Symptoms of peritonitis is a combination of signs of the development and course of the pathological process in the abdominal cavity. Peritonitis is an inflammation of the peritoneum as a result of its infection, violation of the integrity of the internal organs or the abdomen itself, ingress of foreign bodies and fluids, for example, the contents of hollow organs. Pathology has a number of clinical, objective and subjective signs on which the doctor relies, conducting a primary diagnosis of the patient's condition with suspected peritonitis. It is very important to establish the clinical picture, the intensity, duration, and localization of symptoms as accurately as possible in order to recognize specific forms of peritonitis, and to understand what remedial measures should be taken.
The first suspicious symptoms and manifestations - why is it so important to know them? The fact is that with the development of inflammation of the peritoneum for the patient literally every minute matters, which will pass before the start of preparation for the operation. The longer the time of entry into a medical facility is postponed, the greater is the possibility of an unfavorable outcome.
The clinical picture is represented by general and local manifestations. The appearance of common symptoms is due to increasing intoxication. Such signs are not specific, and do not provide sufficient grounds for diagnosis. The patient has a fever, tachycardia, general weakness, nausea, chills, body aches, irritability. Given that peritonitis is always a secondary syndrome, the patient manifests symptoms of the underlying disease, be it appendicitis, peptic ulcer, cholecystitis, or other diseases.
With regard to local symptoms, they are formed as a response to irritation, sheets of peritoneum, foreign elements trapped there - bacteria, fluids, and other agents.
The first complaints that should be alerted are a constant and intense pain in the abdomen. The pain does not subside with time, and tends to increase with the change of position. In this case, the patient takes a forced posture, lying on his back or on his side, bends and attracts his knees to the stomach. When viewed clearly expressed a strong tension of the anterior abdominal wall, symptoms of peritoneal irritation (Mendel syndrome, Shchyotkin-Blumberg syndrome).
In addition, the patient complains of increased body temperature, dry mouth, constant nausea, repeated vomiting. There may be dizziness, headache, darkening of the eyes.
It should be noted that to establish a reliable diagnosis at home, without resorting to medical examination, is almost impossible.
Regardless of the form of the course and the extent of the pathology in the peritoneum, there are a number of symptoms that are always present in a patient diagnosed with peritonitis. At the same time they can appear with different intensity and different duration, they look more bright or blurred.
You can divide the picture of the main symptoms of peritonitis into three groups:
- local: muscular defense, accumulation of exudate and pain syndrome;
- functional disorders of the digestive and urinary organs;
- common signs caused by intoxication.
Acute abdominal pain is the most typical sign of developing peritoneal inflammation. It is especially pronounced with perforated peritonitis. When inflammation is not associated with a violation of the integrity of the walls of internal organs, the pain is less pronounced, aggravated gradually.
The rupture (perforation) of the wall of a hollow organ usually gives way to sharp, shooting through pain, which looks like a thrusting blow or a pistol shot. After this, the patient tends to lie down and not move, since the slightest movement causes severe pain. Shaking the peritoneum, breathing, touching the front wall of the abdomen is also painful. Sometimes the pain is sharp and so strong that the victim loses consciousness, and his pulse becomes filiform.
Pain caused by the breakthrough of the wall, first localized in the zone where the rupture occurred, that is, at the point of focus of peritonitis. Further localization shifts. Perforated appendicitis may be accompanied by pain in the epigastric region. The pain remains in this place for quite a long time, and gradually fades out in its original position.
With a particularly strong pain syndrome, the patient stops breathing with his stomach, breathing becomes frequent and shallow.
Even the most intense pain may subside after 12-36 hours - this trend is a sign of the transition of the reactive stage of peritonitis to the toxic one.
If pain appears during urination, the inflammation has moved to the peritoneum covering the bladder.
During an acute course, pain often irrigates the zone of the shoulder, heart, and chest.
Muscular protection is called the constant tension of the muscular wall of the abdomen, which appears either with the pain or a little later. The state of muscle protection is due to the reflex contraction of muscles that accompanies inflammation of the peritoneum.
The presence of liquid exudate is a common sign of peritonitis. The fluid that accumulates in the abdominal cavity can be purulent, fecal, serous, fibrinous, hemorrhagic, that is, contain various impurities. To detect the presence of exudate can be through the percussion of the abdomen. At the same time, the impact sound is shortened in the lateral zones of the abdomen, and tympanitis is noted on the front wall.
Typical functional disorders that usually accompany peritonitis:
- hiccups and belching;
- delayed stool and gas discharge;
- flatulence and diarrhea (rare).
Vomiting almost always begins with pain, or joins a picture of symptoms some time after the development of intense pain. Emetic masses contain the remnants of undigested food, gradually their volume becomes poorer, and the consistency becomes viscous, thick, with an admixture of bile. If the peritonitis is ulcerative, the patient’s vomit has blood impurities or in the form of “coffee grounds”. Over time, there is an increase in the frequency of emetic urges, the patient because of this begins to experience excruciating thirst. It is impossible to quench the feeling of thirst, as any liquid that is taken in is immediately rejected by the body.
If a patient has hiccups, then she has a stubborn character, it can not be stopped. The cause of the symptom is irritation of the phrenic nerve, or of the peritoneal zone that lines the diaphragm.
Paresis and intestinal paralysis following it is another typical symptom of inflammation. In humans, stool retention, gases do not move away, but accumulate in the intestine, which causes flatulence and bloating. The stomach swells up, the skin on it stretches and becomes smooth, shiny. With percussion, tympanitis is tapped, and the dullness of sound in the hepatic zone disappears.
The development of paresis causes further intestinal paralysis, paralytic obstruction, the onset of fecal vomiting, which greatly complicates the patient's condition.
Paresis can also spread to the bladder, in which case urinary retention develops.
The general symptoms inherent in different types of peritonitis characterize the degree of change in the state of the central nervous system caused by intoxication. The development of peritonitis is accompanied by impaired cardiovascular activity, dehydration and impaired water and electrolyte balance. It should be noted that exhaustion, severe pain and thirst, as well as the general feeling of weakness impose a definite imprint on the victim's appearance - his features are sharpened, his eyes seem to tumble into the skull, dull. A dangerous symptom of intoxication is sleep disturbance, insomnia due to periods of euphoria.
Cardiovascular disorders are manifested by slowing the pulse, its fall to the filamentous, and then - by a gradual increase, sometimes to significant, critical indicators, arrhythmia of the heart develops. As the general condition worsens, blood pressure drops significantly.
The next symptom that accompanies peritonitis is an increase in body temperature, with a terrific chill. However, in some cases, the temperature may remain normal.
With a typical febrile current, temperature indicators quickly reach 38-39 degrees, and stay at this level, almost without decreasing.
With perforated peritonitis, the body temperature can drop sharply after perforation, below normal, but after a while the fever still develops.
If fever, together with other syndromes, preceded the development of peritonitis, the onset of inflammation only enhances its manifestations, for example, if we are talking about postpartum or septic peritonitis.
Fever is most typical for common purulent peritonitis. In such cases, the temperature curve ranges from low to high values. It should be noted that focus on body temperature when establishing the diagnosis of “peritonitis” should not be. However, such a parameter, as a significant difference between the readings of a thermometer inserted into the axillary region and rectally, has a significant diagnostic value. With diffuse peritonitis, the difference reaches 2-3 degrees.
In addition, the acute course of peritonitis is accompanied by a change in the functional ability of the kidneys, a decrease in diuresis is noted, and renal failure develops.
If pathological processes affect the liver, the patient may develop jaundice. The organ's detoxification ability is impaired.
Manifestations with rupture of appendicitis
The rupture of appendicitis is preceded by a state of a clogged and infected appendicitis, against the background of which gangrene is formed. As a result, the process is literally torn, and its contents fall into the peritoneum. The longer the time elapses from the moment of rupture, the stronger the symptoms become, and the more aggravated the general condition of the patient.
The main symptom of peritonitis with rupture of appendicitis is severe and sharp pain. Initially, the sensation appears in the lower abdomen, has a growing character, manifested by impulses. After some time, the pain may change its localization, spread throughout the abdomen.
The moment of rupture is accompanied by:
- an attack of severe shooting through or cutting pain that covers the entire lower abdomen;
- severe nausea and persistent vomiting;
It should be noted that if the patient did not ask for help, but decided to wait out the condition in the hope that it would improve on its own, some symptomatic relief is partly possible. When peritonitis passes from reactive to terminal, paralysis of nerve endings occurs, due to which the manifestation of pain is somewhat dulled. However, this process cannot be called an improvement - on the contrary, the calm indicates a worsening of the patient's condition.
Symptoms of biliary peritonitis
The pathology and its manifestations are directly dependent on the rate of penetration and the volume of bile entering the abdominal cavity, as well as the area of infection. During slow pouring, the patient develops chronic or subacute peritonitis, in which the symptoms are mild. A quick hit of a large amount of bile provokes the appearance of acute peritonitis. The development of pathology goes through several stages, the symptoms of which have their own pronounced features.
Formation of the disease and the first obvious manifestation of the clinical picture occurs several hours after the beginning of the release of bile from the biliary tract. During this period, inflammation has time to develop in the peritoneum, and serous or fibrous-serous exudate begins to accumulate. Severe pains of the cutting or piercing type appear sharply, which give to the right hypochondrium, right scapula or collarbone.
Simultaneously with pain, or somewhat later, reflex vomiting, belching and heartburn. After that, there is a strong deterioration of health, the patient is literally unable to stay on his feet, he is trying to take a position lying on his side or on his back, pulling his knees to his stomach. The face is pale, pointed features. A person is thrown into a cold sweat, shortness of breath appears. The body temperature rises, which indicates the onset of fever. Palpation of the abdomen gives strong spilled pain.
The onset of the toxic stage occurs on the second day after the onset of the first symptoms. The patient's state of intoxication increases, the inflammation becomes generalized, and the general state of health worsens: sopor-stupor is observed, alternating with periods of arousal, dry mouth, excruciating thirst, and all this against the background of unabated vomiting. Outgoing vomit have a brown color and a sharp unpleasant odor. Skin moist, cool, become bluish tint. The patient's breathing is frequent and superficial, while he tries not to breathe with his stomach. Body temperature reaches 39-40 degrees. Palpation feels strong tension of the anterior abdominal wall. Paresis of the intestine is manifested by constipation, difficulty in the discharge of gases.
The terminal phase of biliary peritonitis begins after 2-3 days, proceeds very hard. The patient has a state of stupor, sometimes he screams, practically does not react to external stimuli. The face acquires an earthy hue, the eyes are sunken, the features of the face are strongly pointed. Despite strong bloating, there is no reaction to palpation, and any manifestations of peristalsis are also absent.
Manifestations in women (pelvioperitonit)
Female peritonitis has its own characteristics, as it can be associated with complications after childbirth, with the implementation of cesarean section or instrumental examination of the uterus, as well as with inflammatory processes in the fallopian tubes, uterus or ovaries.
Peritonitis in women may be limited or widespread, but is always a secondary condition caused by certain pathological processes. If the patient has a perforation of the uterus, its rupture or after cesarean section, the development of peritonitis takes no more than two days. When an infection is introduced during childbirth or during an abortion, with its lymphogenous spread, peritonitis can take shape by 7–8 days after the intervention.
The course of peritonitis in obstetrics is divided into typical stages: reactive, toxic and terminal.
Initially, a woman has a pronounced intoxication, however, if prior to the onset of the pathology, the patient underwent intensive antibiotic therapy, the clinical symptoms are blurred, and signs of peritoneal irritation can be detected only after some time.
The transition to the toxic phase is marked by an increase in intoxication, since during this period the concentration of microbes in the body increases significantly, and the toxins are practically not eliminated. Against this background, signs of damage to the central nervous system and metabolic disorders are clearly manifested.
The terminal stage is the final and most difficult in the course of pelvioperitonitis, it is acute or subacute, may be accompanied by the formation of abscesses in the abdominal cavity.The patient has motor and nervous inhibition, a decrease in blood pressure, flatulence and abdominal distension, a decrease in urine output.
Dystrophic changes and dehydration occur in tissues and organs. At this stage, bronchopneumonia, pulmonary edema, purulent inflammation of the pericardium and anterior mediastinum may join.
The general condition of the patient is characterized as severe, she complains of severe thirst and dry mouth, shortness of breath, fever, nausea and vomiting. Breathing becomes chest, the stomach is not involved in the process of breathing. The stomach is swollen. Initially, vomit consists of the contents of the stomach, and over time, bile and the contents of the small intestine are added to them.
Peritonitis clinic after cesarean section may have an atypical appearance. So, the patient has a high temperature, frequent superficial pulse and shortness of breath, on this background there is moderate flatulence, and there are no signs of intestinal paresis. The flow is undulating, periods of deterioration of well-being are replaced by temporary relief.
If the development of peritonitis is associated with salpingoophoritis, the patient has a sharp cutting pain of high intensity, collapse develops. Initially, the pain does not have a clear localization, and after a while it isolates itself in the zone of purulent inflammation. In the same place there is rigidity of the muscles of the anterior abdominal wall.
Conducting a vaginal examination, the attending physician notes the strong pain of the uterus, its dislocation and the vagueness of the contours. On palpation of the posterior vaginal fornix, the victim feels pain. The rear arch can be somewhat bulged out.
Peritonitis, occurring during antibiotic therapy, may not have pronounced symptoms. The pathology clinic is slowly growing, and the general condition of the patient can be considered satisfactory. After about 3-5 days, the manifestations of the disease become typically acute.
Manifestations in children
The development of peritonitis in children is also characterized by some atypical signs. For example, acute pain in a child is the exception rather than the rule. The children's body is in the formative stage, so peritonitis usually begins with a general deterioration of well-being, and, in general, the symptoms are not as pronounced as in adults. If the pathology begins after an injury, appendicitis, or an infectious lesion, it is observed in children:
- general weakness and lethargy;
- loss of appetite;
- tearfulness and capriciousness;
- sleep disorders, insomnia;
- temperature rise;
- upset stool (more often constipation than diarrhea);
- lower abdominal pain;
- dry skin, thirst.
As for the primary form of peritonitis, the fast passing reactive phase proceeds similarly, after which the toxic stage begins with the following symptoms:
- severely elevated temperature (up to 40 degrees);
- lower abdominal pain;
- nausea and frequent vomiting;
- loose stools;
- body aches, muscle aches;
- blanching of the skin;
- tongue dry, white coated.
When the peritonitis is diffuse, the child has pronounced discomfort on the right in the iliac region, a temperature rise of 37.5-38 degrees, weakness, body aches, pain in the joints.
Appendicular peritonitis is accompanied by an infectious-inflammatory syndrome, as well as signs of abdominal damage:
- diffuse abdominal pain without clear localization;
- muscle tension of the anterior abdominal wall;
- a sensation of fluid accumulation in the peritoneum;
- sleep disturbance;
- frequent vomiting relentlessness;
- weight loss;
- yellowness of the skin and sclera;
- depression of general condition, lethargy and weakness.
Ultrasound peritonitis diagnostic method is the most accessible of non-invasive methods of investigation, especially in the early postoperative period, as well as in acute peritonitis prior to surgery. It should be noted that the immediate cause of peritonitis cannot be determined from the results of ultrasound - the diagnostic method only shows the presence of pathology itself. For example, with bacterial peritonitis, an ultrasound scan does not allow differentiation of changes caused by a specific pathogen, however, using an ultrasound apparatus, one can detect perforation or rupture of the appendix, as well as leakage of infected substrate into the abdominal cavity, as well as hematogenous dissemination in tuberculosis.
Aseptic peritonitis on ultrasound is manifested echogenic thickening of the peritoneum, as well as a small amount of delimited fluid in the abdomen. Also, ultrasound diagnostics shows local or diffuse intestinal paresis with a local increase in the liquid contents of the intestine.
An abscess of the abdominal cavity, which develops as a complication of peritonitis, is seen on ultrasound as a fluid limited education. He has a clear wall that forms a capsule with a heterogeneous content in the form of an echoic suspension or filamentary structures. The presence of gas is reflected in the reverberation effect.
The perforation of a hollow organ is the perforation of its wall, in which the contents of the organ extend beyond its limits, that is, into the abdominal cavity. At the same time in the cavity is determined by the presence of free air, sometimes under the anterior abdominal wall. On ultrasound, the sign is displayed by reverberation. In addition, perforation can be determined by the presence of free fluid in the abdomen.
In addition to peritonitis, free fluid in the abdominal cavity may indicate the presence of ascites or acute abdominal pathology, in which the peritoneum is involved in the process. Often this symptom indicates the presence of a closed injury of the abdominal organs. Typical sites for the detection of free fluid are perihepatic or periolissal space, the pelvic area, the left and right lateral channels. Ultrasound fluid is seen as local areas of low echogenicity that do not have clear contours. When you change the position of the body, they change shape. The amount of such a fluid is important for diagnosis, although it is difficult to measure it according to the results of an ultrasound scan.
Postoperative complications of peritonitis, including tertiary peritonitis, can be detected by the presence of intra-abdominal abscesses or exudate accumulations.
In addition, typical ultrasound signs of peritonitis are such indicators:
- expansion of intestinal loops;
- loop full of fluid;
- the presence of free fluid in the abdomen;
- interfacial or subphrenic abscesses;
- thickening of the intestinal wall.
What is the acute course of peritonitis?
The classic picture of the acute course of peritonitis is accompanied by a sharp pain in the abdomen, which is constantly aggravated, with nausea and relentless vomiting, progressive fever. In addition, during palpation, the patient feels a significant soreness of the anterior abdominal wall, its strong tension. After some time, in the acute course, the so-called imaginary well-being syndrome (temporary calm) occurs when partial paralysis of pain receptors occurs, which causes the pain to subside somewhat. However, after 2-3 hours the pain syndrome returns with even greater force.
Signs of chronic disease progression
Chronic peritonitis is characterized by the fact that the symptoms of the pathology are not as pronounced as in the acute state. The patient often remains able to work, although he feels some discomfort, but is in no hurry to consult a doctor. This is dangerous and chronic peritonitis - since it always has a tendency to progression, the time that passes without adequate treatment only aggravates the patient's condition.
The course of chronic peritonitis is always accompanied by prolonged intoxication of the body, the development of adhesions, and increasing dysfunction of the internal organs. The patient has increased sweating, reduced body weight for no apparent reason, there is a constant subfebrile body temperature and disorders of the digestive process. In the abdomen, from time to time there is pain and bloating.
The tension of the anterior abdominal wall is an atypical symptom for a chronic course, as are the symptoms of peritoneal irritation.
Chronic peritonitis is most often exudative or adhesive, sometimes tuberculous form occurs.
In an exudative form, the patient gradually accumulates serous fluid in the abdominal cavity. After some time, the volume of fluid reaches significant performance, its presence becomes noticeably visually. The patient can not remember when it began the formation of the disease. The general state of health worsens, the patient complains of weakness and fast fatigability.
Adhesive peritonitis is a process accompanied by the formation of adhesions, dense cicatricial cords. Initially, the pathology does not manifest itself, but when adhesions and strands begin to interfere with emptying of hollow organs, the first obvious symptoms of chronic peritonitis appear: the general condition worsens, digestive disorders are noted (nausea, vomiting, disorders of the chair). In the abdomen, there is severe pain, urination may stop, women lose their menstrual flow.
Tuberculous peritonitis occurs in the form of an exudative process with a large amount of liquid formed, or in a “dry” form with the formation of tumor tubercles, sometimes with ulcers and adhesions.
In the presence of accumulated fluid, the patient has shortness of breath when walking, the front wall of the abdomen is tense. The paleness of the skin gradually increases, and the weight decreases. The work of the intestine is disturbed, sweating increases, appetite disappears.
Symptoms of peritonitis are diverse and can have both a classic set of symptoms and atypical manifestations. It is very important for the doctor to establish their intensity, duration, sequence of appearance in order to properly diagnose and prescribe treatment.
Specialty: infectious diseases specialist, gastroenterologist, pulmonologist.
Total experience: 35 years.
Education: 1975-1982, 1MMI, San gig, high qualification, infectious diseases doctor.
Science degree: doctor of the highest category, PhD.
- Infectious diseases.
- Parasitic diseases.
- Emergency conditions.