Acute peritonitis: Need early surgery

The article was professionally consulted by MSc Vu Van Quan - Department of General Surgery & Anesthesia, Vinmec Hai Phong International General Hospital. The doctor has more than 10 years of experience working in the field of General Gastroenterology.

Acute peritonitis is a serious disease, if not treated promptly, the patient will have a high risk of death. Surgery for acute peritonitis should be performed as soon as possible on the basis of active resuscitation.

The peritoneum is the largest serosal membrane in the body, composed of parietal and visceral leaves. Parietal leaves lining the inner wall of the abdomen and pelvis. Visceral leaves cover the organs in the abdomen. The space between the parietal and visceral leaves is called the peritoneal cavity. The peritoneal cavity contains a little fluid, which reduces the contact between organs. The peritoneum has an important function to help cover and protect the internal organs. When there is an infection, the peritoneum tends to make a wall around to localize the infection.
Peritonitis is an inflammation of the peritoneum, usually caused by a bacterial or fungal infection. According to disease progression, peritonitis can be divided into acute generalized peritonitis and focal peritonitis. According to the etiology of the disease, it can be divided into primary peritonitis and secondary peritonitis.

Primary peritonitis: accounts for only about 1% of cases of acute peritonitis, usually in children under 10 years of age, rarely in adults. The peritoneum is self-injured from the beginning due to agents such as tuberculosis, pneumococcal bacteria, streptococcus,.. These agents enter the peritoneum by blood, lymphatic routes, without damage to intra-abdominal organs. . Secondary peritonitis: Usually caused by an infection of an intra-abdominal viscera, then diffuse or rupture. Secondary peritonitis accounts for 99% of clinical cases of acute peritonitis. The peritoneum is infected with many bacteria, usually E.coli, Klebsiella pneumoniae, B.flagilis, Streptococcus, Enterococcus, Clostridium,... Common causes of secondary peritonitis are: ruptured appendicitis, perforated pouch appendicitis, peptic ulcer perforation, necrotizing volvulus, cholecystitis, ruptured liver abscess, pancreatitis, pelvic inflammatory disease (uterus, appendages), abdominal trauma, penetrating wound, ...

Symptoms of acute peritonitis vary widely depending on the cause. Common symptoms include:
Constant abdominal pain, initially localized, then diffused Vomiting, hiccups Passing bowel movements, sometimes diarrhea Stiff abdominal muscles, peritoneal tenderness Infection: high fever , rapid pulse, dirty tongue, dry lips, rapid shallow breathing, bad breath Drowsiness, slurred speech, nervous anxiety, when awake and in coma, sunken eyes, emaciated face, rapid pulse, hypothermia, oliguria or anuria. The doctor will diagnose acute peritonitis based on physical examination and laboratory techniques.
If the patient is young, healthy, and comes to the clinic early, the doctor often finds the abdominal wall stiff with symptoms such as: when pressing on the abdomen, it feels as hard as wood, the abdomen does not participate in breathing, and the straight muscles are prominent. On percussion, free air in the peritoneal cavity can be detected, decreased intestinal motility is heard, and Douglas' sign is bulging and painful. If the patient arrives late in the month, there may be no signs of abdominal cramping, the patient has symptoms of intestinal obstruction, the abdomen is resistant, the general condition changes,... Clinical examination: increased white blood cell count, white blood cell count left shift bridge, Hematocrit increased due to dehydration, electrolyte disturbances, blood urea increased,... X-ray film can show specific signs for each cause of peritonitis such as water level, blood level. gas in intestinal obstruction, crescent below diaphragm in perforated peptic ulcer,... Abdominal effusion is the most important test for diagnosing peritonitis. Endoscopy and culture of abdominal fluid to identify pathogenic bacteria.

Acute peritonitis is a serious disease, if not treated promptly, the patient will have a high risk of death. With primary peritonitis, the infection can be treated with empiric antibiotics. After having the results of the antibiogram, the treatment is according to the antibiotic chart. Duration of treatment is 5-14 days depending on the patient's response.
For secondary acute peritonitis, the principle of treatment is a combination of active resuscitation and surgical surgery. Medical treatment helps to resuscitate, provide energy, reduce infection, prevent shock and multi-organ failure. While surgical surgery eliminates the cause and clears the infection.
3.1 Intensive resuscitation The patient will be given fluids and electrolytes to rehydrate and electrolytes. Adjust acid-base balance, ensure respiration, body temperature,... Strong, broad-spectrum antibiotics, if available, use antibiotics according to the antibiotic chart.

3.2 Surgery for acute peritonitis Patients should be operated on for acute peritonitis as soon as possible on the basis of active resuscitation. It is possible to both resuscitate and operate if the patient's condition is too urgent. Interventions vary widely depending on the cause of the peritonitis. In each cause, there are many treatment methods, the choice of which method depends on the condition of the abdominal cavity and the patient's condition.
The method of puncture combined with abdominal drainage: is a method of diagnosis and treatment that is commonly used today. The advantage of this method is that it is gentle, less invasive, and highly effective in some special cases. Often applied in cases of abdominal abscess due to various causes such as appendix, diverticulum, ruptured liver abscess,... Laparoscopic surgery: has advantages such as less invasiveness, quick patient recovery, less complications, less scarring,... Laparoscopic surgery is indicated in many cases such as: appendicitis, diverticulitis, adnexitis, perforation of hollow viscera, cholangitis, abscess Broken liver, penetrating abdominal wound, trauma, necrotic intestinal volvulus,...

Laparotomy: laparotomy for lesion management still plays an important role in the treatment of peritonitis, but indications for this type of surgery are decreasing due to the development of other less invasive techniques. . Indications for laparotomy to treat lesions depend on the cause of the disease (patients with severe generalized peritonitis due to visceral perforation, complications of previous surgery or the inability to intervene through laparoscopic surgery, ...) and patient status (patients with contraindications to laparoscopic surgery). When performing surgery for acute peritonitis, it is necessary to choose an appropriate entrance (skin incision or trocar location), which helps to find the cause and treat the lesion, clean the abdominal cavity, and limit the risk of infection. cut. Conduct injury assessment, treat the cause and clean the abdominal cavity. Then drain and pick up the abdomen.
After surgery, the patient needs to continue medical treatment to resuscitate after surgery. Diet according to the disease situation and surgical method. If the postoperative condition is stable, early mobilization is encouraged.
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