Biliary peritonitis is a severe inflammatory disease of the peritoneum caused by the entry of bile into the abdominal cavity. Clinical manifestations develop rapidly: there is acute intense pain in the right hypochondrium, vomiting, bloating, hypotension and tachycardia, symptoms of intoxication increase. The general condition of the patient worsens up to a violation of consciousness (sopor, stupor). Diagnosis consists in conducting a surgical examination, laboratory tests, ultrasound, X-ray examination and CT of the abdominal cavity. The treatment is combined. In an emergency, surgical intervention is performed to eliminate the source of peritonitis, antibiotics, painkillers and antishock drugs, parenteral solutions are prescribed.
Biliary peritonitis is a complication of inflammatory and destructive diseases of the organs of the biliary system caused by the outpouring of bile into the abdominal cavity. The prevalence of pathology is 10-12% of all peritonitis. The disease refers to life-threatening conditions, occurs in the practice of doctors of various specialties: gastroenterologists, abdominal surgeons, resuscitators. Close attention to this pathology is associated with a high mortality rate, the serious condition of patients and the complexity of early diagnosis. Despite the rapid development of surgery, mortality remains high, ranging from 20 to 35%, depending on the causes of peritonitis. In men, the disease is registered 2-2.5 times more often than in women.
Causes of biliary peritonitis
Among the predisposing factors that increase the risk of developing destructive pathology of the gallbladder and biliary tract, there are: long-term diabetes mellitus, atherosclerosis of blood vessels, anemia, elderly and senile age, systemic and autoimmune diseases, frequent exacerbations of chronic pancreatitis. The immediate causes of the formation of biliary peritonitis include:
- Diseases of the gallbladder. Undiagnosed phlegmonous and gangrenous cholecystitis in time leads to perforation of the gallbladder and outpouring of contents into the abdominal cavity. This condition occurs with a frequency of 6-7%.
- Surgical interventions on the biliary tract. Reconstructive operations and interventions with the imposition of anastomoses can lead to a violation of the tightness of the bile ducts due to the failure of sutures, loosely clamped clips. In this case, there is a leakage of bile and the development of peritonitis. This complication may occur if the technique of performing a puncture biopsy of the liver or transhepatic drainage of the biliary ducts is violated.
- Injuries to the liver or biliary tract. As a result of traumatic damage of various genesis (knife, gunshot wound), the integrity of the gallbladder wall is violated, choledochus with the expiration of bile into the stomach.
- Cholelithiasis. Prolonged presence of concretions in the choledochus leads to the formation of pressure sores and perforation of the bile duct with the outpouring of bile.
Extremely rarely, the disease develops without a specific cause as a result of increased pressure and micro-ruptures in the bile ducts against the background of severe inflammation of the pancreas, spasm of the Oddi sphincter, embolism of the vessels supplying the gallbladder and choledoch.
Bile is formed in the liver cells and enters the gallbladder through the cystic duct. It consists of bile acids, pigments (bilirubin, lecithin, etc.), a small amount of enzymes (amylase, lipase), amino acids and inorganic substances (sodium, potassium, etc.). Bile has an aggressive alkaline environment. When ingested into the abdominal cavity, it first causes irritation and inflammation of the peritoneum, and then necrosis of the walls of the abdominal cavity, parenchymal organs. Further exposure to bile leads to the absorption of its components into the blood and the development of intoxication. Degenerative processes are formed in the liver and kidneys: edema, protein and fat dystrophy occur with the outcome in necrosis.
Biliary peritonitis can be punctured and sweaty. In the latter case, the disease develops due to the filtration of bile through the wall of the gallbladder into the abdominal cavity. In abdominal surgery, acute, subacute and chronic forms of the disease are distinguished. Based on the prevalence of the pathological process, there are:
- Delimited (local) peritonitis. This condition means the accumulation of bile contents in the pockets of the peritoneum or the formation of a delimited formation (infiltrate, abscess).
- Diffuse (common) peritonitis. More than 2 anatomical regions of the abdominal cavity are involved in the pathological process. This option is the most dangerous and often leads to serious complications.
Symptoms of biliary peritonitis
The clinical picture of the disease depends on the rate of penetration and the amount of bile entering the abdominal cavity, the area of the lesion. Slow outpouring of biliary contents leads to the development of chronic and subacute peritonitis with mild symptoms. The rapid penetration of bile into the peritoneal space leads to pronounced symptoms with a sharp deterioration of the patient’s condition. During the course of the disease, several stages are distinguished.
- Stage 1 (initial) manifests a few hours after the bile exits the bile ducts. During this period, inflammatory changes of the peritoneum develop, serous or serous-fibrinous effusion is formed. There are sharp cutting or stabbing pains in the right hypochondrium, radiating into the right shoulder blade, collarbone. There is reflex vomiting, belching, heartburn. The patient’s condition deteriorates sharply: the patient assumes a forced position on his right side with his legs brought to his stomach, his face is pale, cold sweat appears, heart rate increases, shortness of breath appears. Body temperature may remain normal or slightly elevated. Palpation of the abdomen is painful in all parts, muscle tension is detected. Dyspeptic phenomena are noted: bloating, constipation.
- Stage 2 (toxic) develops 1-2 days after the onset of the disease. Intoxication increases, the inflammatory process acquires a generalized form. The general condition of the patient worsens: the level of consciousness is stupor-sopor with periods of excitement, frequent vomiting occurs, dry mouth. The vomit has a brown color and an unpleasant smell. The skin is moist and pale, acrocyanosis is noted. Breathing becomes shallow, frequent. There is hypotension, moderate tachycardia. The body temperature rises to 39-40 ° C, the tongue is dry with a brown coating. The abdomen is tense during palpation, sharply positive symptoms of Shchetkin—Blumberg, Ker, Ortner-Grekov, Mussy, etc. There is no stool, gases do not escape, oliguria appears.
- Stage 3 (terminal) of biliary peritonitis is formed on 2-3 days. It is characterized by an extremely serious condition. The patient is in sopor, periodically screams, the face is earthy, the eyes are sunken, the features are pointed. Breathing is arrhythmic, shallow, pulse is thready, pronounced hypotension. The abdomen is swollen, the patient does not respond to palpation, there is no peristalsis during auscultation, anuria develops.
Prolonged course of biliary peritonitis leads to the penetration of bile acids into the blood, the occurrence of cholemia. The spread of infection and the generalization of the inflammatory process leads to the formation of sepsis and infectious-toxic shock. Biliary peritonitis causes impaired kidney and liver function with the development of renal-hepatic insufficiency.
The correct diagnosis is made by an abdominal surgeon, which often causes difficulties due to the rapid development of symptoms of the disease and the lack of a specific clinical picture. The disease belongs to an urgent pathology, requires rapid rational diagnosis and emergency treatment. Diagnosis of biliary peritonitis consists of several stages:
- Examination by an abdominal surgeon. The specialist conducts a survey of the patient for gallbladder diseases, a history of operations, etc. Then performs a physical examination (palpation, percussion and auscultation of the abdomen) and prescribes instrumental and laboratory tests.
- Abdominal ultrasound. It allows you to identify fluid in the abdominal cavity, the presence of a foreign formation (abscess, cyst), choledochus stones, a change in the shape and configuration of the gallbladder.
- Abdominal x-ray. Detects changes caused by perforation of the gallbladder or choledochus, determines free gas, intestinal obstruction. Indirect signs of peritonitis are a limited excursion of the diaphragm and the presence of effusion in the pleural sinuses.
- CT of abdominal organs. It best visualizes pathological changes on the part of the biliary tract and gallbladder.
- Laboratory tests. In the blood test, leukocytosis, increased ESR, anemia are noted. In the biochemical analysis of blood, the level of ALT, AST, bilirubin, alkaline phosphatase, amylase, etc. increases.
Differential diagnosis is carried out with peritonitis caused by pancreatic necrosis, perforated ulcer of the duodenum and stomach, etc. Often, the cause of peritonitis can be detected only intraoperatively. Abdominal pain is often differentiated with acute appendicitis, cholecystitis, right-sided paranephritis and cholelithiasis.
Treatment of biliary peritonitis
Treatment tactics depend on the initial disease, the extent of the lesion and the general condition of the patient. At all stages of the disease, emergency surgical intervention is carried out, aimed at getting rid of the pathology that led to the development of peritonitis (perforation of the gallbladder, failure of surgical sutures, etc.). With lesions of the biliary tract, cholecystectomy or choledochotomy, drainage of the biliary duct, repeated anastomosis, mandatory drainage and revision of the abdominal cavity are performed.
In the idiopathic form of the disease, they are limited to sanitation and drainage of the abdominal cavity. Along with the operation, the patient is shown to undergo detoxification, combined antibacterial, anti-inflammatory and analgesic therapy. Patients should be in the intensive care unit.
Prognosis and prevention
The prognosis of biliary peritonitis depends on the prevalence and neglect of the pathological process. When performing surgery at the initial stage of the disease, the prognosis is more often favorable. The formation of diffuse peritonitis with the development of sepsis can lead to death even after the intervention. Prevention of biliary peritonitis consists in timely diagnosis and treatment of chronic diseases of the biliary tract, careful monitoring of patients, ultrasound control during rehabilitation after abdominal surgery.