Overview of chemical peritonitis
Chemical peritonitis is a condition in which intrinsic or extrinsic chemicals enter the peritoneal cavity due to a variety of etiologic factors and strongly stimulate the peritoneum to undergo chemical inflammation, accompanied by peritonitis symptoms and signs. Chemical peritonitis is an early stage of peritonitis when there is no bacterial colonization of the peritoneal exudate. Subsequent secondary bacterial infections can develop into septic peritonitis.
Etiology
Chemical peritonitis can be caused by bile, pancreatic fluid, gastric fluid, meconium, and radiographic contrast media.
Symptoms
1. Abdominal pain
This is the most important symptom of chemical peritonitis. It is usually severe, intolerable and persistent. The pain can be aggravated by deep breathing, coughing and turning the body. Therefore, the patient can not change the position, the pain starts from the primary focus, the inflammation spreads and spreads to the whole abdomen, but the primary lesion is still the most significant.
2. Nausea and vomiting
This is a common symptom in the early stage. At the beginning, the peritoneal stimulation causes reflex nausea and vomiting, and the vomit is gastric contents. When paralytic intestinal obstruction occurs in the later stage, the vomit will turn into yellowish green or even brown fecal-like intestinal contents.
3. Fever
Sudden onset of peritonitis can start with normal temperature, and then gradually increase. In the elderly and debilitated, the body temperature does not necessarily rise as the disease worsens. The pulse usually increases with temperature.
4. Infectious poisoning
When peritonitis enters the severe stage, there are often signs of systemic toxicity such as high fever, dry mouth, rapid pulse and shallow respiration. In the later stage, due to the absorption of large amount of toxin, the patient will have apathy, emaciation, sunken eye sockets, cyanosis of lips and mouth, cold limbs, yellow and dry tongue, dry skin, shortness of breath, weak pulse, sharp rise or fall of body temperature, fall of blood pressure, shock, acidosis and other systemic symptoms of infection and poisoning.
5. Abdominal signs
Abdominal breathing is weakened or disappeared, accompanied by obvious abdominal distension. Pressure pain and rebound pain are the main signs of peritonitis, which are always present, usually throughout the abdomen and most prominent at the site of the primary lesion.
Examination
1. Laboratory examination
(1) Blood tests
There is often an elevated white blood cell count (10-20)×109/L and elevated neutrophils, especially when combined with infection. When there is a lot of exudation from the abdominal cavity, the blood may be concentrated, and the red blood cells and hemoglobin may increase instead of decreasing.
(2) Blood biochemistry examination
Some patients may have elevated blood bilirubin and alkaline phosphatase levels, and elevated serum total bile acids.
(3) Laparotomy
Deep yellow fluid may be found in the aspirate of laparotomy.
2. Imaging examination
(1) Radionuclide diagnosis
Radioactive 131 Ⅰ tetrachlorofluorescein sodium, absorbed by hepatic polygonal cells and eliminated through the bile ducts, so it can reflect the polygonal cells and bile duct patency. After injecting 131Ⅰtetrachlorofluorescein from the vein, the presence of the substance from the ascites helps to diagnose whether the patient has active bile leakage.
(2) ERCP examination
ERCP or intraoperative cholangiography with the finding of contrast agent leaking into the abdominal cavity helps to find the site of bile leakage or biliary perforation.
(3) Abdominal X-ray
The findings are non-specific and can be used to rule out gastrointestinal perforation and other causes of abdominal pain. Indirect X-ray signs of gallbladder perforation include an enlarged soft tissue shadow in the gallbladder area, reflex intestinal sludge in the small intestine below the gallbladder, or disappearance of the right side of the abdominal fat line, or a right pleural effusion.
(4) CT and ultrasonography
Imaging examination helps in the diagnosis of biliary peritonitis. In the process of examination, it is necessary to observe in multiple sections, trying to show the notch of the gallbladder wall, and pay attention to observe the flow of fluid at the notch with respiratory movement. Ultrasonography of gallbladder perforation may reveal ascites, increased gallbladder volume or reduced gallbladder lumen, thickened gallbladder wall, intracapsular stones, and more fluid around the bile duct.
Diagnosis
1. Ask in detail about the time and process of onset of disease, whether there is any history of trauma, abdominal surgery, operation of medical instruments, extraction of T-tube, as well as cholecystitis and cholelithiasis. Whether there is jaundice, biliary colic, chills and other manifestations in the pre-morbid period.
2. Acute onset with sudden onset of severe abdominal pain, starting from the right upper abdomen and gradually spreading to the whole abdomen.
3. Peritoneal puncture fluid or peritoneal lavage fluid, yellowish green, yellowish, yellow color to the naked eye, elevated bilirubin and elevated total bile acid content in ascites.
4. Positive radionuclide intravenous test.
Treatment
1. Non-surgical treatment
(1) Body position
In the absence of shock, the patient should take the semi-recumbent position to facilitate drainage treatment. Semi-recumbent position should often move the two lower limbs, change the pressure parts, in order to prevent venous thrombosis and pressure sores.
(2) Fasting
Patients with gastrointestinal perforation must be absolutely fasting to reduce the gastrointestinal contents continue to leak out.
(3) Gastrointestinal decompression
It can reduce the swelling of gastrointestinal tract, improve the blood flow of gastrointestinal wall, and reduce the leakage of gastrointestinal contents into the abdominal cavity through the breach.
(4) Intravenous infusion of crystalloid fluid
Fasting patients with peritonitis must be given fluids to correct water-electrolyte and acid-base imbalances. Plasma and albumin should be entered as appropriate in patients with severe failure to replace protein lost due to peritoneal leakage and to prevent hypoproteinemia and anemia.
(5) Supplemental calories and nutrition
Peritonitis requires a large amount of calories and nutrition to supplement its needs, and compound amino acid solution should be given to reduce the consumption of protein in the body, and deep vein hyper-nutritional therapy should be considered for patients who cannot eat for a long time.
(6) Application of antibiotics
High-dose broad-spectrum antibiotics should be used in the early stage, and then adjusted according to the results of bacterial culture. Choose sensitive antibiotics, such as chloramphenicol, clindamycin, metronidazole, gentamicin, aminobenzylpenicillin and so on. For gram-negative bacillus sepsis, third-generation cephalosporins, such as bacteriophage, can be used.
(7) Analgesia
For patients whose diagnosis has been clearly defined and treatment has been determined, dulcolax or morphine is used for pain relief. However, if the diagnosis has not yet been determined, and the patient still needs to be observed, it is not appropriate to use analgesics, so as not to cover up the condition.
2.Surgical treatment
(1) Treatment of lesions
The earlier the source of infection is removed by surgery, the better the prognosis of the patient. In principle, the closer the surgical incision is to the lesion, the better it is, and a straight incision is preferred, which is easy to extend up and down, and is suitable for changing the surgical method.
(2) Cleaning the abdominal cavity
After eliminating the cause of the disease, pus should be sucked out of the abdominal cavity as much as possible, and food and residue, feces and foreign bodies should be removed from the abdominal cavity.
(3) Drainage
The purpose is to make the seepage that continues to be produced in the abdominal cavity to be discharged out of the body through drainage, so that the remaining inflammation can be controlled, confined and disappeared, and the occurrence of abdominal abscess can be prevented. Drainage is usually not needed after surgery for diffuse peritonitis as long as it is cleaned. However, abdominal drainage must be placed in the following cases: ① the necrotic lesion is not completely removed or there is a large amount of necrotic material that cannot be removed; ② there is a large amount of oozing or seepage of blood from the surgical site; ③ a limited abscess has formed.