腹膜炎腹腔脓肿ppt课件 (2).ppt

1 ACUTEABSCESSEPERITONITIS AnatomyandPhysiologyofthePeritonealCavityTheperitonealcavityiscoveredbyasinglelayerofmesothelialcellsonconnectivetissue includingcollagen elasticfibers macrophages andfatcells 2 AnatomyandPhysiologyofthePeritonealCavityTheparietalperitoneum whichcoverstheabdominalcavity includingtheanteriorabdominalwall diaphragm andpelvis isimmediatelyadjacenttoandreinforcedbythetransversalisfascia Thevisceralperitoneumcoversalltheintraperitonealviscera creatingacompletelyenclosedcavityexceptfortheopenendsofthefallopiantubes Theparietalperitoneumisinnervatedbybothsomaticandvisceralafferentnerves Theperitoneumoftheanteriorabdominalwallistheareamostsensitivetostimuli andthepelvicperitoneumisthearealeastsensitive 3 AnatomyandPhysiologyofthePeritonealCavityPatientswithabdominalpainmayshowtendernesstopalpationoftheabdomen andifperitonealirritationexists theyhavereboundtenderness Localizedinflammationoftheanteriorparietalperitoneummayleadtovoluntarymuscleguarding Thevisceralperitoneumisrelativelyinsensitiveandreceivesafferentinnervationonlyfromtheautonomicnervoussystem Stimulifromthevisceralperitoneumareoftenpoorlylocalizedandareperceivedasdullorintermittentcramping 4 AnatomyandPhysiologyofthePeritonealCavityThevisceralafferentnerveshavenoreceptorstomediatepainandtemperaturebutdorespondtodistention traction andpressure Thebiliarytractandmesenteryhavegreaterinnervationthanthesmallintestine Thus painfromthegallbladderandcommonductismoreaccuratelylocalizedthanthatfromthesmallintestine 5 AcuteGeneralizedPeritonitis1 Definition Acuteabscessperitonitispervadedallperitonealcavityiscalledacutegeneralizedperitonitis AGP Peritonitis classifiedasprimaryorspontaneousperitonitisandsecondaryperitonitis 2 EtiologySecondarydefuseperitonitis themostcommon Acuteperforationofgastricandduodenalulcer Gallbladderperforationfollowingacutecholecystitis Traumaticruptureofintestineandbladder Severeacuteappendicitisandpancreatitis Anastomoticleakagefollowingoperation 6 Primarydefuseperitonitis1 Throughbloodroute2 Upwardinfectionfromfemaleoviduct3 Directspreadingfromurinarytractinfection4 Conditionalbacteriainfectionwhenthefunctionofintestinalmembranebarrierdecrease 7 8 OutcomeofacutedefuseperitonitisTwofactorsdecidetheoutcomeofacutedefuseperitonitis Oneistheabilityofbody sdefensesystemAnotherisbacteria squality numberandduration Ifthebody sdefensesystem bacteria sinvasionability absorbedorlocalizedIfthedefensesystem bacteria sinvasionability infectiveshock MOF death 9 Clinicalfindings1 AbdominalpainThemaincomplaintisabdominal whichissevereandconsistent generallyspreadingfromthelesionpointtothewholeabdomen Patient sbreathcanbeobviouslylimited 2 NauseaandvomitingBecausestimulationtoperitoneum thecontentinsidethestomachandintestinemaybevomitedoutreflectively 10 3 FeverandtachycardiaTheresultofreactiontobothinfectiveandnon infectiveinflammation Sometimeslowertemperaturemeansthatpatient sconditionsispoorortheinfectionhasbecomeworse 4 InfectiveshockmanifestationPalecomplexion coolextremities weakpulse lowerbloodpressure andlossofconsciousness 11 5 AbdominalsignsObviousdistensionanddisappearanceofabdominalrespirationcanbenoticed Tenderness muscularspasm andreboundpainaretypicalsignsofacutedefuseperitonitis Iftheperitonitisiscausedbygastricorgallbladderperforation muscularrigidityandabsenceofperistalsiscanbefound 12 AccessoryExaminationX ray Air fluidlevelindilatedloopsofsmallbowelcanbefound Freeairunderthediaphragmindicateperforationofgastro intestinaltract Ultrasound Usedtofindfluidinsideabdominalcavity andhelptolocalizepositionofaspiration CT Usedtofindlesionsofpancreas Abdominalaspiration samewiththeprevious Rectumfingerexamination Tofindabscessinpelviccavity 13 DiagnosisBasedonclinicalfindingsandaccessoryexaminationsTreatment1 Non operativeIndication 1 slightperitonitis2 localsignshavegotbetterconservativetreatmentMethods1 Halflyingposition tolettheinflammatoryfluidinsideabdominal2 Fastingandgastro intestinalsuction Toavoidthecontentinsidethedigestivetractflowingintoabdominalcavity andalleviateabdominaldistension 14 Treatment3 CorrecttheunbalanceofwaterandelectrolytesGastricsuctionandexudationoffluidinsidetheintestinemaycausethelossofbodyfluidandelectrolytes4 Applicationofantibiotics Trytouseappropriateandsensitiveantibiotics5 Nutritionsupport6 Useofsedativedrugandoxygen 15 2 OperationtreatmentIndications 1 Localsignsgetworseafterconservativetherapy2 Severeperforationofstomachorgallbladder orstrangulatedintestinalobstruction3 Largeamountofintra abdominalfluidandobvioustoxicsymptoms4 CauseisnotclearandnolocalizingtendencyMethodsofoperation1 managementofprimarylesion2 cleaningoftheabdominalcavity3 drainage 16 RERITONEALABSCESSESIntraperitonealabscessesarecommoncomplicationsofperitonitisandmayalsofollowmajorabdominaloperationswithoutestablishedperitonitis Increatesurgery smallsbclinicalleakagefollowingbilliardorpancreaticsurgery smallsubclinicalleaksfromintestinalanastomoses collectionsofblood andcontaminatedperitonealfluidalltendtosettleindependentpartsoftheabdomen andabscessformationmaybeasequel Detritus foreignmaterial andnecrotictissuearemoreimportantfactorsInabscessformationthanbacteriaalone 17 Thecommonsitesareunderthediaphragm alongtheundersurfaceoftherightlobeoftheliver alongthelateralgutters andinthepelvis Inabout15 ofcases multipleabscessesarepresent Persistentfeveristheclassicsignofadevelopingintraperitonelabscess Asthefeverfollowingamajorperitonealinsultsubsides insteadofreturningtonormalitpersistsandgraduallyrisesinastepwisefashion Aprogressivelyrisingtemperaturethatdoesnotreturntonormaloveraperiodofseveraldaysistypicalofabscessformation Withthreatenedperforationofextensionintoadjacentstructures chills fever andhypertensionmaydevelop 30 18 subhepaticabscessesGeneralconsiderationsSubphrenicandsubhepaticabscessesposespecialproblemsindiagnosisandtreatment Almosthalfofallintroabdominalabscessesoccurinthesesites Althoughthereismuchargumentabouttheanatomicnatureofthesubphrenicspaces fromapracticalpointofviewabscessesmayoccurinanyoneof6areas 19 20 ClinicalFindingsandDiagnosisTherecognitionofsubphrenicabscessanditspreciselocalizationrequireacombinationofrepeatedphysicalandx rayexaminationsandscanning Unexplainedfeverafterperitonealinfectionofanytype withoutevidentwoundinfectionorperitonealabscessesshouldimmediatelyarousesuspicionofasubphrenicabscess 21 Alltoooftensubphrenicabscessesdevelopinsidiously butonoccasintheremaybepainandtendernessanteriorlyorposterorlyontheaffectedside Motionofthediaphragmontheaffectedsideisrestricted andineffusion Inadvancedcases theremaybewideningoftheintercostalspaces withfull nessandpalpableedema 22 X rayexaminationisofthegreatestimportance Demonstrationofanair fluidlevelbelowthediaphragmwithapleuraleffusionaboveitisdiagnostic Unfortunately thisrepresentsanadvancedabscessandmorecommonlytheonlyfindingsonplainfilmsarefixationandelevationofthediaphragmandapleuraleffusionontheinvolvedside Lateralfilmsmaybeofgreathelpinlocalizingtheabscesstoananteriororposteriorposition Inmostcases CTorultrasoundscansarediagnostic 23 TreatmentThetreatmentofsubphrenicabscessisdrainage eitherbypercutaneousaspirationorsurgically Posteriorabscessesmaybedrainedthroughthebedofthe12thribontheaffectedside Theincisionmustbetransverseandnotparalleltothebedoftheribtoavoidenteringthepleura Somesurgeonsconsideralateralextraperitonealapproachtobesimplerandmoredirectthantheposteriorroute Anteriorly asubcostalincisionismadeandcarriedthroughthetransversalisfascia Theabscesscavityislocatedbybluntdissectionanddrainedwithoutenteringtheperitonealcavity 24 MidabdominalAbscessTheseabscessesmayoccuranywherewithintheabdominalcavityfromjustbelowthetransversecolontothepelvis Therightandleftguttersarethemostcommonsites butandabscessmayformwhereveracollectionofforeignmaterialorbloodhasoccurred Midabdominalabscessesareparticularlydifficulttoidentify Knowingthecauseoftheoriginalperitonealdiseaseisofconsiderablehelpinidentifyingthepresenceofanabscess divertculitisbeingmorelikelyofanabscess diverticulitisbeingmorelikelytoinvolvetheleftgutterandappendicitistherightgutter Perforationsfromregionalenteritisorulcerativecolitismayresultincentrallyplacedabscesses 25 Abscessesdevelopattherootofthemesenterybetweenloopsofbowelandareprotectedfromtheanteriorabdominalwallbythemesenteryofthesmallintestine Repeatedcarefulandgentleexaminationoftheabdomen feelingforadevelopingmass maybethefirstcluetoamidabdominalabscess Plainx rayfilmsoftheabdomenmaybehelpful Amassshadowmaybeidentified collectionsofgasorairmaybeseen orpersistentlydilatedirregularloopsofbowelmayindicatethepreformedbasedonthedegreeofclinicalsuspicion 26 Aprogressivelyenlargingabdominalmassisanindicationfordrainage Frequentlythiswillbedelayedfor2 3daysuntilthemassappearstobewelllocalizedandinclosecontactwiththeabdominalwall Onotheroccasions withdeep seatedmidabdominalabscesses thepatientmaybecomesoill withhighfever chills andhypotension thatlaparotomybecomesessentialandhypotension thatlaparotomybecomesessentialevenwithoutdeinitivelocalizationofth