Peritonitis

　　Peritonitis can be roughly divided into bacterial peritonitis, fungal peritonitis, tuberculous peritonitis, and chemical peritonitis. The so-called peritonitis usually refers to bacterial peritonitis. The occurrence of peritonitis is not only related to bacterial infection but also to the interference with the defense mechanism of the peritoneum and the low immune function of the patient. The specific introduction is as follows:

　　1. Bacterial infection

　　The routes of infection are mainly internal and surrounding infections in the pipeline, which are closely related to the operator's skill level, strict sterile concept, and absolute sterility of dialysis equipment. Gastrointestinal perforation, leakage of gastrointestinal contents into the peritoneal cavity. Bladder rupture, such as urethral obstruction, bladder stones, bladder puncture, etc. Perforation and rupture of the reproductive system, including pyometra and dystocia rupture. Perforation and contusion of the abdominal wall, infection after abdominal surgery due to disinfectant stimulation during surgery.

　　2. The peritoneal defense mechanism is interfered with

　　Repeated exchange of dialysate changes the physiological environment of the peritoneum, increases the destruction and clearance of peritoneal macrophages, reduces complement activity, decreases the concentration of opsonins in the peritoneal fluid, and increases loss, all of which have an adverse effect on the patient's specific and non-specific immune function, making the peritoneum susceptible to bacteria.

　　3. Immune function impairment

　　According to reports, individuals with a low delayed-type hypersensitivity skin test incidence are more likely to develop peritonitis than those with a high incidence, which may be related to low immune function, hypoproteinemia, and weakened bacteriostatic function of macrophages.

　　Peritonitis is the inflammation of the parietal peritoneum and visceral peritoneum in the abdominal cavity, which can be caused by bacterial, chemical, and physical injuries, among others. What are the complications of peritonitis?

　　If peritonitis is not treated quickly and effectively, it will lead to multi-system failure rapidly. The loss of fluid into the abdomen and intestines can lead to severe dehydration and electrolyte imbalance, with the patient presenting with a mask-like expression (Hippocratic facies), and death can occur within a few days. Adult respiratory distress syndrome can also appear rapidly, followed by renal failure, liver failure, and disseminated intravascular coagulation.

　　Abdominal abscesses occur in the pelvic area, subdiaphragmatic space, left or right colonic pericolic space, subhepatic space, and between intestinal loops. They must be found through clinical examination, ultrasound (useful for examining pelvic or subhepatic abscesses), CT (most effective for examining subdiaphragmatic abscesses), and sometimes laparotomy. Percutaneous catheter drainage guided by ultrasound or CT is often possible.

　　The formation of adhesions or bands is a late complication, which often causes obstruction in the future.

　　The main clinical manifestations of peritonitis include peritoneal stimulation symptoms in the early stage, such as abdominal pain, tenderness, abdominal muscle tension, and rebound pain. In the later stage, due to infection and absorption of toxins, the main manifestation is systemic infection and toxic symptoms. The following will be introduced specifically.

　　1. Abdominal pain

　　This is the main symptom of peritonitis. The degree of pain varies with the extent of inflammation. However, it is usually severe, unbearable, and persistent. Pain can be exacerbated by deep breathing, coughing, or turning the body. Therefore, the pain often starts from the primary focus and spreads to the entire abdomen after the inflammation spreads, but it is still more significant at the primary site of the disease.

　　2. Nausea and vomiting

　　This is a common early symptom. Initially, due to stimulation of the peritoneum, there is reflex nausea and vomiting, with the vomit containing gastric contents. In the later stage, when paralytic ileus occurs, the vomit turns into yellow-green bile-containing fluid, and even brownish fecal-like intestinal contents. Frequent vomiting can lead to severe dehydration and electrolyte imbalance.

　　3. Fever

　　Peritoneal inflammation that occurs suddenly may initially present with normal body temperature, which then gradually increases. In elderly and weak patients, body temperature may not necessarily rise with the severity of the condition. The pulse usually accelerates with the rise in body temperature. If the pulse accelerates while the body temperature decreases, it is often a sign of deterioration in the condition, and effective measures must be taken early.

　　4. Infection and toxicity

　　When peritonitis enters a severe stage, symptoms such as high fever, excessive sweating, dry mouth, rapid pulse, shallow breathing, and other systemic toxic manifestations often occur. In the later stage, due to the absorption of a large amount of toxins, patients may appear indifferent, emaciated, sunken eye sockets, cyanotic lips, cold limbs, yellow and cracked tongue, dry skin, rapid breathing, weak pulse, sudden increase or decrease in body temperature, decreased blood pressure, shock, acidosis. If the condition continues to worsen, death may occur due to liver and kidney failure and respiratory and circulatory failure.

　　5. Abdominal signs

　　Manifested by weakened or absent abdominal breathing, accompanied by significant abdominal distension. Increased abdominal distension is often an important sign of the progression of the disease. Pain on palpation and rebound tenderness are the main signs of peritonitis, always present, usually involving the entire abdomen, with the primary focus being most prominent. The degree of abdominal muscle tension varies with the cause and the overall condition of the patient. Sudden and severe stimulation, such as the chemical stimulation of gastric acid and bile, can cause intense abdominal muscle tension, even presenting as a 'board-like' rigidity, known as 'board-like abdomen' in clinical practice.

　　Most cases of peritonitis can be prevented. For common pathogenic causes such as appendicitis, gastric and duodenal ulcers, they should be detected early and treated promptly. In abdominal surgery, strict aseptic techniques should be followed to prevent the overflow of gastrointestinal fluids and prevent contamination of the abdominal cavity. Prevention of upper respiratory tract infections during childhood, strengthening constitution, and improving the body's resistance to diseases are important.

　　Early and appropriate treatment of abdominal inflammation that may cause peritonitis is the fundamental measure to prevent peritonitis. Any abdominal surgery, including abdominal puncture, should be performed strictly under sterile conditions. Oral antibiotics before intestinal surgery can reduce the occurrence of peritonitis.

 　　Pain on palpation and rebound tenderness are the main signs of peritonitis, always present. The degree of abdominal muscle tension varies with the cause and the overall condition of the patient, and abdominal percussion may produce a tympanic sound due to gastrointestinal distension. When there is a lot of fluid in the abdominal cavity, it can produce mobile dullness, and it can also be used to locate necessary abdominal puncture. Auscultation often reveals decreased or absent bowel sounds. Next, let's introduce the necessary examinations for this disease.

　　1. Laboratory tests and X-ray examination

　　White blood cell count increases, but when the condition is severe or the body's response is low, the white blood cell count is not high, only the proportion of neutrophils increases or toxic granules appear. Abdominal X-ray examination shows general distension of the intestinal lumen and multiple small air-liquid interfaces, indicating intestinal paralysis. In cases of gastrointestinal perforation, free gas under the diaphragm is often visible (should be examined in an upright position). This is of great significance in diagnosis. For patients with weak constitution or those unable to stand for upright透视 due to shock, lateral decubitus radiography can also show the presence or absence of free gas.

　　2. Blood examination

　　The total number of white blood cells increases significantly, with an increase in neutrophils and nuclear left shift. Abdominal puncture examination shows protein content above 4%, cloudy color, increased specific gravity (above 1.018), and white blood cells above 20,000 per cubic millimeter. Smear examination shows the presence of bacteria.

　　If further auxiliary examinations are required during diagnosis. Such as digital rectal examination, pelvic examination, diagnostic peritoneal puncture and female posterior fornix puncture under low semi-recumbent position. According to the color, smell, nature, and microscopic examination of the puncture fluid, or quantitative determination of amylase values, etc., to determine the cause of the disease.

　　Peritonitis is a common serious surgical disease caused by bacterial infection, chemical irritation, or injury. Most cases are secondary peritonitis, originating from the infection of abdominal organs, such as necrosis, perforation, and trauma. So, how should peritonitis patients eat? The following will introduce it to everyone.

　　I. Dietary attention for peritonitis

　　Patients with acute pancreatitis should eat small and frequent meals, with 5 to 6 meals per day, and 1 to 2 types of food per meal. Pay attention to choosing soft and easily digestible semi-liquid or soft foods to avoid overeating and overdrinking.

　　After the condition gradually stabilizes, the amount of food intake should be gradually increased, and low-fat semi-liquid food should be adopted. Protein should be moderate, not excessive, and sufficient carbohydrates should be provided.

　　Pay attention to the supplementation of vitamins and trace elements.

　　II. Diet taboos for peritonitis

　　It is advisable to eat more cooling and diuretic foods, such as amaranth, amaranthus, loofah, loofah seeds, large cucumbers, luffa, kelp, Job's tears, mung beans, herba houttuyniae, light bamboo leaves, and clover sprouts, etc.

　　Drink more cooling and diuretic fruits and vegetables juices, such as pear juice, apple juice, watermelon juice, orange juice, handkerchief orange juice, and herba houttuyniae tea, etc.

　　Patients should drink more than 2500ml of water per day.

　　Avoid spicy and irritating foods such as chili, chili sauce, onions, pepper, curry powder, etc., which can exacerbate inflammation.

　　Avoid eating cold and raw foods such as frozen foods, beverages, ice cream, etc.

　　Avoid eating fried, fried, roasted, smoked, and other foods.

　　Avoid eating hot and dry fruits such as cherries, longans, lychees, durians, black dates, peaches, etc.

　　Peritonitis is a common serious surgical disease caused by bacterial infection, chemical irritation, or injury. Its main clinical manifestations are abdominal pain, abdominal muscle tension, as well as nausea, vomiting, fever. In severe cases, it can lead to a decrease in blood pressure and systemic toxic reactions. Generally, this disease requires the following methods of treatment.

　　1. Position

　　When there is no shock, the patient should assume a semi-recumbent position, which is conducive to the accumulation of peritoneal effusion in the pelvis. Because the toxic symptoms of pelvic abscess are relatively mild, and it is also convenient for drainage and treatment. It is necessary to frequently move both lower limbs and change the compressed parts when in a semi-recumbent position to prevent the formation of venous thrombosis and bedsores.

　　2. Fasting

　　Patients with gastrointestinal perforation must be absolutely fasting to reduce the continued leakage of gastrointestinal contents. For patients with peritonitis caused by other causes who have developed intestinal paralysis, eating can exacerbate the accumulation of fluid and gas in the intestines, leading to increased abdominal distension. It is necessary to wait until intestinal peristalsis returns to normal before starting to eat.

　　3. Gastrointestinal decompression

　　It can alleviate gastrointestinal distension, improve blood supply to the gastrointestinal wall, and reduce the leakage of gastrointestinal contents into the peritoneal cavity through openings, which is an indispensable treatment for patients with peritonitis. However, long-term gastrointestinal decompression can hinder breathing and coughing, and increased fluid loss can cause hypochloremic hypokalemic alkalosis. Therefore, once intestinal peristalsis returns to normal, the gastric tube should be removed as soon as possible.

　　4. Intravenous administration of crystalloid solution

　　Patients with peritonitis who are prohibited from eating must correct water and electrolyte balance and acid-base imbalance through intravenous infusion. For severely exhausted patients, more blood and plasma should be transfused, and albumin should be administered to supplement the protein lost due to peritoneal effusion, preventing hypoproteinemia and anemia. For mild cases, glucose solution or balanced salt solution can be administered. For patients with shock, necessary monitoring, including blood pressure, heart rate, electrocardiogram, blood gas, central venous pressure, urine specific gravity, and acid-base balance, hematocrit, electrolyte quantification observation, and renal function, should be performed simultaneously with the administration of colloid fluid to immediately correct the content and speed of the fluid and increase necessary auxiliary drugs. A certain amount of hormone therapy can also be given. After basic expansion, vasoactive drugs can be used according to circumstances, among which dopamine is relatively safe, and surgery can be performed while treating shock after confirmation of the diagnosis.

　　5. Supplementing Heat and Nutrition

　　Peritonitis requires a large amount of heat and nutrition to meet its needs, with a metabolic rate of 140% of normal levels. The patient needs to consume 3000 to 4000 calories per day. When the required calories cannot be replenished, a large amount of protein in the body is consumed, causing severe damage to the patient. Currently, in addition to providing glucose to supply part of the heat, a compound amino acid solution is also administered to reduce the consumption of protein in the body. For patients who cannot eat for a long time, deep venous hyperalimentation therapy should be considered.

　　6. Application of Antibiotics

　　Due to the severe condition of peritonitis and the mixed infection caused mostly by Escherichia coli and Enterococcus faecalis, a large amount of broad-spectrum antibiotics should be used early on, and then adjusted according to the results of bacterial culture. The route of administration is better by intravenous infusion. In addition to Escherichia coli and Enterococcus faecalis, attention should be paid to the existence of drug-resistant Staphylococcus aureus and anaerobic bacteria without spores (such as Bacteroides), especially in refractory cases. Appropriate selection of sensitive antibiotics such as chloramphenicol, clindamycin, metronidazole, gentamicin, and ampicillin is recommended. For patients with Gram-negative bacillary sepsis, third-generation cephalosporins such as cefoperazone can be used.

　　7. Analgesia

　　It is necessary to appropriately apply sedatives and analgesics to alleviate the pain of patients. For patients with clear diagnoses and treatment methods, the use of pethidine or morphine to relieve severe pain is also permitted, and it has a certain effect on enhancing the tension of the intestinal wall muscles and preventing intestinal paralysis. However, if the diagnosis has not been determined, and the patient needs to be observed, it is not advisable to use analgesics to avoid concealing the condition.