signs and corresponding examinations.

Differential diagnosis of acute peritonitis

The symptoms and signs of primary peritonitis are similar to those of secondary peritonitis, and laboratory test results are also the same. But only non-surgical treatment can be used, which is very different from secondary peritonitis. Therefore, attention should be paid to identification. The main points to distinguish between primary peritonitis and secondary peritonitis are as follows:

1. Primary peritonitis is mainly seen in patients with immunocompromised cirrhosis, ascites, nephrotic syndrome, infants and young children, especially girls under 10 years of age. Most secondary peritonitis is free of such limitations.

2. The onset of primary peritonitis in patients with cirrhosis and ascites is slow, and the "triad of peritonitis" in abdominal signs is often not obvious. Primary peritonitis, which occurs in infants and young children, has a more rapid onset, and the "triad of peritonitis" is not as obvious as secondary peritonitis.

3. The absence of primary infections in the abdominal cavity is the key to the difference between primary peritonitis and secondary peritonitis. X-ray examination if free gas under the diaphragm is evidence of secondary peritonitis.

4. Abdominal puncture, take ascites or peritoneal exudate for bacterial smear and culture examination. Primary peritonitis is a single bacterial infection and secondary peritonitis is almost always a mixed bacterial infection. ^[1-2]

Acute peritonitis disease treatment

Non-surgical treatment of acute peritonitis

Non-surgical treatment is possible for patients with mild disease, or those whose disease course is longer than 24 hours, and whose abdominal signs have been reduced or there is a tendency to reduce, or those who are contraindicated to surgery with cardiopulmonary diseases. Non-surgical treatment can also be used as preparation before surgery.

1. Posture: Generally, a semi-recumbent position with a forward tilt of 30 ° to 45 ° is used to facilitate the inflammatory exudate to the pelvic cavity, reduce the symptoms of poisoning, facilitate localization and drainage, and promote the downward movement of abdominal organs and abdominal muscle relaxation. To reduce the impact of breathing and circulation due to abdominal distension and compression of the diaphragm. If the shock is severe, take a supine position or raise the shock position of the head, trunk and lower limbs by about 20 °.

2. Fasting and gastrointestinal decompression.

3. Correct the imbalance of body fluid, electrolyte and acid-base balance. Sufficient infusion should be given, so that the daily urine volume is around 1500ml, or the urine volume per hour is 30-50ml. It is best to consider the infusion volume based on the results of the central venous pressure measurement. In addition, the amount of potassium chloride or sodium salt to be input should be calculated based on the results of the blood electrolyte measurement, and treatment with sodium bicarbonate or the like should be considered according to the blood carbon dioxide binding rate or blood pH.

4. Antibiotics: Antibiotic therapy is the most important medical treatment for acute peritonitis. Generally, secondary peritonitis is a mixed infection of aerobic and anaerobic bacteria, so broad-spectrum antibiotics or a combination of antibiotics should be used for treatment. Generally, the third-generation cephalosporins are sufficient to kill E. coli without drug resistance. . If pathogenic bacteria can be obtained, antibiotics are more effective if selected according to the results of drug sensitivity tests. It should be emphasized that antibiotics cannot replace surgical treatment, and some cases can be cured only by surgery.

5. Calorie supplementation and nutritional support: The metabolic rate of acute peritonitis is about 140% of normal people, and the daily caloric requirement is 12550 ~ 16740kJ (3000 ~ 4000kcal). Intravenous fat emulsion and glucose supplementation of calories should be supplemented with albumin, amino acids, branched chain amino acids, etc. to improve the patient's overall condition and enhance immunity. For patients who cannot eat for a long time, deep vein hypernutrition should be considered.

6. Sedation, analgesia, and oxygen inhalation: For those who have severe pain or irritability, if the diagnosis is clear, pethidine can be used as appropriate. When the diagnosis is not clear or observation is needed, analgesics are not used for the time to avoid covering up the condition.

Acute peritonitis surgery

The vast majority of secondary peritonitis requires surgery.

1. Indications for surgery: After 6 to 8 hours of non-surgical treatment (usually no more than 12 hours), the peritoneal inflammation and signs do not alleviate but worsen; severe primary disease in the abdominal cavity, such as perforation of the gastrointestinal tract or gallbladder, Peritonitis due to narrow intestinal obstruction, abdominal organ damage and rupture, and anastomotic leakage in the short term after gastrointestinal surgery; inflammation in the abdominal cavity is severe, there is a large amount of fluid, and severe symptoms of intestinal paralysis or poisoning occur, especially Shock manifestation; the etiology of peritonitis is unknown, there is no limited trend.

2. Principles of surgical treatment: clear the cause, deal with the primary disease such as suture the gastrointestinal perforation, remove the appendix, gallbladder and other lesions such as gangrene perforation; thoroughly clean the abdominal cavity, suck the pus and fluid in the abdominal cavity, remove food residues, Feces, foreign bodies, etc., can be washed with metronidazole and normal saline to clean the abdominal cavity. Whether antibiotics should be used before closing the abdomen is controversial. Drain adequately to prevent the occurrence of abdominal abscess. For severe infection, put more than two drainage tubes, and Can do abdominal irrigation.

3. Postoperative treatment: fasting, gastrointestinal decompression, fluid replacement, application of antibiotics and nutritional support treatment to ensure that the drainage tube is unobstructed.

4. Choice of surgical methods. In the choice of surgical methods for acute peritonitis, in addition to traditional laparotomy, laparoscopic exploration can also be selected. Laparoscopy has the advantages of thorough cleaning of the abdominal cavity, less trauma, quick recovery, and fewer complications. Not only can it clear the diagnosis, avoid the delay caused by the unknown diagnosis, but also guide the choice of open incisions or complete some surgical treatments. Some patients with acute peritonitis are a safe and effective option. ^[3-4]

Prognosis of acute peritonitis disease

Due to advances in diagnosis and treatment, the prognosis of acute peritonitis has improved compared to the past. But the case fatality rate is still around 5-10%. Primary peritonitis that occurs on the basis of cirrhosis and ascites is as high as 40%. Delayed diagnosis and delayed treatment, the elderly and children with heart, lung, kidney disease and diabetes have poor prognosis.

Prevention of acute peritonitis

Early and appropriate treatment of inflammatory diseases in the abdominal cavity that may cause peritonitis is a fundamental measure to prevent peritonitis. Any abdominal surgery or even abdominal puncture should be strictly performed aseptically. Antibacterial drugs should be given orally before bowel surgery to reduce the incidence of peritonitis.

Acute peritonitis diet note

Eat small, frequent meals, avoid eating cold, irritating food, and have a regular diet; avoid heavy physical labor; maintain a comfortable mood; return to the clinic as soon as possible when your stomach is unwell.