急性化脓性腹膜炎peritonitis中山大学外科学

急性化脓性腹膜炎peritonitis中山大学外科学第1页/共38页BriefSummaryPeritoneum-anatomyandfunctionPeritonitis-etiologyClinicalfeaturesanddiagnosisofacutesuppurativeperitonitisTreatmentandsupportivecarefortheacutesuppurativeperitonitisItwilltakeabout40minsforthischapter.第2页/共38页AnatomyofperitonealcavityPotentialspacecontainingtheabdominalvisceraTwolayers:visceral/parietalArea1.0xskin(1.7-2.0m2)Openinfemale(orificeofuterinetube)Closedinmale第3页/共38页thegreater(gastrocolic)omentum

大网膜thelesser(gastrohepatic)omentum

小网膜LessersacperforationofstomachAnatomyofperitonealcavitystomachTransversecolon第4页/共38页FunctionsoftheperitoneumProvidesafrictionlesssurfaceoverwhichtheabdominalvisceracanfreelymove

50-100mlofclear,straw-coloredfluid

Servesasabidirectionaldialysismembrane

¤

Isotonicsalinesolution30to35mlperhour¤Hypertonicfluid300to500mlperhour¤Blood,airandgasesareabsorbedata

slowerrate

Peritonealdialysis第5页/共38页PeritonitisInflammationoftheperitoneum

Classification

septicoraseptic

primaryorsecondary

acute,subacuteorchronic

diffuseorlocalizedMostsurgicalperitonitisissecondarytobacterialcontaminationfromthegastrointestinaltract.第6页/共38页Viewofsuppurativeperitonitispurulentintraabdominalfluid

第7页/共38页第8页/共38页Causes

Perforationofaviscusintotheperitonealcavity

intra-abdominalesophagus,stomach,duodenum,bowel,appendix,colon,rectum,gallbladderorbiliarytree,urinarybladder

TraumaInfectedintraperitonealbloodForeignbodiesStrangulatingintestinalobstructionPancreatitisPelvicinflammatorydisease(PID)第9页/共38页Strangulatingintestinalobstruction第10页/共38页RiskFactorsForprimaryperitonitis:Liverdisease(cirrhosis)KidneydamageFluidintheabdomenCompromisedimmunesystem

Pelvicinflammatorydisease

第11页/共38页RiskFactorsForsecondaryperitonitis:Appendicitis(inflammationoftheappendix)StomachulcersTornortwistedintestine

Severelyinflamedgallbladder

DamagetothepancreasInflammatoryboweldisease,suchasCrohn'sdiseaseorulcerativecolitis

Atwistedintestinethatcancauseobstruction

InjurycausedbyanoperationContinuousambulatoryperitonealdialysis(CAPD)–aprocedureusedforpeoplewithend-stagerenaldisease

Trauma

第12页/共38页ClinicalfeaturesSymptomsAbdominalpain(maybesuddenandsevereincaseofrupturedviscus),increasedwithmovement,inspirationdullandpoorlylocalizedlocalizedlocalizeddiffuseNausea,vomitingConstipation,absentflatus停止排气排便第13页/共38页Clinicalfeatures

Signs

Patienttendstoliestill,supine,kneesflexedFeverTachycardia,hypotensionHypoactivebowelsoundsDiffuseabdominaltenderness,reboundtendernessAbdominaldistentionBoard-likerigidityofabdomenInvoluntaryguardingoftheabdominalwallShallow,rapidinspiratoryeffortSignsareattenuatedinthepresenceofascites

第14页/共38页DiagnosisHistoryOnset(acutevs.chronic)DurationofpainLocationRadiationQualityandseverityAssociatedsymptomsAlleviatingoraggravatingfactorsPastmedical/surgicalhistoryIsthereahistoryofpredisposingfactors?recentabdominalsurgery,pepticulcerdisease,diverticulosis,Crohn'sdisease,gastrointestinalmalignancy,pancreatitis第15页/共38页DiagnosisPhysicalexamination

VitalsignsAbdomen:inspection,auscultation,percussion,palpationPelvicexamRectalexamCardiac/respiratoryexamAcompletephysicalexaminationisimportantRectalexaminationVaginalandbimanualexaminationinfemalepatients第16页/共38页Abdominalphysicalexamination

StartawayfromareaofpainLookforareasoflocalizedtendernessandrebound/guardingOrgansmassesorenlargedorgansDiagnosis第17页/共38页DiagnosisBloodtestsCompletebloodcountleukocytosis(>11,000cells/mL)ElectrolytestudiesSerumamylaseBloodcultureOthers:Urinalysis,stoolsample

第18页/共38页DiagnosisPeritonealfluid

analysisParacentesis,aspirationofabdominalfluidcollectionsIntraoperativeperitonealfluidcultures

EvaluatethesampleforpH,glucose,protein,lactatedehydrogenase(LDH),cellcount,Gramstain,andaerobicandanaerobiccultures.AmylaseanalysisifpancreatitisorpancreaticleakissuspectedBilirubinanalysiswhenabiliaryleakissuspectedEvaluatethefluidcreatininelevelwhenaurinaryleakis

suspected第19页/共38页DiagnosisImagingStudies

Plainfilmsoftheabdomensupineanduprightfilms

Distendedloopsofbowelandair-fluidlevels

FreeairunderthediaphragmChestX-ray

Ultrasound

Maybehelpfulintheevaluationofrightupperquadrant

Biliaryandpelvicsymptoms第20页/共38页X-ray第21页/共38页ComputedtomographyscanMagneticresonanceimagingHCGonreproductiveagewomenDiagnosis第22页/共38页第23页/共38页appendicitis第24页/共38页DiagnosisprocedureClinicalfeatureslabfindingsImagingfingdingsIntraperitonealfluidanalysisperitonitisPrimaryperitonitisSecondaryperitonitisAppendicitisCholecystitisPancreatitisDiverticulitisPerforationObstructionAcuteischemiaEctopicprenancyRuptureaorticaneurysmnephrolithiasis第25页/共38页TreatmentGeneralprinciples

(1)tocontroltheinfectioussource(2)topurgebacteriaandtoxins(3)tomaintainorgansystemfunction(4)tocontroltheinflammatoryprocess.

Inthetreatmentofperitonealinfections,medical,interventional,andoperativetreatmentoptionsarecomplimentary,notcompetitive.第26页/共38页Non-operativetherapyMildinfection>24haftertheonsetwiththesymptomsabatingContraindicationforoperationPreoperativepreparation第27页/共38页Asemi-sittingpositionin

bed

Fastingandgastrointestinaldecompression

NasogastricintubationandsuctionReplacementoffluidsandcorrectexistingserumelectrolytedisturbances

Foleycathetersplacedtomonitorurineoutput

AntibiotictherapyNutrition

Enteralnutritionissuperiortoparenteralnutrition

Symptomatictreatment

Considertheintravenousorintramuscularuseofanalgesics

Non-operativetherapyCarefully!!!第28页/共38页Antibiotictherapy

Primaryperitonitis

Initiatewithathird-generationcephalosporinandthentailortherapyaccordingtothecultureresults.

Thetraditionaldurationoftherapyis10daysSecondaryperitonitis

Asecond-orthird-generationcephalosporinTripleantibiotictherapyintravenously,providingaerobic,gramnegativeandanaerobiccoverageDurationdependedontheresponseNon-operativetherapy第29页/共38页SurgicaltherapyIndicationforlaparotomyAggravationofthesymptomsandsignsafter6-8hrsofnon-operativetherapySevereunderlyingdiseasePerforationofGIorgallbladderStrangulateintestinalobstructionetalSevereintraperitonealinfectionDiffuseperitonitisofunknownetiology第30页/共38页PrinciplesforsurgicaltherapyManagementoftheunderlyingdiseasesRemovaloftheinfectiousagentsSufficientdrainagePostoperativetherapyandnutritionsupport第31页/共38页ProcedureofsurgeryAnesthesiamethodsGeneralEpiduralLo