Aseptic peritonitis is an inflammation of the peritoneum that occurs under the influence of non-infectious factors (pancreatic enzymes, accumulation of blood, bile, urine with ruptures of internal organs, injuries) and is accompanied by a pronounced disruption of vital organs. Due to the peculiarities of pathogenesis, the disease soon acquires an infectious and inflammatory character. Diagnosis is based on the assessment of symptoms, the results of radiography and ultrasound scanning of the abdominal cavity, diagnostic laparoscopy. The most important factor of successful treatment is the timely surgical intervention. Intensive therapy continues in the postoperative period.
ICD 10
T81.6 K65.8
Meaning
Aseptic peritonitis is an inflammation of the peritoneum that develops due to the rupture of uninfected hollow organs and formations (for example, gallbladder, ovarian cyst, bladder), abdominal injuries accompanied by hemoperitoneum (accumulation of blood in the abdominal cavity), as well as enzymatic effects on the peritoneum in acute pancreatitis. The features of this pathology are determined by the peculiar response of the body under the influence of a pathogenic agent on the peritoneum, which leads to the development of severe symptoms, pronounced lesions of organs and systems.
The existence of an aseptic form of peritonitis is possible only for a short period of the damaging factor, which has a non-infectious nature. Bile, blood, urine, pancreatic enzymes in the abdominal cavity lead to the development of toxic-chemical damage to the peritoneum, an inflammatory process develops, and due to the increased permeability of the intestinal walls, bacteria easily penetrate into the peritoneum cavity.
Causes of aseptic peritonitis
The most common cause of the development of aseptic peritonitis, according to the observations of specialists in the field of abdominal surgery, is a complication of acute pancreatitis, pancreonecrosis. Enzymatic pancreatogenic peritonitis accompanies about 70% of cases of destructive pancreatitis. Also, the cause of this pathology may be a rupture of internal organs with blood, bile, urine entering the abdominal cavity. In response to their impact, inflammation develops in the peritoneum, significant changes in the vascular wall occur, exudate and fibrin are released. When microorganisms enter, bacterial inflammation joins.
Pathogenesis
The development of peritonitis differs depending on the cause, the prevalence of the process in the abdominal cavity, the reactivity of the patient’s body. As a result of exposure to a pathological agent, paralytic intestinal obstruction occurs, the absorption capacity is impaired, blood vessels dilate, which leads to increased fluid release into the intestinal lumen and metabolic disorders.
Further, inflammation provokes the centralization of blood circulation. The expansion of intestinal vessels leads to the redistribution of blood and its accumulation in this area, the perfusion of vital organs (kidneys, lungs, liver) worsens, their functions are disrupted. At the next stage, a violation of absorption in the intestine is replaced by a significant increase in it, there is a resorption of toxic substances from the intestinal lumen, which exacerbates intoxication.
Classification
Depending on the prevalence of the pathological process in the abdominal cavity, aseptic peritonitis can be local or diffuse. According to the nature of the exudate, hemorrhagic, serous, fibrinous, bile type are distinguished, according to the severity of the disease – three degrees. Three stages of peritonitis are also differentiated: reactive (lasts for the first 24 hours), toxic (24-72 hours), terminal (after 72 hours).
Symptoms of aseptic peritonitis
The clinical picture of the disease is diverse and largely determined by the etiological factor. However, it is possible to distinguish characteristic symptoms that are caused by the time from the onset of the disease, damage to other organs, homeostatic shifts. On the first day of the disease (reactive stage), local manifestations prevail, while the general condition of the patient may remain mild.
There are constant severe abdominal pains, increasing with movements, coughing, decreasing in the lying position on the side with the legs brought down. The localization of pain, as well as its intensity, can be different. It depends on the prevalence of the process, as well as the underlying disease. A rapid pulse is determined, blood pressure does not change significantly. Palpation of the abdominal wall is characterized by soreness in the area of localization of the process. The temperature is subfebrile. In blood tests, there is a slight leukocytosis with a neutrophil shift.
The toxic stage is dominated by general reactions of the body, intoxication syndrome. Due to the increasing intoxication, the symptoms of the underlying disease are hidden. Abdominal pain, abdominal wall tension weaken. There are symptoms of paralytic intestinal obstruction. Bloating is detected, peristaltic noises disappear. The pulse rate increases significantly – 130-140 beats per minute. There is a tendency to decrease blood pressure. The body temperature is above 38 degrees. In the blood – leukocytosis with a pronounced neutrophil shift. The general condition of the patient suffers significantly.
The terminal stage is accompanied by adynamia, confusion of consciousness. The pallor of the skin, the sharpness of the facial features is characteristic. There is respiratory dyspnea, signs of renal, hepatic insufficiency. Copious vomiting of stagnant contents may occur. There is a sharp bloating, pronounced soreness. Pulse is more than 140 per minute, blood pressure is significantly reduced. Such a clinical picture is a prognostically unfavorable sign.
Diagnostics
The diagnosis of aseptic peritonitis in the toxic, terminal stage is usually not in doubt due to the characteristic symptoms. Difficulties may arise at the initial stages, when the clinic is determined by the underlying disease. Abdominal x-ray allows you to determine the presence of free fluid, signs of paralytic intestinal obstruction. Small intestinal “arches” with fluid levels are visualized, the internal contours of the intestine are fuzzy, the folds of the mucosa are thickened.
Ultrasound examination also allows you to visualize free fluid in the abdominal cavity, structural and functional changes in the intestine. An informative diagnostic method is laparoscopy, which makes it possible to examine a large part of the abdominal cavity, assess the condition of the visceral, parietal peritoneum, determine the presence of exudate and its nature.
Treatment for aseptic peritonitis
The treatment is carried out by an abdominal surgeon. The most important factor of successful treatment is early surgical intervention. Due to the pronounced symptoms of the disease, recognizing its specific cause before surgery often does not make sense, since it is only a waste of time. Before surgery, a short intensive preparation is carried out. The decompensated functions of the body are corrected, the volume of circulating blood is restored.
During the operation, the cause of peritonitis is established, the pathological contents are removed from the peritoneal cavity, its sanitation, decompression of the gastrointestinal tract, conditions are created for the possibility of sanitation of the cavity in the postoperative period. The rehabilitation of the abdominal cavity during the operation is carried out by peritoneal lavage. Washing is performed with warm solutions of antiseptics to clean water, while fibrin deposits are removed. Solutions of antibiotics, lysozyme, heparin can be used for lavage, ultrasound treatment of the abdominal cavity is used.
Intensive therapy continues in the postoperative period. It is mandatory to prescribe antibiotics, immunomodulators. Infusion therapy is carried out in order to restore the volume of circulating blood, correct electrolyte disorders, and improve rheological properties. Active detoxification is achieved by the use of blood substitutes, forced diuresis, hemosorption, peritoneal dialysis. An important stage of treatment is the restoration of motor–evacuation functions of the intestine. The vital functions of the body are also maintained.
Prognosis and prevention
Aseptic peritonitis is a serious disease. However, with full-fledged complex treatment, timely surgical intervention, elimination of the source in most cases, the outcome is favorable, recovery occurs. Prevention consists in early adequate treatment of the underlying disease.
