Peritonitis: symptoms

Symptoms of diffuse peritonitis in gynecological patients are expressed quite clearly. In the presence of an acute or chronic purulent focus in the abdominal cavity, there is an appearance or intensification of pain in the abdomen, accompanied by vomiting and increased heart rate. Pain increases with movement, coughing, changes in body position. In severe cases, cyanosis, cooling of the limbs, sometimes there is chills, collapse. When examining patients, paleness or even a grayish shade of skin is noted, the stomach stops participating in the act of breathing, the tongue is dry, covered with a touch. 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 ones. The abdomen is always tense. The tension of the muscles of the anterior abdominal wall is determined even with superficial palpation. Deep palpation is impossible.

Symptoms of irritation of the peritoneum (Shchetkin-Blumberg, Mendel) are positive, as a rule, at the onset of the disease. However, as it progresses and increases intoxication, these symptoms become less clear, and in some, though rare cases, they can not be determined at all. In the toxic stage, local manifestations are smoothed, while the general symptoms of intoxication and especially paresis of the intestine are increasing. Thus, doctors repeatedly observed patients with a perforation of suppurative purulent appendages and diffuse peritonitis, in which the symptoms of irritation of the peritoneum were negative, although up to 1-1.5 liters of liquid pus were detected in the free abdominal cavity.

The cardinal symptom of progressive peritonitis is the progressive paresis of the intestine, which is always detected in auscultation, ultrasound and radiographic studies. In the toxic stage of peritonitis marked abdominal swelling, vomiting and stool retention. Noises in the intestine can be determined first in the form of separate bursts, and then disappear altogether (a symptom of "deathly" silence). The pulsation of the abdominal aorta is heard. Percutally it is possible to determine free fluid (pus) in the abdominal cavity.

For the terminal stage, typical is adynamia, sometimes confusion. Characterized by the type of patient - the so-called face of Hippocrates (facies Hyppocratica) - extremely emaciated form of the patient, pointed features, "sunken" eyes, pale, cyanotic, covered with large drops of perspiration face. There is abundant vomiting of stagnant contents with a characteristic "caloric" smell, constipation is replaced by debilitating diarrhea. Progression of multi-organ failure, clinically manifested in dyspnea, oliguria, icterism of the skin and mucous membranes, limiting tachycardia, followed by bradycardia.

Peritonitis caused by anaerobic microflora has a number of clinical and microbiological features: an unpleasant specific smell of wound detachable, 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 has to be differentiated with acute pelvioperitonitis.

Features of postoperative obstetric peritonitis (peritonitis after cesarean section) are:

1. Absence of a clear stage of the disease (primarily "blurring" of the reactive phase) associated with the use of analgesics, intestinal stimulation and intensive, including antibacterial, treatment undertaken at the first clinical signs of infection, and sometimes "prophylactically".
2. Primary expressed aggravation of "local" symptoms during observation, i.e. Absence of positive dynamics with adequate treatment of endometritis:
   • in the study of the uterus is much larger than the size corresponding to the timing of a normal postpartum involution, it is poor or not at all contoured, its palpation is sharply painful;
   • discharge from the genital tract becomes pueridic or putrefactive in nature (odor - from slight to severely unpleasant);
   • there is an overhanging of the arches, indicating the appearance of pathological effusion (exudate) in the abdominal cavity; when rectal examination, the presence of pathological effusion is confirmed by the overhang and soreness of the anterior wall of the rectum.
3. The appearance of symptoms that indicate the generalization of infection:
   • deterioration of general condition and the appearance of abdominal pain;
   • the appearance or sharp increase in symptoms of intoxication, including symptoms of CNS damage (agitation or depression);
   • the appearance, strengthening or renewal of the symptoms of intestinal paresis, the presence of persistent intestinal paresis, despite vigorous ways of treating it;
   • the appearance of symptoms of multiple organ failure: renal, hepatic, respiratory, cardiac.

In practical terms, the most difficult and responsible is to establish the moment of onset of development in patients with endometritis of peritonitis. Correct interpretation of a set of a number of symptoms may allow differential diagnosis of endometritis and peritonitis after caesarean section.