improving rheological properties of blood; cardiotonic therapy, replenishment of circulating blood volume; detoxication therapy; * antiinflammatory therapy. 8) Indications for surgery: * peritonitis; * ineffectiveness of conservative therapy; + paralytic obstruction of intestines ©) surgical tactics: * in fatal intestinal ischemia or necrosis intestinal resection; * in total necrosis - operation is completed with diagnostic laparotomy. © 3.4. PERITONITIS (PERITONEAL SYNDROME) Peritoneal syndrome is characterized by involvement of peritoneum into inflammatory pro- ‘cess with development of cascade of endotoxic and hyperinflammatory reactions, that could sead to failure of vital organs and systems. Presence of peritoneal syndrome requires immediate hospitalization to the surgical depat- ‘ment for emergency surgery. ‘The most frequent causes of peritoneal syndrome are perforation of the stomach and <éuodenum ulcer, perforation of small and large intestines, inflammatory and destructive [processes in the abdominal organs and their traumatic damage. GENERAL ISSUES OF DIAGNOSTICS AND TREATMENT OF PERITONEAL SYNDROME | Definition. Peritoneal syndrome ~ general systemic disease of the organism, resulting from Shemical, microbial or traumatic effect on the peritoneum, which appears with symptoms of Severely impaired homeostasis, metabolic processes with development of multiple organ failure. 2 Essentials of the problem: A) Polyetiology of peritoneal syndrome determines difficulties in the diagnosis of the under- lying disease, 8) Patient’ condition is characterized by rapidly developing severe pathological changes in the organism. ©) High mortality rate (in reactive stage - 4.10% in toxic stage - 40% and in terminal stage - 98-100 %). 3. Anatomy of the peritoneum: A) Peritoneum is serous membrane, that covers the inner surface of the abdominal wall (parietal peritoneum) and abdominal organs (visceral peritoneum). 3.4. Peritonitis (Peritoneal syndrome) 125 Edit with WPS OfficeB) Total area of the peritoneum is from 15 000 to 20000 cm? C) It consists of seven layers; there are three layers in the subphrenie space. 4, Functions of the peritoneum: |A) Covering function: + provides mechanical protection; * facilitates movement of loops of small and large intestines during peristalsis 8) Resorptive function: *» absorption of water, electrolytes, microelements, antibiotics, microbial cells and to- xins, crystalloids; + does not absorb coarse proteins, fibrin, blood cells; * diaphragmal part of peritoneum possesses the most resorbtive function. ) Transsudative function: + up to 120 liters of quid can be released and absorbed through the peritoneum during the day; + enidaion increases wih iam, D) Plastic function + adhesion occurs 1.5-2 hours after the peritoneal irritation by different agents; + adhesion of the peritoneum leads to limitation of the source of inflammation. £) Protective function ~ antimicrobial and antitoxic properties: + cells of the mesothelium; + greater omentum + polymorphonuclear leukocytes (up to 2.5*10"/); * limitation of the inflammatory focus by adhesion and formation of comissures; * bactericidal effect of forming antibodies. 5. Etiologic factors of acute inflammation of the peritoneum: A) Microbial peritonitis: * bacterial contamination of the peritoneum with microbal associations (aerobic, anaerobic flora) 8) Toxic-chemical (nonbacterial) peritonitis * peritoneal irtation by aggressive agents (bile, gastric juice, urine, pancreatic juice, blood); + accession of bacterial flora short time after the onset of abacterial peritonitis. C) Special forms of peritonitis: * candida; + parasitic; + tuberculous; + cheumatoid 6, Risk factors of peritonitis (Fig. 3.4. AA) Complications of acute inflammatory diseases of the abdominal cavity and small pel- Vis (acute appendicitis, cholecystitis, pancreatitis, acute intestinal obstruction) - up to 40% 8) Perforative peritonitis (perforated ulcer, perforation of intestine) ~ 50% C) Post-traumatic peritonitis (closed and open injuries of abdominal organs) ~ up to 5%. ) Postoperative peritonitis (occurrence of peritonitis after the surgery on abdominal or- gans) ~ up to 5%. 126 Chapter 3. Urgent surgical diseases of abdominal organs Edit with WPS OfficeFig. 3.4.1. Etiological causes of peritonitis: ‘A ~ diseases of stomach, small and large intestines (1 ~ perforated uleer of stomach and duodenum; 2 terminal leis; 3~ acute appendicitis: 4~ perforation of large and small intestine, Bother diseases of stomach (5 - acute cholecystits;6 ~ acute pancreatis;? ~mesennerc vascular throm= boss: diseases of female genitalia) 7. Pathogenesis of acute peritoneal syndrome: A) Pain syndrome, determined by causative factor of peritonitis and irritation of the recep- tor field of the peritoneum. 8) Inflammatory syndrome with a tendency to spread to the peritoneum C) Intoxication syndrome, due to action of microbial factor that releases biogenic amines, unoxidized metabolic products, leading to volemic disorders and hypoxia. ) Development of multiple organ failure. 8. Character of pathogenetic changes depending on the stage of peritoni AA) Reactive stage (until 24 hours after the onset of peritonitis): * peritoneal irtation by aggressive agents and microbial factors; + pain and inflammatory manifestations, expressed near the focus of peritonitis; + tension of protective mechanisms; * toxic, volemic, homeostasis, metabolism and organ disorders in the early stages are not expressed. 8) Toxic stage (24-72 hours after the onset of peritonitis) ‘* inflammatory changes spread throughout the peritoneum; increasing of intoxication and volemic disorders; intensification of metabolism; development of neuroregulatory and humoral disorders; developent of functional and morphological disorders in organs and systems. 3.4 Peitonitis(Peitoneal syndrome) 127 Edit with WPS OfficeC) Terminal stage (more than 72 hours after the onset of peritonitis) * increasing of inflammatory and toxic effects on organs and systems; + profound morphological changes in all organs and systems; + deep depression of vital functions (multiple organ failure). Peritonitis 1, Definition. Peritonitis - general systemic disease resulting from inflammation of the peri- toneum, which is manifested by severely impaired homeostasis and metabolic processes with development of multiple organ failure. 2. Clinical signs of acute peritonitis can be diverse, complex and dynamic. It depends on: * area of microbial contamination of the peritoneum; virulence of microorganisms; ‘+ stage of the process; + reactivity of the organism (gender, age of the patient, availability and nature of co-mor- bidity, degree of compensation). ‘A) Clinical manifestations and diagnc the reactive stage of acute peritonitis (the first 24 hours after the onset of the disease) are defined by: » severity of manifestations of the underlying disease; * involvement of the peritoneum in the inflammatory process; tial signs of intoxication; » exertion of reactive mechanisms of the body. a) complaints: » intense constant pain in the abdomen, more pronounced in the area of inflamma- tion focus; * increased pain when changing body position, coughing, movements; » if localization oF inflammation is in the upper floor of the abdominal cavity — pain irradiates to the shoulder girdle; if localization of inflammation is in the pelvis — false Urge to defecate, dysuric symptoms, pain iradiation to the sacrum and perineum; » nausea and repeated vomiting that does not bring relief; general weakness. b) medical history ~ relations to any disease, injury, surgery. ©) objective signs of disease: + moderate condition; » pale skin; » body temperature above 38 °C and tachycardia; » shortness of breath, chest breathing; + position in the bed is forced (on the back or on the affected side with hips bent to the abdomen); dry tongue; + abdomen is symmetrical; anterior abdominal wall in the area of inflammation lags behind in the act of breathing: » palpation: rigidity of abdominal muscles and sharp pain in the area of inflammation. focus; 128 Chapter 3. Urgent surgical diseases of abdominal organs Edit with WPS Office» strongly positive pathognomonic symptoms of the underlying disease (appendicitis, cholecystitis, pancreatitis, etc.) locally ~ peritoneal signs; Percussion: dullness may be determined in sloping areas of the abdomen; auscultation: decreased sonority of peristaltic sounds; rectal finger examination overhanging and tendemess of the front wall of rectum. 4) methods of diognosis: » list of diagnostic procedures is determined by the disease which is suspected in the patient (plain abdominal radiography, ultrasnography, ECG, etc.) » laboratory methods (complete blood count, urinalysis, urinary diastase, blood glu- cose, hematocrit) £8) Clinical manifestations and diagnosis in the toxic stage of acute peritonitis (24-72 hours after the onset of the disease) are defined by: » dinic effacement (reduction of symptoms) of the underlying disease; » involvement of the whole peritoneum in the inflammatory process; + Intoxication (due to the action of microbial toxins, autocatalytic enzymes, biogenic amines, metabolic toxins, etc.) » hypoxia (respiratory, circulatory, tissue); » violation of coagulation properties of blood (hypercoagulable state); » metabolic disorders; dynamic obstruction of intestines; inhibition of reactive forces of the body; > multi-organ failure (of varying severity) a) complaints: » intensive constant non-localized abdominal pain; nausea, repeated vomiting (often with intestinal contents), regurgitation of gastric contents; » sinking, fever, chills > constipation and gas. b) medical history — increase in terms from the onset of acute disease (24 to 72 hours). ©) objective signs of disease: » severe general condition of the patient; » facial features are sharp (Facies Hippocratica), skin is pale gray, dry; * breathlessness, chest breathing: + blood pressure is less than 100 mm Hg, pulse is speeded up ~ to 100 bpm; » tongue is dry, fissured; » abdomen is swollen; its not involved in the act of breathing; it is moderately tense and painful; ‘symptoms of the underlying disease do not manifest; peritoneal signs dominate; oligoanuria (in the presence of catheter in the urinary bladder!); percussion: dullness in sloping areas of the abdominal cavity; auscultation: peristaltic noise is absent; rectal finger examination: overhang, stiffness and tenderness of the anterior wall of the rectum. 3.4, PeritonitisPeritoneal syndrome) 129 Edit with WPS Office) Clinical manifestations and diagnosis in the terminal stage of acute peritonitis (more than 72 hours after the onset) are defined by: » deepening of pathogenetic processes evolved in the toxic stage; + profound inhibition of vital functions (central nervous, cardiovascular, respiratory, excretory, neurohumoral systems). a) complaints » are dificult or impossible to assess because of confused consciousness and inade- quacy of the patient. ) medical history - the time from the acute onset of the disease ~ from 3 to 5 days. C objective signs of disease: + patient's condition is extremely severe or terminal » confused consciousness, delirium, and toxic coma intoxication; » skin is pale gray, dry, acrocyanosis; facial features are sharp (Facies Hippocratica), sunken eyes, and dry sclera; blood pressure - less than 60 mm Hg, heart rate ~ more than 120 bpm, arrhyth- mmias, no radial pulse; frequent, shallow or pathological breathing; frequent vomiting with smelly intestinal contents, regurgitation; tongue is dry, fissured; abdomen is sprawled, slightly tense and painful, and then it becomes soft and pain- less; mild or no symptoms of peritoneal irritation; anuria; retention of stool and gas: percussion: dull sound throughout the abdomen; + auscultation: peristaltic sound is absent, there is audible splashing in balloting. 3. Forming a preliminary diagnosis based on clinical data Preliminary diagnosis ts formed on the basis of patient's complaints, medical history and ‘objective signs confirmed by physical methods of examination. ‘To confirm or clarify the diagnosis laboratory methods are used, characterized by the seve- rity of the patient's condition, in reactive and toxic stages ~ instrumental studies are aimed at identifying the source of peritonitis are applied. 4, Diagnostic program in patients with peritonitis is formed on the basis of the prelimi- nary diagnosis: A) Laboratory tests: 2) compleie blood count (leukocytosis with leukocyte left shift, white blood cells with toxic granulation); b) urinalysis (presence of protein, erythrocytes, casts), urinary diastase; blood glucose; @) biochemical blood analysis (electrolyte shifts, hypoproteinemia, dysproteinemia, hy- percoagulation, etc.) 8) Additional imaging and instrumental methods of investigation: a) plain abdominal radiography (to reveal signs of mechanical or dynamical obstruction of intestines and identify pleural effusion, mostly on the left); 130 Chapter 3. Urgent surgical diseases of abdominal organs Edit with WPS Officeb) ultrasound (to assess condition of the pancreas and parapancreatic fat tissue, pre- sence of fluid in the abdominal cavity, state of gallbladder and extrahepatic bile ducts); ©) diognostic laparoscopy (can be used to clarify the diagnosis and causes of peritonitis). 5 Differential diagnosis (performed depending on the stage of the pathological process - re active, toxic or terminal stage of peritonitis): A) Differential diagnosis in the reactive stage is conducted with a group of diseases with similar pathogenic syndromes ~ pain, inflammation, dyspepsi a) acute inflammatory surgical disease of the abdominal cavity » acute destructive appendicitis; » acute destructive cholecystitis; acute necrotizing pancreatitis; acute intestinal obstruction; » perforation of a hollow organ. ) acute urological pathology: » acute pyelonephritis; > urolithiasis, ) acute gynecological pathology * torsion and perforation of an ovarian cyst; » purulent salpingitis. ¢) acute therapeutic pathology: » sepsis; » myocardial infarction; » ulcerative colitis, toxic-septic type 8) Differential diagnosis in the toxic stage ~ performed with mesentery thrombosis. ) Differential diagnosis in the terminal stage - with comas of ather genesis: * hypoglycemic coma: + hyperglycemic coma; + uremic com: 6 Clinical and statistical classification of peritoni 65.0 Acute peritonitis Clinical diagnosis model: Acute {R,} {M,} peritonitis, {T, degree}, {F, phase} Process; 2 R, — local {(b,)} (the process involves one topographic zone} {(8, ~ limited (the process is bounded away from the free abdominal cavity) (8, ~ unlimited (inflammation may progress) R, ~ difuse {(b)} (the process involves several topographical zones): (8, - diffusely distributed (there are areas ofthe abdominal cavity that are not covered by inflammatory process, despite the absence of obstacles to its spreading) (8,)~ general (all peritoneal cover is involved in the process) Morphological characteristics: M, ~ serous M, ~ serofibrinous M, - fibrinous M, ~ fibropurulent M, - purulent 3.4. Peritonitis(Peritoneal syndrome) 131 Edit with WPS OfficeM, —hemorthagic M,~ putrid Degree of severity: T, ~ ¥ stage of severity (mild) (peritonitis without involvement of other organs) T, ~2% stage of severity (moderate) (peritonitis with failure of one of organs = lungs, kidneys, liver) T, ~3* stage of severity (severe) (peritonitis with falure of 2-3 and more organs ~ lungs, kidneys, liver) Stages of the process: F, ~ Reactive stage: {Duration 12-24 hours, with slight intoxication, pulse 100 bpm, unexpressed hyperthermia) F, toxic stage: (duration 2-5 days, severe intoxication, pulse 120 bpm, hyperthermia 38-39 °C) F, ~ terminal stage (duration more than 72 hours, severe intoxication, pulse 120 bpm, reduction of blood pressure, paralysis of intestine). 7. Examples of setting a clinical diagnosis: A) Disease (e.g, acute appendicitis), complicated by acute local unlimited serofibrinous peritonitis, 7 stage of severity in the reactive phase. 8) Disease (eg., acute cholecystitis), complicated by acute diffuse (diffusely distributed) fibropurulent peritonitis, 3 stage of severity in the toxic stage. 8. Therapeutic approach to patients with peritonitis depends on the stage of pathological process. Complex treatment with obligatory use of surgical methods: AN) Principles of treatment in the reactive stage of peritonitis: + aimed at treatment of the underlying disease, which must be diagnosed. 8) Principles of treatment in the toxic stage of peritonitis: + time should not be wasted doing a lot of complex diagnostic procedures; + it ist least enough to perform laboratory tests and plain abdominal radiography; + in obscure situations (especially with closed abdominal trauma or in postoperative period) laparoscopy should be used. a) preoperative phase: » intensive infusion therapy for 2-3 hours (intensive therapy) in coordination and Lnder the supervision of anesthesiologist, bringing to parameters: ABP... = 90- 100 mm Hg, CVP = 60-80 mm Wg, amount of urine - 30-40 ml/h; > nasogastric intubation; » adminstration of broad-spectrum antibiotics in therapeutic doses, from the pre- operative period; prophylactic anticoagulant drugs corresponding to coagulation parameters and risk factors for thromboembolic complications (low-molecular weight heparins (LMWH) ~ fraxiparine, pentosan; unfractionated heparins ~ heparin). b) intraoperative stoge: » general anaesthesia with mechanical pulmonary ventilation; + inunexplained peritonitis ~ midline laparotomy (makes it possible to expand access up and down} 152 Chapter 3. Urgent surgical diseases of abdominal organs. Edit with WPS Office» removal of exudates; * inspection of abdominal organs and diagnosing of peritonitis cause (its especially necessary in adhesive obstruction, open and closed injures of the abdomen); + elimination of peritonitis causes; » sanitation (washing) of the abdomen (until clean water’); > nasointestinal intubation and decompression of the small intestine; » drainage of the abdominal cavity through 4-6 counterpuncture lavage or peritoneal dialysis. ©) postoperative stage: > treatment in the ICU for support and correction of functional state of organs and systems; » correction of volemic and homeostatic disorders; » intensive ant-inflammatory therapy; * conducting medical and surgical methods of detoxification; » parenteral and enteral (tube) feeding (after reduction of peritonitis); » syndrome treatment of multiple organ failure; » programmed relaparotomy or laparostomy by indications. ©) Principles of treatment in the terminal stage of peritonitis: a) preoperative phase: + intensive infusion therapy for 2-3 hours (intensive therapy) in coordination and Under the supervision of anesthesiologist, bringing to parameters: ABP, 100 mm Hg, CVP = 60-80 mm We, amount of urine - 30-40 ml/h; » nasogastric intubation; » administration of broad-spectrum antibiotics in therapeutic doses, from the preop- erative period; + prophylactic administration of anticoagulant drugs corresponding to coagulogram indicators and risk factors for thromboembolic events (LMWH - fraxiparine, cle- xane; unfractionated heparins ~ heparin). b) intraoperative stage: » general anaesthesia with mechanical pulmonary ventilation; removal of exudates; inspection of abdominal organs and diagnosing of causes of peritonitis; iF possible - elimination of peritonitis causes with formation of decompression stoma: sanitation (washing) of the abdomen (until “clean water’); drainage of the abdominal cavity through 4-6 counterpuncture lavage or peritoneal dialysis, ©) postoperative stage: » treatment in the ICU for support and correction of the functional state of organs and systems; » syndrome treatment of multiple organ failure. » correction of volemic and homeostatic disorders; » intensive anti-inflammatory therapy; » conducting medical and surgical methods of detoxification; » parenteral nutrition; » programmed relaparotomy or laparostomy by indications. 3.4, Peritonitis(Peritoneal syndrome) 133 Edit with WPS OfficePerforation of peptic ulcer 1. Definition. Perforated ulcers characterized by formation of a perforative defect inthe ulcer site, which connects the lumen of the stomach or intestine with the free abdominal cavity. 2. Prevalence of pathology: A) Perforated ulcer possesses the third place among acute surgical diseases, after acute appendicitis and strangulated herias. 8) Incidence of perforated ulcer ~ 15-3 cases per 10.000 population, C) Predominant age of patients ~ from 20 to 60 years. 3. Perforative ulcer causes: ‘A) Causes contributing to development of perforations: + exacerbation of peptic ulcer disease; + local autoimmune process. 8) Causes leading to development of perforations: * poor blood circulation in the ulcer site; * destruction and necrosis of the organ's wall. 4, Mechanism of perforated ulcer development: ‘A) Exacerbation of ulcer activity n the stomach or duodenum, 8) Destruction of the wall of stomach or duodenum, ) Formation of perforative defects in the wall of stomach or duodenum, D) Releasing ofthe stomach or duodenum contents into the abdominal cavity 5. Clinical manifestations of perforated ulcer: ‘A) Main symptoms of perforated ulcer (Mondors triad): ‘+ sudden sharp (*knife-tke’) pain in the upper abdomen; + existence of ulcerin patient's past history or characteristic ‘stomach-pain® complaints: + high muscle tension of the anterior abdominal wall (wooden belly). 8) Secondary symptoms of perforated ulcer: + somatic disorders (shortness of breath, bradycardia with transition to tachycardia, decrease of blood pressure); + Functional disorders (single vomiting, thirst, dry mouth, weakness, delayed stool); * objective signs (forced position in bed ~ lying on the back with hips bent to the abdo- men, pale skin, cold clammy sweat, positive pathognomonic symptoms). C) Medical history: + presence of ulcers in past history — in 80-90 % of patients; ¢ “silent” ulcers ~ 10-15 % of patients; * presence of prodromal symptoms (pain, nausea, vomiting). ) Clinical manifestations depend on the stage of disease: + stage of shock (or stage of chemical peritonitis) up to 6 hours after the beginning of perforation); + stage of illusion (or stage of peritoneal reaction) with no clinical manifestations ~ 6-12 hours after the beginning of perforation); * stage of peritonitis (or bacterial peritonitis) - more than 12 hours after the beginning of perforation. ‘154 Chapter 3. Urgent surgical diseases of abdominal organs. Edit with WPS Officea) Clinical manifestations in the stage of shock: » Patient's complaints: * sudden sharp ("‘knife-like") pain in the abdomen; + permanent pain; + ifs localized inthe epigastrum, then ~ spreads throughout the abdomen; + more often pain extends through the right side of the abdominal channel, * pain may radiate to the right or left shoulder girdle, scapula, Objective signs of disease (during examination} severe condition; * forced position of the patient in bed ~ lying on the back or on the side with hips bent to the abdomen, acute increase of pain when moving; * painful facial expression; * skin pallor; * cold sweat on face, cold extremities; + frequent breathing, shallow, impossibility to breathe deep; * stomach Is retracted, anterior abdominal wall does not participate n the act of breathing: * Chuguev’s sign ~ transverse skin folds are defined at the level ofthe navel, » Physical data: * palpation: tension of the abdominal muscles, wooden belly (in elderly persons i may be absent), acute pain; * percussion: > Spizharny’s sign - the disappearance of hepatic duliness by percussion; ~ De Quervain’s sign — percutory dullness in sloping areas of the abdomen, * auscultation: increase of peristalsis sounds, Positive peritoneal signs: * Schetkin ~ Blumberg’ sign ~ increased pain upon removal of pressure on the abdominal wall (rebound tenderness); * Voskresensky’s sign (sign of ‘shirt’) ~ worsening of pain in the right ila region hen passing surgeon’ right palm over the anterior abdominal wal from the right subcostal area down on the patient’ shirt stretched with the lft surgeon's hand b) Stage of ilusion: + improvement of objective state; * normalization of blood pressure; * absence of acute pain and appearance of constant dull pain in the abdomen; » disappearance of dyspnea and pain with breathing movements; * moderate bloating and tension of the abdominal wall; » weakly positive peritoneal signs; + decrease in sonority of peristaltic noises; * dullness in stoping areas of the abdomen, ‘c) Stage of peritonitis: * aggravation of general condition due to expansion of peritonitis, severity of intoxi- ‘ation (toxic or terminal stage of peritonitis); * intense diffuse pain throughout the abdomen, frequent vomiting, regurgitation of gastric contents, sinking 53.4. Peritonitis(Peritoneal syndrome) 135 Edit with WPS Office» sharp facial features, pale skin; » decrease of blood pressure, tachycardia, arrhythmia, shortness of breath; » abdomen is inflated, tense and painful; + aperstalsis, persistence of gases, delayed defecation; » positive peritoneal signs throughout the abdominal wall. 6. Factors affecting the clinic of perforated ulcer: + stage of clinical process (shock, illusion, peritonitis); * features of the process or localization of perforations (sealed perforation, atypical perforation); * state of body's defense mechanisms; + combination of perforation with other ulcer complications (bleeding, penetration, stenosis) A) Sealed perforated ulcer occurs in 5-8 % of patients and is characterized by: + a small-sized perforated hole; * small amount of contents in the stomach at the time of perforation; + adhesive process in the area of perforation General characteristics of clinical manifestations of sealed perforation: + less pronounced pain syndrome; + general condition of patient improves faster; + muscle tension on the anterior abdominal walls of local character. 8) Clinical manifestations of perforation in elderly patients: + depend on the dicrease in body defenses; + weakness of muscles ofthe anterior abdominal wall + changes of processes in brain activity General characteristics of clinical manifestations of perforated ulcer in elderly patients: + the disease occurs without marked general and local reaction; * pain during palpation and muscle tension of the abdominal wall are less pro- nounced; = rapidly growing signs of peritonitis. iF 7. Forming a preliminary diagnosis based on clinical data Preliminary diagnosis Is formed on the basis of pa- tient’s complaints, medical history and objective signs confirmed by physical methods of examination. Plain abdominal radiography, laboratory tests (to clar- ify the severity of peritonitis) are performed to confirm or clarify the diagnosis. 8. Diagnostics of perforated ulcer: A) Instrumental diagnostics: ) plain abdominal radiography (Fig, 3.4.2); ») in case of na free gas in the abdominal cavity and presence of clinical data of perforated ul- Fig. 3.4.2, Plane radiography In per cer - pneumogastophagy (Neumark’ test 9.342, Plone cncraphy ng + the tubeis introduced into the stomach inthe {etecesger esos under te position of patient on his her lt side, anton 136 Chapter 3. Urgent surgical diseases of abdominal organs Edit with WPS Office» 500 ml of air is pumped into the stomach with Janet syringe through the tube; » after injection of air, repetitive plain abdominal radiography is performed (presence cof gas under the dome of the diaphragm confirms the perforation). ) gastroduodenoscopy (provides visualization of ulcers and can be served as a kind of Neumark’ test); 4) laparoscopy. 8) Laboratory data: 4) in early stages of the disease there are no characteristic changes; b) with development of peritonitis — inflammatory changes in the blood. 9. Differential diagn AA) Urgent surgical abdominal diseases: + perforation of small and large intestines; + acute cholecystitis; * acute pancreatitis; + acute appendicitis; acute intestinal obstruction; mesenteric vascular thrombosis; + aneurysm of the abdominal aorta, 8) Chronic abdominal diseases: ‘+ duodenal ulcer complicated by penetration. ©) Therapeutic diseases: © myocardial infarction; * basal pneumonia; ® pleurisy. 1D) Urgent urologic diseases: * renal colic: 10. Therapeutic approach to perforated ulcer: A) Perforated ulcer is the absolute indication for surgical treatment. 8) Selecting the method of operation for perforated ulcer: a) in stages of shock and illusion ~ radical operations aimed at eliminating pathological process and treatment of patient are performed: » localization of ulcer in the stomach - partial gastrectomy; > localization of ulcer in the duodenum — vagotomy with excision of ulcer and pyloro- plasty or vagotomy with sparing resection ofthe stomach, b) in the symptomatic stage of peritonitis, "symptomatic’ operations aimed at saving the patients life are performed: » suturing perforated holes; » closure of the perforation with an omental putch (by Oppel ~ Polikarpov). C) Treatment after the surgery: a) treatment of peritonitis, b) infusion therapy; ¢) restoration of motor-evacuation function of stomach and intestines; 4) prevention of complications in other organs and systems; €) after ‘symptomatic’ operations, complex anti-ulcer therapy is indicated after the first day after the surgery. 3.4, Peritontis(Peritoneal syndrome) 137 Edit with WPS Office11, Clinical and statistical classification of peptic ulcer complicated by perforation: K25 Gastric ulcer Clinical diagnosis model: {1 ulcer of {L, stomach}, {K,}, {complicated by 0,} Endoscopic manifestations of the disease: 1, —Active 1, ~ Cicatrizing 1, ~ Gicatrized Localization of ulcer: 1, ~ cardiac part 1 ~subcardiac part 1, - lesser curvature 1, ~ greater curvature 1, ~ pyloric part Helicobacter pylori invasion: K, ~ associated with Hp K, = not associated with Hp Complications: ©, ~ acute bleeding {1} (see “Gastric ulcer") ©, — blood loss fT, stage} ©, - perforation (F, phase} Clinical periods of perforated ulcer progress: F, ~ shock stage (up to 6 hours after perforation) F, ~ stage of illusion (6-12 hours after perforation) F, ~ stage of peritonitis (more than 12 hours after perforation) ©, = perforation and bleeding 0, ~ penetration {in L,} ©, ~ {1 stenosis, 25.3 Acute (symptomatic) gastric ulcer Clinical diagnosis model: Acute ulcer of {L, stomach}, {F, phase} (against the back- ‘ground of €,} complicated by {0,} Localization: 1, cardiac part 1, ~ subcardiac part A -lesser arate ~ greater curvature be pyloric part de active F, ~ cicatrizing Cause ,— extensive burns (Curling ulcer) E, - myocardial infarction, E, - sepsis E, ~ severe injury E, ~ surgeries 138 Chapter 3. Urgent surgical diseases of abdominal organs Edit with WPS Officeintake of medications CNS lesions E, ~hypoxic state Complications: 0, ~ acute bleeding (,) 0, ~ blood loss {T, stage] ©, - perforation {F, phase) (see “Gastric ulcer") ©, - perforation and bleeding 26 Duodenal ulcer Clinical diagnosis modet (1) ulcer of {L,} {K,} complicated by {0,} Endoscopic diagnosis: 1, Active 1, ~ Giatrizing 1, - Cicatrized Localization: 1, ~ duodenal cap = retrobulbar duodenum Helicobacter pylori invasion: K, ~ associated with Hp K, = not associated with Hp Complications: 0, ~ acute bleeding (1) ©, ~ blood loss {T, stage} 0, ~ perforation (F, phase} (see "Gastric ulcer) 0, - perforation and bleeding 0, ~ penetration (int, , ~ (stenosis, 26.5 Acute (symptomatic) duodenal ulcer Clinical diagnosis model: Acute ulcer {L,} of duodenum, {F, phase} {on the background of E,} complicated by {0,) Localization: 1 - duodenal cap 1 = duodenum Phase: F, ~active F, - cicatrizing Etiology: E, ~ extensive burns (Curling’s ulcer) E, ~ myocardial infarction E, — sepsis E, ~severe injury E, - surgeries E, ~ intake of medications E,- CNS lesions E, — hypoxic state 53.4 Peritonitis(Peritoneal syndrome) 139 Edit with WPS OfficeComplications: ©, ~ acute bleeding (1) ©, - blood loss {, stage} ©, - perforation (F, phase} (see “Gastric ulcer’) ©, - perforation and bleeding. 12. Examples of setting a clinical diagnosis: {) Active duodenal ulcer complicated by perforation, in the shock stage. 8) Active duodenal ulcer complicated by perforation, in the peritonitis stage. ©) Acute (symptomatic) ulcer of duodenal cap against the background of myocardial infarc- tion complicated by perforation, in the shock stage. 15, Disability examination and rehabilitation of patients depends on the method of surgery, presence of postoperative complications and degree of comorbidity compensation: A) In uncomplicated postoperative period stitches are removed on the 9-10" day after the surgery. £8) Outpatient treatment after the surgery ~ 6-8 weeks. C) After suturing the ulcer in the postoperative period, a comprehensive anti-ulcer therapy using proton-pump inhibitors and, in the presence of H. pylor infection, gastric decon- tamination with dynamic endoscopic control should be conducted. D) if patient's job involves heavy physical labour, Medical Oversight Subcommittee restricts physical activity up to 4-6 months. E) Patients who underwent surgery due to perforated ulcer are subjected to medical check- ups during one year, performed by surgeon and therapist with further observation by physician or general practitioner in the absence of side-effects after the surgical opera- tion. F) In recurrence of ulcers, other postresection or postvagotomic dysfunctions, ventral herni- as or clinic of gut obstruction, its surgical correction is determined. Perforation of small and large intestines 1. Definition. Perforation — violation of the wall integrity of small and large intestines due to complications of the underlying disease with release of intestinal contents into the free ab- dominal cavity and development of peritonitis, 2. Essentials of the problem: A) High proportion of perforation of intestines as a causal factor of peritonitis 8) Extremely severe pathogenetic changes in the body caused by nature of the underlying disease and peritonitis ) Need for urgent surgical treatment, despite severity of patient's condition. D) High mortality (50%). 3. Btiological factors of small and large intestine perforation: A) Perforation of the wall of small and large intestines as a complication of various dis- ease. 8) The most common diseases complicated by perforations are typhoids, terminal itis, ulcerative colts, malignant tumor, or those caused by foreign bodies. 140 Chapter 3. Urgent surgical diseases of abdominal organs Edit with WPS Office4% Mechanism of disease development — in perforation, pathogenetic factors of the under- tying disease are combined with peritoneal factors: acute pain syndrome, intoxication, perito- neal irritation. 5. Ginical signs of intestinal perforation are diverse, complex, dynamic and depend on manifestations of the underlying disease, to which signs of a hollow organ perforation join. A) Clinical picture is determined by: * nosological form of disease; severity ofthe underlying disease; * localization of perforation; ‘© number of perforated holes; * time elapsed since the perforation: a) complaints: acute increase or sudden appearance of abdominal pain; marked weakness; vomiting; fever, + constipation and delay of gases, b) medical history + availability of chronic, relapsing illness or disease that occurs acutely; * acute deterioration of patient's condition after exacerbation of the underlying disease. ©) objective signs of disease: + general signs: ~ severe condition; igh temperature; > pale-gray or cyanotic skin; ‘weight loss; = tachycardia, decrease of blood pressure; = shortness of breath, chest type of breathing, + local signs: - dryand coated tongue; ~ abdomen: swollen, painful and generally or locally tense (with localized peri tonitis); ~ percussion: blunt sound in sloping areas of the abdomen and possible lack of hepatic dullness; = positive peritoneal signs; ~ auscultation: decrease of sonority or no peristalsis sounds; ~ rectal digital examination ~ presence of liquid stool with admixtures of mucus, pus and blood. 6. Forming a preliminary diagnosis is based on clinical data Preliminary diagnosis is formed on the basis of patient's complaints, medical history and objective signs confirmed by physical methods of examination. To confirm or clarify the diagnosis plane abdominal radiography, laboratory tests (to clarify the severity of peritonitis) are performed. 7. Diagnostics of intestinal perforation: 3.4, Peritonitis(Peritoneal syndrome) 141 Edit with WPS OfficeA) Instrumental diagnostics a) plane abdominal radiography (‘arches’, multiple Kloiber's cups of small or large intes- tine, crescent strip of enlightenment over the liver); b) laparoscopy. 8) Laboratory data: a) complete blood count: leukocytosis, decreased hemoglobin and red blood cell count, accelerated ESR; b) urinalysis - presence of protein, leukocytes, erythrocytes; biochemical blood analysis - decrease of total protein and albumin, activation of he- patic enzymes, increase of residual nitrogen and creatinine. 8. Differential diagnosis: ‘with urgent surgical abdominal diseases: * perforation of ulcer of stomach or duodenum; ™ acute cholecystitis; ® acute pancreatitis; = acute appendicit # acute intestinal obstruction; = mesenteric vascular thrombosis, 9, Treatement of perforation of small and large intestines: Aa) Emergency surgery is indicated. 8B) Requirements for surgical treatment: a) short preparation for operations aimed at stabilizing hemodynamics and supportive infusion therapy; b) gastric decompression; c) general anaesthesia with mechanical ventilation; d) midline laparotomy. ) Types of operations depend on causative factor, severity of the patient's condition and nature of perforations. D) Extent of surgery: a) suturing ofthe perforation; b) stoma formation of the perforated loop; ) resection of intestinal loops and perforation with formation of stoma; d) resection of intestinal loops with perforation and formation of anastomosis. 10. Clinical and statistical classification of non-traumatic perforations of small and large intestines: 63.1 Perforation of intestine (non-traumatic) Clinical diagnosis model: (X,} perforation {L,} of intestines complicated by {0,} Course: X, ~Single X)— Multiple Localization: 1, ~ duodenum 1 ~ small intestine 1 - colon 1, -sigmoid 142 Chapter 3. Urgent surgical diseases of abdominal organs Edit with WPS Office1, -tectum Complications: 0, ~ abscess 0, - peritonitis. 11 Postoperative treatment: syndromic treatment in the ICU. ™ 3.5. ACUTE PROCTOLOGIC DISEASES (SYNDROME OF ACUTE PAIN IN RECTUM, ANAL CANAL AND PERIANAL AREA) ‘Syndrome of acute pain in rectum, anal canal and perianal area occurs with involvement of a part of the rectum located below the recto-ana line, which is innervated by spinal nerves, in the pathological process ‘Acute pain in the perianal region requires a focused examination, digital examination of the rectum with the urgent hospitalization to the proctological or the surgical department and the need of an urgent surgery. The most common cause of acute pain in the rectum, anal canal and perianal region are acute hemorrhoids, acute anal fissure, acute periproctitis and pilonidal abscess. GENERAL ISSUES OF DEVELOPMENT AND DIAGNOSTICS OF PAIN SYNDROME IN ANORECTAL AREA 1. Definition. Syndrome of acute pain in anorectal area ~ acute pathological processes occur- singin the canal with pronounced pain syndrome. 2 Essentials of the problem: 'A) Proctogenic acute disease has been reported in 10 % of patients who consulted a proc tologist. 8) Acute anorectal pathology requires consultation with proctologist or surgeon. 3. Topographic-anatomical background for development of pathological process in anal canal and perianal area (see Fig. 3.2.9, 3.2.10): A) Rectum begins at the third lumbar vertebra and has a length of 12-15 cm. 8) Pelvic floor muscles of the rectum are divided into perineal and pelvic parts. C) Pelvic part of the rectum and pelvic peritoneum are divided into extraperitoneal (7-8 cm) and intraperitoneal (length 3-4 cm) sections. ) Perineal part of the rectum is presented by the anal canal with a length of 3-4 cm, 5) In the perineal part ofthe rectum mucosa forms 8-10 longitudinal Morgagni’s columns, between which anal crypts ate located, anal glands open in them. 4, Blood circulation of rectum (look Fig. 3.2.1!) A) Arterial supply: * inferior (a. rectalis inf), middle (a. rectalis med) rectal arteries - from intemal pu- dendal artery (a. pudenda inf.), superior rectal artery (a. rectalis sup.) - from inferior ‘mesenteric artery (a. mesenterica inf). 3.5, Acute proctologc diseases (syndrome Facute pain in rectum, anal canal and perianalarea) 143 Edit with WPS Office