MINISTRY OF HEALTH OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
"CONFIRM"
Vice Rector of TMA
Professor Teshaev O.R.
_______________________
«27» August, 2015
Department: FACULTY AND HOSPITAL SURGERY
Subject: faculty surgery
ТECNOLOGY OF TEACHING
On practical lesson on the topic:
«PERITONITIS»
Tashkent-2015
Done by:
Professor Khakimov M.Sh.
Docent Berkinov U.B.
Assistant Muminov R.T.
Education technology approved:
By surgical meeting of the department by protocol №1, on «27» August, 2015
Theme: Peritonitis
1. Tuition technology model at practical lessons
Period – 6 hors.
Number of students: 8-10
Practical classes at polyclinics and the brain attack
Form of the lesson
seminar
The lesson is conducted in class room and hospital
Place
Structure of the lesson 1. Introduction
2. Practical part
- curation of patients
- implementation of practical skills
- discussion of the practical part
3. Theoretic part
- discussion of the theoretic part
4. Estimation
- self appraisal and mutual appraisal
- appraisal by the teacher
5. Conclusion made by the teacher. Appreciation of
knowledge. Giving a list of questions for the next theme
(see by rotation)
The aim of the lesson: Teach students methods of screening, diagnosis,
differential diagnosis, choosing treatment options for patients supervised by
example, to analyze the etiology, pathogenesis, clinical course and the general
principles of treatment of peritonitis, after operation .
The purpose of the
The results of studies
teacher:
A student must know:
- systematize,
1. Definition, frequency, etiopathogenesis, clinical
consolidate and extend
features, diagnosis and treatment of peritonitis.
the knowledge on the
2. Principles of conservative treatment of peritonitis.
theme;
3. To teach the diagnosis of peritonitis, before
- acquire skills in
operation preparation.
systematization,
4. Indications for surgical treatment of peritonitis.
comparison,
A student must be able to:
summerising, analysis
Perform practical
skills
- to
acquire some
of information;
practical skills in the examination of patients with
- get experienced in
peritonitis, to perform specialtechniques examination of
conjoint activity in the
these
patients to
determine indications
and
team, communicative
contraindications for operation.
skills.
Method of practical tasks, conjoint tuition, technique
Methods and
brain attack,graphic organizer – fish skeleton, testing.
technique of tuition
Methodic recommendations, moulages, slides,
Theaching facilities
videofilms
Individual work with patients, moulages, conjoint
Forms of tuition
activity in groups, presentations.
Place for tuition
Monitoring and
estimation
Consulting-room of surgeon, class-room, moulages,
instruments, standard steps in implementation of
practical skills.
Oral control: questions for control, solving the given
tasks in groups; written control: testing.
2. Motivation
Instilling students with the need for timely development of adequatу
operations before to severe complications, and in their development - meeting the
most informative and modern methods of diagnosis, surgical treatment,
meeting with potential complications of surgery and operating out of a period of,
prevention. Development of clinical thinking of students. The development of the
modern view of the problem issues from the perspective of world
medicine and general practice doctor.
3. Intra and interdisciplinary communication
Teaching this topic is based on the knowledge bases of students of
anatomy, normal and pathological physiology of circulation. Acquired during the
course knowledge will be used during the passage of gastroenterology, internal
medicine and other clinical disciplines.
4. Contents of classes
4.1. The theoretical part
ACUTE PERITONITIS
Anatomic - physiological characteristics of the peritoneum.
The peritoneum is a thin serous membrane covering the inner surface of the
abdominal wall and positioned in the abdominal viscera. Isolated parietal
peritoneum (90-130 microns thick) covering the inner surface of the abdominal
wall, and visceral (thickness 45-70 mm), covering most of the internal organs. The
total surface of the peritoneum is about 2 meters. The peritoneal cavity is closed in
men, women communicates with the external environment through the openings of
the fallopian tubes. In abdominal cavity is under normal conditions a small amount
of transparent serous fluid surface moistening facilitates the viscera and peristalsis
of the stomach and intestines.
Peritoneum is a connective tissue layer, covered with polygonal mesothelium,
abundantly supplied with blood and lymph vessels, nerves. Rich vascularization
peritoneal leaf determines its ability to suction fluid in the abdominal cavity and
extravasation (inflammatory processes). The most active has the ability to suction
fluid diaphragmatic peritoneum, to a lesser extent pelvic. This feature of the
diaphragmatic peritoneum, coupled with an extensive network of lymphatic vessels
connecting the proximal peritoneal leaf and basal pleural, determine the possibility
of moving the inflammatory process of the upper abdomen in the pleural cavity.
Parietal peritoneum is innervated sensitive somatic nerves (branches of the
intercostal nerves). Consequently, parietal peritoneum sensitive to any kind of
impact (mechanical, chemical, et al.), And wherein the pain arising clearly
localized (somatic pain). Visceral peritoneum is the autonomic innervation
(parasympathetic and sympathetic) and has somatic innervation. In this regard,
pain arising from stimulation visceral peritoneum are diffuse in nature, not
localized (visceral pain). Pelvic peritoneum has no somatic innervation.
This feature explains the absence of the protective muscle tension anterior
abdominal wall (vistseromotornogo reflex) in inflammatory changes in the pelvic
peritoneum. The peritoneum has pronounced plastic properties. In the next few
hours after application of mechanical or chemical injury to the peritoneal surface
falls fibrin, which results in bonding the contacting serosal surfaces, and
delimitation of the inflammatory process. Peritoneum and produced its liquid and
have antimicrobial properties.
ACUTE PERITONITIS
Revelance. Acute peritonitis - inflammation of the visceral and parietal
peritoneum, which is accompanied by severe general symptoms of the disease
organism within a short time leads to serious and often irreversible damage to vital
organs and systems. This is one of the severe complications of various diseases and
injuries of the abdominal cavity. Peritoneal injuries are of two types - open and
closed. Open injuries (penetrating injuries) of the abdomen, usually combined with
a wound to the internal organs, necessitating emergency surgery (laparotomy and
inspection of the abdominal cavity). Clinic open lesions depends on the nature of
the trauma of internal organs. With closed abdominal trauma may be damaged
peritoneum, which are often combined with injuries to internal organs. Depending
on the nature of the damage in the first place are the symptoms of internal
bleeding, peritonitis and others. In addition to microbial peritonitis caused by
penetration into the abdominal cavity of a species of bacteria isolated aseptic
(abacterial) peritonitis caused by hit in the abdomen uninfected different agents
with aggressive effect on the peritoneum: blood, urine, bile, pancreatic juice.
Despite advances in surgical technique, cardinal and antibiotic therapy, the
use of methods of anesthesia, the ability to correct the function of vital organs, the
problem of the treatment of purulent peritonitis attracts the attention of surgeons
around the world. The progressive development of suppurative process in a closed,
anatomically complex abdomen, the rapid development of intoxication, intestinal
and resulting severe hemodynamic and respiratory dramatically impaired
metabolism, extremely difficult for peritonitis. This is evidenced by the large
number of specific and non-specific events (12% to 48%) and a high mortality
(10% to 50%) (B.D.Savchuk, 1979; A.A. Shalimov, 1981; Popov V. 1985; V.M.
Brawlers, 1990; V.K. Gostishchev, 2002).
Taking into account the prevalence of the disease, tends to increase the
incidence of acute inflammatory diseases of the abdominal cavity, as well as an
increase in recent years, microbial resistance to antibiotics, we can understand how
important for clinical medicine is the problem.
Historical aspects. Inflammatory processes are known to the abdominal
cavity, it is obvious in the distant past. There is a reasonable position (Muller,
1892) that for three millennia BC doctors have a basic understanding of
manifestations of peritonitis and tried to treat it surgically. In the III century BC
Greek physician Erzostratus with accumulation of pus in the abdomen sought to
remove it through an incision in the groin area. In 100 AD Roman physician
Ozerapus Ephesus wrote: "Where can escape the pus from the abdomen, if there is
an outpouring of it between the peritoneum and intestines, is much easier to give
him a way out by making an incision in the groin."
In the middle of the III century, Ambroise Pare, speaking of "common
infected" by the clinic reminds septicopyemia, as one of the causes of this
condition is called inflammation of the abdominal viscera. In the eighteenth
century, another famous French surgeon Jean Louis Petit in the study of the
anatomy of the stomach called attention to the possibility of burrowing pus
between peritoneal organs. In Russia during the charlatanic medicine all
inflammatory diseases of the stomach are collectively called "gangrene" and
considered incurable.
The first reliable description of the clinic belongs peritonitis military doctor
Vasily Shabanov (1816), which described the development of a young soldier on
the ground of perforation peritonitis gastric ulcer and 12 duodenal ulcer. Much
later (1840), the Military Medical Journal published the work of G. Shaliya
intestine perforation, which describes the clinical picture of peritonitis. The manual
is on operative surgery, published in the same year, the academician Salomon
offers median laparotomy, different ways of intestinal sutures and suturing
technique the anterior abdominal wall.
In 1881, the Moscow surgeon L.I. Schmidt made the world's first successful
laparotomy at widespread purulent peritonitis caused by suppuration of the spleen
in malaria. Only 4 years later (1885) Trawee in England and in Germany Oberet
strongly in favor of surgical treatment of peritonitis. Thus, the operation of AI
Schmidt was the beginning of surgical treatment of peritonitis.
In the first quarter of the XX century, the majority opinion reputable surgeons
in principle agreed on one thing - the need to possibly early surgery. However, the
issues of drainage and lavage of the abdominal cavity debated particularly acute. If
the V.M. Zykov (1897), A. Gagman (1901) believed that the abdominal cavity
must be thoroughly washed, then S.P.Fedorov (1901) and J. Greco (1952) were
opposed to copious irrigation of the abdominal cavity, considering that in this case,
possibly of infection in remote pockets of the peritoneum. The introduction of the
30-ies in the clinical practice of sulfa drugs, which S.S. Yudin (1937) proposed the
use and intraperitoneally, improved treatment outcomes. This once again
confirmed during the Great Patriotic War, when surgeons met with the most severe
forms of purulent peritonitis, where mortality reached 38-50%.
War period contributed to the education of abdominal surgery, improve their
technical skills, gaining experience in the treatment of severe injuries
intraperitoneal organs, as well as the development of the principles of treatment of
complications of peritonitis: intestinal fistula, eventrations, residual and recurrent
ulcers infiltrates the abdomen.
The era of antibiotics (Flamming, I946; Yermolyeva, 1946), as well as an
appearance in the 50 years of broad spectrum antibiotics, allowing directed
antibacterial treatment of purulent peritonitis, which helped dramatically reduce
mortality in peritonitis (B.A. Petrov, 1951; H.G. Gafurov, 1957 et al.). However, in
recent decades, antibiotics, despite the increasing number of drugs and increase the
dosage gradually lost its effectiveness in relation to surgical infection and the
results of treatment of peritonitis worsened.
Thus, in recent years due to increasing microbial resistance to antibiotics has
worsened the prognosis of peritonitis, increased mortality. The difference in the
percentage of mortality in different authors due to the fact that there is still no
uniform classification of peritonitis, although the first attempts to create a
classification made back in 1886 A.D. Pavlovsky.
Сlassification of peritonitis. In recent years there has been a tendency to
concise classifications peritonitis. So, A.M. Karjakin (1968) divides peritonitis
only on local and spills, V.I. Pods et al (1967) highlights the local diffuse and
diffuse (general) peritonitis. K.S. Simonyan (1971) believes that the prevalence of
clinical peritonitis is not very important and highlights the classification in which
peritonitis considered from the point of view of hyperergic reactions, releasing
during peritonitis three stages - phases: reactive, toxic and terminal.
It is appropriate to recall the words of I.I. Grekov (1952), who wrote: "in
patients who have relatively small spread of pus, very often develop severe clinical
course of the disease, often fatal, despite all the measures of treatment." Indeed,
watching the many cases of peritonitis in clinical practice, it is easy to make sure
that the incidence of peritonitis, although it is an important predictor of, but not
always fully correlate the severity of patient's general condition and prognosis. The
severity of the inflammatory process, without a doubt, makes a different amount of
therapeutic measures, and does not allow in principle to give up or reduce the value
of the factor of stages during peritonitis.
For all these reasons, the most simple and convenient for clinical practice is
the classification of peritonitis given B.D. Savchuk (1979).
I. Localized peritonitis.
1. Limited - a cluster of fluid in one, sometimes two anatomical regions of the
abdominal cavity with a clear demarcation of suppurative process (Fig. 1). This
corresponds to the notion of an abscess.
2. Unlimited - this exudate accumulation in not more than two anatomical
regions of the abdominal cavity, but without a clear demarcation of the other
divisions.
II. Generalized peritonitis
1. Diffuse - this accumulation of fluid occupying at least two but not more
than five anatomical regions of the abdominal cavity.
2. Generalised peritonitis - a cluster of exudate, which occupies more than
five anatomical regions of the abdominal cavity, and often the entire abdominal
cavity.
By the nature of effusion peritonitis is divided into: serous, sero-purulent,
putrid, fibropurulent, hemorrhagic, ihorosis, anaerobic, urine, bile, pancreatic and
dry.
On the origin of peritonitis are distinguished:
Primary peritonitis - is extremely rare. We have the following ways of
infection:
• hematogenous;
• lymphogenous;
• cryptogenic;
• breakthrough (draining the abscess of the surrounding organs and tissues in
the free abdominal cavity);
secondary peritonitis:
• appendicular;
• cholecystopancreatic;
• ruptured (gastric ulcer (GU) and duodenal ulcer (DU), Crohn's disease, etc.);
• traumatic (with damage to the hollow organs of the abdominal cavity and no
damage);
• necrotic (in acute intestinal obstruction, with phlegmonous lesions of the
digestive tract, with purulent inflammation of the mesenteric lymph nodes,
with rare inflammation of the abdominal cavity;
• postoperative (surgery on the stomach, small and large intestine, bile ducts,
and other organs);
• gynecological (on the basis of inflammation tubes, ovaries, uterus, burst
pipes, perforation of the uterus, uterine trauma during childbirth and on the
basis of twisting of ovarian cysts, and tumors of the appendages).
In most cases, peritonitis is a polymicrobial disease, where a group of E. coli
retains the leading role. Recently, however, became increasingly important role to
play Proteus vulgaris and other opportunistic bacteria significantly increased the
role of anaerobes. Pneumococci and Koch's bacillus is rare.
In the clinical course of peritonitis are three stages of development of acute
peritonitis.
1. Reactive stage of peritonitis (first 24 hours, with perforated - 12 hours) the stage of maximum expression of local manifestations: a sharp pain, protective
muscle tension, vomiting, motor agitation, etc. Common symptoms: increased
heart rate to 120 beats, increased blood pressure, shortness of breath, etc., are
typical manifestations of a painful shock for more than intoxication.
2. Toxic stage of peritonitis (24-72 h, perforated - 24 h) - stage subsided
local manifestations and the prevalence of common reactions characteristic of
severe intoxication: pointy features, pallor, stiffness, euphoria, pulse 120 beats,
blood pressure reduction, late vomiting, hectic nature temperature, a significant
shift suppurative toxic blood formula. Of the local manifestations of the toxic stage
is characterized by reduction of pain, stress shielding of the abdomen, flatulence
rising.
3. Terminal stage (more than 72 hours, with perforated - more than 24 hours)
- the stage of deep intoxication on the verge of reversibility: Hippocratic face,
weakness, prostration, often intoxication delirium, significant respiratory distress
and cardiovascular activity, profuse vomiting of fecal odor, temperature drop on
the background sharp purulent-toxic changes in blood composition, sometimes
bacteremia. From local manifestations characterized by a complete absence of
peristalsis, significant bloating, pain spilled around the abdomen.
Etiology and pathogenesis of peritonitis
Acute peritonitis - inflammation of the visceral and parietal peritoneum,
which is accompanied by severe general symptoms of the disease organism within
a short time leads to serious and often irreversible damage to vital organs and
systems. In most cases, purulent peritonitis develops secondary, as a complication
of suppurative disease of any organ in the abdomen. The main sources of infection
of the abdominal cavity are the appendix (30-65%), gallbladder (10-12%), female
sex organs (12.3%) and intestine (3-5%). Less common causes are: traumatic
injury (to 2.7%), pancreas (1.0%), and postoperative peritonitis (1.0%).
The most common etiologic factor causing peritonitis, a microbial factor
(infectious peritonitis); chemical and physical factors play in the development of
peritonitis lesser role (aseptic). In the subsequent accession aseptic peritonitis
infection becomes infectious (purulent). However, in some cases, the primary
cause of peritonitis cannot be established even after autopsy. This is called
peritonitis cryptogenic. The main cause of peritonitis is the penetration into the
abdominal cavity of pathogenic organisms, however, there is much evidence of the
fact that the presence of microflora in the abdomen does not determine the
occurrence of peritonitis.
According A.A.Zaporozhets (1968) and K.S.Simonyan (1971), crops from the
abdominal cavity, where the operation was performed under aseptic conditions,
and the seam is absolutely tight, often reveals the growth of a particular microflora.
At the same time, the postoperative period in these patients completely proceeded
smoothly. These facts indicate that the presence of bacteria in the peritoneal cavity
is not sufficient for the development of peritonitis, as in these cases, the body's
defenses are sufficient-governmental, in order to suppress the action of aggressive
start.
On this basis, it would be natural to assume that an increase in the forces of
aggression (dose of microbes), should lead to the development of peritonitis. The
experimental study and analysis of clinical material (K.S. Simonyan, 1971; B.D.
Savchuk, 1979 et al.) showed that the previous point in the event of acute
peritonitis is the presence of a destructive process in the body. Experimental
confirmation of this got N.M. Baklykova et al. (1976), which was introduced into
the abdominal cavity of fecal slurry and further causes destruction (necrosis) of
soft tissues of hind legs (the introduction of a 10% solution of calcium chloride) to
give the dog a clinical picture of peritonitis. Consequently, the presence of acute
destructive process in the body can be considered as preface of peritonitis.
Variety of etiological factors causing peritonitis (acute destructive
inflammation of the abdominal cavity), the set of agent types, as well as the variety
of clinical manifestations show poly etiology of this disease.
Catecholamines, histamine, corticoids, standing under the influence of
endotoxins can cause serious damage to parenchymal organs, deep hemodynamic
disorders, significant violations of protein, water-salt metabolism and acid-base
balance (hypoproteinemia, hypovolemia, hypoalbuminemia, hypokalemia,
hyponatremia, hypocalcemia and metabolic acidosis) .
As a result of destructive changes in the neuromuscular system of the
gastrointestinal tract that occur as a result of humoral or neural inhibitory
influences, as well as due to the disturbance of microcirculation in the intestinal
wall in the midst of inflammation develop atony and paralysis of the bowel. At the
onset of the disease occurs enteroplegia which is accompanied by stretching in the
width of the intestinal loops, which leads to irritation of the intestinal wall
mechanoreceptors. In response to this, even more inhibited motor activity of the
digestive system, i.e. developing entero-enteral inhibitory reflex (A.A. Shalimov et
al., 1981). Paralysis of the digestive system leads to stagnation of food located
therein masses, and then blocked for fermentation, which increases the toxicity of
the organism. Proportionally with progressively increasing the formation of gases
increases intra-abdominal pressure that every hour of the disease increases the
blood circulation in the abdominal cavity.
Thus, a number of pathological changes occurring in complex, which with the
growth of the inflammatory process supplemented by additional irritating factors
lead to the development of a vicious circle as throughout the body, and at the level
of the function-national activity of the digestive system.
In this regard, Yu.M. Halperin (1975), the cause of death in patients with
acute peritonitis said no paralysis of the intestine, and enterergia under which
implies an acute failure of all functions of the small intestine: propulsion, secretory
and absorptive.
An important role in acute peritonitis belongs to violations gistohematical
permeability, tissue respiration, endocrine system, redox processes, function of cell
membranes, as well as the liver and kidneys. There comes a decrease of
immunobiological activity of the organism, inhibition of phagocytic activity,
broken and anti- clotting system of the blood in the direction of a hypercoagulable.
The clinical picture of peritonitis
From a clinical point of view manifestations of peritonitis conventionally
divided into general and local. The most typical early symptoms are:
- The general plight of the patient,
- Forced position of the patient,
- Pained expression on the sharp features (Hippocratic face)
- Icteric staining of the skin and sclera, which indicates severe intoxication,
- Abdominal pain (by its nature, it may be somatic and visceral, somatic pain
have precise localization and permanent nature, accompanied by tension of the
abdominal muscles and visceral pain appear as colic with typical irradiation and do
not have a specific location)
- Nausea, vomiting; early in the disease, it is a reflex nature, with the spread
of the inflammatory process at the abdomen, it is determined paralytic condition of
the digestive system,
- Delay chair and gases (depending on the severity of paresis), less frequent
stools,
- Tachycardia (120-150 beats. Min) reflex origin (sometimes bradycardia perforation of gastric ulcer and 12 duodenal ulcer - up to 60 beats. Min)
- Shortness of breath, which is related not only to the restriction of respiratory
excursions of the diaphragm, and with incipient or already developing pneumonia,
especially of the lower lobes of the lungs,
- Dry tongue as a "brush"
- Increase in body temperature to 38-40 ° C, although the temperature of the
terminal stage of the disease can be reduced,
- Stomach is retracted, in the later stages swollen due to paresis, passively or
not at all involved in the act of breathing, tense or sharply tense.
Positive symptom of Shchetkin-Blumberg suggests involvement in the
inflammatory process of the parietal peritoneum. The disappearance of hepatic
dullness to percussion indicates the presence of abdominal effusion or free gas.
Absence of bowel sounds on auscultation suggests bowel paralysis.
Soreness pelvic peritoneum, and protrusion of one of the walls of the rectum
during rectal examination, indicate the presence of fluid in the small pelvis or
infiltration.
Hemodynamic disturbances play an important role in the clinic purulent
peritonitis, moreover, cardiovascular and respiratory disorders are the leading
cause of deaths in the spread of inflammation of the peritoneum. Hemodynamic
disturbances are considered to be the result of direct effects of endotoxin on the
myocardium, and respiratory failure is attributable largely to the direct effect of the
toxin on the lung vasculature, considering the primary component of pulmonary
hemodynamics in violation.
Based on this, the first cause of hemodynamic disorders is a massive diffusion
of fluid from the vascular bed into the free peritoneal cavity and internal organs, as
well as because of this, the extraction fluid in the bloodstream of the intermediate
spaces. In this situation, the abdominal cavity can move up to 50% of the
extracellular body fluid that is 6-10 l. In the past, such a shift of fluid called
sequestration, as it is excluded from the circulation.
Most of the sequestered fluid is drawn into the end of the fluid with which it
occurs and losses, including electrolytes, proteins, active enzymes, etc. A smaller
portion of the liquid in the form of pathological secretion penetrates the intestinal
lumen where incorporates numerous components intracolonic disturbed
metabolism. In large amounts, it also may be lost from vomiting. Under these
conditions, one would expect to reduce the total blood volume, changes the
dynamics of cardiac output, increased hematocrit, etc.
As the disease progresses, there comes quite natural depletion of functional
reserve of the cardiovascular system, resulting in the deterioration of cardiac
output, parallel reduction of impact in cardiac output, a moderate decrease in total
blood flow velocity and a decline in the effectiveness of circulation.
Severe suppurative diseases are accompanied by sharp activation of metabolic
processes and shift them towards catabolic reactions giving rise to the
extraordinary energy needs. Increased body temperature by 1 ° C, leading to
increased energy costs by 15%. If we also consider that even in normal local
exchange in the abdominal entrails is about 50% of the total exchange of the body,
and in inflammatory processes of the past increases, it should be recognized that
the energy needs of patients with severe peritonitis may be at least 3,000-3,500
kcal / per day.
Quantitative violation of protein metabolism is marked by all the authors who
have studied this issue, citing as the main arguments expressed hypoproteinemia
and a sharp increase in foreign protein loss in peritonitis. According to
K.S.Simonyan (1971), the absolute loss of protein in the urine, vomit, exudate can
reach 50-200 g / day, and these losses are not always accompanied by
hypoproteinemia. V.D. Fedorov (1974), by contrast, noted a significant reduction
in total plasma protein; hypoproteinemia observed even at the local peritonitis,
reaching a maximum at "diffuse and general peritonitis." A.N. Cradle and
V.Begunyak (1976) also found a significant reduction in circulating plasma
proteins with common forms of peritonitis.
The highest absolute protein losses occur purulent exudate, which, according
to Welch, Burke (I963) is from 30 to 50 g / L protein that is similar to the protein
content of blood plasma. The second place by value, occupy protein loss with
vomit and the least - in the urine, resulting in impaired renal filtration and
reabsorption in deep intoxication.
Finally, fairly large amounts of protein into the lumen diffuses paretic
intestine where it undergoes enzymatic cleavage pathological. Ability reabsorption
cleavage products of this apparently exists, but their utilization by the body as
immune and plastic material is highly questionable.
In acute purulent peritonitis occur and qualitative abnormalities of protein
metabolism. First of all, attention is drawn to hypoalbuminemia, which is absolute,
as observed on the background of a general reduction of plasma protein.
Particularly sharp decline in albumin levels observed in diffuse peritonitis, with a
tendency to reduce it increases up to 10 days of observation.
Changes in the content globulin fraction is not so one-sided, although in
general there is a very moderate trend to the overall increase in the content of
globulin plasma component. This trend is more pronounced at the local and less with peritonitis.
In peritonitis also undergoes violation mineral metabolism, causing changes in
fluid and electrolyte balance in the body. As is well known, potassium (K +) cation
is the main cell, besides the most mobile. In the context of impaired tissue
hydrostatic equilibrium in the inflammation potassium ion as the most mobile,
leaves the cell and replaced in cellular structures or sodium ion (under anaerobic
hydrolysis) hydrogen ion. In addition, a large amount of potassium is released as a
result of the massive destruction of cellular elements. This is confirmed by an
unusually high content of potassium in the inflammatory peritonitis exudates that
reach 8,1-10,1 mmol / l, i.e. 2 times higher than in plasma. Even greater
displacement of potassium occurs in the part of pathologically altered
gastrointestinal contents. Regarding the enhanced excretion of potassium, it can be
assumed that in conditions of impaired reabsorption peritonitis evident at the renal
tubule level are replaced by cations of sodium, potassium or hydrogen ions, which
leads to an increase in the content of potassium in the urine.
In verily the same time, due to the enhanced excretion of potassium in the
urine, as well as the massive losses it with inflammatory exudate and vomiting,
hyperkalemia rather quickly replaced by hypokalemia, which already shows the
appearance of an absolute deficiency of potassium in the body. Finally, the growth
of acute renal failure in the terminal stage of peritonitis dramatically violates the
excretion of cations (and especially potassium) by the kidneys, which again leads
to progressive hypokalemia, although the content of intracellular potassium is low.
There is no need to emphasize the particular importance of the pathological
loss of potassium to the organism, as it plays a crucial role in the processes of
conduction of the nerve fiber. Apparently, the general deficiency of potassium is
essential in causing intestinal paresis in peritonitis, as well as in violation of the
functional ability of the myocardium. In turn, the latter circumstance has a certain
importance in the genesis of the hemodynamic disorders that occur during
peritonitis.
Add sodium (Na +) is characterized by the reverse trend, i.e. enhanced
tendency to delay this cation in the body. This is evident as to increase its content
in the cellular elements, and the appearance and hyponatremia moderate decrease
urinary sodium excretion. Such sodium retention due to increased
mineralocorticoid adrenal function, in particular, increased production of
aldosterone.
Given that the sodium cation has a leading role in maintaining osmotic
equilibrium in biological media, it should be recognized increased production of
aldosterone kind of defensive reaction in a severe disruption of the balance of the
body. This is demonstrated by relatively low sodium content in exudates, contents
of the stomach and intestines.
Violation of the acid-base balance (acid-base balance) of the organism in case
of peritonitis for many years served as the subject of attention of clinicians. Some
authors (V.Y. Shlapobarsky, 1958; P.L. Seltsovskiy 1963) believed that in the
conditions of peritonitis, especially common, there is always a pronounced
acidosis. However, with the advent of accurate microelectrolite rapid method
Astrup noted that the trend in peritonitis is not constant. Moreover, in case of
peritonitis often observed marked alkalosis and indicators of acid-base balance in
these conditions can change rapidly.
Increasing paralytic ileus complicates the course of peritonitis in 45-85% of
cases. Not accidentally, many authors see a direct relationship between the degree
of paresis, with the likely outcome of the disease. This complication, with the
reactive stage of peritonitis may be found in 40%, with the toxic stage - 80%, and
in the terminal - in all patients. Moreover, at the local peritonitis expressed
enteroplegia can an observer in 54% of patients, and with common forms of
peritonitis - in 82.7% of patients (B.D. Savchuk, 1979).
Thus, in the pathogenesis of peritonitis can be traced fairly strong correlation
between the occurrence of paralytic ileus and the growth of disease severity.
Diagnostic of Peritonitis.
Examination of patients with peritonitis should be systematic, comprehensive
and include the study of medical history, complaints, results of inspection,
palpation, auscultation and percussion, necessary clinical and biochemical studies.
Careful study of the history of the disease is of paramount importance for the
correct diagnosis, timely and reasonable treatment. In history should include first
and foremost accurate data about the beginning the main symptoms of the disease,
therapeutic measures applied to the patient prior to admission to the surgical
department.
One of the main manifestations of acute surgical diseases of the abdominal
cavity is a pain, its location, intensity, character. The emergence of severe pain in
the abdomen, accompanied by a deterioration of general condition of the patient, is
one of the terrible symptoms indicative of severe accident in the abdominal cavity.
Important role in the diagnosis of peritonitis belongs vomiting frequency her
character vomit.
The study of language is one of the main factors (peritonitis dry tongue as a
"brush"), which may be due to deposition of liquid and developing dehydration. In
the diagnosis of peritonitis important research abdomen.
On examination, the abdomen pay attention to its shape (inverted),
participation in the act of breathing, skin color. Notes the limited mobility of the
abdominal wall, more pronounced in the area of the projection of the main
inflammatory focus.
When the superficial palpation of the abdomen define protective muscle
tension anterior abdominal wall, respectively zone inflammatory altered parietal
peritoneum. Particularly pronounced muscular defense perforation of a hollow
organ ("hard abdomen"). Protective muscle tension anterior abdominal wall may
be negligible in the localization of the inflammatory process in the small pelvis,
with the defeat of the posterior parietal peritoneum. In the first case in the
diagnosis of peritonitis is a valuable rectal examination, in which you can define
the overhang of the front wall of the rectum due to accumulation of fluid, pain on
pressure on the rectal wall. In women, vaginal examination can detect overhang
posterior vaginal fornix, pain cervical motion. For signs of inflammation posterior
parietal peritoneum is necessary to define the tone of muscles of the back of the
abdominal wall.
Percussion of the abdomen is a research method that allows to establish the
presence of pneumoperitoneum, streamed blood effusion at peritonitis. For
percussion can detect pain zone corresponding to areas of inflammation of the
peritoneum, high tympanitis (due to paresis) and dullness at the accumulation of
significant amounts of fluid in a particular area of the abdomen. Absence of bowel
sounds on auscultation indicates the presence of paralytic ileus.
Due paralytic ileus, usually marked intestinal contents repeated vomiting and
hiccups showing stimulation of the phrenic nerve. Also deserves attention delayed
stool and gas.
Attaches great importance to the appearance of the patient, studies of the
cardiovascular system, respiratory system, as well as the measurement of body
temperature, which may provide additional information in the diagnosis.
In the analysis of the blood was high leukocytosis, which is then reduced and
may be replaced with exhaustion leukopenia body's defenses. Violations of waterelectrolyte balance, acid-base status peak. An electrocardiogram shows signs
characteristic of toxic myocardial damage and electrolyte disorders (hypokalemia).
In the study of coagulation show signs of disseminated intravascular coagulation
(DIC), which violates the microcirculation, increase the weight of the disease. All
of these adverse factors lead to decompensation of vital organs and systems with
the development of cardiovascular, pulmonary and renal failure.
Instrumental research methods used for diagnostic of acute peritonitis can be
divided into 2 groups.
Non-invasive: plain radiography, ultrasound study rheography. An important
role is played by the radiological diagnosis, the phonograph, the thermal imaging
and ultrasound.
Plain radiography of the abdomen. In this study, especially when the
perforation of a hollow organ (ulcer perforation, or tumors of the stomach and
duodenum, small intestine, etc.), it is possible to detect the accumulation of gas
under the right or left dome of the diaphragm, limiting its mobility and high
standing dome of the diaphragm on the affected side, exudative pleurisy (in the
form of more or less fluid in costal - diaphragmatic sinus). In some cases, you can
identify the paretic, swollen bowel gas, adjacent to the site of inflammation, and in
the later stages of peritonitis - fluid levels of gas in the bowel loops (Kloiber’s
symptom) characteristic of intestinal obstruction. The diagnostic capabilities of the
X-ray method is greatly enhanced with the use of pneumoperitoneography,
retropneumoperitoneography that can detect inflammation of an organ in the early
stage (thickening of the body, its cohesion with neighboring authorities and walls,
early hyperplasia of abdominal lymph nodes, which accompanies the inflammatory
process).
Ultrasound abdominal scanning: allows us determine the accumulation of
fluid in a particular section of the abdominal cavity, and in some cases you can
define the infiltration or destruction of gall bladder or pancreas paretic, bowel and
inflated gas.
Rheography reveals a sharp increase in diastolic wave height compared with
systolic (normally vice versa), allowing you to think about the stagnation vessels
of the stomach and intestines.
2. Invasive: paracentesis, the method of "groping" catheter, diagnostic
laparoscopy and laparotomy.
Laparocentesis being more simple way research is carried out by puncture of
the abdominal wall with the introduction into the abdominal cavity of a thin
catheter through which aspirated peritoneal exudate. She performed at
diagnostically difficult cases when the operation is associated with a greater risk,
reveals the presence of abdominal effusion aspirate it and subjected to microscopic
examination. By nature of the resulting liquid (blood, pus, et al.) Can be concluded
on the nature of changes in the peritoneal cavity. Exploring effusion on pH,
amylase, erythrocytes, its appearance, odor, color, you can set the indications for
laparotomy, and the use of the method of "groping catheter" allows 91% of the
correct diagnosis.
Laparoscopy is a more reliable method that can detect directly the source of
inflammation. Last shown in the absence of confidence in the diagnosis, when noninvasive methods of investigation are not informative. At laparoscopy, you can see
almost all the organs of the abdominal cavity, to assess the state of the parietal and
visceral peritoneum, the presence or absence of fluid.
Laparotomy and revision of the abdominal cavity, in difficult cases, allows to
determine the most correct diagnosis.
Differential diagnostics of peritonitis
Approximately 85% of the pathological changes in any of the abdominal
organs develop in parallel with the symptoms and diagnosis is not difficult. In this
case, the diagnosis is based on the syndrome, which is a set of distinct features that
characterize a particular disease. However, approximately 15% of cases of acute
surgical diseases of local manifestations are fuzzy, blurry character, as can be
vague and general symptoms. In such cases it is necessary to pay special attention
to the nature of the attack of pain, pain crisis at acute destructive disease that
manifests itself much more sharply than in functional disorders of the
gastrointestinal tract. The second important feature is the differential nature of
dyspepsia. If there is no degradation in the history of vomiting is a rare exception,
whereas degradation in the presence of vomiting, dyspepsia in general - leading
signs of disease. An important symptom is a positive symptom of ShchetkinBlumberg, as it suggests the involvement of a destructive process leaves the
peritoneum.
The differential diagnosis in toxic and terminal stage of peritonitis is
usually not a serious difficulty, but it is at these stages of treatment of peritonitis is
often ineffective. Recognition of peritonitis in its initial phase is much more
difficult because its clinical manifestations are not very different from the
symptoms of the disease, which has become a source of peritonitis (acute
appendicitis, acute cholecystitis, etc.). In acute pancreatitis can identify a number
of symptoms characteristic of peritonitis. However, against the background of
pancreatitis uncontrollable vomiting, lack of protective muscle tension anterior
abdominal wall, or it is not expressed. There are no signs of peritoneal irritation,
the temperature at the beginning of the disease remains normal. In the study of
blood and urine diastase detected increase in the concentration of the enzyme.
Acute mechanical intestinal obstruction clinically different from peritonitis only in
the early stages, and subsequently in the absence of adequate treatment and bowel
perforation, intestinal obstruction is attached to and diffuse peritonitis. If, at the
beginning of acute intestinal obstruction pain are pretty intense (cramping)
character for peritonitis is characterized by persistent pain. Peristalsis intestinal
obstruction initially dramatically enhanced, sometimes visible to the eye is
determined by peristalsis. Radiologically, peritonitis may also be determined
characteristic symptom of intestinal obstruction - Kloiber's symptom.
For biliary colic is characterized by paroxysmal pain in the right upper
quadrant radiating to the right shoulder, right shoulder girdle, vomiting, a small
amount of gastric contents with bile. Muscle tension in the right upper quadrant.
not expressed, no symptoms of peritoneal irritation. The application of heat and
antispasmodics quickly relieves attack of biliary colic.
Much more difficult to carry out the differential diagnosis between acute
cholecystitis and peritonitis. In acute phlegmonous cholecystitis, they can identify
the most typical local peritonitis symptoms: persistent pain, protective voltage.
muscles, symptoms of peritoneal irritation, depression peristaltic activity of the
intestine, pyrexia, leukocytosis. Careful hourly monitoring of patients with
multiple definition of objective evidence of inflammation - temperature pulse rate,
blood pressure values, leukocytosis, taking into account changes in the patient's
complaints and objective research data allow doctors to properly navigate the
course of the acute stage of the process in the gall bladder, the effectiveness of the
treatment and further tactics of treatment.
During exacerbation of peptic ulcer, especially when large callous or
penetrating ulcers, when the inflammatory process involves the peritoneum, we
can note a rather intense abdominal pain of a permanent nature, protective muscle
tension, sometimes weakly positive symptom of Shchetkin - Blumberg. However,
unlike peritonitis can reveal a slight decrease in pain after eating, lack of inhibition
of peristalsis. Body temperature is normal and there is no tachycardia language wet changes in blood composition, usually small.
Renal colic may be accompanied by pain in the abdomen, bloating,
delayed discharge of stool and gas, and what happens in case of peritonitis.
However, the characteristic localization of pain (especially in the lumbar region,
paroxysmal in nature and their irradiation in the thigh, genitals, lack of
communication with the pain change in body position of the patient, the patient's
restlessness, lack of hyperthermia symptoms of peritoneal irritation, leucotcytosis
and characteristic changes in the analysis urine (hematuria, leucocyturia) allow for
a clear differential diagnostic distinction between these two diseases.
Some other diseases not associated with lesions of the abdominal cavity
(basal pleurisy, pneumonia, myocardial infarction, multiple rib fractures) may be
accompanied by symptoms characteristic of peritonitis. In these cases helps a
thorough examination of the chest cavity using instrumental methods and
especially X-ray.
Significant difficulties may present diagnosis of peritonitis in elderly
and senile age, as well as difficult to collect the history of the disease, and as a
result reduce the reactivity pain signs and symptoms of the disease (muscular
defense, pyrexia, leukocytosis) may be a little severe.
In children, diagnosis of peritonitis is difficult due to lack of adequate
contact with the patient and the inability to collect a complete medical history. It
should be remembered that children peritonitis often proceeds as hyperergic
reaction with severe pain, dramatic tension of the abdominal muscles, high
hyperthermia and leukocytosis.
Special difficulties in the diagnosis of postoperative peritonitis present when
this formidable disease complicates the postoperative period. The main source of
infection in this case is the previously suture failure anastomosis between organs or
blood accumulation of exudate and their subsequent suppuration as microbes
during operation always fall into the operative field. The difficulty in diagnosis due
to the fact that in the postoperative period when the body mobilizes the body's
defenses in response to surgical trauma, symptoms of peritonitis can be quite
scarce.
Basic principles of complex treatment of peritonitis.
Emergency preoperative patients with peritonitis should be individualized,
taking into account comorbidities and intense, with a targeted correction of water
and electrolyte balance, acid-base balance, protein metabolism and hemodynamic
disturbances, under the control of biochemical research. Occupies a special place
premedication and gastric emptying. The duration of preoperative preparation
should not exceed 2 hours.
The method of choice of anesthesia for peritonitis is common endotracheal
anesthesia with controlled breathing, allowing the elimination of pain, promotes
correction and normalization neurocirculatory and neurohumoral reactions.
When installing the diagnosis of acute peritonitis, the vast majority of
patients, as the surgical approach used median laparotomy, as this access is less
traumatic and giving the opportunity to spend an adequate audit of the abdominal
cavity.
If the source of peritonitis is the organ that can be removed (appendix,
gall bladder), and technical conditions allow you to do, it is advisable to remove
the radical source of infection from the abdomen. Perforation of a hollow organ
(gastric ulcer, duodenal diverticulum of the colon, cancer of the stomach or colon)
often perform suturing perforated holes, especially if after perforation has been
more than 6 hours, and we can expect a massive bacterial contamination of the
abdominal cavity. When you break the diverticulum or cancer closure of a defect is
usually not feasible. In these cases, the resection of the affected organ is shown
(this is technically feasible) or by a discharge of the stoma. When postoperative
peritonitis caused by failure of seams before anastomosis is usually not possible to
take in a defect in the anastomosis, due to significant inflammatory infiltrate in to
the surrounding tissues, so often have to be limited to summarizing double-lumen
drainage tube to the hole for the aspiration of intestinal contents of this site for the
delimitation of the hearth infection or fistula formation or excretion of the
anastomosis from the abdominal cavity as a stoma on the anterior abdominal wall.
The abdomen was carefully Drying electric pumps and gauze, remove loose fibrin
raids. Followed by a wash with a solution of the abdominal cavity antiseptics:
furatsilina solutions, dioksidine, chlorhexidine.
Laparotomic wounds before suturing the anterior abdominal wall, it is
imperative drainage of the abdominal cavity through a subcostal or iliac region.
Methods of drainage of the abdominal cavity is completely dependent on the extent
of the peritoneum. Thus, when the local peritonitis, drainage is installed in the
affected area, with diffuse peritonitis - 3 2 or drainage, control, and intraperitoneal
administration of antibiotics.
For the practitioner, of particular interest is diffuse purulent peritonitis, which
is also an absolute indication for emergency surgery. Timely diagnosis of early
forms of peritonitis and adequate surgical intervention is the key to success in the
treatment of this terrible disease.
Operative intervention in this case should include the following:
• revision of the abdomen and eliminate the source of peritonitis,
• sampling of fluid from the abdomen to express microscopy, bacteriological
analysis and sowing microflora to determine sensitivity to antibiotics.
• evacuation of fluid, sanitation and lavage of the abdominal cavity with
antiseptic solutions (5-8 liters of solution furacyllini, Ringer's solution,
saline or rivanol).
• Novocaine injections at root of the mesentery of the small intestine or the
installation of microirrigator for drip-new solution for the prevention of
cocaine paresis.
• transnasal intubation intestine by the introduction of a 2-luminal enteral probe
for the evacuation of the gastrointestinal tract, intestinal lavage and enteral
tube feeding in the postoperative period.
• abdominal drainage for the control and conduct of postoperative peritoneal
lavage or dialysis.
The operation is completed by indications: stratified suturing wounds, sutures
through all layers (tying them to bow) or the application to the wound zipper (for
program revision of the abdominal cavity) or left open, as laparostomy to open the
management of patients.
Open management of the abdominal cavity - laparostomy. Indication for
laparostomy are:
• End-stage widespread purulent peritonitis complicated by intestinal fistulas,
• generalized peritonitis, if you cannot eliminate the source of simultaneous
peritonitis,
• Postoperative peritonitis with severe,
• eventrations intestine into the wound, with diffuse peritonitis,
• Anaerobic peritonitis.
In this intervention, bowel loops are covered by 2-layer gauze, the edges
tucked under the abdominal wall by 5-6 cm from the top 6-8 wipes impose gauze
swabs. Under the napkin in the upper corner wound drainage administered
antibiotics for administration.
Postoperative management of patients with diffuse peritonitis.
It consists of a targeted antibiotic therapy, restoring disturbed homeostasis and
detoxification therapy with forcing urine output, correction of comorbidities, as
well as of immune therapy. Equally important, in this case, belongs to peritoneal
dialysis (PD) or the abdominal cavity lavaged adequate decompression of the
intestine (DI) with intestinal lavage (IL) and enteral tube feeding (ETF).
Antibacterial therapy in the first 3 days should be appointed on the basis of express
microscopy studies. At present, there are the following methods for determining rapid microflora
and antibiotics.
B.D. Savchuk’s method (1979). The essence of the technique: using a special
reagent tests determined the sensitivity of pathogenic organisms to antibiotics
peritoneal exudate and within 10-15 minutes, get an answer. The disadvantage of
the technique: the reagent is activated in the presence of high concentrations of
microbes 106-108 lg CFU / ml in peritoneal exudate.
V.E. Roseman’s method (1983). The essence of the technique: fluorescent
microscopy performed native smear with the formation of a complex between the
clostridia and immunized horse serum. Lack of methods: a method to diagnose and
determine the sensitivity of only gram-positive spore-forming rods.
S.V. Fedorchuk’s method (1987). Being identified the species of microorganisms by microscopic examination of the native smear peritoneal exudate and
sensitivity on a specially designed table.
However, as the clinical practice, the accuracy of these methods, the
expression of certain species of flora from 72 to 87%. Consequently, already at the
2 nd, 3 rd day after the operation is necessary to make a correction on the results of
the culture on the flora and sensitivity to antibiotics.
The route of administration of antibacterial drugs: oral, intramuscular,
intravenous, intra, intraarterial, into the abdominal cavity, and the combined
intraportal.
Peritoneal dialysis.
The idea use it belongs to S.T. Rozenak (1926). In the USSR, with the
recommendation to use peritoneal dialysis in acute peritonitis made his debut in
1958 A.N. Filatov, and it has been clinically applied H.G. Gafurov (1957) and K.S.
Simonyan (1964). In the complex treatment of peritonitis, especially his heavy
steps, many authors attach great importance to the method of peritoneal dialysis
(K.S. Simonyan, 1971; V.S. Mayat et al., 1974; B.D. Savchuk, 1979; A.A.
Shalimov et al., 1982).
However, to date, remain controversial, not only the number of installed
drainages and methods of administration, but also the technique of peritoneal
dialysis, the amount and composition of the spent solution, as well as the timing of
abdominal dialysis.
Peritoneal dialysis can be performed or fractional flow method, solutions
with a mandatory inclusion in the solution of antibiotics and novocaine. Dialysis
can be carried out with solutions Petrov- Ringer-Locke, Ringer, Darrow I and II, as
well as saline.
Peritoneal dialysis helps:
• Fast washout fluid, pus, blood clots, fibrinous films of the abdomen,
• regulation of water balance in the body by changing the osmotic
pressure of the dialysate,
• the introduction into the abdominal cavity of antibiotics, creating the
necessary concentrations in the abdominal cavity,
• regulate electrolyte metabolism using electrolyte solutions with a high
content of K + ions,
• the introduction of novocaine to remove reflex influences (blockade)
• the creation of local hypothermia in the abdomen, through the
introduction of cooled dialysate,
• Prevention of adhesions by the administration of drugs that prevent the
development of adhesions in the abdominal cavity (heparin, etc.)
• the removal of nitrogenous wastes (urea, creatinine, and t. D.).
Based on numerous studies carried out in our clinic with diffuse purulent
peritonitis, we are convinced that the best is to carry out the method of fractional
peritoneal dialysis in the first 4-5 days after surgery. The best means of electrolyte
solution is identical electrolyte composition of blood plasma (with hypokalemia - a
solution with a high number of K + ions).
For uniform irrigation of the abdominal cavity and the dialysate for
adequate dialysis we have proposed the following scheme drainage of the
abdominal cavity (Fig. 2).
In severe forms of diffuse purulent peritonitis, for full irrigation and washing
of the abdominal cavity is sufficient consumption of dialysis solution on I
postoperative day - 13-15 liters, for the 2nd -12-13 liters, on the third - 10-12 l, on
the 4th day - 8-10 liters and on the 5th day - 6-7 liters of dialysate. In this case, you
need a daily bacteriological and biochemical control of the washings and
electrolyte composition. For timely correction of disorders of homeostasis and
hemodynamic need every 2-3 hours to determine heart rate, central venous
pressure, blood pressure, as well as to carry out biochemical studies of blood, urine
and wash water from the abdominal cavity (Na +, K +, Ca ++, hematocrit, residual
nitrogen, urea, creatinine, total protein, etc.).
Enteral tube feeding in patients with peritonitis
Arsenal drugs used in the treatment of patients with peritonitis for parenteral
nutrition is very large, but their use is associated with a number of difficulties.
These include complications related deep vein catheterization (inflammatory and
septic processes caused by the prolonged stay of the catheter in the vein), allergic
reactions, and the difficulty of direct parenteral fluid therapy, when is not always
possible to calculate the required quantity and quality of input ingredients. In the
context of parenteral therapy, the body loses the ability to virtually regulation of
the processes. Thus, the search for a simple, physiological and less dangerous
methods of substitution therapy remain relevant for practical surgery.
In recent years, a significant number of papers in which to correct metabolic
disorders, as well as meet the energy needs of the body and plastic in the
immediate postoperative period successfully used enteral nutrition through a tube
held during surgery directly into the small intestine (E.K. Kurapov, 1974. M.I.
Yatsentyuk, 1974). However, the widespread clinical use, despite the obvious
advantages, this method still thresh not found. This is due to several reasons, the
most important of which - the lack of precise knowledge of the optimal
composition of the nutrient mixture for enteral tube feeding (ETF).
Analysis of the literature reveals two fundamentally different approach to the
composition of nutrient resources put into the small intestine. The first, proposed
by S.I. Spasokukotsky (1933), is the introduction of digestible substances from
natural products containing a sufficient amount of protein (broth, eggs, sour cream,
juices) (E.K. Kurapov, 1974, M.I. Yatsentyuk, 1974). It should be emphasized that
the main contingent of patients who were prescribed these nutrient mixtures were
patients undergoing resection for cancer of the stomach or peptic ulcer disease, in
which there were no significant violations of the functional state of the small
intestine. At the same time, many scientists (Y.M. Galperin, 1975, T.S .Popova,
1973, A.A. Shalimov, 1977} shows that when peritonitis phenomenon occurs
intestinal atony, which are based on combined disturbance of the motor, secretory
and absorptive function of the small intestine, leading to the accumulation of large
amounts of gas and liquid into the lumen of the intestinal loops with subsequent
stretching of the latter. Clearly, in these circumstances, an attempt to compensate
catabolic disorders by administration of nutrients to the small intestine alone is not
successful, but can worsen the postoperative period. The basic premise for the
second, widespread method was the idea of the need to introduce in the early
postoperative period, pre-hydrolyzed polymers, which allowed for the use ETF
known medium for intravenous administration. In all the works, which used a
mixture of nutrients containing nutrients only in the form of monomers, it was
noted that the pace of their introduction into the lumen of the small intestine was
limited, Increasing the rate of introduction of these solutions was associated with
the emergence of a number of complications: nausea, vomiting, diarrhea
development.
These complications are primarily, monomeric were determined
hyperosmotic solutions, leading to disruption of water and salt exchange. Thus, the
maximum daily amount of elemental blends, in which there is no complications
reaches 1-1.5 liters. By reducing the monomer concentration of nutrients due to
dilution of the mixture volume can be increased, but the total amount of nutrients
entering these conditions in the internal environment of the body, it remains
insufficient to compensate for its plastic and energy needs, resulting in the need for
simultaneous parenteral nutrition.
A promising new direction for solving the problem of correction of metabolic
disorders in acute disease is to develop methods intracolonic administration of
nutritional formulas based on fundamental research digestive processes carried out
in the Laboratory of Experimental Pathology (under the direction- Y.M. Galperin)
Scientific Centre behalf N.V. Sklifosofskiy.
Based on the above, for a full ETF today, the necessary conditions are:
1. Bowel preparation ETF.
2. Selection of the optimal composition of the nutrient mixtures with the
constancy of the enteric environment and their partial treatment.
3. Technical support (pumps, probes, etc.).
4. The method of delivery of nutrient mixtures.
5. Determination of the safety of the digestion and absorption of the intestine.
1. Bowel preparation for GII. Resistant intestinal paresis accompanied by
acute peritonitis, worsens the disease process and increases toxicity due to
accumulation in the intestinal lumen of large amounts of toxic substances and
gases, which necessitates the use of different methods of evacuation of the
stomach, small and large intestine in various ways open, closed or combined
decompression of the bowel (DC).
The most advanced and user-friendly of them today, is the method of twochannel DC probe by its transnasal intubation during surgery and large intestine
intubation transanal one-channel probe with promoting it to the splenic angle. For
gastrointestinal decompression, we use dual-probe original design (AS number
1,174,031), which allows the probe through this exercise and intestinal lavage.
Transnasal intubation of the small intestine that the probe will allow for active
recreation center as during surgery and in the early postoperative period.
Although the fight against paralytic ileus start already on the operating table
(intraoperative DC, the introduction of novocaine at the root of the mesentery of
the small intestine). Postoperatively, the patient produces pharmacological
stimulation of motor activity of the intestine (prednisolone, Reglan, ubretid, ornid
et al.), And continue to keep an active DC, pumping out up to 1.5 liters of
gastrointestinal contents, with severe cases of peritonitis.
To improve the passage of the contents of the gastrointestinal tract and extracompensation-of water and electrolyte balance in patients with peritonitis was
performed KL brine, identical in its electrolyte composition of chyme of the small
intestine. Composition of gut lavage solution was as follows: Na + - 220 mg / L, K
+ - 79 mg / l, Ca ++ - 40 mg / L and Cl - 420 mg / l.
TF started already on the first day, immediately after surgery, by introducing
1500 ml of saline through the series of four small tip clearance, with an exposure
of 30 minutes, and its subsequent aspiration.
Efficiency DC and TF is estimated to improve the general condition of
patients, lack of abdominal distention and pain, occurrence of intestinal motility,
reduced toxicity, and improved performance of the peripheral and central
hemodynamics, acid-base balance and restoration of essential clinical and
biochemical parameters of blood.
Thus the best option gastrointestinal decompression should recognize
nasointestinal intubation using a special probe. Bowel during surgery facilitates
manipulation and reduces abdominal trauma surgery, reduces toxicity.
Nasointestinal intubation allows early postoperative remove toxic intestinal
contents and relieve the tension of the intestinal wall, which contributes to the
restoration of motor activity of the intestine, improves blood circulation and
microcirculation of the intestines, prevents the development of early adhesive
obstruction, and also helps to prevent insolvency intestinal anastomosis and
eventeration. DK combination with KL, facilitating passage of the digestive tract
contents and implementing additional correction of water and electrolyte balance,
preparing the intestines and creates conditions for connection ETF.
2. Selection of the optimal composition of nutrient mixtures taking into
account the constancy of the enteric environment and their partial processing.
Requirements for nutrient mixture for ETF in patients with acute peritonitis are:
• Persistence of enteric environment
• Pre-hydrolysis of ingredients
• Low osmolality (within 300 - 500 mOsm)
• High energy value.
3. For technical support of ETF used: two-channel multifunctional probes
nazointestinalnyh original designs, reservoirs (tanks) for nutrient mixes and
pumps.
4. The method of delivery of nutrient mixtures served nasointestinal dualprobe with original design proposed by Sh.I. Karimov et al. 1985.
5. Determination of the safety of the digestion and absorption of the
intestine. Restoring the digestive and intestinal absorption was assessed by the test
sample.
Its essence was as follows: starting with the second day of early postoperative
period, the patient within 1 hour have been active aspiration intestinal contents
through the aspiration lumen nasoenteral probe. Then, through a small lumen
infusion probe (60 drops per minute) was introduced 100 ml of a nutrient salt
mixtures. Creating exposure for 30 minutes.
Then, have been active aspiration into a graduated vessel and aspirate was
obtained qualitative and quantitative research.
If the results of research (qualitative and quantitative composition) showed
that 55% of the injected fluid aspirated, the test sample is considered negative and
the probe continued to operate. If aspirated fluid was less than 55%, it is
considered a positive test sample and the probe operated in the ETF.
This involves the use of a nutrient salt mixture initially (the 3rd day after the
operation), then the balanced nutritive mixture (4, 5, day 6), the extraction of the
probe and the transition to oral feeding.
The results showed that the use in the treatment of peritonitis complex
adequate DC in combination with ETF promotes better correction of disorders of
homeostasis, early recovery of gastrointestinal function, a sharp decrease in the
number of postoperative complications and mortality.
To enhance the effectiveness of drug therapy can be successfully used for a
long intra-catheter therapy and intraportal catheter therapy.
In addition to the above medical therapy in patients with severe acute
peritonitis, to detoxify the body, you can use the following methods of
extracorporeal detoxification: enterosorption, thoracic duct drainage,
lymphosorption, hemosorption, UFO, plasmapheresis, ksenosorptsion and HBO.
The prognosis of peritonitis depends on the nature of the underlying disease
caused peritonitis, timely surgical intervention, the adequacy of the treatment.
Individual forms of peritonitis.
Tuberculous peritonitis develops in most cases by means of the Extra
hematogenous sources (lungs, lymph nodes) and of the abdominal organs and
mesenteric lymph nodes affected by tuberculosis. The clinical course of
tuberculous peritonitis may be acute, subacute or chronic, with the latter form
occurs most frequently. Isolated exudative, and ulcerative caseous and fibrous
forms. And depending on the shape of the process in the clinical picture is
dominated by a variety of symptoms - increasing ascites, partial or complete bowel
obstruction, peritonitis. In the diagnosis helps history (myocardial tuberculosis),
increased sensitivity to tuberculin, laparoscopy. Treatment: as a rule, drug, taking
into account modern principles of treatment of tuberculous process, and only if you
have symptoms of peritonitis or acute intestinal obstruction surgery is indicated.
Gynecological peritonitis. Isolated nonspecific and specific peritonitis.
Nonspecific peritonitis occurs when the breakthrough into the abdominal cavity of
pus from an inflammatory tumor of the uterus, ulcers parameters festering ovarian
cyst with torsion of her legs. The greatest difficulty in diagnosis are gynecological
peritonitis developing postpartum and post-abortion due to community-acquired
septic infection of the uterus (metroendometritis, metrotromboflebitis) lymphatic
or hematogenous route. Another possible cause of peritonitis - microflora entering
into the abdominal cavity in penetrating injuries of the uterus and vagina
(perforation and rupture of the uterus after cesarean section, and others.). At the
same time, the inflammatory process can capture the pelvic cavity, causing the socalled pelvioperitonitis, but can also apply to most of the peritoneal surface and
then there is a diffuse peritonitis. Diffuse peritonitis pelvic origin occurs as
peritonitis and in other most common sources of infection. Pelvioperitonitis
proceeds relatively benign. Observed early in the disease blunt abdominal pain,
muscle tension anterior abdominal wall, high body temperature under the influence
of massive antibiotic therapy after a while decrease exudate undergoes resorption,
recovery occurs. With the progression of pelvioperitonitis gradually increase the
pain, symptoms of purulent intoxication, severe hyperthermia. In this case, surgical
treatment.
Specific pelvioperitonitis often due to gonococcal flora. In 15% of all
patients with gonorrhea develops pelvioperitonitis. Microbes penetrate into the
abdominal cavity of the uterus infected with gonorrhea. The process typically does
not extend beyond the pelvis. This gives rise to intense abdominal pain, tenesmus,
diarrhea, increased body temperature. Distended abdomen, palpation reveal muscle
tension anterior abdominal wall, positive symptom of Shchetkin - Blumberg. For
rectal and vaginal examination reveals signs of inflammation of the pelvic
peritoneum, vaginal note sero-purulent discharge. Bacteriological examination
confirms the diagnosis. Treatment: drug with gonorrheal peritonitis. Assign
detoxification and antibiotic therapy, an elevated position of the body in bed.
4.2. Using during the lesson, new teaching technologies.
1. USE OF THE «BLACK BOX»
The method provides for joint activities and active participation in the
classroom each student, the teacher works with the entire group.
Each student takes out a "black box" issue. (Options of questions are
attached.) Students are required to detail the reasons for his answer.
To think about each answer the student is given 3 minutes. Then discuss the
answers, given in addition etiopathogenesis, clinical course. At the end of the
method of teacher comments on your answer is correct, its validity, the activity
level of students.
This methodology promotes student speech, forming the foundations of
critical thinking as In this case, the student learns to assert his view, analyze
responses band members - participants of the contest.
Options abstracts:
1. Put the diagnosis: The patient noted fever, pain around the stomach, dry
mouth.
2. Put the diagnosis: The patient was 65 years after fasting for 24 days
suddenly appeared in great pain in the epigastrium after that went around the
abdomen.
1. USING "WEB"
Steps:
Previously students are given time to prepare questions on the passed
occupation. Participants sit in a circle. One of the participants is given skein of
thread, and he sets his prepared question (for which he must know the full answer),
hold the end of the filament coil and transferring to any student.
A student who receives skein, answers the question (in this party, who asked
him, commented on a response) and passes the baton on the issue. Participants
continue to ask questions and answer them until everything will be in the web.
Once students have completed all the questions, a student holding a roll,
returning his party, from whom he received the issue, while asking his question,
and so on, until the "unwinding" of the coil.
Note: To prevent the students, which should be attentive to each answer,
because they do not know who to throw skein.
4.3. The analytical part
Tests:
1.In patient observed fever, pain in the belly, dryness in the mouth and belly like a
wood.
I. Your diagnosis:
А. Peritonitis*
B. Colitis
C. Gastritis
D. Mialgy
E. Artrosis
II. Clinical manifestation of peritonitis
A. pain in the belly *
B. ballooning
C. Becoming red of the skin
D. No pain
E. no right answer
5. The practical part
The task of practical skills (interview a patient, physical examination and
inspection of body parts, to justify the differential diagnosis and final diagnosis,
assign the appropriate diet and regular treatment).
1. HOLD DIFFERENTIAL DIAGNOSIS AND JUSTIFY THE FINAL DIAGNOSIS.
Purpose: To educate and carry out a differential diagnosis to justify a
definitive diagnosis.
Fully
Not
№
Activity
implemented
fulfilled
correctly
1. List the disease, clinical symptoms, which are
0
25
similar to the disease.
2. Make a differential diagnosis of major clinical
0
35
syndromes.
3. On the basis of complaints, medical history,
0
40
objective data and results of laboratory and
instrumental examinations, as well as differential
diagnosis to put a definitive diagnosis.
Total
0
100
№
2. APPOINT APPROPRIATE DIET AND PLANNED TREATMENT
Purpose: The treatment of the disease and to achieve remission.
Activity
Not
Fully
fulfilled
1. The study of the characteristics of medical tables on
Pevsner.
2. The right choice of dietary table in accordance with
the diagnosis.
3. Assessment of usefulness of the diet
4. In accordance with the diagnosis, disease severity
and stage of the appointment of primary therapy.
5. In accordance with the diagnosis, disease severity
and stage of the appointment of symptomatic
therapy.
6. Prophylactic measures.
Total
0
implemented
correctly
10
0
10
0
0
20
20
0
20
0
0
20
100
3. TECHNIC OF PERFOMING PERITONEAL LAVAGE
Цель: stopping of development of infection in abdominal cavity and avoiding
of development of bowel disease
Not
Fully implemented
№
Activity
fulfilled
correctly
1 The condition of the patient on the
0
15
back
2 Close lower dranages
0
20
3 Conduct upper dranages to antiseptic
0
10
liquid
4 Introduce into abdominal cavity 2-3 l
0
30
of antiseptic liquid
5 Change the condition of the patient
0
5
6 Open lower dranages
10
7 Estimate the quantity of fluid
10
excreted from the dranages
Total
0
100
6. Forms of control of knowledge and skills
1. Speaking;
2. Writing;
3. Solving the situation problems;
4. Demonstration of gained practical skills.
№
1
7. Criteria for evaluating the current control
Progress in% evaluation
The level of student knowledge
96-100%
Perfectly
“5”
Complete the correct answer to the
questions. Summarizes and makes
decisions, creative thinking, self-
2
91-95%
Perfectly
“5”
3
86- 90%
Perfectly “5”
4
81-85%
well “4”
5
76-80%
Well “4”
6
71-75%
well “4”
7
66-70%
satisfactorily
“3”
analyzing. Solve situational
problems correctly, with a creative approach,
with full justification for the answer.
Actively and creatively participate in
interactive games, the right to make informed
decisions and summarize, analyze.
Complete the correct answer to the
questions. Creative thinking, selfanalyzing. Solve situational
problems correctly, with a creative
approach, the rationale for the answer.
Actively and creatively participate in
interactive games, the right decision makers.
The questions covered completely, but there
are inaccuracies in the
answer 01.02. Independently analyzed. Inaccur
acies in solving situational problems, but with
the right approach.
Actively involved in interactive games, make
the right decisions.
The questions covered in full, but there is
a 03/02 inaccuracies, errors. Into
practice, understand the essence of the issue,
says confidently, is a faithful
representation. Case solved the problem
correctly, but the rationale for not fully answer.
Actively involved in interactive games, make
decisions correctly.
Correct, but incomplete coverage of the
issue. Understands the issue, says confidently,
is a faithful representation. Actively involved
in interactive games. On case studies gives
a partial solution.
Correct, but
incomplete coverage
of the
issue. Understands the issue, says confidently,
is a faithful representation. On case studies
gives a partial solution.
The correct answer to half the
questions. Understands the issue, says
confidently, is accurate representations only on
individual issues topics. Case solved the
problem correctly, but there is no justification
response.
8
61-65%
Satisfactorily
“3”
9
55-60%
satisfactorily
“3”
50-54%
unsatisfactoril
y “2”
11
46-49%
unsatisfactoril
y “2”
12
41-45%
unsatisfactoril
y “2”
13
36-40%
14
31-35%
unsatisfactoril
y “2”
unsatisfactoril
y “2”
10
The correct answer to half the
questions. Says uncertainly is accurate
representations only on individual
issues topics. Mistakes in solving situational
problems.
Reply with errors on half of the
questions. Says uncertainly, is partial view on
the subject. Case solved the
problem incorrectly.
The correct answer to the third set of
questions. Situational problems
solved correctly if the wrong approach.
The correct answer to the fourth set of
questions. Situational
problems solved correctly if the
wrong approach.
Lighting fifth of the
questions correctly. Gives incomplete and parti
ally incorrect answers to questions.
Lighting 1 / 10 of questions at the
wrong approach.
To the questions are not answers.
8. Chronological map of lessons
№
1
2
3
4
5
6
Stages of lessons
Introductory word teacher (study subjects)
Discussion topics practical lessons,
assessment of baseline knowledge of
students with new educational
technologies (small groups, case studies,
business games, slides, videos, etc.)
Summing up the discussion
Providing students with visual aids
and giving explanations to them
Self-study students in mastering skills
Clarification
of the
extent
to
which lessons objectives on the basis of
developed theoretical
knowledge
and practical
experience on
the
Form of lessons
The survey, an
explanation
Duration
in minute
s
5
25
5
10
Oral interview, writte
n
survey,
testing, checking the
results of
practical
15
25
7
results and taking
into
account
this evaluation activities of the group.
Conclusion of the teacher
on this lesson. Assessment of the students on
a 100 point
system and its publication. Cottage set onthe
next class (a set of questions)
work,
discussion debate.
Information,
questions for selfstudy
5
9. Quiz Questions
1) The concept of peritonitis, etiopathogenesis, classification, clinical features,
diagnosis, differential. diagnosis and treatment. Cause of death.
2) Preoperative preparing.
3) The symptoms of peritonitis.
4) The specific course of peritonitis in the elderly and pregnant women.
5) The principles of postoperative management of patients with peritonitis.
10. Recommended Literature
I. Main:
1. SH.I. Karimov - "Surgical Diseases" Tashkent 2005.
2. MI Kuzin, "Surgical Diseases." Medicine 1986
3. S. Karimov, "Hirurgik kasalliklar." Medicine 1994
4. Littman I. "Operative Surgery" 1982.
5. Agzamhozhaev SM "Hirurgik kasalliklar" 1991.
6. BV Peter "Guide to Surgery" 7 tons Medicine 1970.
II. Additional:
1. Karimov SH.I., Babajanov BD Diagnosis and treatment of acute
peritonitis. Tashkent, 1994.
2. Savchuk BD Purulent peritonitis, Moscow, 1995.
3. Gostischev V., Sazhin VP Peritonitis. Moscow, 2002.
4. Shurkalin BK Purulent peritonitis. Moscow, 2000.
5. Karimov, S. I. Acute peritonitis. Guidelines. Tashkent, 1985.
6. Karimov SH.I., Akhmedov RM Peritonitis in patients with
elderly.Guidelines. 1985.
7. Asrarov A.A. Surgical and endovascular methods of prevention and treatment
of septic complications and multiple organ failure in patients with diffuse purulent
peritonitis, 1994.
Internet addresses on the subject of activity: http://www.tma.uz, http://medi.ru,
http://www.rmj.net/index.htm, http://www.consilium-medicum.com