The Surgical Abdomen

Introduction. The combined course of acute peritonitis and diabetes increasingly leads to the development of secondary immunodeficiencies, which contribute to an increase in the percentage of postoperative complications and fatalities, the emergence of complexity of treatment and diagnosis.
 The aim of the study – to learn the peculiarities of humoral link of the immune response in the organism of experimental animals during simulated acute common peritonitis on the background of diabetes mellitus compared with animals with experimental acute peritonitis alone.
 Reserch Methods. 56 white rats were used in this work. Diabetes mellitus was modeled by intraperitoneal administration of Srethosotocin from “Sigma” firm with the rate of 7 mg per 100 g of animal mass, acute peritonitis – insertion of 0.5 ml of 10 % of the captured fecal suspension into the abdominal cavity of the animals. The concentration of immunoglobulins in serum was determined. Observation time points: 1, 3, and 7 days from the beginning of the peritonitis modeling.
 Results and Discussion. Analyzing the results of studies, it can be stated that there were observed directed changes in the concentration of immunoglobulins in blood serum of rats of different groups. Thus, on the first day after simulating acute common peritonitis on the background of diabetes, the level of Ig G decreased by 1.5 times, Ig M – by 1.3 times and Ig A – by 1.4 times (p<0.05). On the seventh day of the experiment, levels of all classes of immunoglobulins were statistically significantly lower than those of the group with acute common peritonitis: Ig G level was lower by 21 %, Ig M and Ig A were lower by 17 % and 56 % respectively (p<0.05). The results of our studies indicate that the presence of diabetes in acute general peritonitis leads to a decrease in the resistance of the humoral level of the immune system with antigenic stimulation and secondary immunodeficiency states.
 Conclusion. In animals with acute peritonitis, protective mechanisms of the humoral immunity level are substantially reduced on the background of diabetes, which is confirmed by statistically significantly lower levels of immunoglobulins of classes A, M, G compared to a group of animals with a pattern of acute peritonitis. The revealed functional impairment of humoral immunity indicates an appreciable weakening of the organism's protection factors in acute peritonitis on the background of diabetes mellitus with the development of secondary immunodeficiency.

Background: Fecal barium peritonitis is a complication of a colon contrast enema. It is a rare form of peritonitis, but associated with high mortality. It has not yet been clarified to what extent barium is absorbed in toxicologically relevant quantities in peritonitis of this sort. An experimental study with animals was carried out to answer this question. Method: Eight pigs in all were examined; fecal barium peritonitis was induced operatively in 3 pigs, fecal peritonitis in 2 pigs and pure barium peritonitis in 2 pigs. With the help of trace element analysis with inductively coupled plasma-optical emission spectrometry (ICP), the following organs of the experimental animals were analyzed for barium: brain, heart, kidney, liver, lung. Results: The highest barium concentrations were measured in animals which were given pure barium peritonitis or fecal barium peritonitis. The highest levels were in lung, liver and kidney. Statistical analysis using a block comparison, found a highly significant difference (p = 0.001) between animals which had been treated with barium and those which had only been given fecal peritonitis or were healthy. There was no significant difference between the groups with pure barium peritonitis and those with fecal peritonitis. The barium concentrations measured here are of toxicological relevance when extrapolated to the whole animal. This may explain the extremely high mortality of fecal barium peritonitis in comparison to pure fecal peritonitis.

Hemogram, haptoglobin and clotting factors indices were evaluated in local buffaloes breed affected with acute and chronic peritonitis in, Mosul -Iraq. Fifty one local buffaloes breed ,3-10 years old, of both sexes were studied in this study .Among these animals (16) were affected with traumatic reticloperitonitis (TRP), (8) animals suffering from acute ruminitis due to ruminal overload, (6) animals were suffering from severe tympany that needed trocarization and (10) showed sings of chronic peritonitis as a sequel of ruminatomy. Eleven clinically normal local buffaloes breed were served as control group. Results indicated that clinically diseased buffaloes exhibited different clinical sings which were varying in degree with the severity and extent of the peritonitis. Statistically significant increase (p < 0.05) was encountered in PCV and TLC in animals exhibited acute peritonitis. Animals affected with acute peritonitis showed nutrophelia(Band type nutrophils were increased in cases of TRP only ,whereas mature type were increased in all animals showed acute peritonitis), and lymphocytopenia. Eosinophelia were indicated in buffaloes affected with acute ruminitis and monocytes were increased significantly in animals affected with chronic peritonitis. Results also showed significant decrease (P<0.05) in the mean values of total platelets count in buffaloes affected with acute peritonitis compared with normal control and animals affected with chronic peritonitis .Values of mean platelets volume, platelets distribution width, , prothrombin time and partial thrombpplastine time were increased significantly (P<0.05) in animals affected with acute peritonitis. Clotting time was only increased significantly (P<0.05) in animals affected with TRP. Serum values of fibrinogen and habtoglobin in control and diseased buffaloes indicated significant increase of fibrinogen (P<0.05) in all diseased animals whereas habtoglobin increased significantly (P<0.05) in animals affected with acute peritonitis.

The effect of acute nonbacterial dependent peritonitis on lung and liver oxidant stress and antioxidant activity.

I. Roentgen Irradiation in Acute Peritonitis Roentgen irradiation is an accepted method of treating many inflammatory conditions, but its use in acute peritonitis is quite recent and not widespread. Kelly and Dowell advocated roentgen therapy in acute peritonitis and reported 24 cases thus treated. Literature: Experimental studies of the value of roentgen irradiation in the treatment of acute peritonitis are relatively few. Osugi induced acute diffuse peritonitis in dogs and then irradiated the peritoneal cavity with ultraviolet, infra-red, or roentgen rays. Kelly ligated and punctured the appendixes of dogs. After seven hours in one group and seventeen hours in another, the incisions were opened and it was observed that all the animals had acute spreading peritonitis. The appendix was then removed and roentgen treatment was begun. All irradiations were of 30 r, with the following factors: 85 kv.p., 1 mm. Al filter, 5 ma., and 16 in. (41 cm.) distance. In the first group, the mortality rate among 7 irradi...

Acute peritonitis in childhood

Amino acid profile and nitric oxide pathway in patients on continuous ambulatory peritoneal dialysis: L-arginine depletion in acute peritonitis

Purpose: to establish efficiency of enteral protection therapy in correction of a syndrome of endogenic intoxication at acute peritonitis. Materials and methods: pilot studies on dogs (n=32) and clinical observations (n=46) are the basis for work. The acute purulent fibrinous peritonitis was modelled. After operation in dynamics series of biophysical and biochemical indicators of intestine structures, markers of endogenic intoxication were studied at the organ and organism levels. Results: it is established that in development of endogenic intoxication syndrome at acute peritonitis the important role belongs to an enteral failure owing to membrane destruction phenomena because there were excessive intensity of lipids peroxidation, increased phospholipase activity and a hypoxia. The Remaksolum was effective in correction of an enteral failure and, as a result, in cupping of endogenic intoxication. Clinical and laboratory researches confirmed Remaksolum efficiency in cupping of endogenic intoxication at patients with acute peritonitis. Summary: in the development of enteral insufficiency syndrome in acute peritonitis play a key role membranodestabiliziruyuschie phenomenon due to the high intensity of lipid peroxidation, increased phospholipase activity and hypoxia. Application remaxol in the early postoperative period pathogenetically substantiated and clinically advisable to correct the endogenous intoxication in acute peritonitis. The drug, possessing antioxidant, antihypoxic, fosfolipazdepres-sive action leads to stabilization of the phospholipid bilayer of cell membranes ki shechnika reduces the negative aspects of enteric disease.

Peritoneal clearance of urea and potassium and protein removal during acute peritonitis in dogs.

Seventy-four patients of acute diffuse peritonitis were briefly reviewed. Fecal peritonitis due to perforation of the colon showed a remarkably high mortality, though the operation was carried out in general earlier than in other types of peritonitis. Three types of peritonitis, fecal, gastric juice and bile peritonitis, were produced experimentally in dogs. Changes in blood pressure, hematocrit, plasma protein, plasma volume, water contents of the intestine, acid-base balance and bacterial culture of the blood were studied in each type of peritonitis. Severe hypovolemia was considered to be an important factor in the early development of shock in fecal peritonitis, but hypovolemia alone was not sufficient to account for the extreme severity of fecal peritonitis. Blood culture became positive within a few hours after the onset of fecal peritonitis and severe septicemia, seemed to be another important factor which contributed to aggravation of symptoms in this disease. The present authors, however, could not demonstrate endotoxin-like substance in the circulating blood of dogs with severe fecal peritonitis.

An urgent problem of urgent abdominal surgery remains acute diffuse peritonitis. Mortality rate with acute diffuse peritonitis is quite high due to development of multiple organ failure syndrome. The objective of the study is to investigate the dynamics of morphological changes in the internal organs in animals with simulated acute diffuse peritonitis depending on the stage of the inflammatory process of the peritoneum. Materials and Methods. Acute peritonitis was modeled on 48 nonlinear rats according to V.A. Lazarenko’s method. Both, experimental and control groups included 24 animals. Animals were taken from the experiment on the 1, 3 and 7 days after simulated peritonitis. Results and conclusions: on the first day of modeling peritonitis histological examination of the peritoneum found the following in animals of the main group: focal purulent peritonitis with parietal peritoneal involvement, diffuse hyperemia, and focal edema of the connective tissue. Morphological and functional changes in the liver and kidneys were not found. However, on the third day of the study, the structure of the liver lobe was preserved only partially. The central veins were visualized well. Some of them were dilated and contained a small amount of red blood cells. Changes in the pulmonary tissue: enlarged alveoli, hyperemia of small vessels and hemorrhages. On the seventh day the structure of the liver lobe was significantly disturbed. The central veins were well visualized, slightly enlarged and contained a large number of red blood cells. Sinusoids were visualized in most fields of vision. Sometimes only central lobular ones were seen. The balloon organization of hepatocytes was disturbed throughout the size of the lobe. Histological examination of the kidney tissues of animals on the 7th day of the experiment in the cortical layer of the kidney found the following: the glomeruli were somewhat enlarged, vessels were filled with blood, serous exudates were observed in the lobes, and certain glomeruli were wrinkled. The vessels of the venous circulation were dilated and full of blood. Small perivascular dotted hemorrhages were visualized.

Bacterial peritonitis remains the main cause of technique failure in peritoneal dialysis (PD). During peritonitis, the peritoneal membrane undergoes structural and functional alterations that are mediated by IL-1β The NLRP3 inflammasome is a caspase-1-activating multiprotein complex that links sensing of microbial and stress products to activation of proinflammatory cytokines, including IL-1β The potential roles of the NLRP3 inflammasome and IL-1β in the peritoneal membrane during acute peritonitis have not been investigated. Here, we show that the NLRP3 inflammasome is activated during acute bacterial peritonitis in patients on PD, and this activation associates with the release of IL-1β in the dialysate. In mice, lipopolysaccharide- or Escherichia coli-induced peritonitis led to IL-1β release in the peritoneal membrane. The genetic deletion of Nalp3, which encodes NLRP3, abrogated defects in solute transport during acute peritonitis and restored ultrafiltration. In human umbilical vein endothelial cells, IL-1β treatment directly enhanced endothelial cell proliferation and increased microvascular permeability. These in vitro effects require endothelial IL-1 receptors, shown by immunofluorescence to be expressed in peritoneal capillaries in mice. Furthermore, administration of the IL-1β receptor antagonist, anakinra, efficiently decreased nitric oxide production and vascular proliferation and restored peritoneal function in mouse models of peritonitis, even in mice treated with standard-of-care antibiotherapy. These data demonstrate that NLRP3 activation and IL-1β release have a critical role in solute transport defects and tissue remodeling during PD-related peritonitis. Blockade of the NLRP3/IL-1β axis offers a novel method for rescuing morphologic alterations and transport defects during acute peritonitis.

Activation of the innate immune system is critical for clearance of bacterial pathogens to limit systemic infections and host tissue damage. Here, we report a key role for calpain proteases in bacterial clearance in mice with acute peritonitis. Using transgenic mice expressing Cre recombinase primarily in innate immune cells (fes-Cre), we generated conditional capns1 knockout mice. Consistent with capns1 being essential for stability and function of the ubiquitous calpains (calpain-1, calpain-2), peritoneal cells from these mice had reduced levels of calpain-2/capns1, and reduced proteolysis of their substrate selenoprotein K. Using an acute bacterial peritonitis model, we observed impaired bacterial killing within the peritoneum and development of bacteremia in calpain knockout mice. These defects correlated with significant reductions in IL-1α release, neutrophil recruitment, and generation of reactive oxygen species in calpain knockout mice with acute bacterial peritonitis. Peritoneal macrophages from calpain knockout mice infected with enterobacteria ex vivo, were competent in phagocytosis of bacteria, but showed impaired clearance of intracellular bacteria compared with control macrophages. Together, these results implicate calpains as key mediators of effective innate immune responses to acute bacterial infections, to prevent systemic dissemination of bacteria that can lead to sepsis.

Metabolic resuscitation is definitely not an accomplished task for intensive care of patients with acute peritonitis. The efficacy of ethylmethylhydroxypyridine succinate (Elfunate) in the complex of intensive care of patients with acute secondary peritonitis was evaluated to make basis for the early beginning of the organ-protective medications.Patients were divided into two groups: group 1 (control) (n = 20) included patients who received standard intensive care in the postoperative period. The second group (main) (n = 30) included patients who additionally received Elfunate 100 mg 3 times a day in the physiological saline solution (200 ml) from the first day of hospitalization for the first 5 days after surgery, intravenously dripping with speed of 40-60 drops per minute.During the analysis it was revealed that during the first day of hospitalization, the C-reactive protein increased 17 and 18 times higher than normal and was 70.0 ± 13.7 mg/L in group 1, 73.3 ±18.3 mg/L – in the 2nd group, the intergroup differences were not significant (p = 0.888). Significant decrease in mean CRP values to 34.7 ± 5.4 mg /l (p = 0.008) and 19.5 ± 3.7 mg / l (p = 0.018 to the previous stage) was recorded after 5 days of surgery, respectively. At the same time, in patients who received Elfunate in the intensive care unit, the level of CRP at this stage was 1.8 times lower compared to the control group (p = 0.032).Hypoproteinemia was registered in patients with acute peritonitis during the first 24 hours after surgery, when the average protein values in patients of the 1 group significantly decreased to 58.6 ± 1.8 g/L (p = 0.043 to baseline), in the 2nd group – up to 60.2 ± 1.3 g/l (p = 0.010). On the 3rd day after surgery, hypoproteinemia continued to increase to 56.2 ± 1.3 g /L (p = 0.002) in the control group, the average protein value was significantly lower than the baseline level (p = 0.029). In main group where Elfunate was used, the tendency of the total blood protein increase up to 61.4 ± 1.0 g /l (p = 0.021) was registered, the average protein value did not reach the baseline, but did not differ significantly (p = 0.497). Intergroup differences were significant (p = 0.006).In conclusion, the usage of ethylmethylhydroxypyridine succinate (Elfunate) in the intensive care of acute peritonitis is pathogenetically grounded, as it allows to stop the SIRS manifestation, improving the protein synthesis in the liver on the background of endogenous intoxication caused by the underlying disease.

BACKGROUND : Peritonitis is classified as primary, secondary and tertiary. In primary peritonitis (spontaneous bacterial peritonitis) and continuous ambulatory peritoneal dialysis-associated peritonitis, the source of the infection is not due a breach in the gastrointestinal tract and usually caused by a single organism. Secondary peritonitis ensues, which may be localized and contained or diffuse carrying a high mortality in the absence of surgical intervention and appropriate antimicrobial therapy. Another sequelae of perforated viscus is intra-abdominal abscesses, located in the intra or retroperitoneal space, which occur in partially treated diffuse peritonitis, postoperatively or in localized disease where the omentum has sealed off the perforation and formed an inflammatory barrier. In contrast, secondary peritonitis following perforation of the gastrointestinal tract or an infection originating in an intra-abdominal structure, e.g. gall bladder, pancreas etc. Tertiary peritonitis is an ill-defined entity, which occurs despite adequate treatment of primary or secondary peritonitis. Combination antibiotic therapy has been used to provide the patient with broad-spectrum coverage against the many potential pathogens encountered in abdominal sepsis. Several potential benefits of the clinical use of antibiotic combinations have been advanced. So this study will be conducted to focus on the efficacy of combination of two versus three antimicrobial drug in the management of patients with perforated peritonitis. OBJECTIVES OF THE STUDY: 1.To assess the efficacy of two antimicrobials(Ceftriaxone And Metronidazole) in perforative peritonitis. 2.To assess the efficacy of three antimicrobials(Ceftriaxone, Metronidazole And Amikacin)in perforative peritonitis. 3.To compare the clinical outcome of perforative peritonitis with two and three antimicrobials in the terms of reduction in postoperative infections and hospital stay. MATERIALS AND METHODS SOURCE OF DATA: This is a prospective clinical study conducted on 140 consecutive patients who presented to the surgical department of R. L. Jalappa Hospital and Research Centre, Tamaka, Kolar with peritonitis secondary to hollow viscus perforation. Study period was from December 2015 to June 2017. This is a randomized study and all the patients were divided in two groups. GROUP A: Patients with all odd serial numbers were included in this group and treated with two antimicrobials (Inj Ceftriaxone 1gm IV BD and Inj Metronidazole 500mg IV TID). GROUP B: Patients with all even serial numbers were included in this group and treated with three antimicrobials(Inj Ceftriaxone 1gm IV BD , Inj Metronidazole 500mg IV TID and Inj Amikacin 500mg IV BD). INCLUSION CRITERIA : 1.Patients with peritonitis secondary to hollow viscus perforation. 2.Patients with age >18years and <70years. EXCLUSION CRITERIA: 1.Peritonitis secondary to trauma to the abdomen. 2.Peritonitis secondary to gynaecological interventions like D&C. 3.Peritonitis secondary to malignancies and immuno-compromised state 4.Patients allergic to Ceftriaxone, Metronidazole and Amikacin. 5.Tertiary peritonitis. RESULTS: The clinical outcome in the form reduction in postoperative complications and hospital stay were assessed in 140 patients, in Group A( with the usage of two antimicrobials , Ceftriaxone and Metronidazole) and Group B( with usage of three antimicrobials, Ceftriaxone, Metronidazole and Amikacin). There was decrease in postoperative complications and hospital stay in Group B. The p-value was significant in Group B patients <0.05(0.007). There were 6 deaths, all of them had severe form of peritonitis with massive contamination and delayed presentation to the hospital. This study also revealed that men are commonly affected and duodenal ulcer perforation is the commonest site of perforation. Escherichia coli is the most common organism isolated. CONCLUSION: In our study peritonitis is more common in men compared to women. The most common age group is in between 21 – 40 years in cases of peritonitis with the mean age of 37 years. Duodenal ulcer perforation is the commonest site of perforation. Escherichia coli is the most common organism isolated in the peritoneal fluid. Use of with usage of three antimicrobials, Ceftriaxone, Metronidazole and Amikacin(p<0.05) is beneficial in reduction in postoperative complications and hospital stay when compared to usage of two antimicrobials, Ceftriaxone and Metronidazole which is statistically significant.