MINISTRY OF HEALTH

REPUBLIC OF UZBEKISTAN

CENTRE FOR MEDICAL EDUCATION

Tashkent Medical Academy

"Approved"
Prorector for Academic Affairs
Prof. Teshaev OR
______________________ 2012

Department:
Faculty and hospital surgery.

Subject:
Faculty Surgery

SUBJECT:
PERITONITIS

Educational-methodical development
(for teachers and medical students)

Tashkent-2012
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SUBJECT :
PERITONITIS

1. Place of the lessons, equipment

- Chair of faculty and hospital surgery, training room, dressing

- Posters, tables, schemes of classification of disease, treatment regimen, radiographs, videos.

2. The duration of the study subjects

Number of hours - 4.9.

3. Session Purpose

Teach students methods of screening, diagnosis, differential diagnosis, choosing treatment

options for patients supervised by example, to analyze the etiology, pathogenesis, clinical course and the general
principles of treatment of peritonitis, after operation .
Tasks
The student should know:
1. Definition, frequency, etiopathogenesis, clinical features, diagnosis and treatment of peritonitis.
2. Principles of conservative treatment of peritonitis.
3. To teach the diagnosis of peritonitis, before operation preparation.
4. Indications for surgical treatment of peritonitis.
The student should be able to:
- Perform practical skills - to acquire some practical skills in the examination of patients with peritonitis, to perform
specialtechniques examination of these patients to determine indications and contraindications for operation .

4.Motivation

Instilling students with the need for timely development of adequat operations before to severe complications, and
in their development - meeting the most informative and modern methods of diagnosis,surgical treatment,
meeting with potential complications of surgeryand operating out of a period of, prevention. Development of clinical
thinking of students. The development of the modern view of the problem issues from the perspective of world
medicine and general practice doctor.

5. Interdisciplinary communication and Intersubject

Teaching this topic is based on the knowledge bases of students of anatomy, normal and pathological physiology of
circulation. Acquired during the course knowledge will be used during the passage of gastroenterology, internal
medicine and other clinical disciplines.

6. The content of lessons

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6.1. Theoretical part

Peritonitis is a severe complication of different diseases and injuries of the abdominal cavity. The most frequent
peritonitis, in which the intestinal contents released into the abdominal cavity. Loss of intestinal contents depends on
the nature of peritonitis, the magnitude of the defect in the intestinal wall and the feeding patient. The higher the
level of intestinal peritonitis, where more liquid and the most active content, the loss of intestinal contents, and place
them in water, protein, electrolytes and enzymes are more important and the impact on the surrounding tissue more
devastating. Given that the formation of peritonitis preceded, as a rule, marked purulent inflammation, leading to
severe intoxication, the development of peritonitis is against this background not only leads to exhaustion, but also
to additional infection of the wound, the formation of streaks, the spread of infection, thereby exacerbating the
chronic inflammatory process and increasing the toxicity.
Acute peritonitis - inflammation of the visceral and parietal peritoneum, which is accompanied by severe general
symptoms of the disease and the body in a short time leads to a serious and often irreversible damage to vital organs
and systems. This is one of the most severe complications once personal injuries and diseases of the abdominal
cavity. Damage to the peritoneum can be of two types - open and closed.
Classification of peritonitis. In the last years tended to brief classifications peritonitis. Thus, A.M Karjakin (1968)
shares only to local peritonitis and , V. Struchkov et al (1967) identifies local diffuse and poured
peritonitis. K.S Simonian (1971) suggests that the incidence of peritonitis in the clinic does not play a role and brings
forth classification, which peritonitis from the perspective of reactions, releasing during peritonitis three phases -
phases: reactive, toxic and terminal.
The most simple and convenient for clinical practice is the classification of peritonitis, reduced BD Savchuk (1979).
In the clinical course of peritonitis are three stages of development of acute purulent peritonitis:
1. Reactive stage of peritonitis (first 24 hours, if perforated - 12 hours) - the stage of maximum expression of local
manifestations: a sharp pain sindroms , protective muscle tension, retching , motor agitation, etc. Common
symptoms: increased heart rate to 120 beats, raising blood pressure, shortness of breath, etc., are typical
manifestations of a painful shock for more than intoxication.
2. The toxic stage of peritonitis (24-72 hours, if perforated - 24 hours) - the stage of local manifestations subsided
and the prevalence of systemic reactions, characteristic of severe intoxication: sharp facial features, pale In
particular, stiffness, euphoria, and heart rate over 120 beats, reducing blood pressure, Late retching, hectic pace
character temperature, a significant shift of pyo-toxic blood counts. Of the local manifestations for toxic stage is
characterized by reduced left pain syndrome, abdominal voltage protection, flatulence groth.
3. End-stage (more than 72 hours, if perforated - over 24 hours) - the stage of deep intoxication on the verge of
Reciprocity: Hippocratic face, weakness, prostration, often delirium intoxication, significant respiratory distress and
cardiovascular , profuse vomiting with fecal odor, drop in temperature on background of the shift in
purulent toksiches in the blood formula, sometimes . Local manifestations of the complete absence peristalsis,
significant flatulence, pain spilled around the abdomen.
Emergency preoperative patients with peritonitis should be individualized, taking into account comorbidities and
intense, with a targeted correction of water-salt balance, acid-base balance, protein metabolism and geodynamic
violations under the control of biochemical studies. Occupies a special place premedication and the evacuation of
the gastricka. The duration before operation preparation should not be exceed
2 hours.
The method of choice of anesthesia in case of peritonitis, is common endotracheal anesthesia with controlled
respiration, allowing the elimination of pain, contributing to the correction and normalization of neurocirculatory
and neurohumoral reactions.
When you install the diagnosis of acute peritonitis, the vast majority of patients, as a surgical approach using median
laparotomy, as this access is less traumatic and gives an opportunity to adequately audit the abdominal cavity.
If the source of peritonitis is the body that can be removed (appendix, gall bladder), and technical conditions allow
this, it is advisable to remove the radical source of infection of the abdominal cavity. When perforation of a hollow
organ (stomach ulcer, duodenum, diverticulum of the colon, stomach cancer or colon) is most often performed
suturing the perforated holes, especially if from the moment of perforation is more than 6 hours, and we can expect a
massive bacterial contamination of the abdominal cavity.When you break the diverticulum or cancer of suturing a
defect is usually not feasible. In these cases, resection of the affected organ is shown (if technically feasible) or the
imposition of unloading the stoma. When after operative peritonitis, caused by failure of seams before anastomosis
is usually not possible to take in a defect in the anastomosis, due to pronounced inflammatory and infiltrative
changes in the surrounding tissues, so often have to be limited to summing up the double-barreled drainage tube to
the hole for aspiration of intestinal contents of the site for separating the sourceinfection or fistula formation, or the
same breeding of the anastomosis (intercolicum) of the abdomen as a stoma on the anteroom abdominal
wall. Peritoneal cavity thoroughly dry with electric pumps and gauze are removed friable fibrin raids. Then you wash
the abdominal cavity with a solution of antiseptic agents: furatsilins solutions, dioksidins, chlorhexidine.
Before suturing the wound laparotomic anterior abdominal wall, a prerequisite is the drainage of the abdominal
cavity through counteropening hypochondrium or in the iliac regions. Methods of drainage of the abdominal cavity
is completely dependent on the degree of destruction of the peritoneum. Thus, when a local peritonitis, drainage
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installed in the affected area, with diffuse peritonitis - 2 or 3 of drainage, to control and intra-abdominal
administration of antibiotics.
For the practitioner, particular interest is the diffuse purulent peritonitis, which is also an absolute indication for
emergency surgery. Timely diagnosis of early forms of peritonitis, and appropriate surgical intervention are the key
to success in treating this terrible disease.
Operative intervention in this case must include the following:
- Revision of the abdominal cavity and remove the source of peritonitis,
- Intake of fluid from the abdominal cavity for rapid bacterio microscopy, bacteriological analysis and drilling to
determine the sensitivity of microflora sequence to antibiotics.
- Evacuation of fluid, rehabilitation and lavage of the abdominal cavity antiseptical Skim solution (5-8 liters of
solution furatsilins, Ringer's saline or rivanola).
- Novokainisation root of mesentery of the small intestine, or installation mikroirrigator to drip novocaine for the
prevention of intestinal atony.
- Transnazaloy bowel intubation through the introduction of 2-translucence nazoenteralnogo probe for the
evacuation of the gastrointestinal tract, intestinal lavage and enteral tube feeding patients in the postoperative period.
- Drainage of the abdominal cavity to monitor and conduct in-posleo peritoneal lavage peratsionnom period or
dialysis.
The operation ends on the testimony of: a fiber suturing wounds, sutures through all layers (tying their bow) or the
imposition of the wound zip fasteners (for software revision of the abdominal cavity) or left open (laparostoma) for
public management.
Used in this lesson, new teaching technologies, "Black Box", "Web."
USE OF THE 'BLACK BOX'
The method provides for joint activities and active participation in the classroom each student, the teacher works
with the entire group.
Each student takes out a "black box" issue. (Options of questions are attached.) Students are required to detail the
reasons for his answer.
To think about each answer the student is given 3 minutes. Then discuss the answers, given in addition
etiopathogenesis, clinical course. At the end of the method of teacher comments on your answer is correct, its
validity, the activity level of students.
This methodology promotes student speech, forming the foundations of critical thinking as In this case, the student
learns to assert his view, analyze responses band members - participants of the contest.
Options abstracts:
1. Put the diagnosis: The patient noted fever, pain around the stomach, dry mouth.
2. Put the diagnosis: The patient was 65 years after fasting for 24 days suddenly appeared in great pain in the
epigastrium after that went around the abdomen.
USING "WEB"
Steps:
1. Previously students are given time to prepare questions on the passed occupation.
2. Participants sit in a circle.
3. One of the participants is given skein of thread, and he sets his prepared question (for which he must know the
full answer), hold the end of the filament coil and transferring to any student.
4. A student who receives skein, answers the question (in this party, who asked him, commented on a response) and
passes the baton on the issue. Participants continue to ask questions and answer them until everything will be in the
web.
5. Once students have completed all the questions, a student holding a roll, returning his party, from whom he
received the issue, while asking his question, and so on, until the "unwinding" of the coil.
Note: To prevent the students, which should be attentive to each answer, because they do not know who to throw
skein.
6.2. Analytical part
Situational problem:
3. 1. The patient noted fever, pain around the stomach, dry mouth, wooden belly.
I. Your diagnosis:
A. peritonitis *
B. colitis
B. gastritis
G. miolgiya
D. Osteoarthritis
II. clinical picture of peritonitis
A pain throughout the abdomen *
B. bloating
B. Redness of the skin
Mr. Root is not
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D. there is no right answer

6.3. Practical part

The task of practical skills (interview a patient, physical examination and inspection of body parts,
to justify the differential diagnosis and final diagnosis, assign the appropriate diet and regular
treatment).
1. PATIENT SURVEY, GENERAL INSPECTION AND INSPECTION OF PARTS OF THE BODY.
Purpose:
- Information necessary for diagnosis;
- Assessment of the likelihood of disease;
- The identification of other sources of information (relatives, other doctors, etc.);
- Establishing trust relationships with patients;
- Assessment of a patient's personality and his attitude to the disease (the internal picture of
disease);
- Assess the state of consciousness and mental status of the patient, his position, general appearance,
state of the external cover and some parts of the body.
Uses: survey is mandatory for all patients in mind, survey conducted in all patients.
Equipment: well-lit chambers, doctors' offices, fluorescent lighting.
Conditions of performance: the absence of unauthorized persons, confidential atmosphere.
Performed steps (stages):
Fully implemented
Activity Not fulfilled
correctly
1 Inquire one passport data 0 5
2 Complaints Collection 0 15
3 Collecting history of the disease 0 20
4 History taking of life 0 15
5 Epidemio, allergic history 0 5
6 Objective patient survey 0 5

7 Make a plan survey 0 5

8 The correct diagnosis 0 5

9 Differential Diagnosis 0 20

10 treatment plan 0 5
Total 0 100
2. HOLD DIFFERENTIAL DIAGNOSIS and justify the final diagnosis.
Purpose: To educate and carry out a differential diagnosis to justify a definitive diagnosis.

Fully implemented
Activity Not fulfilled
correctly
1 List the disease, clinical symptoms, which are 0 25
similar to the disease
2 Make a differential diagnosis of major 0 35
clinical syndromes
3 On the basis of complaints, medical history, 0 40
objective data andresults of laboratory
and instrumental examinations, as well asdifferential
diagnosis to put a definitive diagnosis

Only 0 100
3. APPOINT appropriate diet and planned treatment.
Purpose: The treatment of the disease and to achieve remission
Fully implemented
Activity Not fulfilled
correctly
1 The study of the characteristics of medical tables 0 10
on Pevsner
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2 The right choice of dietary table in accordance with 0 10
the diagnosis
3 Assessment of usefulness of the diet 0 20
4 In accordance with the diagnosis, disease 0 20
severity and stage of the appointment of primary
therapy
5 In accordance with the diagnosis, disease 0 20
severity and stage of the appointment of
symptomatic therapy
6 prophylactic measures 0 20
Only 0 100

7. Forms of control knowledge, skills and abilities

- Interpreting;
- Writing;
- the decision of case problems;
- Demonstration of skills mastered.

8. Criteria for evaluating the current control

Progress in% evaluation The level of student knowledge

1 96-100% Perfectly Complete the correct answer to the

questions. Summarizes andmakes decisions, creative thinking,
5
self-analyzing. Solve situational problems correctly, with a
creative approach, with full justification forthe answer.
Actively and creatively participate in interactive games, the
right to make informed decisions and summarize, analyze.
2 91-95% Perfectly Complete the correct answer to the questions. Creative thinking,
self-analyzing. Solve situational problems correctly, with a
5
creative approach, the rationale for the answer.
Actively and creatively participate in interactive games, the
rightdecision makers.

3 86- 90% Perfectly 5 The questions covered completely, but there are inaccuracies in the
answer 01.02. Independently analyzed. Inaccuracies in
solvingsituational problems, but with the right approach.
Actively involved in interactive games, make the right decisions.
4 81-85% well 4 The questions covered in full, but there is a 03/02 inaccuracies,
errors. Into practice, understand the essence of the issue,
saysconfidently, is a faithful representation. Case solved the
problemcorrectly, but the rationale for not fully answer.
Actively involved in interactive games, make decisions correctly.
5 76-80% Well 4 Correct, but incomplete coverage of the issue. Understands
theissue, says confidently, is a faithful representation. Actively
involvedin interactive games. On case studies gives
a partial solution.

6 71-75% well 4 Correct, but incomplete coverage of the issue. Understands

theissue, says confidently, is a faithful representation. On case
studiesgives a partial solution.
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7 66-70% satisfactorily 3 The correct answer to half the questions. Understands
the issue, saysconfidently, is accurate representations only on
individual issuestopics. Case solved the
problem correctly, but there is no justificationresponse.
8 61-65% Satisfactorily 3 The correct answer to half the
questions. Says uncertainly is accurate representations only on
individual issues topics. Mistakes in solvingsituational problems.
9 55-60% satisfactorily 3 Reply with errors on half of the questions. Says uncertainly,
is partialview on the subject. Case solved the problem incorrectly.
10 50-54% unsatisfactorily 2 The correct answer to the third set of questions. Situational
problemssolved correctly if the wrong approach.
11 46-49% unsatisfactorily 2 The correct answer to the fourth set of questions. Situational
problems solved correctly if the wrong approach.
12 41-45% unsatisfactorily 2 Lighting fifth of the
questions correctly. Gives incomplete and partiallyincorrect
answers to questions.
13 36-40% unsatisfactorily 2 Lighting 1 / 10 of questions at the wrong approach.
14 31-35% unsatisfactorily 2 To the questions are not answers.

9. Chronological map of lessons

Stages of lessons forms lessons duration in m

inutes. 90

1 Introductory word teacher (study subjects) 5

2 Discussion topics practical lessons, assessment of baseline The survey, an explanation 25
knowledge of students with new educational
technologies (small groups, case studies, business games,
slides, videos, etc.)
3 Summing up the discussion 5

4 Providing students with visual aids and giving explanations to 10

them
5 Self-study students in mastering skills 15
6 Clarification of the extent to which lessons objectives on the Oral interview, written 25
basis of developed theoretical knowledge and practical survey, testing, checking the
experience on the results and taking into account results of practical work,
this evaluation activities of the group. discussion debate.
7 Conclusion of the teacher on this lesson. Assessment of the Information, questions 5
students on a 100 point for self-study
system and its publication. Cottage set onthe next class (a
set of questions)

10. Quiz Questions

1) The concept of peritonitis, etiopathogenesis, classification, clinical features, diagnosis, differential. diagnosis and
treatment.Cause of death.
2) Preoperative.
3) The symptoms of peritonitis.
4) The specific course of peritonitis in the elderly and pregnant women.
5) The principles of postoperative management of patients with peritonitis.
11. Recommended Reading
1. SH.I. Karimov - "Surgical Diseases" Tashkent 2005.
2. MI Kuzin, "Surgical Diseases." Medicine 1986
3. S. Karimov, "Hirurgik kasalliklar." Medicine 1994
4. Littman I. "Operative Surgery" 1982.
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5. Agzamhozhaev SM "Hirurgik kasalliklar" 1991.
6. BV Peter "Guide to Surgery" 7 tons Medicine 1970.
7. Tutorial on the subject.
8. Karimov SH.I., Babajanov BD Diagnosis and treatment of acute peritonitis. Tashkent, 1994.
9. Savchuk BD Purulent peritonitis, Moscow, 1995.
10. Gostischev V., Sazhin VP Peritonitis. Moscow, 2002.
11. Shurkalin BK Purulent peritonitis. Moscow, 2000.
12. Karimov, S. I. Acute peritonitis. Guidelines. Tashkent, 1985.
13. Karimov SH.I., Akhmedov RM Peritonitis in patients with elderly.Guidelines. 1985.
14. Asrar AA Surgical and endovascular methods of prevention and treatment of septic complications and multiple
organ failure in patients with diffuse purulent peritonitis, 1994.
Internet addresses on the subject of activity:
http://www.tma.tmn.ru/Vestnik
http://medi.ru/doc/83.htm
http://www.rmj.net/index.htm
http://www.consilium-medicum.com/media/refer