外科學(xué)教學(xué)課件：Acute suppurative化膿的 peritonitis腹膜炎

1、Acute suppurative化膿的 peritonitis腹膜炎PeritoneumPeritoneum is a membrane that covers the surface of both the organs that lie in the abdominal cavity and the inner surface of the abdominal cavity itself.PeritoneumPeritoneumSecreteAbsorbDefenseRehablubricate the internal organs(150ml)1effusion & blood &

2、air2phagocytic cell3anti-infection of fibrin4Definition A kind of acute inflammation resulted from the stimulation which caused by bacterial infection, injury or digestive juices, urine, blood and so on.It is a common surgical critical illness which mostly requires surgical treatment to save patient

3、s lives.Classification Bacterial & nonbacterialAcute & subacute & chronic Primary &secondaryDiffusivity & limitation (a quarter quadrant)Abdomen zoning2 Major TypesPrimary There is no primary disease in peritoneal cavity or with unknown etiology of peritonitis called primary peritonitis also known a

4、s spontaneous bacterial peritonitis. The pathogens mostly are hemolytic streptococci, streptococcus pneumonia【溶血鏈球菌】 or E.coil. 引起的腹腔滲液不同Haematogenousupper respiratory tract, urinary tract infection the bacteremia peritonitis(children and infants)Retrograde infectionreproductive tract abdominal cavi

5、tyDirect diffusionperitoneal layer peritoneal cavity(urinary tract is infected)Transmural infectionintestinal wall the abdominal cavity (cirrhosis, kidney disease, scarlet fever or malnutrition)2 Major Types2 Major TypesSecondary A kind acute peritonitis which secondary injuries in the abdominal vis

6、ceral perforation damage, rupture and inflammation which accounted for 98% of the peritonitis.The pathogens mainly are intestinal floras, such as the most case-Escherichia coli, streptococcus, proteus, and anaerobic bacteroides.2 Major TypesInflammatory perforation of hollow organsInjury rupture of

7、hollow organsThe proliferation of inflammation in intra-abdominal organsOperation pollution and complication2 Major TypesPathologySecretion Function ：digestive juice, fecal bacteria peritoneum secrete large amounts of liquid dehydration, electrolyte imbalance ，hypovolemic shock, bacteria growth Peri

8、toneal absorption：bacteria and toxins are absorbed into the bloodstream sepsis and septic shock Intestinal paralysis ：a high degree expansion of intestine affect the heart and lung function increase the shock. Pathophysiology Clinical ManifestationsEarly or diffuse infection results in localized or

9、generalized peritonitis.Late and localized infections produces an intra-abdominal abscessClinical ManifestationsAbdominal pain persistent severe pain is the main clinical manifestations.Vomit early as the reflex vomiting(Stomach contents)Late due to the paralytic ileus (yellow-green bile, even brown

10、 fecal contents).Temperature and pulse the changes related to the severity of inflammation.Systemic reaction decreased blood pressure and so on performances of severe dehydration, metabolic acidosis and shock.Rectal examination nest full of rectal and tenderness indicate that pelvic is already infec

11、ted or pelvic abscess are formed. Symptoms & SignsBreathing & Heart RatesShallow BreathsLow BPLimited Urine ProductionInability to pass gas or fecesSwelling & tenderness in the abdomenFever & ChillsLoss of AppetiteNausea & VomitingSymptomsAn acutely ill patient tends to lie “very” still because any

12、movement causes excruciating pain.They will lie with there knees bent to decrease strain on the tender peritoneum. SignsInspection: abdominal distension, weakening or disappearance of abdominal breathing. Bloating emphasis is an important sign of deteriorationAuscultation: gurgling sounds diminished

13、 or disappearedSignsPercussion: Flatulence胃腸脹氣 was the drum sound鼓聲, liver dullness reduce or disappear肝濁音界縮小. When peritoneal fluid are too much, knocking can bring out shifting dullness移動(dòng)性濁音.Palpation: peritoneal irritation is tenderness壓痛, redound tenderness反跳痛, muscle tension肌緊張; muscle tension

14、severe person would have abdominal plate板狀腹(gastrointestinal or gallbladder perforation).ExaminationBlood Test The numbers of white blood cell and proportion of neutrophils is increased. Abdomal X-rays The small intestine generally appears flatulence and accompanies a number of small fluid plane int

15、estinal paralysis signs.B type ultrasound there are different amount of liquid in the abdominal.CT Scan solid organ lesions in peritoneal cavityPeritoneal puncture position & natureRectal examination nest full of rectal and tenderness indicate that pelvic is already infected or pelvic abscess are fo

16、rmedVaginal examination or puncture of posterior fornixAbdomal X-raysIntestinal obstructionAbdomal X-raysSubdiaphragmatic free gas CT ScanAcute simple pancreatitisCT ScanSevere acute pancreatitis Peritoneal puncturePosition Both sides of the anterior abdominal iliac spine within the bottomAttention

17、To make sure there is shifting cloud in puncture place by knocking method before puncturing.Peritoneal punctureA: Fresh blood from liver and spleen blood vessels ruptures is non-condensable or hesitate.B: Dark purple bloody fluid necrotizing pancreatitis, strangulating intestinal obstruction intesti

18、nal necrosis, amylase checking can identify it.C. Purulent appendix, liver abscess rupture.Peritoneal punctureD. Bile gallbladder perforation (gangrenous cholecystitis), duodenal perforationE. White turbid liquid with food residues gastric perforationF. Manure with small intestinal fluid intestinal

19、perforationDiagnosisPeritonitis？SymptomsSignsBlood testDiagnosisPrimarySecondaryPrimary lesion TreatmentSurgical operationIndications Of unknown etiology & no limitationsIntestinal paralysis，Septic shock Primary disease aggravated6-8 hoursSurgical operationAdequate drainageThorough clean-up Original

20、 diseaePreoperative preparationoperationoperationoperationoperationNon-surgical treatmentMedical treatment Medical treatment Medical treatment Mild 24 hours，The signs have been reduced Can not tolerate surgery. Medical treatmentFasting and gastrointestinal decompression PostureCorrect water and elec

21、trolyte disturbance Antibiotics Sedation, analgesia, Inspired oxygen Calorie supplement and Nutritional support MedicaltreatmentAbdominal abscessAbdominal abscessSubphrenic abscessPelvic abscessInterloop abscessThe othersAbdominal abscessDefinitionSubphrenic abscessPus is accumulated within one or b

22、oth sides of the diaphragm and gap of transverse colon and its mesentery.Pelvic abscessPus easily accumulated in pelvic location. The area of pelvic peritoneum is small. Low ability to absorb toxins. Mild symptoms of systemic poisoning.Interloop abscessPus accumulated within intestine, omentum and m

23、esentery.Subphrenic abscessPathologyAs subphrenic site is lowest when supine, pus easily accumulates here. Bacteria can arrive in subphrenic through Portal vein and lymphatic system.Clinical manifestationsGeneral symptomsFever, first remittent fever, persistent fever after abscess formed. Or mild pe

24、rsistent fever. Pulse rate increased, thick greasy tongue fur. Gradually appear fatigue, weakness, night sweats, anorexia, weight loss, white blood cell count increased, proportion of neutrophils increased. Clinical manifestationsLocal symptomsThe abscess parts continue dull and exacerbated when dee

25、p breathing. The pain is located near the center line of the costal margin or xiphoid. ? sometimes, it would spread to shoulder and neck. Stimulating the diaphragm causes hiccups.Diagnosis and differential diagnosisImproved after treatment of acute peritonitis, or inflammation of the abdominal organ

26、s or the number of abdominal surgery in the future develop fever, abdominal pain, should be thought of the disease, and further X-ray, B-ultrasound, CT.TreatmentPercutaneous tube drainageClose to the body wall, the limitations of the single room abscess CT guided puncture Left subphrenic abscess pun

27、cture Treatment Incision and drainage Make the incision at the edge of previous abdominal wall rib which applies to the pus located at upper right lobe, forward position of under right lobe or under left diaphragm.Make the incision at the lower back which applies to the pus located at under right lobe and backward position of under left diaphragm. The pus located at backward position of upper right lobe gap.Pelvic abscessClinical manifestation and diagnoseWe should take the pelvic abscess into consideration during the treatment course of acute peritonitis and