Peritonitis in Children - Purulent Inflammation of the Peritoneum. Primary and secondary peritonitis in children: causes, symptoms, treatment

This pathology is widely known in the practice of pediatric surgery under the names “diplococcal”, “pneumococcal”, “cryptogenic” or “primary” peritonitis. The disease most often occurs in girls aged 3 to 7 years. It has been established that the infection enters the abdominal cavity through the vagina with the development of endosalpingitis. At older ages, this disease occurs much less frequently. This fact is explained by the appearance of Döderlein's rods in the vagina, which, by creating an acidic environment, prevent the development of hard-nuclear microflora. The widespread introduction of laparoscopy has made it possible to convincingly confirm this point of view and change the tactics of treating such patients.

With a localized process, a transparent or cloudy mucous effusion is present in the lower floor of the abdominal cavity, stretching behind the manipulator. The largest amount is detected in the pelvic cavity. The uterus and fallopian tubes are somewhat edematous, moderately hyperemic, the ovaries are intact. Already at this early stage of the disease, even in the absence of hyperemia of the parietal and visceral peritoneum, pronounced inflammatory changes are noted in the ampullary area of ​​the fallopian tubes. The fimbriae are sharply hyperemic, with petechial hemorrhages, and due to pronounced edema, they are moved apart to the sides in the form of a corolla. This sign is called the “red corolla” symptom and is caused by the presence of endosalpingitis, which indicates the primary localization of the inflammatory process. In this regard, it is advisable to characterize this pathology as primary ampullary pelvioperitonitis.

As the disease progresses, the effusion becomes purulent in nature, its quantity increases, but its viscous mucous consistency still remains. Endoscopically, a picture of acute purulent pelvioperitonitis is revealed. The fallopian tubes at this moment they sharply thicken due to edema, pronounced hyperemia of all pelvic organs and petechial hemorrhages appear on the peritoneum. Even with such severity of the process, the ovaries, as a rule, remain intact; oophoritis is observed extremely rarely.

Clinical picture and diagnostics Clinically, two forms of primary ampullary pelvioperitonitis are distinguished - toxic and local. The toxic form is characterized by an acute and violent onset of the disease. Severe pain in the abdomen is noted, usually in its lower parts. Body temperature most often rises to 38-39 °C. Vomiting can be repeated. Loose stools often occur, which occurs when peristalsis increases due to a pronounced inflammatory process in the abdominal cavity.

Significant severity of the general condition is observed, despite the short period that has passed from the onset of the disease (sometimes only 2-6 hours). The child is usually restless, moans, the skin is pale, the eyes are shiny. The tongue is dry, covered with a white coating. When examining the abdomen, all the signs of severe peritonitis are revealed: severe pain and clear rigidity in all parts of the anterior abdominal wall, but somewhat larger below the navel and on the right. The Shchetkin-Blumberg symptom is positive. Moderate intestinal paresis is also noted. In many cases, it is possible to detect the phenomena of vulvovaginitis with mucopurulent discharge from the vagina. When researching peripheral blood high leukocytosis is found (up to 20x10 9 /l and higher).

IN last years In the clinical picture of primary ampullary pelvioperitonitis, changes have occurred, characterized by a predominance of localized (local) forms. The toxic form of the disease occurs quite rarely (no more than 5% of cases).

In the localized form of primary ampullary pelvioperitonitis, the clinical picture is erased, intoxication is not expressed, pain is often localized in the lower abdomen or even only in the right iliac region. At the same time, body temperature does not reach high numbers and is often within the range of 37.5-38 °C. However, a more acute sudden onset of the disease, the presence of ARVI at the time of examination or ARVI suffered the day before - all these signs make one suspect primary ampullary pelvioperitonitis. However, even with a typical manifestation of the disease, surgical intervention is performed, since the surgeon cannot completely exclude the diagnosis acute appendicitis. Perform unnecessary appendectomy, potentially causing serious complications. postoperative complications, such as adhesive intestinal obstruction (ACI), progression of the inflammatory process, etc. Laparoscopy allows you to highly accurately confirm or exclude the diagnosis.

Treatment and prognosis Diagnostic laparoscopy often becomes therapeutic. Aspiration of pus is performed and an antiseptic solution is administered. Appendectomy is not performed in such cases. All patients are prescribed antibacterial therapy with penicillins or cephalosporins for 5-7 days. The prognosis is always favorable.

7.12.2. Appendiceal peritonitis

Peritonitis is a common and most severe complication of acute appendicitis in childhood, occurring in 8-10% of all cases of the disease, and in children of the first 3 years of life 4-5 times more often than in older children. In recent years, it has been possible to reduce mortality among patients hospitalized in the initial phases of the disease, but in advanced forms, mortality remains very high.

Classification Of the many proposed classifications, the most widespread is the principle of dividing peritonitis according to the stages of the process and the prevalence of peritoneal damage, the severity of intestinal paresis (Fig. 7-15).

The most appropriate division of peritonitis into local and diffuse should be considered. Local peritonitis, in turn, is divided into limited and unlimited. The latter is characterized by inflammatory changes in the affected area with possible leakage of exudate into the adjacent area along the path of natural distribution (right lateral canal and pelvic cavity). At diffuse peritonitis Inflammatory changes in the peritoneum do not go beyond the boundaries of the lesion along the path of natural spread. Extension of the inflammatory process beyond the right lateral canal should practically be considered diffuse peritonitis.

The most widespread in peritonitis is the identification of three phases of its course (reactive, toxic and the phase of polymorphic disorders), reflecting the severity of the clinical manifestations of the disease. The phase nature of the course of peritonitis is confirmed by changes in central hemodynamics, microcirculation, and immunological reactivity.

Pathogenesis diffuse peritonitis - a complex chain of functional and morphological changes systems and organs. Anatomist o-physiological features child's body affect the course of appendiceal peritonitis. The smaller the child, the faster purulent process extends to all parts of the peritoneum. This is facilitated by the low plastic properties of the peritoneum and the underdevelopment of the greater omentum. Intoxication and metabolic disorders, many defensive reactions become pathological.

The leading role in the pathogenesis of peritonitis belongs to the microbial factor and the state of the body's immunoreactivity. The nature and severity of changes depend on the severity of pathological processes. It has been established that in most cases peritonitis is a polymicrobial disease. The dominant role in its development belongs to E. coli, but other microorganisms are also of great importance: enterococci, Klebsiella and others, as well as anaerobes. In a targeted study, anaerobic flora is cultured in more than a third of patients, and in the formation of intra-abdominal abscesses - in almost 100% of cases. This fact must be taken into account when prescribing empirical antibiotic therapy, since many antibiotics are ineffective against anaerobic infection.

One of the leading factors in the development of pathophysiological changes that occur during peritonitis is the resorption by the peritoneum of toxic products of purulent exudate from the abdominal cavity. The surface of the peritoneum in children, especially young children, is relatively larger than in adults. It has been established that during peritonitis, especially in its initial stages, the resorption of toxic products by the peritoneum occurs very intensively. As a result, bacterial toxins and decay products of microbial bodies enter the blood and lymph in large quantities. It is the absorption of toxic products that causes a chain of various pathophysiological disorders, including dehydration, circulatory disorders, hyperthermia, acid-base disorders, etc.

With appendiceal peritonitis, children develop dehydration and circulatory disorders quite quickly. Biologically active substances released in large quantities have a vasodilating effect, which increases the permeability of the vascular wall and promotes the release of water and low molecular weight proteins from the vascular bed. Exudation of fluid and protein into the abdominal cavity increases. At the same time, there is a significant loss of water due to frequent vomiting and loose stools. Fluid loss is also aggravated by perspiration and shortness of breath. With intestinal paresis, a massive accumulation of fluid occurs in its lumen. Massive loss of fluid from the bloodstream leads to a significant decrease in blood volume and, consequently, hemoconcentration. Hypovolemia and the hypoxemia that develops after it cause spasm of peripheral and renal vessels, which leads to redistribution of blood while maintaining nutrition of vital organs, mainly the heart and brain (centralization of blood circulation). In response to this, compensatory tachycardia occurs, leading to overstrain of the heart muscle and disruption of heart function.

A decrease in renal blood flow contributes to a decrease in urine filtration in the renal glomeruli and the occurrence of renal ischemia. Subsequently, renal dysfunction leads to water, electrolyte and metabolic disorders.

Due to spasm of skin vessels, heat transfer decreases, which aggravates hyperthermia. A significant increase in body temperature (39-40 °C and above) occurs in most patients with purulent peritonitis. In young children with hyperthermia, due to increased energy consumption, energy reserves are very quickly depleted, metabolic disorders and disorders of the respiratory and cardiovascular system occur. All this can lead to adrenal insufficiency.

One of the important pathophysiological links in the development of peritonitis is metabolic disorder. With peritonitis, replenishment is impaired energy resources with food, the use of carbohydrates from the body’s own reserves (liver glycogen) begins. Then proteins and fats are used as an energy source, the breakdown of which under conditions of tissue hypoxia leads to the accumulation of under-oxidized products. The detoxification function of the liver gradually begins to suffer. In severe peritonitis, protein metabolism disorders develop. Protein loss occurs with exudate, diffusion into the intestinal lumen. Dysproteinemia develops.

The formation of acidic products changes the pH of the blood - metabolic acidosis occurs. At first, metabolic changes are compensated to a sufficient extent by breathing (due to compensatory shortness of breath and increased release of carbon dioxide) and by the kidneys (by reabsorption of sodium and release of excess acid radicals). Compensatory mechanisms very quickly depleted in conditions of peritonitis due to the limitation of respiratory excursions due to paresis and intestinal bloating, as well as due to hemodynamic disorders. Acidosis enters the stage of decompensation.

With peritonitis, significant disturbances in electrolyte metabolism also occur. Vomiting and loose stools lead to loss of fluid and electrolytes (potassium, sodium, chloride ions). As potassium and chloride ions are lost against the background of a decrease in plasma volume, disturbances in the acid-base balance occur, consisting in the development of intracellular acidosis against the background of extracellular alkalosis (Darrow mechanism). Depletion of the cell in potassium ions contributes to disruption of ATP synthesis and a decrease in energy reserves, which leads to a weakening of the contractile force of the myocardium and respiratory muscles. Shortness of breath, tachycardia occur, the stroke volume of the heart decreases and circulatory failure develops with phenomena of general tissue hypoxia. Potassium ion deficiency reduces smooth muscle tone, leading to the development and progression of gastrointestinal paresis.

Consequently, the main pathophysiological processes in peritonitis are hypovolemia and disturbances of central and peripheral hemodynamics, changes in water-electrolyte balance and acid-base status, and dysfunction of vital organs. In severe peritonitis, these disorders can be considered manifestations of peritoneal shock.

Most of these disorders are reflected in clinical symptoms. It is only necessary to take into account that in children under 3 years of age, protective mechanisms quickly turn into pathological ones, and general clinical symptoms prevail over local ones.

The course of diffuse peritonitis is accompanied by pronounced disturbances in the immunological reactivity of the child’s body, which have a clearly defined phase character.

In the reactive phase of peritonitis, a tension in the factors of natural nonspecific reactivity, an increase in the activity of p-lysines, the number of leukocytes, lymphocytes, an increase in the level of immunoglobulins in the blood serum, an increase in the absolute number of rosette-forming cells, and a decrease in the relative number of T- and B-lymphocytes are noted.

In the toxic phase there is a further increase general level nonspecific indicators, however, there is a change in the number of functionally active leukocytes and a drop in the concentration of serum immunoglobulins.

In the phase of multiple organ disorders, complete failure is noted protective forces, a catastrophic decrease in the indicators of both specific and nonspecific immune reactions.

Clinical picture The history usually includes pain, vomiting, and increased body temperature. In the future, the pain may subside somewhat, but hyperthermia persists, although sometimes insignificant; the general condition may also improve somewhat, but is never restored to satisfactory. After the “bright interval,” deterioration occurs: abdominal pain intensifies again, vomiting appears, and the general condition progressively worsens. The presence of such a gap is apparently associated with the destruction and necrosis of nerve endings in the appendix. The onset of a period of deterioration is explained by the involvement of the entire peritoneum in the inflammatory process as a result of perforation of the appendix or a violation of the integrity of the conglomerate with “covered” perforation. It is possible to develop peritonitis without perforation of the appendix due to the passage of microflora through the altered wall. The speed of onset of perforation and the duration of the “bright interval” depend on the age of the patient: the younger the child, the faster the onset of perforation and the shorter the period of apparent improvement. The use of antibiotics sharply erases the severity of the clinical manifestations of appendicitis, which increases the likelihood of developing peritonitis. Antibiotics cannot stop the destructive process that has already begun, but their use reduces the severity of pain, temperature reaction and general disorders, while inflammation of the peritoneum progresses. Therefore, the use of antibiotics, especially in young children, until the cause of abdominal pain is determined is contraindicated.

Diagnostics When examining a child with appendiceal peritonitis, a significant severity of the general condition is noted. The skin is pale and sometimes has a “marble” tint. The eyes are shiny, the tongue is dry, with a white coating. Usually there is shortness of breath, which is more pronounced the younger the child. It is often possible to establish a discrepancy between the pulse rate and the degree of increase in body temperature. The abdomen is swollen, sharply painful on palpation in all parts, protective muscle tension and the Shchetkin-Blumberg symptom are clearly visible, most pronounced in the right iliac region.

Sometimes there is tenesmus, loose, frequent stools in small portions, painful and frequent urination. Rectal examination reveals severe pain and overhang of the rectal wall.

In young children, the general condition may be slightly impaired at first, which is associated with good compensatory capabilities of the cardiovascular system at this age. Respiratory failure may come to the fore. After some time, decompensation of the cardiovascular and respiratory systems, as well as metabolic processes, occurs, as a result of which the patient’s condition begins to progressively deteriorate. At an early age, with appendiceal peritonitis, loose stools are often observed, sometimes green in color with mucus.

Treatment Peritonitis in children is a difficult task and consists of three main stages: preoperative preparation, surgical intervention and postoperative period.

Preoperative preparation Immediate surgical intervention for peritonitis in conditions of significant violations internal environment body - a serious mistake. These changes can be aggravated during surgery and in the postoperative period under the influence of surgical trauma, anesthesia errors and further progression of the pathological process.

The purpose of preoperative preparation is to reduce disturbances in hemodynamics, acid-base status and water-electrolyte metabolism.

The basis of preoperative preparation is the fight against hypovolemia and dehydration. The degree of dehydration can be determined using the following formula using hematocrit values.

where m is body weight, k is the coefficient (for children over 3 years old - 1/5, for children under 3 years old - 1/3).

When carrying out infusion therapy, first of all, solutions of hemodynamic and detoxification action are prescribed (dex-ran, average molecular weight 30,000-40,000, albumin, dext-ran, average molecular weight 50,000-70,000, Ringer's solution, blood plasma). The volume and quality of infusion therapy depend on the severity of peritonitis, the nature of hemodynamic disorders and the age of the patient. The entire complex of preoperative measures must be completed in a fairly short time (no more than 2-3 hours).

Therapy with broad-spectrum antibiotics begins already in the preoperative period. Intravenous administration of a third-generation £)cephalosporin (cefotaxime, ceftriaxone) or an inhibitor-protected penicillin (amoxicillin + clavulanic acid) is recommended, under the protection of which the operation is performed. In the postoperative period, the administration of antibiotics is continued in the form of combined antibiotic therapy (cephalosporin + aminoglycoside + metronidazole or amoxicillin-Nclavulanic acid + aminoglycoside), which allows covering the entire spectrum of potential pathogens of peritonitis (Gram-negative bacteria, enterococci and anaerobes) Intubation and gastric lavage help reduce intoxication, improvement of breathing, prevention of aspiration. An important role, especially in children in the first months of life, is played by the fight against hyperthermia, pneumonia, pulmonary edema, and convulsions.

Surgery Surgical intervention begins when hemodynamic processes, acid-base status, water-electrolyte metabolism are compensated and stabilized, and body temperature does not exceed subfebrile levels. Surgery for peritonitis is carried out to eliminate the primary focus, sanitation and drainage of the abdominal cavity. The effect on the primary focus is appendectomy. Further tactics depend on the depth of changes in the intestines and peritoneum. The most important thing in this situation is to assess peristalsis and circulatory disorders.

Features of surgical tactics for appendiceal peritonitis depend on its phase.

In the reactive phase during surgery, abundant purulent effusion in the abdominal cavity is usually detected. The intestinal loops are somewhat swollen, hyperemic, without fibrin overlay and circulatory disturbances. Despite the fact that the inflammatory process spreads to the entire abdominal cavity, local symptoms still predominate; the body, as it were, copes with the disturbances that have arisen, using its own reserves. Among intraoperative measures in the reactive phase important role are given to thorough sanitation of the abdominal cavity. Then the surgical wound is sutured tightly, leaving a silicone drainage or a polyethylene tube from a disposable blood transfusion system in the pelvis. Drainage is introduced through an additional puncture incision in the right iliac region, slightly above and lateral to the “appendicular” incision. For its correct fixation, the abdominal wall is pierced in an oblique (at an angle of 45°) direction, after which the drainage is placed in the right lateral canal and as far as possible on the pelvic floor (for boys - between the rectum and bladder, for girls - between the rectum and uterus). The diameter of the holes in the section of the tube located in the pelvis should not exceed 0.5 cm. With smaller holes, the drainage quickly becomes clogged, and with larger ones, suction of the intestinal wall, omentum, and fatty deposits is possible. The drainage tube is fixed on the skin with silk sutures (Fig. 7-16).

During the toxic phase of peritonitis in the abdominal cavity you can find a large number of pus, significant paresis (up to paralysis), severe circulatory disorders with fibrin deposits on the intestinal loops. Surgical tactics for this phase of peritonitis in general principles similar to that in the previous phase, but has its own characteristics. Simultaneous rinsing of the abdominal cavity should be more thorough and use a large amount of rinsing solution. With significant intestinal paresis, various methods of decompression are used: intubation of the small intestine through a gastrostomy, cecostomy, retrograde through anus or “pumping” the contents of the small intestine into the large intestine. As with the exudative phase of peritonitis, aspiration drainage of the pelvic cavity is carried out using a drainage tube. The root of the mesentery of the small intestine is inoculated with a 0.25% procaine solution. Epidural anesthesia is indicated, which is performed in the postoperative period.

In the phase of polymorphic disorders, deep functional disorders of the intestine are revealed during surgery. Due to its paralysis, stasis and dilation of the small intestine due to the accumulation of fluid and gases is noted. In this case, delimited abscesses in the abdominal cavity are more often detected. After dividing the intestinal loops, it is advisable not to suture the midline laparotomy wound (laparostomy). After thorough sanitation of the abdominal cavity, the pelvic cavity is drained with a silicone tube. The intestines are covered with a plastic film with multiple holes up to 5 mm, napkins soaked in petroleum jelly are placed on top, over which the skin is brought closer to the aponeurosis with separate sutures without tension, covering only the edges of the napkins. The absence of compression on the intestines and the possibility of free exit of infected exudate from the abdominal cavity through the wound help improve microcirculation in the intestines, restore peristalsis and relieve the inflammatory process. In this phase of peritonitis, decompression of the gastrointestinal tract is of particular importance. After 2-3 days, a repeat operation is performed: the napkins and film are removed, the wound is sanitized, the abdominal wall is sutured tightly through all layers with U-shaped mattress silk sutures. The edges of the wound are separated from the fused intestine so that the intestinal loops are not deformed during stitching.

Postoperative treatment After the operation, the patient is created in an elevated position in the bed by raising its head end at an angle of 30°, which facilitates the child’s breathing and promotes the outflow of exudate to the lower abdomen. Place a cushion under the bent knees to prevent the child from sliding down.

It is extremely important to carefully monitor cardiac activity (pulse, blood pressure, ECG), breathing, protein composition of the blood, water-electrolyte balance, acid-base state of the blood. During the first 2-3 days, body temperature, pulse, blood pressure, and respiratory rate are monitored every 2-4 hours. Carefully measure the volume of fluid drunk and parenterally administered and excreted in urine and vomit.

In addition to the general condition (reaction to the environment, appetite, normalization of gastrointestinal function), extremely important indicators of the course of the inflammatory process in the abdominal cavity are the dynamics of the temperature reaction and the picture of peripheral blood.

The complex of therapeutic measures consists of the following points: the fight against toxicosis and infection, the elimination of hemodynamic disorders and hypovolemia, the correction of water-electrolyte and metabolic changes, the elimination of anemia and hypoproteinemia.

Great importance should be attached to the prevention and treatment of respiratory disorders. The complex of these measures includes decompression of the stomach by inserting a probe into it. The constant presence of a probe in the first 2-3 days after surgery prevents aspiration, helps reduce intra-abdominal pressure, increasing the ventilation capabilities of the respiratory system.

Prevention and treatment of respiratory failure are necessary throughout the immediate postoperative period. According to indications, catheterization of the tracheobronchial tree is performed, followed by suction of mucus. This makes it possible to prevent the development of atelectasis and pneumonia.

In the early postoperative period, homeostasis disturbances may again occur due to surgical trauma and the ongoing inflammatory process. The main ones are disturbances of hemodynamics, acid-base status and water-electrolyte balance. More than a third of patients with diffuse peritonitis have similar violations with symptoms of severe metabolic acidosis. It is extremely rare, in very severe forms of peritonitis, that metabolic alkalosis is observed. Correction of hemodynamic changes and metabolic acidosis does not differ from that carried out in the preoperative period. It is achieved by intravenous administration of plasma, high molecular weight drugs, and 4% sodium bicarbonate solution. Metabolic alkalosis is corrected by intravenous administration of a 7.5% solution of potassium chloride, an average of 8 to 10 ml (0.5 ml/kg body weight) diluted. Respiratory acidosis that occurs in the postoperative period is eliminated by dosed oxygen therapy and evacuation of gastric contents using a tube. Correction of water-electrolyte metabolism disorders does not differ from that carried out before surgery.

The success of treatment for peritonitis largely depends on the rational use of antibiotics. Combination antibiotic therapy is indicated (based on third-generation cephalosporins or inhibitor-protected penicillins). For children undergoing repeated surgery due to complications (subhepatic, subdiaphragmatic abscesses, intestinal fistulas, etc.). For patients with previous hospitalization and antibiotic therapy, as well as for postoperative peritonitis, the antibiotics of choice are carbapenems (imi-penem + cilastatin, meropenem) in monotherapy or in combination with aminoglycosides. An important link in the postoperative period in patients with peritonitis is the normalization of intestinal functions. In severe peritonitis, intestinal paresis often lasts for several days. To combat postoperative paresis, repeated hypertensive enemas are used, agents that stimulate peristalsis are prescribed subcutaneously (0.05% solution of neostigmine methyl sulfate, 0.1 ml per 1 year of life), and intravenous transfusions of hypertonic dextrose solutions (10-20 ml of 40% solution) , 10% sodium chloride solution (psG2-shgna 1 year of life) and potassium chloride solutions. The infusion of the latter is carried out in a dextrose solution by drip. The safest concentration of potassium chloride is 1%. It is necessary to monitor the regularity of stool: if it is delayed, cleansing enemas are done once every 2 days. Taking into account the possibility of formation of infiltrates and abscesses in the abdominal cavity in the postoperative period, control over the temperature reaction and the content of peripheral blood leukocytes is necessary. For all patients, even in the absence of complaints, it is advisable to periodically conduct a digital examination of the rectum for the timely detection of pelvic infiltrate or abscess, since the use of antibiotics smoothes out their clinical manifestations. Treatment of peritonitis in children, especially young children, is a task that requires an individual approach, taking into account many factors. Only massive complex therapy may be effective in this severe disease.

7.12.3. Peritonitis in newborns

Peritonitis in newborns is a serious complication of pathological conditions of various etiologies. These include necrotizing enterocolitis, gastrointestinal malformations, acute appendicitis, iatrogenic perforations of hollow organs, bacterial infection of the peritoneum by contact, hematogenous and lymphogenous routes in sepsis. The most common cause of peritonitis is perforation of the gastrointestinal tract wall (84% of cases). Intrauterine intestinal perforations with developmental defects lead to aseptic adhesive peritonitis, postnatal ones - to diffuse fibrinous-purulent, fecal peritonitis. With necrotizing enterocolitis against the background of intensive therapy, limited peritonitis may develop. Non-perforative fibrinous-purulent peritonitis, which develops in utero with hematogenous, lymphogenous and transplacental infection, is now rarely observed. In the postnatal period, infection of the peritoneum occurs through contact with purulent periarteritis and periphlebitis of the umbilical vessels, liver abscesses, purulent diseases retroperitoneal space, phlegmon of the anterior abdominal wall. These forms also occur rarely today.

Classification. Peritonitis in newborns is classified as follows.

Based on etiology. Perforated : necrotizing enterocolitis (posthypoxic, septic); malformations of the gastrointestinal tract (segmental defect of the muscular layer of the wall of a hollow organ, complications with atresia, volvulus, meconium ileus, Hirschsprung's disease); acute appendicitis; destructive cholecystitis and cholangitis; Iatrogenic perforation of hollow organs. Imperforate peritonitis: hematogenous, lymphogenous infection of the peritoneum; contact infection of the peritoneum.

By time of occurrence: prenatal; postnatal.

According to the degree of distribution in the abdominal cavity: diffuse; delimited.

According to the nature of the effusion in the abdominal cavity: fibroadhesive; fibrinous-purulent; fibrinous-purulent, fecal.

Clinical picture postnatal perforated peritonitis in newborns with intestinal wall defects is manifested by acute symptoms of peritoneal shock on the 2-3rd day of life. The child is lethargic and moans. The skin is pale gray, acrocyanosis. Breathing is frequent and shallow due to the high position of the diaphragm dome. Heart sounds are muffled. Notice the sharp swelling, tension and pain in the abdomen, and the expansion of the subcutaneous venous network. With peritonitis, newborns often experience hyperemia of the skin in the lower abdomen and genitals. Intestinal peristalsis cannot be heard. Percussion above the liver reveals a box sound - a symptom of the disappearance of hepatic dullness. There is constant vomiting of intestinal contents, stool and gases do not pass away.

Diagnosis The diagnosis is confirmed by a survey x-ray of the abdominal organs. Significant pneumoperitoneum is detected under the dome of the diaphragm (Fig. 7-17).

Treatment Treatment is only surgical. After puncture of the abdominal cavity and reduction of intra-abdominal pressure, comprehensive preoperative preparation is carried out for 2-3 hours, aimed at eliminating the symptoms of centralization of blood circulation. Preference is given to upper transverse laparotomy, which allows for a full examination of the abdominal organs. The intestinal loop with the perforation area is sutured to the abdominal wall in the form of an intestinal fistula. After this, the abdominal cavity is washed with antiseptic solutions and sutured, leaving drainage.

Prevention Currently, special attention is paid to the prevention of peritonitis in newborns. Early diagnosis of malformations and diseases leading to peritonitis can significantly reduce its incidence and improve treatment results.

7.12.4. Necrotizing enterocolitis

One of the most common causes of postnatal perforated peritonitis (60% of all perforations) is hemorrhagic or septic infarction, which develops as a result of circulatory disorders in the wall of the gastrointestinal tract. Among children during the adaptation period, necrotizing enterocolitis occurs in 0.25%, and among children requiring intensive care in the neonatal period - in 4%. Necrotizing enterocolitis is a polyetiological disease. In the early neonatal period, the disease develops in children who have suffered severe neonatal hypoxia and asphyxia; it can also be a complication of infusion therapy and replacement blood transfusion administered through the umbilical vein; it can develop with decompensation of severe birth defect heart and decompensated form of Hirschsprung's disease. Irrational use of antibiotics also contributes to the development of enterocolitis. Along with the direct damaging effect of some antibiotics (ampicillin, tetracycline) on the intestinal mucosa, the suppression of colonization resistance of saprophytic flora with the development of severe dysbiosis is essential. Despite the diversity etiological factors The pathogenesis of necrotizing enterocolitis involves severe microcirculatory disorders in the wall of the gastrointestinal tract. Centralization of blood circulation occurs with spasm of mesenteric vessels (up to complete cessation of blood circulation), which is resolved by intestinal paresis with hemorrhages. Morphologically, large or small infarctions of the intestinal wall are identified. More frequent damage to premature babies is explained by the low resistance of their capillaries to pressure changes in the vascular bed. Predominantly, damage occurs to the distal ileum and the angles of the colon (ileocecal, hepatic, splenic, sigmoid). The process begins with necrosis of the mucous membrane, and then spreads to the submucosal, muscular and serous layers, ending with perforation (Fig. 7-18).

Clinical picture and diagnosis In the clinical picture of necrotizing enterocolitis in children who have suffered chronic perinatal hypoxia and infection, a clear staged course of the disease is noted.

Stage I can be regarded as prodromal. The condition of children at risk who have suffered perinatal hypoxia and infection is closer to severe due to neurological disorders, respiratory impairment and cardiovascular activity. From the gastrointestinal tract, symptoms of dyskinesia are detected. Sluggish intermittent sucking, regurgitation during and after feeding with milk, occasionally bile, malnutrition, aerophagia, bloating, restlessness of the child while stroking the abdomen in the absence of symptoms of peritoneal irritation, delayed passage of meconium stool, quick loss body weight. X-rays show increased uniform gas filling of all parts of the gastrointestinal tract with slight thickening of the intestinal walls.

Stage II is characterized by clinical manifestations of necrotizing enterocolitis. In newborns on the 5-9th day of life, the condition worsens, the symptoms of dynamic intestinal obstruction increase, the body weight deficit is 10-15% due to dehydration. The child sucks poorly, regurgitates with an admixture of bile, abdominal bloating increases, and local pain appears, most often in the right iliac region. The passage of feces is frequent, occurs in meager portions, with an admixture of mucus and greens. The color of the stool is determined by the nature of the pathological intestinal microflora. Thus, staphylococcal dysbacteriosis is characterized by pronounced general toxicosis, and in liquid, foamy stool there is mucus and greens. A gram-negative infection is more characterized by severe dehydration, scanty, porous, pale yellow stool with mucus and a large water spot. A plain X-ray of the abdominal organs shows increased uneven gas filling of the gastrointestinal tract with a shadowing zone corresponding to the area of ​​maximum intestinal damage. The stomach is distended, with fluid levels. Thickening of the shadows of the intestinal walls is characteristic due to their edema, inflammation and interloop effusion. The rigidity of the intestinal walls leads to straightening of their contours. Submucosal cystic pneumatosis of the intestinal wall appears (Fig. 7-19). In severe cases, gas is detected in the portal system of the liver (Fig. 7-20). Progressive dehydration and loss of body weight further disrupt the microcirculation of the intestinal wall and contribute to the progression of the necrotic process. Violations of the barrier function of the intestinal wall are accompanied by severe infectious toxicosis.

Stage III- (preperforation) intestinal paresis is expressed. The duration of the stage is no more than 12-24 hours. The condition is very serious, symptoms of toxicosis and exicosis are pronounced, characterized by persistent vomiting of bile and “feces”, severe bloating, pain and tension throughout the abdomen. Peristalsis is sluggish, but audible. Feces and gases do not pass. The anus is closed. During a rectal examination (finger, probe), scarlet blood is released. Radiologically, due to hydroperitoneum, shading of the abdominal cavity increases, the external contours of the intestinal loops lose their clear outline (Fig. 7-21).

Stage IV - (spread perforated peritonitis) is characterized by symptoms of peritoneal shock and intestinal paralysis. The peculiarity of perforated peritonitis in necrotizing enterocolitis is a significant area of ​​intestinal damage, the severity of the adhesive-inflammatory process in the abdominal cavity, and moderate pneumoperitoneum (Fig. 7-22).

A more favorable complication of necrotizing enterocolitis is limited peritonitis, observed in a third of cases during treatment. In a child with clinical symptoms of enterocolitis, a dense infiltrate with clear contours, moderately painful, appears in the abdominal cavity (usually in the iliac region). Against the backdrop of ongoing conservative therapy both complete resorption of the infiltrate and its abscess formation with the formation of an intestinal fistula on the anterior abdominal wall are possible. When carrying out differential diagnosis, great difficulties arise, since the clinical manifestations are similar to acute appendicitis.

> Peritonitis treatment in children

Inflammation of the peritoneum is called peritonitis. The disease peritonitis in children occurs as a complication after surgery, for example, when appendicitis was removed. The disease is classified into two types: primary and secondary. Primary is easier than secondary, but if you ignore the child’s complaints, the consequences can be very serious, even fatal.

Peritonitis in children differs from a similar disease in adults, because the organs are not fully formed, and the body systems are working at full capacity. Treatment is prescribed by a doctor; self-medication is unacceptable.

Children's appendiceal peritonitis has two main types.

Free peritonitis or widespread form. This variety includes several types that determine where the source of the disease is located:

• Localization of inflammation in the area of ​​the cecum, name: local unlimited;
• The area of ​​inflammation does not extend beyond the lower part of the peritoneum, name: diffuse;
• The process of inflammation covers the bottom and middle of the peritoneum, name: diffuse;
• The entire cavity is affected, name: general.

Very often, free peritonitis accompanies the so-called purulent effusion. Fluid accumulates at the site of localization, complicating the course of the disease and its treatment.

Abscessing

Abscessing peritonitis or localized form. In this case, the following are possible:

• Appendiceal infiltrate, when the appendix area is thickened with products of the inflammatory process (blood, cells, purulent effusion);
• Periappendicular abscess of three degrees, means total suppuration;
• A combined form, when an extensive abscess and purulent effusion complicate the problem;
• The form of total inflammation is the most dangerous subtype of peritonitis for a child’s life; it is accompanied by sepsis and infectious-toxic shock.

Severe consequences of the second type are sometimes inevitable.

Why does peritonitis occur?

The causes of this disease in a child are varied, the list is as follows:

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Most often, appendiceal peritonitis occurs, since appendicitis in children, especially small ones, is very difficult to diagnose: the symptoms are similar to other diseases.

Stages of appendiceal peritonitis:

1. Reactive. Valid for about a day from the moment of localization.
2. Toxic. Lasts up to 72 hours.
3. Terminal. Signs appear on the third day.

At each stage, appendicular peritonitis has specific symptoms. The sooner appropriate treatment is started, the greater the chance of avoiding serious complications.

Adults should pay attention that the baby’s condition is deteriorating right before our eyes. It is worth noting that the signs of the disease in children can be very different from the corresponding symptoms in adults or the elderly. The initial stage in the first ones is not so identified, the symptoms are smoothed out, and the signs do not make themselves felt. However, peritonitis develops and can become purulent as the focus of inflammation grows.

What symptoms should adults respond to:

• Nausea and vomiting;
• High body temperature of the baby (more than 38 degrees);
• Sharp pain in the right hypochondrium, then spreading throughout the entire abdominal cavity;
• The general condition worsens: the child is capricious, restless, and experiences severe weakness;
• Intestinal dysfunction (diarrhea and obstruction are equally possible);
• Frequent urination, often accompanied by pain;
• Sleep disturbance (fears and insomnia);
• Loss of appetite;
• The abdominal muscles are tense (easy to determine by palpation).

At an early stage, some symptoms sometimes disappear, a false improvement in health occurs, but the body temperature remains high. The child experiences relief, but then the condition worsens sharply, symptoms appear again with new strength.

During false improvement, treatment should not be stopped under any circumstances, since the causes of peritonitis have not been eliminated.

Late stages are characterized by the following symptoms:

• Severe dehydration;
• The complexion takes on a gray tint;
• The eyes shine and water;
• The mucous membrane dries out, the child experiences extreme thirst;
• The tongue becomes covered with a white coating;
• The heart rate increases noticeably;
• Abdominal bloating occurs;
• The chair disappears;
• Palpation becomes painful.

Diagnostics

The first thing parents should do is call a doctor immediately. After the diagnosis is established, the child is hospitalized.

Inpatient diagnostics include:

• Blood tests;
• Urine tests;
• Ultrasound examination;
• X-ray pictures.

In serious situations: puncture, laparoscopy (surgical examination), laparocentesis (puncture, pumping out pus or fluid).

Most often, treatment is impossible without surgery. The causes of the inflammatory process may be different, but surgical intervention is inevitable.

The operation for inflammation of the peritoneum takes place in several stages:

1. Preparation for surgery. The set of measures depends on the stage and type of the disease. Sometimes this takes more than three hours.
2. Surgery to eliminate the cause of inflammation. Possible removal of a section of intestine.
3. Rinsing the area with a special composition, including an antibiotic and other antibacterial medications.
4. Stitching. The wound is sutured, a drain is inserted, and sanitization solutions are injected through it after the operation, during the recovery period.

In parallel with the above, powerful infusion therapy is carried out:

• Injections with antibiotics;
• Medicines to reduce body temperature;
• Products for improving metabolism and blood microcirculation.

Rehabilitation and prevention

After the operation, the child is under the supervision of a doctor. It is necessary to ensure the correct position (head raised). It is necessary to prevent infection, further dehydration and intoxication of the body.

If the baby experiences pain, painkillers are administered. A gentle diet is followed to normalize intestinal function. Tests are done regularly.

Peritonitis is a dangerous disease. It is absolutely unacceptable to self-medicate and delay calling an ambulance. It is important not to miss the initial stage and seek medical help in a timely manner. Sometimes, this is the only way to save a child’s life.

As a preventative measure, educational outreach is carried out among the population. Adults should understand that timely seeking help from a specialist will help avoid complications. The key to success in the treatment of this disease is a clear understanding of what is happening and prompt surgical intervention. The prognosis for recovery in such cases is always positive.

Peritonitis is called acute inflammation layers of the peritoneum, which develops as a result of the aggressive influence of various irritants (infectious, non-infectious). The development of peritonitis is accompanied by a progressive deterioration of the patient's condition and severe pain. According to medical statistics, death from peritonitis accounts for about 20% of deaths from acute surgical pathology.

There are many causes of peritonitis in the abdominal cavity, so there are several classifications of inflammation of the peritoneum, which are based on different symptoms.

What causes peritonitis? According to the routes of infection, they are distinguished:

• Primary peritonitis (when inflammation develops after infection through the blood or lymph from an organ).
• Secondary peritonitis (when inflammation develops as a result of injury or surgery). Among these peritonitis there are:
• perforative (when the wall of an organ located in the abdominal cavity ruptures);
• traumatic (as a result of an injury to the abdomen);
• infectious-inflammatory (during the transition of the pathological process from the abdominal organ to the peritoneum);
• postoperative (due to surgical interventions on the abdominal organs).
• Tertiary peritonitis (when inflammation of the peritoneum occurs against the background of weakened immunity during severe generalized infections or immunodeficiency states).

Depending on the extent and what is inflamed during peritonitis in the abdominal cavity, there are:

• Limited (involvement of the peritoneum occurs at the site of the primary focus) - appendicular, subhepatic, subphrenic, pelvioperitonitis.
• Common:
• diffuse peritonitis (two areas of the abdominal cavity are involved);
• diffuse (more than two areas of the abdominal cavity are involved);
• general (the entire peritoneum is inflamed).

According to pathogenesis, peritonitis is distinguished, which develops as a result of infection, gastric contents (together with hydrochloric acid), intestinal contents (feces and microflora), bile (in case of rupture of the gallbladder), urine (in case of rupture of the renal pelvis or ureters), blood (in case of injuries or blood reflux during heavy periods through the fallopian tubes).

The most common causes of peritonitis are:

• appendix rupture;
• perforated ulcer of the stomach or duodenum;
• perforation of the intestinal wall at the site of the typhoid plaque during typhoid fever;
• damage to the intestinal wall by a foreign body;
• necrosis of a section of the intestine due to a strangulated hernia;
• rupture of intestinal diverticulum;
• intestinal rupture due to intestinal obstruction;
• perforation of an organ wall by a malignant tumor.

In some conditions (for example, with hypertension syndrome in the hepatic portal vein system), fluid leaks into the abdominal cavity from varicose veins - ascites. This liquid various reasons may become inflamed. With internal bleeding (from the liver, spleen, kidneys), hemoperitoneum (blood peritonitis) occurs.

How does peritonitis manifest? The symptoms of peritonitis in adults are very clear. The first signs of peritonitis are severe pain and a positive symptom of peritoneal irritation. Pain syndrome is the leading one in symptoms. The pain is unbearable and forces patients to take a forced position - on their side with their legs tightly pressed to their stomach. In clinical therapy, three phases of the disease are distinguished:

• Reactive (initial, exudative) phase. Usually occurs in the first two days. Beginning peritonitis manifests itself in the form of increasing symptoms: from abdominal cramps to intolerable severe pain. In this case, a reflex tension of the muscles of the anterior abdominal wall occurs, as a result of which the patient’s stomach becomes like a board. From common symptoms the patient complains of severe weakness, his body temperature rises.
• Toxic phase of peritonitis. This is a period of imaginary improvement in the patient’s well-being. Patients are inhibited, often euphoric. During this period, toxins accumulate in the abdominal cavity and penetrate into the blood. Often patients suffer from nausea and vomiting (as a sign of increasing intoxication of the body). The appearance of patients changes: facial features become sharper, the skin turns pale. About 1/5 of patients with peritonitis die during the toxic stage. This often occurs due to the fact that a couple of days after the onset of the disease, after taking a large number of painkillers, the patient’s condition “improves”, which is perceived as recovery.
• Terminal phase (multiple organ disorders). The body's defenses are depleted. As a result of this, a sharp deterioration in the patient’s condition occurs: debilitating vomiting, severe bloating abdomen, the slightest movement causes severe pain in the patient, internal organs swell, resulting in severe shortness of breath, palpitations, and urine stops flowing. The skin takes on an earthy color, the cheeks and eyes are sunken. Only every tenth patient survives the terminal stage, even if surgery is performed.

According to the data medical statistics, the most common is complicated appendicitis with peritonitis. Complication of appendicitis with peritonitis occurs in 10-15%, while gangrenous appendicitis is detected in almost 95% of cases of rupture of the appendix.

A slightly different picture can be observed with biliary peritonitis. It occurs due to the effusion of bile from the gallbladder into the abdominal cavity. The course of biliary peritonitis depends on the volume of bile released and its sterility. If bile enters the abdominal cavity in small quantities, then peritonitis can be subacute or chronic in nature with mild pain and peritoneal signs.

Another clinical picture develops with the rapid flow of bile into the abdominal cavity. In this case, the symptoms increase very quickly, biliary hemorrhagic peritonitis develops and death occurs.

Biliary peritonitis develops as an early consequence after removal of phlegmonous or gangrenous cholecystitis as a result of threads slipping from the suture after surgery. When making a diagnosis, the fundamental symptom will be a recent cholecystectomy (removal of the gallbladder).

How long will it take to die from peritonitis if you do not seek help in a timely manner? There are no clear statistics on this issue. This depends on many factors (age, course of the disease, concomitant diseases).

Are there any chances of surviving with extensive peritonitis? We can say with confidence that without appropriate medical care, 100% of patients die from extensive peritonitis.

Symptoms and treatment for peritonitis in adults differ from those in children. The causes of peritonitis in children can be very different. Most often, peritonitis occurs due to rupture of abdominal organs. Perforated peritonitis in children in most cases develops after appendicitis (appendicular peritonitis). But children often experience peritonitis, the cause of which is extremely difficult to establish (so-called cryptogenic).

Depending on the cause of peritonitis and the age of the child, the symptoms, course and prognosis of peritonitis change. In pediatric surgery there are special forms peritonitis, which do not occur in adults:

• cryptogenic pelvioperitonitis in girls;
• perforated peritonitis, developing against the background of necrotizing enterocolitis in newborns (more often occurs in premature infants due to severe asphyxia during childbirth);
• peritonitis against the background of malformations of the digestive tract (Hirschsprung's disease, meconium ileus, atresia).

How to define peritonitis? Upon examination and palpation of patients, the following symptoms are determined:

• the mobility of the anterior abdominal wall is limited - it does not participate in breathing;
• the anterior abdominal wall is very tense, asymmetry or retraction of the abdomen may be observed;
• the abdomen is sharply painful on palpation;
• a positive symptom of peritoneal irritation is determined (Shchetkin-Blumberg symptom) - when pressing, and then sharply removing the hand from the localization site the greatest pain there is increased pain;
• During a vaginal examination, women experience pain and sagging of the posterior vaginal vault;
• at rectal examination you can palpate the infiltrate in the pelvis.

When the anterior wall of the abdominal cavity is tapped, the hepatic dullness disappears and tympanitis (the sound of beating a drum) is heard throughout the abdomen. When listening to the intestines using a phonendoscope, bowel movements are not heard (deathly silence) or pathological bowel sounds are detected.

Usually, making a diagnosis of peritonitis is not difficult. But to confirm and clarify it, additional research methods are required (laboratory diagnostics and instrumental research methods):

• general blood test (signs of inflammation are determined - an increase in the number of leukocytes, acceleration of the erythrocyte sedimentation rate);
• biochemical blood test (identifies the possible cause of the development of peritonitis, determines the degree of disturbance of the acid-base balance in the blood);
• general urine analysis;
• Ultrasound of the abdominal organs, if necessary - ultrasound of the pelvic organs (ultrasound may reveal the primary lesion);
• X-ray of the abdominal cavity (the “sickle” symptom is a reliable sign for a perforated ulcer, Kloiber’s cups for intestinal obstruction);
• puncture through the posterior vaginal fornix (often fluid or pus accumulates there, because between the vagina and rectum there is the deepest pocket of the peritoneum in the pelvis);
• laparocentesis (obtaining effusion from the abdominal cavity);
• CT scan.

How is peritonitis treated? Treatment of peritonitis is always surgical. It is preceded by preoperative preparation, without which it is difficult to achieve good results during surgery.

Preoperative preparation includes:

• catheterization of the patient through the subclavian vein;
• emptying the bladder and installing a catheter in it (to monitor kidney function during surgery);
• emptying the stomach using a tube;
• replacement of the volume of circulating blood through a subclavian catheter (colloid and crystalloid solutions, antibiotics are infused, alkalization of the blood is eliminated);
• antienzyme therapy;
• medicinal maintenance of liver and kidney functions, heart activity;
• premedication (preparation for general anesthesia).

The surgical intervention itself is carried out after preparing the patient and after introducing him into a state of deep anesthesia. During surgery for peritonitis it is necessary:

• detect and eliminate the source of infection;
• wash the abdominal cavity;
• install a gas outlet tube into the intestine;
• drain the abdominal cavity.

Access for peritonitis is median (along the white line of the abdomen), from the pubis to the navel and sternum. Such large access is necessary in order to thoroughly rinse the abdominal cavity.

The course of the operation largely depends on the cause of peritonitis:

• when an organ is perforated (for example, with a perforated stomach ulcer), it is sutured;
• in case of intestinal peritonitis, which develops against the background of intestinal obstruction, part of the intestine is removed to form an artificial anastomosis or with a stoma placed on the anterior abdominal wall;
• When the appendix is ​​perforated, it is removed and the intestinal defect is sutured.

After identifying and eliminating the cause of peritonitis, the entire abdominal cavity is washed with antiseptic solutions and then dried. How to wash the abdominal cavity? Modern medicine has a choice of strong antiseptics, solutions of which are used for washing the abdominal cavity during peritonitis (Chlorhexidine, Furacillin).

To remove gases from the intestines after surgery, a special gas tube is installed in the small intestine during surgery.

Before suturing the abdominal cavity, drainage tubes are inserted into the pockets formed by the sheets of peritoneum, through which the effusion will be removed in the first days.

Postoperative treatment is aimed at restoring the body after surgery and normalizing all organs and organ systems. Postoperative recovery period can be roughly divided into:

• Early (up to 5 days). In the early period, patients are given:
• intensive drug (infusion) therapy - infuse up to 10 liters of liquid per day;
• detoxification (removal of toxic breakdown products from the body);
• antibiotic therapy;
• stimulation of intestinal activity;
• immunocorrective therapy;
• support of cardiovascular activity;
• observation and prevention of complications.
• Late (before discharge, usually 2-3 weeks).
• Remote (until returning to work or becoming disabled).

How long is peritonitis treated? If postoperative period proceeds favorably, then the drainages can be removed on the 3-4th day, and the sutures on the 8-9th day. From 5-6 days the patient may be allowed to move around the hospital. As a rule, after the stitches are removed, patients are discharged home.

Diet after peritonitis is of great importance for recovery. Regardless of what the cause of intestinal peritonitis was, after surgery the patient is prescribed complete fasting for the first 2-3 days. From the second postoperative day, parenteral nutrition (glucose solution, amino acids) begins. If the patient recovers well and has intestinal peristalsis (movement), he may be allowed to drink in small sips - no more than 1 teaspoon per hour, gradually increasing the volume. At the same time, they switch to liquid food feeding through a tube.

The patient can be transferred to eating in the usual way only after normal intestinal motility has been established, gas has passed spontaneously and the first stool has appeared. The patient’s diet in the first week after surgery should be as gentle as possible:

• meals at least 6 times a day;
• portions are small;
• the temperature of the food should not be higher than room temperature;
• the majority of dishes should be in liquid form - first courses (weak broths, pureed soups, pureed soups), mashed potatoes, soft-boiled eggs, jelly;
• 3-4 days after the start of nutrition, you can add boiled lean meat or pureed fish, slimy porridges, low-fat dairy products to the diet;
• fatty meat, legumes, cabbage, easily digestible carbohydrates, fresh bread, spices are excluded from the menu;
• The diet after discharge should also be gentle (fatty, fried, hot, spicy foods, baked goods, white bread, overeating, and alcoholic beverages should be avoided).

How to recover after surgery for peritonitis? Clinical recommendations after surgery for peritonitis include:

• The weight of heavy objects allowed to be carried should not exceed 3 kg during the first 3 months after surgery.
• Abstinence from intimacy for at least 1.5 months after surgery.
• Hiking, physiotherapy to strengthen the abdominal muscles.
• Swimming.

After such a major operation, the patient should permanently change his lifestyle, since management is very active life, especially during the recovery period, can lead to undesirable consequences.

What consequences may occur in patients in the postoperative period? Consequences after surgery for peritonitis can be early and long-term. Usually, early complications peritonitis occurs when the patient seeks medical help late. These include conditions that can lead to death:

• acute vascular insufficiency;
• toxic shock;
• bleeding;
• sepsis;
• disseminated intravascular coagulation syndrome (DIC syndrome).

Long-term consequences of peritonitis include diseases or pathological conditions that arise after discharge from the hospital:

• intestinal paresis;
• intestinal obstruction;
• adhesive disease;
• female infertility;
• abscess between intestinal loops;
• hernias

Can peritonitis be cured? The patient's health prognosis after surgery depends on:

• age of the patient;
• spillage of the process;
• the period elapsed from the onset of the disease to the operation;
• how quickly peritonitis developed;
• severity of clinical manifestations;
• surgeon qualifications;
• adequacy of infusion therapy;
• accompanying pathologies.

The prognosis for the patient's life also depends on the cause of peritonitis. For example, with intestinal cancer, the patient's life expectancy after surgery will be shorter than with appendicitis.

How long do they live after surgery? If the operation is successful, then the patient’s life expectancy after the operation depends on himself. The death of a patient after surgery can occur only if early or late consequences occur.

Special attention deserves infant mortality from peritonitis. This is especially pronounced in premature infants, for whom the consequences in the event of diffuse peritonitis are disastrous: in almost 80% of cases of perforated peritonitis in premature newborns, they end in death.

The prognosis for a patient's life with extensive peritonitis is not entirely favorable: in 40% of cases, such peritonitis ends in death. But the mortality rate with limited (local) peritonitis is quite low (no more than 2-3%). Modern medicine has a wide range of antibiotics, which can help reduce the incidence of deaths.

Peritonitis is a dangerous acute surgical pathology that cannot be delayed. The variability of the clinical picture of peritonitis greatly complicates its diagnosis. Therefore, with intense abdominal pain, all surgical doctors (surgeons, pediatric surgeons, gynecologists), first of all, should be wary of peritonitis.

Peritonitis in children is an acute inflammatory process that occurs due to a violation of the protective function of the peritoneum. The main causes of the development of the disease are exo- and endogenous factors. Clinicians note that most often peritonitis in children develops as a consequence of acute appendicitis. If help is not provided to the child in time, serious consequences may follow. inflammatory processes and even death.

Depending on the cause of the disease, a classification can be made childhood peritonitis. According to the distribution of the disease, they are distinguished:

According to localization, peritonitis in children can be of the following form:

• appendiceal peritonitis in children is characterized by the collection of blood, pus and a number of compactions from the cells around the appendix;
• Cryptogenic or primary peritonitis in children most often occurs at the age of 4–7 years. This form of the disease affects only girls, as the infection enters the peritoneum through the vagina. The cryptogenic type is divided into two more forms: local and toxic. They are difficult to distinguish from ordinary appendicitis, so patients undergo an appendectomy;
• peritonitis of newborns is characterized by perforation of the gastrointestinal tract wall or the development of intestinal defects;
• periappendicular abscess of three degrees - detected as an accumulation of pus;
• combined peritonitis - pus and fluid accumulation in the peritoneum;
• the total form is accompanied by sepsis and shock from infections and toxins.

In newborns, peritonitis is divided into several other types. By etiology:

By degree of growth:

According to the nature of the development of the pathological process:

• fibroadhesive;
• fibrinous-purulent;
• fecal

Doctors distinguish 3 stages of peritonitis:

• reactive - lasts a maximum of 24 hours from the onset of the disease;
• toxic - lasts 72 hours;
• terminal - determined on the 3rd day.

Symptoms

Acute pain, as the first sign, may be the exception and not the rule. The child’s body is still developing, so the symptoms of the disease begin with the usual deterioration of the condition. Signs of peritonitis in children are not clearly expressed. If peritonitis is provoked by injuries, appendicitis, infection, then the following symptoms may occur:

• lethargic appearance;
• anxiety and tearfulness;
• appetite worsens;
• poor sleep;
• heat;
• problems with stool;
• localized abdominal pain;
• bloating;
• the skin becomes dry and darkens a little.

For primary peritonitis toxic form characterized by rapid development of the clinical picture. The following signs are observed:

• pain in the lower abdomen;
• heat;
• frequent vomiting;
• loose stools;
• general heaviness in the body;
• pale skin;
• shiny eyes;
• dry mouth, tongue with a white coating.

With a localized form, the signs of the disease are less clear. It is characterized by:

• unpleasant sensations in the right iliac region;
• body temperature maximum 38;
• ARVI.

Appendiceal peritonitis is characterized by abdominal, infectious-inflammatory and adaptation syndromes. Abdominal signs:

• visibility of damage to the abdominal wall;
• non-localized abdominal pain;
• muscle tension on the abdominal wall;
• sensation of a volumetric formation or fluid in the peritoneum.

Infectious and inflammatory symptoms may be:

• sleep disturbance;
• hyperthermia;
• changes in the general reactivity of the body.

Adaptation signs manifest themselves in the form of the following symptoms:

• the stomach becomes inflamed;
• frequent vomiting;
• anorexia;
• urine density increases;
• kidney filtration is impaired;
• the skin and membranes of the eyes turn yellow;
• hypoxia;
• hypovolemia;
• depression;
• coma;
• dysmetabolic sign.

Diagnostics

At the first signs, you should immediately seek medical help. Initially, if the child’s condition allows, a detailed physical examination is performed to clarify the medical history. Upon arrival at the hospital, blood and urine tests are required. An accurate diagnosis can be made using x-rays or ultrasound.

With peritonitis in children of different ages There is only one way to fight it - surgery. The surgeon performs a laparotomy and examines the condition of the peritoneum. If there is a need, the cause of infection is removed and washed with antibiotics and antibacterial agents. While suturing the wound, a small drain is attached to supply antibiotics.

In the postoperative period, the child is treated:

• antibiotics into a vein;
• antipyretic;
• tablets for intoxication and to improve blood circulation;
• restriction of diet.

Treatment of peritonitis in children takes a fairly long period. After surgery, you must follow a diet. The child can:

• chicken broths;
• plain yogurt;
• vegetable puree;
• rice porridge with water;
• fruits and berries.

Without the recommendations and instructions of a doctor, you should not take any measures. The child's condition can quickly deteriorate. If all the rules of the postoperative period have been followed, then recovery occurs quite quickly.

Complications

Peritonitis for minor patients is dangerous due to a number of complications:

• sepsis;
• disorders of the kidneys;
• adhesive diseases;
• gastrointestinal ailments.

Prevention

The disease can be prevented if you follow the basic rules healthy image life. This includes proper nutrition, daily routine, and personal hygiene. If there is slight suspicion of illness, parents should contact professional help rather than self-medicate.

What kind of disease is peritonitis? This is an acute stage of the inflammatory process, which occurred due to dysfunction of the peritoneum. Most often, peritonitis in children occurs with appendicitis, after surgery to remove it. If the child is not helped in a timely manner, serious complications and death may follow.

Peritonitis in children differs significantly from the adult disease, since the internal organs of children are not fully formed, and the systems work at full capacity. In case of illness, only the surgeon selects the treatment method; self-medication and the use of traditional medicine are completely unacceptable.

The article will discuss peritonitis. What kind of disease is this, what are its symptoms and causes of development? We will also talk about treatment and prognosis, prevention and possible complications.

Reasons for the development of the disease

Doctors identify factors that provoke the development of this condition in children. The main causes of peritonitis:

• exacerbation of acute appendicitis;
• bleeding in the abdominal cavity;
• intestinal obstruction;
• worms;
• inflammatory processes in internal organs or in the abdominal cavity;
• umbilical sepsis;
• infections;
• ruptures in the abdominal cavity;
• injuries and wounds in the abdominal area;
• the presence of meconium in the peritoneum.

It is very difficult to diagnose appendicitis in children. This disease is more common among adults. But it is in children that appendiceal peritonitis most often occurs after surgery (appendicitis requires such treatment). The symptoms are very similar to other diseases of the peritoneum. And the younger the child, the more difficult it is to make an accurate diagnosis.

Appendiceal appendicitis goes through the following stages:

• Reactive period. Lasts about a day.
• The toxic stage lasts 72 hours.
• Terminal stage, appear obvious signs illness, high temperature.

Each stage has its own signs and symptoms; the earlier the disease is detected, the greater the chance of avoiding complications.

Classification

Depending on the causes of peritonitis and its spread, the following classifications have been developed:

• According to the distribution of peritonitis, there are: local; spilled; general.
• According to the location of the disease in children, the following forms are distinguished: Appendicular - it is characterized by the collection of blood, cells and pus around the appendix; Primary peritonitis in children (cryptogenic), most often occurs in children between 4 and 7 years of age. The form of the disease affects only girls, when the infection enters the peritoneum through the vagina. Peritonitis in newborns occurs due to perforation of the wall of the gastrointestinal tract or the development of defects in the intestines. Combined peritonitis - when pus and fluid accumulate directly in the peritoneum.

Acute pain in children occurs in very rare cases. Since the child’s body is just forming, the symptoms of peritonitis in children manifest themselves with a general deterioration of their condition. It should be noted that all characteristic features diseases are not clearly expressed.

The main symptoms of peritonitis in children, if it is caused by appendicitis, injury or infection:

• tearfulness, anxiety of the child;
• sluggish appearance;
• poor appetite;
• insomnia;
• high body temperature;
• bloating;
• diarrhea or constipation;
• abdominal pain;
• dry skin.

Primary peritonitis is characterized by rapid development of the disease. The following signs are observed:

• high body temperature;
• pain in the lower abdomen;
• vomit;
• diarrhea;
• pale and dry skin;
• sparkling eyes;
• white coating on the tongue;
• thirst.

With a localized form of peritonitis in children, the symptoms are less striking, but appear as follows:

• discomfort in the right side of the abdomen;
• body temperature not higher than 38 degrees;
• rapidly developing symptoms of ARVI.

Parents should note that the symptoms of the disease in children differ significantly from those in adults. At the initial stage, signs of the disease may not be observed at all. But, nevertheless, peritonitis develops further and can develop into purulent form, because the focus of inflammation is rapidly increasing.

Adults should be sure to pay attention to the following warning signs and immediately seek medical help. Sound the alarm if your child:

• vomiting and nausea;
• body temperature above 38 degrees;
• sharp pain in the right side of the abdomen;
• general condition quickly deteriorates;
• intestinal dysfunction;
• painful and frequent urination;
• loss of appetite;
• very tense abdominal muscles.

At an early stage, symptoms sometimes disappear and a temporary improvement in well-being occurs (false), but the body temperature remains high. The child feels better, but then the condition worsens sharply, and the symptoms begin to appear with renewed vigor. During the period of false improvement, treatment cannot be stopped, since the causes that provoked peritonitis have not been completely eliminated.

In the later stages of the disease, the following symptoms of peritonitis in children are observed:

• eyes constantly water and shine;
• the skin becomes gray;
• absence of bowel movements for several days;
• rapid pulse;
• severe throbbing abdominal pain.

Diagnostics

At the first signs of illness, you should immediately seek medical help. The doctor examines the patient, takes blood and urine for analysis, and conducts ultrasound diagnostics.

In severe and advanced cases, puncture and surgical intervention are performed, the peritoneum can be punctured and fluid and pus can be pumped out (in case of emergency).

The only way treatment of severe peritonitis - surgical intervention. The surgeon performs a laparotomy and examines the peritoneum. If necessary, the cause of infection is eliminated, the peritoneal cavity is washed with antibacterial agents and antibiotics. After suturing the wound, a small drain is attached to administer antibiotics.

In the postoperative period of peritonitis, children are treated as follows:

• Antibiotics are injected into a vein.
• The child is given antipyretic drugs.
• Enter medications against intoxication and to improve blood circulation.
• They put them on a strict diet.

It is very important to adhere to a special diet after treatment of peritonitis. After surgery, the child can eat:

• broths (chicken or turkey);
• yoghurts without additives (classic);
• vegetable puree;
• rice porrige on the water;
• berries and fruits.

You should not take any food or medications without your doctor's knowledge. If all the rules for the treatment of peritonitis in children and clinical guidelines If the doctors are followed, recovery will come very quickly.

Complications

Despite the level of modern medicine, peritonitis is dangerous due to a number of complications:

• adhesive diseases;
• sepsis;
• kidney dysfunction;
• disruptions in the functioning of the gastrointestinal tract.

In this case, complications may not arise immediately, but several years after primary peritonitis in children. These are fairly common occurrences in pediatric surgery.

Rehabilitation and prevention

This serious disease can be prevented; the main thing is to adhere to a healthy lifestyle, which includes:

• proper nutrition;
• adherence to sleep and wakefulness;
• compliance with personal hygiene rules;

You also need to remember two important rules:

• at the first suspicion, parents should seek professional help;
• do not self-medicate, it can lead to serious complications and even the death of a baby.

The key to success in treating this disease is timely surgical intervention. The prognosis for recovery in such cases is positive.

The disease develops gradually, the initial stage passes into the compensated stage (when the body itself is able to cope with inflammation). However, after this, the stage of decompensation begins (the body is no longer able to fight, it has lost all its strength, the patient is very weakened and lethargic). In this case, only surgical intervention can save the child’s life. Of great importance in the success of the operation is timely access to a doctor and the general health of the child at the time of hospitalization.

Let's sum it up

Peritonitis, in medicine, is called inflammation of the abdominal region. Moreover, this disease in children has a number of distinctive features. Their organs and systems continue to form, so the symptoms are not so clearly expressed. You should carefully monitor the child and show him to the surgeon at the first symptoms. Delay in dealing with this disease can cost the child’s life. The risk of death with peritonitis in children is 50-90% of all cases.

Parents should do everything to prevent the development of peritonitis in children. Diseases need to be treated promptly internal organs and infections that can trigger the development of peritonitis. Even minor illness or a simple gastrointestinal disorder can lead to serious consequences. To avoid this terrible disease, the whole family must try to lead a healthy lifestyle, provide the child with proper nutrition, and make sure that he has proper rest. Parents bear full responsibility for the life and health of their children. Only proper organization a child’s life can minimize the risk of developing dangerous diseases.

Peritonitis in children develops more often as a complication of appendicitis. The cause of peritonitis in children can also be perforation of an ulcer due to staphylococcal or typhoid enterocolitis, perforation of Meckel's diverticulum. Less commonly, peritonitis develops as a consequence of the inflammatory process in the gallbladder and ovaries. A special place is occupied by diplococcal peritonitis; The entrance gate of infection can be the mucous membrane of the pharynx and vagina. The development of peritonitis is accompanied by vomiting and abdominal pain; appetite worsens, the child becomes restless or lethargic (adynamic), the temperature usually rises to 38-38.5°. As the peritoneum becomes involved in the inflammatory process, the pulse increases, which does not correspond to the temperature, and leukocytosis increases. Stool is often retained, but diarrhea is possible in young children. Further progression of peritonitis leads to severe intoxication, the condition worsens sharply: adynamia increases, the skin takes on a grayish tint, and dehydration develops due to repeated vomiting. Thirst, dry mucous membranes and skin appear; tongue dry, coated. The pulse becomes frequent and weak. The greatest importance in diagnosing peritonitis in children is the identification of local symptoms. As a rule, pronounced diffuse pain is detected during palpation and percussion of the abdomen, protective tension in the muscles of the abdominal wall, and the Shchetkin-Blumberg symptom. Peristalsis is weakened, and in advanced cases, flatulence develops due to intestinal paresis.

It is particularly difficult to diagnose peritonitis in children in the first 3 years of life, since at this age the same general disorders can occur with a variety of diseases, complaints cannot be reliably identified, and examination of the abdomen is often complicated by the child’s behavior. In such cases, it is necessary to palpate the child's abdomen during sleep, which can be induced artificially (after an enema with chloral hydrate), but this can only be used by a doctor in a hospital (see Appendicitis, in children). Peritonitis in newborns deserves special attention. It can develop as a manifestation of sepsis. Meconium peritonitis occurs due to congenital obstruction intestines, perforation may also be a consequence of a malformation of the intestinal wall. The clinical picture in these cases is characterized by persistent vomiting, the abdomen is distended, and swelling of the anterior abdominal wall is often detected.

Treatment of peritonitis consists of urgent surgical intervention. The child must be immediately taken to a surgical hospital, following the same rules as for peritonitis in an adult (see above): do not drink or eat, do not give cleansing enemas, etc.

In all cases, preoperative preparation is necessary (see. Preoperative period in children) for several hours. The purpose of the operation is to eliminate the source of peritonitis and remove effusion from the abdominal cavity. For diffuse appendiceal peritonitis in children in the postoperative period, long-term lavage of the abdominal cavity is successfully used. Antibiotics are administered intramuscularly or intravenously, as well as into the abdominal cavity. Intravenous injection is also indicated drip administration 10% glucose solution with insulin, plasma, saline solutions.

Peritonitis in children is quite common and differs in severity, especially in young children. The anatomical and physiological characteristics of the peritoneum and omentum in newborns and young children (weak restrictive abilities due to the low plastic properties of the peritoneum, underdevelopment of the omentum) contribute to the occurrence of diffuse peritonitis. Peritonitis is most severe in newborns. Mortality among them so far reaches 75-80% (S. Ya. Doletsky, A. I. Lenyushkin). In most cases, peritonitis develops secondary, spreading from the abdominal organs or abdominal wall. Primary peritonitis in children is less common (usually pneumococcal etiology).

The clinical picture of peritonitis in children differs little from that in adults: pain, vomiting, bloating, tension in the muscles of the abdominal wall and other symptoms of peritoneal irritation, increased temperature, discrepancy with the pulse, toxicosis, increased white blood cells. In newborns, abdominal bloating is often detected without clearly defined muscle tension.

The diagnosis of peritonitis in young children and newborns is often very difficult. Fear of the doctor, the child’s restless behavior during the examination, his active defense, and the lack of data on the patient’s subjective sensations at the time of palpation of the abdomen complicate the diagnosis. The use of antibiotics and painkillers (pantopon) makes the symptoms of peritonitis less pronounced. The forecast should be made with caution. Early diagnosis, timely and correct treatment make it more favorable.

Treatment is carried out in a surgical hospital. In the complex of events, a central place is given to early surgery. Conservative activities, carried out before, during and after surgery, come down to the fight against purulent infection, intoxication, sensitization, disorders of water-salt metabolism and activity gastrointestinal tract, and also provide for increasing the body’s defenses, preventing and treating pneumonia.

IN Lately Pediatric surgeons are paying more and more attention to the preoperative preparation of children with severe peritonitis. Preparation for surgery can take from 1 to 5 hours. The question of preparation time and necessary measures is decided in each case individually (type of peritonitis, severity of the condition, duration of the disease). Preoperative preparation includes prescribing and administering antibiotics before surgery; administration of cardiac and painkillers (0.1 ml of 10% caffeine solution and 1% omnopon solution); perinephric blockade with 0.25% novocaine solution (10 ml on each side); gastric lavage, sometimes leaving a permanent tube; introduction of a high gas outlet tube, administration of prozerin; venesection and simultaneous administration of 25-30 ml of blood or plasma, 10 ml of 20% glucose solution, 2-3 ml of 10% solution of sodium and calcium chloride, 2 ml of 0.25% novocaine solution; long-term intravenous drip administration of fluid (5% glucose solution or 10% glucose and Ringer's solution in a 3:1 ratio with the addition of vitamins C, B1, saline); prescription of diphenhydramine, pipolfen or suprastin; for hyperthermia - administration of a 1% amidopyrine solution and a 50% analgin solution, physical cooling. When carrying out activities according to this scheme, use age-specific dosages the specified funds.

Surgical intervention for peritonitis is reduced to eliminating the infectious focus, removing (suction) pus from the abdominal cavity, introducing antibiotics into the abdominal cavity and ensuring the possibility of their further intraperitoneal administration through a thin drainage. Conservative measures in the postoperative period are carried out mainly according to the same scheme, and repeated operations are performed according to indications.

Among the types of peritonitis that are not found in adults, meconium peritonitis should be distinguished - aseptic inflammation of the peritoneum caused by meconium entering the abdominal cavity. It usually occurs during the prenatal period. It can develop as a result of congenital intestinal obstruction with its perforation, as well as with meconium obstruction associated with the presence of congenital cystic fibrosis (see) and the most unfavorable prognostically.

Clinical symptoms: bloating and dilated skin veins, indomitable vomiting of bile, lack of stool, sluggish peristalsis. Tumor-like formations are sometimes palpable in the abdominal cavity. An X-ray examination reveals swelling of the overlying parts of the intestine with gases, fluid levels, free gas in the abdominal cavity, and calcifications against the background of intestinal loops.

Treatment is surgical. Intestinal patency is restored, the perforation is sutured, and after using the toilet, antibiotics are injected into the abdominal cavity. In case of meconium obstruction, enterostomy is performed. Viscous meconium is washed through the enterostomy through a rubber catheter inserted into it.

To liquefy it, 10-15 ml of 5% pancreatin is administered. Some authors prefer resection with removal of the intestinal loop according to Mikulicz (S. Ya. Doletsky, S. Dimitrov).

In children, peritonitis of an appendicular and cryptogenic nature is most common; in addition, peritonitis of newborns is especially distinguished. Peritonitis in children, resulting from inflammatory processes of the gallbladder and perforation of a duodenal ulcer, is extremely rare and, according to the clinical picture of the disease, is no different from peritonitis in adults (as well as post-traumatic).

Appendicular peritonitis. Peritonitis is the most severe complication of acute appendicitis in childhood, occurring in 6.2-25% of cases of acute appendicitis, and in children under 3-11 years of age 4-5 times more often than in older children

age.

This is explained by the late diagnosis of acute appendicitis due to the blurred clinical picture, the predominance of general symptoms over local ones, the lack of experience of outpatient doctors, and the widespread use of antibiotics that change the clinical picture of appendicitis, but do not prevent the progression of the inflammatory process in the abdominal cavity. In any case, if the inflammatory process extends beyond the right lateral recess, it should be considered diffuse peritonitis.

Anatomist and physiological characteristics of the child’s body affect the course of appendiceal peritonitis. The smaller the child, the faster the purulent process spreads to all parts of the peritoneum. This is facilitated by the low plastic properties of the peritoneum and the functional underdevelopment of the greater omentum. Intoxication increases faster, metabolic processes develop

violations.

It should be noted, however, that in children under 3 years of age, protective mechanisms quickly turn into pathological ones, and general clinical symptoms prevail over local ones.

In the reactive phase of the disease, the child’s body loses oxygen, proteins and water, but this does not affect cellular metabolism, enzyme systems function normally, therefore at this stage in the child, local symptoms prevail over the general ones. The child is restless, does not sleep, refuses food, asks

Drink. Vomiting appears. Belly has regular form, identify active and passive muscle tension, Shchetkin’s symptom -J! Bloomberg turns positive. With comparative palpation of the abdomen, these symptoms are most pronounced in the right subiliac region. The stool is usually normal.

In the toxic phase, disturbances in cellular metabolism occur. In addition to the deficiency of water, salt and proteins, there is a dysfunction of the enzyme system, the cell mass loses anions and cations. Clinical symptoms caused by prominent signs of intoxication. The child continues to worry, at times weakness sets in, facial features become sharpened, vomiting is frequent and green. The mucous membranes of the mouth and tongue become dry. Tachycardia is pronounced. The abdomen changes its configuration somewhat and becomes swollen. Soreness occurs, active and passive muscle protection is more pronounced in all parts of the abdomen. The Shchetkin-Blumberg symptom is sharply positive. Stool in young children is often liquid with mucus and greens.

The terminal phase is characterized by deeper disturbances in body function and the effects of toxins on all organs and systems, including the central nervous system. During this period, severe disturbances of hemodynamics, acid-base status, and water-electrolyte balance are observed.

The main symptoms are impaired peripheral microcirculation: pallor of the skin and mucous membranes, marbled skin pattern, “pale spot” symptom. The skin is cold, damp, with a gray tint. There is shortness of breath and shallow breathing. Changes also occur in the child’s behavior: lethargy, adynamia, lethargy, especially with hyperthermia, and delirium appear. Hyperthermia is a symptom characteristic of peritonitis, reaching high numbers (39-40°C), and is difficult to respond to drug therapy.

Hemodynamic disturbances are expressed in tachycardia, decreased arterial and central venous pressure, and are explained by hypovolemia.

When examining the abdomen in older children, pronounced widespread muscle tension is detected (“board-shaped” abdomen). In young children, early developing intestinal paresis relatively easily overcomes the resistance of the abdominal muscles, and the abdomen looks bloated. Peristaltic sounds are not heard. Symptoms of peritoneal irritation are pronounced. On rectal examination of the patient, sagging of the fornix and severe pain are noted. The differential diagnosis of peritonitis is especially difficult in young children, since its symptoms have significant similarities with the clinical picture of pleuropneumonia, severe forms of dyspepsia, dysentery and a number of other somatic and infectious diseases. In this case, it is necessary to take into account the initial manifestations of the disease. If a patient has peritonitis of the appendix,

If the disease is paired, then at the beginning of the disease abdominal pain prevails over all symptoms, then other symptoms appear. The main symptom of peritonitis, which removes all doubts, is, of course, passive muscle tension in the abdomen, which remains even if the child is induced to sleep; To do this, after a cleansing enema, a 3% solution of chloral hydrate is injected into the rectum. Doses of the drug depending on age are as follows: up to 1 year - 10-15 ml; from 1 year to 2 years - 15-20 ml; from 2 to 3 years - 20-25 ml. The child falls asleep after 15-20 minutes, motor excitement disappears, psycho-emotional reactions and active abdominal tension are relieved. Examining a child during sleep allows not only to differentiate active from passive defence, but also to obtain reliable data on pulse rate and respiration, and also facilitates examination of the child and auscultation of the abdomen and chest.

If the diagnosis cannot be clarified, then surgical intervention is recommended, but it is more advisable to first perform laparoscopy and establish an accurate diagnosis. In children in serious condition, as well as young children, laparoscopy should be performed under intubation anesthesia.

The examination plan for a patient with peritonitis to determine the severity of the condition and the phase of the disease must include a number of laboratory and functional research methods: determination of hemoglobin, hematocrit, and electrolyte levels. Tachycardia, decreased arterial and increased central venous pressure, changes in the rheogram indicate a violation of central and peripheral hemodynamics. The appearance of alkalosis, usually associated with significant hypokalemia, is considered an unfavorable prognostic indicator.

Treatment of peritonitis consists of three main parts: preoperative preparation, surgical intervention and postoperative management of the patient.

The basis of preoperative preparation is the fight against hypovolemia and dehydration. For infusion therapy, solutions of hemodynamic and detoxification action are used (hemodez, rheopolyglucin, polyglucin, albumin, Ringer's solution, blood plasma).

Intravenous administration of broad-spectrum antibiotics is mandatory. Probing and gastric lavage are manipulations aimed at reducing intoxication, improving breathing, and preventing aspiration.

An important factor in preparing the patient for surgery and anesthesia is the fight against hyperthermia, carried out both by physical methods (cooling) and medications. Intubation combined anesthesia is indicated.

Surgical treatment involves two tasks: eliminating the source of peritonitis and sanitation of the abdominal cavity.

"4 Pepntpni! 209

The generally accepted approach for adult patients with widespread peritonitis is midline laparotomy. In pediatric surgery, access is dictated by the stage of peritonitis and the age of the child. In the reactive stage (the first 24 hours), especially in children under 3 years of age, the Volkovich-Dyakonov approach is used [Isekov Yu. F. et al., 1980; Dreyer K.L. et al., 1982]. This access, despite the relatively small size of the abdominal cavity in children, does not interfere with the main task of surgical intervention - sanitation of the abdominal cavity. If peritonitis has been diagnosed for a long time (more than 3 days), a median laparotomy is indicated.

The next sequential stages of the operation are evacuation of exudate, elimination of the source of peritonitis, toilet of the abdominal cavity and suturing of the abdominal cavity.

Exudate is removed using an electric suction. Appendectomy is performed with the obligatory immersion of the stump into purse-string and z-shaped sutures. Toilet of the abdominal cavity is carried out by lavage. The rinsing medium is based on isotonic or weak hypertonic saline solutions, furatsilin solution at a dilution of 1:5000, in which most surgeons include antibiotics (aminoglycosides) at a rate of 1 g/l. The total volume of liquid for rinsing is 2-3 liters. Lavage is performed as the final procedure after completion of the appendectomy.

The final stage surgery is the most controversial among both adult and pediatric surgeons. The question of whether to suture the abdominal cavity tightly and leave drains and tampons in place has not been finally resolved. Proponents of blind suture use microirrigators to administer antibiotics.

Drainage of the abdominal cavity is carried out using special drainages made of silicone rubber, a strip of rubber gloves, but in particularly severe cases of widespread peritonitis in the terminal phase, it is not necessary to suture the median laparotomy wound. After thorough sanitation of the abdominal cavity, drainage is performed with a silicone tube of the small pelvis. The intestines are covered with plastic film with multiple diamond-shaped holes cut out with a diameter of up to 5 mm, and napkins soaked in petroleum jelly are placed on top. Above them, the skin with the aponeurosis is brought together with separate sutures without tension, covering only the edges of the napkin. The absence of compression on the intestines and the possibility of free exit of infected exudate from the abdominal cavity through the wound help improve intestinal microcirculation, restore peristalsis and relieve the inflammatory process. After 2-3 days, a repeat operation is performed: the napkins and film are removed, the abdominal wall wound is sutured tightly through all layers. The edges of the wound are separated from the intestine so much that when they are sutured, the intestinal loops are not deformed.

Peritoneal dialysis, unfortunately, does not guarantee against such complications as the occurrence of residual ulcers in the abdominal cavity, infiltrates, eventration, and the formation of fistulas. Peritoneal dialysis in pediatric practice is used according to strict indications - with widespread peritonitis and in its terminal phase.

In all other cases, the operation should end with thorough sanitation of the abdominal cavity and the introduction of microirrigators for antibacterial therapy in the postoperative period. The success of treatment of peritonitis is largely determined by the correct management of the patient after surgery, with the obligatory consideration of the following provisions: 1) massive antibacterial therapy, correction of metabolic disorders and the fight against intoxication; 2) the struggle to restore the motor-evacuation function of the digestive tract.

Peritonitis is in most cases a polymicrobial disease, in which associations of microorganisms are cultured, often with a clear predominance of intestinal flora, as well as Proteus and Pseudomonas aeruginosa; anaerobes make up an average of 30%, and in the lumen of the gangrenous process, non-spore-forming anaerobic flora was found in 100% [Kuzin M.I., 1983; Roy V.P., 1983], bacteroids are most often isolated. During treatment, the microflora can change significantly towards the predominance of gram-negative. Aminoglycosides (kanamycin, gentamicin), cephalosporins, semisynthetic penicillins (ampicillin, carbenicillin), and nitrofurans have the greatest activity in children against the associated peritoneal flora among modern antibiotics. Considering the role of anaerobic flora, the use of metronidazole is indicated for peritonitis. It is necessary to remember the influence of antibiotics on the biocenosis of the body and the development of dysbacteriosis, which in turn can cause auto-reinfection of the patient in the postoperative period.

Intravenous and intraperitoneal administration of antibiotics in combination is generally accepted, as well as intramuscular injections. In recent years, works have appeared in the literature on the intra-arterial and endolymphatic routes of antibiotic administration for peritonitis.

The volume of infusion therapy consists of the daily age requirement, calculated according to the Aberdeen table, the deficit in circulating blood volume and pathological losses with hyperthermia through perspiration, sweating of fluid into the intestinal lumen during paresis. The calculation is based on 10 ml/(kg-day) for each degree above 37°C, 10 mg/(kg-day) for every 10 breaths above normal, 20 ml/(kg-day) for second degree paresis, 40 ml/ (kg-day) for third degree paresis.

The qualitative composition of the injected solutions is determined by the body’s needs for proteins, carbohydrates, electrolytes, and the need to bind and remove toxins.

Low molecular weight plasma substitutes are prescribed: hemodez at the rate of 10 ml/(kg-day), rheopolyglucin 15 ml/kg, canned blood, plasma or protein plasma substitutes at the rate of 1-2.5 g of protein/(kg-day). The remaining volume of fluid is replenished with a 10% glucose solution with insulin and potassium.

When restoring bcc, hemoglobin indicators should be no lower than 100 g/l, hematocrit - no lower than 30%, total protein - 60 g/l, A/G ratio - 1 -1.2, potassium content - 3.5-4.5 mmol/l.

Energy costs are replenished by transfusing a 10-20% glucose solution, 6-8 ml of 96° alcohol per 100 ml of 10% glucose (1 g of glucose - 4 calories; 1 g of alcohol - 7.5 calories).

In case of prolonged severe peritonitis and the impossibility of oral nutrition, parenteral nutrition using amino acids and fat emulsions is prescribed. Restoring the motor-evacuation function of the gastrointestinal tract is one of the main tasks of intensive care for patients with peritonitis in the postoperative period.

Since intoxication and deterioration of regional blood flow play a major role in the pathogenesis of intestinal paresis, its treatment necessarily involves detoxification therapy and improvement of hemodynamics. The complex for combating paresis of the gastrointestinal tract also includes its decompression (probing of the stomach, intubation of the intestine in advanced stages), the administration of hypertensive and siphon enemas, stimulation of peristalsis with a 0.05% solution of proserin or dimecaine (0.1 ml for 1 year of life , but not more than 1 ml), the use of novocaine blockades and epidural anesthesia. According to G. A. Bairov, the presence of appendiceal peritonitis is an indication for the use of epidural anesthesia. When catheterizing the epidural space, the tip of the catheter should be at the level of the IV-V thoracic vertebrae (radiological control is required), the duration of anesthesia is 4-5 days, the intervals between the administration of trimecaine are 3 hours. The infusion therapy program should provide for replenishment of the body's need for potassium . Good effect The administration of sorbitol helps prevent paresis.

In recent years, work has appeared indicating high efficiency hyperbaric oxygen therapy with peritonitis [Gorokhovsky V.I., 1981; Isakov Yu. F. et al., 1981]. Improving tissue oxygenation, stimulating regenerative processes, improving microcirculation and rheological properties of blood and cellular immune mechanisms explain the therapeutic effect of this method.

For detoxification purposes, the literature of recent years has noted the use of hemo- and lymphosorption. However great experience There is no use of these treatment methods in pediatric surgical practice.

Cryptogenic peritonitis. In clinical practice in children

togenic peritonitis is relatively rare. He is famous

in the literature under various names: primary, hematogenous, pneumococcal, diplococcal, etc. None of the names is absolutely accurate, since the routes of infection of the abdominal cavity have not been clarified, the nature of the microflora of the peritoneal exudate is diverse, and there may be no growth of the microflora.

Girls are more likely to suffer from cryptogenic peritonitis. Thus, of the 127 patients with cryptogenic peritonitis described by N. L. Kush (1973), 122 were girls. This indicates a connection between this disease and the condition of the genitals. Children aged 3 to 8 years are most often affected. The decrease in incidence in older girls is associated with a change in the vaginal environment to the acidic side, which is not favorable for the proliferation of pneumococcus.

There are three forms of cryptogenic peritonitis: toxic, septicopyemic, localized. In recent years, a milder, often abortive course of the disease has become more common.

Severe forms are characterized by an acute onset of the disease, a rapidly progressive course (2-5 hours) with increasing intoxication. Patients complain of abdominal pain, often of uncertain localization, but sometimes localized in the lower abdomen or in the first half. High body temperature (up to 39° and even 40°C), hyperleukocytosis are noted.

On examination, abdominal bloating, pain on palpation in all parts, and a positive Shchetkin-Blumberg sign are noted. Peristalsis is not heard. On rectal examination, overhang of the anterior wall of the rectum is observed.

Peritoneal exudate is liquid, sticky, cloudy, odorless, without fibrin. The amount of effusion varies and depends on the severity of the disease. Hyperemia of intestinal loops, tubes, tubal fimbriae, and sometimes subserous hemorrhages are noted. Histological examination of the appendix reveals signs of periappendicitis.

There are fairly uniform reports in the literature about the causative agent of cryptogenic peritonitis, indicating a diplococcal infection (pneumococcus) with a large percentage of sterile cultures. Only a thorough bacteriological study with inoculation of the exudate on various nutrient media and dynamic monitoring of microbial growth for 10 days makes it possible to identify microbes in 90% of patients with hematogenous peritonitis [Polyak M. S., Zhigulin V. P., 1970]. In half of the patients, the isolated bacteria belong to a monoculture, in others - to associations belonging to species that grow in the intestines: bacteria of the Escherichia coli group, enterococci, clostridia, staphylococcus. The peculiarity of these microbes is their tendency to anaerobiosis. Moreover, in children from 1 year to 4 years old, coccal bacteria predominate: staphylococcus, enterococcus, pneumococcus. Gram-negative

Rods, along with coccal flora, are isolated in children over 4 years of age. In severe forms of peritonitis, pneumococcus, beta-hemolytic streptococcus, and Escherichia coli with hemolytic activity are more often isolated.

Most authors believe that in case of cryptogenic peritonitis, surgical intervention is advisable, mainly due to the difficulties of differential diagnosis with acute appendicitis. Laparoscopy allows you to make the correct diagnosis and, in the presence of cryptogenic peritonitis, introduce antibiotics into the abdominal cavity.

It is most advisable to prescribe antibiotics from the aminoglycoside group, chloramphenicol, ampicillin.

The surgical intervention ends with removal of exudate, appendectomy and administration of antibiotics. In the postoperative period, detoxification and antibacterial therapy continues.

Peritonitis in newborns. Peritonitis in newborns is a serious complication of a number of different diseases and malformations of the gastrointestinal tract.

Almost until the 40s of this century, the diagnosis of peritonitis in newborns was made only at autopsy. Malformations and “spontaneous perforations” were considered the main cause of peritonitis.

Further development science, morphological and experimental studies have made it possible to establish that the genesis of many “spontaneous” perforations lies in ischemia of the intestinal wall - a disease that has received the name “necrotizing enterocolitis” in the world literature since the 60s of our century. The first successful surgical intervention for peritonitis in a newborn was performed in 1943.

Peritonitis in newborns is a polyetiological disease and, as numerous studies have shown, its causes can be: 1) malformations of the gastrointestinal tract; 2) necrotizing enterocolitis; 3) iatrogenic intestinal perforation; 4) bacterial infection of the peritoneum by contact, hematogenous or lymphogenous route in sepsis.

According to our data, in 85% of cases the cause of peritonitis is perforation of the wall of the gastrointestinal tract.

Intrauterine intestinal perforations (with intestinal malformations) lead to aseptic, adhesive peritonitis, postnatal ones - to diffuse fibrinous-purulent, fecal peritonitis. With necrotizing enterocolitis against the background of intensive therapy, limited peritonitis may develop.

Non-perforative fibrinous-purulent peritonitis, which develops in utero with hematogenous and lymphogenous, transplacental infection and with ascending infection of the birth canal, is rare. In the postnatal period, infection of the peritoneum is more often observed by contact with purulent periarteritis and periphlebitis of the umbilical vessels, abscess

liver disease, purulent diseases of the retroperitoneal space, phlegmon of the anterior abdominal wall, purulent omphalitis.

We propose a working classification of peritonitis in newborns as follows.

I. According to etiological and pathogenetic characteristics. A. Perforated peritonitis:

1) with necrotizing enterocolitis:

a) posthypoxic,

b) septic;

2) with malformations of the gastrointestinal tract:

a) segmental defects of the wall of a fallen organ,

b) developmental defects causing mechanical obstruction of the stomach
pre-intestinal tract;

1) with hematogenous, lymphogenous infection of the peritoneum;

2) in case of contact infection of the battlewort.
II. According to the time of onset of peritonitis:

1) prenatal,

2) postnatal.

III. According to the degree of spread of the process in the abdominal cavity:

1) spilled,

2) limited.

IV. According to the nature of the effusion in the abdominal cavity:

1) fibroadhesive,

2) fibrinous-purulent,

3) fibrinous-purulent, fecal.

The clinical picture and diagnosis of peritonitis are largely determined by its etiology.

Perforated peritonitis is characterized by a sharp deterioration in the patient's condition, manifested by symptoms of peritoneal shock, lethargy, adynamia, and sometimes anxiety. The skin is grayish-pale, dry, cold. Breathing is frequent, shallow, groaning, muffled heart sounds, tachycardia. Sharp bloating, tension, pain on palpation. Peristalsis is not audible. Hepatic dullness is not detected. Vomiting mixed with bile and intestinal contents. Chair And gases do not pass away. When radiography is performed in a vertical position, free air under the dome of the diaphragm is determined. Small compensatory capabilities quickly lead to severe disturbances of homeostasis and the death of the child after 12-24 hours.

The clinical picture of diffuse non-perforative peritonitis is characterized by a more gradual increase in symptoms of intoxication and intestinal paresis with a pronounced hyperthermic reaction and changes in the hemogram (neutrophilia, increased ESR, etc.). As a rule, the reaction from the anterior abdominal wall is more pronounced: hyperemia, infiltration, dilated venous network, swelling of the external genitalia. Hepatosplenomegaly is significantly expressed. Radiologically, hydroperitoneum is noted.

The vivid clinical picture of peritonitis at the height of the disease, as a rule, does not cause diagnostic difficulties.

The causes of perforation of the gastrointestinal tract may be the following malformations: 1) malformations causing mechanical intestinal obstruction: a) with phenomena of obstructive obstruction (atresia, meconium ileus, Hirsch. prung disease); b) with symptoms of strangulation (volvulus, strangulated internal hernia); 2) segmental defects of the wall of the gastrointestinal tract (defect of the muscle layer of an isolated section of the wall of a hollow organ, angiomatosis of the intestinal wall).

Defects that cause mechanical obstruction of the gastrointestinal tract in 50% of cases lead to intrauterine intestinal perforation and adhesive peritonitis. By the time the baby is born, the perforation is usually closed, and the leaked meconium is calcified. There are two types of intrauterine peritonitis: 1) fibroadhesive (significant adhesions in the abdominal cavity); 2) cystic (formation of a cystic cavity with fibrous walls in the free abdominal cavity, communicating with the intestinal lumen through a perforation).

Postnatal perforations of the gastrointestinal tract due to developmental defects are always accompanied by fibrinous-purulent, fecal peritonitis.

It is difficult to diagnose intrauterine adhesive peritonitis before surgery. Moderate pain and tension in the abdominal muscles against the background of symptoms of small intestinal atresia and radiologically detectable calcifications in the free abdominal cavity help to suspect it. In cystic peritonitis, a cystic cavity in the free abdominal cavity, often adjacent to the anterior wall, is determined radiologically. The walls of the cyst are thickened, calcified, and a high level of fluid is detected in its lumen.

Segmental malformations of the gastrointestinal tract in the first days of life of children do not have symptoms that portend a catastrophe. Perforation always develops acutely, in the midst of complete well-being, on the 3rd-6th day of life it manifests itself as a picture of peritoneal shock. Clinically and radiologically, this group of patients has a large amount of free gas in the abdominal cavity, which leads to severe disorders breathing and cardiac activity.

A feature of perforated peritonitis in necrotizing enterocolitis is the large area of ​​intestinal damage and the severity of the adhesive-inflammatory process in the abdominal cavity. Pneumoperitoneum is moderate.

A more favorable form of peritoneal complications of necrotizing enterocolitis in newborns is limited peritonitis, observed in "/3 ​​cases. In these cases on Against the background of symptoms of enterocolitis, a dense infiltrate with clear contours appears in the abdominal cavity, moderately painful, often localized in the right iliac region. When opening the intestinal lumen and abscess formation of the infiltrate, note

There is an increase in its size, the child’s anxiety increases, especially when palpating the abdomen. Tension of the abdominal wall muscles is revealed, and the general condition worsens. Often these symptoms are difficult to catch, since they appear against the background of a severe, usually septic, condition.

Limited peritonitis at the infiltration stage is subject to conservative treatment, which in 38% of cases leads to relief of the inflammatory process. We give preference to the following antibiotics: the cephalosporin group, oxacillin, gentamycin. Selective decontamination of the intestine is indicated, and in the most severe cases, complete decontamination in a gnotobiological isolator.

Selective decontamination is prescribed from the moment of enteral feeding by administering antibiotics that are not absorbed by the intestinal mucosa. Most often, gentamicin is prescribed at a dose of 10 mg/(kg-day), kanamycin at 10-20 mg/(kg-day), nevigramon at 0.1 mg/(kg-day) for a period of 7-10 days from subsequent administration of bifidum-bacterin 2.5-5 doses 3-4 times a day for a period of 2-4 weeks under the control of stool analysis for dysbacteriosis.In addition, along with replacement therapy, stimulating therapy (antistaphylococcal drugs, anti-coliplasm) is recommended , drugs that relieve the immune block (levamisole, thymalin, prodigiosan), desensitizing agents.Vitamins and enzyme preparations are prescribed according to general principles.

Surgical treatment of necrotizing enterocolitis is indicated: 1) at the stage of diffuse perforated peritonitis; 2) with acute intestinal infarction; 3) at the stage of pre-perforation with the ineffectiveness of intensive conservative therapy for 6-12 hours and an increase in clinical and radiological symptoms; 4) with abscess formation of the abdominal cavity infiltrate.

Transrectal access is most often used. In case of diffuse peritonitis, the operation of choice is resection of the necrotic part of the intestine with the removal of a double intestinal stoma. After simultaneously washing the abdominal cavity with solutions of antiseptics and antibiotics, the latter is sutured, leaving a catheter for the administration of antiseptics (dioxidine). In case of total damage to the colon, we recommend a shutdown operation by placing an unnatural anus on the terminal ileum (ileostomy).

In cases of abscess formation of the abdominal infiltrate, an abscessotomy is necessary. Through a small incision in the anterior abdominal wall, the abscess cavity is drained as gently as possible, without disturbing the delimiting capsule. As a rule, a low intestinal fistula is formed. A feature of intestinal fistulas in newborns is their independent closure when the underlying disease is relieved.

Online access. It is advisable to use a transrectal or transverse incision.

In patients with intrauterine adhesive peritonitis, it is necessary

It is necessary to carry out separation of adhesions, resection of the atretic part of the intestine, followed by an end-to-end or side-to-side anastomosis. We use a single-row U-shaped silk seromuscular suture.

For segmental defects of the colon, the operation of choice is to isolate the perforation zone on the abdominal wall in the form of a colostomy. Gastric perforations are sutured with double-row sutures. The abdominal cavity is washed with solutions of antiseptics and antibiotics and sutured tightly. Reconstructive closure of the colostomy is carried out after 3- 4 months

Iatrogenic peritonitis. Iatrogenic perforations include perforations of the gastrointestinal tract that occur when probing techniques, instrumental examination methods, and cleansing enemas are violated. Mechanical trauma is the main cause of iatrogenic perforation of the wall of a hollow organ, mainly the rectum, the region of the rectosigmoid zone.

In all cases, perforation of the rectum penetrated into the abdominal cavity, was localized on the anterior wall in the zone of the transitional fold of the peritoneum, and was accompanied by diffuse hemorrhagic-purulent fecal peritonitis.

A sharp deterioration in the child's condition, accompanied by symptoms of peritoneal shock, usually occurs immediately after the manipulation. The typical clinical picture of diffuse peritonitis develops very quickly.

The operation of choice for rectal perforation is suturing the perforation hole with the application of a proximal sigmostoma. Sanitation of the abdominal cavity is carried out according to general rules.

Non-perforative peritonitis. Non-perforative or septic peritonitis develops in newborns due to intrauterine or postnatal infection. According to our data, it occurs in 16% of cases.

With intrauterine infection, a severe septic process with serous-purulent peritonitis, pleurisy, pericarditis and meningitis, caused by both gram-positive and gram-negative flora, often develops hematogenously and lymphogenously.

In the postnatal period, peritonitis occurs when a purulent infection passes through contact from the umbilical vessels or from the retroperitoneal space.

Non-perforative postnatal peritonitis in approximately 50% of cases is limited in nature.

In newborns, in the case of intrauterine infection, symptoms of peritonitis appear on the 1st day of life. Clinical symptoms are general and local in nature: severe toxicosis, vomiting of bile, bloating And abdominal pain, stool retention. The abdominal wall is thickened, tense, shiny, and hyperemia appears.

X-ray reveals significant hydroperitoneum, darkening the abdominal cavity and leading to unclear contours of the intestinal loops. There is darkening of the upper floor of the abdominal cavity due to hepatosplenomegaly.

The clinical picture of postnatal peritonitis develops gradually against the background of a focus of purulent infection. There is a gradual deterioration of the condition and an increase in toxicosis, symptoms of paresis of the gastrointestinal tract appear: vomiting, bloating, stool retention, then tension in the muscles of the abdominal wall increases and swelling is noted, which spreads to the external genitalia. With limited peritonitis, the infiltrate of the abdominal cavity passes to the anterior abdominal wall, often in the area of ​​inflammation of the umbilical vessels.

X-rays reveal hydroperitoneum and intestinal paresis; the intestinal walls are not thickened. Thickening of the anterior abdominal wall. In the case of infiltration, a darkening appears in the abdominal cavity, pushing aside the intestinal loops.

Therapeutic tactics for non-perforative peritonitis initially consist of conservative antibacterial and infusion therapy to stop both the primary source of infection and incipient peritonitis. If there is no effect V within 6-12 hours and an increase in clinical and radiological symptoms, surgery is recommended. The abdominal cavity is immediately washed with solutions of antiseptics and antibiotics with mandatory drainage of the source of purulent infection.

N. S. Tokarenko (1981) proposes laparocentesis with catheterization of the abdominal cavity and fractional rinsing with antibiotic solutions for the treatment of septic peritonitis.

With limited peritonitis at the stage of abscess formation, abscessotomy and drainage of the abscess cavity are indicated.

What kind of disease is peritonitis? This is an acute stage of the inflammatory process, which occurred due to dysfunction of the peritoneum. Most often, peritonitis in children occurs with appendicitis, after surgery to remove it. If the child is not helped in a timely manner, serious complications and death may follow.

Peritonitis in children differs significantly from the adult disease, since the internal organs of children are not fully formed, and the systems work at full capacity. In case of illness, only the surgeon selects the treatment method; self-medication and the use of traditional medicine are completely unacceptable.

The article will discuss peritonitis. What kind of disease is this, what are its symptoms and causes of development? We will also talk about treatment and prognosis, prevention and possible complications.

Reasons for the development of the disease

Doctors identify factors that provoke the development of this condition in children. The main causes of peritonitis:

• exacerbation of acute appendicitis;
• bleeding in the abdominal cavity;
• intestinal obstruction;
• worms;
• inflammatory processes in internal organs or in the abdominal cavity;
• umbilical sepsis;
• infections;
• ruptures in the abdominal cavity;
• injuries and wounds in the abdominal area;
• the presence of meconium in the peritoneum.

It is very difficult in children. This disease is more common among adults. But it is in children that appendiceal peritonitis most often occurs after surgery (appendicitis requires such treatment). The symptoms are very similar to other diseases of the peritoneum. And the younger the child, the more difficult it is to make an accurate diagnosis.

Goes through the following stages:

• Reactive period. Lasts about a day.
• The toxic stage lasts 72 hours.
• The terminal stage, obvious signs of the disease appear, the temperature remains high.

Each stage has its own signs and symptoms; the earlier the disease is detected, the greater the chance of avoiding complications.

Classification

Depending on the causes of peritonitis and its spread, the following classifications have been developed:

• According to the distribution of peritonitis, there are: local; spilled; general.
• According to the location of the disease in children, the following forms are distinguished: Appendicular - it is characterized by the collection of blood, cells and pus around the appendix; in children (cryptogenic), most often occurs in children between 4 and 7 years of age. The form of the disease affects only girls, when the infection enters the peritoneum through the vagina. Peritonitis in newborns occurs due to perforation of the wall of the gastrointestinal tract or the development of defects in the intestines. Combined peritonitis - when pus and fluid accumulate directly in the peritoneum.

Symptoms

Acute pain in children occurs in very rare cases. Since the child’s body is just forming, the symptoms of peritonitis in children manifest themselves with a general deterioration of their condition. It should be noted that all the characteristic signs of the disease are not clearly expressed.

The main symptoms of peritonitis in children, if it is caused by appendicitis, injury or infection:

• tearfulness, anxiety of the child;
• sluggish appearance;
• poor appetite;
• insomnia;
• high body temperature;
• bloating;
• diarrhea or constipation;
• abdominal pain;
• dry skin.

Primary peritonitis is characterized by rapid development of the disease. The following signs are observed:

• high body temperature;
• pain in the lower abdomen;
• vomit;
• diarrhea;
• pale and dry skin;
• sparkling eyes;
• white coating on the tongue;
• thirst.

With a localized form of peritonitis in children, the symptoms are less striking, but appear as follows:

• discomfort in the right side of the abdomen;
• body temperature not higher than 38 degrees;
• rapidly developing symptoms of ARVI.

Parents should note that the symptoms of the disease in children differ significantly from those in adults. At the initial stage, signs of the disease may not be observed at all. But, nevertheless, peritonitis develops further and can turn into a purulent form, because the focus of inflammation is rapidly increasing.

Adults should be sure to pay attention to the following warning signs and immediately seek medical help. Sound the alarm if your child:

• vomiting and nausea;
• body temperature above 38 degrees;
• sharp pain in the right side of the abdomen;
• general condition quickly deteriorates;
• intestinal dysfunction;
• painful and frequent urination;
• loss of appetite;
• very tense abdominal muscles.

At an early stage, symptoms sometimes disappear and a temporary improvement in well-being occurs (false), but the body temperature remains high. The child feels better, but then the condition worsens sharply, and the symptoms begin to appear with renewed vigor. During the period of false improvement, treatment cannot be stopped, since the causes that provoked peritonitis have not been completely eliminated.

In the later stages of the disease, the following symptoms of peritonitis in children are observed:

• eyes constantly water and shine;
• the skin becomes gray;
• absence of bowel movements for several days;
• rapid pulse;
• severe throbbing abdominal pain.

Diagnostics

At the first signs of illness, you should immediately seek medical help. The doctor examines the patient, takes blood and urine for analysis, and conducts ultrasound diagnostics.

In severe and advanced cases, puncture and surgical intervention are performed, the peritoneum can be punctured and fluid and pus can be pumped out (in case of emergency).

Treatment

The only way to treat severe peritonitis is surgery. The surgeon performs a laparotomy and examines the peritoneum. If necessary, the cause of infection is eliminated, the peritoneal cavity is washed with antibacterial agents and antibiotics. After suturing the wound, a small drain is attached to administer antibiotics.

In the postoperative period of peritonitis, children are treated as follows:

• Antibiotics are injected into a vein.
• The child is given antipyretic drugs.
• Prescribed medications for intoxication and to improve blood circulation.
• They put them on a strict diet.

It is very important to adhere to a special diet after treatment of peritonitis. After surgery, the child can eat:

• broths (chicken or turkey);
• yoghurts without additives (classic);
• vegetable puree;
• rice porridge with water;
• berries and fruits.

You should not take any food or medications without your doctor's knowledge. If all the rules for the treatment of peritonitis in children and the clinical recommendations of doctors are followed, then recovery will occur very quickly.

Complications

Despite the level of modern medicine, peritonitis is dangerous due to a number of complications:

• adhesive diseases;
• sepsis;
• kidney dysfunction;
• disruptions in the functioning of the gastrointestinal tract.

In this case, complications may not arise immediately, but several years after primary peritonitis in children. These are fairly common occurrences in pediatric surgery.

Rehabilitation and prevention

This serious disease can be prevented; the main thing is to adhere to a healthy lifestyle, which includes:

• proper nutrition;
• adherence to sleep and wakefulness;
• compliance with personal hygiene rules;

You also need to remember two important rules:

• at the first suspicion, parents should seek professional help;
• Do not self-medicate, it can lead to serious complications and even the death of the baby.

The key to success in treating this disease is timely surgical intervention. The prognosis for recovery in such cases is positive.

Forecast

The disease develops gradually, the initial stage passes into the compensated stage (when the body itself is able to cope with inflammation). However, after this, the stage of decompensation begins (the body is no longer able to fight, it has lost all its strength, the patient is very weakened and lethargic). In this case, only surgical intervention can save the child’s life. Of great importance in the success of the operation is timely access to a doctor and the general health of the child at the time of hospitalization.

Let's sum it up

Peritonitis, in medicine, is called inflammation of the abdominal region. Moreover, this disease in children has a number of distinctive features. Their organs and systems continue to form, so the symptoms are not so clearly expressed. You should carefully monitor the child and show him to the surgeon at the first symptoms. Delay in dealing with this disease can cost the child’s life. The risk of death with peritonitis in children is 50-90% of all cases.

Parents should do everything to prevent the development of peritonitis in children. It is necessary to promptly treat diseases of internal organs and infections that can provoke the development of peritonitis. Even a minor illness or simple gastrointestinal disorder can result in serious consequences. To avoid this terrible disease, the whole family must try to lead a healthy lifestyle, provide the child with proper nutrition, and make sure that he has proper rest. Parents bear full responsibility for the life and health of their children. Only proper organization of a child’s life can minimize the risk of developing dangerous diseases.