Pseudomyxoma peritonei

　　The etiology of pseudomyxoma peritonei is not yet clear. Since the disease is caused by the rupture of ovarian mucinous cysts, ovarian mucinous cystadenomas, or appendiceal mucinous cysts, when the mucinous fluid is discharged, it often contains epithelial cells, which enter the peritoneal cavity together. On one hand, the mucin and epithelial cells stimulate the peritoneum, causing an inflammatory reaction; on the other hand, the continued secretion of mucin accumulates a large amount of colloidal mucin in the peritoneal cavity, forming a gelatinous ascites, known as 'gel abdomen'. It may also be caused by metastatic spread through blood vessels and lymphatic vessels. Statistics show that about 45% of tumor cells originate from the ovary, 29% from the appendix, 26% are of unknown origin, and 1% to 2% of ovarian tumors can develop into pseudomyxoma peritonei..

　　In addition, a small number of patients may be secondary to ovarian teratoma, ovarian fibroma, uterine cancer, intestinal mucinous adenocarcinoma, urachal cyst adenocarcinoma, mesenteric mesenteric cystic cyst, common bile duct mucinous adenocarcinoma, pancreatic mucinous cystadenocarcinoma, and peritoneal mesothelioma, but they are extremely rare.

　　Although pseudomyxoma peritonei is rarely metastatic, it grows aggressively with a strong vitality, adhering to the parietal layer of the peritoneum and regrowing rapidly after removal, resulting in the patient's entire abdomen being filled with mucinous masses, adhering to the parietal layer of the peritoneum, omentum, and mesentery, leading to compression of the intestinal lumen, often causing intestinal obstruction, peritonitis, and other complications, resulting in adhesive intestinal obstruction, intestinal fistula, pyloric stenosis, and biliary obstruction, ultimately leading to the patient's inability to eat and mesenteric failure and death.

　　The course of pseudomyxoma peritonei can last for several months or even several years, with some cases lasting over a decade. Clinically, it is mainly characterized by progressive abdominal enlargement and abdominal pain. There may also be recurrent right lower quadrant pain and discomfort, right lower quadrant mass, intestinal obstruction, peritonitis, and other complications. Physical examination may show signs of ascites and unclear nodules.

　　1. Nausea and vomiting

　　Mucinous ascites grows progressively, causing gastrointestinal reactions in the early stage, such as nausea, vomiting, lower abdominal pain, or a sense of pelvic prolapse.

　　2. Progressive abdominal distension and abdominal pain

　　As ascites gradually increases, the patient feels a progressive bloating in the abdomen, an increase in abdominal circumference, abdominal pain, and difficulty breathing; it gradually develops into respiratory distress, with symptoms of shortness of breath and inability to lie flat.

　　3. Weight loss

　　Pseudomyxoma peritonei grows rapidly, consuming the body's nutrition while also compressing abdominal organs, causing the patient to have reduced appetite, fatigue, and weight loss.

　　4. Gastrointestinal obstruction

　　Patients may experience pyloric stenosis, intestinal obstruction, even obstructive jaundice, and have corresponding clinical symptoms.

　　To prevent pseudomyxoma peritonei, one should pay attention to rest, combine work and rest, maintain an orderly life, and keep an optimistic, positive, and upward attitude towards life. The patient's diet should be light and easy to digest, eat more vegetables and fruits, and rationally match the diet, ensuring adequate nutrition.

　　Pseudomyxoma peritonei should undergo blood routine examination, blood biochemical examination, and ascites examination, as specified below:

　　One, Blood routine examination

　　Generally no obvious abnormalities, or only mild anemia. In secondary infections, there may be an increased white blood cell count.

　　Two, Blood biochemical examination

　　Blood biochemical examination usually shows no abnormalities, but in cases with concurrent pyloric stenosis, intestinal obstruction, obstructive jaundice, there may be abnormalities in water and electrolytes and acid-base balance disorders, increased bilirubin index and blood bilirubin, and in the late stage, malnutrition can lead to hypoalbuminemia, etc.

　　Three, Ascites examination

　　During abdominal puncture, if abnormal ascites is found, such as jelly-like or jelly cake-like, suspicion of the disease should be raised. Although there is a large amount of ascites, when using a 8-12 gauge thick needle, only a small amount of pale yellow, transparent, sticky, jelly-like fluid can be aspirated. Routine and special tests of the puncture fluid show fibrin and red blood cells. The Rivalta test for mucin qualitative test is usually positive, and this examination often has a decisive significance for the diagnosis of the disease. The ascites is exudative, and there are no special changes in the routine ascites.

　　Four, Histopathological examination

　　Rectal puncture biopsy shows pseudomyxoma peritonei.

　　Five, Imaging examination

　　1. X-ray abdominal film: Some reports suggest that the characteristic calcification curve found in X-ray abdominal film should raise suspicion of the disease, but this sign is not common.

　　2. Barium meal examination of the digestive tract: Generally no abnormal changes, but when there is pyloric stenosis or intestinal obstruction, there may be external pressure defects in the gastric wall and narrowing at the site of compression of the intestine.

　　3. Ultrasound examination: Non-invasive, low cost, reliable, should be the first choice. If ultrasound shows a slightly grayish white liquid area in the abdominal cavity, with coarse spots, spots, and halos slowly swinging, with deep breathing, changes in body position, or with pressure or impact exploration, there is a 'ceremonial flower' floating, it should be highly suspected of pseudomyxoma peritonei.

　　It shows irregular small cystic anechoic areas on the inner wall or surface of the intestinal wall (as shown in Figure 4); as well as large areas of honeycomb-like anechoic areas in the abdominal cavity, with unclear boundaries. Fine dot-like echoes can be seen inside, and with changes in body position, fine dot-like echoes can float in the anechoic areas. Small cysts generally do not have smooth and complete cyst walls, and a large number of small cysts聚集 together can form a honeycomb-like structure. Small cystic structures can also be attached to the surface of organs such as the liver, bladder, and uterus. According to the features of the ultrasound image, combined with the medical history, the diagnosis of this disease is not difficult.

　　4. CT examination: Liver and spleen are compressed and shrunken, with scallop-like defects at the edges of liver and spleen, thickened peritoneum, and a large amount of watery low-density shadows in the abdominal cavity. The CT value is 20Hu, significantly higher than ascites, showing diffuse cystic masses in the abdominal and pelvic cavities. The sizes of the cysts vary, most are less than 1cm, and the omentum is infiltrated and thickened. The CT value of the lesions is relatively low, usually around 3Hu. The liver margin shows multiple scalloped indentations without liver parenchymal metastasis. There is a large amount of ascites, often with septation, and the ascites is jelly-like with low density, pushing the intestines to the center.

　　Sixth, laparotomy or laparoscopic surgery exploration

　　Since this disease is rare, misdiagnosis may occur due to lack of understanding, even with puncture and laboratory results that still do not suggest this disease. In necessary cases, laparotomy or laparoscopic surgery can be performed to clarify the diagnosis. The abdominal cavity of this disease is filled with white, transparent, semi-solid, thick liquid, with many homogeneous tumors or multiple cystic masses. Some are firmly attached to the peritoneum, and the masses can be excised for pathological examination.

　　In addition to general treatment, peritoneal pseudomyxoma patients can also relieve symptoms through dietary methods during the recovery period.

　　1. Xanthium and radish decoction:100 grams of xanthium, 20 grams of lonicera japonica, 25 grams of dandelion, and 200 grams of white radish. Boil all these ingredients together, eat the radish after removing the medicine, and drink the soup. Take one dose per day, which has the clinical effect of clearing heat and detoxifying. Lonicera japonica has varying degrees of inhibitory effects on various bacteria such as staphylococcus, streptococcus, pneumococcus, escherichia coli, pseudomonas aeruginosa, and skin fungi.

　　2. honeysuckle winter melon seed kernel syrup:20 grams of winter melon seed kernel, 20 grams of lonicera japonica, 2 grams of coptis, and 50 grams of honey. First decoct lonicera japonica, remove the residue and take the juice, then add winter melon seed kernel and honey after boiling for 15 minutes. Take one dose per day, and take it for one week consecutively.

　　3. Safflower and peel tea:10 grams of green peel, 10 grams of safflower, the green peel is dried and cut into strips, and mixed with safflower in a pot. Soak in water for 30 minutes, boil for 30 minutes, filter with clean gauze, remove the residue, and take the juice, which can be taken as tea and drunk frequently.

　　The treatment of peritoneal pseudomyxoma is divided into focus treatment, abdominal cavity cleaning, and drainage, as follows.

　　1. Treatment of the focus:The main purpose of surgical treatment for peritonitis is to eliminate the etiology. The earlier the source of infection is eliminated, the better the prognosis will be. In principle, the surgical incision should be as close to the focus as possible, with a straight incision being preferable for extending upwards and downwards and for changing the surgical approach. The exploration should be gentle and meticulous, and unnecessary dissection and separation should be avoided to prevent the spread of infection due to improper operation. The primary focus should be judged according to the situation before treatment, and necrotic appendicitis and cholecystitis should be resected. If local inflammation is severe, the anatomical layers are unclear, or the condition is critical and cannot tolerate major surgery, the operation can be simplified to only perform drainage or fistulization around the focus. After the overall condition improves and the inflammation heals, come to the hospital for elective cholecystectomy or appendectomy 3 to 6 months later. For necrotic intestinal segments, resection is necessary. If the conditions are really not permissible, an external necrotic intestinal segment operation can be performed. On one hand, shock should be counteracted, and on the other hand, the necrotic intestinal segments should be removed as soon as possible to save the patient, which is the best surgical option. For gastric and duodenal ulcer perforation, if the patient's condition allows and the perforation time is short and in the stage of chemical peritonitis, with an empty stomach and light peritoneal contamination, and if the lesion indeed needs to be resected, consider performing a subtotal gastrectomy. If the condition is severe, the patient is in a toxic shock state, and the peritoneal contamination is heavy in the stage of purulent peritonitis, then only a gastric perforation repair can be performed, and the patient should be hospitalized for elective surgery 3 to 6 months later after the body recovers.

　　2. Cleaning the peritoneal cavity:After eliminating the cause, it is necessary to remove as much peritoneal pus as possible, clear the food and residue, feces, foreign bodies, and other substances in the peritoneal cavity, and the best way to clear is by negative pressure suction. If necessary, wet gauze can be used as an auxiliary, and rough actions should be avoided to damage the endothelial cells on the serosal surface. If there is a large amount of bile and the contents of the gastrointestinal tract are severely contaminated throughout the peritoneal cavity, a large amount of normal saline can be used for peritoneal lavage, while washing and suctioning. To prevent contamination of the diaphragm below during lavage, the operating bed can be appropriately tilted to a head-high slope position. Wash until the water is clear. If the patient's body temperature is high, 4 to 10°C normal saline can also be used to wash the peritoneal cavity, which can also achieve the effect of cooling. When a large amount of pus in the peritoneal cavity is separated by formed pseudomembranes and fibrin, in order to achieve the purpose of unobstructed drainage, it is necessary to separate and remove the pseudomembranes and fibrin, etc., although there is some damage, but the effect is good.

　　3. Drainage:The purpose of drainage is to allow the exudate produced continuously in the peritoneal cavity to be discharged outside through the drainage material, so that the remaining inflammation can be controlled, localized, and disappear. Prevent the occurrence of peritoneal abscess. After surgery for diffuse peritonitis, as long as it is cleaned up, it is generally not necessary to drain. However, it is necessary to place peritoneal drainage under the following conditions.