腹膜炎腹腔脓肿

ACUTEABSCESSEPERITONITIS

AnatomyandPhysiologyofthePeritonealCavityTheperitonealcavityiscoveredbyasinglelayerofmesothelialcellsonconnectivetissue,includingcollagen,elasticfibers,macrophages,andfatcells.1精选课件AnatomyandPhysiologyofthePeritonealCavityTheparietalperitoneum,whichcoverstheabdominalcavity,includingtheanteriorabdominalwall,diaphragm,andpelvis,isimmediatelyadjacenttoandreinforcedbythetransversalisfascia.Thevisceralperitoneumcoversalltheintraperitonealviscera,creatingacompletelyenclosedcavityexceptfortheopenendsofthefallopiantubes.Theparietalperitoneumisinnervatedbybothsomaticandvisceralafferentnerves.Theperitoneumoftheanteriorabdominalwallistheareamostsensitivetostimuli,andthepelvicperitoneumisthearealeastsensitive.2精选课件AnatomyandPhysiologyofthePeritonealCavityPatientswithabdominalpainmayshowtendernesstopalpationoftheabdomen;andifperitonealirritationexists,theyhavereboundtenderness.Localizedinflammationoftheanteriorparietalperitoneummayleadtovoluntarymuscleguarding.Thevisceralperitoneumisrelativelyinsensitiveandreceivesafferentinnervationonlyfromtheautonomicnervoussystem.Stimulifromthevisceralperitoneumareoftenpoorlylocalizedandareperceivedasdullorintermittentcramping.

3精选课件AnatomyandPhysiologyofthePeritonealCavity

Thevisceralafferentnerveshavenoreceptorstomediatepainandtemperaturebutdorespondtodistention,traction,andpressure.Thebiliarytractandmesenteryhavegreaterinnervationthanthesmallintestine.Thus,painfromthegallbladderandcommonductismoreaccuratelylocalizedthanthatfromthesmallintestine.4精选课件

AcuteGeneralizedPeritonitis

1.Definition:Acuteabscessperitonitispervadedallperitonealcavityiscalledacutegeneralizedperitonitis(AGP).Peritonitis,classifiedasprimaryorspontaneousperitonitisandsecondaryperitonitis.

2.Etiology

Secondarydefuseperitonitis(themostcommon)①Acuteperforationofgastricandduodenalulcer②Gallbladderperforationfollowingacutecholecystitis③Traumaticruptureofintestineandbladder④Severeacuteappendicitisandpancreatitis⑤Anastomoticleakagefollowingoperation

5精选课件Primarydefuseperitonitis1.Throughbloodroute2.Upwardinfectionfromfemaleoviduct3.Directspreadingfromurinarytractinfection4.Conditionalbacteriainfectionwhenthefunctionofintestinalmembranebarrierdecrease.6精选课件7精选课件OutcomeofacutedefuseperitonitisTwofactorsdecidetheoutcomeofacutedefuseperitonitis:Oneistheabilityofbody’sdefensesystemAnotherisbacteria’squality,numberandduration.Ifthebody’sdefensesystem>bacteria’sinvasionability-------absorbedorlocalizedIfthedefensesystem<bacteria’sinvasionability-------infectiveshock,MOF,death8精选课件

Clinicalfindings1.AbdominalpainThemaincomplaintisabdominal,whichissevereandconsistent,generallyspreadingfromthelesionpointtothewholeabdomen.Patient’sbreathcanbeobviouslylimited.2.NauseaandvomitingBecausestimulationtoperitoneum,thecontentinsidethestomachandintestinemaybevomitedoutreflectively.9精选课件

3.FeverandtachycardiaTheresultofreactiontobothinfectiveandnon-infectiveinflammation.Sometimeslowertemperaturemeansthatpatient’sconditionsispoorortheinfectionhasbecomeworse.

4.InfectiveshockmanifestationPalecomplexion,coolextremities,weakpulse,lowerbloodpressure,andlossofconsciousness.10精选课件

5.AbdominalsignsObviousdistensionanddisappearanceofabdominalrespirationcanbenoticed.Tenderness,muscularspasm,andreboundpainaretypicalsignsofacutedefuseperitonitis,Iftheperitonitisiscausedbygastricorgallbladderperforation,muscularrigidityandabsenceofperistalsiscanbefound.11精选课件

AccessoryExaminationX-ray:Air-fluidlevelindilatedloopsofsmallbowelcanbefound.Freeairunderthediaphragmindicateperforationofgastro-intestinaltract.Ultrasound:Usedtofindfluidinsideabdominalcavity,andhelptolocalizepositionofaspiration.CT:Usedtofindlesionsofpancreas.Abdominalaspiration:samewiththeprevious.Rectumfingerexamination:Tofindabscessinpelviccavity.12精选课件

DiagnosisBasedonclinicalfindingsandaccessoryexaminations

Treatment

1.Non-operativeIndication:1)slightperitonitis2)localsignshavegotbetterconservativetreatmentMethods

1)Halflyingposition:tolettheinflammatoryfluidinsideabdominal2)Fastingandgastro-intestinalsuction:Toavoidthecontentinsidethedigestivetractflowingintoabdominalcavity,andalleviateabdominaldistension13精选课件

Treatment

3)CorrecttheunbalanceofwaterandelectrolytesGastricsuctionandexudationoffluidinsidetheintestinemaycausethelossofbodyfluidandelectrolytes4)Applicationofantibiotics:Trytouseappropriateandsensitiveantibiotics5)Nutritionsupport6)Useofsedativedrugandoxygen14精选课件

2.Operationtreatment

Indications:1)Localsignsgetworseafterconservativetherapy2)Severeperforationofstomachorgallbladder,orstrangulatedintestinalobstruction3)Largeamountofintra-abdominalfluidandobvioustoxicsymptoms4)CauseisnotclearandnolocalizingtendencyMethodsofoperation1)managementofprimarylesion2)cleaningoftheabdominalcavity3)drainage15精选课件RERITONEALABSCESSESIntraperitonealabscessesarecommoncomplicationsofperitonitisandmayalsofollowmajorabdominaloperationswithoutestablishedperitonitis.Increatesurgery,smallsbclinicalleakagefollowingbilliardorpancreaticsurgery,smallsubclinicalleaksfromintestinalanastomoses,collectionsofblood,andcontaminatedperitonealfluidalltendtosettleindependentpartsoftheabdomen,andabscessformationmaybeasequel.Detritus,foreignmaterial,andnecrotictissuearemoreimportantfactorsInabscessformationthanbacteriaalone.16精选课件Thecommonsitesareunderthediaphragm,alongtheundersurfaceoftherightlobeoftheliver,alongthelateralgutters,andinthepelvis.Inabout15%ofcases,multipleabscessesarepresent.Persistentfeveristheclassicsignofadevelopingintraperitonelabscess.Asthefeverfollowingamajorperitonealinsultsubsides,insteadofreturningtonormalitpersistsandgraduallyrisesinastepwisefashion.Aprogressivelyrisingtemperaturethatdoesnotreturntonormaloveraperiodofseveraldaysistypicalofabscessformation.Withthreatenedperforationofextensionintoadjacentstructures,chills,fever,andhypertensionmaydevelop.3017精选课件subhepaticabscessesGeneralconsiderationsSubphrenicandsubhepaticabscessesposespecialproblemsindiagnosisandtreatment.Almosthalfofallintroabdominalabscessesoccurinthesesites.Althoughthereismuchargumentabouttheanatomicnatureofthesubphrenicspaces,fromapracticalpointofviewabscessesmayoccurinanyoneof6areas.18精选课件19精选课件ClinicalFindingsandDiagnosisTherecognitionofsubphrenicabscessanditspreciselocalizationrequireacombinationofrepeatedphysicalandx-rayexaminationsandscanning.Unexplainedfeverafterperitonealinfectionofanytype-withoutevidentwoundinfectionorperitonealabscessesshouldimmediatelyarousesuspicionofasubphrenicabscess.20精选课件Alltoooftensubphrenicabscessesdevelopinsidiously,butonoccasintheremaybepainandtendernessanteriorlyorposterorlyontheaffectedside.Motionofthediaphragmontheaffectedsideisrestricted,andineffusion.Inadvancedcases,theremaybewideningoftheintercostalspaces,withfull-nessandpalpableedema.21精选课件X-rayexaminationisofthegreatestimportance.Demonstrationofanair-fluidlevelbelowthediaphragmwithapleuraleffusionaboveitisdiagnostic.Unfortunately,thisrepresentsanadvancedabscessandmorecommonlytheonlyfindingsonplainfilmsarefixationandelevationofthediaphragmandapleuraleffusionontheinvolvedside.Lateralfilmsmaybeofgreathelpinlocalizingtheabscesstoananteriororposteriorposition.Inmostcases,CTorultrasoundscansarediagnostic.22精选课件TreatmentThetreatmentofsubphrenicabscessisdrainage,eitherbypercutaneousaspirationorsurgically.Posteriorabscessesmaybedrainedthroughthebedofthe12thribontheaffectedside.Theincisionmustbetransverseandnotparalleltothebedoftheribtoavoidenteringthepleura.Somesurgeonsconsideralateralextraperitonealapproachtobesimplerandmoredirectthantheposteriorroute.Anteriorly,asubcostalincisionismadeandcarriedthroughthetransversalisfascia.Theabscesscavityislocatedbybluntdissectionanddrainedwithoutenteringtheperitonealcavity.23精选课件MidabdominalAbscessTheseabscessesmayoccuranywherewithintheabdominalcavityfromjustbelowthetransversecolontothepelvis.Therightandleftguttersarethemostcommonsites,butandabscessmayformwhereveracollectionofforeignmaterialorbloodhasoccurred.Midabdominalabscessesareparticularlydifficulttoidentify.Knowingthecauseoftheoriginalperitonealdiseaseisofconsiderablehelpinidentifyingthepresenceofanabscess-divertculitisbeingmorelikelyofanabscess-diverticulitisbeingmorelikelytoinvolvetheleftgutterandappendicitistherightgutter.Perforationsfromregionalenteritisorulcerativecolitismayresultincentrallyplacedabscesses.24精选课件Abscessesdevelopattherootofthemesenterybetweenloopsofbowelandareprotectedfromtheanteriorabdominalwallbythemesenteryofthesmallintestine.Repeatedcarefulandgentleexaminationoftheabdomen,feelingforadevelopingmass,maybethefirstcluetoamidabdominalabscess.Plainx-rayfilmsoftheabdomenmaybehelpful:Amassshadowmaybeidentified,collectionsofgasorairmaybeseen,orpersistentlydilatedirregularloopsofbowelmayindicatethepreformedbasedonthedegreeofclinicalsuspicion.25精选课件Aprogressivelyenlargingabdominalmassisanindicationfordrainage.Frequentlythiswillbedelayedfor2-3daysuntilthemassappearstobewelllocalizedandinclosecontactwiththeabdominalwall.Onotheroccasions,withdeep-seatedmidabdominalabscesses,thepatientmaybecomesoill,withhighfever,chills,andhypotension,thatlaparotomybecomesessentialandhypotension,thatlaparotomybecomesess