Spontaneous bacterial peritonitis (SBP) is a common and serious complication in patients with cirrhotic ascites. It is an abdominal infection caused by pathogenic bacteria via the intestinal tract, blood or lymphatic system, and occurs in the abdominal cavity without a direct source of bacterial infection in the adjacent organs in the abdominal cavity (e.g. intestinal perforation, intestinal abscess). It is an important cause of death in patients with end-stage liver disease. The incidence of SBP in patients with decompensated cirrhosis is l0%-47%, and the death rate is 48%-57%, but with the improvement of early diagnosis and treatment of SBP, the death rate has decreased, but the death rate is still in the range of 20%-40%. Therefore, it is necessary to actively prevent the occurrence of SBP, diagnose and treat it early, so as to reduce its incidence and death rate.
I. Non-surgical treatment
1.Position
In the absence of shock, the patient should be placed in a semi-recumbent position to facilitate drainage treatment. When semi-recumbent position, the patient should move both lower limbs frequently and change the pressurized parts to prevent venous thrombosis and pressure sores.
2.Fasting
Patients with gastrointestinal perforation must be absolutely fasted to reduce the continued leakage of gastrointestinal contents.
3.Gastrointestinal decompression
It can reduce the expansion of gastrointestinal tract, improve the blood flow of gastrointestinal wall, and reduce the leakage of gastrointestinal contents into the abdominal cavity through the rupture.
4.Intravenous input of crystalloid fluid
Patients with peritonitis fasting must be given fluids to correct water-electrolyte and acid-base imbalance. More blood and plasma should be transfused to patients with severe failure, and albumin to replenish protein lost due to peritoneal exudation to prevent hypoproteinemia and anemia.
5, supplemental heat and nutrition
Peritonitis needs a lot of heat and nutrition to make up for its needs, compound amino acid solution should be given to reduce the consumption of protein in the body, and deep vein high nutrition therapy should be considered for patients who cannot eat for a long time.
6, the application of antibiotics
In the early stage, a large number of broad-spectrum antibiotics should be used, and then adjusted according to the results of bacterial culture. Select sensitive antibiotics, such as chloramphenicol, clindamycin, metronidazole, gentamicin, aminobenzyl penicillin, etc. For Gram-negative bacillus sepsis, third-generation cephalosporins can be used, such as bacteriophage, etc.
7.Analgesia
For patients whose diagnosis is clear and treatment method has been determined, use Dulcolax or morphine for pain relief. However, if the diagnosis has not yet been determined and the patient needs to be observed, analgesics should not be used to avoid masking the disease.
II. Surgical treatment
1. Treatment of lesion
In principle, the closer the surgical incision should be to the site of the lesion, the better, and a straight incision is appropriate to facilitate up and down extension and to change the surgical method.
2, clean up the abdominal cavity
After eliminating the cause of the disease, the pus in the abdominal cavity should be sucked out as much as possible, and the food and residue, feces and foreign bodies in the abdominal cavity should be removed.
3.Drainage
The purpose is to make the exudate that continues to be produced in the abdominal cavity to be discharged through drainage so that the remaining inflammation can be controlled, limited and disappeared. To prevent the occurrence of abdominal abscess. Drainage is not usually necessary after surgery for diffuse peritonitis as long as it is cleaned.
However, abdominal drainage must be placed in the following cases.
① necrotic lesions are not completely removed or there is a large amount of necrotic material that cannot be removed;
(ii) there is a large amount of exudate or oozing blood from the surgical site;
(iii) a limited abscess has formed.