The cathedra of the faculty and hospital surgery

The cathedra of the faculty and hospital surgery of the treatment faculty of the Tashkent medical academy Acute peritonitis

« Me and my generation are well-manered in a fair of God and peritonitis» acad. Vagner (1876).

Peritonit – inflammation of the visceral and parietal peritoneum, which conduct by the own diseases and during short time induct the defeats of the patient.

Spreading of the peritonitis Primary Secondary Females Males

Death at the peritonitis Савчук Б. Д. , 1979 Шалимов А. А. , Попов В. А. , 1985 Гостищев В. К. , 1981 2002 Acute peritonitis Postoperative peritonitis

The reasons of the high morbidity at the peritonitis: 1) Late addressing of the patients. 2) Significant increasing of the number of the patients of elder and senile age. 3) Increasing of the number of the oncologic diseases. 4) Increasing of the number of the patients with the diabetes. 5) Resistance of the microorganisms to the antibiotics and not enough efficiency of the antibacterial therapy. 6) Mistakes of the diagnostic and surgical tactic. 7) Special gravity of the currency of the festering process.

Etiology of the peritonitis 1. Microbe (bacterial) peritonitis: • Not specific, inducted with the microflora of the GIP. • Specific, inducted with the microflora not from GIP 2. Aseptic (abacterial) peritonitis 3. Traumas and defeats of the organs of the abdominal cavity. 4. Special forms of the peritonitis: • canceromatous, parasite, reumatoid, granulematous.

Main sources of the infection of the abdominal cavity 1. 2. 3. 4. 5. 6. 7. 8. Appendix 30 -65% Stomach and duodenum 7 -14% Female reproductive organs 3 -12% Intestine 3 -5% Gall bladder 10 -12% Pancreas 1% Postoperative peritonitis % Traumatic defeats 2, 7%

Acute gangrenous appendicitis Flegmona of the stomach

Reasons of the peritonitis Acute flegmonous cholecystitis холецистит Tube pregnancy Breakup of the gonad’s cyst

Crone’s disease Abscess of the pancreas Flegmona of the caecum

Strangulation of the hernias. Wall strangulation

Classification by B. D. Savchuk, 1979 I. Local peritonitis. 1)Limited 2)Not limited. II. Spreaded peritonitid. 1)Diffuse 2)Poure.

By the stages of the currency Reactive (the first 24 h. ) Toxic (24 -72 h. ) Terminal (over 72 h. )

Clinic picture of the acute pancreatitis depends on Etiology of the peritonitis Virulent of the microflora Localization of the process Spreading of the process Reactivity of the organism Stage of the disease

Symptoms of the acute pancreatitis Local General Constant symptoms of the acute pancreatitis Not constant symptoms of the acute pancreatitis

Constant symptoms of the peritonitis 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Pain in the abdomen, pain at the palpation of the abdomen Shetkin-Blumberg’s symptom Muscular effort of the anterior abdominal wall Dry and covered tongue Sickness, retching, thirst Hippocrates's face Paresis of the intestine, stopping of the gases and excrements. Change of the breathing Rising of the temperature, backlog of the temperature from the pulse “scissor's symptom” Pain at the research from the rectum Leucocytosis in bloodв крови, movement to the left, acceleration of SES Changes in urine

Symptoms of the acute peritonitis at the reactive stage Local Pain in the abdomen Significant effort of the abdominal muscules Выраженный симптом Щеткина-Блюмберга The peristaltic of the Intestines is reduced General Acceleration to 120 beats in a min. Increased BP Acceleration of the breathing Rising of the temperature

Symptoms of the acute peritonitis at the toxic stage Local Reducing of the Pain in the abdomen Reducing of the effort of the muscles of the abdomen Shetkin-Blumberg is not significant The intestinal peristaltic isn’t heared General Increased pulse over 120 beats in a min. Reducing of the BP Euphoria Sharp lines of face, pallor Hectic temperature

Symptoms of the acute peritonitis at the terminal stage Local General Hippocrates's face Poured pain in the all abdomen Adynamy Significant meteorism Intoxicated dilirium Absence of the intestinal peristaltic Retching with the smell of the excrement PON Decreasing with the uretra

Diagnostic f the acute peritonitis • • • Complaints Anamnesis of life and disease Objective status Local status Clinic-biochemical researhes

Instrumental methods of researches Not invasive • US • Overview X-ray • Rheography Invasive • laparocentesis • Method of the wandering catheter • Diagnostic laparoscopy • Diagnostic laparotomy

US of the abdominal cavity Presence of the free liquid in the abdominal cavity

Overview X-ray of the abdominal cavity At the overview X-ray overwinding chalices of Cloyber Presence of the gas and loquid in the extended intestine

Diagnostic laparoscopy Is the reliable method, that allows directly find out the source of the peritonitis, presence and character of the exudates.

Diagnostic laparotomy In the complicated cases aloows in good time state the most right diagnosis

Treatment of the patients with the acute peritonitis includes three periods: • Preoperative preparation • Operative treatment • Postoperative preparation

Problem of the preoperative preparation At one side Is the correction of defeated functions to the level at which the surgical treatment is the least dangerous At another It is necessary to liquidate the festering process in the abdominal cavity (reason of the defeat of the haemosta sis), that limits with the minimal short terms of decision of all treatmentdiagnostic problems of the period

As harder the state of the patient, so longer lasts the preoperative preparation Not more than 2 hours Early operative intervention

I. correction of the volume, electrolytes and microcirculatory defeats Lactosol Лактосоль Disol Дисоль Ringer’s Раствор Solution Рингера 30 -40 мл 30 -40 ml 10% р-ра sol. хлористого Chloride калия calcium Rheopoly glucin and haemodes

II. Correction of the peptide defeats Альбумин Albumin 100 -200 мл ml or СFFP ЗП 200 -300 мл ml

III. Decompression of the GIP and reducing of the secretion Zantak 2, 0 im To reduce the secretion of the GIP and prevent the aspiration

Preoperative preparation includes VI. Liquidation of the VI. Устранение анемии anemia VII. Устранение VII. Liquidation of the метаболического metabolic acidosis ацидоза VIII. Блокада VIII. Blockade of the болевых painful impulses импульсов

Preoperative preparation includes: IX. Введение IX. Introducing of the глюкокортикоидов glucocorticoids X X. . Введение X. Introducing of the ингибиторов inhibitors of протеаз theпротеаз proteases XI. Антибактериальная XI. Antibacterial therapy терапия

The main method of treatment of the acute peritonitis Urgent operative treatment

Main principles of the operative treatment at the peritonitis • • General anesthesia with forced breathing Wide access Revision of the organs of the abdominal cavity Liquidation of the source of the peritonitis Sanation of the abdominal cavity Nasointestinal intubation Drainage of the abdominal cavity

Frequently used access at the acute peritonitis: Middle-median laparotomy

State of the peritoneum: – color, – transparency – thickness, – hypostasis, – hyperemia, – injection of the vessels

Characteristic of the exudates Serous-fibrinous Fibrinous-pus Hemorrhagic Ichorous Urine Bilious Excremental Mixed

Revision of the organs of the abdominal cavity Main rule: • solving of the stages of revision of the organs of the abdominal cavity.

Liquidation of the source of the peritonitis Acute destructive appendicitis Appendectomy

Liquidation of the source of the peritonitis Acute destructive cholecystitis Cholecystectomy

Liquidation of the source of the peritonitis Peritonitis on the background of the gangrene of the intestine Resection of the intestine with the EEA “side-by-side”.

Liquidation of the source of the peritonitis Peritonitis on the background of the perforation of the ulcer of stomach Sewing of the perforation Resection of the stomach

Choose of the operative treatment at the gastroduodenal peritonitis Stage of fermentative peritonitis of festering peritonitis Radical operation Palliative operation Resection of the stomach TV+antrumec tomy TV+ДЖО Sewing of the perforative ulcer

Nasointestinal intubation

Drainage of the abdominal cavity At the local peritonitis – drainage by 1 or 2 drainages At the diffuse peritonitis – drainage by 2 or 3 drainages Drainage at the poured peritonitis

Peritoneal dialysis • Method of cleaning of the organism from the bad materials, based on the high adsorption possibility of the peritoneum. • Essence of the dialysis: Internal ambience of the organism Half-permeable membrane Dialysing solution

я Running dialysis

я The abdominal cavity is filled by the dialysate Fractional dialysis

я Method of our clinic

Complications at the peritonitis Specific • complications in a wound anyerior abdominal cavity: ffestering of a wound, flegmona of the anterior abdominal wall. • abscess of the abdominal cavity • eventration • paralytic intestinal obstruction • defeat of stitches • postoperative peritonitis • intestinal fistulas • sepsis. Not specific • Hypostatic pneumonia, • Thromboembolic complications • Encephalopathy, delirium • DIC - syndrome, • Acute brathing, heart- vascular, renal-hepatic insufficiency.