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1、Acutesuppurative化脓化脓的的peritonitis腹膜炎腹膜炎PeritoneumvPeritoneumisamembranethatcoversthesurfaceofboththeorgansthatlieintheabdominalcavityandtheinnersurfaceoftheabdominalcavityitself.PeritoneumPeritoneum1.Secrete2.Absorb3.Defense4.Rehablubricate the internal organs(150ml)1effusion & blood & air2phagocyti
2、c cell3anti-infection of fibrin4DefinitionvAkindofacuteinflammationresultedfromthestimulationwhichcausedbybacterialinfection,injuryordigestivejuices,urine,bloodandsoon.vItisacommonsurgicalcriticalillnesswhichmostlyrequiressurgicaltreatmenttosavepatientslives.ClassificationvBacterial&nonbacterialvAcu
3、te&subacute&chronicvPrimary&secondaryvDiffusivity&limitation(aquarterquadrant)Abdomenzoning2MajorTypesvPrimaryThereisnoprimarydiseaseinperitonealcavityorwithunknownetiologyofperitonitiscalledprimaryperitonitisalsoknownasspontaneousbacterialperitonitis.vThepathogensmostlyarehemolyticstreptococci,stre
4、ptococcuspneumonia【溶溶血链球菌血链球菌】orE.coil.引起的腹腔渗液不同引起的腹腔渗液不同vHaematogenousupper respiratory tract, urinary tract infection the bacteremia peritonitis(children and infants)vRetrogradeinfectionreproductive tract abdominal cavityvDirectdiffusionperitoneal layer peritoneal cavity(urinary tract is infected)
5、vTransmuralinfectionintestinal wall the abdominal cavity (cirrhosis, kidney disease, scarlet fever or malnutrition)2MajorTypes2MajorTypesvSecondaryvAkindacuteperitonitiswhichsecondaryinjuriesintheabdominalvisceralperforationdamage,ruptureandinflammationwhichaccountedfor98%oftheperitonitis.vThepathog
6、ensmainlyareintestinalfloras,suchasthemostcase-Escherichiacoli,streptococcus,proteus,andanaerobicbacteroides.2MajorTypesvInflammatoryperforationofholloworgansvInjuryruptureofholloworgansvTheproliferationofinflammationinintra-abdominalorgansvOperationpollutionandcomplication2MajorTypesPathologySecret
7、ion Function ：digestive juice, fecal bacteria peritoneum secrete large amounts of liquid dehydration, electrolyte imbalance ，hypovolemic shock, bacteria growth Peritoneal absorption：bacteria and toxins are absorbed into the bloodstream sepsis and septic shock Intestinal paralysis ：a high degree expa
8、nsion of intestine affect the heart and lung function increase the shock. PathophysiologyClinicalManifestationsvEarlyordiffuseinfectionresultsinlocalizedorgeneralizedperitonitis.vLateandlocalizedinfectionsproducesanintra-abdominalabscessClinicalManifestationsvAbdominalpainpersistentseverepainisthema
9、inclinicalmanifestations.vVomitearlyasthereflexvomiting(Stomachcontents)Lateduetotheparalyticileus(yellow-greenbile,evenbrownfecalcontents).vTemperatureandpulsethechangesrelatedtotheseverityofinflammation.vSystemicreactiondecreasedbloodpressureandsoonperformancesofseveredehydration,metabolicacidosis
10、andshock.vRectalexaminationnestfullofrectalandtendernessindicatethatpelvicisalreadyinfectedorpelvicabscessareformed.Symptoms&SignsvBreathing&HeartRatesvShallowBreathsvLowBPvLimitedUrineProductionvInabilitytopassgasorfecesvSwelling&tendernessintheabdomenvFever&ChillsvLossofAppetitevNausea&VomitingSym
11、ptomsvAnacutelyillpatienttendstolie“very”stillbecauseanymovementcausesexcruciatingpain.vTheywillliewiththerekneesbenttodecreasestrainonthetenderperitoneum.SignsvInspection:abdominaldistension,weakeningordisappearanceofabdominalbreathing.BloatingemphasisisanimportantsignofdeteriorationvAuscultation:g
12、urglingsoundsdiminishedordisappearedSignsvPercussion:Flatulence胃肠胀气胃肠胀气wasthedrumsound鼓声鼓声,liverdullnessreduceordisappear肝浊音界缩小肝浊音界缩小.Whenperitonealfluidaretoomuch,knockingcanbringoutshiftingdullness移动性浊音移动性浊音.vPalpation:peritonealirritationistenderness压痛压痛,redoundtenderness反跳痛反跳痛,muscletension肌紧张肌紧
13、张;muscletensionseverepersonwouldhaveabdominalplate板状腹板状腹(gastrointestinalorgallbladderperforation).ExaminationvBloodTestThenumbersofwhitebloodcellandproportionofneutrophilsisincreased.vAbdomalX-raysThesmallintestinegenerallyappearsflatulenceandaccompaniesanumberofsmallfluidplaneintestinalparalysissi
14、gns.vBtypeultrasoundtherearedifferentamountofliquidintheabdominal.vCTScansolidorganlesionsinperitonealcavityvPeritonealpunctureposition&naturevRectalexaminationnestfullofrectalandtendernessindicatethatpelvicisalreadyinfectedorpelvicabscessareformedvVaginalexaminationorpunctureofposteriorfornixAbdoma
15、lX-raysIntestinalobstructionAbdomalX-raysSubdiaphragmaticfreegasCTScanAcutesimplepancreatitisCTScanvSevereacutepancreatitisPeritonealpuncturevPositionBothsidesoftheanteriorabdominaliliacspinewithinthebottomvAttentionTomakesurethereisshiftingcloudinpunctureplacebyknockingmethodbeforepuncturing.Perito
16、nealpuncturevA:Freshbloodfromliverandspleenbloodvesselsrupturesisnon-condensableorhesitate.vB:Darkpurplebloodyfluidnecrotizingpancreatitis,strangulatingintestinalobstructionintestinalnecrosis,amylasecheckingcanidentifyit.vC.Purulentappendix,liverabscessrupture.PeritonealpuncturevD.Bilegallbladderper
17、foration(gangrenouscholecystitis),duodenalperforationvE.WhiteturbidliquidwithfoodresiduesgastricperforationvF.ManurewithsmallintestinalfluidintestinalperforationDiagnosisPeritonitis？SymptomsSignsBloodtestDiagnosisPrimarySecondaryPrimarylesionTreatmentSurgicaloperationIndications Ofunknownetiology&no
18、limitationsIntestinalparalysis，Septicshock Primarydiseaseaggravated6-8hoursSurgicaloperationAdequatedrainageThoroughclean-up OriginaldiseaePreoperativepreparationoperationoperationoperationoperationNon-surgical treatmentMedical treatmentMedical treatment Medical treatmentMedical treatment Medical tr
19、eatmentMedical treatment Mild24hours，Thesignshavebeenreduced Cannottoleratesurgery. MedicaltreatmentFastingandgastrointestinaldecompression PostureCorrectwaterandelectrolytedisturbance Antibiotics Sedation,analgesia,Inspiredoxygen CaloriesupplementandNutritionalsupport MedicaltreatmentAbdominalabsce
20、ssAbdominalabscessvSubphrenicabscessvPelvicabscessvInterloopabscessvTheothersAbdominalabscessDefinitionSubphrenicabscessPus is accumulated within one or both sides of the diaphragm and gap of transverse colon and its mesentery.PelvicabscessPus easily accumulated in pelvic location. The area of pelvi
21、c peritoneum is small. Low ability to absorb toxins. Mild symptoms of systemic poisoning.InterloopabscessPus accumulated within intestine, omentum and mesentery.SubphrenicabscessPathologyvAssubphrenicsiteislowestwhensupine,puseasilyaccumulateshere.BacteriacanarriveinsubphrenicthroughPortalveinandlym
22、phaticsystem.ClinicalmanifestationsvGeneralsymptomsvFever,firstremittentfever,persistentfeverafterabscessformed.Ormildpersistentfever.Pulserateincreased,thickgreasytonguefur.Graduallyappearfatigue,weakness,nightsweats,anorexia,weightloss,whitebloodcellcountincreased,proportionofneutrophilsincreased.
23、ClinicalmanifestationsvLocalsymptomsvTheabscesspartscontinuedullandexacerbatedwhendeepbreathing.Thepainislocatednearthecenterlineofthecostalmarginorxiphoid.?sometimes,itwouldspreadtoshoulderandneck.Stimulatingthediaphragmcauseshiccups.DiagnosisanddifferentialdiagnosisvImprovedaftertreatmentofacutepe
24、ritonitis,orinflammationoftheabdominalorgansorthenumberofabdominalsurgeryinthefuturedevelopfever,abdominalpain,shouldbethoughtofthedisease,andfurtherX-ray,B-ultrasound,CT.TreatmentvPercutaneoustubedrainagevClosetothebodywall,thelimitationsofthesingleroomabscess CT guided puncture Left subphrenic abs
25、cess punctureTreatmentvIncisionanddrainagevMaketheincisionattheedgeofpreviousabdominalwallribwhichappliestothepuslocatedatupperrightlobe,forwardpositionofunderrightlobeorunderleftdiaphragm.vMaketheincisionatthelowerbackwhichappliestothepuslocatedatunderrightlobeandbackwardpositionofunderleftdiaphrag
26、m.Thepuslocatedatbackwardpositionofupperrightlobegap.ClinicalmanifestationanddiagnosevWeshouldtakethepelvicabscessintoconsiderationduringthetreatmentcourseofacuteperitonitisandafterappendicularperforation,iftherearebodytemperaturedecreasedandthenincreased,typicalRectalorbladderirritationsuchas?,stoo
27、lfrequencywhilelessbutfrequentstools,mucous,frequenturination,dysuria.Furthermore,todootherauxiliaryexaminationtodecide.Treatment:vToadoptnon-operationtreatmentwhenthepelvicabscessissmallornotformed.Musttoadoptoperationtreatmentwhenthepelvicisbig.InterloopabscessvItcanhappensingleormultipleandbringo
28、utadhesiveintestinalobstruction.vPatientshavepurulentinfectionsymptomsaccompaniedwithabdominaldistention,abdominalpain,abdominaltendernessorpalpablemass.vAbscessruptureintotheintestineorbladdertoformfistulaandthenthepuswiththeurineexcreted.vWhennon-operationtreatmentfailsorIntestinalobstructed,wouldtakelaparotomytorelieveobstructionandthendodrainage.THE END
