Secondary peritonitis in children, their characteristics and diagnosis. Peritonitis in children

Peritonitis is an inflammatory process of the mucous membrane abdominal cavity. In most cases he acts secondary disease, occurs against the background of other internal inflammatory processes.

Peritonitis in adults and children has distinctive features. Firstly, this concerns the etiology of the disease, in children the number of causes is much shorter, in most cases peritonitis is observed after acute appendicitis. Secondly, the process of diagnosis and treatment in children is a little more complicated, especially for young children who cannot articulate symptoms. How to recognize peritonitis in time, and what treatment methods should be used?

General characteristics of peritonitis in children

In children it is considered not a very common condition; the percentage of patients does not exceed 2%. The most dangerous disease is between the ages of 0 and 3 years. After 5 years, children are no longer considered to be at particular risk; the shape of their abdominal cavity allows them to quickly eliminate the symptoms of the disease and stop the process.

Inflammation of the peritoneum at a young age develops quite quickly. The cavity is small in size and the internal organs function clearly, so the inflammatory process can cover its cavity or develop locally.

The nature of the disease is influenced by the following indicators:

Primary disease and its form;
Child's age;
General health and immune defense.

The prognosis of peritonitis in children is also different. If the diagnosis is correctly determined in time and specialized therapy is carried out, the child can quickly return to normal life. Absence specialized assistance can lead to the most adverse consequences, including death.

What can cause peritonitis?

The key reasons for the development of peritonitis in children are internal pathological processes. Experts place acute in first place. This inflammation of the cecum, which requires urgent removal, in children can penetrate into especially severe forms. Peritonitis in such cases occurs as a complication.

Among others possible reasons The following pathological conditions include:

Intra-abdominal bleeding (can be caused by many disorders);
Tears and large cracks in the peritoneum;
Acute intestinal obstruction;
Extensive helminthic infestations;
Injury to the abdominal cavity, violation of the integrity of internal organs;
Sepsis caused internal inflammation navel;
Diplococcal infectious disease;
Complications after surgery;
Meconium in the peritoneum.

To eliminate the disease it is necessary A complex approach, treatment is prescribed to eliminate primary disease and peritonitis.

How to recognize a disease in a child?

The main danger of peritonitis is in childhood when the symptoms are vague and the child cannot yet determine the nature of the pain.

With peritonitis, the child’s condition sharply worsens, he becomes capricious, cries, and refuses to eat. This happens as a result acute pain caused by an inflammatory process.

Then other symptoms develop:

The pain is localized in the right side, intensifies with movement, and has a sharp, stabbing character;
Nausea with frequent attacks vomiting, after which the patient does not feel better, first the contents of the stomach come out, then bile and parts of feces appear;
Extensive diarrhea, stool has a liquid, foamy consistency;
with frequent release of gases;
Heaviness in the intestines caused by impaired peristalsis;
The smallest children become in the form of a fetus with bent knees, so the pain subsides a little;
Heart rate increases;
Body temperature rises to 38 or more;
The skin becomes dry, pale, and looks like marble;
The mouth feels dry;
Blood pressure decreases.

The disease progresses very actively, and the symptoms only intensify. At an advanced stage of peritonitis, the child’s central nervous system is affected, so loss of consciousness, dysfunction of some organs, and even coma may occur.

How to diagnose peritonitis in children?

The specialist examines the child very carefully, listens to all complaints from the child or parents, and palpates the abdomen. With peritonitis, the pain intensifies when pressed.

Also mandatory procedures are measuring body temperature, blood pressure and pulse.

To confirm the diagnosis, the doctor must observe the child’s condition for several hours; with peritonitis, the condition worsens.

You should undergo a number of laboratory tests:

General and biochemical analysis blood and culture;
General urine analysis and culture.

It is impossible to confirm the diagnosis without a number of instrumental studies:

CT and MRI;
Ultrasound;
Electrocardiogram;
Laparoscopy;
Radiography.

After the complex diagnostic procedures urgent specialized treatment is prescribed.

Treatment

Peritonitis requires drastic measures treatment, urgent surgical intervention. But before this it is necessary to go through a number of preparatory procedures.

To begin with, it is carried out medicinal preparation, including the following procedures:

Full antibacterial therapy to destroy infection;
General anesthesia;
Acceptance of funds for withdrawal;
Symptomatic treatment.

This is followed by surgery, the source of peritonitis is eliminated, and the abdominal cavity is antiseptic treatment. After surgery, a drain is placed for postoperative treatment. Full treatment course lasts at least 7 days. All this time the child must remain in the hospital under strict supervision.

Experts say that self-medication in case of peritonitis can be dangerous for the child’s life. Warming up, folk remedies, washing and others unconventional methods They have no effect, they only provoke inflammation. Therefore, peritonitis should be eliminated only by specialists in a hospital setting and as soon as possible.

After surgery, you should also not deviate from the prescribed therapy and rehabilitation. Otherwise, complications may arise in the form of an abscess and other processes that are dangerous to the health and even the life of the child.

Peritonitis in children is an acute inflammation of the abdominal cavity, which poses a danger to the child’s health and can lead to fatal outcome. As a rule, it develops against the background of another inflammatory process, abdominal injuries, infectious lesion or violation of the integrity of internal organs, etc. Manifests sharp deterioration well-being, signs of intoxication and other negative symptoms. Used as a treatment drug therapy And surgical intervention.

Causes of peritonitis in a child

In childhood, the development of secondary and primary forms of peritonitis is possible. The first type is much more common and may be due to the following factors:

Availability .
Acute inflammation peritoneum, provoked by various pathological processes in organism.
Exacerbation of appendicitis - appendicular peritonitis.
Umbilical sepsis.
Hit pathogenic organisms or food particles into the abdominal cavity.

The primary form is diagnosed quite rarely and can be caused by blunt or acute injury abdomen, ruptures of internal organs, intestinal obstruction, hemorrhage into the abdominal cavity. The cause of the pathology may be the entry of meconium (feces of newborns) into the peritoneum of the baby, as well as a diplococcal infection.

Peritonitis develops gradually. First of all, the child’s well-being worsens, he experiences weakness, lack of appetite and sleep disturbances. Getting worse psycho-emotional state, the baby becomes capricious, restless and irritable. He often cries and refuses games and other entertainment.

Symptoms of general intoxication are observed: increased body temperature to 38-38.5⁰C, nausea and vomiting. Worried dyspeptic disorders: diarrhea or diarrhea, abdominal pain that is not clearly localized, and excessive tension of the peritoneum. Skin acquire a grayish tint. The outcome of the disease depends on how quickly and efficiently medical care is provided.

There are several forms of peritonitis:

Diplococcal develops in children school age, predominantly female. Pathogenic (pneumococcal) microorganisms enter the abdominal cavity through the female genital organs due to reduced vaginal immunity. The disease manifests itself very acutely: a sharp and significant increase in body temperature, severe diarrhea, abdominal pain and abscess development.

Tuberculous peritonitis develops against the background of tuberculosis and is manifested by stool disturbances, weakness and exhaustion, painful sensations in the abdominal cavity, with an increase in temperature to febrile levels.

Exudative peritonitis is characterized by the accumulation of serous fluid. The disease is accompanied by an enlarged abdomen, skin tension, problems with blood circulation and the development of respiratory failure.

When warning signs you should contact a surgeon. The doctor will conduct visual inspection and palpation of the abdomen. To confirm the diagnosis, they are prescribed laboratory tests(OAC and OAM), radiographic examination and ultrasound of the abdominal organs. If the diagnosis of “peritonitis” is confirmed, the child is immediately hospitalized and receives qualified medical care in a hospital setting.

Used for the treatment of peritonitis in children surgery– laparotomy. An incision is made in the abdominal cavity and the condition of the peritoneum is examined, the cause of the pathology is eliminated, and the cavity is sanitized with an antiseptic or antibacterial solution. A drainage is inserted into the incision, through which the peritoneum is washed and exudate is pumped out.

To maintain well-being, alleviate the child’s condition and prevent relapse after surgery, medications are prescribed:

Intravenous antibiotics wide range actions.
The use of antipyretic drugs (Nurofen, Panadol, Paracetamol). The form and dosage depends on the age and weight of the small patient.
Carrying out infusion therapy.
The use of drugs that normalize blood circulation and have a detoxifying effect.

Timely delivery qualified assistance and following all the doctor’s instructions during the postoperative period will avoid complications and speed up recovery.

Peritonitis in any shape or form is extremely dangerous for a child, therefore, when the first symptoms of the disease appear, you should immediately seek help from a doctor and undergo necessary examination. For get well soon and to prevent relapse of the disease, you should strictly follow all the specialist’s recommendations, adhere to a diet and undergo rehabilitation.

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

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

Children's appendiceal peritonitis has two main types.

Free

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

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

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

Abscessing

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

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

Severe consequences of the second type are sometimes inevitable.

Why does peritonitis occur?

Causes of this disease the child has a variety, the list is as follows:

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

Stages of appendiceal peritonitis:

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

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

Symptoms

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

What symptoms should adults respond to:

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

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

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

Late stages are characterized by the following symptoms:

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

Diagnostics

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

Inpatient diagnostics include:

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

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

Treatment

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

Operation

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

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

Drugs

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

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

Rehabilitation and prevention

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

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

Peritonitis is a dangerous disease. It is absolutely unacceptable to self-medicate and delay calling an ambulance. Important, don't miss it initial stage and promptly apply for medical care. Sometimes, this is the only way to save a child’s life.

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

Peritonitis is an inflammation of the peritoneum. The peritoneum is not the source of the primary purulent infection. It is directly related to all organs of the abdominal cavity and is affected secondarily, i.e. through these organs. Therefore, peritonitis is diverse due to its occurrence (primary, secondary, post-traumatic, postoperative, etc.) Peritonitis is one of the severe purulent diseases in children, it is also accompanied by mortality and many complications.
Anatomy and physiology. All organs of the abdominal cavity are covered by the peritoneum: some are partially (pancreas, duodenum, bladder and etc.); others - completely. This creates duplications, folds, and pockets of various sizes. There are visceral and parietal (parietal) layers of the peritoneum. Anatomically we're talking about not about a cavity as a current one, but about a narrow space between organs, creating conditions of capillarity. Transverse colon and mesentery divide the abdominal cavity into 2 floors. The upper floor contains the stomach, liver, and spleen; in the lower - intestines and pelvic organs. The floors are connected by lateral channels, through which exudate can spread in both directions. The greater omentum, which consists of four layers of peritoneum, is of exceptional importance in delimiting purulent process. The peritoneum has a rich network of blood vessels and lymphatic vessels, through which outflow occurs into the inferior and superior vena cava. This explains the possibility of infection spreading from the peritoneum to the pleura and vice versa. The parietal layer of the peritoneum is innervated by the sacral plexus, lumbar intercostal nerves and phrenic nerves. Visceral leaf - vegetative nervous system. The parietal leaf reacts with pain to any irritant, the visceral leaf is almost insensitive to pain. Great importance for clinicians, it has a reflex interaction between the sensory nerves of the parietal peritoneum and the muscles of the anterior abdominal wall.

The peritoneum is characteristic high ability to exudation and resorption. Exudation is the reaction of the peritoneum to any irritant. The exudate released in response to a microbial irritant is higher in bactericidal activity than blood. A massive bacterial invasion is required for peritonitis to develop. Resorption occurs osmotically and diffusely directly into the bloodstream (water and water-soluble substances) or by resorption from the mesothelium into the interlymphatic spaces (colloids, bacteria, etc.). On early stages inflammation of the peritoneum, increased resorption is observed; venous stasis, paralysis of the intestines sharply impede it. In addition to the production of exudate, to protective function peritoneum refers to the plastic ability of the peritoneum. Thanks to it, the inflammatory focus is demarcated (fibrin falls out, adhesions and adhesions form).

Morphology. At the site of contact with infection, hyperemia of the peritoneum is first observed, then serous exudate appears, then it becomes cloudy due to the influx of leukocytes and fibrin, and becomes purulent. Changes begin in the visceral layer of the peritoneum. The smooth, shiny surface of the peritoneum becomes matte, rough, and fine-grained. Then fibrinous deposits appear, which are extensive in places where pus accumulates. The inflammatory exudate contains bacteria, cellular elements, leukocytes, fibrin, a lot of protein, intestinal contents. Based on the nature of the pus, one can assume the type of pathogen. If anaerobic infection causes inflammation, the pus acquires a fetid odor of decaying tissue, coli will give pus from brown tint and the smell of feces, coccal flora - liquid exudate with fibrin. The exudate may contain an admixture of air, blood, pancreatic enzymes, etc. The intestinal wall is swollen and thinned from the contents. The nature morphological changes one can judge the severity of peritonitis and the prognosis of the disease.

The greater omentum takes part in inflammation, limiting the process. Enclosed ulcers form and drain onto the skin. They may be emptied into the intestinal lumen or abdominal cavity. With massive infection and other reasons, delineation does not occur and the movement of pus occurs along the right and left lateral canals, along the subphrenic fissure, between the intestinal loops. General peritonitis are rare. In pathoanatomical and clinical terms they do not have the same meaning, since peristalsis may be absent in diffuse peritonitis.

Pathophysiology and pathogenesis.
Purulent peritonitis - serious disease with profound impairments important functions. The disease is especially severe in infants and young children.
Intoxication, circulation disorder, dehydration. Peritoneal surface in young children age group equal to skin performance. Therefore, microbial toxins and cell breakdown products are absorbed into the blood and lymph through a huge surface. Mobilization of vasoactive substances occurs: adrenaline, norepinephrine, glucocorticoids, histamine, kinins. They cause expansion of capillaries and increase the permeability of their walls. Exudation of fluid and protein into the abdominal cavity increases. There is also a loss of fluid in the intestines with vomiting and perspiration. Vasodilation in the periphery and loss of fluid from the bloodstream lead to hypovolemia of the microcirculation. Amount of blood in internal organs increases (centralization of blood circulation). Resorption is impaired and this further aggravates hypovolemia. This is followed by hemoconcentration and metabolic disorders.

Purulent peritonitis is accompanied by an increase in body temperature to 39-40 "due to an imbalance between heat production and heat transfer, a disorder of interstitial metabolism. An increase in temperature by 1° causes an increase in basal metabolism by 13%. Children of the younger age group are especially affected. They experience depletion of energy reserves, the brain, adrenal glands and other organs suffer.Mainly liver glycogen is used, and subsequently proteins and fats, the breakdown of which under hypoxic conditions leads to the accumulation of milk and pyruvic acids, keto acids. Metabolic acidosis occurs. At first, acidosis is compensated by breathing and the kidneys, then intestinal paresis occurs, abdominal pain limits respiratory excursions and acidosis passes into the stage of decompensation.

Violation mineral metabolism. In parallel with fluid loss, there is also a loss of electrolytes (potassium, sodium, chlorine). There is a decrease in potassium in the cell and an increase in sodium (transmineralization). Potassium depletion of cells leads to decreased muscle tone and paralysis smooth muscle, progressive paresis of the gastrointestinal tract.
Thus, the pathogenesis of peritonitis is based on intoxication, hypovolemia, abdominal pain, hyperthermia, violation electrolyte balance, dehydration, intestinal paresis and other disorders that should be taken into account when carrying out preoperative preparation and subsequent treatment.

Clinical picture.
The main symptoms of peritonitis:
1) abdominal pain;
2) protective tension of the abdominal muscles;
3) Shchetkin-Blumberg symptom;
4) paralytic ileus intestines.
Constant abdominal pain- most early sign peritonitis. Its initial location corresponds to the source of infection. With the appearance of effusion, the pain spreads and covers the entire abdomen. An important symptom is considered to be muscle protection, which depends on the nature of the effusion and occurs constantly, just like the Shchetkin-Blumberg symptom. Intestinal motility fades slowly with the development of peritonitis. Muscle deflation is replaced by bloating with the onset of general peritonitis. Secondary symptoms are vomiting and hyperthermia. tachycardia, sometimes collapse. The skin color is pale, the facial expression is pained, the tongue is dry and coated.

Preoperative preparation includes all elements of program 2, with the following additions:
- oxygen therapy through a face mask with constant positive pressure V respiratory tract with transfer to mechanical ventilation;
- at arterial hypotension (systolic pressure reduced by 10-15% from age norm) intravenously 20 ml/kg 0.9% sodium chloride solution for 20-30 minutes; with persistent hypotension, 5-10 ml of fresh frozen plasma at a rate of up to 0.5 ml/kg-min against the background of dopamine titration 3-5 µg/kg-min;
- after stabilization of blood circulation, catheterization of internal jugular vein followed by monitoring of central venous pressure (optimal level 3-5 cm
- angioprotection: dicinone 0.1 ml/kg, contrical 500-1000 units/kg, prednisolone 5 mg/kg or hydrocortisone for intravenous administration 15-25 mg/kg intravenously.

The criteria for the adequacy of training are the same as in program 2, with an emphasis on hemodynamic stability and adequacy of gas exchange.

Surgical treatment
Local and general treatment peritonitis. Target local treatment- elimination of the source of infection and sanitation of the abdominal cavity, and in general - the fight against infection and intoxication, restoration of impaired functions of organs and systems. During laparotomy, the source of peritonitis is found and eliminated ( appendectomy, cholecystectomy, wall suturing hollow organ etc.), and if it is absent, then remove the pus from all parts of the abdominal cavity and thoroughly rinse with Ringer's solution (8-10 liters of solution). Lavage is a generally accepted method of local treatment of peritonitis, based on mechanical removal billions of microbial bodies, cell decay products, fibrin and other elements of the purulent process. While with local and diffuse peritonitis Sometimes a one-time rinse is enough; in general, lavage is planned after 1 day, 2 days, etc. from the beginning of the first wash until the complete elimination of the inflammatory process. Drainage of the abdominal cavity is carried out in exceptional cases when the source of infection cannot be removed. The best drainage is a perforated tube, through which constant rinsing is carried out after the operation for 2-4 days. IN last years high efficiency showed laparoscopic surgery and sanitation of the abdominal cavity. Minor trauma to the abdominal wall, prevention of intestinal adhesions with postoperative scar make this method attractive for pediatric surgeons. To combat intestinal paresis, antegrade and retrograde intubation is performed with removal of contents, and in severe cases, an ileostomy or cecostomy is applied.
General treatment after surgery is a continuation of preoperative preparation with the same tasks and monitoring.