Peritonitis: diagnosis

Laboratory diagnostics of peritonitis

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

However, in most cases, a clinical blood test allows you to clarify the diagnosis. At the same time, an increase in the total number of white blood cells is observed, sometimes up to 30-35 thousand, a shift of the leukocyte formula towards young and stab cells, the appearance of toxic granularity of neutrophils. It is necessary to pay special attention to the need for mandatory dynamic blood testing in suspicious cases of peritonitis. Increasing leukocytosis, a pronounced shift of the leukocyte formula to the left suggest a progression of peritonitis. The appearance of leukopenia with an increasing shift of 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 endotoxicosis development at the initial stage should be considered an increased level of the total number of leukocytes, INR (nuclear shift index), LII (leukocyte intoxication index), while the level of LII more accurately reflects the degree of intoxication.

Practically all the patients with peritonitis show an anemia that is pronounced and growing as a result of endogenous intoxication.

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

The development and flow of peritonitis is always associated with large losses of the body protein (especially the loss of the body albumin), so biochemical indicators reflect hypo- and dysproteinemia. Typical are also metabolic disorders (acidosis or alkalosis).

With functional bowel obstruction, full nutrition is impossible, which exacerbates all kinds of metabolic processes, causes vitamin deficiency, dehydration, disruption of 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 a multi-organ, and primarily renal, insufficiency.

According to some researchers, already in the reactive stage of peritonitis chronic and subacute forms of DIC-syndrome develop, with no significant consumption of coagulation factors noted. The generalized process is characterized by the development of acute and subacute forms of DIC syndrome, which in the study of hemostasis is confirmed by coagulopathy and thrombocytopathy of consumption.

Echographic criteria for peritonitis are:

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

The main radiographic evidence of peritonitis is the picture of paralytic intestinal obstruction: overgrowth of intestinal walls with the presence of a multitude of horizontal fluid levels and Kloyber's bowls.

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

In especially difficult cases for diagnostics or insufficiently clear diagnosis, especially in postpartum patients, it is important to apply diagnostic laparoscopy in a timely manner, which makes it possible to clarify the diagnosis. According to research, the cause of peritonitis in these patients, in addition to endometritis and insufficiency of sutures on the uterus, were the following diseases:

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

[1], [2], [3], [4], [5], [6], [7], [8]