Peritonitis - Symptoms

Symptoms of diffuse peritonitis in gynecological patients are quite distinct. In the presence of an acute or chronic purulent focus in the abdominal cavity, abdominal pain appears or intensifies, accompanied by vomiting and increased heart rate. The pain intensifies with movement, coughing, and changes in body position. In severe cases, cyanosis, cold extremities, and sometimes chills and collapse are observed. When examining patients, pallor or even a grayish tint of the skin is noted, the abdomen stops participating in the act of breathing, the tongue is dry and coated. The pulse becomes more frequent and weak. Palpation is painful in almost all parts of the abdomen, and in the upper parts it is more sensitive than in the lower. The abdomen is always tense. Tension of the muscles of the anterior abdominal wall is determined even with superficial palpation. Deep palpation is impossible.

Symptoms of peritoneal irritation (Shchetkin-Blumberg, Mendel) are positive, as a rule, at the beginning of the disease. However, as it progresses and intoxication increases, these symptoms become less clear, and in some, albeit rare, cases they may not be determined at all. In the toxic stage, local manifestations are smoothed out, while general symptoms of intoxication and especially intestinal paresis increase. Thus, doctors have repeatedly observed patients with perforation of purulent formations of the appendages and diffuse peritonitis, in whom the symptoms of peritoneal irritation were negative, although during the operation up to 1-1.5 liters of liquid pus were determined in the free abdominal cavity.

The cardinal symptom of progressive peritonitis is progressive intestinal paresis, which is always detected by auscultation, ultrasound and X-ray examinations. In the toxic stage of peritonitis, pronounced abdominal distension, vomiting and stool retention are observed. Intestinal noises can be determined at first as separate splashes, and then disappear completely (symptom of "dead" silence). Pulsation of the abdominal aorta is heard. Percussion can determine free fluid (pus) in the abdominal cavity.

The terminal stage is characterized by adynamia, sometimes confusion. The patient's appearance is characteristic - the so-called Hippocratic face (facies Hyppocratica) - an extremely emaciated appearance of the patient, pointed facial features, "sunken" eyes, a pale, cyanotic face covered with large drops of sweat. There is profuse vomiting of stagnant contents with a characteristic "fecal" odor, constipation is replaced by debilitating diarrhea. Multiple organ failure progresses, clinically manifested in dyspnea, oliguria, icterus of the skin and mucous membranes, extreme tachycardia, replacing bradycardia.

Peritonitis caused by anaerobic microflora has a number of clinical and microbiological features: an unpleasant specific odor of wound discharge, black or green color of exudate, the presence of gas bubbles in tissues, necrosis in the foci of inflammation, septic thrombophlebitis.

Differential diagnosis of peritonitis

Most often, peritonitis must be differentiated from acute pelvic peritonitis.

The characteristics of postoperative obstetric peritonitis (peritonitis after cesarean section) are:

1. The absence of a clear stage of the disease (primarily the “blurring” of the reactive phase), associated with the use of painkillers, intestinal stimulation and intensive treatment, including antibacterial, undertaken at the first clinical signs of infection, and sometimes “prophylactically”.
2. Primary pronounced worsening of “local” symptoms during observation, i.e. absence of positive dynamics with adequate treatment of endometritis:
   • upon examination, the uterus significantly exceeds the size corresponding to the time of normal postpartum involution, it is poorly or not at all contoured, and its palpation is extremely painful;
   • discharge from the genital tract becomes purulent or putrid in nature (odor - from slight to sharply unpleasant);
   • an overhang of the vaults appears, indicating the appearance of pathological effusion (exudate) in the abdominal cavity; during a rectal examination, the presence of pathological effusion is confirmed by overhang and soreness of the anterior wall of the rectum.
3. The appearance of symptoms indicating the generalization of the infection:
   • deterioration of general condition and the appearance of abdominal pain;
   • the appearance or sharp increase in symptoms of intoxication, including symptoms of damage to the central nervous system (excitation or depression);
   • the appearance, intensification or resumption of symptoms of intestinal paresis, the presence of persistent intestinal paresis, despite vigorous methods of its treatment;
   • the appearance of symptoms of multiple organ failure: renal, hepatic, respiratory, cardiac.

In practical terms, the most difficult and responsible task is to establish the moment of the onset of development of peritonitis in patients with endometritis. Correct interpretation of a set of symptoms can allow differential diagnostics of endometritis and peritonitis after cesarean section.