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THE HEALTH OFFICE OF UKRAINE

BUKOVINIAN STATE MEDICAL UNIVERSITY

Ratified

on a methodical conference

departments of surgery

Head of department

professor I.Yu. Polyanskiy

___ ___________ 20__y.

METHODICAL DIRECTION

to the students of course of medical faculties

!"# I$%&P&$%&$' ("#)

*' P#&P*#*'I"$ '" P#*+'I+*, ,&--"$

"%/,&

1BASES of SURGERY 1

'hematic module

1URGENT ABDOMINAL SURGERY

'H&& "! ,&--"$- 1ACUTE !ERITONITIS

&ducational discipline

-urgery

* course3 medical faculty

4 hours

ethodical direction made

*s. 'ara5anchuk ..

+herni6tsy 7 200

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1" A#t$a%it& of t'e(e) Peritonitis * acute or chronic inflammation of parietal and 6isceral

sheets of peritoneum3 8hich arises up as a result of operating on it of microorganisms or physical

or chemical factors3 sho8s up 5oth local 5y changes and general disorders of the functional state

of different organs and systems of organism.

*cute 8idespread peritonitis is one of the hea6iest and most fre9uent diseases in

a5dominal surgery. ost acute surgical diseases and traumas organs of a5dominal region

complicated peritonitis :acute appendicitis3 perforated ulcer3 acute cholecystitis3 pancreonecrosis3perforation of ca6ity organs and them traumatic damage;. acute surgical diseases of

internal organs complicated acute 8idespread peritonitis. In /kraine concerning peritonitis

annually treat almost ?0 000 patients.

!rom data of statistics3 a5domen or duodenum perforation is reason of de6elopment

peritonitis in ?0=?4 > patients3 colon = in 20=24 >3 small 5o8el = in 0=4 >3 acute appendicitis

= in 20=24 >3 other reasons = in 0 >.

*cute 8idespread peritonitis is principal reason of death at all of acute diseases of organs

of a5dominal region. ortality from peritonitis from data of I International congress of surgeons

:osco83 @@4;3 makes from 20 to A0 %, depending on his kind3 reason of de6elopment and

state of protecti6e forces of organism. $either achie6ement in anti5acterial therapy3 and

introduction of ne8 methods of treatment :peritoneal dialysis3 laparostomy; nor modernachie6ements of intensi6e therapy pro6ide the desired results of treatment of acute peritonitis.

!or local peritonitis characteristic is that the area of inflammation is marked off from other

areas of peritoneal ca6ity anatomic structures = large and small omentum3 shri6els of 5o8els3 5y

the 8all of 5o8els and other local peritonitis de6elops su5Bect to the condition lo8 6irulence of

microflora on a 5ackground normal reacti6ity of organism. It also is complication of different

acute surgical diseases of organs of peritoneal ca6ity.

+" D$,atio- of %e..o-)4 hours

/" Ed$#atio-a% 0$,0o.e #o-#,ete ai(.2)

To 3-o4)

anatomy information a5out a peritoneumC

determination of concept is peritonitisC

modern looks are to etiology3 pathogenesis of peritonitisC

mechanisms of de6elopment of different types of peritonitisC

classification of peritonitisC

features of clinical picture depending on reason of de6elopment3 stage of disease andC to

pre6alence of acute peritonitisC

diagnostic possi5ilities of additional methods of research :la5oratory3 instrumental3 D= ray;

are at peritonitisC differential diagnostics of local and 8idespread acute peritonitisC

principles of preoperati6e preparation of patients 8ith local and 8idespread peritonitisC

a task of operati6e interference is at the different forms of acute peritonitisC

medical tactic depending on the degree of 8eight of motion an acute peritonitisC

methods of sanation of peritoneal ca6ity are at acute peritonitisC

methods of defence of guy=sutures on an intestine at imposition of them in the conditions of

acute peritonitisC

sho8s and methods of closing of operating 8ound are at acute peritonitisC

modern principles of postoperati6e treatment of peritonitisC prophylaEis of acute peritonitis.

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A5%e)

to collect anamnesis of diseaseC

to define the symptoms of acute peritonitisC

to propose the pre6ious diagnosis of acute peritonitis3 set his reason3 pre6alenceC

to 8ork out a plan of inspection patient 8ith acute peritonitisC

to conduct diagnostics of peritonitisC

to analyse the results of roentgenologic and ultrasonic researches and laparoscopyC

to conduct differential diagnostics of peritonitis 8ith ulcerous illness3 intestinal o5struction3

acute pancreatitis3 acute pleurisy3 pneumonia3 a5dominal form of heart attack of myocardium3

nephrocolic3 gynaecological diseases3 throm5osis of mesenterial 6esselsC

to formulate the grounded clinical diagnosis of acute peritonitis in o5edience to the

re9uirements of classificationC

to define sho8s to operati6e interference at local and 8idespread acute peritonitisC

to appoint the 6olume of preoperati6e preparation at local and 8idespread acute peritonitisC

to define the 6olume of operati6e interference at local and 8idespread acute peritonitisC

to define sho8s to the use of programed laparapertionC

to appoint postoperati6e treatmentC

to define sho8s to the leadthrough of eEtracorporal methods of detoEication at peritonitisC

to design a medical document.

!,a#ti#a% .3i%%.)

method 9uestioning patient 8ith acute peritonitis and to the analysis of data of 9uestioningC

method inspections sick 8ith acute peritonitisC

determination of the most 8idespread clinical symptoms is at acute peritonitisC estimation and analysis of these la5testsC

a method of drafting of the medical program is at acute peritonitis :determination of free gas

and li9uid is in a peritoneal ca6ity;C

leadthrough of laparocentesisC

6" Ba.e 3-o4%ed7e.8 a5i%itie.8 .3i%%.8 -e#e..a,& fo, a .t$d& t'e(e. i-te,.$59e#t i-te7,atio-2

Na(e. of 0,e:io$. di.#i0%i-e. S3i%%. a,e 7ot

. *natomy3 topographical anatomy

:departments of humen anatomy3

topographical anatomy and operati6e

surgery;

,eadthrough of laparocentesis

2. Pathoanatomy :department of

pathologoanatomy and Budicial

medicine;

%etermination of morphological changes is at

inflammation of peritoneum

?. 'opographical anatomy and

operati6e surgery :department of

topographical anatomy and operati6e

surgery;

* choice of operating access and method of operation are

at the different forms of acute peritonitis

A. Pre6ention of internal disease

:department of pre6ention of internaldisease3 clinical immunology and

allergology;

'here is can6assing and physical inspection of patient

8ith acute peritonitis

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4. Feneral surgery :department of

general surgery;

Preparation of patient to the treatment3 diagnostic

measures and operating interferences.

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amount o6er 240 cages in ml. ore fre9uent all spontaneous 5acterial peritonitis complicates

the cirrhosis of li6er :in patients;3 considera5ly rarer is a nephrotic syndrome3 sometimes

7 cardio=6ascular insufficiency. In the organism of man constantly there are 04=0Q

microorganisms. *mong them select macromolecular forms :prions3 6eroids;3 cellular nuclear

and nuclear=free forms :5acteria3 mushrooms3 the simplest;. ,ately mark the increase of particle

of nonclostridial of anaero5ic microflora.

Principal reason of origin an acute peritonitis is a hit in the peritoneal ca6ity ofmicroorganisms from the different departments of the digesti6e system. In this connection it is

necessary to kno8 and mean 9uantitati6e and high=9uality composition of microflora of different

departments of the digesti6e system during esta5lishment of diagnosis of acute peritonitis and

choice of anti5acterial preparations. In addition3 from a disease or damage of that or other JOL

depends not only composition of microflora 5ut also its 6irulence3 speed of distri5ution of

inflammatory process in a peritoneum3 degree of 8eight of disease.

Yes3 in a norm in ml of gastric Buice contained to 000 microorganisms. ainly it is

aero5ic streptococcus3 anaero5es disco6er 6ery rarely. *t lo8 acidity of gastric Buice the amount

of microorganisms is considera5ly increased.

+onse9uently3 resulted information testify that the hea6iest after motion is acute peritonitis

caused the microorganisms of colon.!at'o7e-e.i. of a- a#$te 4ide.0,ead 0e,ito-iti. is 6ery difficult. In reply to

de6elopment of inflammatory process and intoEication syndrome3 predefined formation of plenty

of toEins3 at death of microorganisms and cages of organs and tissues of organism of man there

is acti6ating of 5ioacti6e matters 8hich play a leading role in su5se9uent motion of peritonitis

and syndrome of endogenous intoEication. /nder their action receptors is struck3 permea5ility of

capillaries is increased3 arises up stasis of 5lood. -ystem 6iolations sho8 up the changes of

8ater=electrolyte 5alance3 acid=5asic state3 eEchange of al5umens3 car5onhydratess and gre8 fat.

It results in hipoEy of tissues3 de6elopment of meta5olic cydosis3 increase of hemostais3 stasis

of 5lood.

'one goes do8n at the defeat of interoreceptors3 and after8ards there is paresis of

intestinum 8ith se9uestration of plenty of li9uid3 salts3 oligoelementss3 al5umens3

car5onhydratess3 gre8 fat and hemocytes 5oth in the road clearance of 5o8el and in an

a5dominal region. In the 8all of 5o8el ischemic changes make progress hereupon3 it 5ecomes

JLMRLS for microorganisms3 that predetermines their hit in an a5dominal region and in the

system 5lood stream3 predetermining appearance of cytokines3 that is reason of considera5le

6iolations 6itally of important functions of organism. It should 5e noted that in intestinum

constantly there are different microorganisms 8hich peacefully coeEist 8ith the organism of

man. 'hey take part in many necessary processes3 in particular in pro6iding of trophic processes

of 8all of colon3 micro5al fermentation on the stages of o6ercooking of meal3 synthesis of

6itamins and others like that.

"n a 5ackground acute peritonitis there are pathological changes in all of organs andtissues of organism of man. akes progress TUV3 considera5ly permea5ility of capillaries of3

rises 8hich causes a tissue edema 8ith de6elopment of hypo6olemy and diminishing of 6olume

of circulatory 5lood. 'he toEic products of eEchange3 8hich strengthen URTMRV3 8orsen the

state sick3 accumulate in an organism. -u5se9uent gro8th of endotoEicosis predetermines

considera5le 6iolation of functions of organs 8hich pro6ide the processes of desintoEication

:li6er3 lungs;. 'he signs of syndrome of polyorgans insufficiency3 the first sign of 8hich is a

defeat of the respiratory system 8ith su5se9uent appearance of cardial3 hepatic and kidney

insufficiency3 appear at progress of these changes.

In pathogenesis of peritonitis an important role is played 5y the neurohumors of

inflammation = cytokines3 8hich are lo8=molecular al5uminous neurohumors 8hich are

producted different cages :endotheliocytes3 leucocytes and others like that;. 'hem 5iologicalacti6ity sho8s up operating on high=specific receptors3 located on cages :high=specific action;.

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$eEt to that3 I, and factor of necrosis of tumours operate on all of cages3 sho8ing a system

effect.

In a healthy organism constantly there are processes of self=regulation3 including

automanaged immunoreactions3 and the role of cytokines in maintenance of these processes is

6ery important. 'hey regulate motion of meta5olic processes3 strengthen formation of energy3

instrumental in the origin of hyperthermal reaction3 stimulate the regeneration of the damaged

tissues and cicatriWation of 8ounds.*t critical conditions3 in particular at acute peritonitis3 the products of are stimulated or

the alternati6e 8ays of their education are acti6ated3 as a result of 8hat the reactions of

autoadBusting mutate and 5ecome out of control. In6estigation of these processes is an origin of

interstitial edemas3 8hich causes a not regeneration3 5ut destruction of tissues.

*s an endothelia3 cages of 5lood and tissue macrofages are 5asic sources of synthesis of

cytokines = present in all of organism3 clearly3 that the increase of maintenance of cytokines

predetermines 6iolation of functions of not only those organs 8hich are the source of critical

condition 5ut also all of organs and systems of organism :syndrome of polyorgans insufficiency;.

*t the diseases of organs of a5dominal region look after the especially eEpressed

aggression of neurohumors of inflammation as a result of appearance in 5lood of endotoEin of

gram=negati6e microorganisms.Gacillosis and a intoEication syndrome is related to it at acute 8idespread peritonitis cause

de6elopment of the immunodeficient state 8hich predetermines progress of peritonitis and

considera5le 8orsening of the state sick. It should 5e noted that the temporal immunodeficient

state during the first days an acute peritonitis plays a positi6e role3 limiting appearance second3

autoimmune on the essence3 to necro5iosis. Herein there is physiology essence of the transitional

immunodeficient state.

'hus3 to pre6ent 6iolation of acti6ity of internalss and systems of organism or impro6e

their state at acute peritonitis and attain successes in his treatment3 5ecause of pathogenesis of

disease3 possi5ly only on condition of timely delete of source of peritonitis3 sanation of

a5dominal region3 normaliWation of function=5o8els3 leadthrough of rational anti5acterial

therapy3 remo6al of disorders of homoeostasis.

C%a..ifi#atio- of 0e,ito-iti.) 'here are a fe8 classifications of peritonitis3 from 8hich

most 8idespread in clinical practice are such

B& etio%o7&)

=primaryC

=secondary.

'he primary arises up as a result of hit of microorganisms in an a5dominal region 5y a

haematogenic or lymphogenic 8ays3 and also as a result of their translocation from other organs.

'he second is predefined the hit of microorganisms in an a5dominal region as a result an acute

surgical diseases of its organs or their damage at the trauma of a5domen.

B& ,ea.o-. of o,i7i- of t'e .e#o-d 0e,ito-iti.) *traumaticC=postoperati6eC

=perforati6eC

=inflammatory = distri5ution of inflammatory process from staggered organXs of a5dominal

region 8ithout his perforation.

B& t'e .ta7e. of (otio-)

*reacti6eC

=toEic.

B& #'a,a#te, of e

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=fecalC

=chemicalC

=miEed.

B& #'a,a#te, of (i#,of%o,a.)

=aero5icC

=anaero5icC

= miEed :aero5ic=anaero5ic;.B& (otio-)

=acuteC

=chronicC

=fla55y.

B& 0,e:a%e-#e)

*marked offC

=unmarked offC

=8hat is di6ided on =local3 =diffuse3 =poured out and general.

=2 (a,3ed off = 8hen the hearth of inflammation is marked off from other part of

peritoneal ca6ity anatomic structures = large omentum3 loops of 5o8els. It is at good reacti6ity of

organism and lo8 6irulence of microflora. Infiltrate can eEemplify at appendicitis3 cholecystitis3pancreatitis3 a5scesses of different localiWation.

>2 $-(a,3ed off = 8hen an inflammatory process from the place of origin 8ithout

difficulty can spread on a peritoneal ca6ity.

In dependence on that3 8hat areas of peritoneal ca6ity he spreads on3 select

1" Lo#a% = 8hich spreads on one of @ anatomic areas of front a5dominal 8all3 that on the

adBoining to the place origins of peritonitis at appendicitis = on a right illiac area3 at a

cholecystitis = on a right infracostal area.

+" Diff$.e = 8hen an inflammatory process engulfs not only a peritoneum in the place of

origin 5ut also spreads on adBoining areas3 5ut no more than ? anatomic areas. -o3 an acute

appendicitis3 gynaecological peritonitis the peritoneum of small pel6is3 right iliac and suprapu5ic

areas3 are pulled in an inflammatory process.

/" !o$,ed o$t = 8hen an inflammatory process spreads more than on ?3 5ut no more than

on < anatomic areas. *s an eEample the displays of inflammation appear in the ground floor of

peritoneal ca6ity at appendicitis3 perforation of sigma=meson3 intestinal o5struction.

6" Ge-e,a% = 8hen the displays of inflammation appear on all of peritoneal ca6ity.

B& t'e de7,ee of 7,a:e) I de7,ee:easy; = the signs of endotoEicosis are not eEpressedC

?? de7,ee :middle degree; = for the remo6al of signs of endotoEicosis enough li9uidation of

reason of de6elopment of acute peritonitis 5y an operati6e 8ay and leadthrough of intensi6e

therapyC II A a de7,ee :gra6e; is signs of endotoEicosis after li9uidation of reason of

de6elopment of acute peritonitis it is possi5le to remo6e only 5y the eEtracorporal methods of

detoEication :haemosor5tion3 lymphosor5tion;C II B de7,ee:as gra6e as lead; = the leadthroughof repeated sanation of a5dominal region re9uiresC ?V de7,ee:terminal; = there is a syndrome of

polyorgans insufficiency3 incompati5le 8ith life.

'he impro6ed is lately offered and something 5rief classification of acute peritonitis for the

practical use3 in 8hich distri5ution of pathological process is marked only 5y a peritoneum and

character of eEsudate :'he plenum of pro5lem commissions is incorporated 1&Eigent surgery1

and 1!estering surgery1 of " of #ussia3 osco8 @@@;. It foresees distri5uting of acute

peritonitis on

. localC

2. 8idespread

; diffuse :8ill nurse outside a hearth inflammation and spreads on adBoining areas;C

Z; general :spreads on considera5le areas or all of peritoneum;.

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C%i-i# a- a#$te 0e,ito-iti." #an across acute peritonitis depends on reason of origin3

character and 6irulence of microorganisms3 distri5ution of pathological process3 stage of motion3

state of the immune system of organism and other organisms 8hich got in an a5dominal region.

In clinical practice select the su5Becti6e and o5Becti6e signs of acute 8idespread peritonitis.

'o the su5Becti6e signs 5elong a; pain is in an a5dominal regionC 5; nauseaC c; 6omitC d;

parafunction of intestinum3 8hat patients pay attention on :delay of emptying and gases3

destendion of a5domen;*n acute peritonitis is 5egun 8ith appearance of pain in an a5dominal region3 8hich is

localiWed in the area of source of peritonitis and in future spreads on all of a5domen and 5ecomes

more intensi6e. In the late stages intensity of pain diminishes through the damage of sensi5le

ner6ous completions of peritoneum.

$ausea and 6omit are permanent signs an acute peritonitis. 'hey appear at the 5eginning of

disease and is refleE. +haracter of 6omit the masses depends on the stage of peritonitis3 at the

5eginning of disease maintenance of a5domen pre6ails in them3 in case of occurring of paresis an

a5domen and 5o8els = the admiEtures of maintenance of thin 5o8el appear. omit does not

5ring a facilitation.

*s a result of parafunction 5o8els patients grum5le a5out the delay of gases and emptying3

s8elling of a5domen. 'hese signs are in6estigation of appearance of paralytic acute o5structionof 5o8els. * patient is passi6e3 position is a5ed forced. He as though tries to protect sickly3

staggered an inflammatory process area from an additional irritation.

+haracteristic is original appearance of patient. *t the 5eginning of disease of face sick of

red3 eyes are 5rilliant3 a tongue is hard=5aked3 assessed 8hite stratification. *t progress of

peritonitis of line of person acute3 5ruises appear under eyes3 lip and su5nail 5lue3 a person is

co6ered a death=damp3 a tongue is assessed3 dry3 the temperature of 5ody rises to ?[\] and

anymore.

iolation of cardiac=6essels acti6ity is caused endotoEicosis3 sho8s up pain in the area of

heart3 a pulse is fre9uent3 soft3 o6er 00 5^min. +orrelations of these indeEes utilliWe for the

e6aluation of degree of 8eight of motion of peritonitis and prognosis of disease.

*s a result of the high standing of diaphragm dome3 caused flatulence3 and also tension of

muscles of front a5dominal 8all is 6iolated 5reathing function 5reathing fre9uency is 2A=?0 per

minC 5reathing is superficially and eEceptionally pectoral type. In the case of 8orsening of the

state sick one of the first symptoms there is 6iolation of 5reathing3 his rhythm and depth. (hat

more shallo8 5reathing3 8hat it more fre9uent3 the 8orse prognosis of disease.

*n a5domen at the 5eginning of disease is hollo83 does not take participating in the act of

5reathing. *fter the origin of paresis of intestinum flatulence and a5domen appears destended

ones the cheeks3 and in course of time 5ecomes too eEaggerated.

%uring palpation of a5dominal 8all mark its tension and painfulness. Pain and tension

increase at palpation of a5domen in the area of source of peritonitis. Positi6e the signs of

peritoneum irritation -chotkin=Glyum5ergXs and endelXs. It follo8s to determine the -chotkin=Glyum5ergXs sign3 5eginning from an area3 remote from the hearth of peritonitis3 gradually

approaching him3 8hile the endelXs sign is appearance of pain during pattering of fingers tags

on a front a5dominal 8all3 most sho8n in the proBection of hearth of peritonitis.

%uring percusion of front a5dominal 8all mark a high percusion sound = tympanitis. In the

case of appearance and accumulation in the a5dominal region of li9uid in lo8er places and

dulling of percusion sound appears a5o6e pu5is. %uring auscultation of a5domen on the early

stages of acute peritonitis the peristalsis of 5o8els is stored3 ho8e6er hyposthenic. *s far as

distri5ution of inflammation and progress of intoEication syndrome there is paresis of intestinum3

not hearkened to peristaltic noises : an a5domen a complete 9uiet is a symptom of 1coffin

9uiet1;.

%uring rectal research find out o6erhanding and pain of front 8all of rectum3 6aginalresearch = painfulness 6aults of 6agina 8hich increases at a metrectopia.

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It is necessary to mark that lately the clinical displays of acute peritonitis changed

considera5ly. *tipycal of clinical signs is marked3 unclearness of classic peritoneal symptoms

for hyposthenic patients 8ith the second immunodeficient state3 5y the caused radial influence as

a result of the +herno5ilXs catastrophe3 after the leadthrough of radial therapy3 and also for

patients 8ith hea6y concomitant diseases and patients old years.

ost difficult is diagnostics of specific peritonitis 8hich arises up as a result of perforation

of ulcers of intestinum at tu5erculosis3 typhoid3 mortality arri6es at @0> here.'he considera5le changes of degree of 8eight of clinical motion an acute peritonitis are

related to the 8ide use of anti5acterial preparations and other medications.

#an across a disease takes a place in t8o stages

In the first3 reacti6e3 stages characteristic signs of 5eginning an acute peritonitis and proper

reaction of organism depending on reason of its origin. * disease 5egins pain 8hich appears

suddenly = at the damage of organ or gro8s = in the case of its inflammation. $ausea3 6omit3 Boin

9uickly3 the temperature of 5ody rises. * patient is languid3 a pose is constrained3 a tongue is

dry3 5reathing is fre9uent3 local tension of muscles of front a5dominal 8all3 positi6e symptoms

of irritation of peritoneum3 is determined :-chotkin=Glyum5ergXs and endelXs;. $eEt to it find

out leycocytosis3 6iolation of homoeostasis3 progress of intoEication syndrome. 'he reacti6e

stage as first stage an acute peritonitis can sho8 up in the different terms of disease 8hichentailed acute peritonitis3 5e different duration 8hich represents co=operation of 6irulent eEciter

and reacti6ity of organism.

*t the ill=timed remo6al of source of peritonitis :ill=timed appeal of patient for medical

help3 inade9uate medical tactic; the reacti6e stage passes in a friend = toEic3 8hich signs3

predefined a intoEication syndrome3 8hich arises up as a result of hit in the system 5lood stream

of toEic matters 8hich appear at death of microorganisms and damage of tissues3 pre6ail at3 and

also through stagnant maintenance of intestinum. Intensity of pain diminishes3 arise up paresis of

5o8els3 6iolation of circulation of 5lood in the system of 6ein of gate. omit 5ecomes more

fre9uent. * tongue is dry3 the lines of person are acute3 under eyes there are 5ruises3 halted pass

gases. Pulse till 20 5^min and anymore3 the le6el GP goes do8n. Greathing is a speed=up3

superficially. *n a5domen is 5lo8n a8ay3 in an act3 5reathing of participation does not take3 the

peristalsis of 5o8els a5sents3 the -chotkin=Glyum5ergXs sign is positi6e in all o8er an a5domen.

'he signs of o5struction of 5o8els Boin 7 )i6ulXs :at percusion of front a5dominal 8all

timpanitis is marked 8ith a metallic tint;3 -klyaro6Xs :at push of front a5dominal 8all hearkened

to phonendoscope the capotement; and others like that.

%egree of gra6e of motion an acute peritonitis predefined operating of toEins on the

ner6ous3 cardiac and respiratory systems3 li6er3 5uds3 as a result of 8hat there are degenerati6e

changes in them. * role is important in motion of this stage 5elongs to paralytic o5struction of

5o8els3 8hich predetermines 6iolation of homoeostasis and all of types of eEchange.

Dia7-o.ti#. a- a#$te 0e,ito-iti." 'he diagnosis an acute 8idespread peritonitis is set on

the 5asis of analysis of complaints patient :pain in an a5dominal region3 nausea3 6omit3 delay ofgases and emptying3 s8elling of a5domen;3 information of anamnesis :presence for the patient of

diseases 8hich can entail peritonitis = gastric or duodenum3 acute cholecystitis3 acute

pancreatitis3 opened or closed trauma of a5domen;C o5Becti6e inspection of patient :a skin is

pale3 5ruises under eyes3 the lines of person are acute3 dry3 a tongue3 not mo5ility of patient3

constraint of pose3 is assessed; and information of o5Becti6e inspection of a5domen :tense3 does

not take participating in the act of 5reathing3 the -chotkin=Glyum5ergXs sign is positi6e3

parafunctions intestinum3 is a languid or a5sent peristalsis;3 cardiac and respiratory systems

:fre9uent pulse3 mionectic le6el of arteriotony3 shallo8 fre9uent 5reathing3 pectoral type of

5reathing;C results of la5oratory researches :leycocytosis is eEpressed3 change of leucocytes

formula to the left3 appearance of young forms of leucocytes3 increase of speed of settling of red

corpuscles;.

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!or confirmation of diagnosis3 especially in dou5tful clinical cases3 apply the additional

methods of research of organs of a5dominal and pectoral regions sur6ey D=ray and

roentgenologic research3 +'3 ultrasonic research3 laparoscopy.

Diffe,e-tia% dia7-o.ti#. a- a#$te 0e,ito-iti." %ifferential diagnostics an acute

8idespread peritonitis must 5e conducted 8ith diseases 8hich after clinical motion similar to

acute peritonitis3 ho8e6er need surgical treatment. It is diseases 8hich the origin of the so=called

6icious acute peritonitis is possi5le for. 'he lung and pleural diseases :pneumonia3 5asalepleuritis;3 cardio=6ascular system :heart attack of myocardium3 a5dominal syndrome of

rheumatism; 5elong to them3 gynaecological :adneEitis; and urology :renal colic;3 poisoning3

dia5etic melitus and others like that.

*t the diseases of lungs and pleura :pneumonia and 5asale pleurisy; as a result of irritation

of intercostal ner6es and inflammation of diaphragm surface of peritoneum pain in an a5dominal

region and s8elling of a5domen appear refleEly. %uring palpation of front a5dominal 8all find

out tension of its muscles3 poured out painfulness in a epigastric area. 'he temperature of 5ody

rises3 there is leucocytosis. -igns is resulted reminds such at peritonitis. Ho8e6er the leading

signs of diseases of lungs and pleura is a parafunction eEternal 5reathing 8hich sho8s up the

increase of his fre9uency3 5y the shortness of 5reath and others like that. %uring auscultation of

lungs hearken to the 8heeWes3 during percusion = muffling of `JRUJLO sound. Informationof roentgenologic research of organs of pectoral ca6ity help in diagnostics :darkening is in lungs3

limitation of respiratory eEcursion of diaphragm3 presence of li9uid in pleura ca6ities = at a

pleurisy and others like that;.

*t cardiac diseases :heart attack of myocardium3 a5dominal syndrome of rheumatism;

sometimes in the initial stages appear pain in an a5dominal region3 tension of muscles of front

a5dominal 8all3 paresis of intestinum. /nlike peritonitis3 pain in an a5dominal region is

unsteady3 patients grum5le also a5out pain in the area of heart3 during the leadthrough of

electrocardiography research find out changes3 tipical for the heart diseases.

*t gynaecological diseases3 in particular adneEitis3 5eginning and ran across the um5ilical

ring remind such3 as an acute peritonitis. *s at peritonitis of disease 5egun 8ith acute pain in an

a5dominal region3 tension of muscles in the lo8er half of a5domen3 parafunction intestinum.

Ho8e6er localiWed pain3 as a rule3 is at the 5ottom of a5domen3 panthodic in the area of crotch

and anus3 tension of muscles of front a5dominal 8all less than is eEpressed3 it is found out him

only in the lo8er half of a5domen. (ithout regard to that at adneEitis a pain syndrome is

considera5ly eEpressed3 the state of sick remains satisfactory. %uring a 6aginal inspection the

sickly disco6er and salpinEs3 megascopic sickly o6aries and 6ault of 6agina3 the Promto6Xs

symptom is positi6e3 are incrassate :pain is during displacement of neck of uterus;. !rom data of

ultrasonic research find out the increase of uterus and 5ulge of salpinEs. 'he presence of mucous

festerings confirms the diagnosis of gynaecological disease3 festerings or 5lood eEcretions from a

6agina.

'he alike signs of renal colic and an acute peritonitis is the eEpressed pain in an a5dominalregion3 nausea3 6omit3 paresis of intestinum3 protecti6e tension of muscles of front a5dominal

8all during palpation3 fer6escence. Ho8e6er much pain at a nephrocolic arises up suddenly3 on a

5ackground a satisfactory feel3 as a rule3 in a lum5ar area3 after8ards spreads on all of half of

a5domen3 and e6en on all of a5domen. In maBorities sick a renal colic pain is panthodic along

uterus3 in scrotum3 iliac areas. /nlike acute peritonitis a patient is uneasy3 continuously changes

position of 5ody a5ed.

!or poisoning characteristic dyspepsia signs :6omit3 nausea3 diarrhea; 8hich are preceded

appearance of pain in an a5dominal region3 thus pain of cramp character. *n a5domen is soft3

moderate sickly during palpation3 s8elling of a5domen and the signs of irritation of peritoneum

a5sent.

T,eat(e-t'he modern is nosotropic grounded treatment an acute 8idespread peritonitis is 5ased on

three 5asic principles

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. Implementation of ade9uate operati6e interference is in an eEigent order 8ith

6alua5le sanation of a5dominal region.

2. * leadthrough of 6alua5le anti5acterial therapy is taking into account the

sensiti6eness of the selected eEciters to anti5acterial preparations.

?. ,eadthrough of compleE intensi6e therapy3 directed on the correction of 6iolations

of the functional state of organs and systems of organism3 meta5olic disorders.

Preoperati6e preparation is conducted in the short=term modeC its 6olume is determined thegeneral state of patient and stage of peritonitis.

Important measures is a leadthrough of desintoEication therapy3 correction of 6iolations of

homoeostasis :disorders of 8ater=electrolyte 5alance3 acid=5asic state 5ut other; and measures for

the impro6ement of the functional state of the cardiac and respiratory systems3 and also

anti5acterial3 symptomatic therapy.

Preoperati6e preparation of patients 8ith acute peritonitis in the toEic and terminal stages

is conducted in the separations of reanimation and intensi6e therapy. Intensity of infusion

preoperati6e preparation depends on the stage of acute peritonitis.

'he method of choice of anaesthesia during implementation of operati6e interference

concerning acute 8idespread peritonitis is the com5ined intratracheal anesthesia.

Ba.i# 0,i-#i0%e. of t,eat(e-t a- a#$te 4ide.0,ead 0e,ito-iti.. &arly implementation of operati6e interference3 8hich foresees the remo6al of source of

peritonitis3 effecti6e sanation of a5dominal ca6ity.

*s surgical access is utilliWed middling middle laparotomy. *t a necessity3 depending on

localiWation of hearth of peritonitis3 this access can 5e eEtended bb`JN and do8n8ard. It ena5les

to carry out the 6alua5le re6ision of organs an a5dominal region and its sanation.

*fter opening an a5dominal region 5y sucking delete an eEsudate3 audit its organs for the

eEposure of source of peritonitis. Gegin a re6ision 8ith an a5domen3 farther eEamine a small and

large 5o8el3 gall=5ladder3 organs of small pel6is3 pancreas. (ill li9uidate the source of

peritonitis. 'he 6olume of operati6e interference depends on sho8n of pathological changes in

an organ 8hich entailed peritonitis. 'he special attention is spared the choice of 6olume of

operati6e interference concerning the resection of 5o8el. *t its necrosis after the delete of

non6ia5le area of 5o8el operati6e interference is completed forming the ileostomy or colostomy.

*t the critical condition of patients and presence of dou5tful pathological changes in the 5o8el

of decision of 9uestion in relation to its 6ia5ility and necessity of resection of the staggered

segment put aside on

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%uring the last decade in the compleE of treatment of acute 8idespread festering peritonitis

8idely apply laparoscopy sanation of a5dominal region ad6antage of 8hich is small traumatic.

?. %esintoEication of the digesti6e system and proceeding in the function of 5o8els 5y

e6acuation of maintenance of a5domen 5y the pro5e3 intu5ation of 5o8els3 medicinal and

physical therapy stimulation of his functions3 entered for him.

!or more rapid rene8al the functions of 5o8els conduct early his stimulation 5y cleansing

enemas3 medications :proserini3 u5retid and other;3 realiWation of paranephric 5lockade.*t proof paresis of 5o8els apply the prolonged epidural anaesthesia in com5ination 8ith

raising of cleansing enemas.

A. *nti5acterial therapy 8hich it follo8s to 5egin in the period of preoperation preparation

and continue during implementation of operati6e interference and in a postoperati6e period is

one of maBor constituents of holiatry of acute peritonitis. Presence of hearth of polyinfection and

its toEins in an a5dominal region3 their rapid suction is predetermined a peritoneum start of

reaction of system inflammatory ans8er and cause the origin of syndrome of polyorgans

insufficiency. In this connection a 5asic task of anti5acterial therapy is a 5lockade of

inflammatory reaction at the le6el of micro5al neurohumors of damage.

It follo8s to appoint anti5iotics and other preparations taking into account a sensiti6eness

to them the selected microorganisms. Ho8e6er to get the results of determination ofsensiti6eness of eEciters to the anti5iotics possi5ly only in 2=? days from the 5eginning of

disease. 'herefore in the first days after operati6e interference appoint the anti5iotics of 8ide

spectrum of action :tienam3 meronem;3 that acti6e in relation to gram=negati6e and gram=

positi6e3 aero5ic and anaero5ic microorganisms. *ntianaero5ic action inherent mtragil.

4. It is carried out a general desintoEication organism not only 5y sanation of intestinum3 to

the aEsufflation of his maintenance3 leadthroughs of peritoneal dialysis3 enterosorption3 5ut also

5y realiWation of haemosorption3 lymphosorption3 forced diuresis3 infusion therapy.

solutions of

glucose.

Q. !or the correction of the noted 6iolations3 eEcept for the resulted therapy3 it is eEpedient

to appoint hormonal and anticoagulating preparations of direct and undirect action.

[. 'he important factor of fa6oura5le motion of postoperati6e period is stimulation of

protecti6e forces of organism and imunocorection3 as for patients 8ith acute 8idespread

peritonitis3 as a rule3 find out an immunodeficit noy the state.

@. *s symptomatic therapy3 directed3 a5o6e all things3 on an impro6ement and

normaliWation of acti6ity of the Tardio=6ascular system3 hepatic and kidney 5lood stream3 central

6enous pressure3 sta5iliWing of le6el of arteriotony3 increase of diuresis :to 40=

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normaliWation of functions of all of organs and systems of organism3 can pro6ide con6alescence

sick.

* prognosis at acute 8idespread peritonitis depends on reason 8hich stipulated peritonitis3

6irulence of microflora3 timeliness of diagnostics and implementation of operati6e interference3

directed on the delete of source of peritonitis3 and su5se9uent intensi6e treatment.

In relation to the prognosis of disease actuality is kept 5y a thesis3 formulated 5y -.

-pasokukocky as early as @2< J. 1*t acute peritonitis an operation3 eEecuted at first hour3pro6ides con6alescence @0 > patients3 in the first days = 40 >3 later3 than in ? days = in all 0

>1.

!o.to0e,ati:e #o(0%i#atio-.

'he early signs of postoperati6e peritonitis is 8orsening of the state sick3 8hich it is

impossi5le to eEplain o56ious reasons :a relapse of pain is in an a5dominal region3 increase of

fre9uency of heart=thro5s3 pain during palpation of a5domen;. -ome authors consider the relapse

of pain in an a5dominal region or its strengthening the o5ligatory sign of postoperati6e

peritonitis. 'he fre9uent signs of postoperati6e peritonitis is nausea and 6omit.

Important information is gi6en 5y ultrasonic research and +'3 and also gi6en

roentgenologic research.

If the diagnosis of postoperati6e peritonitis is confirmed3 carry out J`laparotomy3 sanationof a5dominal region3 continue intensi6e therapy. 'han relaparotomy is 5efore eEecuted3 the more

so chances on success.

Most frequent posoperative complications:

. Insol6ency of enteropleEies = accompanied proceeding in a pain syndrome3

8orsening of the state sick3 dryness of tongue3 s8elling of a5domen3 progress of symptoms of

irritation of peritoneum.

2. *5scesses of a5dominal region. ,ocal pain increases at their appearance3 a chill

appears3 the temperature of 5ody 5ecomes hectic. -upposition a5out the presence of a5scess is

confirmed information of ultrasonic and roentgenologic researches. 'reatment is operati6e.

A. &arly postoperati6e o5struction of 5o8els can 5e spike or paralytic3 accompanied

the delay of gases and emptying3 s8elling of a5domen3 presence of o5Becti6e symptoms. *t

paralytic o5struction of 5o8els apply conser6ati6e facilities3 at spike is operati6e interference.

4. -uppuration of 8ound = disco6er often enough3 as a 8ound during implementation

of operati6e interference 9uite often is infected. &6en the leadthrough of anti5acterial therapy

pre6ents de6elopment of this complication not al8ays. If the signs of suppuration appeared3 a

8ound is eEposed3 sanation3 set drainage. -ometimes at suppuration of 8ound there is an

e6entration 8hich re9uires implementation of operati6e interference.

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4. Postoperati6e complications an acute peritonitis their diagnostics3 prophylaEis and treatment.

;"/" !,a#ti#a% 4o,3. ta.32 4'i#' a,e e

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2. 'he Pt.3

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hearkened the peristalsis. ,a5oratory leucocytes 7 Q32N0@^l. (hat complication of mechanical

intestinal o5struction did arise up for this patient

*. %estructi6e pancreatitis

G. Peritonitis is 8idespread

+. Interintestinal a5scess

%. *5scess of %uglas space

&. Pylefle5itis

Q.'he Pt. ,.3 @ years old3 hospitaliWed in a surgical department 8ith the clinic of acute

appendicitis. *t implementation of operati6e interference3 after opening of peritoneal ca6ity

found out the gangrenous changed appendiE. In the lo8er departments of a5domen sero=purulent

eEsudate. Parietal peritoneum of suprapu5ic3 right and left illiac areas3 8ith local hemorrhages.

(hat complication of acute appendicitis did arise up at this patient

*. %iffuse seropurulent peritonitis

G. ,ocal peritonitis

+. *5scess of %uglas space

%. Interintestinal a5scess&. -erous peritonitis

[.'he Pt3 %.3 4< years old3 entered surgical department 8ith the clinic of acute destructi6e

pancreatitis. %efance is o5Becti6ely determined and painfulness a5domen in the proBection of

pancreas3 8here immo5ile tumular education palpation. ,a5oratory leucocytes 7 23AN0@^l.

'emperature of 5ody in the morning 7 ?Q3[\]3 in the e6ening 7 ?@3[\]. "n +' 5et8een the 5ack

8all of a5domen and pancreas 5y 6olume education 8hich contains a li9uid is determined. (hat

complication of acute pancreatitis did arise up for this patient

*. !ermentati6e cholecystitis

G. *5scess of retroperitoneal space

+. *5dominal mass

%. *5scess of omentum 5ag

&. *5sces of %uglasX space

@. 'he Pt3 A2 years old3 during the leadthrough of operati6e interference concerning a destructi6e

pancreatitis in all of departments of peritoneal ca6ity found out3 hyperemia of parietal

peritoneum and far of serosal=hemorragic eEsudate. (hat complication of pancreatitis did arise

up for this patient

*. Feneral serosal=hemorragic peritonitis

G. Haemoperitoneum+. ,ocal peritonitis

%. %iffuse sero=purulent peritonitis

&. ,ocal peritonitis

0. 'he Pt3 ?@ years old3 entered surgical department 8ith complaints a5out permanent pains in

all=o8er of a5domen3 nausea3 dryness3 general 8eakness. It is kno8n from anamnesis3 that is ill

during A[ hours. Geginning of disease a patient does not link 8ith anything. "5Becti6ely an

a5domen is su5=inflated3 resistance and sickly. 'he Glyum5erg=-chotkinXs3 #oWdolskiyXs signs

are positi6e. * peristalsis is hyposthenic. ,a5oratory leucocytes 7

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*. /rgent operati6e interference

G. %ynamic super6ision

+. "P% treatment

%. -ymptomatic therapy

&. %ynamic permanent esta5lishment

;"" Te.t. fo, .e%f*#o-t,o%). 'he 5asic pathogenic mechanisms of peritonitis are

*. &ndotoEicosis

G. *cid 6iolations

+. iolation of eEchange of al5umens

%. *d6antage of ana5olism

&. Inflammatory process is in a peritoneal ca6ity

2. Gasic 8ays of distri5ution of toEins are at peritonitis

*. isceral lymphatic system

G. -ystems of portal 6ein

+. -ystems of 6. ca6a superior%. -ystems of 6. ca6a inferior

&. Parietal lymphatic system

?. 'he characteristic displays of the poured out peritonitis at a la5oratory eEamination are

*. ,eykocytosis

G. Presence of ,&=cells

+. Increase of concentration of urea and creatinini

%. Fro8th of acti6ity of diastase

&. Fro8th of acti6ity of aminotransferasis

A. *t the poured out peritonitis anti5iotics are entered*. "rally

G. Intramuscular

+. Intra6enously

%. &ndolimphatic

&. Indicated all 8ays

4. Indications to operati6e interference at the poured out peritonitis is

*. *5sence effect 5y conser6ati6e treatment during 2=2A hours

G. 'he patients 8ith no concomitant pathology

+. *n operation is a5solutely indication all of patients 8ith the set diagnosis

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[. (hat stage of peritonitis a clinical picture is identical in3 regardless of reason of his origin

*. 'o the reacti6e

G. 'o the toEic

+. 'o the neutral

@. 'he signs of irritation of parietal peritoneum are*. 'he Gurney=olko6ichXs sign

G. 'he oskresenskiyXs :shirts; sign

+. 'he #oWdolskiyXs sign

%. 'he Glyum5erg=-chotkinXs sign

&. the "5raWco6Xs sign

0. *t 8idespread peritonitis at auscultation of a5domen heard

*. * peristalsis is increased

G. #espiratory and cardiac noises

+. $ot hearkened to intestinal noises

" Lite,at$,e

. Hospital surgery ^ &dited 5y ,. )o6alchuk3 . -ayenko3 F. )nyso63 . $ychytailo . 7

'ernopil /krmedknyga3 200A. 7 AQ2 p.

2. 'eEt5ook of surgery :third edition; ^ &dited 5y -. %as. 7 +alcutta 200. 7 ?2A p.

?. -=AA?@. ,iechty #.%.3 -oper #.'. !undamentals of surgery