The department of the faculty and hospital surgery of the medical faculty of the Tashkent medical academy Acute peritonitis

Clinic of peritonitis firstly was described by military doctor Vasiliy Shabanov in 1816, Which described peritonitis in young soldier after perforation of duodenum

In 1881 Smidt L.I. from Moscow became pioneer in performing Laparotomy in patient with diffuse purulent peritonitis

Способ лечения перитонита СООЗ СОВЕТСНИХ СОЦИАЛИСТИЧЕСКИХ РЕСПУБЛИК ГОСУДАРСТВЕННЫЙ КОМИТЕТ СССР ПО ДЕЛАМ ИЗОБРЕТЕНИЙ И ОТКРЫТИЙ ОПИСАНИЕ ИЗОБРЕТЕНИЯ К АВТОРСКОМУ СВИДЕТЕЛЬСТВУ (72) Ш. И. Каримов, К. Н. Турсунов, А. А. Асраров и Б. П. Бабаджанов (71) Ташкентский ордена Трудового Красного Знамени государственный медицинский институт (56) Травин А. А. и др. Формирование дренажных, систем при перитоните. В кн.: Гнойный перитонит. Труды Московского НИИ скорой помощи им. И. В. Склифосовского т. ХХХУ11М., 1979, с 108-111, (54)(57) СПОСОБ ЛЕЧЕНИЯ ПЕРИТОНИТА путем дренирования верхнего и нижнего отделов брюшной полости, о т л и—. ч а ю щ и й с я тем,... Номер патента: 1174031 | Автор(ы): Асраров, Бабаджанов, Каримов, Турсунов | Метки: лечения, способ,перитонита | Опубликовано: 23.08.1985 Karimov Sh.I.

well-manered in a fair of God and peritonitis» « Me and my generation are well-manered in a fair of God and peritonitis» acad. Vagner (1876).

Peritonitis – inflammation of the visceral and parietal peritoneum, which conduct by the own diseases and during short time induct the defeats of the patient.

STATISTIC 1. Peritonitis frequently complicates the course of acute surgical diseases of the abdomen and occurs in 20-25% of patients; 2 Ranked Among the deaths from acute surgical diseases of the abdominal cavity dies of peritonitis 67-70% of patients; 3 still peritonitis is a major cause of death in acute appendicitis, perforated gastric ulcer and duodenal ulcer, strangulated hernia, acute cholecystitis and acute intestinal obstruction (60 to 90%).

Spreading of the peritonitis Primary Females Males Secondary

Postoperative peritonitis Death from the peritonitis Савчук Б.Д., 1979 Шалимов А.А., 1981 Попов В.А., 1985 Гостищев В.К., 2002 Acute peritonitis Postoperative peritonitis

The reasons of the high morbidity at the peritonitis: Late addressing of the patients. Significant increasing of the number of the patients of elder and senile age. 3) Increasing of the number of the oncologic diseases. 4) Increasing of the number of the patients with the diabetes. Resistance of the microorganisms to the antibiotics and not enough efficiency of the antibacterial therapy. 6) Mistakes of the diagnostic and surgical tactic. 7) Special gravity of the currency of the festering process.

Etiology of the peritonitis 1. Microbe (bacterial) peritonitis: Not specific, inducted with the microflora of the GIP. Specific, inducted with the microflora not from GIP 2. Aseptic (abacterial) peritonitis 3.Traumas and defeats of the organs of the abdominal cavity. 4. Special forms of the peritonitis: canceromatous, parasite, reumatoid, granulematous.

Main sources of the infection of the abdominal cavity Appendix 30-65% Stomach and duodenum 7-14% Female reproductive organs 3-12% Intestine 3-5% Gall bladder10-12% Pancreas 1% Postoperative peritonitis % Traumatic defeats 2,7%

Acute gangrenous appendicitis Flegmona of the stomach

Acute flegmonous cholecystitis Reasons of the peritonitis Acute flegmonous cholecystitis холецистит Tube pregnancy Breakup of the gonad’s cyst

Abscess of the pancreas Crone’s disease Abscess of the pancreas Flegmona of the caecum

Strangulation of the hernias. Wall strangulation

Classification by B.D. Savchuk, 1979 I.Local peritonitis. 1)Limited 2)Not limited. II. Spreaded peritonitid. 1)Diffuse 2)Poure.

By the stages of the currency Reactive (the first 24 h.) Terminal (over 72 h.) Toxic (24-72 h.)

Clinic picture of the acute pancreatitis depends on Reactivity of the organism Etiology of the peritonitis Localization of the process Spreading of the process Stage of the disease Virulent of the microflora

Symptoms of the acute pancreatitis Local General Local Constant symptoms of the acute pancreatitis Not constant symptoms of the acute pancreatitis

Constant symptoms of the peritonitis Pain in the abdomen, pain at the palpation of the abdomen Shetkin-Blumberg’s symptom Muscular effort of the anterior abdominal wall Dry and covered tongue Sickness, retching, thirst Hippocrates's face Paresis of the intestine, stopping of the gases and excrements. Change of the breathing Rising of the temperature, backlog of the temperature from the pulse “scissor's symptom” Pain at the research from the rectum Leucocytosis in bloodв крови, movement to the left, acceleration of SES Changes in urine

Symptoms of the acute peritonitis at the reactive stage General Local Acceleration to 120 beats in a min. Pain in the abdomen Significant effort of the abdominal muscules Increased BP Выраженный симптом Щеткина-Блюмберга Acceleration of the breathing Rising of the temperature The peristaltic of the Intestines is reduced

Symptoms of the acute peritonitis at the toxic stage Local General Reducing of the Pain in the abdomen Increased pulse over 120 beats in a min. Reducing of the effort of the muscles of the abdomen Reducing of the BP Euphoria Shetkin-Blumberg is not significant Sharp lines of face, pallor The intestinal peristaltic isn’t heared Hectic temperature

Symptoms of the acute peritonitis at the terminal stage Local General Hippocrates's face Poured pain in the all abdomen Adynamy Significant meteorism Intoxicated dilirium Absence of the intestinal peristaltic Retching with the smell of the excrement Decreasing with the uretra PON

Diagnostic f the acute peritonitis Complaints Anamnesis of life and disease Objective status Local status Clinic-biochemical researhes

Instrumental methods of researches Not invasive US Overview X-ray Rheography Invasive laparocentesis Method of the wandering catheter Diagnostic laparoscopy Diagnostic laparotomy

US of the abdominal cavity Presence of the free liquid in the abdominal cavity

Overview X-ray of the abdominal cavity At the overview X-ray overwinding chalices of Cloyber Presence of the gas and loquid in the extended intestine

Diagnostic laparoscopy Is the reliable method, that allows directly find out the source of the peritonitis, presence and character of the exudates.

Diagnostic laparotomy In the complicated cases aloows in good time state the most right diagnosis

Treatment of the patients with the acute peritonitis includes three periods: Preoperative preparation Operative treatment Postoperative preparation

Problem of the preoperative preparation At one side Is the correction of defeated functions to the level at which the surgical treatment is the least dangerous At another It is necessary to liquidate the festering process in the abdominal cavity (reason of the defeat of the haemosta sis), that limits with the minimal short terms of decision of all treatment- diagnostic problems of the period

Early operative intervention As harder the state of the patient, so longer lasts the preoperative preparation Not more than 2 hours Early operative intervention

I. correction of the volume, electrolytes and microcirculatory defeats Lactosol Disol Ringer’s Solution Лактосоль Дисоль Раствор Рингера Лактосоль Дисоль Раствор Рингера Лактосоль Дисоль Раствор Рингера Лактосоль Дисоль Раствор Рингера 30-40ml 10% sol. Chloride calcium 30-40мл 10% р-ра хлористого калия 30-40мл 10% р-ра хлористого калия 30-40мл 10% р-ра хлористого калия Rheopoly glucin and haemodes

II. Correction of the peptide defeats Альбумин 100-200 мл Albumin 100-200 ml FFP 200-300 ml С З П 200-300 мл or

III. Decompression of the GIP and reducing of the secretion Zantak 2,0 i\m To reduce the secretion of the GIP and prevent the aspiration

Preoperative preparation includes VI. Устранение анемии VI. Liquidation of the anemia VII. Liquidation of the metabolic acidosis VII. Устранение метаболического ацидоза VIII. Блокада болевых импульсов VIII. Blockade of the painful impulses

Preoperative preparation includes: IX. Введение глюкокортикоидов IX. Введение глюкокортикоидов IX. Introducing of the glucocorticoids X. Введение ингибиторов протеаз X. Introducing of the inhibitors of the proteases X. Введение ингибиторов протеаз XI. Антибактериальная терапия XI. Antibacterial therapy

The main method of treatment of the acute peritonitis Urgent operative treatment

Main principles of the operative treatment at the peritonitis General anesthesia with forced breathing Wide access Revision of the organs of the abdominal cavity Liquidation of the source of the peritonitis Sanation of the abdominal cavity Nasointestinal intubation Drainage of the abdominal cavity

Frequently used access at the acute peritonitis: Middle-median laparotomy

State of the peritoneum color, transparency thickness, hypostasis, hyperemia, injection of the vessels

Characteristic of the exudates Serous Serous-fibrinous Fibrinous-pus Hemorrhagic Ichorous Urine Bilious Excremental Mixed

Revision of the organs of the abdominal cavity Main rule: solving of the stages of revision of the organs of the abdominal cavity.

Liquidation of the source of the peritonitis Appendectomy Acute destructive appendicitis Appendectomy

Cholecystectomy Liquidation of the source of the peritonitis Acute destructive cholecystitis Cholecystectomy

Liquidation of the source of the peritonitis Peritonitis on the background of the gangrene of the intestine Resection of the intestine with the EEA “side-by-side”.

Liquidation of the source of the peritonitis Peritonitis on the background of the perforation of the ulcer of stomach Sewing of the perforation Resection of the stomach

Choose of the operative treatment at the gastroduodenal peritonitis Stage of fermentative peritonitis Stage of festering peritonitis Radical operation Palliative operation Resection of the stomach TV+antrumectomy Sewing of the perforative ulcer TV+ДЖО

Nasointestinal intubation

Drainage of the abdominal cavity At the local peritonitis – drainage by 1 or 2 drainages At the diffuse peritonitis – drainage by 2 or 3 drainages Drainage at the poured peritonitis

Peritoneal dialysis Method of cleaning of the organism from the bad materials, based on the high adsorption possibility of the peritoneum. Essence of the dialysis: Internal ambience of the organism Dialysing solution Half-permeable membrane

я Running dialysis

The abdominal cavity is filled я The abdominal cavity is filled by the dialysate Fractional dialysis

я ДРЕНИРОВАНИЕ БРЮШНОЙ ПОЛОСТИ ПО МЕТОДУ КЛИНИКИ. Method of our clinic

Complications at the peritonitis Specific Not specific complications in a wound and anyerior abdominal cavity: ffestering of a wound, flegmona of the anterior abdominal wall. abscess of the abdominal cavity eventration paralytic intestinal obstruction defeat of stitches postoperative peritonitis intestinal fistulas sepsis. Hypostatic pneumonia, Thromboembolic complications Encephalopathy, delirium DIC - syndrome, Acute brathing, heart- vascular, renal-hepatic insufficiency.

Duties of the general practitioner in peritonitis - Provision of primary health and social care; - Health education (promoting healthy lifestyles); - Preventive work (timely detection of early and latent forms of the disease, risk groups); - Dynamic monitoring; - Emergency assistance in case of emergency and acute conditions; - Timely consultation and hospitalization in the prescribed manner; - Medical and rehabilitation work in accordance with the qualifying characteristic; - An examination of temporary disability; - The organization of medical and social care and household together with the bodies of social protection and services of mercy alone, the elderly, the disabled, the chronically ill; - Maintaining the approved forms of records and reports.