医学教程 急性化脓性腹膜炎

急性化脓性腹膜炎(AcuteSuppurativePeritonitis)[əˈkju:t'sʌpjuərətiv

,peritəu'naitis]

重庆医科大学附属第一医院普外科孔令泉

腹膜Peritoneum

[ˌperitəu'niəm]

壁腹膜ParietalPeritoneum[pə'raiitlˌperitəu'niəm]

脏腹膜

VisceralPeritoneum['visərəlˌperitəu'niəm]

腹腔

PeritonealCavity

[,peritəu'ni:əl'kæviti]大腹腔

PeritonealCavity

小腹腔

LesserPeritonealCavity

神经支配（NerveSupply）壁腹膜ParietalPeritoneum

[pə'raiitlˌperitəu'niəm]

躯体神经SomaticN[səu'mætik

nə:v]

对刺激敏感，疼痛定位准确→锐痛sharppain

[ʃɑ:p

pein]

※

腹膜炎体征Peritonealsigns

[,peritəu'ni:əl

sainz]

﹡

压痛Tenderness['tendənis]

﹡反跳痛ReboundTenderness[ri'baund'tendənis]

﹡腹肌紧张Involuntarymusclespasm[inˈvɔləntəri'mʌsl'spæzəm

]

rigidity

[ri'dʒidəti]

脏腹膜VisceralPeritoneum

['visərəlˌperitəu'niəm]

自主神经AutomaticN

[,ɔ:tə'mætik

nə:v]

对牵引、张力、炎症刺激敏感，定位差（poorlylocalizedpain）→钝痛Dullpain[dʌl

pein]

消化道症状：恶心nausea['nɔ:sjə]

呕吐Vomiting['vɔmitiŋ]

腹膜结构和功能

StructureandFunctionofthePeritoneum）

结构（Structure）一层扁平的间皮细胞Mesothelium

[,mes(z)əu'θi:ljəm]

面积约1.8m2双向的半透性膜。

功能（Function）

分泌功能Secretion[si'kri:ʃən]

吸收功能Absorption

[əb'sɔ:pʃən]

防御功能defense[di'fens]

修复功能Repair[ri'pɛə]

病因（Etiology）原发性腹膜炎PrimaryPeritonitis['praiməri,peritəu'naitis]

(无原发病灶)Spontaneous～[spɔn'teinjəs,peritəu'naitis]

1.血行播散Hematogenousinvasion[,he(i:)mə'tɔdʒinəs

in'veiʒən]

溶血性链球菌streptococcus

[,streptəu'kɔkəs]

肺炎双球菌

pneumococcus

[,nju:mə'kɔkəs]

2.生殖、泌尿系感染扩散urogenitalinfection

[,juərəu'dʒenitl

in'fekʃən

]

genitourinaryinfection

[,dʒenitəu'juərinəri

in'fekʃən]

3.

肝硬化腹水、肾病等，

肠道细菌易位

BacterialTranslocation

[bæk'tiəriəl

,trænsləu'keiʃən]

Bacteriaenterperitonealcavityvia4portals:

★1)Bloodstream

★2)Ascendinginfection

★3)Transmuralinfection

★4)Directinvasion继发性腹膜炎SecondaryPeritonitis['sekəndəri,peritəu'naitis]

1、脏器穿孔化学性腹膜炎（ChemicalPeritonitis）细菌性腹膜炎（BacterialPeritonitis）2、炎症扩散inflammation

[,inflə'meiʃən]

3、损伤Injury4、坏死necrosis

[ne'krəusis]

5、手术污染Contamination

[kən,tæmi'neiʃən]

吻合口漏

anastomosis

Leakage

[ˌənæstə'məusis'li:kidʒ

]病理生理

Pathophysiology

[,pæθəu,fizi'ɔlədʒi]

[,peritəu'ni:əl

əd'hi:ʒən]

临床表现（ClinicalManifestations）

症状

Symptoms

腹痛AbdominalPain

恶心Nausea、呕吐Vomiting

腹胀AbdominalDistension

全身症状systemicsymptoms腹部体征（Abdominalsigns）望诊（Inspection）腹胀（AbdominalDistention），腹式呼吸减弱或消失触诊（Palpation）

压痛

Tenderness['tendənis]

反跳痛

ReboundTenderness[ri'baund'tendənis]

肌紧张

MuscleSpasm['mʌsl'spæzəm

]

肌卫

MuscleGuarding

['mʌsl

ga:diŋ]

※腹膜炎体征（Peritonealsigns)[,peritəu'ni:əl

sainz]叩诊

Percussion

[pə:'kʌʃən]

鼓音Tympany

移动性浊音ShiftingDullness听诊

Auscultation[,ɔ:skəl'teiʃən]

肠鸣音BowelSounds减弱Diminished

消失Disappear直肠、阴道检查

Rectal&VaginalExaminations

盆腔感染PelvicInfection

盆腔脓肿PelvicAbscess辅助检查AccessoryExamination

[æk'sesəri

iɡ,zæmi'neiʃən

]

血象Hemogram

['hi:məgræm]

WBC↑伴核左移

leukocytosiswithleftshiftofdifferential[,lju:kəsai'təusis

wɪðleftʃift

ɔv,difə'renʃəl]

腹部立位平片AbdominalPlainfilm

膈下游离气体FreeAirbeneaththeDiaphragm

['daiəfræm]

腹腔穿刺AbdominalParacentesis

[æb'dɔminl,pærəsen'ti:sis]

B超

CT诊断

Diagnosis

病史History

体格检查PhysicalExamination

※腹膜炎体征

PeritonealSigns[,peritəu'ni:əl

sainz]

压痛

Tenderness['tendənis]

反跳痛

ReboundTenderness[ri'baund'tendənis]

肌紧张

MuscleSpasm['mʌsl'spæzəm

]

辅助检查（AccessoryExamination）目的在于鉴别原发病和腹膜炎的类型治疗（Treatment）非手术治疗（NonoperativeTreatment）

1、体位Posture['pɔstʃə]

半卧位semisupineposition

[semi-sju:'pain/'sju:pain

pə'ziʃən]

2、禁食、胃肠减压fasting,gastrointestinaldecompression

['fɑ:stiŋ][ˌɡæstrəuin'testinl,di:kəm'preʃən]

3、纠正水电解质紊乱FluidandElectrolyteImbalance

['flu(:)id

ænd

i'lektrəulait

im'bælən

]

4、抗生素治疗AntibioticTherapy5、营养支持NutritionalSupport[nju(:)'triʃənl

sə'pɔ:t]手术治疗（OperativeTreatment）1.去除病因（Removingthecause）

剖腹探查explorativelaparotomy

[ik'splɔrətiv

læpə'rɔtəmi]

2.清理腹腔（CleaningtheAbdominalCavity）

(1)清洁腹腔Cleaning(2)腹腔灌洗

lavage[læ'vɑ:dʒ]

3.充分引流Drainage['dreinidʒ]

4.术后处理PostoperativeManagement

半卧位semi-supinepositionPeritonealabscess[,peritəu'ni:əl

'æbsis]

※腹腔脓肿膈下脓肿subphrenic[sʌb'frenik'æbsis]

盆腔脓肿

PelvicAbscess

['pelvik'æbsis]肠间脓肿

InterloopAbscess

[intə'lu:p'æbsis]

Fever,pain,ileus&sometimesa

palpablemass

Diarrhea,tenderness&fullnessincaseofpelvicabsess

膈下脓肿

SubphrenicAbscess

[sʌb'frenik'æbsis]

临床表现

ClinicalManifestations

全身症状：不明原因持续发热UnexplainedPersistentFever

toxicsymptoms['tɔksik'simptəm

]

fever&abdominalpainreoccurseveraldays

afterrecoveryof★acuteperitonitis

★infectionofintra-abdominalviscus

★abdominaloperation

局部症状：不典型，可有疼痛（腹痛、胸痛、肩痛）呃逆hiccup/hiccough

['hɪkʌp/'hɪkəp]

诊断

Diagnosis

B超引导诊断性穿刺

CT

治疗Treatment

1、经皮穿刺插管引流术PercutaneousAbscessDrainage,PAD

[,pə:kju(:)'teinjəs'æbsis

'dreinidʒ]

2、切开引流术OpenTransabdominal

incisionanddrainage

[,trænsæb'dɔminl

in'siʒən

ænd'dreinidʒ]

※预防

preventionrelativelylowspaceinsupineposition

半卧位semi-supineposition盆腔脓肿

PelvicAbscess

['pelvik'æbsis

]

临床表现（Chinical

Manifestions）

全身症状：toxicsymptoms['tɔksik'simptəm

]

直肠刺激症状Irritationoftherectum

[ˌiri'teiʃən

'rektəm]

里急后重rectal

tenesmus

['rektəl

ti'nezməs]

尿路刺激症状urinary

irritation

['juərinəriˌiri'teiʃən

]

诊断Diagnosis

※直肠或阴道检查Rectal，VaginalExam

tenderness&fullness

B超&

CT治疗Treatment

antibiotic,hotsitzbath,warmsalineenema

[wɔ:m

'seilain

'enimə]

盆腔引流PelvicDrainage['pelvik

'dreinidʒ

]肠间脓肿

InterloopAbscess

[intə'lu:p'æbsis]

单发脓肿（SingleAbscess）多发脓肿（MultipleAbscess）症状体征不典型toxicsymptoms['tɔksik'simptəm

]

Fever,pain,abdominaldistention

ileus

&sometimesapalpablemass粘连性肠梗阻intestinalobstructionduetoadhesions[in'testinl

əb'strʌkʃən

dju:tu

əd'hi:ʒən]

诊断Diagnosis

B超&

CT治疗：surgicalintervention※预防

prevention半卧位semi-supinepositionAbstractofaMedicalHistory

Amalepatientof30wasadmitted,complainingofintermittentabdominalpainfor10yearswhichwasmoremarkedinthepast6hours.Tenyearsago,hebegantohaveepisodesofpainovertheepigastriumpersistedfordaysorevenweeksateachtime&oftenassociatedwithdietaryindiscretion.Sometimeshehadnocturnalabdominalpain,severeenoughtowakeuphimfromsleepattimes,butbothfood&alkalinemedicinesmayrelievethepain.Suchepisodesoccurredalmostonceayear.6hoursago,hesuddenlysufferedfromsevereupperabdominalpainwhichspreadtothewholeabdomen,accompaniedwithnausea&vomiting.

P.E:T38.5℃,P105/min,R21/min,BP120/80mmHg

Normallydeveloped&mentallyclearbutacutelyill-looking.Nojaundiceonskinorsclerae.Superficiallymphnodesnotpalpable.Necksoftandsupple.Tracheainmidline.Thyroidnotenlarged.Heart&lungsnotabnormal.Abdomenflat&board-likerigidwithmarkedtenderness&reboundtendernessespeciallyinepigastrium,togetherwithdecreasedliverdullness.Spleennotpalpable.Bowelsoundsdecreased.Nopathologicalreflexesfound.

X-ray&Laboratoryfindingsreveal:

1.X-ray:

freeairunderdiaphragm

2.Bloodpicture:

Hb98g/l,WBC15.6×109/LN0.89,L0.11

Discussthediagnosis,criteria&thrapeuticplan?

AbstractofaMedicalHistory

Amalepatientof30wasadmitted,complainingofintermittentabdominalpainfor10yearswhichwasmoremarkedinthepast6hours.Tenyearsago,hebegantohaveepisodesofpainovertheepigastriumpersistedfordaysorevenweeksateachtime&oftenassociatedwithdietaryindiscretion.Sometimeshehadnocturnalabdominalpain,severeenoughtowakeuphimfromsleepattimes,butbothfood&alkalinemedicinesmayrelievethepain.Suchepisodesoccurredalmostonceayear.6hoursago,hesuddenlysufferedfromsevereupperabdominalpainwhichspreadtothewholeabdomen,accompaniedwithnausea&vomiting.

P.E:T38.5℃,P105/min,R21/min,BP120/80mmHg

Normallydeveloped&mentallyclearbutacutelyill-looking.Nojaundiceonskinorsclerae.Superficiallymphnodesnotpalpable.Necksoftandsupple.Tracheainmidline.Thyroidnotenlarged.Heart&lungsnotabnormal.Abdomenflat&board-likerigidwithmarkedtenderness&reboundtendernessespecial