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Acute peritonitis call primary if the source of an infection is out of an abdominal cavity and she is had in the hematogenous or lymphogenous way. The infection is considered secondary when it is connected with dissimination of microorganisms on a peritoneum, arises owing to a gap or abscessing of an abdominal organ.
Peritonitis of newborns can arise owing to a transmission of infection through a placenta during pregnancy, but more often infection occurs in time or soon after the delivery. It can be a consequence of a septicaemia, an inflammation in a navel, perforation of intestines or, occasionally, a rupture of a worm-shaped shoot. Mekoniyevy peritonitis is described in section 7.43.
Acute primary peritonitis
Etiology. Primary peritonitis — a bacterial infection of a peritoneum at which the source of infection is out of an abdominal cavity. Frequency of this disease decreases, apparently, thanks to effective antibacterial therapy, but nevertheless it arises at patients with ascites which is caused by a nephrosis and cirrhosis, and sometimes and at healthy children. Among the microorganisms allocated at primary peritonitis the pneumococcus and a streptococcus of group A prevail, also gram-negative bacteria often are found (E. coli). Boys and girls are ill equally often; the illness occurs generally at children more young than 6 years.
Clinical manifestations. The onset of the illness can be gradual or acute; abdominal pains, vomiting and fever are characteristic of it. Often there are ponosa, the heavy prostration can develop. In very hard cases, especially babies, can have normal temperature or lowered. Pulse is fast, soft, weak filling. Breath frequent and superficial as the respiratory movements of an abdominal wall strengthen pain. The stomach is increased, moderately intense, pasty resistance is defined. Inspection quite often reveals signs of an active nephrosis or cirrhosis, including ascites. In response to attempt of a deep palpation there is a rigidity of muscles. Intestinal noise are weakened or in general are absent.
Diagnosis and Treatment. The leukocytosis is characteristic; polymorphonuclear cells make 85 — 95%. The active nephrosis is followed by the expressed proteinuria. On survey roentgenograms expanded loops of intestines and hypostasis of walls of a small bowel are visible about what it is possible to judge by increase in distance between the adjacent, filled with gas loops of a small bowel. In the majority a case the clinical picture is indistinguishable from an acute appendicitis (with perforation or without it) therefore the diagnosis of acute primary peritonitis can be made only at a laparotomy. However if the child sick with a nephrosis or cirrhosis, has symptoms of diffuse peritonitis, then it is necessary to try to make the diagnosis, investigating the peritoneal liquid received by means of a puncture. Carry out the cytologic and chemical analysis of exudate. The infected astsitny liquid usually contains the increased amount of protein and more than 300 leukocytes in 1 mm3, and about 25% from them make polymorphonuclear cells. Microscopic examination of the astsitny liquid painted across Gram usually reveals one of types gram-positive or, more rare, gram-negative microorganisms. In such cases intravenous injection of ampicillin or gentamycin is shown. Further the choice of an antibiotic is defined by sensitivity of the activator. Usually process is allowed during 48 h, however a parenteral antibioticotherapia it is necessary to continue not less than 7 days. Resort to surgical intervention if after an active antibioticotherapia during 2 days the condition of the child does not improve or symptoms of peritonitis do not disappear.
Acute secondary peritonitis
This type of peritonitis is most often caused by penetration of colibacilli into an abdominal cavity through a wall of a gut or other body as a result of impassability, a necrosis or a heart attack. Appendicitis is the most frequent reason of secondary peritonitis at children; peritonitis is possible also at invagination and torsion of intestines, the restrained hernia, a rupture of a mekkelev of a diverticulum. Peritonitis can arise as complication of damage of a mucous membrane of intestines (a round ulcer, ulcer colitis, a pseudomembranous coloenteritis). In the neonatal period peritonitis is usually connected with a necrotic coloenteritis, and sometimes with mekoniyevy impassability of intestines, a spontaneous rupture of a stomach or intestines. Among the allocated microorganisms the normal aerobic and anaerobic form of a digestive tract prevails.
Clinical manifestations. Precursory clinical signs of secondary peritonitis are defined by a basic disease. Fever, nausea, vomiting, diffuse abdominal pains are characteristic. At inspection typical signs of an inflammation of a peritoneum — a symptom of "return", rigidity of an abdominal wall, easing or lack of intestinal noise are observed. After this there are symptoms of the shock developing as a result of transuding of a large amount of liquid rich with protein in an abdominal cavity and a gleam of intestines and the corresponding decrease in volume of the circulating blood.
Manifestations of shock at a rupture of body or early symptoms of an acute appendicitis are imposed on symptoms of peritonitis; they are followed by the accruing toxaemia what confirm concern, irritability of the patient, fervescence to 39,6 °C and above, the accelerated pulse, oznoba and spasms. In the most hard cases, mainly at babies, temperature normal or reduced. The chair is absent.
The quantity of leukocytes in blood exceeds 12 000 mm3, polymorphonuclear cells prevail. On roentgenograms in equal projections free air is visible, in an abdominal cavity signs of paralytic or mechanical impassability, exudate and strengthening of a shadow of a lumbar muscle are noted.
Treatment. The main principle of treatment — stabilization of a condition of the patient. For this purpose compensate for the deficiency of liquids and salts by means of parenteral administration; unload intestines, sucking away its contents through a probe; enter antibiotics of a broad spectrum of activity. Numerous schemes of treatment by antibiotics depending on character of the previous disease are offered. If earlier the chemotherapy was not applied, then ampicillin, gentamycin and chloramphenicol are shown. Other scheme provides administration of gentamycin and clindamycin. Surgical treatment is begun as soon as the general condition of the patient allows. In addition to recovery of an integrity of the damaged body during operation take material for microbiological research to find out whether it is necessary to replace antibiotics.
Acute secondary limited peritonitis (peritoneal abscess)
Etiology. The single purulent abscess most often arising as a result of appendicitis occurs at children a little less than at adults. Inability to localize a suppurative focus is explained with the lowered general resilience of children and rather short epiploon. Abscesses are usually localized in the field of a worm-shaped shoot, but can arise also in any other part of an abdominal cavity depending on a suppuration source; perhaps also distribution of an infection from the inflamed worm-shaped shoot, mainly to the area of a small pelvis. Abscess in subphrenic space can proceed appendicular or other intra belly center, and also (in rare instances) from an empyema. Ultrasonic research and a computer tomography help to define localization abscesses.
Clinical manifestations. The main symptoms of peritoneal abscess — a constant or the alternating fever, a small appetite, vomiting after food. The leukocytosis with dominance of polymorphonuclear cells is characteristic. At appendicular abscess tension in the right lower quadrant of a stomach is observed, dense education is often palpated.
Pelvic abscess is shown by increase in a stomach, tenesmus, a frequent mucous chair, irritation of a bladder. At manual research of a rectum dense education is defined by its front wall.
Signs of defeat of the lower shares of lungs are characteristic of subphrenic abscess, is more often right that is explained by preload of a diaphragm and is frequent availability of liquid in a pleural cavity. The diagnosis is made on the basis of data of X-ray inspection. On the roentgenogram high standing of a diaphragm and a hepatoptosis (if the infectious center is on the right) is visible, under a diaphragm the gas bubble owing to formation of gas bacteria quite often comes to light.
Treatment. Abscess it is necessary to drain and appoint the corresponding antibiotics of a broad spectrum of activity; the further choice of an antibiotic is defined by result of an assessment of sensitivity of the allocated activators. If the worm-shaped shoot cannot be removed at once, then operation is performed within 3 months.
Tubercular peritonitis, inguinal hernia and to the gidrotsela see in appropriate sections.