THE HEALTH OFFICE OF UKRAINE BUKOVINIAN STATE MEDICAL UNIVERSITY

Ratified on a methodical conference departments of surgery Head of department professor I.Yu. Polyanskiy ___ ___________ 20__y.

METHODICAL DIRECTION to the students of course of medical faculties !"# I$%&P&$%&$' ("#) *' P#&P*#*'I"$ '" P#*+'I+*, ,&--"$ ."%/,& 0 BASES of SURGERY 1 1 'hematic module 0 URGENT ABDOMINAL SURGERY 1 'H&.& "! ,&--"$-2 1ACUTE !ERITONITIS

&ducational discipline2 -urgery * course3 medical faculty 4 hours .ethodical direction made *s. 'ara5anchuk . .

+herni6tsy 7 2000

1" A#t$a%it& of t'e(e) Peritonitis * acute or chronic inflammation of parietal and 6isceral sheets of peritoneum3 8hich arises up as a result of operating on it of microorganisms or physical or chemical factors3 sho8s up 5oth local 5y changes and general disorders of the functional state of different organs and systems of organism. *cute 8idespread peritonitis is one of the hea6iest and most fre9uent diseases in a5dominal surgery. .ost acute surgical diseases and traumas organs of a5dominal region complicated peritonitis :acute appendicitis3 perforated ulcer3 acute cholecystitis3 pancreonecrosis3 perforation of ca6ity organs and them traumatic damage;. 0<=20 > acute surgical diseases of internal organs complicated acute 8idespread peritonitis. In /kraine concerning peritonitis annually treat almost ?0 000 patients. !rom data of statistics3 a5domen or duodenum perforation is reason of de6elopment peritonitis in ?0=?4 > patients3 colon = in 20=24 >3 small 5o8el = in 00=04 >3 acute appendicitis = in 20=24 >3 other reasons = in 00 >. *cute 8idespread peritonitis is principal reason of death at all of acute diseases of organs of a5dominal region. .ortality from peritonitis from data of I International congress of surgeons :.osco83 0@@4;3 makes from 20 to A0 %, depending on his kind3 reason of de6elopment and state of protecti6e forces of organism. $either achie6ement in anti5acterial therapy3 and introduction of ne8 methods of treatment :peritoneal dialysis3 laparostomy; nor modern achie6ements of intensi6e therapy pro6ide the desired results of treatment of acute peritonitis. !or local peritonitis characteristic is that the area of inflammation is marked off from other areas of peritoneal ca6ity anatomic structures = large and small omentum3 shri6els of 5o8els3 5y the 8all of 5o8els and other local peritonitis de6elops su5Bect to the condition lo8 6irulence of microflora on a 5ackground normal reacti6ity of organism. It also is complication of different acute surgical diseases of organs of peritoneal ca6ity. +" D$,atio- of %e..o-) 4 hours /" Ed$#atio-a% 0$,0o.e 1#o-#,ete ai(.2) To 3-o4) anatomy information a5out a peritoneumC determination of concept is peritonitisC modern looks are to etiology3 pathogenesis of peritonitisC mechanisms of de6elopment of different types of peritonitisC classification of peritonitisC features of clinical picture depending on reason of de6elopment3 stage of disease andC to pre6alence of acute peritonitisC diagnostic possi5ilities of additional methods of research :la5oratory3 instrumental3 D= ray; are at peritonitisC differential diagnostics of local and 8idespread acute peritonitisC principles of preoperati6e preparation of patients 8ith local and 8idespread peritonitisC a task of operati6e interference is at the different forms of acute peritonitisC medical tactic depending on the degree of 8eight of motion an acute peritonitisC methods of sanation of peritoneal ca6ity are at acute peritonitisC methods of defence of guy=sutures on an intestine at imposition of them in the conditions of acute peritonitisC sho8s and methods of closing of operating 8ound are at acute peritonitisC modern principles of postoperati6e treatment of peritonitisC prophylaEis of acute peritonitis.

A5%e) to collect anamnesis of diseaseC to define the symptoms of acute peritonitisC to propose the pre6ious diagnosis of acute peritonitis3 set his reason3 pre6alenceC to 8ork out a plan of inspection patient 8ith acute peritonitisC to conduct diagnostics of peritonitisC to analyse the results of roentgenologic and ultrasonic researches and laparoscopyC to conduct differential diagnostics of peritonitis 8ith ulcerous illness3 intestinal o5struction3 acute pancreatitis3 acute pleurisy3 pneumonia3 a5dominal form of heart attack of myocardium3 nephrocolic3 gynaecological diseases3 throm5osis of mesenterial 6esselsC to formulate the grounded clinical diagnosis of acute peritonitis in o5edience to the re9uirements of classificationC to define sho8s to operati6e interference at local and 8idespread acute peritonitisC to appoint the 6olume of preoperati6e preparation at local and 8idespread acute peritonitisC to define the 6olume of operati6e interference at local and 8idespread acute peritonitisC to define sho8s to the use of programed laparapertionC to appoint postoperati6e treatmentC to define sho8s to the leadthrough of eEtracorporal methods of detoEication at peritonitisC to design a medical document. !,a#ti#a% .3i%%.) method 9uestioning patient 8ith acute peritonitis and to the analysis of data of 9uestioningC method inspections sick 8ith acute peritonitisC determination of the most 8idespread clinical symptoms is at acute peritonitisC estimation and analysis of these la5testsC a method of drafting of the medical program is at acute peritonitis :determination of free gas and li9uid is in a peritoneal ca6ity;C leadthrough of laparocentesisC 6" Ba.e 3-o4%ed7e.8 a5i%itie.8 .3i%%.8 -e#e..a,& fo, a .t$d& t'e(e. 1i-te,.$59e#t i-te7,atio-2 Na(e. of 0,e:io$. di.#i0%i-e. 0. *natomy3 topographical anatomy :departments of humen anatomy3 topographical anatomy and operati6e surgery; 2. Pathoanatomy :department of pathologoanatomy and Budicial medicine; ?. 'opographical anatomy and operati6e surgery :department of topographical anatomy and operati6e surgery; A. Pre6ention of internal disease :department of pre6ention of internal disease3 clinical immunology and allergology; S3i%%. a,e 7ot ,eadthrough of laparocentesis

%etermination of morphological inflammation of peritoneum

changes

is

at

* choice of operating access and method of operation are at the different forms of acute peritonitis 'here is can6assing and physical inspection of patient 8ith acute peritonitis

4. Feneral surgery :department of Preparation of patient to the treatment3 diagnostic general surgery; measures and operating interferences. <. .icro5iology :department of * fence of material for micro5iological research. micro5iology; ;" Ad:i#e. to t'e .t$de-t" ;"1" Ta5%e of #o-te-t. of t'e(e) $ot 5ecause of the attained successes in diagnostics and treatment of peritonitis3 mortality here does not ha6e a proof tendency to the decline. 'he impro6ement of results of treatment of peritonitis is possi5le only 5y the compleE going near its diagnostics3 operati6e and postoperati6e treatment. *natomy features of peritoneum. Peritoneum = thin connect tissue transparent shell3 8hich co6ers the 8alls of a5dominal region :parietal peritoneum; and co6ers the surface of organs3 located in an a5dominal region :6isceral peritoneum;. 'he area of peritoneum approEimately e9uals the area of skin and makes 2=? m2. 'he histological structure of peritoneum is difficult. It is formed siE layers 8hich ha6e a different histological structure2 0. .esotelium. 2. Gasale3 mem5rane superficial part of 8hich is homogeneous3 and deep = contains tender interlacements of reticularis fi5res. ?. * superficial 8a6e collagen layer is presented thin collagen fi5res3 located longitudinally. A. 'he fi5res of superficial diffuse elastic net are located densely. 4. 'he deep is prolonged elastic net3 the fi5res of 8hich are thick3 connected 5y thin connections. <. %eep latticed callogen=elastic layer. In the different areas of a5dominal region a peritoneum has a different amount of layers. Yes3 the peritoneum of small 5o8el and a5dominal 8all consists of siE glo8ed3 large omentum = from four3 diaphragm surface = from three. It follo8s to mean it during treatment of patients 8ith peritonitis3 in fact intensity of suction and secretion of li9uid depends on the amount of layers :than glo8ed a less than peritoneum3 the more intensi6e suction;. 'he 5lood and lymphatic 6essels of peritoneum are located only 8ithin the limits of siEth layer3 8here the processes of selection and suction are carried out. 'he physiology functions of peritoneum are 6arious. Gasic from them2 0. -uction. 2. 'ranssudation. ?. Protecti6e3 or 5arrier. A. Plastic. Etio%o7& a-d 0at'o7e-e.i. of a#$te 0e,ito-iti." #eason of origin of acute peritonitis is mainly an autoinfection 8hich gets in an a5dominal region in the case of 6iolation of safety of HIJIKLMLLMN organs of the digesti6e system or their necrosis :a gangrenous cholecystitis and appendicitis3 ulcerous illness of a5domen and duodenum3 heterospecific ulcerous colitis and illness3 is +ro8n3 acute o5struction of 5o8els; or 6iolation of permea5ility of 8all of IJOPLP at acute surgical diseases :acute appendicitis3 acute cholecystitis3 acute 5o8els o5struction and other;. *cute peritonitis can accompany necrosis of pancreas at an acute pancreatitis. #arer reason of its de6elopment is a hit of heteroinfection in an a5dominal region = at the trauma of a5dominal 8all3 after operati6e interferences. *fter modern presentations select spontaneous 5acterial peritonitis 8hich is one of the hea6iest complications of hydroperitoneum also. 'hus other sources of intraa5dominal infection a5sent in an organism3 and in a peritoneal li9uid microorganisms or neutrocytes disco6er in an

amount o6er 240 cages in 0 ml. .ore fre9uent all spontaneous 5acterial peritonitis complicates the cirrhosis of li6er :in <=?0 > patients;3 considera5ly rarer is a nephrotic syndrome3 sometimes 7 cardio=6ascular insufficiency. In the organism of man constantly there are 0004=000Q microorganisms. *mong them select2 macromolecular forms :prions3 6eroids;3 cellular nuclear and nuclear=free forms :5acteria3 mushrooms3 the simplest;. ,ately mark the increase of particle of nonclostridial of anaero5ic microflora. Principal reason of origin an acute peritonitis is a hit in the peritoneal ca6ity of microorganisms from the different departments of the digesti6e system. In this connection it is necessary to kno8 and mean 9uantitati6e and high=9uality composition of microflora of different departments of the digesti6e system during esta5lishment of diagnosis of acute peritonitis and choice of anti5acterial preparations. In addition3 from a disease or damage of that or other IJOPLP depends not only composition of microflora 5ut also its 6irulence3 speed of distri5ution of inflammatory process in a peritoneum3 degree of 8eight of disease. Yes3 in a norm in 0 ml of gastric Buice contained to 0000 microorganisms. .ainly it is aero5ic streptococcus3 anaero5es disco6er 6ery rarely. *t lo8 acidity of gastric Buice the amount of microorganisms is considera5ly increased. +onse9uently3 resulted information testify that the hea6iest after motion is acute peritonitis caused the microorganisms of colon. !at'o7e-e.i. of a- a#$te 4ide.0,ead 0e,ito-iti. is 6ery difficult. In reply to de6elopment of inflammatory process and intoEication syndrome3 predefined formation of plenty of toEins3 at death of microorganisms and cages of organs and tissues of organism of man there is acti6ating of 5ioacti6e matters 8hich play a leading role in su5se9uent motion of peritonitis and syndrome of endogenous intoEication. /nder their action receptors is struck3 permea5ility of capillaries is increased3 arises up stasis of 5lood. -ystem 6iolations sho8 up the changes of 8ater=electrolyte 5alance3 acid=5asic state3 eEchange of al5umens3 car5onhydratess and gre8 fat. It results in hipoEy of tissues3 de6elopment of meta5olic Pcydosis3 increase of hemostais3 stasis of 5lood. 'one goes do8n at the defeat of interoreceptors3 and after8ards there is paresis of intestinum 8ith se9uestration of plenty of li9uid3 salts3 oligoelementss3 al5umens3 car5onhydratess3 gre8 fat and hemocytes 5oth in the road clearance of 5o8el and in an a5dominal region. In the 8all of 5o8el ischemic changes make progress hereupon3 it 5ecomes HJILMRLIS for microorganisms3 that predetermines their hit in an a5dominal region and in the system 5lood stream3 predetermining appearance of cytokines3 that is reason of considera5le 6iolations 6itally of important functions of organism. It should 5e noted that in intestinum constantly there are different microorganisms 8hich peacefully coeEist 8ith the organism of man. 'hey take part in many necessary processes3 in particular in pro6iding of trophic processes of 8all of colon3 micro5al fermentation on the stages of o6ercooking of meal3 synthesis of 6itamins and others like that. "n a 5ackground acute peritonitis there are pathological changes in all of organs and tissues of organism of man. .akes progress TUPV3 considera5ly permea5ility of capillaries of3 rises 8hich causes a tissue edema 8ith de6elopment of hypo6olemy and diminishing of 6olume of circulatory 5lood. 'he toEic products of eEchange3 8hich strengthen UIRTMRIV3 8orsen the state sick3 accumulate in an organism. -u5se9uent gro8th of endotoEicosis predetermines considera5le 6iolation of functions of organs 8hich pro6ide the processes of desintoEication :li6er3 lungs;. 'he signs of syndrome of polyorgans insufficiency3 the first sign of 8hich is a defeat of the respiratory system 8ith su5se9uent appearance of cardial3 hepatic and kidney insufficiency3 appear at progress of these changes. In pathogenesis of peritonitis an important role is played 5y the neurohumors of inflammation = cytokines3 8hich are lo8=molecular al5uminous neurohumors 8hich are producted different cages :endotheliocytes3 leucocytes and others like that;. 'hem 5iological acti6ity sho8s up operating on high=specific receptors3 located on cages :high=specific action;.

$eEt to that3 I, and factor of necrosis of tumours operate on all of cages3 sho8ing a system effect. In a healthy organism constantly there are processes of self=regulation3 including automanaged immunoreactions3 and the role of cytokines in maintenance of these processes is 6ery important. 'hey regulate motion of meta5olic processes3 strengthen formation of energy3 instrumental in the origin of hyperthermal reaction3 stimulate the regeneration of the damaged tissues and cicatriWation of 8ounds. *t critical conditions3 in particular at acute peritonitis3 the products of are stimulated or the alternati6e 8ays of their education are acti6ated3 as a result of 8hat the reactions of autoadBusting mutate and 5ecome out of control. In6estigation of these processes is an origin of interstitial edemas3 8hich causes a not regeneration3 5ut destruction of tissues. *s an endothelia3 cages of 5lood and tissue macrofages are 5asic sources of synthesis of cytokines = present in all of organism3 clearly3 that the increase of maintenance of cytokines predetermines 6iolation of functions of not only those organs 8hich are the source of critical condition 5ut also all of organs and systems of organism :syndrome of polyorgans insufficiency;. *t the diseases of organs of a5dominal region look after the especially eEpressed aggression of neurohumors of inflammation as a result of appearance in 5lood of endotoEin of gram=negati6e microorganisms. Gacillosis and a intoEication syndrome is related to it at acute 8idespread peritonitis cause de6elopment of the immunodeficient state 8hich predetermines progress of peritonitis and considera5le 8orsening of the state sick. It should 5e noted that the temporal immunodeficient state during the first days an acute peritonitis plays a positi6e role3 limiting appearance second3 autoimmune on the essence3 to necro5iosis. Herein there is physiology essence of the transitional immunodeficient state. 'hus3 to pre6ent 6iolation of acti6ity of internalss and systems of organism or impro6e their state at acute peritonitis and attain successes in his treatment3 5ecause of pathogenesis of disease3 possi5ly only on condition of timely delete of source of peritonitis3 sanation of a5dominal region3 normaliWation of function=5o8els3 leadthrough of rational anti5acterial therapy3 remo6al of disorders of homoeostasis. C%a..ifi#atio- of 0e,ito-iti.) 'here are a fe8 classifications of peritonitis3 from 8hich most 8idespread in clinical practice are such2 B& etio%o7&) =primaryC =secondary. 'he primary arises up as a result of hit of microorganisms in an a5dominal region 5y a haematogenic or lymphogenic 8ays3 and also as a result of their translocation from other organs. 'he second is predefined the hit of microorganisms in an a5dominal region as a result an acute surgical diseases of its organs or their damage at the trauma of a5domen. B& ,ea.o-. of o,i7i- of t'e .e#o-d 0e,ito-iti.) *traumaticC =postoperati6eC =perforati6eC =inflammatory = distri5ution of inflammatory process from staggered organXs of a5dominal region 8ithout his perforation. B& t'e .ta7e. of (otio-) *reacti6eC =toEic. B& #'a,a#te, of e<.$date) =serosalC =fi5rinousC =festeringC =haemorragicC =5iliousC

=fecalC =chemicalC =miEed. B& #'a,a#te, of (i#,of%o,a.) =aero5icC =anaero5icC = miEed :aero5ic=anaero5ic;. B& (otio-) =acuteC =chronicC =fla55y. B& 0,e:a%e-#e) *marked offC =unmarked offC =8hat is di6ided on2 =local3 =diffuse3 =poured out and general. =2 (a,3ed off = 8hen the hearth of inflammation is marked off from other part of peritoneal ca6ity anatomic structures = large omentum3 loops of 5o8els. It is at good reacti6ity of organism and lo8 6irulence of microflora. Infiltrate can eEemplify at appendicitis3 cholecystitis3 pancreatitis3 a5scesses of different localiWation. >2 $-(a,3ed off = 8hen an inflammatory process from the place of origin 8ithout difficulty can spread on a peritoneal ca6ity. In dependence on that3 8hat areas of peritoneal ca6ity he spreads on3 select2 1" Lo#a% = 8hich spreads on one of @ anatomic areas of front a5dominal 8all3 that on the adBoining to the place origins of peritonitis2 at appendicitis = on a right illiac area3 at a cholecystitis = on a right infracostal area. +" Diff$.e = 8hen an inflammatory process engulfs not only a peritoneum in the place of origin 5ut also spreads on adBoining areas3 5ut no more than ? anatomic areas. -o3 an acute appendicitis3 gynaecological peritonitis the peritoneum of small pel6is3 right iliac and suprapu5ic areas3 are pulled in an inflammatory process. /" !o$,ed o$t = 8hen an inflammatory process spreads more than on ?3 5ut no more than on < anatomic areas. *s an eEample2 the displays of inflammation appear in the ground floor of peritoneal ca6ity at appendicitis3 perforation of sigma=meson3 intestinal o5struction. 6" Ge-e,a% = 8hen the displays of inflammation appear on all of peritoneal ca6ity. B& t'e de7,ee of 7,a:e) I de7,ee :easy; = the signs of endotoEicosis are not eEpressedC ?? de7,ee :middle degree; = for the remo6al of signs of endotoEicosis enough li9uidation of reason of de6elopment of acute peritonitis 5y an operati6e 8ay and leadthrough of intensi6e therapyC II A a de7,ee :gra6e; is signs of endotoEicosis after li9uidation of reason of de6elopment of acute peritonitis it is possi5le to remo6e only 5y the eEtracorporal methods of detoEication :haemosor5tion3 lymphosor5tion;C II B de7,ee :as gra6e as lead; = the leadthrough of repeated sanation of a5dominal region re9uiresC ?V de7,ee :terminal; = there is a syndrome of polyorgans insufficiency3 incompati5le 8ith life. 'he impro6ed is lately offered and something 5rief classification of acute peritonitis for the practical use3 in 8hich distri5ution of pathological process is marked only 5y a peritoneum and character of eEsudate :'he plenum of pro5lem commissions is incorporated 1&Eigent surgery1 and 1!estering surgery1 of ."Y of #ussia3 .osco8 0@@@;. It foresees distri5uting of acute peritonitis on2 0. localC 2. 8idespread2 P; diffuse :8ill nurse outside a hearth inflammation and spreads on adBoining areas;C Z; general :spreads on considera5le areas or all of peritoneum;.

C%i-i# a- a#$te 0e,ito-iti." #an across acute peritonitis depends on reason of origin3 character and 6irulence of microorganisms3 distri5ution of pathological process3 stage of motion3 state of the immune system of organism and other organisms 8hich got in an a5dominal region. In clinical practice select the su5Becti6e and o5Becti6e signs of acute 8idespread peritonitis. 'o the su5Becti6e signs 5elong2 a; pain is in an a5dominal regionC 5; nauseaC c; 6omitC d; parafunction of intestinum3 8hat patients pay attention on :delay of emptying and gases3 destendion of a5domen; *n acute peritonitis is 5egun 8ith appearance of pain in an a5dominal region3 8hich is localiWed in the area of source of peritonitis and in future spreads on all of a5domen and 5ecomes more intensi6e. In the late stages intensity of pain diminishes through the damage of sensi5le ner6ous completions of peritoneum. $ausea and 6omit are permanent signs an acute peritonitis. 'hey appear at the 5eginning of disease and is refleE. +haracter of 6omit the masses depends on the stage of peritonitis3 at the 5eginning of disease maintenance of a5domen pre6ails in them3 in case of occurring of paresis an a5domen and 5o8els = the admiEtures of maintenance of thin 5o8el appear. omit does not 5ring a facilitation. *s a result of parafunction 5o8els patients grum5le a5out the delay of gases and emptying3 s8elling of a5domen. 'hese signs are in6estigation of appearance of paralytic acute o5struction of 5o8els. * patient is passi6e3 position is a5ed forced. He as though tries to protect sickly3 staggered an inflammatory process area from an additional irritation. +haracteristic is original appearance of patient. *t the 5eginning of disease of face sick of red3 eyes are 5rilliant3 a tongue is hard=5aked3 assessed 8hite stratification. *t progress of peritonitis of line of person acute3 5ruises appear under eyes3 lip and su5nail 5lue3 a person is co6ered a death=damp3 a tongue is assessed3 dry3 the temperature of 5ody rises to ?[\] and anymore. iolation of cardiac=6essels acti6ity is caused endotoEicosis3 sho8s up pain in the area of heart3 a pulse is fre9uent3 soft3 o6er 000 5^min. +orrelations of these indeEes utilliWe for the e6aluation of degree of 8eight of motion of peritonitis and prognosis of disease. *s a result of the high standing of diaphragm dome3 caused flatulence3 and also tension of muscles of front a5dominal 8all is 6iolated 5reathing function2 5reathing fre9uency is 2A=?0 per minC 5reathing is superficially and eEceptionally pectoral type. In the case of 8orsening of the state sick one of the first symptoms there is 6iolation of 5reathing3 his rhythm and depth. (hat more shallo8 5reathing3 8hat it more fre9uent3 the 8orse prognosis of disease. *n a5domen at the 5eginning of disease is hollo83 does not take participating in the act of 5reathing. *fter the origin of paresis of intestinum flatulence and a5domen appears destended one_s the cheeks3 and in course of time 5ecomes too eEaggerated. %uring palpation of a5dominal 8all mark its tension and painfulness. Pain and tension increase at palpation of a5domen in the area of source of peritonitis. Positi6e the signs of peritoneum irritation2 -chotkin=Glyum5ergXs and .endelXs. It follo8s to determine the -chotkin= Glyum5ergXs sign3 5eginning from an area3 remote from the hearth of peritonitis3 gradually approaching him3 8hile the .endelXs sign is appearance of pain during pattering of fingers tags on a front a5dominal 8all3 most sho8n in the proBection of hearth of peritonitis. %uring percusion of front a5dominal 8all mark a high percusion sound = tympanitis. In the case of appearance and accumulation in the a5dominal region of li9uid in lo8er places and dulling of percusion sound appears a5o6e pu5is. %uring auscultation of a5domen on the early stages of acute peritonitis the peristalsis of 5o8els is stored3 ho8e6er hyposthenic. *s far as distri5ution of inflammation and progress of intoEication syndrome there is paresis of intestinum3 not hearkened to peristaltic noises : an a5domen a complete 9uiet is a symptom of 1coffin 9uiet1;. %uring rectal research find out o6erhanding and pain of front 8all of rectum3 6aginal research = painfulness 6aults of 6agina 8hich increases at a metrectopia.

It is necessary to mark that lately the clinical displays of acute peritonitis changed considera5ly. *tipycal of clinical signs is marked3 unclearness of classic peritoneal symptoms for hyposthenic patients 8ith the second immunodeficient state3 5y the caused radial influence as a result of the +herno5ilXs catastrophe3 after the leadthrough of radial therapy3 and also for patients 8ith hea6y concomitant diseases and patients old years. .ost difficult is diagnostics of specific peritonitis 8hich arises up as a result of perforation of ulcers of intestinum at tu5erculosis3 typhoid3 mortality arri6es at @0> here. 'he considera5le changes of degree of 8eight of clinical motion an acute peritonitis are related to the 8ide use of anti5acterial preparations and other medications. #an across a disease takes a place in t8o stages2 In the first3 reacti6e3 stages characteristic signs of 5eginning an acute peritonitis and proper reaction of organism depending on reason of its origin. * disease 5egins pain 8hich appears suddenly = at the damage of organ or gro8s = in the case of its inflammation. $ausea3 6omit3 Boin 9uickly3 the temperature of 5ody rises. * patient is languid3 a pose is constrained3 a tongue is dry3 5reathing is fre9uent3 local tension of muscles of front a5dominal 8all3 positi6e symptoms of irritation of peritoneum3 is determined :-chotkin=Glyum5ergXs and .endelXs;. $eEt to it find out leycocytosis3 6iolation of homoeostasis3 progress of intoEication syndrome. 'he reacti6e stage as first stage an acute peritonitis can sho8 up in the different terms of disease 8hich entailed acute peritonitis3 5e different duration 8hich represents co=operation of 6irulent eEciter and reacti6ity of organism. *t the ill=timed remo6al of source of peritonitis :ill=timed appeal of patient for medical help3 inade9uate medical tactic; the reacti6e stage passes in a friend = toEic3 8hich signs3 predefined a intoEication syndrome3 8hich arises up as a result of hit in the system 5lood stream of toEic matters 8hich appear at death of microorganisms and damage of tissues3 pre6ail at3 and also through stagnant maintenance of intestinum. Intensity of pain diminishes3 arise up paresis of 5o8els3 6iolation of circulation of 5lood in the system of 6ein of gate. omit 5ecomes more fre9uent. * tongue is dry3 the lines of person are acute3 under eyes there are 5ruises3 halted pass gases. Pulse till 020 5^min and anymore3 the le6el GP goes do8n. Greathing is a speed=up3 superficially. *n a5domen is 5lo8n a8ay3 in an act3 5reathing of participation does not take3 the peristalsis of 5o8els a5sents3 the -chotkin=Glyum5ergXs sign is positi6e in all o8er an a5domen. 'he signs of o5struction of 5o8els Boin 7 )i6ulXs :at percusion of front a5dominal 8all timpanitis is marked 8ith a metallic tint;3 -klyaro6Xs :at push of front a5dominal 8all hearkened to phonendoscope the capotement; and others like that. %egree of gra6e of motion an acute peritonitis predefined operating of toEins on the ner6ous3 cardiac and respiratory systems3 li6er3 5uds3 as a result of 8hat there are degenerati6e changes in them. * role is important in motion of this stage 5elongs to paralytic o5struction of 5o8els3 8hich predetermines 6iolation of homoeostasis and all of types of eEchange. Dia7-o.ti#. a- a#$te 0e,ito-iti." 'he diagnosis an acute 8idespread peritonitis is set on the 5asis of analysis of complaints patient :pain in an a5dominal region3 nausea3 6omit3 delay of gases and emptying3 s8elling of a5domen;3 information of anamnesis :presence for the patient of diseases 8hich can entail peritonitis = gastric or duodenum3 acute cholecystitis3 acute pancreatitis3 opened or closed trauma of a5domen;C o5Becti6e inspection of patient :a skin is pale3 5ruises under eyes3 the lines of person are acute3 dry3 a tongue3 not mo5ility of patient3 constraint of pose3 is assessed; and information of o5Becti6e inspection of a5domen :tense3 does not take participating in the act of 5reathing3 the -chotkin=Glyum5ergXs sign is positi6e3 parafunctions intestinum3 is a languid or a5sent peristalsis;3 cardiac and respiratory systems :fre9uent pulse3 mionectic le6el of arteriotony3 shallo8 fre9uent 5reathing3 pectoral type of 5reathing;C results of la5oratory researches :leycocytosis is eEpressed3 change of leucocytes formula to the left3 appearance of young forms of leucocytes3 increase of speed of settling of red corpuscles;.

!or confirmation of diagnosis3 especially in dou5tful clinical cases3 apply the additional methods of research of organs of a5dominal and pectoral regions2 sur6ey D=ray and roentgenologic research3 +'3 ultrasonic research3 laparoscopy. Diffe,e-tia% dia7-o.ti#. a- a#$te 0e,ito-iti." %ifferential diagnostics an acute 8idespread peritonitis must 5e conducted 8ith diseases 8hich after clinical motion similar to acute peritonitis3 ho8e6er need surgical treatment. It is diseases 8hich the origin of the so=called 6icious acute peritonitis is possi5le for. 'he lung and pleural diseases :pneumonia3 5asale pleuritis;3 cardio=6ascular system :heart attack of myocardium3 a5dominal syndrome of rheumatism; 5elong to them3 gynaecological :adneEitis; and urology :renal colic;3 poisoning3 dia5etic melitus and others like that. *t the diseases of lungs and pleura :pneumonia and 5asale pleurisy; as a result of irritation of intercostal ner6es and inflammation of diaphragm surface of peritoneum pain in an a5dominal region and s8elling of a5domen appear refleEly. %uring palpation of front a5dominal 8all find out tension of its muscles3 poured out painfulness in a epigastric area. 'he temperature of 5ody rises3 there is leucocytosis. -igns is resulted reminds such at peritonitis. Ho8e6er the leading signs of diseases of lungs and pleura is a parafunction eEternal 5reathing 8hich sho8s up the increase of his fre9uency3 5y the shortness of 5reath and others like that. %uring auscultation of lungs hearken to the 8heeWes3 during percusion = muffling of H`JRaUIJLIOI sound. Information of roentgenologic research of organs of pectoral ca6ity help in diagnostics :darkening is in lungs3 limitation of respiratory eEcursion of diaphragm3 presence of li9uid in pleura ca6ities = at a pleurisy and others like that;. *t cardiac diseases :heart attack of myocardium3 a5dominal syndrome of rheumatism; sometimes in the initial stages appear pain in an a5dominal region3 tension of muscles of front a5dominal 8all3 paresis of intestinum. /nlike peritonitis3 pain in an a5dominal region is unsteady3 patients grum5le also a5out pain in the area of heart3 during the leadthrough of electrocardiography research find out changes3 tipical for the heart diseases. *t gynaecological diseases3 in particular adneEitis3 5eginning and ran across the um5ilical ring remind such3 as an acute peritonitis. *s at peritonitis of disease 5egun 8ith acute pain in an a5dominal region3 tension of muscles in the lo8er half of a5domen3 parafunction intestinum. Ho8e6er localiWed pain3 as a rule3 is at the 5ottom of a5domen3 panthodic in the area of crotch and anus3 tension of muscles of front a5dominal 8all less than is eEpressed3 it is found out him only in the lo8er half of a5domen. (ithout regard to that at adneEitis a pain syndrome is considera5ly eEpressed3 the state of sick remains satisfactory. %uring a 6aginal inspection the sickly disco6er and salpinEs3 megascopic sickly o6aries and 6ault of 6agina3 the Promto6Xs symptom is positi6e3 are incrassate :pain is during displacement of neck of uterus;. !rom data of ultrasonic research find out the increase of uterus and 5ulge of salpinEs. 'he presence of mucous festerings confirms the diagnosis of gynaecological disease3 festerings or 5lood eEcretions from a 6agina. 'he alike signs of renal colic and an acute peritonitis is the eEpressed pain in an a5dominal region3 nausea3 6omit3 paresis of intestinum3 protecti6e tension of muscles of front a5dominal 8all during palpation3 fer6escence. Ho8e6er much pain at a nephrocolic arises up suddenly3 on a 5ackground a satisfactory feel3 as a rule3 in a lum5ar area3 after8ards spreads on all of half of a5domen3 and e6en on all of a5domen. In maBorities sick a renal colic pain is panthodic along uterus3 in scrotum3 iliac areas. /nlike acute peritonitis a patient is uneasy3 continuously changes position of 5ody a5ed. !or poisoning characteristic dyspepsia signs :6omit3 nausea3 diarrhea; 8hich are preceded appearance of pain in an a5dominal region3 thus pain of cramp character. *n a5domen is soft3 moderate sickly during palpation3 s8elling of a5domen and the signs of irritation of peritoneum a5sent. T,eat(e-t 'he modern is nosotropic grounded treatment an acute 8idespread peritonitis is 5ased on three 5asic principles2

0. Implementation of ade9uate operati6e interference is in an eEigent order 8ith 6alua5le sanation of a5dominal region. 2. * leadthrough of 6alua5le anti5acterial therapy is taking into account the sensiti6eness of the selected eEciters to anti5acterial preparations. ?. ,eadthrough of compleE intensi6e therapy3 directed on the correction of 6iolations of the functional state of organs and systems of organism3 meta5olic disorders. Preoperati6e preparation is conducted in the short=term modeC its 6olume is determined the general state of patient and stage of peritonitis. Important measures is a leadthrough of desintoEication therapy3 correction of 6iolations of homoeostasis :disorders of 8ater=electrolyte 5alance3 acid=5asic state 5ut other; and measures for the impro6ement of the functional state of the cardiac and respiratory systems3 and also anti5acterial3 symptomatic therapy. Preoperati6e preparation of patients 8ith acute peritonitis in the toEic and terminal stages is conducted in the separations of reanimation and intensi6e therapy. Intensity of infusion preoperati6e preparation depends on the stage of acute peritonitis. 'he method of choice of anaesthesia during implementation of operati6e interference concerning acute 8idespread peritonitis is the com5ined intratracheal anesthesia. Ba.i# 0,i-#i0%e. of t,eat(e-t a- a#$te 4ide.0,ead 0e,ito-iti. 0. &arly implementation of operati6e interference3 8hich foresees the remo6al of source of peritonitis3 effecti6e sanation of a5dominal ca6ity. *s surgical access is utilliWed middling middle laparotomy. *t a necessity3 depending on localiWation of hearth of peritonitis3 this access can 5e eEtended bb`JN and do8n8ard. It ena5les to carry out the 6alua5le re6ision of organs an a5dominal region and its sanation. *fter opening an a5dominal region 5y sucking delete an eEsudate3 audit its organs for the eEposure of source of peritonitis. Gegin a re6ision 8ith an a5domen3 farther eEamine a small and large 5o8el3 gall=5ladder3 organs of small pel6is3 pancreas. (ill li9uidate the source of peritonitis. 'he 6olume of operati6e interference depends on sho8n of pathological changes in an organ 8hich entailed peritonitis. 'he special attention is spared the choice of 6olume of operati6e interference concerning the resection of 5o8el. *t its necrosis after the delete of non6ia5le area of 5o8el operati6e interference is completed forming the ileostomy or colostomy. *t the critical condition of patients and presence of dou5tful pathological changes in the 5o8el of decision of 9uestion in relation to its 6ia5ility and necessity of resection of the staggered segment put aside on <=02 hours3 it is carried out during repeated laparotomy 8ith simultaneous repeated sanation of a5dominal region. *t impossi5ility of radical delete of source of peritonitis the staggered organ is destroyed 5y retroperitoneal or mark off gauWe tampons from a free a5dominal region. *fter a delete the sources of peritonitis carry out final sanation of a5dominal region to the clean scourages. 2. Postoperati6e sanation of a5dominal region is carried out 5y its draining 5y HIcdNcIJbdLdcIbMN tu5es 8ith the additional openings. 'u5es enter in the lateral areas of a5domen3 ca6ity of small pel6is3 in the su5hepatic or su5diaphragm deepenings :depending on the location of hearth of peritonitis and accumulation of pus;. 'hrough such drainages not only delete an eEsudate 5ut also 8ash an a5dominal region. In gauWe tampons3 lateE drainages 8hich applied in days gone 5y3 a pus and fi5rin accumulate on 2=? days3 and they 5reak off to function. 'he searches of impro6ement of methods of sanation of a5dominal region and estimation of results of treatment resulted in introduction in medical practice of laparostomy. *n a5dominal region after the delete of source of peritonitis is not se8n up tight3 5ut close temporally 5y fastenings3 special sticky strips and other de6ices. In a postoperati6e period open an a5dominal region and carry out sanation t8ice3 three times and3 at a necessity = anymore3 to the complete remo6al of inflammatory process. *fter the remo6al of signs of peritonitis an a5dominal region is shut to.

%uring the last decade in the compleE of treatment of acute 8idespread festering peritonitis 8idely apply laparoscopy sanation of a5dominal region ad6antage of 8hich is small traumatic. ?. %esintoEication of the digesti6e system and proceeding in the function of 5o8els 5y e6acuation of maintenance of a5domen 5y the pro5e3 intu5ation of 5o8els3 medicinal and physical therapy stimulation of his functions3 entered for him. !or more rapid rene8al the functions of 5o8els conduct early his stimulation 5y cleansing enemas3 medications :proserini3 u5retid and other;3 realiWation of paranephric 5lockade. *t proof paresis of 5o8els apply the prolonged epidural anaesthesia in com5ination 8ith raising of cleansing enemas. A. *nti5acterial therapy 8hich it follo8s to 5egin in the period of preoperation preparation and continue during implementation of operati6e interference and in a postoperati6e period is one of maBor constituents of holiatry of acute peritonitis. Presence of hearth of polyinfection and its toEins in an a5dominal region3 their rapid suction is predetermined a peritoneum start of reaction of system inflammatory ans8er and cause the origin of syndrome of polyorgans insufficiency. In this connection a 5asic task of anti5acterial therapy is a 5lockade of inflammatory reaction at the le6el of micro5al neurohumors of damage. It follo8s to appoint anti5iotics and other preparations taking into account a sensiti6eness to them the selected microorganisms. Ho8e6er to get the results of determination of sensiti6eness of eEciters to the anti5iotics possi5ly only in 2=? days from the 5eginning of disease. 'herefore in the first days after operati6e interference appoint the anti5iotics of 8ide spectrum of action :tienam3 meronem;3 that acti6e in relation to gram=negati6e and gram= positi6e3 aero5ic and anaero5ic microorganisms. *ntianaero5ic action inherent mtragil. 4. It is carried out a general desintoEication organism not only 5y sanation of intestinum3 to the aEsufflation of his maintenance3 leadthroughs of peritoneal dialysis3 enterosorption3 5ut also 5y realiWation of haemosorption3 lymphosorption3 forced diuresis3 infusion therapy. <. *de9uate correction of 6iolations of eEchange of al5umens3 car5onhydratess3 gre8 fat3 acid=5asic state3 8ater=electrolyte 5alance3 5egins microcirculation to realiWation of operati6e interference3 proceeds during his implementation3 especially intensi6ely = in a postoperati6e period. * parenterally feed is carried out the use of amino acid3 lipophilics3 00=20 > solutions of glucose. Q. !or the correction of the noted 6iolations3 eEcept for the resulted therapy3 it is eEpedient to appoint hormonal and anticoagulating preparations of direct and undirect action. [. 'he important factor of fa6oura5le motion of postoperati6e period is stimulation of protecti6e forces of organism and imunocorection3 as for patients 8ith acute 8idespread peritonitis3 as a rule3 find out an immunodeficit noy the state. @. *s symptomatic therapy3 directed3 a5o6e all things3 on an impro6ement and normaliWation of acti6ity of the Tardio=6ascular system3 hepatic and kidney 5lood stream3 central 6enous pressure3 sta5iliWing of le6el of arteriotony3 increase of diuresis :to 40=<0 ml of urine per 0 hours;3 apply cardiac glycoside :strophanthin;3 nitrates. !or a prophylaEis and treatment of 6iolations of functions of 5reathing organs conduct acti6ating of the moti6e mode3 respiratory gymnastics3 inhalations3 massage of pectoral 8all and others like that. *t a necessity3 the leadthrough of forced=circulation of lights is rotined patients 8hich are in a gra6e condition in the mode of o6er6entilation during Q days. !or patients3 operated concerning acute 8idespread peritonitis3 there is a threat of origin of some complications3 related to the presence of infectious factor in an a5dominal region. #eason of it can 5e inade9uate sanation of a5dominal region during implementation of operati6e interference and especially in a postoperati6e period3 insol6ency of guy=sutures3 imposed on ca6ity organs3 infecting of operating 8ound3 sepsis3 formation of infiltrate and a5scess of a5dominal region and internalss3 o5struction of 5o8els. In a postoperati6e period treatments sick 8ith acute 8idespread peritonitis are carried out in the conditions of separation a reanimation and intensi6e therapy. "nly a holiatry3 directed on

normaliWation of functions of all of organs and systems of organism3 can pro6ide con6alescence sick. * prognosis at acute 8idespread peritonitis depends on reason 8hich stipulated peritonitis3 6irulence of microflora3 timeliness of diagnostics and implementation of operati6e interference3 directed on the delete of source of peritonitis3 and su5se9uent intensi6e treatment. In relation to the prognosis of disease actuality is kept 5y a thesis3 formulated 5y -. -pasokukocky as early as 0@2< J.2 1*t acute peritonitis an operation3 eEecuted at first hour3 pro6ides con6alescence @0 > patients3 in the first days = 40 >3 later3 than in ? days = in all 00 >1. !o.to0e,ati:e #o(0%i#atio-. 'he early signs of postoperati6e peritonitis is 8orsening of the state sick3 8hich it is impossi5le to eEplain o56ious reasons :a relapse of pain is in an a5dominal region3 increase of fre9uency of heart=thro5s3 pain during palpation of a5domen;. -ome authors consider the relapse of pain in an a5dominal region or its strengthening the o5ligatory sign of postoperati6e peritonitis. 'he fre9uent signs of postoperati6e peritonitis is nausea and 6omit. Important information is gi6en 5y ultrasonic research and +'3 and also gi6en roentgenologic research. If the diagnosis of postoperati6e peritonitis is confirmed3 carry out J`laparotomy3 sanation of a5dominal region3 continue intensi6e therapy. 'han relaparotomy is 5efore eEecuted3 the more so chances on success. Most frequent posoperative complications: 0. Insol6ency of enteropleEies = accompanied proceeding in a pain syndrome3 8orsening of the state sick3 dryness of tongue3 s8elling of a5domen3 progress of symptoms of irritation of peritoneum. 2. *5scesses of a5dominal region. ,ocal pain increases at their appearance3 a chill appears3 the temperature of 5ody 5ecomes hectic. -upposition a5out the presence of a5scess is confirmed information of ultrasonic and roentgenologic researches. 'reatment is operati6e. A. &arly postoperati6e o5struction of 5o8els can 5e spike or paralytic3 accompanied the delay of gases and emptying3 s8elling of a5domen3 presence of o5Becti6e symptoms. *t paralytic o5struction of 5o8els apply conser6ati6e facilities3 at spike is operati6e interference. 4. -uppuration of 8ound = disco6er often enough3 as a 8ound during implementation of operati6e interference 9uite often is infected. &6en the leadthrough of anti5acterial therapy pre6ents de6elopment of this complication not al8ays. If the signs of suppuration appeared3 a 8ound is eEposed3 sanation3 set drainage. -ometimes at suppuration of 8ound there is an e6entration 8hich re9uires implementation of operati6e interference. <. 'hrom5em5olytic complications. * throm5osis and em5olism is dangerous complications of postoperati6e period. ;"+" T'eo,eti#a% @$e.tio-. a,e to %e..o-) 0. *natomy information a5out peritoneum. 2. &tiology and pathogenesis an acute peritonitis. ?. +lassification an acute peritonitis. A. &Eamination methods of patient 8ith an acute 8idespread and local peritonitis. 4. +linical picture of 8idespread acute peritonitis. <. +linical picture of local acute peritonitis. Q. %ifferential diagnostics an acute peritonitis. [. 'rou5leshooting routine for a patient 8ith an acute local and peritonitis is 8idespread. @. 'he medical tactic of patient 8ith an acute 8idespread peritonitis. 00. 'he medical tactic of patient 8ith an acute local peritonitis. 00. +omplication an acute peritonitis. 02. !eatures of preoperati6e preparation are an acute peritonitis 0?. .ethods of operati6e interferences are an acute local and 8idespread peritonitis 0A. Programma5le laparapertion in treatment an acute peritonitis.

04. Postoperati6e complications an acute peritonitis their diagnostics3 prophylaEis and treatment. ;"/" !,a#ti#a% 4o,3. 1ta.32 4'i#' a,e e<e#$ted o- %e..o-) 0. 'o collect anamnesis3 conduct a re6ie83 palpation3 percusion3 auscultation for a patient 8ith an acute local and 8idespread peritonitisC 2. 'o estimate information of inspection at an acute local and 8idespread peritonitisC ?. 'o disco6er and correctly estimate the degree of eEpressed :negati6e3 poorly positi6e3 positi6e3 acutely positi6e; of signs the Glyum5erg=-chotkinXs3 #oWdolskiXs3 oskresenskiyXs at acute local and 8idespread peritonitisC A. 'o analyse and interpret the results of la5oratory and instrumental methods of research at an acute local and 8idespread peritonitis 4. 'o conduct differential diagnostics of acute peritonitis 8ith the syndrome of 6icious acute a5domenC <. 'o ground and formulate the pre6ious diagnosis of 5asic disease3 complications and concomitant pathology at an acute peritonitisC Q. 'o define a testimony to mini=in6asion and eopened operati6e interferences depending on pre6alence of peritonitisC [. 'o define the testimony of programma5le laparapertion at an acute 8idespread peritonitis @. 'o make an indi6idual trou5leshooting routine for a concrete patient 8ith an acute local and 8idespread peritonitisC 00. 'o carry out the estimation of results of la5oratory and instrumental methods of research at an acute local and 8idespread peritonitisC 00. 'o use deontologic principles of socialiWing 8ith a patient ;"6" A @$e.tio- fo, .e%f*#o-t,o%) 0. (hy is it important to find out all complaints3 that in a presence for a patient 8ith an acute peritonitisf 2. (hy is it important to kno8 a date and time of 5eginning of disease for a patient 8ith an acute peritonitisf ?. (hat is it found out at the re6ie8 of patient and his 5elly at suspicion an acute peritonitisf A. (hy is the origin of delay of participating possi5le in 5reathing of areas of front a5dominal 8all at an acute peritonitisf 4. *re there features of inspection of patient 8ith suspicion on de6elopment of destructi6e forms of diseases 8hich resulted in the origin an acute peritonitisf <. (hat is 5ased on the ground of pre6ious diagnosis of disease an acute peritonitisf Q. (hat acute diseases of organs of a5dominal region 8ill you choose for the leadthrough of differential diagnostics for patients from an acute peritonitisf [. (hat is it important to define at forming of medical tactic for patients 8ith an acute peritonitisf ;";" Ta.3. fo, .e%f*#o-t,o%) 0. It is disco6ered after implementation laparotomy3 that in a peritoneal ca6ity far of eEsudate 8hite=grey color3 foamy3 tur5id3 8ith a strong unpleasant smell. A'at (i#,oo,7a-i.(. do 0,edete,(i-e .$#' #'a,a#te, of e<.$date (o,e ,e%ia5%e i- a%%B *. *ero5es G. *naero5es +. !ungi %. 'he simplest &. -treptococcus

2. 'he Pt.3 <4 years3 operated concerning the perforati6e ulcer of duodenum3 poured out festering peritonitis. %uring an operation at the re6ision of peritoneal ca6ity found out the presence of concrements in a gall=5ladder. A'at (o.t o0ti($( :o%$(e of o0e,atio- fo, t'i. 0atie-tB *. -uture of the perforati6e opening3 truncal 6agotomy3 sanation of peritoneal ca6ity G. -uture of the perforati6e opening3 cholecystectomy3 sanation of peritoneal ca6ity +. -uture of the perforati6e opening3 cholecystostomy3 sanation of peritoneal ca6ity %. -uture of the perforati6e opening3 papilosphincterotomy3 sanation of peritoneal ca6ity &. -uture of the perforati6e opening3 pyloroplasty3 cholecystectomy. ?. %uring an operation concerning a perforati6e gastric ulcer3 complicated peritonitis3 it is disco6ered that there is a li9uid pus in all=o8er departments of peritoneal ca6ity3 the loops of intestine are co6ered stratifications of fi5rin3 5et8een loops the accumulations of pus are marked off. *fter e6acuation of the last and dou5le 8ashing of peritoneal ca6ity antisepticXs solution on an intestine is a far of fi5rin. C'oo.e t'e (o.t #o,,e#t (et'od of #o(0%etio- o0e,atio-" *. Introduction of drainages and suture of operating 8ound tight G. Imposition of peritoneal dialysis +. Introduction of drainages and suture of operating 8ound 5y situatioonal sutures %. -uture of operating 8ound tight A. 'he Pt.H.3 ?A y.o.3 hospitaliWed into surgical department in a gra6e condition 8ith complaints on pain in all=o8er of a5domen3 dryness in a mouth3 nausea3 eEpressed general 8eakness. It is kno8n from anamnesis3 that eEperienced pain A days ago3 8hich gradually had spread on all= o8er of a5domen in a #t illiac area. *t a re6ie82 Ps 7 00A 5^min.3 GP = @0^Q0 mm.Hg. *n a5domen is inflated3 sickly in all=o8er. Positi6e signs of irritation of parietal peritoneum. $ot hearkened to the peristalsis. (hat complication of acute appendicitis did arise up for a patientf *. Peritonitis is 8idespread G. ,ocal peritonitis +. *ppendiculare a5scess %. Pylephle5itis &. .ass 4. 'he Pt.3 ?A y.o.3 deli6ered on &# in a gra6e condition 8ith complaints on pain in all=o8er of a5domen3 dryness in a mouth3 nausea3 eEpressed general 8eakness. It is kno8n from anamnesis3 that ? days ago felt acute gknife=likeh pain in an epigastric3 8hich gradually spread on all=o8er of a5domen. -uffers on ulcerous illness during 24 years. "5Becti6ely2 Ps 7 00A 5^min.3 GP =@0^Q0 mm.Hg. *n a5domen is inflated3 sickly in all=o8er. Positi6e signs of irritation of parietal peritoneum. ,i6er dullness is not determined. * peristalsis a5sents. Ho8 most correctly to formulate a pre6ious diagnosis for this patientf *. Perforati6e gastro=duodenal ulcer3 peritonitis is 8idespread G. *cute pancreatitis3 8idespread peritonitis +. Perforati6e gastro=duodenal ulcer3 peritonitis is marked off %. Perforati6e gastro=duodenal ulcer3 a5scess of omentum 5ag &. *cute appendicitis3 general peritonitis <. 'he Pt. ".3 ?@ years old3 hospitaliWed in a surgical department in a gra6e condition 8ith complaints a5out permanent pains on all=o8er of a5domen3 nausea3 6omit 5y intestinal contains. It is kno8n from anamnesis3 that is ill during A[ hour3 8hen suddenly eEpressed appeared on all= o8er of a5domen3 nausea3 6omit. "5Becti6ely2 an a5domen is inflated3 sickly on all=o8er. 'he Glyum5erg=-chotkinXs3 #oWdolskiyXs3 .ondorXs3 -klyaro6Xs3 Freko6Xs signs are positi6e. $ot

hearkened the peristalsis. ,a5oratory2 leucocytes 7 0Q32N00@^l. (hat complication of mechanical intestinal o5struction did arise up for this patientf *. %estructi6e pancreatitis G. Peritonitis is 8idespread +. Interintestinal a5scess %. *5scess of %uglas space &. Pylefle5itis Q.'he Pt. ,.3 0@ years old3 hospitaliWed in a surgical department 8ith the clinic of acute appendicitis. *t implementation of operati6e interference3 after opening of peritoneal ca6ity found out the gangrenous changed appendiE. In the lo8er departments of a5domen sero=purulent eEsudate. Parietal peritoneum of suprapu5ic3 right and left illiac areas3 8ith local hemorrhages. (hat complication of acute appendicitis did arise up at this patientf *. %iffuse seropurulent peritonitis G. ,ocal peritonitis +. *5scess of %uglas space %. Interintestinal a5scess &. -erous peritonitis [.'he Pt3 %.3 4< years old3 entered surgical department 8ith the clinic of acute destructi6e pancreatitis. %efance is o5Becti6ely determined and painfulness a5domen in the proBection of pancreas3 8here immo5ile tumular education palpation. ,a5oratory2 leucocytes 7 203AN00@^l. 'emperature of 5ody in the morning 7 ?Q3[\]3 in the e6ening 7 ?@3[\]. "n +' 5et8een the 5ack 8all of a5domen and pancreas 5y 6olume education 8hich contains a li9uid is determined. (hat complication of acute pancreatitis did arise up for this patientf *. !ermentati6e cholecystitis G. *5scess of retroperitoneal space +. *5dominal mass %. *5scess of omentum 5ag &. *5sces of %uglasX space @. 'he Pt3 A2 years old3 during the leadthrough of operati6e interference concerning a destructi6e pancreatitis in all of departments of peritoneal ca6ity found out3 hyperemia of parietal peritoneum and far of serosal=hemorragic eEsudate. (hat complication of pancreatitis did arise up for this patientf *. Feneral serosal=hemorragic peritonitis G. Haemoperitoneum +. ,ocal peritonitis %. %iffuse sero=purulent peritonitis &. ,ocal peritonitis

00. 'he Pt3 ?@ years old3 entered surgical department 8ith complaints a5out permanent pains in all=o8er of a5domen3 nausea3 dryness3 general 8eakness. It is kno8n from anamnesis3 that is ill during A[ hours. Geginning of disease a patient does not link 8ith anything. "5Becti6ely2 an a5domen is su5=inflated3 resistance and sickly. 'he Glyum5erg=-chotkinXs3 #oWdolskiyXs signs are positi6e. * peristalsis is hyposthenic. ,a5oratory2 leucocytes 7 0<32N00@^l. "n D=ray of a5domen = free air and the )loy5erXs cups it is not disco6ered in a peritoneal ca6ity. * diagnosis is set2 8idespread peritonitis . (hat medical tactic is most optimum in this casef

*. /rgent operati6e interference G. %ynamic super6ision +. "P% treatment %. -ymptomatic therapy &. %ynamic permanent esta5lishment ;"C" Te.t. fo, .e%f*#o-t,o%) 0. 'he 5asic pathogenic mechanisms of peritonitis are2 *. &ndotoEicosis G. *cid 6iolations +. iolation of eEchange of al5umens %. *d6antage of ana5olism &. Inflammatory process is in a peritoneal ca6ity 2. Gasic 8ays of distri5ution of toEins are at peritonitis2 *. isceral lymphatic system G. -ystems of portal 6ein +. -ystems of 6. ca6a superior %. -ystems of 6. ca6a inferior &. Parietal lymphatic system ?. 'he characteristic displays of the poured out peritonitis at a la5oratory eEamination are2 *. ,eykocytosis G. Presence of ,&=cells +. Increase of concentration of urea and creatinini %. Fro8th of acti6ity of diastase &. Fro8th of acti6ity of aminotransferasis A. *t the poured out peritonitis anti5iotics are entered2 *. "rally G. Intramuscular +. Intra6enously %. &ndolimphatic &. Indicated all 8ays 4. Indications to operati6e interference at the poured out peritonitis is2 *. *5sence effect 5y conser6ati6e treatment during 02=2A hours G. 'he patients 8ith no concomitant pathology +. *n operation is a5solutely indication all of patients 8ith the set diagnosis <. In the conditions of the poured out festering peritonitis in the eEsudate are mainly2 *. "nly aero5ic 5acteria G. "nly anaero5ic 5acteria +. #iketsy %. -pirochet &. .icro5al associations Q. (hat methods of decompression of intestine are most effecti6e at the poured out peritonitis2 *. $asogastrointestinal intu5ation G. #etrograde intu5ation of small and large intestinum +. +aecostomy %. Introduction rectal tu5e

[. (hat stage of peritonitis a clinical picture is identical in3 regardless of reason of his origin2 *. 'o the reacti6e G. 'o the toEic +. 'o the neutral @. 'he signs of irritation of parietal peritoneum are2 *. 'he Gurney= olko6ichXs sign G. 'he oskresenskiyXs :shirts; sign +. 'he #oWdolskiyXs sign %. 'he Glyum5erg=-chotkinXs sign &. the "5raWco6Xs sign 00. *t 8idespread peritonitis at auscultation of a5domen heard2 *. * peristalsis is increased G. #espiratory and cardiac noises +. $ot hearkened to intestinal noises C" Lite,at$,e 0. Hospital surgery ^ &dited 5y ,. )o6alchuk3 . -ayenko3 F. )nyso63 .. $ychytailo . 7 'ernopil2 /krmedknyga3 200A. 7 AQ2 p. 2. 'eEt5ook of surgery :third edition; ^ &dited 5y -. %as. 7 +alcutta2 2000. 7 0?2A p. ?. -=AA?@. ,iechty #.%.3 -oper #.'. !undamentals of surgery <=th ed. = -t. ,ouis ect. .os5y 0@[@. A. (=2[Q. .elaschie F.#. "Eford hand5ook of glimed .suigery. repr.3 "Eford ect. 0@@2. 4. &d. -8artW. -urgery. 4=th ed. <. %.+. -a5iston. Gasic -urgery. Q. Hand5ook of -urgery :&d. 5y I.#. -ehroek [=th ed.;