Peritonitis: Pathologic physiology involved in treatment

Abstract

Peritonitis can usually be divided into an early formative or absorptive stage during which bacteriemia and bacterial toxemia preponderate, and the fully developed later stage in which circulatory disturbances and inhibition ileus preponderate. The most important factors that enter into the production of symptoms are: (a) bacteriemia and toxemia; (b) dehydration and demineralization; (c) reflex symptoms of nausea, anorexia and general depression; (d) inhibition ileus; (e) circulatory disturbances; (f) anoxemia, and (g) starvation. The most important local defensive factors against peritoneal infection are phagocytosis, formation of a fibrinous exudate and early localized intestinal inhibition. The general antibacterial activities are interfered with by anhydremia, demineralization, disturbances of the acidbase balance, anoxemia and circulatory disturbances. The surgical treatment involves the early removal of the focus of infection, with constant consideration of the importance of not disturbing the local defensive mechanisms. Dehydration and demineralization are treated by means of normal saline, Ringer's and Hartmann's solutions. The anoxemia is treated by correcting circulatory disturbances and by the early use of oxygen inhalations. To increase the colloid osmotic pressure of the plasma when a shock syndrome exists, 6 per cent acacia solution with minute doses of pitressin are to be used. (Suprarenal cortex extract may be of some value.) Fluids are not to be administered by mouth during any stage of peritonitis because they stimulate gut activity. However fluids may be given by mouth during the time that duodenal intubation with suction is applied. Proctoclysis and enemas are contraindicated in the early cases of peritonitis due to gangrenous appendicitis, when physiologic rest of the cecum is most desirable. Morphine is needed to control pain. It is doubtful whether deep morphinization has any specific beneficial effect in peritonitis and its deleterious effect upon the respiratory mechanism as well as upon the immune reactions must be borne in mind. The splanchnic vasomotor paralysis may be treated in the early stages only by means of small doses of ephedrine. Ephedrine also probably lessens “weeping” from the peritoneum and plasma loss into the intestine, and its inhibitory effect upon gut motility is of advantage during the early stages. Inhibition ileus and distention are treated by means of duodenal intubation and hypertonic salt solution intravenously. The stimulating effect of hypertonic salt solution upon propulsive intestinal motility contraindicates its use in the early formative stages. Glucose solutions are especially indicated during the starvation stage. Fowler's position is of definite value during the early, formative stages. Later the state of the circulation and the patient's comfort should determine the position of the patient. Mild x-ray treatment during the early formative stages of peritonitis is probably indicated because it raises the antibacterial defense mechanisms. The possibility of a mechanical obstruction occurring in peritonitis, from kinking of the bowel, localized abscess, or from a plastic exudate is to be borne in mind. Enterostomy is indicated only after the simple method of duodenal intubation with suction has been given a trial. Spinal anesthesia is contraindicated during the early absorptive stages of peritonitis because of its stimulating effect upon peristalsis. Ether is contraindicated during any stage of peritonitis. The inefficacy of drainage in general peritonitis cases is briefly discussed.