O.O. Bohomolets National Medical University

CHAIR OF GENERAL SURGERY No. 1

Approved by methodical meeting of the chair"__"___2007, minutes No.___

Prof., MD, PhD. O.I. Dronov

METHODICAL GUIDES FOR PRACTICAL LESSONSMaterials for teachers and students

Subject:Peritonitis: Inflammation of the peritoneal cavity. Classifications, clinics,

diagnosis, prophylaxis

Course 3Faculties 2 and 3, faculty for educating the doctors for Ukrainian Army, faculty of medical psychologyDuration: 4 academic hoursPrepared by assistant M.D. S.V. Zemskov

Kyiv 2007

I. Priorities of the subject:

The concept of the relative and absolute indications for a surgery exists in the surgical practice. The absolute indication is the patient's condition which could not be corrected by the conservative means. Peritonitis or he threat of peritonitis is the most prevalent absolute indication for the urgent abdominal surgery. Therefore, the knowledge of the clinical features of peritonitis and the major principles of its treatment is of vital importance for the clinicians.

II. The aims of training:

А-1. Scope of the knowledge: - Anatomy and histology of the peritoneum and the greater omentum;- Resorptive and exudative properties of the peritoneum;- Biological and chemical characteristics of the secretions of the glands comprising the

digestive system and other biological fluids of the body capable of contacting the peritoneum;

- Features of the local and general inflammatory response of the peritoneum;- Clinical symptoms and syndromes peculiar to peritonitis

А-2. Student should be acquainted with the following subjects:- Mechanisms of the development of localized and general peritonitis;- Extent of clinical manifestations depending on the etiology of peritonitis;- Pathogenesis of complications due to peritonitis;- Hazards of peritonitis and importance of the timely adequate treatment.

А-3. Scope for practical skills:- Competent anamnesis for the assessment of the causes of peritonitis;- Use of physical examination techniques and assessment of pathognomonic symptoms of

peritonitis;- Timely recognition of peritonitis and use of the require complex of the diagnostic

procedures for confirmation / refusal of peritonitis diagnosis.

А-4. List of practical technique to be trained:- Detection of Schotkin-Blumberg symptom;- Interpretation of the survey X-ray film of peritoneal cavity- Interpretation of the ultrasonographic data.

III. Training and educational objectives:1. To demonstrate the importance of the subject for the timely and adequate treatment of

peritonitis.2. To demand the adherence to the principles of the medical ethics and deontology. 3. To demonstrate the importance of the knowledge and skills in the field employing the

practical examples.

2

IV. Interdisciplinary integration:

Subject for study and corresponding chair

Scope of knowledge Scope of skills

General surgery with care for patients

Pathological states resulting in complications manifesting as peritonitis

Detection and interpretation of pathognomonic symptoms of peritonitis

Human anatomy Anatomical structure and relation of the peritoneal organs to the peritoneum

Interpretation of peritonitis probability in case of injury of the specified organ located in peritoneal cavity

Histology and embryologyStructure and embryogenesis of peritoneum

MicrobiologyMicroflora of the specific divisions of the intestines

Differential prescription of antibacterial agents according to the etiology of peritonitis

PhysiologyExudative and resorptive functions of peritoneum

Indications for drainage / lavage of the peritoneal cavity

V. Content of training

INTRODUCTION

The peritoneum is a two-layered serous membrane that lines the abdominal cavity

covering the inside walls of the abdomen (parietal peritoneum) and the abdominal organs

(visceral peritoneum). Passing from the abdominal walls to the intra-abdominal organs and from

one organ to another one, the peritoneum generated the folds and the mesenteries bordering the

spaces, the sinuses, and the recesses.

The peritoneal cavity is limited by the diaphragm from above, the pelvic diaphragm and

the ilia from below, then backbone and the muscles of the back posteriorly, the rectus muscles of

abdomen anteriorly, and the internal oblique and transverse muscles of abdomen anteriorly and

laterally.

The peritoneum is a semipermeable actively functioning membrane possessing several

functions such as exudative-and-resorptive function and the barrier function (due to migrating

and resident macrophages, immunoglobulins, and non-specific factors.

Histologically, the peritoneum comprises six layers: mesothelium, basal membrane and

four layers of elastic and collagenous fibers. On average, the thickness of the serous membrane is

about 0.2 mm.

The total area of the peritoneal cover amounts to 17000-20400 square centimeters, which

practically equals to the area of the skin surface.

3

The exudative areas of the peritoneum are represented for the most part by the serous

cover of the intestines. The most intensive exudation is in the duodenal area with the gradual

decrease in caudal direction.

The most intensive resorption is inherent to the peritoneum of the diaphragm, the greater

omentum, the ileum, and the cecum. The amount of the fluid absorbed by peritoneum within one

hour makes up to 8% of body mass.

The greater omentum represents the duplicature of the peritoneum containing the fat with

well-developed blood and lymphatic vessels providing for the protective function circumscribing

the foci of the inflammation by means of the fibrin.

The peritoneum is supplied by the blood from the basins of the vessels feeding the

corresponding organs. The outflow of the venous blood is provided mainly through the portal

system and partly through the caval system. The most intensive outflow of the lymph occurs

from the surface of the greater omentum and the diaphragm.

The visceral peritoneum has the vegetative innervation (parasympathetic and

sympathetic) and practically is devoid of the somatic innervation. This is the reason why the

visceral pains due to the irritation of the visceral peritoneum are not localized. The most

sensitive are so called reflex areas of the root of mesentery, the areas of the celiac trunk, the

pancreas, the ileocecal angle, and Douglas pouch. The parietal peritoneum is devoid of the

somatic innervation. This fact explains the absence of the protective tension of the muscles of the

anterior abdominal wall in the case of the inflammations in the small pelvis.

PERITONITIS CLASSIFICATION(after Yu.M. Lopukhin and V.S. Saveliev)

І. According to the clinical course: acute and chronic.

ІІ. According to the route of penetration of bacteria into the peritoneal cavity:

А. Primary peritonitis when the infection spreads by hematogenic or lymphogenic route or via

the fallopian tubes.

B. Secondary peritonitis when the infection penetrates due to the acute surgical conditions or the

injury of the peritoneal organs.

1. Infectious and inflammatory peritonitis results from the following diseases of the

peritoneal organs:

- acute appendicitis,

- acute cholecystitis,

- acute ileus,

4

- acute pancreatitis,

- thromboembolia of the mesenterial blood vessels,

- diverticulitis,

- intestinal tumors,

- gynecological conditions.

2. Perforative peritonitis results from the perforations due to:

- duodenal and gastric ulcers;

- intestinal ulcerations associated with typhus, dysentery, tuberculosis, cancer, stress, etc.)

- decubitus ulcer in the obturation ileus;

- strangulation groove in strangulated intestinal obstruction in the foreign bodies of

gastrointestinal tract;

- intestinal necrosis in the strangulated hernia or thromboembolia of the mesenterial blood

vessels.

3. Traumatic peritonitis develops in the open and closed abdominal traumas both with

accompanying damage of the abdominal organs and without such damage.

4. Postoperative peritonitis results from:

- the failure of the sutures of anastomosis after the abdominal surgery;

- the infection of the peritoneal cavity in the course of the surgery;

- the defects of the ligatures applied to the large areas of the omentum and the mesentery

followed by the necrosis of the tissues distal to the ligature

- the mechanical damage of the peritoneum: drying or the hemorrhage into the free

abdominal cavity without the reliable hemostasis.

ІІІ. According to the microbiological features

1. Bacterial peritonitis: non-specific caused by microflora of the gastrointestinal tract and

specific caused by microflora, which is not associated with the gastrointestinal tract such as

gonococci (Neіsserіa gonorrhoeae), pneumococci (Streptococcus pneumonіaе), hemolytic

streptococci (Streptococcus pyogenes, Streptococcus vіrіdans), micobacteria of tuberculosis

(Mycobacterіum tuberculosіs).

2. Aseptical peritonitis develops because of the exposure of peritoneum to the toxic and

enzymatic agents of non-infectious origin (the blood, the bile, the gastric juice, the chylous fluid,

the pancreatic juice, the urine, the aseptic necrosis if the internal organs).

3. Specific forms of peritonitis:

Carcinomatous.

Parasitic.

5

Rheumatoid.

Granulomatous.

ІV. According to the character of the peritoneal exudate.

" Serous

" Fibrinous

" Purulent

" Hemorrhagic

V. According to the character of the lesions of the peritoneal surface

1. Depending on the circumscription, the following forms of peritonitis may be delineated:

The circumscribed peritonitis may be represented as an abscess or infiltrate (for example,

paravesical abscess or pericholecystitis as the complication of the gangrenous cholecystitis)

Non-circumscribed peritonitis lacks the strict boundaries and the tendencies towards the

circumscription.

2. Depending on the extent of the spread, the following forms of peritonitis may be

delineated :

Localized: confined only to one anatomical division of the abdominal cavity.

Diffuse: extended to 2-5 anatomical divisions of the abdominal cavity.

Generalized: total involvement of the peritoneum (6 and more divisions of the abdominal cavity.

VІ. According to the phases of the development.

1. Reactive phase (first 24 h, 12 h for perforative peritonitis)

2. Toxic (24-72 h, 12-24 h for perforative peritonitis)

3. Terminal (more than 72 h, more than 24 h for perforative peritonitis).

Definition of peritonitis as the surgical pathology

Peritonitis is defined as the acute inflammation of the peritoneum. Peritonitis represents one of

the most severe complication accompanying the diseases and the injuries of the intra-abdominal

organs and may be delineated as the separate nosology with the characteristic clinical pattern and

the complex of the severe pathophysiological reactions with the impairment of the whole

homeostasis systems. Referring to the peritonitis and its surgical treatment, one bears in mind

acute, secondary, non-specific peritonitis being the cause of complications of about 15-20 % of

all the acute pathologies of the abdominal organs.

Among the forms of the acute peritonitis, the acute appendicitis with the incidence of 30-

65% ranks the first followed by the perforated ulcer (7-15 %), the acute cholecystitis (10-12 %),

the gynecological pathologies (3-12 %), the ileus (3-5 %), the pancreatitis (1 %), and

postoperative peritonitis (1 %).

6

The chronic peritonitis may develop in tuberculosis, mycosis, carcinomatosis, also in ascitic

conditions and in the presence of the numerous syphilitic gummas.

The aseptic peritonitis develops

- Upon irritation of the peritoneum with various chemical agents (iodine, ethanol, non-

isotonic solutions, some antiseptics, enzymes);

- Upon irritation of the peritoneum with the aggressive biological fluids (urine, bile,

pancreatic or gastric juice, the content of the hydatid cyst),

- Upon the extensive ligation of the tissues.

All the forms indicated above make up to less than 1 % of all peritonitis cases, the rest being

attributed to the acute secondary peritonitis.

CLASSIFICATION OF SURGICAL PERITONITIS

The general classification is rather bulky for everyday use. That is why in so called

working classifications the cause of the peritonitis is given (the perforated ulcer or acute

gangrenous perforated appendicitis) with accompanying morphological description (diffuse,

fibrinous-purulent peritonitis). The words such as "secondary" and "infectious non-specific" are

usually being avoided).

In final diagnosis, the complications resulting from the infectious (septic) processes and

postoperative complications are referred to (if any).

Circumscription and extent of spreading: The redundant terms (circumscribed – local or

non-circumscribed – diffuse) should not be used together. The area of the lesion should be

strictly indicated.

Phases of the development: We use the pathogenetic classification after K. Simonian:

Reactive phase: The manifestations of the peritonitis are caused by the activated defense

systems such as the massive release of the kinins in the response to the primary infectious

aggression. Therefore, when the source of infection is eliminated, in reactive phase the radical

surgery is possible with anastomoses being applied to the abdominal organs. In the inflammatory

process, the reactive phase lasts up to 24 hours (in perforative peritonitis up to 12 hours). Upon

the source of the peritonitis is eliminated (the perforated ulcer, for example) in the early

(reactive) phase, the peritonitis does not progress as usual and the lethality is rather low.

Toxic phase is characterized by the alterations in the functions of all systems of the body

because of the syndrome of the systemic inflammatory response. The toxic phase is evident in

12-24 hours after the onset of the disease in perforative processes and 24-48 hours in the

inflammatory processes. The lethality is 20% and higher.

7

Terminal phase is characterized by the development of the polyorgan insufficiency

syndrome representing the depletion of the functional reserves of the major systems of the body.

The toxic phase is evident in 24-36 hours in the perforative peritonitis and in 48-72 hours in the

inflammatory processes.

The lethality in the patients with polyorgan insufficiency syndrome is about 90%.

ComplicationsThe local and general complications may be delineated.

The local complications comprise pylephlebitis, the multiple abscesses of the liver.

The general complications comprise the liver insufficiency, the toxic encephalopathy, the

renal failure, the cardiovascular failure.

The predominant part of the peritoneum covers the intestines. It is naturally, therefore,

that the toxic products flowing out with blood or lymph impair microcirculation in the intestinal

wall and neuromuscular transmission resulting in decreasing and arresting the peristalsis

(intestinal paresis). The intestinal content is a good milieu for the development of bacteria

including the anaerobic ones since the aerobic bacteria realize the available oxygen. The arrest of

the intestinal passage results in the increasing microbial content in the middle and upper thirds of

the small intestine where the bacteria are normally absent.

The serous edema extends to the whole intestinal wall. The mucosa loses the barrier

function. Ads a result, the bacteria and their metabolites are absorbed into the lymph and the

blood circulation not only from the peritoneal cavity but from the intestine as well. Therefore,

since the onset of the intestinal paresis in peritonitis, the intoxication and dehydration of the

body progress rapidly.

The increase in the toxic load to the liver results in then rapid depletion of its detoxifying

function and other metabolic functions as well. The penetration of the bacteria and toxins into

the caval system results in extra loading to the lungs resulting in the development of the

inflammation in the lung tissue. As a consequence, the respiratory function is impaired with the

development of the respiratory distress syndrome resulting finally in the pneumonia.

Microbiological features of peritonitis

As a rule, the exudate is infected with variety of bacterial species inhabiting the cavities

and the surfaces of the human body.

The most prevalent batteries are the Escherichia coli, Enterococcus, and Proteus sp. The

putrefactive odor and the sordid of the exudate suggest that the predominant microflora relates to

the facultative anaerobic bacteria (so-called non-clostridial anaerobic microflora).

8

Earlier, gas chromatography was used as the express method for detecting the bacteria

comprising the exudates based on the analysis of the specific bacterial metabolites – volatile

fatty acids (propionic, butyric, valeric). The up-to-date techniques of detection and identification

are based on the immunocytochemistry and polymerase chain reaction.

Upon the prolonged treatment, the nosocomial infection caused by penicillinase-

producing cocci or Pseudomonas aerugіnosa may be evident.

The results of the commonly used bacteriologic techniques are evident in three days.

Therefore, the initial antibiotic therapy should be based on the previous experience in the field.

The following findings should be taken into account:

– Gram-positive cocci are the major bacterial species in the case of the localization of the

primary focus in the upper division of the gastrointestinal tract (the stomach, the duodenum, the

bile ducts, the pancreas, upper third of the small intestine). The probability of the involvement of

the anaerobic bacteria is rather low (10-15%) and depends entirely on the duration of the

process.

– Gram-negative bacilli and non-clostridial anaerobic bacteria prevail in the perforation

of the small intestine and the appendix as well as in the cases of peritonitis with the

accompanying ileus.

– Escherichia coli ranks among the first in the development of the peritonitis when the

perforation is not available.

SYMPTOMATICS AND DIAGNOSIS OF PERITONITIS

The diagnosis of the peritonitis is based on the complex assessment of the anamnesis, the

local symptoms, the presence of the inflammation and intoxication, and the specific

complications.

Complaints: The steady blunt pain throughout the abdomen increasing upon the

movements and the breathing. The irradiation into the shoulder is possible upon the irritation of

the diaphragm. The general sickness is evident with frequent nausea and stool retention.

Anamnesis

The time passed since the onset of the symptoms should be clarified. The dynamics of the

character and the localization of the pain, the dynamics of the toxic manifestations are followed.

In most cases, the signs of the previous disease (appendicitis, cholecystitis, acute condition of the

ulcer) resulting in peritonitis are evident. Frequently, in the setting of some improvement of the

general state and decreasing of the abdominal pains, the sudden increase of the pain occurs

9

which becomes more extensive. Since this moment, the general state of the patient deteriorates,

the dryness in mouth and the thirst appear, the palpitation increases.

General examination

As usual, the patient lies in supine position with the knees bent. The attempts to change

the pose or to rise fail due to the increasing pain. When the patient sits, the attempt to lie down

results in increasing abdominal pain and the pain irradiating to the shoulders due to the irritation

of the diaphragmatic nerve. The patient is forced to take up the previous sitting position (the

tumbler toy symptom).

The patient speaks quietly and does not shout claiming the attention. Such a behavior of

the patient especially the breathing accompanied by the quiet moaning is a sign of particular

concern for the doctor.

All the components of the infectious process and the intoxication such as the temperature,

the tachycardia, the rate, and the deepness of breathing, the changes in blood pressure, the

dryness of the tongue and the internal buccal surface should be taken into account. The loss of

consciousness should be of special concern signifying the severe intoxication.

The tachycardia with heart rate of 100-120 beats per minutes is evident with normal or

decreased blood pressure and the increased respiration rate (20-24 breathings per minute).

The toxic encephalopathy may be manifested both as the inhibition and the excitation in

the form of delirium.

The paleness of the skin and cutis marmorata reflects the deep disorder of

microcirculation.

Specific examination

The abdomen is usually symmetrical, somehow distended, is not involved in breathing

movements. By palpation, the diffuse pain, the tension of the abdomen, and Mendel and

Schotkin-Blumberg symptoms are revealed. The peristalsis sounds are usually weakened or

absent.

The presence of the free gas should be checked by the disappearance of the liver dullness.

The presence of the free liquid is proved by the dullness of the percussion sound in the lateral

divisions disappearing upon turning the patient to the side.

In rectal and vaginal examination, the overhang of the fornices and the tenderness due to

the accumulation of the inflammatory exudates are frequently evident.

In general blood analysis, the pronounced leukocytosis and the shift towards the

immature forms are present.

10

Biochemically, normo- or hyperglycemia, the moderate increase of urea, creatinine, the

alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase activities are

detected; the syndrome of the disseminated intravascular blood coagulation may develop.

Laboratory examination

The moderate leukocytosis (14-20 х 109/L) with the shift of the formula to the left,

lympho- and monopenia, aeosinophilia, thrombocytopenia are evident. For the objective

assessment of the intoxication extent, Calf-Calif leukocytic index of intoxication is calciulated

with its value of 4 characteristic of the reactive phase, the value of 8 characteristic of the toxic

phase, and the value of 12-18 characteristic of the terminal phase.

The increase of the hematocrit, the increased content of urea and creatinin, the increased

activity of transaminases, the elevation of bilirubin, glucose, lactate, the alteration of the

parameters of coagulation system, the changes of acid-alkaline state, the increase in the blood

partial pressure of CO2 and the decrease in the blood partial pressure of O2 are the signs of the

impaired functions of various organs and systems.

Additional examinations

The presence of the free fluid in the abdominal cavity may be confirmed sonographically.

X-ray examination may be useful for detecting free gases, the signs of ileus (Kloiber bowls), the

high position of the diaphragmatic cupolas and the limitation of their mobility due to the tension

of the abdominal muscles (the muscular defense). In the severe cases, the respiratory distress

syndrome develops.

In doubtful cases, laparoscopy may be performed for clarifying the source and the

extent of the source of the peritonitis. The diagnosis of peritonitis may be confirmed by

laparocentesis by the presence of the specific exudate.

The manifestations of the peritonitis in reactive and terminal phases are quite different. In

the reactive phase, the pain syndrome prevails. The area of the utmost tenderness corresponds to

the primary inflammatory focus. The rigidity of the abdomen, due to contraction of the muscles

of the abdominal wall is a characteristic feature. The tense abdomen looks somehow tucked and

boat-like. This sigh is of peculiar importance for the peritonitis with perforation of the hollow

organs. Mendel and Schotkin-Blumberg symptoms are revealed. The peristalsis sounds are

usually weakened or absent. The overt signs of dehydration are absent. The tachycardia may

reach 90-100 beats per minute. The respiration rate is not increased. Several elements of the

excitation phase of the shock such as the elevated blood pressure may also be evident. The

11

neutrophilic leukocytosis 12-18 х 109/L, lympho- and monopenia, aeosinophilia, may be present.

The biochemical parameters are usually within the normal limits.

In the terminal phase the diagnosis of the peritonitis may be rather difficult if the

anamnestic details are not available. The vomiting with the congestive content takes place

several times a day. The stool is scarce, frequently only after the enema. The stool has the

putrefactive odor.

The objective state: Adynamia, the general inhibition, the acute dehydration, the hollow

eyes, the sharpened features of the face, the superficial frequent respiration, frequently with the

quiet moaning. The tongue is dry and difficult to hang out; the internal buccal surfaces are also

dry. The abdomen is inflated, weakly painful. Mendel and Schotkin-Blumberg symptoms are

rather dubious. The percutory sound is not uniform. The symptoms of the deathly silence may be

evident when the respiratory and the vascular noises are heard instead of the intestinal

movements. The splash sound may be detected when the abdominal wall is stroke by the hand.

The multiple Kloiber bowls are evident in survey X-ray pictures. The tachycardia is

above 120 beats per minute. The blood pressure is decreased, especially after the transportation

of the patient. The maintenance of the normal blood pressure requires the intensive infusion. The

breathing rate is about 30 per minute. The oxygen saturation of the blood is diminished. The

shadows of various sides in the lungs are characteristic of the respiratory distress syndrome.

Hydrothorax may be developed. In blood, normocytosis, sometimes leukopenia are detected with

the sharp shift to the left (towards the immature elements), sometimes plasma cells are detected.

GENERAL PRINCIPLES OF TREATMENT

1. The early elimination of the infection source.

2. The decrease of the possible intraoperative contamination.

3. The treatment of the residual infection and the prevention of further infection of the

abdominal cavity.

4. The maintenance of vitally important functions prior to and after the surgery, incuding

the techniques requiring the artificial organs.

METHOD OF TREATMENTА. Surgical

Laparotomy, early elimination or isolation of the peritonitis source.

Intra- and postoperative sanitization of the abdominal cavity.

Decompression of the small intestine.

12

B. General

Massive antibioticotherapy.

Medicamentous correction of hemostasis shifts.

Stimulation or temporary substitution of the major detoxifying systems of the body by means of

extracorporeal hemocorrection.

PREOPERATIVE PREPARATION. It is impossible to correct the hemostasis

impairment prior to the surgery. Nevertheless, it is advantageous to delay the surgery for 2-3

hours for directed preparation. It is sufficient to stabilize arterial pressure and central venous

pressure and to reach the diuresis at 25 mL/h. The total preoperative infusion volume is 1.5-2.0 L

within two hours. In advanced cases when the hemodynamic imbalance is pronounced (the loss

of fluid exceeding 10% of body mass), the infusion volume increases up to 3-4 L within 2-3

hours.

The catheterization of the central (for example subclavian) vein is always performed

providing for high infusion flow rate and the control of the central venous pressure. The

catheterization of the urinary bladder is expedient providing for measuring the diuresis as the

objective criterion of the infusion therapy efficacy.

PREPARATION OF GASTROINTESTINAL TRACT. The stomach is emptied with the

aid of the probe. In the advanced cases, the permanent presence of the probe in the stomach is

expedient pre-operatively, intraoperatively and postoperatively for specified time until the

recovery of gastric motor activity.

ANESTHESIA. The multicomponent anesthesia with the artificial lung ventilation is

used in surgery due to peritonitis.

MAJOR OPERATIVE STAGES IN PERITONITIS

1. Surgical access.

2. Possible Novocain blockade of the reflexogenic areas.

3. Elimination or reliable isolation of septic focus.

4. Sanitization of the abdominal cavity.

5. Decompression of the intestine.

6. Draining of the abdominal cavity.

7. Suturing of the laparotomic wound.

1. Surgical access. The optimal access to all divisions of the abdominal cavity is provided

by the midline laparotomy. Depending on the localization of the septic focus, the wound may be

13

extended in superior or inferior direction. When the diffuse peritonitis is revealed in the course

of the surgery started from another access, it is worth to perform the midline laparotomy.

2. Novocain blockade of the reflexogenic areas is performed by administering 0.5%

solution of Novocain (up to 100.0 mL) into the area of the celiac trunk, the root of the

mesocolon, transverse mesocolon, the mesentery of the small intestine, and sigmoid mesocolon.

Such blockade eliminates the reflex vascular spasm providing for earlier recovery of peristalsis.

In addition, such blockade allows diminishing the amount of the narcotic substances used as the

analgesics.

3. Elimination or reliable isolation of septic focus. In the reactive phase, the radical

operations (resection of the stomach, hemicolectomy) are possible since the risk of the

anastomosis failure is rather low. In the toxic and terminal phases the scope of the surgery should

be minimal (appendectomy, the suturing of the perforative hole, the resection of the necrotic area

of the gastrointestinal tract with entero- or colostoma, the isolation of the septic focus from the

free abdominal cavity. The reconstructive surgery should be postponed until more favorable

conditions.

4. Sanitization of the abdominal cavity. The washing of the abdominal cavity allows for

decreasing the bacterial count in the exudates below the critical level (105 in 1 mL) facilitating

the elimination of the infection. The dense deposits of fibrin are not removed because of the risk

of deserozation. The removal of exudate by means of the wiping with the gauze pieces is

unacceptable due to the risk of the injury of the serous membrane. The washing fluid must be

isotonic. The use of antibiotics is meaningless because the short-term contact with the

peritoneum is not sufficient for their effects. Most antiseptics are cytotoxic; this fact restricts

their use in the cases under consideration. With this aim, one may use sodium chloride solution

upon electrochemical activation (0.05% sodium hypochlorate) containing activated chlorine and

oxygen. This solution is particularly indicated in then cases when anaerobic bacteria are present.

Several clinics also use the ozonized solutions.

5. Decompression of the intestine. In the toxic and terminal phases when the intestinal

paresis is of particular clinical importance, nasogastrointestinal intubation is performed. The

polyvinylchloride tube is used with this aim. The intubation is extended distally from Treitz

ligament. When necessary, the colon is intubated through the anus. Rarely, gastro-, jejuno- or

appendicostoma is required for passing the probe. Postoperatively, the probe-assisted correction

of the enteral content is performed comprising the decompression, the intestinal lavage, the

enterosorption, and early enteral feeding. All these measures are useful for decreasing the

permeability of the intestinal walls for the bacteria and the toxins facilitating early recovery of

the functional activity of the gastrointestinal tract.

14

6. Draining of the abdominal cavity is performed by the tubes made of polyvinylchloride

or rubber. Multichanneled polyvinylchloride drainages are the good choice for this procedure.

One channel is used for supplying the antiseptic, while another one is used for the aspiration of

the exudate.

7. Suturing of the laparotomic wound may be performed with the draining of the

subcutaneous fat.

The treatment of the residual infection, namely the techniques of the draining and the

exudate removal, depends on the techniques used for the final stages of the surgery.

Methods of suturing laparotomic wound:

1. The tight suturing without the drainage may be employed only in the case of the local,

non-circumscribed peritonitis serous peritonitis with the low level of the bacterial load and low

risk of abscesses and infiltrates. In these cases, the self-defense of the body and the use of

antibiotics may be sufficient for curbing the infection.

2. The suturing with the passive drainages. The drainages are also used for the local

administration of antibiotics.

3. The suturing with the drainages for the flow and fractional lavage. The technique is not

employed in wide scale due to the difficulties in correcting the shifts in protein and electrolytic

balance. Moreover, the efficacy of the technique lowers in 12-24 hours since the beginning of the

lavage.

4. Semi-closed technique with approaching of the wound edges provides for the

drainages being installed in the posterior abdominal wall for the dorsoventral washing with the

aspiration of the outflowing fluid via the midline wound.

5. The approaching of the wound edges with the specific appliances used for the repeated

revisions and sanitizations. We use the term "scheduled laparosanitization". The indication for

such technique is the pronounced adhesion process in the severe forms of the fibrinopurulent

peritonitis with sub- and decompensation of the vitally important functions. The number of the

revisions is from 2-3 to 7-8 with 1248-hours interval.

6. The open technique (laparostomy after N. Macokh or Steinberg-Miculich) with the

exudate outflow through the wound covered by the tampons with the ointment is used in the case

of the multiple non-shaped intestinal fistulas. The doctor may observe the condition of the

intestinal loops adjacent to the wound in every change of the tampons.

15

GENERAL TREATMENT

Antibacterial therapy

The most adequate schedule of the empirical antibacterial therapy before the microbiological

verification of the causative agent and the assessment of its sensitivity to antibiotics is a

combination of the synthetic penicillins (Ampicillin) or cephalosporins with aminoglycosid

(Gentamicin or Vancomicin) and Metronidasol. Such a combination seems to be effective

against the broad spectrum of the possible causative agents of the peritonitis.

When the data of bacteriological analysis are obtained, the corresponding antibiotics or

their combination are prescribed.

The routes of the administration:

1) Local (intraperitoneal) through irrigators and drainages (the double function of

draining)

2) General

a) intravenous (systemic)

b) intramuscular (only after the recovery of microcirculation)

c) intra-arterial (into aorta, celiac trunk, mesenteric or omental artery)

d) intraportal (through the recanalized umbilical vein of the round ligament of the liver

(regional way)

e) endolymphatic

– antegradely: through microsurgically catheterized peripheral lymphastic vessel

in the back of the foot, the depulpated inguinal lymph node

– retrogradely: through thoracic lymphatic duct

– lymphotropically: through the lymphatic net of the shin or retroperitoneal space.

Immunotherapy

The following preparations improving the immune reactivity of the body may be used:

immunoglobulins (antistaphylococcus gamma-globulin), the leukocytic mass, antistaphylococcus

plasma. Interleukin-2, α- and γ-interferons, interferon inducers (cycloferon) also may be

employed as the modern drugs improving the immune reactivity. Meanwhile, the use of

Pyrogenal, Decaris (Levamisol), Prodigiosan, Thymalin and other agents "stimulating the

reduced immunity" seems to de contraindicated.

16

Postoperative correction therapy

For the adequate anesthetization, besides the narcotic analgesics, the prolonged epidural

analgesia with the local analgesics, acupuncture analgesia, and electroanalgesia are employed.

The balanced infusion therapy is performed. The total daily volume of the infused fluid

comprises the physiological daily requirement (1500 mL/m2), the deficit of the liquid, and the

physiological expenses (vomiting, drainage, increased sweating, and hyperventilation).

The preventing and the treatment of multiple organ failure syndrome:

The pathogenetic bases of the multiple organ failure syndrome is hypoxia and cell

hypotrophy due to the impaired respiration and hemodynamics.

The following measures should be undertaken to prevent and to treat multiple organ

failure syndrome:

– Elimination of the infectious and toxic focus.

– Elimination of the toxins by the techniques of the efferent therapy.

– Maintenance of the adequate lung ventilation and gas exchange (sometimes long=-term

artificial lung ventilation).

– Stabilization of blood circulation with restoration of the blood circulation volume, the

support of heart function. Normalization of microcirculation in organs and tissues.

– Correction of protein, electrolyte, and acid-base balance of the blood.

– Parenteral feeding

Recovery of functions of gastrointestinal tract

The most effective means for recovering the functions of gastrointestinal tract consists in

the intestinal decompression by transnasal probe followed by the intestinal lavage.

For the normalization of the nervous regulation and the recovery of the tonus of intestinal

musculature, the correction of the protein and electrolyte balance is performed. Then

anticholinesterase drugs (Proserin, Ubretid), Metaclopramide and ganglioblockers (Dimecolin,

Benzohexonium) may be used.

The forced diuresis, hemodialysis, plasmapheresis, hemofiltration through the porcine

organs, the artificial lung ventilation, hyperbaric oxygenation are indicated in case of the

multiple organ failure syndrome. The hyperbaric oxygenation is capable for arresting all types of

hypoxia in peritonitis, facilitates the decrease in the bacterial load of the peritoneum, stimulates

motor and evacuatory function of the intestine.

For preventing endotoxicemia, the surgical methods and antibacterial therapy are to be

used for eliminating the residual infection.

Hemosorption, lymphosorption, plasmapheresis and other detoxifying techniques are to

be regarded only as the supplementary methods in the complex therapy of peritonitis.

17

VI. Plan and arrangement of training

6.1 Duration of classes: 4 academic hours6.2. Stages of classes:

N Content and program of teaching

Educa-tional objectives within learning levels

Methods of teaching and control

Supporting materials

Time in min

1 2 3 4 5 6І12

3

Preparatory stepOrganization of classes Formulation of the teaching goalsPreparatory stage (control of the initial level of knowledge and skills):а) major concepts on the anatomy and physiology of peritoneum;б) infectious process;в) approaches for the surgical treatment;

α-ІІ

α-ІІα-ІІ

Tests α-ІІ

Tests α-ІІTests α-ІІTypical check situations

Log-book for entering the learning progress of students

Tables, slides Tables, slides

Tables, slides

5

20

20

15

ІІ1.

2.

3.

Principal step Training the professional skills and knowledgeExamination of the patients with peritonitisDifferential; diagnosis of peritonitis. Diagnostical and clinical features.

α-ІІІ

α-ІІІ

Training

Non-typical check situations

Equipment and facilities

120

ІІІ1.

2.

3.

Final step Control and correction of the attained level of professional skills Summary of classes (theoretical, practical, organizational)Home tasks

α-ІІ

α-ІІІ

Individual control of students' knowledge

Control questions , tasks.Advice for homework with the literature

50

5

5

VII Supporting materials required for teaching

Materials for the control of initial level of knowledge and skills:А. Control questions:1. Anatomical relations between the peritoneum and the organs of the abdominal cavity 2. Histological structure and innervation of the peritoneum.3. Physiology of the peritoneum: resorptive and exudative functions.

18

4. Definition of peritonitis.5. Classification of peritonitis according to the clinical course.6. Classification of peritonitis according to the character of penetration of bacteria into the

abdominal cavity.7. Infectious inflammatory peritonitis.8. Perforative peritonitis.9. Traumatic peritonitis.10. Postoperative peritonitis.11. Classification of peritonitis according to the microbiological features.12. Bacterial peritonitis.13. Aseptic peritonitis.14. Specific forms of peritonitis.15. Classification of peritonitis according to the character of the peritoneal exudate.16. Classification of peritonitis according to the character of lesions on the surface of the

peritoneum.17. Circumscribed peritonitis.18. Non-circumscribed peritonitis.19. Classification of peritonitis according to the extent of spreading.20. Localized peritonitis.21. Generalized (diffuse) peritonitis.22. General (total) peritonitis.23. Phases of the development of peritonitis.24. Reactive phase of peritonitis.25. Toxic phase of peritonitis.26. Terminal phase of peritonitis.27. Complications of peritonitis.28. Microbiological features of peritonitis.29. Patients' complaints and the anamnestic data in peritonitis.30. General and specialized examination of the patients with peritonitis.31. Laboratory examinations32. Supplementary examinations.33. General principles of treating peritonitis.34. Method for treating peritonitis.35. Preoperative preparation.36. Preparation of gastrointestinal tract.37. Anesthesia.38. The major steps of the surgical treatment of peritonitis.39. Draining of the abdominal cavity and suturing of the laparotomic wound in peritonitis.40. The general treatment of peritonitis.

TESTS

І. The most pronounced exudative activity is peculiar to:A. peritoneum of ileum;B. peritoneum of duodenum;C. peritoneum is devoid of exudative activity;D. peritoneum of diaphragm;E. peritoneum of sigmoid colon.

19

ІІ. The most pronounced resorptive activity is peculiar to:A. peritoneum of jejunum;B. peritoneum of duodenum;C. peritoneum is devoid of resorptive activity;D. peritoneum of diaphragm and greater omentum;E. peritoneum of sigmoid colon.

ІІІ. The peritoneum covers (completely or partially) all the organs of the abdominal cavity except for:

A. pancreas;B. kidneys;C. urinary bladder;D. omentum;E. in the abdominal cavity all the organs without exception are covered by the peritoneum.

IV. Select the wrong statement – peritonitis may be:A. primary;B. secondary;C. perforative; D. traumatic;E. all the statements are correct.

V. Infectious and inflammatory peritonitis is not a consequence of: A. acute appendicitis;B. acute cholecystitis;C. acute ileus;D. traumatic injuries of parenchymatous organs;E. gynecological pathology.

VI. Which of the form in the list below is not regarded as the specific form of peritonitis:A. infectious;B. parasitic;C. rheumatoid;D. granulomatous;E. carcinomatous.

VII. Which of the pathologies from the list below do not belong to the systemic complications of peritonitis:A. pylephlebitis;B. syndrome of the disseminated intravascular blood coagulation;C. toxic encephalopathy;D. renal failure;E. cardiovascular failure.

VIII. Select the wrong statement – the following symptom does not belong to the pathognomonic symptoms of peritonitis:A. Mussi-Heorhievskyi symptom;B. Ortner symptom;C. Karavaiev symptom;D. Schotkin-Blumberg symptom;E. Pasternatsky symptom.

20

IX. The stage which does not comprises the major stages of the surgical treatment of peritonitis:A. operative access;B. elimination or reliable isolation of the septic focus;C. sanitization of the abdominal cavity;D. draining of the abdominal cavity;E. antibioticotherapy.

Х. Select the wrong statement: Paresis of the intestine… A. ...accompanies the development of peritonitis;B. …is a pathogenetic factor contributing to the severity of the clinical course in peritonitis;C. …in peritonitis is subjected to the conservative correction; D. … is not observed in all cases of the local form of peritonitis;E. …is in most cases an indication for intestinal intubation.

The correct answers:1 – A 4 – E 7 – A 10 – C 2 – D 5 – E 8 – A 3 – E 6 – D 9 – D

REFERENCES1. S.V. Petrov. «General surgery». Peter. 2005 (in Russian).4. Yu.M. Lopukhin, V.S. Saveliev «Surgery» Moscow. 1997 (in Russian).5. C.M. Townsend. Textbook of Surgery. The biological basis of modern surgical practice.

2001.

21