Mezhyshechnye and subdiaphragmatic abscesses

In essence, the delimited forms of purulent peritonitis refer to extragenital foci of purulent inflammation.

[1], [2]

Causes of interintestinal abscesses

In patients with purulent formations of the uterine appendages, especially with a prolonged recurrent course, microperforations can occur during the next activation (exacerbation) of the process. In rare cases, diffuse peritonitis develops (according to our data, not more than 1.9% of all perforations). More often the purulent process is delimited, which is due to a number of reasons: first, due to the huge suction, exudative and plastic properties of the peritoneum, capable of neutralizing some of the microorganisms; secondly, as a result of loss of fibrin and the development of adhesions and, thirdly, due to the "sanitary" role of the omentum, which performs besides bactericidal and phagocytic and "delimiting" functions.

[3]

Symptoms of interintestinal abscesses

1. Patients have an anamnesis and all clinical signs of purulent inflammation of the pelvic organs, while it must be remembered that with the remission of the purulent-infiltrative process and especially with the use of palliative draining operations, palpation data during the gynecological examination may be scarce, which does not mean exclusion of the gynecological nature interintestinal abscess. In such cases, to determine the genesis of the disease, a thorough history review is crucial.
2. In the remission phase for interintestinal abscesses are characterized by weakness, propensity to constipation and symptoms of prolonged purulent chronic intoxication.
3. In acute stage patients are concerned with pain localized mainly in the mesogastric abdominal cavity and accompanied by the phenomena of transient intestinal paresis or partial intestinal obstruction, as well as fever and other phenomena of purulent intoxication.

When gynecological examination in patients is determined, as a rule, a single conglomerate occupying a small pelvis and a partially abdominal cavity. Dimensions of the conglomerate can reach 25-30 cm in diameter. In the study, limited mobility or, more often, complete immobility of formation, absence of distinct contours, uneven consistency (from dense to tautoelastic) and its sensitivity are determined. At an exacerbation the sizes of an infiltrate increase, there is a sharp local morbidity.

Symptoms of subdiaphragmatic abscess

1. Patients have an anamnesis and all clinical signs of a complicated course of purulent inflammatory process in the pelvic cavity.
2. In patients with unilateral purulent tubo-ovarian formations of the appendages, the sub-diaphragmatic abscess is always formed on the side of the lesion.
3. There are pains in the chest caused by reactive pleurisy. The intensity of pain is different, more often they have a pulling character, irradiate into the neck, shoulder blade, shoulder area, intensify with inspiration and movements.
4. With a subdiaphragmatic abscess, the patient takes a forced position on the back or side (on the side of the lesion) with the upper part of the trunk raised.
5. Characteristic is the sign of Duchesne, or the syndrome of paradoxical breathing, when in the epigastric region there is a retraction of the abdominal wall during inspiration and protrusion during exhalation.
6. With deep inspiration in patients, pain is observed in the rib arch (IX, X, XI rib), as well as retraction of intercostal spaces in these areas (Littin's symptom).
7. In some cases, soreness appears on the neck - at the site of the projection of the diaphragmatic nerve (Mussie's symptom).

Diagnosis of interintestinal abscesses

When echography, infiltrates of the abdominal cavity without abscessing have the following echographic characteristics: echopositive formations of irregular shape without a clear capsule with reduced echogenicity in relation to surrounding tissues due to increased hydrophilicity; Intestinal loops, abnormal purulent structures of various localization and foreign bodies can be identified as part of infiltrates.

With the abscessing, the structure of the infiltrates themselves becomes non-uniform (against the background of the main echopositive structures, one or a number of cystic formations with a clear capsule and heterogeneous liquid contents, reflecting the accumulation of purulent exudate) is determined.

Echographic signs of interintestinal abscesses are the presence in the corresponding projection (the area of the intestinal loops) of encapsulated echo-negative formations with an echopositive capsule and liquid non-uniform contents.

CG, NMR - highly informative diagnostic methods, which should be used in complex cases. Informativeness of CT in single interintestinal abscess is 94.4%, with multiple abscesses - 94.7%.

[4], [5], [6], [7]

Diagnosis of subdiaphragmatic abscess

The echographic criterion of a subdiaphragmatic abscess is the presence of a coherent echo-negative formation with an echopositive capsule and a liquid non-uniform content localized in the corresponding projection (sub-diaphragmatic region). In the abdominal cavity there is an extensive adhesive process, the additional identification of suppurative appendages facilitates differential diagnosis.

The main significance for the formulation of the correct diagnosis is roentgenological examination. In the presence of a subdiaphragmatic abscess, a high diaphragm standing is detected, with a complete immobility of the diaphragm dome on the side of the lesion. In some cases, the paradoxical movement of the diaphragm is observed: it rises with a deep inspiration and falls when exhaled. Sometimes, when the patient is in a vertical position under the diaphragm, a gas bubble of various sizes located above the horizontal liquid level can be found. When the position changes or the woman tilts to the side, the horizontal level of the liquid remains. With left-sided localization, the diagnosis of sub-diaphragmatic abscess is radiologically more complicated due to the presence of a gastric gas bubble. In these cases, it is advisable to carry out a study with a large amount of barium sulfate administered through the mouth.

[8], [9], [10], [11], [12], [13],

Features of performing operations with interintestinal abscesses

1. It is advisable to prolong the incision of the anterior abdominal wall.
2. The fissures between the loops of the small intestine must be separated only by an acute route, with the abscess being emptied. It requires a thorough revision of the walls of the abscess cavity, i.e. Determination of the degree of destructive changes in the intestinal wall and its mesentery.
3. Small defects in the serous and muscular layers of the intestine are eliminated, imposing the approaching gray-serous or serous-muscular sutures in the transverse direction with the Vicril No. 000 on the atraumatic intestinal needle. In the presence of an extensive defect or complete destruction of the intestinal wall, including the mucous membrane, resection of the intestine is shown within healthy areas with the application of anastomosis "side to side" or "end to side."
4. For prevention of intestinal obstruction, improvement of evacuation and repair conditions, and also in the large adhesive process between the loops of the small intestine at the end of the operation, a transnasal intubation of the small intestine with a probe should be performed. In the case of a gut resection, this procedure with conducting a probe beyond the anastomosis area is mandatory.
5. In addition to transvaginal transabdominal, additional drains with a diameter of 8 mm are introduced into the mesogastric regions through the counter-lines to conduct the ADF.
6. In order to regulate the motor function of the intestine in the postoperative period, a long epi- dural anesthesia is used.

[14], [15], [16]

Features of performing operations in patients with subdiaphragmatic abscesses

1. It is expedient to further extend the incision of the anterior abdominal wall.
2. To completely remove the abscess, it is necessary to perform not only a palpatory, but also a thorough visual audit of the sub-cytophragmal space.
3. In addition to transvaginal transabdominal, on the side of the lesion, additional drains with a diameter of 8 mm are introduced into the meso- and epigastric regions to perform the ADP.

[17], [18], [19], [20], [21], [22], [23]