Peritonitis - Diagnosis

Laboratory diagnostics of peritonitis

It is believed that there is a clear discrepancy between the clinical symptoms of postoperative peritonitis and the laboratory signs of a developing complication, which is manifested in a delay in laboratory data with a clear clinical picture of peritonitis.

However, in most cases, a clinical blood test allows for a more precise diagnosis. It reveals an increase in the total number of leukocytes, sometimes up to 30-35 thousand, a shift in the leukocyte formula towards young and band cells, and the appearance of toxic granularity of neutrophils. Particular attention should be paid to the need for mandatory dynamic blood testing in cases suspected of peritonitis. Increasing leukocytosis and a pronounced shift in the leukocyte formula to the left indicate the progression of peritonitis. The appearance of leukopenia with an increasing shift in the leukocyte formula to the left - the so-called "scissors" - is a poor prognostic sign in patients with peritonitis.

It is believed that the first and most informative signs of the development of endotoxicosis at the initial stage should be considered an increased level of the total number of leukocytes, NSI (nuclear shift index), LII (leukocyte intoxication index), while the LII level more accurately reflects the degree of intoxication.

Almost all patients with peritonitis have severe and increasing anemia as a result of endogenous intoxication.

The following changes are noted in the urine analysis: the relative density of urine decreases, its quantity decreases, protein, hyaline and granular cylinders appear.

The development and course of peritonitis is always associated with large losses of protein by the body (especially large losses of albumin by the body), therefore biochemical indices reflect hypo- and dysproteinemia. Metabolic disorders (acidosis or alkalosis) are also typical.

Functional intestinal obstruction makes adequate nutrition impossible, which aggravates all types of metabolic processes, causes vitamin deficiency, dehydration, disruption of the adrenal and enzymatic systems and electrolyte balance. Patients with peritonitis are characterized by pronounced and increasing hypokalemia, the appearance of clinical and laboratory signs of hyperkalemia is a poor prognostic sign indicating the presence of multiple organ failure, primarily renal failure.

According to some researchers, chronic and subacute forms of DIC syndrome develop already in the reactive stage of peritonitis, while significant consumption of coagulation factors is not observed. The generalized process is characterized by the development of acute and subacute forms of DIC syndrome, which is confirmed by coagulopathy and consumption thrombocytopathy when studying hemostasis.

The echographic criteria for peritonitis are:

• the presence of free fluid (an echo-negative formation that does not have a capsule and changes shape when the body position changes) in the utero-rectal space, lateral canals of the abdominal cavity, between intestinal loops, under the liver, and diaphragm;
• the appearance of a large amount of gas and fluid in overstretched intestinal loops;
• a sharp weakening or absence of peristaltic waves.

The main radiological sign of peritonitis is the picture of paralytic intestinal obstruction: overstretching of the intestinal walls with the presence of multiple horizontal fluid levels and Kloiber cups.

In cases where clinical symptoms do not allow differential diagnosis between endometritis and peritonitis, laparoscopy should play a decisive role.

In cases that are particularly difficult to diagnose or have an insufficiently clear diagnosis, especially in postpartum patients, it is important to use diagnostic laparoscopy in a timely manner, which makes it possible to clarify the diagnosis. According to research, the cause of peritonitis in such patients, in addition to endometritis and failure of the sutures on the uterus, were the following diseases:

• specific purulent endomyometritis, salytingo-oophoritis;
• rupture of endometrioid cyst;
• acute appendicitis;
• foreign body (napkin) in the abdominal cavity.

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