Peritonitis in children

Peritonitis in children often develops as a complication of appendicitis. Cause peritonitis in children can be also perforation, ulcers with staphylococcal or brusnitsa enterocolitis, perforation mechkereva diverticulum. Less peritonitis develops as a consequence of the inflammatory process in the gall bladder, ovaries. Special place diplokokkovyh peritonitis; entrance gate of infection may be the mucous membrane of the mouth, vagina. The development of peritonitis is accompanied by vomiting, abdominal pain; appetite worsens, the child becomes restless or sluggish (dinamichnym), the temperature usually rises to 38-38,5 degrees. As peritoneal involvement in the inflammatory process grows increased heart rate, not the appropriate temperature, leukocytosis. Stool often detained, but in children of early age possible diarrhea. Further progressing of peritonitis leads to severe intoxication, a condition is deteriorating: there is a growing weakness, the cutaneous integument perceives grayish tint due to repeated vomiting develops dehydration. Appears thirst, dry mucous membranes and skin; language dry, lined. The pulse becomes frequent, weak filling. The largest value in the diagnosis of peritonitis in children is identifying local symptoms. As a rule, it is found expressed spilt pain on palpation and percussion belly, protective muscles of the abdominal wall, a symptom Shchetkina - Blomberg. Peristalsis weakened, in advanced cases develops flatulence because of intestinal paresis.
A specific challenge is the diagnosis of peritonitis in children during the first 3 years of life, because at this age the same General disorders can occur at various diseases, unable to accurately identify the complaint, and the study of the abdomen is often hindered by the behavior of the child. In such cases, you need to touch the baby's stomach during sleep, which can be induced (after the enema with a hydrate), but it can be applied only doctor in the hospital (see Appendicitis in children). Special attention should be paid peritonitis in newborns. It can develop as a manifestation of sepsis. Makarieva peritonitis arise on the grounds of congenital intestinal obstruction, perforation may also be a consequence of malformation of the intestinal wall. The clinical picture in these cases characterized by persistent vomiting, belly swollen, often determined by edema of the abdominal wall.
Treatment of peritonitis is urgent surgical intervention. The child should be sent immediately to the surgical hospital, following the same rules as when peritonitis in an adult (see above): do not give to eat and drink, not to put purifying enemas, etc.
In all cases the necessary preoperative preparation (see the Preoperative period in children) within a few hours. The goal of surgery is to remove the source of peritonitis and remove effusion of the abdominal cavity. When spilled appendicular peritonitis in children in the postoperative period is successfully used for a long lavage of the abdominal cavity. Antibiotics injected intramuscularly or intravenously, as well as in the abdominal cavity. It is also shown intravenous drip 10% glucose with insulin, plasma, salt solutions.

Peritonitis in children is quite common and is characterized by the severity of disease, especially in younger children. Anatomical and physiological features abdominal cover and seal in newborns and young children (weak restrictive capacity due to low plastic properties of the peritoneum, the underdevelopment of the gland) contribute to the emergence of spilled P. the Most severe is P. newborns. Mortality among them until the present time reaches 75-80% (C. J. Doletsky, A. I. Lyonyushkin). In most cases P. develops secondarily, spreading from the abdomen or the abdominal wall. Primary P. in children is less common (more pneumococcal vaccination).
The clinical picture P. in children differs little from that of adults: pain, vomiting, bloating, muscle tension of the abdominal wall and other symptoms of peritoneal irritation, fever, dismissing her with a pulse, toxicosis, improvement of blood leukocytes. In newborns often determine bloating without the Express muscle tension.
Diagnosis of peritonitis in infants and young children often difficult. Fear of the doctor, restless behavior of the child at the time of the survey, its active protection, the lack of data on the subjective sensations of the patient at the time palpation of the abdomen complicate diagnosis. The use of antibiotics and painkillers (pantopon) makes symptoms P. less pronounced. The forecast should be set with caution. Early diagnosis, timely and correct treatment make it more favorable.
Treatment in the hospital. In the complex of measures will play a Central role early operations. Conservative activities before, during and after the operation, are reduced to the struggle with purulent infection, intoxication, sensitization, violations of water-salt metabolism and the activity of the gastrointestinal tract and provide for increasing the protective force of the organism, prevention and treatment of pneumonia.
Recently, children's surgeons increasingly focused preoperative preparation of children with severe peritonitis. Preparing for surgery can take from 1 to 5 hours. The question about the time of preparation and necessary activities is decided in each case (a kind of P., severity, duration of disease). Preoperative preparation includes the purpose and introduction to the operation of antibiotics; introduction of heart and painkillers (0.1 ml of 10% solution of caffeine and 1% solution of omnopon); perinephral blockade 0.25% solution novokaina (10 ml per side); washing stomach, sometimes leaving a permanent probe; introduction of high exhaust pipes, the appointment prozerina; venezela and introduction of simultaneous 25 - 30 ml of blood or plasma, 10 ml of 20% glucose solution, 2-3 ml of 10% solution of sodium chloride and calcium, 2 ml of 0.25% solution novokaina; continuous intravenous drip fluid (5% glucose solution or 10% glucose, ringer's solution in the ratio of 3:1 with the addition of vitamins C, B1, physiological solution); appointment of Dimedrol, pipolfen or suprastin; when hyperthermia - introduction 1 % solution amidopirina and 50% solution of dipyrone, physical cooling. When performing activities under this scheme are of age dosages of these funds.
The surgical intervention in P. is a removal of infectious hearth, removal (extraction) of pus from the abdomen, the introduction of antibiotics in the abdominal cavity and to ensure the possibility of their further intraperitonealno insertion through thin drainage. Conservative treatment of postoperative period carried out mainly according to the same scheme, according to testimony resort to re-operation.
Of the types of peritonitis, which is not found in adults, highlight maconey P. - aseptic inflammation of peritoneum, caused by introduction of meconium into the abdominal cavity. Usually occurs during the prenatal period. May develop due to a congenital intestinal obstruction with perforation, and when meconium plug obstruction associated with a congenital cystic fibrosis (see) and prognostically the most unfavorable.
Clinical symptoms: bloating and expansion of dermal veins, uncontrollable vomiting bile, no chair, sluggish peristalsis. In the abdominal cavity sometimes felt like formation. The radiological examination are determined by the swelling of the overlying intestine gases, liquid level, free gas in the abdominal cavity, calcifications and intestinal loops.
Surgical treatment. Restore the patency of the intestines, is sutured punching a hole, after using the toilet in the abdominal cavity administered antibiotics. In the case of meconium plug obstruction produce enterostomal. Through enterostomy imposed on her rubber catheter washed viscous meconium.
To liquefy it is introduced 10-15 ml of 5% Pancreatin. Some authors prefer resection with elimination of intestinal loops on Mikulich (S. Ya. Doletsky, S. Dimitrov).