Management of acute liver failure as a key component of multiple organ dysfunction in patients with severe purulent peritonitis

Sh. Z. Otaev; Sh. K. Nazarov; B. K. Valiev; A. M. Kholbegov; S. G. Ali-Zade; F. P. Jalilov

doi:10.52888/0514-2515-2025-367-4-76-91

Management of acute liver failure as a key component of multiple organ dysfunction in patients with severe purulent peritonitis

Sh. Z. Otaev, Sh. K. Nazarov, B. K. Valiev, A. M. Kholbegov, S. G. Ali-Zade, F. P. Jalilov

https://doi.org/10.52888/0514-2515-2025-367-4-76-91

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Abstract

Objective: to evaluate the effectiveness of planned relaparotomy with staged peritoneal lavage and small intestinal lavage using electrolyzed isotonic saline in the management of acute hepatic failure in patients with generalized purulent peritonitis.

Materials and methods: the study included 69 patients with generalized purulent peritonitis, divided into an intervention group (n = 35) and a control group (n = 34). After source control, the intervention group underwent planned relaparotomy with staged peritoneal lavage plus small intestinal lavage using electrochemically activated isotonic saline; controls received conventional peritoneal lavage with standard isotonic saline. The following parameters were evaluated: clinical status, characteristics and stage of acute hepatic failure, comorbidities, dynamics of hepatic blood flow (ultrasound with Doppler imaging), biochemical indices of liver and kidney function, inflammatory markers (interleukin-6, procalcitonin, D-dimer), hemostasis parameters, microbial contamination of the abdominal cavity, need for relaparotomy, incidence of recurrent peritonitis and septic complications, duration of mechanical ventilation, clinical recovery and mortality.

Results: use of planned relaparotomy with staged peritoneal lavage plus small intestinal lavage using electrolyzed isotonic saline was associated with faster restoration of portal venous flow and normalization of liver function. Portal vein blood flow velocity in the intervention group increased from 9.8 [8.7–10.9] to 19.2 [17.4–21.0] cm/s by day 15, whereas in the control group it increased from 9.6 [8.3–10.9] to 16.1 [14.5–17.7] cm/s. Total bilirubin decreased from 142 [130–154] to 54 [47–61] μmol/L in the intervention group and from 144 [131–157] to 78 [70–86] μmol/L in the control group. The time to bilirubin normalization was significantly shorter in the intervention group (6.8 [6.3–7.3] vs. 11.4 [10.6–12.2] days; p < 0.01), as was the time to INR normalization (7.2 [6.7–7.9] vs. 12.1 [11.2–13.0] days; p < 0.01). Levels of interleukin 6, procalcitonin and D-dimer decreased more markedly in the intervention group: by day 15, procalcitonin was 0.8 [0.7–0.9] vs. 1.5 [1.2–1.8] ng/mL, and D-dimer was 560 [499–621] vs. 840 [772–908] ng/mL. The total microbial load in the abdominal cavity decreased from 905 [815–995] to 13 [10–16] ×10³ CFU/mL in the intervention group and from 933 [838–1028] to 44 [38–50] ×10³ CFU/mL in the control group. The incidence of recurrent peritonitis was lower in the intervention group (8.6% vs. 26.5%; relative risk [RR] 0.32), as was the rate of septic complications (11.4% vs. 32.4%; RR 0.35; odds ratio [OR] 0.27; 95% confidence interval [CI] 0.08–0.96). Clinical recovery by hospital discharge was achieved in 85.7% of patients in the intervention group and in 61.8% in the control group (RR 1.39; OR 3.71; 95% CI 1.15–12.0). Mortality was 14.3% and 32.4%, respectively (RR 0.44).

Conclusions. Planned relaparotomy with staged peritoneal lavage combined with small intestinal lavage using using electrolyzed isotonic saline provides more effective management of acute hepatic failure in generalized purulent peritonitis, accelerates restoration of hepatic blood flow and normalization of biochemical and coagulation parameters, reduces the severity of systemic inflammation and microbial contamination of the abdominal cavity, and is associated with a lower incidence of septic complications and more than a twofold relative reduction in mortality.