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 penetrates into the abdominal cavity through the vagina with the development of endosalpingitis. At an older age, this disease is much less common. This fact is explained by the appearance of Döderlein sticks in the vagina, which, creating an acidic environment, prevent the development of natogenic microflora. The widespread introduction of laparoscopy has convincingly confirmed this point of view and changed the tactics of treating such patients.

With a localized process in the lower floor of the abdominal cavity, there is a transparent or cloudy mucous effusion that stretches behind the manipulator. Its greatest 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 in the area of the ampulla of the fallopian tubes are noted. The fimbriae are sharply hyperemic, with petechial hemorrhages, due to pronounced edema, they are moved apart in the form of a corolla. This symptom 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 ampullar pelvioperitonitis.

With the progression of the disease, the effusion becomes purulent, its quantity increases, but its viscous mucous consistency is still preserved. Endoscopically reveal a picture of acute purulent pelvioperitonitis. The fallopian tubes at this moment sharply thicken due to edema, there is a pronounced hyperemia of all organs of the small pelvis and petechial hemorrhages on the peritoneum. Even with this severity of the process, the ovaries, as a rule, remain intact, the phenomena of oophoritis are observed extremely rarely.

Clinical picture and diagnosis Clinically, two forms of primary ampullar pelvioperitonitis are distinguished - toxic and local. The toxic form is characterized by an acute and rapid onset of the disease. Severe abdominal pain is noted, usually in its lower sections. Body temperature most often rises to 38-39 ° C. Vomiting may be repeated. Often, loose stools are added, which occurs when peristalsis is increased due to a pronounced inflammatory process in the abdominal cavity.

A significant severity of the general condition is observed, despite the short period that has elapsed from the onset of the disease (sometimes only 2-6 hours). The child is usually restless, groans, the skin is pale, the eyes are shiny. Tongue dry, coated with white coating. When examining the abdomen, all signs of severe peritonitis are found: sharp pain and a clear rigidity in all parts of the anterior abdominal wall, but somewhat greater below the navel and on the right. Shchetkin-Blumberg's 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 examining peripheral blood, high leukocytosis is found (up to 20x10 9 /l and above).

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

With a localized form of primary ampullar 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 more often in 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 transferred the day before - all these signs make one suspect primary ampullar pelvic peritonitis. However, even with a typical manifestation of the disease, surgery is performed, since the surgeon cannot completely exclude the diagnosis of acute appendicitis. An unnecessary appendectomy is performed, potentially dangerous for the occurrence of serious postoperative complications, such as adhesive intestinal obstruction (ILE), progression of the inflammatory process, etc. Laparoscopy allows you to confirm or exclude the diagnosis with high accuracy.

Treatment and prognosis Diagnostic laparoscopy often becomes curative. Aspiration of pus is performed, a solution of antiseptics is injected. Appendectomy is not performed in such cases. All patients are prescribed antibiotic therapy with penicillins or cephalosporins for 5-7 days. The prognosis is always favorable.

7.12.2. appendicular peritonitis

Peritonitis is a frequent 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 with advanced forms, mortality remains very high.

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

The most appropriate should be considered the division of peritonitis into local and diffuse. 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). With diffuse peritonitis, inflammatory changes in the peritoneum go beyond the focus, not along the path of natural spread. The exit of the inflammatory process beyond the right lateral canal should practically be considered diffuse peritonitis.

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

Pathogenesis diffuse peritonitis - a complex chain of functional and morphological changes in systems and organs. Anatomical and physiological features of the child's body affect the course of appendicular peritonitis. The smaller the child, the faster the purulent process spreads to all parts of the peritoneum. This is facilitated by low plastic properties of the peritoneum, underdevelopment of the greater omentum. Intoxication and metabolic disorders increase faster, 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 sown 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 in anaerobic infections.

One of the leading factors in the development of pathophysiological changes that occur with peritonitis is the resorption of toxic products of purulent exudate from the abdominal cavity by the peritoneum. The surface of the peritoneum in children, especially young children, is relatively larger than in adults. It has been established that in 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, circulation disorders, hyperthermia, acid-base disturbances, etc.

In children with appendicular peritonitis, dehydration and circulatory disorders develop quite rapidly. 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. Increased exudation of fluid and protein into the abdominal cavity. In parallel, there is a significant loss of water due to frequent vomiting, loose stools. Fluid loss is also aggravated by perspiration and shortness of breath. With intestinal paresis, there is a massive accumulation of fluid in its lumen. Massive loss of fluid from the bloodstream leads to a significant decrease in BCC and, consequently, hemoconcentration. Hypovolemia and subsequent hypoxemia cause spasm of peripheral and renal vessels, which leads to redistribution of blood while maintaining the 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 the heart.

A decrease in renal blood flow contributes to a decrease in urine filtration in the renal glomeruli and the occurrence of renal ischemia. In the future, disorders of kidney function lead to water-electrolyte and metabolic disorders.

Due to the spasm of the skin vessels, heat transfer decreases, which exacerbates 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 functions occur. All this can lead to adrenal insufficiency.

One of the important pathophysiological links in the development of peritonitis is a metabolic disorder. With peritonitis, the replenishment of energy resources with food is disrupted, 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 underoxidized products. Gradually, the detoxification function of the liver begins to suffer. In severe peritonitis, protein metabolism disorders develop. Loss of protein occurs with exudate, its diffusion into the intestinal lumen. Dysproteinemia develops.

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

With peritonitis, there are also significant disturbances in electrolyte metabolism. Vomiting and loose stools lead to loss of fluid and electrolytes (potassium, sodium, chloride ions). As the loss of potassium and chlorine ions against the background of a decrease in plasma volume, acid-base balance disorders occur, consisting in the development of intracellular acidosis against the background of extracellular alkalosis (Darrow mechanism). The impoverishment of the cell with potassium ions contributes to the 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 symptoms of general tissue hypoxia. A deficiency of potassium ions reduces the tone of smooth muscles, leading to the development and progression of paresis of the gastrointestinal tract.

Consequently, the main pathophysiological processes in peritonitis are hypovolemia and impaired central and peripheral hemodynamics, changes in the water and electrolyte balance and acid-base state, and dysfunction of vital organs. In severe peritonitis, these disorders can be considered as 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 old, protective mechanisms quickly turn into pathological ones, and general clinical symptoms prevail over local ones.

The course of diffuse peritonitis is also accompanied by pronounced violations of the immunological reactivity of the child's body, which have a clearly expressed phase character.

In the reactive phase of peritonitis, the tension of 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 in the overall level of non-specific 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, a complete failure of the defense forces, a catastrophic decrease in the indicators of both specific and nonspecific immune responses are noted.

Clinical picture In the anamnesis, as a rule, pain, vomiting, fever are noted. In the future, the pain may subside somewhat, but hyperthermia persists, although sometimes insignificant; the general condition also may improve somewhat, but never recovers to a satisfactory level. After a "light interval" worsening occurs: the pain in the abdomen increases again, vomiting appears, the general condition progressively worsens. The presence of such a gap is apparently associated with the destruction and necrosis of the 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 violation of the integrity of the conglomerate with a “covered” perforation. Perhaps the development of peritonitis and without perforation of the appendix due to the passage of microflora through the altered wall. The speed of the onset of perforation and the duration of the "light interval" depend on the age of the patient: the smaller the child, the faster the perforation occurs and the shorter the period of imaginary 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 the pain symptom, temperature reaction and general disorders, while peritoneal inflammation progresses. Therefore, the use of antibiotics, especially in young children, is contraindicated until the cause of abdominal pain is established.

Diagnostics When examining a child with appendicular peritonitis, a significant severity of the general condition is noted. The skin is pale, sometimes has a "marble" hue. The eyes are shiny, the tongue is dry, with a white coating. Usually there is shortness of breath, the 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 departments, protective muscle tension and the Shchetkin-Blumberg symptom are clearly revealed, most pronounced in the right iliac region.

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

In young children, the general condition at first may be slightly disturbed, 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 worsen. At an early age, with appendicular peritonitis, loose stools are more often observed, sometimes green with mucus.

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

Preoperative preparation Immediate surgical intervention for peritonitis in conditions of significant disturbances in the internal environment of the body is a serious mistake. These shifts can be exacerbated 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 hemodynamic disturbances, 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 by the following formula using hematocrit values.

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

When conducting infusion therapy, solutions of hemodynamic and detoxification action are primarily prescribed (dex-stran, average molecular weight 30000-40000, albumin, dextran, average molecular weight 50000-70000, 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 whole complex of preoperative measures should be performed in a fairly short time (no more than 2-3 hours).

Therapy with broad-spectrum antibiotics begins already in the preoperative period. Recommend intravenous administration of £) third-generation cephalosporin (cefotaxime, ceftriaxone) or an inhibitor-protected penicillin (amoxicillin + clavulanic acid), under the protection of which the operation is performed. In the postoperative period, the administration of antibiotics in the form of combined antibiotic therapy (cephalosporin + aminoglycoside + metronidazole or amoxicillin-Nclavulanic acid + aminoglycoside) is continued, which makes it possible to cover the entire spectrum of potential causative agents of peritonitis (gram-negative bacteria, enterococci and anaerobes). intoxication, improved breathing, prevention of aspiration. An important role, especially in children of the first months of life, is played by the fight against hyperthermia, pneumonia, pulmonary edema, convulsions.

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

Features of surgical tactics in appendicular peritonitis depend on its phase.

In the reactive phase during surgery, a profuse purulent effusion in the abdominal cavity is usually found. The intestinal loops are somewhat swollen, hyperemic, without fibrin and circulatory disorders. Despite the fact that the inflammatory process spreads to the entire abdominal cavity, local symptoms still prevail, the body, as it were, copes with the disorders that have arisen, using its own reserves. Among intraoperative measures in the reactive phase, an important role is assigned to a 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 small pelvis. Drainage is introduced through an additional puncture incision in the right iliac region, slightly above and lateral to the "appendicular" incision. For its proper 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 maximally on the bottom of the small pelvis (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 small pelvis should not exceed 0.5 cm. With smaller holes, the drainage quickly becomes clogged, and with larger holes, suction of the intestinal wall, omentum, and fatty suspensions is possible. On the skin, the drainage tube is fixed with silk sutures (Fig. 7-16).

In the toxic phase of peritonitis in the abdominal cavity, a large amount of pus, significant paresis (up to paralysis), pronounced circulatory disorders with fibrin overlays on intestinal loops can be detected. Surgical tactics in this phase of peritonitis in general principles is similar to that in the previous phase, but has some features. Simultaneous washing of the abdominal cavity should be more thorough and using a large amount of washing solution. With significant paresis of the intestine, various methods of its decompression are used: intubation of the small intestine through a gastrostomy, cecostomy, retrograde through the anus or "pumping" the contents of the small intestine into the large intestine. As in 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 cut off with a 0.25% solution of procaine. Epidural anesthesia is indicated, which is carried out in the postoperative period.

In the phase of polymorphic disorders, operations reveal deep functional disorders of the intestine. Due to its paralysis, stasis and expansion of the small intestine due to the accumulation of fluid and gases are noted. In this case, delimited abscesses in the abdominal cavity are more often detected. After separation of the intestinal loops, it is advisable not to suture the median laparotomy wound (laparostomy). After a thorough sanitation of the abdominal cavity, the pelvic cavity is drained with a silicone tube. The intestines are covered with a polyethylene film with multiple holes up to 5 mm, napkins soaked in vaseline oil are applied on top, over which, with separate seams, without tension, the skin is brought closer to the aponeurosis, covering only the edges of the napkins. The absence of compression on the intestines and the possibility of free exit of the infected exudate from the abdominal cavity through the wound contribute to the improvement of microcirculation in the intestines, the restoration of peristalsis and the relief of the inflammatory process. In this phase of peritonitis, decompression of the gastrointestinal tract is of particular importance. After 2-3 days, a second operation is performed: napkins and a 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 soldered intestine so that the loops of the intestines are not deformed during stitching.

Postoperative treatment After surgery, the patient is placed in an elevated position in the bed by raising its head end at an angle of 30°, which facilitates the child's breathing and facilitates the outflow of exudate into the lower abdomen. A roller is placed under bent knees so that the child does not slide down.

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

In addition to the general condition (reaction to the environment, appetite, normalization of the function of the gastrointestinal tract), 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 shifts, 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 the probe in the first 2-3 days after surgery prevents aspiration, helps to reduce intra-abdominal pressure, increasing the ventilation capacity of the respiratory system.

Prevention and treatment of respiratory failure is essential throughout the immediate postoperative period. According to indications, catheterization of the tracheobronchial tree is carried out, followed by suction of the 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 violations of hemodynamics, acid-base state and water-electrolyte balance. More than a third of patients with diffuse peritonitis have similar disorders with symptoms of severe metabolic acidosis. Extremely rarely, with very severe forms of peritonitis, the phenomena of metabolic alkalosis are also noted. 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, macromolecular drugs, 4% sodium bicarbonate solution. Metabolic alkalosis is corrected by intravenous administration of a 7.5% solution of potassium chloride, on average from 8 to 10 ml (0.5 ml/kg of body weight) in dilution. Respiratory acidosis that occurs in the postoperative period is eliminated by dosed oxygen therapy and evacuation of gastric contents using a probe. Correction of violations of water and electrolyte metabolism does not differ from that carried out before surgery.

The success of treatment for peritonitis largely depends on the rational use of antibiotics. Combined antibiotic therapy (based on third-generation cephalosporins or inhibitor-protected penicillins) is indicated. For children operated on again due to complications (subhepatic, subdiaphragmatic abscesses, intestinal fistulas, etc.). in patients with previous hospitalization and antibiotic therapy, as well as in postoperative peritonitis, the antibiotics of choice are carbapenems (imipenem + cilastatin, meropenem) in monotherapy or in combination with aminoglycosides. An important link in the postoperative period in patients with peritonitis is the normalization of bowel functions. In severe peritonitis, intestinal paresis often lasts for several days. To combat postoperative paresis, repeated hypertonic 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), hypertonic dextrose solutions are transfused intravenously (10-20 ml of a 40% solution) , 10% sodium chloride solution ~ (psG2-schgna 1 year of life) and potassium chloride solutions. The infusion of the latter is carried out in a dextrose solution drip. The safest concentration of potassium chloride is 1%. It is necessary to monitor the regularity of the stool: if it is delayed, cleansing enemas are done once every 2 days. Taking into account the possibility of formation in the postoperative period of infiltrates and abscesses in the abdominal cavity, it is necessary to control the temperature reaction and the content of peripheral blood leukocytes. 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 smooths 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 can be effective in this serious disease.

7.12.3. Peritonitis in newborns

Peritonitis in newborns is a formidable complication of pathological conditions of various etiologies. Among them are necrotizing enterocolitis, malformations of the gastrointestinal tract, 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 wall (84% of cases). Intrauterine intestinal perforations with malformations lead to aseptic adhesive peritonitis, postnatal - to diffuse fibrinous-purulent, fecal peritonitis. With necrotizing enterocolitis against the background of intensive therapy, the development of delimited peritonitis is possible. 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 by contact with purulent periarteritis and periphlebitis of the umbilical vessels, liver abscesses, purulent diseases of the retroperitoneal space, phlegmon of the anterior abdominal wall. These forms also rarely occur now.

Classification. Peritonitis in newborns is classified as follows.

On an etiological basis. 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, intestinal volvulus, meconium ileus, Hirschsprung disease); acute appendicitis; destructive cholecystitis and cholangitis; iatrogenic perforations of hollow organs. non-perforative 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: spilled; limited.

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

Clinical picture postnatal perforative peritonitis in newborns with intestinal wall defects is manifested by acute symptoms of peritoneal shock on the 2nd-3rd day of life. The child is lethargic, groans. The skin is pale gray, acrocyanosis. Breathing is frequent, superficial due to the high standing of the dome of the diaphragm. Heart sounds are muffled. Attention is drawn to a sharp swelling, tension and soreness of the abdomen, expansion of the subcutaneous venous network. With peritonitis in newborns, hyperemia of the skin in the lower abdomen and on the genitals is often observed. Intestinal peristalsis is not heard. Percussion above the liver reveals a box sound - a symptom of the disappearance of hepatic dullness. They note constant vomiting of intestinal contents, stools and gases do not go away.

Diagnosis The diagnosis is confirmed by a survey radiograph of the abdominal organs. Under the dome of the diaphragm, a significant pneumoperitoneum is detected (Fig. 7-17).

Treatment Treatment is surgical only. After a puncture of the abdominal cavity and a decrease in intra-abdominal pressure for 2-3 hours, a comprehensive preoperative preparation is carried out, aimed at eliminating the symptoms of centralization of blood circulation. Preference is given to upper transverse laparotomy, which allows for a complete revision of the abdominal organs. An intestinal loop with a perforated area is sutured to the abdominal wall in the form of an intestinal fistula. After that, 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 outcomes.

7.12.4. Necrotizing enterocolitis

One of the most common causes of postnatal perforative peritonitis (60% of all perforations) is hemorrhagic or septic infarction, which develops as a result of circulatory disorders in the gastrointestinal wall. Among children of 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 undergone severe neonatal hypoxia and asphyxia; it can also be a complication of infusion therapy and exchange transfusion through the umbilical vein, it can develop with decompensation of severe congenital heart disease 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 the saprophytic flora with the development of severe dysbacteriosis is essential. Despite the variety of etiological factors in the pathogenesis of necrotizing enterocolitis, there are severe microcirculatory disorders in the wall of the gastrointestinal tract. There is a centralization of blood circulation with a spasm of mesenteric vessels (up to a complete stop of blood circulation), which is resolved by intestinal paresis with hemorrhages. Morphologically, large or small infarcts of the intestinal wall are detected. More frequent damage to premature babies is explained by the low resistance of their capillaries to pressure drops in the vascular bed. Mostly there is a lesion of the distal ileum and the corners of the colon (ileocecal, hepatic, splenic, sigmoid). The process begins with necrosis of the mucosa, 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 undergone chronic perinatal hypoxia and infection, a clear staging of the course of the disease is noted.

Stage I can be regarded as prodromal. The condition of children at risk who have undergone perinatal hypoxia and infection is closer to severe due to neurological disorders, respiratory disorders and cardiovascular activity. From the gastrointestinal tract, symptoms of dyskinesia are detected. Sluggish intermittent sucking, regurgitation during and after feeding milk, occasionally bile, malnutrition, aerophagia, bloating, anxiety of the child during stroking the abdomen in the absence of symptoms of peritoneal irritation, delayed discharge of meconium stool, rapid loss of body weight are clearly expressed. Radiologically, an increased uniform gas filling of all parts of the gastrointestinal tract with a slight thickening of the intestinal walls is noted.

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, burps with an admixture of bile, bloating increases, local pain appears, more often in the right iliac region. The discharge of feces is accelerated, occurs in meager portions, with an admixture of mucus and greenery. The color of the stool is determined by the nature of the pathological intestinal microflora. So, for staphylococcal dysbacteriosis, a pronounced general toxicosis is characteristic, and in a liquid foamy stool - mucus and greens. For gram-negative infection, severe dehydration, scanty, porous, pale yellow stools with mucus and a large water spot are more characteristic. On the survey radiograph of the abdominal organs, an increased uneven gas filling of the gastrointestinal tract with a shading zone corresponding to the area of maximum intestinal damage is noted. The stomach is swollen, with a level of liquid. Thickening of the shadows of the intestinal walls due to their edema, inflammation and interloop effusion is characteristic. The rigidity of the intestinal walls leads to the 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 weight loss 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 - (pre-perforation) paresis of the intestine is expressed. The duration of the stage is not more than 12-24 hours. The condition is very serious, symptoms of toxicosis and exicosis are expressed, persistent vomiting of bile and "feces", sharp swelling, soreness and tension throughout the abdomen are characteristic. Peristalsis is sluggish, but auscultated. Feces and gases do not depart. Anus closed. During rectal examination (finger, probe) scarlet blood is released. Radiologically, due to the hydroperitoneum, the shading of the abdominal cavity increases, the outer contours of the intestinal loops lose their clarity of outline (Fig. 7-21).

Stage IV - (diffuse perforative peritonitis) is characterized by symptoms of peritoneal shock and intestinal paralysis. The peculiarity of perforative 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 delimited peritonitis observed in a third of cases against the background of ongoing treatment. A child with clinical symptoms of enterocolitis in the abdominal cavity (more often in the iliac region) develops a dense infiltrate with clear contours, moderately painful. Against the background 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 conducting a 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. The primary one is easier than the secondary one, but if the child's complaints are ignored, the consequences can be very serious, even fatal.

Peritonitis in children is different from a similar disease in adults, because the organs are not fully formed, and the body's systems work at full strength. Treatment is prescribed by a doctor, self-medication is unacceptable.

Pediatric appendicular peritonitis has two main varieties.

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

Localization of inflammation in the region of the caecum, name: local unlimited;
The zone of inflammation does not fall beyond the lower part of the peritoneum, name: diffuse;
The process of inflammation covers the bottom and middle of the peritoneum, the name: spilled;
The entire cavity is affected, name: common.

Very often, free peritonitis accompanies the so-called purulent effusion. The 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:

Appendicular infiltrate, when the appendix area is sealed with products of the inflammatory process (blood, cells, purulent effusion);
Periappendicular abscess of three degrees, means total suppuration;
An associated form, where a large abscess and purulent effusion complicate the problem;
The form of total inflammation is the most life-threatening subspecies of peritonitis for a child; it is accompanied by sepsis and infectious-toxic shock.

Severe consequences of the second variety 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, appendicular peritonitis occurs, since appendicitis in children, especially small ones, is very difficult to diagnose: the symptoms are similar to other diseases.

Stages of appendicular peritonitis:

Reactive. Valid for about a day from the moment of localization.
Toxic. Continues up to 72 hours.
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 to the fact 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 former is not so identified, the symptoms are smoothed out, and the signs do not make themselves felt. However, peritonitis develops and may become purulent as the focus of inflammation grows.

What symptoms adults should definitely respond to:

Nausea and vomiting;
High body temperature of the baby (more than 38 degrees);
Sharp pain in the right hypochondrium, then spreads throughout the abdominal cavity;
The general condition worsens: the child is naughty, restless, experiencing severe weakness;
Violation of the intestines (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 deteriorates sharply, the symptoms reappear with renewed vigor.

During a false improvement, in no case should you stop treatment, since the causes of peritonitis have not been eliminated.

Late stages are characterized by the following symptoms:

Severe dehydration of the body;
The complexion takes on a gray tint;
Eyes shine and watery;
The mucous membrane dries, the child is very thirsty;
Tongue covered with white coating;
Significantly increased heart rate;
There is bloating;
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.

Stationary diagnostics includes:

Blood tests;
Urinalysis;
Ultrasound examination;
X-rays.

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

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

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

Preparation for surgery. The complex of measures depends on the stage and type of the disease. Sometimes it takes more than three hours.
Surgery to eliminate the cause of inflammation. Possible removal of a portion of the intestine.
Washing the area with a special composition, which includes an antibiotic and other antibacterial drugs.
Suturing. The wound is sutured, a drain is inserted, through it after the operation, during the recovery period, sanitation solutions are introduced.

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

Injections with antibiotics;
Medications to lower body temperature;
Means for improving the process of metabolism and micro blood circulation.

Rehabilitation and prevention

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

If the baby is in pain, painkillers are administered. A sparing diet is observed to normalize bowel function. Analyzes are done regularly.

Peritonitis is a dangerous disease. It is categorically unacceptable to engage in self-medication and delay the call for an ambulance. It is important not to skip 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 preventive measure, educational explanations are being conducted among the population. Adults should understand that timely access to the help of a specialist will help to avoid complications. The key to success in the treatment of this disease is a clear understanding of what is happening and surgical intervention. The prognosis for recovery, in such cases, is always positive.

Peritonitis is an acute inflammation of the sheets of the peritoneum, which develops as a result of the aggressive action of various stimuli (infectious, non-infectious) on it. The development of peritonitis is accompanied by a progressive deterioration of the patient's condition and a severe pain syndrome. According to medical statistics, death from peritonitis is about 20% of deaths from acute surgical pathology.

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

What causes peritonitis? According to the ways of introducing the infection, there are:

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

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

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

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

The most common causes of peritonitis are:

rupture of the appendix;
perforated ulcer of the stomach or duodenum;
perforation of the intestinal wall at the site of a typhoid plaque in typhoid fever;
damage to the intestinal wall by a foreign body;
necrosis of a section of the intestine when a hernia is infringed;
rupture of the intestinal diverticulum;
intestinal rupture with intestinal obstruction;
perforation of the wall of the organ by a malignant tumor.

In some conditions (for example, in the syndrome of hypertension in the portal vein system of the liver), fluid leaks into the abdominal cavity from the varicose venous bed - ascites. This fluid can become inflamed for various reasons. With internal bleeding (from the liver, spleen, kidneys), hemoperitoneum (bloody peritonitis) occurs.

How does peritonitis manifest itself? Symptoms of peritonitis in adults are very bright. The first signs of peritonitis are severe pain and a positive symptom of peritoneal irritation. Pain syndrome in symptoms is the leading one. The pain is unbearable and forces patients to take a forced position - on their side with legs tightly pressed to the 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. Of the general 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 are tormented by nausea and vomiting (as a sign of increasing intoxication of the body). The appearance of patients is changing: facial features are sharpened, the skin turns pale. About 1/5 of patients with peritonitis die during the toxic stage. Often this happens due to the fact that a couple of days after the onset of the disease, after taking a large amount of painkillers, the patient's condition "improves", which is perceived as a 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, the slightest movement causes severe pain in the patient, the internal organs swell, so there is severe shortness of breath, palpitations and urine ceases to separate. The skin takes on an earthy color, the cheeks and eyes sink. Only every tenth patient survives after the terminal stage, even in the case of surgery.

According to medical statistics, the most common is complicated appendicitis with peritonitis. The 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 bile peritonitis. It occurs due to the outflow of bile from the gallbladder into the abdominal cavity. The course of bile peritonitis depends on the volume of bile flowing out and its sterility. If bile enters the abdominal cavity in small quantities, then peritonitis can be subacute or chronic 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, bile-hemorrhagic peritonitis develops and death occurs.

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

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

Is there any chance of survival with extensive peritonitis? We can say with confidence that without appropriate medical care, 100% of patients die from extensive peritonitis.

Symptoms and treatment in adults of peritonitis differ from those in children. The causes of peritonitis in children can be very different. Most often, peritonitis occurs due to rupture of the abdominal organs. Perforative peritonitis in children in most cases develops after appendicitis (appendicular peritonitis). But children often have peritonitis, the cause of which is extremely difficult to establish (the 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 of peritonitis that do not occur in adults:

cryptogenic pelvioperitonitis in girls;
perforative peritonitis, which develops against the background of necrotizing enterocolitis in newborns (more often occurs in premature babies due to severe birth asphyxia in childbirth);
peritonitis against the background of malformations of the digestive tract (Hirschsprung's disease, meconium ileus, atresia).

How to define peritonitis? During 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, there may be asymmetry or retraction of the abdomen;
the abdomen is sharply painful on palpation;
a positive symptom of peritoneal irritation (Shchetkin-Blumberg symptom) is determined - with pressure, and then a sharp removal of the hand from the place of localization of the greatest pain, there is an increase in pain;
during vaginal examination, women experience soreness and sagging of the posterior fornix of the vagina;
with rectal examination, you can feel the infiltrate in the pelvis.

When the anterior wall of the abdominal cavity is tapped, the disappearance of hepatic dullness is observed and tympanitis is heard throughout the abdomen (the sound of a blow to the drum). When listening to the intestines with a phonendoscope, no bowel movement is heard (dead silence) or pathological intestinal noises are determined.

Usually the 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, an acceleration of the erythrocyte sedimentation rate);
a biochemical blood test (reveals a possible cause of the development of peritonitis, determines the degree of violation of the acid-base balance in the blood);
general urine analysis;
Ultrasound of the abdominal organs, if necessary - ultrasound of the pelvic organs (the primary focus may be detected on ultrasound);
X-ray of the abdominal cavity (symptom of the "sickle" - a reliable sign for a perforated ulcer, Kloyber's bowl - for intestinal obstruction);
puncture through the posterior fornix of the vagina (often fluid or pus accumulates there, because between the vagina and the rectum there is the deepest pocket of the peritoneum sheet in the small pelvis);
laparocentesis (obtaining effusion from the abdominal cavity);
CT scan.

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

Preoperative preparation includes:

catheterization of the patient through the subclavian vein;
emptying the bladder and inserting a catheter in it (to monitor kidney function during surgery);
emptying the stomach with a probe;
compensation of the volume of circulating blood through the subclavian catheter (colloidal and crystalloid solutions, antibiotics are poured in, alkalization of the blood is eliminated);
antienzymatic therapy;
drug maintenance of the functions of the liver and kidneys, the activity of the heart;
premedication (preparation for general anesthesia).

The actual surgical intervention is carried out after the preparation of the patient and after introducing him into a state of deep anesthesia. During the operation for peritonitis, it is necessary:

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

Access for peritonitis - median (along the white line of the abdomen), from the pubis to the navel and sternum. Such a large access is necessary in order to conduct a thorough washing of 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;
with intestinal peritonitis, which develops against the background of intestinal obstruction, a part of the intestine is removed with the formation of an artificial anastomosis or with a stoma placed on the anterior abdominal wall;
when the appendix is perforated, it is removed and the defect of the intestine is sutured.

After the discovery and elimination of the cause of the development of peritonitis, the entire abdominal cavity is washed with antiseptic solutions with its further drying. How to wash the abdominal cavity? Modern medicine has a choice of strong antiseptics, the solutions of which are used to wash the abdominal cavity with peritonitis (Chlorhexidine, Furacillin).

To remove gases from the intestines after surgery, a special gas tube is inserted into the small intestine during the operation.

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

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

Early (up to 5 days). In the early period, patients undergo:
intensive drug (infusion) therapy - pour in up to 10 liters of fluid per day;
detoxification (removal of toxic decay products from the body);
antibiotic therapy;
stimulation of intestinal activity;
immunocorrective therapy;
support for cardiovascular activity;
observation and prevention of complications.
Late (before discharge, usually 2-3 weeks).
Distant (before returning to work or receiving disability).

How much is peritonitis treated? If the postoperative period proceeds favorably, then the drains 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 removal of stitches, patients are discharged home.

Diet after peritonitis is of great importance for recovery. Regardless of what was the cause of intestinal peritonitis, after the operation, in the first 2-3 days, the patient is prescribed complete hunger. Starting from the second postoperative day, parenteral nutrition (glucose solution, amino acids) is started. If the patient is recovering well and he has peristalsis (movement) of the intestine, 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 through a tube.

The patient can be transferred to nutrition in the usual way only after the establishment of normal intestinal motility, with the independent discharge of gases and the appearance of the first stool. The diet of the patient in the first week after the operation should be as sparing as possible:

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

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

The weight of weights allowed for transfer should not exceed 3 kg during the first 3 months after the operation.
Abstinence from intimacy for a period of at least 1.5 months after surgery.
Hiking, therapeutic exercises to strengthen the abdominal muscles.
Swimming.

After such an extensive operation, the patient should permanently change their lifestyle, as leading a very active life, especially during the recovery period, can lead to undesirable consequences.

What consequences can occur in patients in the postoperative period? Consequences after surgery for peritonitis can be early and long-term. As a rule, early complications of peritonitis occur in the case of late patient seeking medical help. These include conditions that can lead to death:

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

The long-term consequences of peritonitis include diseases or pathological conditions that occur after discharge from the hospital:

intestinal paresis;
intestinal obstruction;
adhesive disease;
female infertility;
abscess between intestinal loops;
hernia.

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

patient's age;
spillage of the process;
the time elapsed from the onset of the disease to the operation;
how quickly peritonitis developed;
severity of clinical manifestations;
qualifications of surgeons;
adequacy of infusion therapy;
related pathologies.

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

How long do they live after surgery? If the operation was successful, then the life of the patient after the operation depends on him. The death of the patient after the operation can occur only in the event of early or long-term consequences.

Child mortality from peritonitis deserves special attention. This is especially pronounced in premature babies, the consequences for which in the event of diffuse peritonitis are deplorable: in almost 80% of cases of perforated peritonitis in premature newborns, they end in death.

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

Peritonitis is a dangerous acute surgical pathology, in which it is impossible to delay. The variability of the clinic of peritonitis greatly complicates its diagnosis. Therefore, with intense pain in the abdomen, all surgical doctors (surgeons, pediatric surgeons, gynecologists), first of all, should be wary of peritonitis.

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

Depending on the cause of the onset of the disease, a classification of childhood peritonitis can be made. According to the spread of the disease, there are:

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

appendicular peritonitis in children is characterized by the collection of blood, pus and a number of seals 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 are given an appendectomy;
neonatal peritonitis is characterized by perforation of the gastrointestinal wall or the development of malformations in the intestines;
periappendicular abscess of three degrees - is detected as an accumulation of pus;
combined peritonitis - pus and accumulation of fluid in the peritoneum;
the total form is accompanied by sepsis and shock from infections and toxins.

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

Growth rate:

By 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 - is determined on the 3rd day.

Symptoms

Acute pain as the first symptom may be the exception rather than the rule. The child's body is still being formed, so the symptoms of the disease begin with the usual deterioration. Signs of peritonitis in children are not pronounced. If peritonitis is provoked by injuries, appendicitis, infection, then the manifestation of such symptoms is possible:

sluggish look;
anxiety and tearfulness;
appetite worsens;
bad sleep;
heat;
stool problems;
localized abdominal pain;
bloating;
the skin becomes dry and darkens a little.

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

pain in the lower abdomen;
heat;
frequent vomiting;
liquid stool;
general heaviness in the body;
pale skin;
shining eyes;
dry mouth, white coated tongue.

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

discomfort in the right iliac region;
body temperature maximum 38;
SARS.

Appendicular peritonitis is characterized by abdominal, infectious-inflammatory and adaptive 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-inflammatory symptoms can be as follows:

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

Adaptive signs are manifested in the form of such symptoms:

the stomach becomes inflamed;
frequent vomiting;
anorexia;
the density of urine increases;
impaired filtration of the kidneys;
yellowing of the skin and the membranes of the eyes;
hypoxia;
hypovolemia;
depression;
coma;
dysmetabolic sign.

Diagnostics

At the first sign, you should immediately seek medical help. Initially, if the child's condition allows, a detailed physical examination is performed with anamnesis. 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, you can fight in only one way - by surgery. The surgeon performs a laparotomy and examines the condition of the peritoneum. If there is a need, then the cause of infection is removed, washed with antibiotics and antibacterial agents. During the suturing of the wound, a small drain is attached to deliver antibiotics.

In the postoperative period, the child is treated:

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

Treatment of peritonitis in children takes quite a long period. After the operation, it is necessary to follow a diet. The child can:

chicken broths;
yogurt without additives;
vegetable puree;
rice porridge on the water;
fruits and berries.

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

Complications

Peritonitis for juvenile patients is dangerous with a number of complications:

sepsis;
disorders in the work of the kidneys;
adhesive diseases;
ailments of the gastrointestinal tract.

Prevention

You can prevent the disease if you follow the basic rules of a healthy lifestyle. This includes proper nutrition, daily routine, personal hygiene. With slight suspicion of an ailment, parents should seek professional help, and not 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 treated in time, then serious complications and death can follow.

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

The article will focus on peritonitis. What is this disease, 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 the internal organs or in the abdominal cavity;
umbilical sepsis;
infections;
breaks in the abdominal cavity;
injuries and wounds in the abdomen;
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 appendicular peritonitis most often occurs after surgery (appendicitis requires such treatment). Symptoms are very similar to other abdominal diseases. And the younger the child, the more difficult it is to make an accurate diagnosis.

Appendicular appendicitis goes through the following stages:

Reactive period. Continues for about a day.
The toxic stage is 72 hours long.
The terminal stage, there are obvious signs of the disease, the temperature is high.

Each stage has its own signs and symptoms, the sooner the disease is detected, the more likely it is to avoid complications.

Classification

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

On distribution of peritonitis, allocate: local; spilled; general.
According to the localization 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. Neonatal peritonitis occurs due to perforation of the gastrointestinal tract wall or with the development of malformations in the intestine. 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 being formed, the symptoms of peritonitis in children appear with a general deterioration in the condition. It should be noted that all the characteristic signs of the disease are not expressed clearly.

The main symptoms of peritonitis in children if it is provoked by appendicitis, trauma 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 the rapid development of the disease. The following signs are observed:

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

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

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

Parents should pay attention to the fact that the symptoms of the disease in children differ significantly from the symptoms 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 definitely pay attention to the following alarming symptoms, and seek medical help immediately. 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 is rapidly deteriorating;
disruption of the intestines;
painful and frequent urination;
loss of appetite;
strongly tense abdominal muscles.

At an early stage, symptoms sometimes disappear and there is a temporary improvement in well-being (false), but the body temperature remains high. The child feels better, but then, the condition deteriorates sharply, the symptoms begin to manifest with renewed vigor. During the period of false improvement, treatment should not 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 are constantly watering and shining;
the skin becomes gray;
no bowel movements for several days;
rapid pulse;
severe throbbing pain in the abdomen.

Diagnostics

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

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

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 for the administration of antibiotics.

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

Inject antibiotics into a vein.
Give the child antipyretic drugs.
Medicines are prescribed for intoxication and to improve blood circulation.
They are on a strict diet.

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

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

Without the knowledge of the doctor, you should not take any food and drugs. If all the rules for the treatment of peritonitis in children and the clinical recommendations of doctors are followed, then recovery will come very quickly.

Complications

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

adhesive diseases;
sepsis;
violation of the kidneys;
malfunctions of the digestive tract.

In this case, complications may not occur immediately, but several years after primary peritonitis in children. In pediatric surgery, this is a fairly common occurrence.

Rehabilitation and prevention

You can prevent this serious disease, the main thing is to adhere to a healthy lifestyle, which includes:

proper nutrition;
compliance with sleep and wakefulness;
compliance with the rules of personal hygiene;

There are also two important rules to remember:

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

The key to success in the treatment of 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 surgery can save the child's life. Of great importance in the success of the operation is the timely visit to the doctor and the general health of the child at the time of hospitalization.

Summing 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 pronounced. You should carefully monitor the child and show it to the surgeon at the first symptoms. Delay in this disease can cost the child's life. The risk of death in 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 the internal organs and infections that can provoke the development of peritonitis. Even a minor illness or a simple gastrointestinal disorder can result in serious consequences. To avoid this terrible disease, it is necessary to try with the whole family to lead a correct lifestyle, organize the child with proper nutrition, and make sure that he has a good rest. Parents bear all responsibility for the life and health of their children. Only the correct organization of a child's life can minimize the risk of developing dangerous diseases.

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

Of particular difficulty is the diagnosis of peritonitis in children of the first 3 years of life, since at this age the same general disorders can occur with a variety of diseases, it is not possible to reliably identify complaints, and the study of the abdomen is often hampered by the behavior of the child. In such cases, the child's abdomen should be palpated during sleep, which can be artificially induced (after a chloral hydrate enema), but this can only be done by a doctor in a hospital (see Appendicitis, in children). Particular attention deserves peritonitis in newborns. It can develop as a manifestation of sepsis. Meconium peritonitis occurs on the basis of congenital intestinal obstruction, perforation may also be the result of a malformation of the intestinal wall. The clinical picture in these cases is characterized by persistent vomiting, the abdomen is swollen, and swelling of the anterior abdominal wall is often determined.

Treatment of peritonitis is 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 give food and drink, do not put cleansing enemas, etc.

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

Peritonitis in children is quite common and is characterized by the severity of the course, especially in young children. Anatomical and physiological features of the peritoneal cover and omentum in newborns and young children (weak restrictive abilities due to low plastic properties of the peritoneum, underdevelopment of the omentum) contribute to diffuse peritonitis. The most severe peritonitis occurs in newborns. Mortality among them up to the present time reaches 75-80% (S. Ya. Doletsky, A. I. Lenyushkin). In most cases, peritonitis develops secondarily, spreading from the abdominal organs or the abdominal wall. Primary peritonitis in children is less common (more often pneumococcal etiology).

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

The diagnosis of peritonitis in young children and newborns is often very difficult. Fear of the doctor, restless behavior of the child at the time of examination, his active defense, lack of data on the subjective sensations of the patient 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 measures, the central place is given to the early operation. Conservative measures taken before, during and after surgery are reduced to the fight against purulent infection, intoxication, sensitization, disorders of water-salt metabolism and the activity of the gastrointestinal tract, and also provide for an increase in the body's defenses, prevention and treatment of pneumonia.

Recently, pediatric surgeons have paid more and more attention to the preoperative preparation of children with severe peritonitis. Preparation for the operation can take from 1 to 5 hours. The question of the time of preparation and the necessary measures is decided in each case individually (type of peritonitis, severity of the condition, duration of the disease). Preoperative preparation includes the appointment and administration of antibiotics before surgery; the introduction of cardiac and painkillers (0.1 ml of a 10% caffeine solution and a 1% solution of omnopon); perirenal blockade with 0.25% solution of novocaine (10 ml on each side); gastric lavage, sometimes leaving a permanent probe; the introduction of a high gas outlet tube, the appointment 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% sodium and calcium chloride solution, 2 ml of 0.25% novocaine solution; long-term intravenous drip of liquid (5% glucose solution or 10% glucose and Ringer's solution in a ratio of 3: 1 with the addition of vitamins C, B1, saline); the appointment of diphenhydramine, pipolfen or suprastin; with hyperthermia - the introduction of a 1% solution of amidopyrine and a 50% solution of analgin, physical cooling. When performing activities according to this scheme, use the age dosages of these funds.

Surgical intervention for peritonitis is reduced to the elimination of the infectious focus, the removal (suction) of pus from the abdominal cavity, the introduction of antibiotics into the abdominal cavity and the possibility of their further intraperitoneal administration through thin drainage. Conservative measures of the postoperative period are carried out mainly according to the same scheme, according to indications, they resort to repeated operations.

Of 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 in 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 prognostically the most unfavorable.

Clinical symptoms: bloating and expansion of 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 determines the swelling of the overlying sections of the intestine with gases, the level of fluid, free gas in the abdominal cavity, calcifications against the background of intestinal loops.

Surgical treatment. The patency of the intestine is restored, the perforation is sutured, after the toilet, antibiotics are injected into the abdominal cavity. In the case of meconial obstruction, enterostomy is performed. Viscous meconium is washed out through the enterostomy through the rubber catheter inserted into it.

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

In children, peritonitis of the appendicular and cryptogenic nature is most common, in addition, neonatal peritonitis is especially distinguished. Peritonitis in children resulting from inflammation of the gallbladder and perforation of a duodenal ulcer is extremely rare and, according to the clinical picture of the disease, does not differ in any way from peritonitis in adults (as well as post-traumatic ones).

appendicular peritonitis. Peritonitis is the most severe complication of acute appendicitis in childhood, occurs 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 due to the late diagnosis of acute appendicitis due to the blurring of the clinical picture, the predominance of general symptoms over local ones, the lack of experience of polyclinics, the widespread prescription 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, the release of the inflammatory process beyond the right side pocket should be considered diffuse peritonitis.

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

violations.

However, it should be noted that in children under 3 years of age, defense 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 salt, proteins and water, but this does not affect cellular metabolism, the enzyme systems function normally, therefore, at this stage, the child's local symptoms prevail over the general ones. The child is restless, does not sleep, refuses to eat, asks

Drink. There is vomiting. The abdomen has a normal shape, you detect active and passive muscle tension, Shchetkin's symptom -J! Bloomberg becomes positive. With comparative palpation of the abdomen, these symptoms are most pronounced in the right under the iliac 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, a violation of the function of the enzyme system is noted, the cell mass loses anions and cations. Clinical symptoms are due to prominent signs of intoxication. The child continues to worry, at times adynamia occurs, facial features are sharpened, Vomiting is frequent, green. The mucous membranes of the mouth and tongue become dry. Expressed tachycardia. The abdomen somewhat changes its configuration, becomes swollen. Soreness occurs, active and passive muscular protection is more pronounced in all parts of the abdomen. Symptom Shchetkin - Blumberg sharply positive. The stool in young children is often liquid with mucus and greenery.

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

The main symptoms are violation of peripheral microcirculation: pallor of the skin and mucous membranes, marble pattern of the skin, symptom of "pale spot". The skin is cold, moist, with a gray tint. There is shortness of breath, 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), poorly amenable to drug therapy.

Violation of hemodynamics is expressed in tachycardia, a decrease in arterial and central venous pressure, due to hypovolemia.

When examining the abdomen in older children, a pronounced widespread muscle tension (“board-shaped” abdomen) is found. In young children, early developing intestinal paresis relatively easily overcomes the resistance of the abdominal muscles, the abdomen looks swollen. Peristaltic noises are not heard. Symptoms of peritoneal irritation are pronounced. During rectal examination of the patient, overhanging of the arch and sharp pain are noted. The differential diagnosis of peritonitis is especially difficult in young children, since its symptoms are very similar to 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 the patient has peritonitis of the appendix,

of a paired nature, then at the beginning of the disease, pain in the abdomen prevails over all the symptoms, then other symptoms already appear. The main symptom of peritonitis, which removes all doubts, is, of course, the passive muscle tension of the abdominal mouse, which remains even if the child is induced to sleep with medication; for 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 in 15-20 minutes, motor excitation disappears, psycho-emotional reactions and active tension of the abdomen are relieved. The study of the child during sleep allows not only to differentiate the active defense from the passive one, but also to obtain reliable data on the pulse rate, respiration, and also facilitates the examination of the child and the auscultation of the abdomen and chest.

If the diagnosis could not be clarified, then surgical intervention is recommended, but it is more expedient to preliminarily perform laparoscopy and establish an accurate diagnosis. In children who are in serious condition, as well as younger children, laparoscopy should be performed under intubation anesthesia.

The plan for examining a patient with peritonitis to determine the severity of the condition and the phase of the course of the disease must necessarily include a number of laboratory and functional research methods: determination of hemoglobin, hematocrit, and electrolytes. Tachycardia, a decrease in arterial and an increase in 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 a poor prognostic indicator.

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

The preoperative preparation is based on the fight against hypovolemia and dehydration. For infusion therapy, solutions of hemodynamic and detoxification action are used (hemodez, reopoliglyukin, polyglukin, 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 by drugs. The intubation combined anesthesia is shown.

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

"4 Pipnpni! 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 old, Volkovich-Dyakonov access 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 prevent the main task of surgical intervention - sanitation of the abdominal cavity. With diagnosed peritonitis of great prescription (more than 3 days), median laparotomy is indicated.

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

Exudate is removed using an electric suction. Appendectomy is performed with the obligatory immersion of the stump into the purse-string and z-shaped sutures. The toilet of the abdominal cavity is carried out by washing. The basis of the washing medium is isotonic or weak hypertonic saline solutions, a solution of furacilin 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 washing is 2-3 liters. Irrigation is performed as the final manipulation after completion of the appendectomy.

The final stage of the operation causes the greatest controversy among both adult and pediatric surgeons. The question of whether to close the abdominal cavity tightly, leave drains and tampons, has not been finally resolved. Proponents of a blind suture use microirrigators to administer antibiotics.

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

Peritoneal dialysis, unfortunately, does not guarantee against such complications as the occurrence of residual abscesses in the abdominal cavity, infiltrates, eventration, fistula formation. 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 a thorough sanitation of the abdominal cavity, the introduction of microirrigators for antibiotic therapy in the postoperative period. The success of the 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 antibiotic therapy, correction of metabolic disorders and the fight against intoxication; 2) the struggle for the restoration of the motor-evacuation function of the digestive tract.

Peritonitis is in most cases a polymicrobial disease in which associations of microorganisms are sown, more often with a clear predominance of the intestinal flora, as well as Proteus and Pseudomonas aeruginosa; anaerobes account for an average of 30%, and in the lumen of the gangrenous-altered 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. Among modern antibiotics, aminoglycosides (kanamycin, gentamicin), cephalosporins, semi-synthetic penicillins (ampicillin, carbenicillin), nitrofurans have the greatest activity in children against the associated peritoneal flora. Given the role of the anaerobic flora, the appointment of metronidazole is indicated for peritonitis. It is necessary to remember the effect of antibiotics on the biocenosis of the body and the development of dysbacteriosis, which in turn can cause autoreinfection of the patient in the postoperative period.

Intravenous and intraperitoneal administration of antibiotics in combination, as well as intramuscular injections, are generally accepted. In recent years, works have appeared in the literature on the intra-arterial and endolymphatic routes of administration of antibiotics in 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 during hyperthermia by perspiration, sweating of fluid into the intestinal lumen during paresis. The calculation is carried out from 10 ml / (kg-day) for each degree above 37 ° C, 10 mg / (kg-day) for every 10 breaths above the norm, 20 ml / (kg-day) with II degree paresis, 40 ml / (kg-day) with paresis of the III degree.

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

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

When restoring BCC, hemoglobin should be at least 100 g / l, hematocrit - at least 30%, total protein - 60 g / l, A / G ratio - 1 -1.2, potassium content - 3.5-4.5 mmol / l.

Energy costs are replenished due to the transfusion of 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).

With a protracted severe course of peritonitis and the impossibility of feeding through the mouth, parenteral nutrition is prescribed using amino acids and fat emulsions. Restoration of 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 includes detoxification therapy and improvement of hemodynamics. The complex of combating paresis of the gastrointestinal tract also includes its decompression (stomach probing, intestinal intubation in advanced stages), the appointment of hypertonic and siphon enemas, stimulation of peristalsis with a 0.05% solution of prozerin or dimecaine (0.1 ml per 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 appendicular 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 mandatory), the duration of anesthesia is 4-5 days, the intervals between the administration of trimecaine are 3 hours. The program of infusion therapy should provide for the replenishment of the body's need for potassium . A good effect to prevent paresis has the introduction of sorbitol.

In recent years, works have appeared that testify to the high efficiency of hyperbaric oxygenation in peritonitis [Gorokhovskiy VI, 1981; Isakov Yu. F. et al., 1981]. Improvement of tissue oxygenation, stimulation of regenerative processes, improvement of microcirculation and rheological properties of blood and cellular mechanisms of immunity explain the therapeutic effect of this method.

With the purpose of detoxification in the literature of recent years, the use of hemo- and lymphosorption has been noted. However, there is not much experience in pediatric surgical practice on the use of these methods of treatment.

Cryptogenic peritonitis. In clinical practice, children with crypto-

togenic peritonitis is relatively rare. He is known

in the literature under various names: primary, hematogenous, pneumococcal, diplococcal, etc. None of the names is absolutely accurate, since the ways of infection of the abdominal cavity have not been elucidated, the nature of the microflora of the peritoneal exudate is diverse, and the absence of microflora growth is possible.

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

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

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

On examination, there is bloating, pain on palpation in all departments, a positive Shchetkin-Blumberg symptom. Peristalsis is not heard. On rectal examination, an overhang of the anterior wall of the rectum is observed.

Peritoneal exudate - liquid, sticky, cloudy, odorless, without fibrin. The amount of effusion is different and depends on the severity of the disease. Hyperemia of intestinal loops, tubes, tube fringes, sometimes subserous hemorrhages are noted. Histological examination of the appendix revealed signs of periappendicitis.

There are fairly homogeneous reports about the causative agent of cryptogenic peritonitis in the literature, indicating a diplococcal infection (pneumococcus) with a large percentage of sterile cultures. Only a thorough bacteriological study with inoculation of 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 vegetate in the intestine: bacteria of the Escherichia coli group, enterococci, clostridia, staphylococcus aureus. A feature of these microbes is their tendency to anaerobiosis. Moreover, in children from 1 to 4 years, coccal bacteria predominate: staphylococcus aureus, enterococcus, pneumococcus. Gram negative

Sticks, along with coccal flora, are isolated in children older than 4 years. In severe forms of peritonitis, pneumococcus, beta-hemolytic streptococcus, Escherichia coli with hemolytic activity are more often isolated.

Most authors believe that surgical intervention is advisable in cryptogenic peritonitis, mainly because of 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.

The most appropriate is the appointment of antibiotics of the aminoglycoside group, chloramphenicol, ampicillin.

Surgical intervention ends with the removal of exudate, appendectomy and the introduction 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 our 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 of science, morphological and experimental studies made it possible to establish that the genesis of many "spontaneous" perforations is intestinal wall ischemia - 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 perforations; 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 perforations of the intestine (with malformations of the intestine) lead to aseptic, adhesive peritonitis, postnatal - to diffuse fibrinous-purulent, fecal peritonitis. With necrotizing enterocolitis against the background of intensive therapy, the development of limited peritonitis is possible.

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, abscesses

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

We offer a working classification of peritonitis in newborns in the following form.

I. According to etiological and pathogenetic features. 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 the hollow organ,

b) malformations that cause mechanical obstruction of the stomach
dochno-intestinal tract;

1) with hematogenous, lymphogenous infection of the peritoneum;

2) in case of contact infection of the bojushina.
II. By the time of occurrence 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. By the nature of the effusion in the abdominal cavity:

1) fibroadhesive,

2) fibrinous-purulent,

3) fibrinous-purulent, fecal.

The clinic and diagnostics 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. Respiration is frequent, shallow, groaning, heart sounds are muffled, tachycardia. Sharp bloating, tension, pain on palpation. Peristalsis is not audible. Hepatic dullness is not defined. Vomiting mixed with bile and intestinal contents. Chair and gases do not escape. When x-rays in a vertical position, free air under the dome of the diaphragm is determined. Small compensatory possibilities quickly lead to severe disturbances of homeostasis and death of the child in 12-24 hours.

The clinical picture of diffuse nonperforative 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, expanded venous network, swelling of the external genital organs. Significant hepatosplenomegaly. X-ray shows hydroperitoneum.

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

The following malformations can be the causes of perforation of the gastrointestinal tract: 1) malformations that cause mechanical intestinal obstruction: a) with obstructive obstruction (atresia, meconium ileus, Hirsch. Prung disease); b) with the phenomena of strangulation (inversion of the intestines, 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).

Malformations that cause mechanical obstruction of the gastrointestinal tract in 50% of cases lead to intrauterine perforation of the intestine and adhesive peritonitis. By the time the baby is born, the perforation usually closes, and the meconium that escapes is calcified. There are two types of intrauterine peritonitis: 1) fibroadhesive (significant adhesive process 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 with malformations are always accompanied by fibrinous-purulent, fecal peritonitis.

It is difficult to make a diagnosis of intrauterine adhesive peritonitis before surgery. Moderate soreness and tension of the abdominal muscles against the background of symptoms of atresia of the small intestine and radiographically detectable calcifications in the free abdominal cavity help to suspect it. With cystic peritonitis, a cystic cavity in the free abdominal cavity is determined radiologically, often adjacent to the anterior wall. The walls of the cyst are thickened, calcified, a large level of fluid is determined 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, among complete well-being, on the 3rd-6th day of life it manifests itself as a picture of peritoneal shock. Clinically and radiographically, this group of patients has a large amount of free gas in the abdominal cavity, which leads to severe respiratory and cardiac disorders.

A feature of perforative peritonitis in necrotizing enterocolitis is a large area of intestinal damage and the severity of the adhesive-inflammatory process in the abdominal cavity. The pneumoperitoneum is moderate.

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

there is an increase in its size, the child's anxiety increases, especially with palpation of the abdomen. The tension of the muscles of the abdominal wall is revealed, the general condition worsens. Often these symptoms are difficult to catch, as they appear against the background of a severe, usually septic condition.

Limited peritonitis at the stage of infiltration is subject to conservative treatment, which in 38% of cases leads to the relief of the inflammatory process. We prefer the following antibiotics: a group of cephalosporins, oxacillin, gentamicin. Selective decontamination of the intestine is shown, and in the most severe cases - complete decontamination in the conditions of a gnotobiological isolator.

Selective decontamination is prescribed from the moment of enteral feeding with the introduction of 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 appointment of bifidum-bacterin 2.5-5 doses 3-4 times a day for 2-4 weeks under the control of fecal analysis for dysbacteriosis.In addition, along with replacement, stimulating therapy is recommended (antistaphylococcal drugs, anti-coliplasma) , drugs that stop 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) in acute intestinal infarction; 3) at the stage of preperforation with the ineffectiveness of intensive conservative therapy for 6-12 hours and an increase in clinical and radiological symptoms; 4) with abscessing of the infiltrate of the abdominal cavity.

Transrectal access is more commonly used. With diffuse peritonitis, the operation of choice is resection of the necrotic part of the intestine with the removal of a double intestinal stoma. After simultaneous washing of the abdominal cavity with solutions of antiseptics and antibiotics, the latter is sutured, leaving a catheter for the introduction of antiseptics (dioxidine). With a total lesion of the colon, we recommend the operation of switching off by imposing an unnatural anus on the terminal ileum (ileostomy).

In cases of abscessing of the infiltrate of the abdominal cavity, an abscessotomy is necessary. Through a small incision of the anterior abdominal wall, the abscess cavity is drained as sparingly as possible, without violating 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.

Operational 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 the separation of adhesions, resection of the atrezed part of the intestine, followed by the imposition of an anastomosis end-to-end or side-to-side. We use a single-row U-shaped silk serous-muscular suture.

With segmental defects of the colon, the operation of choice is the allocation of a perforation zone on the abdominal wall in the form of a colostomy. Perforations of the stomach 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 the probing technique, 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 was penetrating into the abdominal cavity, localized on the anterior wall in the area of the transitional fold of the peritoneum, 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. A typical clinic of diffuse peritonitis develops very quickly.

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

Nonperforative peritonitis. Nonperforative or septic peritonitis develops in newborns with 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, develops more often hematogenously and lymphogenously.

In the postnatal period, peritonitis occurs during the contact transition of a purulent infection from the umbilical vessels or from the retroperitoneal space.

Nonperforative postnatal peritonitis is limited in about 50% of cases.

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

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

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

X-ray reveals hydroperitoneum, intestinal paresis; intestinal walls are not thickened. Thickening of the anterior abdominal wall. In the case of an infiltrate, a blackout appears in the abdominal cavity, pushing the intestinal loops back.

Therapeutic tactics for non-perforative peritonitis initially consists of conservative antibiotic and infusion therapy to stop both the primary focus of infection and incipient peritonitis. With no effect in within 6-12 hours and an increase in clinical and radiological symptoms, surgery is recommended. At the same time, the abdominal cavity is washed with solutions of antiseptics and antibiotics with mandatory drainage of the focus of purulent infection.

N. S. Tokarenko (1981) suggests laparocentesis with abdominal catheterization and fractional lavage 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 is this disease - 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 treated in time, then serious complications and death can follow.

The article will focus on peritonitis. What is this disease, 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 the internal organs or in the abdominal cavity;
umbilical sepsis;
infections;
breaks in the abdominal cavity;
injuries and wounds in the abdomen;
the presence of meconium in the peritoneum.

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

It goes through the following stages:

Reactive period. Continues for about a day.
The toxic stage is 72 hours long.
The terminal stage, there are obvious signs of the disease, the temperature is high.

Each stage has its own signs and symptoms, the sooner the disease is detected, the more likely it is to avoid complications.

Classification

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

On distribution of peritonitis, allocate: local; spilled; general.
According to the localization 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. Neonatal peritonitis occurs due to perforation of the gastrointestinal tract wall or with the development of malformations in the intestine. Combined peritonitis - when pus and fluid accumulate directly in the peritoneum.

Symptoms

The main symptoms of peritonitis in children if it is provoked by appendicitis, trauma 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 the rapid development of the disease. The following signs are observed:

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

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

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

Adults should definitely pay attention to the following alarming symptoms, and seek medical help immediately. 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 is rapidly deteriorating;
disruption of the intestines;
painful and frequent urination;
loss of appetite;
strongly tense abdominal muscles.

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

eyes are constantly watering and shining;
the skin becomes gray;
no bowel movements for several days;
rapid pulse;
severe throbbing pain in the abdomen.

Diagnostics

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

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

Treatment

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

Inject antibiotics into a vein.
Give the child antipyretic drugs.
Medicines are prescribed for intoxication and to improve blood circulation.
They are on a strict diet.

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

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

Complications

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

adhesive diseases;
sepsis;
violation of the kidneys;
malfunctions of the digestive tract.

In this case, complications may not occur immediately, but several years after primary peritonitis in children. In pediatric surgery, this is a fairly common occurrence.

Rehabilitation and prevention

You can prevent this serious disease, the main thing is to adhere to a healthy lifestyle, which includes:

proper nutrition;
compliance with sleep and wakefulness;
compliance with the rules of personal hygiene;

There are also two important rules to remember:

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

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

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

Abscessing

Why does peritonitis occur?

Diagnostics

Rehabilitation and prevention

Symptoms

Diagnostics

Complications

Prevention

Reasons for the development of the disease

Classification

Diagnostics

Complications

Rehabilitation and prevention

Summing up

Reasons for the development of the disease

Classification

Symptoms

Diagnostics

Treatment

Complications

Rehabilitation and prevention

Forecast

Summing up