PATHOGENETIC ASPECTS OF MOTOR-EVACUATION DISORDERS OF THE SMALL INTESTINE IN ACUTE GENERALIZED PERITONITIS AND THEIR TREATMENT

Abstract

Introduction. Despite the constant improvement of surgical techniques and intensive care methods, acute peritonitis is the main cause of mortality in surgical patients. One of the key pathogenetic factors in the development of multiple organ failure in acute generalized peritonitis is intestinal insufficiency syndrome, the main cause of which is intestinal paresis with impaired motor and evacuation functions due to the source of intoxication. Early diagnosis and correction of intestinal insufficiency syndrome affect the results of treatment of patients with abdominal sepsis and multiple organ failure.

Objective: To study the mechanisms of development of motor-evacuation disorders of the small intestine in acute generalized peritonitis and to develop pathogenetically based treatment tactics.

Materials and methods. Experimental modeling of acute inflammation of the peritoneum was performed on sexually mature non-linear white male rats (n=32) by intraperitoneal injection of 10 % filtered fecal suspension at a dose of 0.5 ml per 100 g of body weight. Animals of the control group were injected subcutaneously in 0.9 % NaCl solution. The experiment investigated the severity of endogenous intoxication, the activity of lipid peroxidation and the state of the antioxidant system in the blood of animals on the first, on the third, and on the seventh days after the administration of faeces suspension. A bacteriological examination of the parietal intestinal biotope and a histological study of the small intestine were performed, the bioenergetic state of the small intestine and the content of IgA-, IgG-, or IgM-producing cells were studied.

The results of diagnosis and treatment of 132 patients with acute generalized peritonitis who were inpatients in the surgical department of the Ternopil Municipal City Hospital No. 2 were analyzed, and a retrospective analysis of 50 patient records who died from peritonitis was performed. The severity of peritonitis was determined according to Mannheim peritonitis index. The severity of endogenous intoxication was determined by the leukocyte intoxication index, the level of middleweight molecules in the blood, and the erythrocyte intoxication index. Intra-abdominal pressure was measured.

Results. Clinical manifestations of enteral insufficiency syndrome during experimental modeling of acute generalized peritonitis are accompanied by an increase in the concentration of thiobarbituric acid reactive substances and lipid-hydroperoxides in the blood of animals, a decrease in the activity of enzymatic and non-enzymatic antioxidants. A depletion of intestinal Adenosine triphosphate, and a decrease in the number of intestinal IgA-producing plasma cells against the background of dystrophic and necrobiotic lesions of epithelial cells were detected. The manifestation of acute inflammation of the peritoneum is characterized by quantitative and qualitative changes in the microbiota of the parietal intestinal biotope. A decrease in the number of Escherichia coli strains isolated in monoculture and an increase in the number of two-component and three-component microbial associations were revealed, among which Escherichia coli, Enterobacter aerogenes, Enterococcus spp and Candida species prevailed.

In patients with acute generalized peritonitis with a favorable course in the postoperative period, the dynamics of endogenous intoxication was studied and the influence of intra-abdominal pressure on the restoration of small intestine motility after surgical treatment was determined. The treatment tactics were optimized by performing intracavitary pneumomassage of the small intestine.

Conclusions: The main links in the pathogenesis of motor-evacuation disorders of the small intestine in peritonitis are endogenous intoxication, which is a trigger for the activation of lipid peroxidation processes, impaired immune defense of the small intestine mucosa, a decrease in the bioenergetic capabilities of myocytes, dystrophic and necrobiotic lesions of epithelial cells. The use of a complex of therapeutic measures aimed at early restoration of the motor-evacuation function of the small intestine and prevention of increased intra-abdominal pressure allows reducing the degree of intestinal insufficiency syndrome in the early stages of the postoperative period and preventing the development of abdominal sepsis.