Peritonitis
| Classification according to ICD-10 | |
|---|---|
| K65.0 | Acute peritonitis |
| K65.8 | Other peritonitis |
| K65.9 | Peritonitis, unspecified |
| ICD-10 online (WHO version 2019) | |
The peritonitis or peritoneal inflammation is a life threatening infection of the peritoneum (the peritoneum). If the peritonitis is localized, it is called local peritonitis. If it affects the entire peritoneum, it is a diffuse (generalized) peritonitis.
A Pseudoperitonitis even Scheinperitonitis called, often occurs in the disease process of diabetic coma , the acute intermittent porphyria or Addison's crisis on. The cause is largely unclear.
Symptoms, findings and diagnosis
A local peritonitis caused mostly a strong but localized abdominal pain (eg. As acute perforated appendicitis ).
In addition to severe acute abdominal pain, a characteristic feature of diffuse peritonitis is an increasing defensive tension of the entire abdominal muscles , which can increase to a hard stomach, and a disruption of the intestinal function.
Peritonitis is only rarely an independent disease, but a key symptom that has been described in more detail since the 18th century . The acute generalized peritonitis manifests itself in an acute abdomen with paralytic ileus . In addition, the abdominal complaints from various causes are accompanied by general complaints. These can range from fever, nausea, nausea, vomiting to symptoms of shock and multiple organ failure due to the formation of microthrombi.
Peritonitis can be divided into community-acquired and nosocomial forms, as well as:
- Primary peritonitis (including peritonitis due to liver cirrhosis, liver inflammation and ascites as well as spontaneous juvenile peritonis of hematogenous origin)
- Secondary peritonitis (with around 80% of all peritonitis the most common form with the main causes of perforation of hollow organs and leakage, e.g. after gastric perforation, acute gallbladder inflammation or perforated appendicitis and postoperative peritonitis)
- Tertiary peritonitis (persistent peritonitis despite adequate surgical and antimicrobial therapy).
causes
Peritonitis is caused by an intra-abdominal infection. According to the cause, a distinction is made between the primary, often spontaneously (hematogenous) peritonitis occurring in a systemic infection, from the secondary, perforation or migration peritonitis, usually arising from the gastrointestinal tract.
The most common cause of peritonitis is still acute perforated appendicitis today . The germs released here are mostly Escherichia coli , enterococci , less often salmonella , streptococci or staphylococci . A perityphlitic abscess also leads to peritonitis. Tuberculosis (called peritoneal tuberculosis ) can also cause inflammation of the peritoneum ( tuberculous peritonitis ). The biliary colic is accepted by many patients still as troublesome symptom of their known gallstone disease, it is acute cholecystitis now the most common cause of upper abdominal peritonitis. In the differential diagnosis of this clinical picture, acute inflammation of the pancreas must also be considered.
The perforation of a duodenal ulcer has become rather rare due to the treatment of this disease ( Helicobacter eradication ).
The diverticulitis , is moved up by the appendicitis to the second most common cause of pelvic peritonitis. Severe inflammation of the internal sexual organs in women (purulent fallopian tube inflammation ) can also trigger this clinical picture.
Peritonitis can also occur as a result of an untreated intestinal obstruction, either due to the escape of germs from the thin, mechanically damaged serosa ( migration peritonitis due to gaps between mesothelial cells called stomata ) or due to the rupture of the pent-up intestine. Immigration peritonitis can also result from necrosis of the intestine during mesenteric infarction .
Other causes of peritonitis can be perforating intestinal injuries due to foreign bodies or perforating abdominal injuries (stab and gunshot wounds). In addition, the familial Mediterranean fever , which is rare in Central Europe, can u. a. cause peritonitis.
Peritonitis is also the most common complication of peritoneal dialysis . Even under aseptic conditions, peritonitis occurs approximately once in 16 to 24 months of treatment. This can be caused by non-sterile work on the peritoneal catheter, a leak on the catheter, non-sterile rinsing solution or an infection at the catheter outlet.
The peritoneal is in clinical parlance as peritonitis carcinomatosis called: The extensive tumor seeding to the peritoneum here leads to a primarily non-bacterial inflammatory response, often with severe ascites .
Ultimately, the penetration of urine into the abdomen, for example after traumatic injuries to the urinary bladder, leads to peritonitis, which is known as the uroperitoneum .
Differential diagnosis
Some diseases can clinically simulate peritonitis.
The preliminary stage of the mesenteric infarction , the so-called angina abdominalis , often leads to the appearance of the acute abdomen , without the presence of peritonitis.
The beginning ketoacidotic coma in (mostly young) diabetics can also simulate acute peritonitis ( pseudoperitonitis diabetic ).
Clinical symptoms
With local peritonitis (e.g. acute, imperforate appendicitis), there is usually local pressure pain in the abdominal wall, possibly also pain in letting go and local defensive tension, and pain triggered by tensioning certain muscles ( psoas stretching pain ) ; Spontaneous pain can be absent (“I don't hurt anything when I am lying down”). The general condition is often only slightly impaired, fever may be present or absent. The intestinal noises are at best slightly reduced.
With generalized peritonitis, the patient looks seriously ill at first glance ( hippocratic facies ). The face looks sunken, gray, the breathing is shallow, the pulse accelerated, the blood pressure low, but sometimes also very high. The legs are drawn up while lying down. The abdominal wall is very tense ( "board-hard abdomen" ), every touch, even light tapping, causes severe pain. Bowel noises are barely audible, if at all. Usually there is a high fever. This clinical picture is also summarized under the term acute abdomen .
In very old, frail patients, a large part of these symptoms can be absent, for example due to stunted ( atrophic ) abdominal muscles that can no longer provide tension.
In addition to abdominal pain, the first symptom of peritoneal dialysis is the opacity of the dialysate, which is caused by the increased leukocyte count. In addition, the amount of ultrafiltration can decrease significantly, so that there is also the risk of overwatering.
Diagnosis
Laboratory chemical and apparatus-based diagnostic methods help in making the diagnosis and often also provide information on the cause of the peritonitis. The list is then limited to acute, generalized peritonitis.
Laboratory chemical investigations
In the early stage of acute peritonitis, the two most important inflammatory parameters are particularly noticeable: the blood count shows a significant increase in the number of leukocytes , and CRP is also greatly increased. The ESR (blood sedimentation) is also greatly accelerated, in the field of surgery , however, this parameter is no longer used routinely due to its low specificity.
In the advanced stage, further pathological findings are found in the laboratory: changes in the coagulation parameters (drop in platelet count , increase in fibrinogen concentration , loss of prothrombin and tissue factor ) are signs of consumption coagulopathy ; Worsening of kidney function values (increase in urea and creatinine in the blood), liver values (increase in transaminases , decrease in cholinesterase ) and decrease in hemoglobin values are signs of the onset of multi-organ failure .
Sonography
The ultrasound examination of the abdomen usually reveals free fluid and / or free air in the abdominal cavity. The reduced motility (proper movement) of the intestine is also visible here . In many cases, sonography succeeds in narrowing down the cause of the peritonitis (gall bladder perforation, large intestinal mileus with perforation, pancreatitis, etc.).
X-ray examination
The radiological examination of the abdomen - usually a simple blank image of the abdomen without contrast agent while standing or lying on the left side - can show free air (as a sign of a hollow organ perforation ) and / or the presence of a bowel arrest . A computed tomography or magnetic resonance imaging may also give clues to the cause of peritonitis.
surgery
In cases of doubt, intra-abdominal diagnosis is carried out using an exploratory laparoscopy or propelaparotomy .
therapy
Operative treatment
In addition to drug antimicrobial therapy, acute peritonitis therapy is always surgical. The time of the operation is set as early as possible, since the clinical picture usually takes a rapidly progressive , often even fuzzy course. The basic principles of surgical therapy are:
- Elimination (elimination) of the focus of inflammation, i.e. definitive surgical treatment of the underlying disease or injury
- Removal of toxic material such as necroses , pus and fibrin coatings ( debridement and abdominal lavage )
- Complete discharge of the infectious material from all areas of the abdominal cavity ( drainage )
Surgical treatment of the underlying disease - depending on the cause of the peritonitis - includes : appendectomy , cholecystectomy , sigmoid resection or corresponding resection of other sections of the intestine, excision and suturing of a perforated duodenal ulcer and a few others. In the context of peritonitis, a necessary anastomosis is usually preceded by an enterostomy ("artificial anus"), since the risk of anastomotic leakage is always significantly higher in an inflammatory environment. The enterostoma prevents pressure on the anastomosis caused by gas formation and protects the abdominal cavity from leakage of intestinal contents in the event of an insufficiency.
Depending on the time of the first intervention, necroses can be found e.g. B. the great web , the mesentery or other tissues. These must be removed as completely as possible ( debridement ), as they are an ideal breeding ground for bacteria, which maintain the inflammation. The purulent ascites , which is usually present in large quantities, must also be completely removed by rinsing with physiological saline or Ringer's solution ( lavage ). Finally, the abdominal cavity is rinsed with an antiseptic solution , usually taurolidine .
Since the inflamed peritoneum still produces plenty of exudate after the operation , which is also a good breeding ground for germs, it is drained from all four quadrants of the abdominal cavity through large-lumen drainage . If there is no improvement in the clinical condition, an operative revision is carried out.
So far, a distinction has essentially been made between three approaches to surgical therapy: closed, continuous peritoneal lavage , stage lavage through planned relaparotomies, and which was developed in the 1970s by Ernst Kern and his team at the Würzburg Surgical University Clinic for the "open" treatment of severe peritonitis Open abdomen procedure ("open package").
Intensive medical accompanying therapy
Since acute purulent peritonitis is a severe septic clinical picture with correspondingly diverse complications (see below), postoperative treatment is carried out in an intensive care unit as far as possible .
The patient is often re-ventilated until the clinical condition and the laboratory test results show a clear improvement. Post-ventilation facilitates the high-dose analgesia required , as there is no need to take into account the respiratory depressive side effects of the analgesics used , usually opiates and opioids such as fentanyl or hydromorphone , which are administered intravenously using a syringe pump . In addition, the optimal oxygenation (oxygen enrichment) of the blood supports the organism in the body's defense against infection, which is significantly reduced under hypoxia .
The systemic therapy is carried out by high-dose administration of an appropriate combination of broad-spectrum antibiotics and antifungals (e.g., B. Piperacillin + metronidazole + fluconazole ) that the resistance layer to be adapted of the found germs.
→ For special intensive medical therapy of sepsis see there .
forecast
Depending on the severity and concomitant diseases, the mortality ( lethality ) ranges from almost 0 to over 50%. The Mannheim Peritonitis Index is available to estimate mortality .
Peritonitis in animals
Common causes of peritonitis in animals are injuries to the abdominal wall, ruptures of the gallbladder due to blunt trauma (horse kick) or severe diseases of the gallbladder (biliary peritonitis), foreign bodies or tumors that perforate the intestinal wall, injuries and ruptures of the uterus during childbirth or after pyometra , Ruptures of the urinary bladder and injuries to the rectum from improper rectal examination . In cats there is a viral infection with FIP , which manifests itself primarily as peritonitis. In cattle, foreign bodies that perforate the reticulum are the main cause of peritonitis.
The clinical picture, diagnosis and treatment largely correspond to those of human peritonitis; only FIP is not treated.
literature
- Richard W. Nelson and CG Couto: Internal Medicine of Small Animals. Elsevier, Urban & Fischer, Munich 2006, ISBN 3-437-57040-4 .
- Walied Abdulla: Interdisciplinary Intensive Care Medicine. Urban & Fischer, Munich a. a. 1999, ISBN 3-437-41410-0 , pp. 486-488 ( peritonitis ).
- Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , pp. 119-124 ( peritonitis ).
- Alexander L. Gerbes, Veit Gülberg, Tilman Sauerbruch, Reiner Wiest, Beate Appenrodt, Matthias J. Bahr, Matthias M. Dollinger, Martin Rössle, Michael Schepke: S3 guideline ascites, spontaneous bacterial peritonitis, hepatorenal syndrome. In: Journal of Gastroenterology. Volume 49, number 6, 2011, pp. 749-779, doi : 10.1055 / s-0031-1273405 .
- Hans Adolf Kühn: Inflammatory diseases of the peritonaeum. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition ibid. 1961, pp. 843-846.
Web links
- More information about peritonitis (English)
Individual evidence
- ↑ Gundolf Keil : Peritonitis therapy in historical review. (Lecture given on September 11, 1997) In: Würzburger medical-historical reports. Volume 17, 1998, pp. 251-259, here: pp. 253-255.
- ^ Marianne Abele-Horn: Antimicrobial Therapy. 2009, pp. 119-122.
- ↑ Walied Abdulla (1999), p. 487.
- ↑ Walied Abdulla (1999), p. 486.
- ↑ Hans E. Franz (Ed.): Dialysis for nursing professions. 2nd, revised edition. Thieme, Stuttgart et al. 1996, ISBN 3-13-781402-2 , p. 175.
- ↑ Dan Mischianu, Ovidiu Bratu Cristian Ilie, Victor Madan: Notes Concerning the peritonitis of urinary aetiology. In: Journal of medicine and life. Volume 1, Number 1, 2008 Jan-Mar, pp. 66-71, PMID 20108482 , PMC 3018956 (free full text).
- ↑ Walied Abdulla (1999), p. 487.
- ↑ Ernst Kern: Seeing - Thinking - Acting of a surgeon in the 20th century. ecomed, Landsberg am Lech 2000, ISBN 3-609-20149-5 , p. 24.
- ↑ Walied Abdulla (1999), p. 487 f.
