Pelvioperitonitis

Pelvioperitonitis - inflammation of the peritoneum of the pelvis (pelvic peritonitis) - almost always is a secondary process and develops as a complication in inflammation of the uterus or its appendages. In some cases, the formation of pelvioperitonitis can lead to perforation of the uterus (with abortion, diagnostic scraping), acute appendicitis, torsion of the legs of the ovarian cyst and other diseases and pathological processes in the pelvic region.

[1], [2], [3], [4]

Causes of the pelvioperitonitis

In surgical and gynecological practice, the term "peritonitis" means acute inflammation of the peritoneum. Peritonitis is a severe complication of various acute diseases of the abdominal cavity, often leading to death. Gynecologic peritonitis most often completes such destructive processes in the internal genital organs as:

• melting of the wall of pyosalpinx, pyovar or purulent tubo-ovarian formation;
• various gynecological operations;
• criminal abortions, including those complicated by perforation of the uterus wall;
• necrosis of the tumor of the ovary due to torsion of its legs or rupture of the tumor capsule.

The main causes of pelvioperitonitis are:

1. Bacterial infection of the peritoneum by getting infection from the lower parts through the uterus and fallopian tubes into the abdominal cavity (an ascending infection in acute gonorrhea).
2. The transition of the inflammatory process from the appendages (with the already existing inflammatory tubo-thoracic formation) to the pelvic peritoneum. It is for suppurative lesions of the appendages that the most severe course of pelvioperitonitis and its complications is characteristic, since unlike the acute specific there is already a chronic purulent process. Pelvioperitonitis with purulent lesion of the appendages is recurrent: when the inflammation disappears between the peritoneum of the pelvis and adnexa, adhesions and adhesions remain (chronic adhesive pelvioperitonitis), with another aggravation all new parts of the pelvic peritoneum are involved in the process.

A special place in the clinic is acute pelvioperitonitis - the progression of the process with a specific inflammation or a sharp activation of the infection against the background of a chronic purulent foci in the appendages of the uterus as a result of the failure of compensatory immune reactions.

Acute pelvioperitonitis is, in fact, one of the forms of peritonitis (local, or delimited, peritonitis). Acute pelvioperitonitis causes severe clinical manifestations in purulent inflammatory formations of the appendages and can at any time lead to serious complications, such as opening of the abscess of the appendage into neighboring organs, bacterial shock, less often to diffuse peritonitis. The possibility of their development depends on the aggressiveness of the flora, the state of the immune system and the prevalence of inflammatory changes in the pelvic peritoneum and their depth.

Pelvioperitonitis as a result of ascending gonorrhea also can not be underestimated, since with inadequate therapy it can be complicated by the formation of pelvic abscesses and the development of peritonitis.

Until now, there is no single classification of peritonitis. Depending on the prevalence of the inflammatory process, the following forms of peritonitis are distinguished:

1. Local (limited and unlimited).
2. Common (diffuse, diffuse and common).

Local localized peritonitis refers to an inflammatory infiltrate or abscess in some abdominal organ. With regard to gynecological practice such purulent formation can be piosalpinx, pyovar, tubo-ovarian abscess. With local unlimited peritonitis, the process is localized in one of the pockets of the peritoneum. In gynecology, the local unlimited peritonitis includes pelvic peritonitis, which can be closed by developing fusion between the loops of the intestine, the omentum and pelvic organs, or open - with free communication of the pelvic area with the overlying abdominal parts.

In the case of the development of diffuse diffuse peritonitis, the process covers from 2 to 5 anatomical areas of the abdominal cavity; when spilled - more than 5, but less than 9; at the general - there is a total defeat of a serous integument of organs and walls of an abdominal cavity. Many modern surgeons and gynecologists combine the last two variants into one - the widespread diffuse peritonitis.

Depending on the nature of the exudate, serous-fibrinous and purulent pelvic peritonitis are distinguished . In the first case, the rapid development of the adhesion process, the delimitation of inflammation, is characteristic. With purulent pelvioperitonitis there is a build-up of pus in the anterior space. The amount of encapsulated pus can be significant at that, and is called the "zamatocnogo abscess".

It should be noted that in most cases of the disease a detailed determination of the degree of spread of the inflammatory process is possible only during laparotomy and has prognostic significance, and also dictates adequate volume of operation and drainage of the abdominal cavity. However, in all cases, it is necessary to differentiate local and widespread peritonitis, since a fundamental difference in the tactics of therapy of these conditions is possible.

Pelvioperitonitis can be a consequence of the spread of infection on the peritoneum of the small pelvis in serous and purulent salpingitis, and almost always accompanies the development of pyosalpinx, pyovar or tubo-ovarian abscess. It can occur in the following types: serous, fibrinous and purulent, and the fibrinous-purulent form can pass into purulent.

Inflammatory reaction in the acute stage of pelvioperitonitis is characterized by microcirculation disorder, increased vascular permeability, the appearance of serous exudate, the exit from the vascular bed of albumin, fibrinogen, and elemental elements (leukodiapedesis). In the focus of the lesion, histamine, kinins, serotonin, organic acids accumulate, and the concentration of hydrogen and hydroxyl ions increases. Reduction of the damaging effect of the infectious agent is characterized by a decrease in microcirculation disorders, a decrease in exudation, the formation of adhesions that limit the pathological process outside the pelvic area. With the continuing damaging effect of the microbial flora, dystrophic changes in mesothelium increase, exudation and leukodiapesis increase: serous pelvioperitonitis becomes purulent. When pyogenic pelvioperitonitis occurs, the process is slower or does not occur at all: widespread peritonitis develops.

[5], [6], [7], [8]

Symptoms of the pelvioperitonitis

Symptoms of the acute stage of pelvic peritonitis are similar to the initial stage of diffuse peritonitis. However, with pelvioperitonitis, these signs are less pronounced, and local phenomena usually prevail over the general. The patient with localization of the inflammatory process in the area of the uterine appendages suddenly experiences a deterioration in the general condition. Pain in the lower abdomen is getting worse. The body temperature rises sharply to 38-39 ° C. There is nausea, sometimes one or two times vomiting. In objective research, a frequent pulse is determined, somewhat outstripping the temperature response. The tongue remains moist, can be coated with a white coating. The abdomen is slightly inflated in the lower parts, there is also determined some tension in the muscles of the abdominal wall, positive symptoms of irritation of the peritoneum. Peristalsis of the intestine becomes more sluggish, but the abdominal wall always participates in the act of breathing. Vaginal examination in patients with pelvioperitonitis is difficult due to the sharp soreness and tension of the lower abdomen. The severe pain that occurs with the slightest displacement of the cervix, with a clear indication of the involvement of the peritoneum in the inflammatory process. In some patients, it is possible to detect flattening or even overhanging of the vaginal vaults, indicating the presence of exudate in the pelvis.

Clinical blood test for pelvioperitonitis should be performed many times during the day, at the beginning of the disease - hourly. For pelvic peritonitis, in contrast to peritonitis, moderate leukocytosis, an unsharp shift of the leukocyte formula to the left, a slight decrease in the number of lymphocytes and an increase in ESR are characteristic.

In unclear cases, it is advisable to resort to diagnostic laparoscopy and, when confirming the diagnosis, administer a micro-irrigator for antibiotics. To diagnose and monitor the effectiveness of treatment, it is recommended to perform dynamic laparoscopy.

Common peritonitis, including gynecological, is an extremely severe pathology characterized by early endogenous intoxication. Without going into the details of complex pathogenetic mechanisms of the development of intoxication in peritonitis not fully understood, it should be noted that as a result of the action of biologically active substances, the patients develop pronounced generalized vascular disorders, mainly at the level of the microcirculatory part of the vascular bed. Inadequate blood supply to organs and tissues leads to the development of general tissue hypoxia, the violation of metabolic processes and the rapid emergence of destructive changes in the kidneys, pancreas, liver, small intestine. Violation of the barrier function of the intestine leads to a further increase in intoxication.

Stages

KS Simonyan in 1971 proposed the classification of peritonitis, reflecting the dynamics of the pathological process. This classification has not lost its significance to the present time. The author singled out 3 phases of peritonitis flow: 1 phase - reactive, 2 phase - toxic, 3 phase - terminal.

In the reactive phase, the compensatory mechanisms are preserved. There are no violations of cellular metabolism. There are no signs of hypoxia. The general condition is still relatively satisfactory. The patients are somewhat euphoric, excited. There is a moderate paresis of the intestine, its peristalsis is sluggish. Tachycardia somewhat outstrips the body's temperature response. In the blood, moderate leukocytosis with a slight shift of the formula to the left.

The toxic phase of peritonitis is associated with increasing intoxication. The general condition of the patient suffers: it becomes sluggish, the color of the skin changes, vomiting, hiccoughs. Violated metabolic processes, changes the electrolyte balance, develops hypo- and dysproteinemia. Peristalsis of the intestine is absent, the abdomen is swollen. Grows leukocytosis with a shift of the leukocyte formula to the left, the toxic granularity of neutrophils appears.

In the terminal phase, all changes have a deeper character. The symptoms of the central nervous system predominate. The condition of the patients is extremely severe, severe inhibition, adynamia. Pulse is arrhythmic, sudden dyspnea, lowering of blood pressure. The motor function of the intestine is completely impaired.

The dynamics of pathological processes with peritonitis is extremely rapid: 48-72 hours may pass from the reactive phase to the terminal phase.

Symptoms of peritonitis in gynecological patients have some differences from similar complications in patients with surgical pathology. First of all, one should keep in mind the possible absence of vivid manifestations of peritonitis, both general and local. Local manifestations of peritonitis include the following symptoms: abdominal pain, protective muscle tension of the abdominal wall and other symptoms of irritation of the peritoneum, paresis of the intestine. For gynecological forms of peritonitis, the most characteristic feature is persistent intestinal paresis, despite the use of an epidural block or peripheral ganglionic block.

Of the general symptoms of peritonitis, the most common are the following: high fever, superficial rapid breathing, vomiting, restless behavior or euphoria, tachycardia, cold sweat, and a change in certain laboratory parameters, including pronounced leukocytosis in the peripheral blood with a sharp shift of the leukocyte formula to the left and toxic granularity of neutrophils, an increase in the leukocyte index of intoxication is greater than 4, an increase in the level of alkaline phosphatase, a sharp decrease in the number of platelets.

[9], [10]

Complications and consequences

Most often, in patients with purulent tubo-thoracic formations against a background of acute pelvic peritonitis, perforation occurs in adjacent organs with the formation of genital fistulas or the formation of intercuspal or subdiaphragmatic abscesses (33.7%).

Purulent purulent peritonitis is rarely found today - with a significant perforation of the purulent appendage and massive infectious agent intake, and according to our data, 1.9% of patients are observed.

[11], [12], [13], [14],

Diagnostics of the pelvioperitonitis

In blood tests, the changes in the severe inflammatory process-leukocytosis, shift of the leukocyte formula to the left, high leukocyte intoxication index, increase in ESR, are noted.

Vaginal examination in the first days of the disease due to soreness and tension of the anterior abdominal wall is ineffective. Later in the small pelvis, immediately behind the uterus, the infiltrate that protrudes the posterior vaginal vault is determined. Fluctuations indicate the formation of a zametochny abscess. The uterus is not enlarged, immovable, its dislocations are sharply painful. Attachments of the uterus can not be determined. The same changes are determined with a rectal examination. When performing ultrasound, it is possible to determine the fluid in the Douglas space.

Echographic criteria for pelvic peritonitis are:

• presence of free fluid in the cavity of the small pelvis, mainly in the Douglas space (echonegative content, reflecting the accumulation of purulent exudate, which does not have a capsule and changes its shape when the body position changes);
• weakening of peristaltic waves.

Differential diagnosis

Differential diagnosis of pelvioperitonitis should be performed with diffuse peritonitis. With diffuse peritonitis, deterioration in the general condition of patients is more pronounced, symptoms of irritation of the peritoneum are determined throughout the abdomen, and changes in the pelvic region are absent (according to the data of the vaginal examination).

Pelvic peritonitis is characterized by a prolonged undulating course. With short-term remissions. In most cases, with timely and proper treatment, pelvic peritonitis results in recovery.

The transferred disease leaves extensive cicatrical and adhesive motions between the organs and walls of the small pelvis. In the complicated course of pelvioperitonitis, it is possible to develop diffuse peritonitis or breakth of pus into the hollow organs (intestine, bladder).

[15], [16], [17], [18], [19]

Treatment of the pelvioperitonitis

Having diagnosed, they start treating peritonitis, which is mandatory in 3 stages: preoperative preparation, surgical intervention and intensive care in the postoperative period.

Preoperative preparation takes 1 1 / 2-2 hours. During this time, the stomach is decompressed through the nasogastric tube; catheter subclavian vein and perform infusion therapy aimed at eliminating hypovolemia and metabolic acidosis, to correct water, electrolyte and protein balance, to detoxify the body; introduce cardiac agents; provide adequate oxygenation. In the process of preoperative preparation, intravenous antibiotics are given in the maximum possible dosages with mandatory consideration of the characteristics. Their side effects.

After sufficient preparation, they start operative intervention. Opening of the abdominal cavity is performed by the median incision, which provides an opportunity for. Careful revision of the abdominal and pelvic organs, sanation and extensive drainage. The scope of surgical intervention is determined exclusively individually in each case. The main requirement for him is a complete removal of the focus of infection. The abdominal cavity is washed with a solution of furacilin 1: 5000, the rinse liquid is removed by an electric pump. In the mesentery of the small intestine, 150-200 ml of 0.25% solution of novocaine is administered. If there are indications, unloading of the intestine is performed, and closed decompression with a long transnasal probe of Miller-Abbott type should be preferred. The next stage of the operation is the drainage of the abdominal cavity. Chlorovinyl or silicone tubes are installed under the right and left dome of the diaphragm and in both ileal regions. Simultaneously, a thick elastic drainage tube is inserted into the area of the rectum-uterine cavity through the open dome of the vagina or colpotomy. The incision of the abdominal wall is sutured tightly. Sanitation of the abdominal cavity continues in the postoperative period by fractional perfusion with iso-osmolar solutions with the addition of antibacterial drugs. Through all the drains, 1.5-2 liters of dialysate are dripped, then all the tubes are closed for 1 to 2 hours, after which they are opened for outflow. The procedure is repeated 4-6 times a day. Dialysis is carried out for 3 days, drains are removed on the 4th day. It should be emphasized that dialysis patients need terminal or toxic stages of peritonitis.

The postoperative period of treatment of peritonitis is conclusive and extremely important. Continuing infusion therapy should pursue the following objectives:

• elimination of hypovolemia by the introduction of colloidal solutions and protein preparations;
• loss of chloride and potassium;
• correction of acidosis;
• ensuring the energy needs of the body;
• antiferment and anticoagulant therapy by. Combined administration of heparin and contrikal;
• provision of forced diuresis;
• the fight against infection through the use of broad-spectrum antibiotics;
• prevention and treatment of functional failure of the cardiovascular system;
• prevention and elimination of hypovitaminosis.

One of the central places in the treatment of peritonitis is restoration of motor and evacuation functions of the stomach and intestines. For this purpose, nasogastric probing is used; prolonged epidural blockade; intravenous introduction of cerulekal 2 ml 3 times a day; ganglion blockers of the benzohexonium type of 0.5 ml 2.5% solution 4 times a day intravenously or intramuscularly; subcutaneous administration of 1 ml of a 0.1% solution of prosirin.

To enhance the effectiveness of the therapy in a complex of therapeutic activities, it is rational to include sessions of the UFOAC. The effect of the action of the UFOAC increases if the composition of therapeutic measures is supplemented with hyperbaric oxygenation (HBO). All kinds of purulent-septic infection are accompanied by oxygen starvation of the body, which is very successfully corrected by the use of hyperbaric oxygenation. In addition, HBO has bactericidal, bacteriostatic and antiseptic properties. HBO increases tissue P ₀₂ in the lesion, which increases the effect of antibiotics. The most demonstrative in this respect is the role of HBO with respect to anaerobic pathogens. The optimal mode of HBO-therapy is the pressure of 1.5-3 atm (147.1-294.3 kPa), the duration of the session is 45-60 minutes, the course of treatment is 6-7 sessions daily or every other day.

UFOAK can be combined with extracorporeal hemosorption (HS). In the treatment of early terms of peritonitis, the GE is also effective when used alone. It is noticed that after the GS session the patients feel better, the leukocytosis decreases, the manifestations of encephalopathy decrease, breathing normalizes, blood levels of bilirubin and creatinine decrease, the protein content increases.

In recent years, there have been reports of the successful treatment of septic states by perfusion through the donor porcine spleen, which is a powerful biological filter that sorbs and eliminates a large number of microorganisms and toxins circulating in the blood of patients. In addition, xeno-perfusion of the spleen gives a powerful immunostimulating effect.

Thus, only early diagnosis, a clear use of the entire arsenal of remedies and methods of treatment, close interaction of gynecologists, surgeons and resuscitators can ensure success in treating such a severe pathology as peritonitis.

Treatment of pelvic peritonitis, as a rule, is carried out by conservative methods. The patient needs rest, a full-fledged sparing diet. On the bottom of the stomach recommend periodic application of a bubble with ice.

The leading role in the complex of medical measures belongs to antibacterial therapy, which is carried out according to the same principles, which treat severe forms of acute inflammatory processes in the uterine appendages. Purposes of detoxification serve as infusion-transfusion therapy, which includes protein solutions, rheologically active plasma-substituting drugs, saline solutions, glucose, hemodez. With severe intoxication during the day, 2-3 liters of liquid are administered, in the case of a decrease in diuresis, diuretics are prescribed.

In a set of therapeutic agents include desensitizing, nonspecific anti-inflammatory and analgesic drugs, vitamins. It is advisable to conduct sessions of ultraviolet irradiation of autoblood.

Surgical treatment requires pelvioperitonitis, which occurs against the background of pyosalpinx, pyovar or tubo-ovarian abscess. In such cases, pelvioperitonitis is characterized by a prolonged and severe course, especially if it is caused by associations of aerobic infection with anaerobes, to poorly succumb to conservative therapy.

The treatment of the two forms of pelvioperitonitis is fundamentally different depending on the cause of its occurrence.

1. In the case of a specific "ascending" pelvioperitonitis, the treatment is carried out according to the principles, which consist in preoperative preparation aimed at arresting acute inflammation, when the medical treatment (antibacterial and infusion therapy) is the basic therapeutic measure, and purulent exudate evacuation (surgical component of treatment). The method of "small" surgical intervention can be different. The easiest and easiest method to remove a purulent secretion is the puncture of the utero-rectal cavity through the posterior vaginal arch. However, the most effective method of surgical treatment at the present stage should be considered laparoscopy, which is shown to all patients with pelvioperitonitis of the "ascending" genesis, and its use is mandatory in nulliparous patients to improve the fertile prognosis. The adequate volume for laparoscopy is the evacuation of purulent exudate with its fence for bacteriological and bacterioscopic examination; sanation and transvaginal (through the colpotomy orifice) drainage of the small pelvis. In the postoperative period, active aspiration-washing drainage is carried out for 2-3 days, antibacterial and infusion therapy is continued, resorptive drugs are used, followed by rehabilitation for 6 months.
2. In the presence of acute pelvioperitonitis in patients with purulent formations of the uterine appendages, conservative treatment can be considered only as the first stage of complex therapy aimed at arresting an acute inflammatory process and creating optimal conditions for the forthcoming operation. The peculiarities of the treatment of pelvic peritonitis are the need to prescribe antibiotic therapy in the preoperative period to prevent the generalization of the process. The effect of detoxification and preparation of patients for surgery is significantly increased when purulent exudate is evacuated. Drainage in this case should be considered only as an element of complex preoperative preparation, which allows performing the operation in conditions of remission of the inflammatory process. The main draining operations are puncture and colpotomy, the latter is expedient to be performed only in those cases when the subsequent aspiration-flushing drainage is supposed, which allows to obtain a greater effect. In other cases, they are limited to a single puncture.

The duration of preoperative preparation in patients with purulent tubo-thoracic formations and pelvic-peritonitis depends on the effect of the therapy:

• With a favorable course of the process and the remission of purulent inflammation, intensive conservative treatment can last 5-6 days, since the stage of remission of the suppurative process is considered optimal for the operation. Do not delay with the implementation of surgical intervention in such patients, and even more so to prescribe them from the hospital, since the time of a new activation of the infection is unpredictable and its severity will be incomparably greater.
• In the absence of the effect of intensive therapy, the patient should be operated within the first 24 hours, as the likelihood of life-threatening complications increases.
• When negative dynamics appear (signs of generalization of infection - diffuse purulent peritonitis or sepsis), urgent surgical intervention is necessary after preoperative preparation for 1-1.5 hours.