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Peritonitis > 86. Peritoneum_Retroperitoneum > Flashcards

86. Peritoneum_Retroperitoneum Flashcards

1
Q

what passes through the esophageal, aortic and caval hiatus respectively

A

esophageal: esophagus, esophageal vessels, vagus trunkcaval: cd vena cavaaortic: aorta, lumbar cistern of the thoracic duct, hemiazygous and azygous veins

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2
Q

what travels through the inguinal canal

A
  1. vaginal process (spermatic cord in male, round ligament female)2. external pudendal vessels3. genital branch of the genitofemoral a, v, n
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3
Q

what is the characteristic Cullen sign

A

ring of SQ hemorrhage around the umbilicus indicative of hemoperitoneum or peritonitis

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4
Q

the peritoneal cavity (space btwn parietal and visceral pleural) does not contain organs with the exception of……

A

ovulation: when egg ruptures from ovary (abdominal cavity and peritoneal cavity are used interchangeably but anatomically they are distinct)

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5
Q

portions of the greater omentum

A
  1. bursal: largest portion with superficial ventral leaf and deep dorsal leaf2. splenic portion: gastrosplenic ligament3. veil portion: contains the left limb of pancreasomental bursa is the space btwn these layers
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6
Q

opening of the omental bursa and it’s borders

A

EPIPLOIC FORAMENDORSALLY: Caudal vena cavaVENTRALLY: portal veinCAUDALLY: hepatic artery (branch of celiac artery)CRANIALLY: liver

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7
Q

what is the pringle maneuver

A

place finger in epiploic foramen (cranial to pylorus?)press ventrally and caudally to occlude portal vein and hepatic arterythis will temporarily stop bleeding to the liver

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8
Q

ligaments within the lesser omentum

A

hepatogastric and hepatoduodenal ligaments

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9
Q

organs within the retroperitoneum

A

kidneysureters (for most of their length)adrenal glandsaortacd vena cava lumbar LN

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10
Q

normal peritoneal fluid

A

COP 28 mm HgP < 3 g/dllacks fibrinogen—DOES NOT CLOTacellular with < 300 cells (of which macros should predominate)< 1500 cells TRANSUDATE> 5000 cells EXUDATE

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11
Q

mechanism of lymphatic drainage of the abdominal cavity

A

thoracic duct drains ab cavity to the mediastinal LNcontract diaphragm during expiration and decrease intrathoracic P causes lymphatics to flow into efferent ductsright side of diaphragm has a greater distribution of lymphathics

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12
Q

normal intra abdominal P in a dog

A

2-7.5 cm H20 (measured with indwelling UCath)> 20 can be associated with poor organ perfusion, renal failure and respiratory compromise (organ failure reversible if treated early!)increases of IAP have been seen in dogs post OHE

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13
Q

T/Ffibrous adhesions in the abdominal cavity only occur if there was ischemic insult

A

TRUEin the absence of ischemia, adhesions do NOT formwith ischemia, fibrin clots are infiltrated with fibroblasts which make collagen converting fibrinous adhesions to fibrous adhesions

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14
Q

intraperitoneal substances that are known adjuvants in peritonitis (virulence enhancement factors)

A

–gastric mucin: heparin like molecules and inhibit phagocytosis–bile salts: decr surface tension, changes cell adhesion, lyse RBC–hemoglobin: interfere with cell killing, provides iron to bacT–bariumall are virulence enhancement factors that promote bacT growth

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15
Q

MODS and dogs with septic peritonitis based on Kenney et al JAVMA 2010

A

Septic peritonitis secondary from GI leak treated surgicallyMODS 50% patientsmortality 70% with MODSMortality 25% without MODSMODS = poor px

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16
Q

omentum’s role in peritoneal defense

A
  1. RICH blood supply2. with pronounced angiogenic activity3. high absorptive capacity (only organ in ab cavity to absorb bacT and particles)4. isolates and seals source of contaminationomentectomy has NO effect on clearance of particulate matter from ab cavity
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17
Q

why does ileum occur with peritonitis

A

peritoneal inflammation induces GI ileum by sympathoadrenergic reflex INHIBITION BLOCK myenteric cholinergic neurons

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18
Q

potential benefit of ileus induced by peritonitis

A

impeding intraperitoneal circulation and decreasing the spread of contaminationbut overall can lead to bacT translocation

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19
Q

what is reflex rigidity

A

peritoneal irritation causes reflex rigidity of the abdominal and diaphragmatic musclesthis rigidity will impair respiratory movementleads to decreased intraperitoneal circulation and decrease lymphatic clearance/drainage

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20
Q

signs of pain on abdominal palpation during septic peritonitis in cats

A

pain on palpation was only noted in 40-60% (38%)

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21
Q

nerves to peritoneum vs viscera

A

peritoneum innervated by somatic nerves–respond to local inflammation/irritationviscera innervated by visceral nerves–respond to stretch and is poorly localized

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22
Q

classifications of peritonitis

A
  1. primary (rare) vs secondary2. acute vs chronic3. localized vs generalized4. septic vs asepticmost common: acute, generalized, secondary septic peritonitis (most common form in dogs)
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23
Q

1 cause of primary peritonitis in vet med

A

feline corona virus —-feline infectious peritonitis

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24
Q

primary bacterial peritonitis in a recent retrospective by Culp et al JAVMA 2009

A

monobacterial 60% dogs 100% cats majority were gram positive organisms (as opposed to gm neg seen in secondary peritonitis)secondary peritonitis was most likely to have exudate fluid compared to primary peritonitis~ 50% survived to discharge to the hospital (was worse than secondary peritonitis cases) but overall outcome was not different btwn primary and secondary peritonitis

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25
types of aseptic secondary peritonitis
-chemical (bile, urine--normally sterile, pancreatic, barium, antiseptics)-peritoneal FB (particles too big to go through lymph)-starch granuloma (surgery glove powder--corn starch replaced with silicon based Talcum)-mechanical (air, suture material, sponge)-sclerosing encapsulating (chronic form, onion like layers of collagenous CT)-neoplasia
26
US appearance of gossipyboma
retained surgical spongehypoechoic mass with an irregular hyper echoic centercytology usually mononuclear with multinucleate giant cells with fibers
27
causes of secondary septic peritonitis
#1: GI leakage (60% from previous R&A)other causes: --corticosteroid induced colonic or duodenal or pyloric perf--post colonscopy or gastroduodenoscopy--rupture abscess (pancreas, liver, spleen, kidney, omentum, LN, prostate)--jejunostomy/gastrotomy tubes--penetrating ab trauma--neoplastic infiltration--pyometra rupture--rupture bladder or GB with infection present--hepatobiliary disease--post op abdominal surgery--peritoneal dialysis contaminated tubing
28
risk factors for leakage following intestinal surgery according to RALPHS JAVMA 2009
RALPHS 2003 JAVMAhypoalbuminemia < 2.5intestinal foreign body (**contrast to Grimes 2011--FB was protective)preop peritonitis12 % leakage rate (85% of which DIED)
29
risk factors for increased mortality following intestinal surgery according to Hayes JSAP 2009
--long duration clinical signs--linear FB--multiple intestinal procedures
30
rate of post op leakage following GI surgery
12-14%
31
risk factors for leakage following intestinal surgery according to Grimes JAVMA 2011
preop peritonitisserum albumin < 2.5serum protein < 5intraop hypotension14% leakage rate****FB WAS PROTECTIVE****
32
concurrent pancreatitis with secondary septic peritonitis
50% cases
33
survivability of GB rupture and biliary peritonitis with sepsis and asepsis
Ludwig Vet surgery 1997septic biliary 30% SURVIVEsterile biliary 100% SURVIVEMehler Vet Surgery 2004septic biliary 50% SURVIVEsterile biliary 85% SURVIVECrews JAVMA 2009septic biliary 80% SURVIVE (?!?!?!)
34
bacterial load in the gastrointestinal tract
increase bacT along GI tractincrease anaerobic bacT proportionstomach and SI low # acid resistant microbes, no anaerobescolon: dense # bacT, obligate anaerobes 1000:1 aerobe
35
bacT most common in septic peritonitis
poly microbialE coli Bacteroidesearly mortality associated w gm - aerobes with circulating endotoxin (E.coli)B fragilis enhances E.coli mortality
36
factor associated with E. coli's virulence
endotoxinexotoxin (alpha hemolysin)--toxic to mammalian cells, allows tissue invasion or destruction, decreases pH, lyses intraperitoneal RBC, reduces recoverable viable WBC
37
volume of fluid present in order to be detected on PE ballottment
10 mg/kg
38
pneumoperitoneum can occur from what three mechanisms
1. luminal organ penetration2. infection with gas producing bacteria3. penetrating abdominal wall injury
39
contrast agents from GI studies
--barium--iodinated water soluble (preferable)
40
simultaneous pleural and peritoneal effusions have been reported to occur with what condition
infectious agents and pancreatitisand 3.3 x increased risk of death
41
normal thickness of duodenum and jejunum on US
duodenumcat 3 mm20kg 6 mmjejunumcat 2 mm< 20 kg 4 mm> 20 kg 5 mm
42
% positive abdominal paracentesis results when ab has 3 ml/kg vs 10 ml/kg
3 ml/kg 20% +10 ml/kg 80% +lower amounts of fluid may need a diagnostic peritoneal lavage
43
to increase diagnostic yield and avoid FN "dry" abdominocentesis ---what other options do you have
1. four quadrant technique2. US guided3. diagnostic peritoneal lavage
44
diagnostic accuracy of needle centesis vs catheter centesis vs peritoneal lavage
needle: 43% (high FN bc "dry taps")catheter: 83%DPL: 95%
45
DPL technique
empty patient bladderaseptically prepare skininfuse warm sterile isotonic solution 20-22 ml/kg with over the needle catheter caudal to umbilicusroll, walk patientretrieve fluid (not attempt to get full amount back)
46
ways to examine abdominal fluid
biochemically ( sugar, and blood to fluid glucose, creatinine, amylase, lipase)cytologically (WBC morphology, bacT presence, bile salts, starches)grossly (color, clearness)microbiologically (culture and sensitivity)
47
study of cytological examination of post op dogs with DPL
post opdogs with no surgical complications had DPL fluid obtained1-3 days post opcell # 500-10,500 cells/microliterpredominately NONDEGN neutrophils
48
ab fluid diagnostic for uroperitoneum
fluid creatinine >2.4 x serumfluid K > 1.4 x serum
49
ab fluid diagnostic for bile leakage
fluid bilirubin > 2x serumgold green granular pigment icotest for fluid is inaccurate in icteric patients
50
ab fluid diagnostic for chylothorax
cholesterol in fluid > serumTG in fluid > 3x serumnondegen PMNSMALL MATURE LYMPHOCYTES
51
SN and SP of blood glucose to fluid difference in dogs vs cats with septic peritonitis
difference > 20 mg/ml (BG: glucose fluid difference)dog: 100/100cats: 86/100another study said ab fluid glucose < 50 mg/ml was 100% SP in dogs
52
SN and SP of blood lactate to fluid difference in dogs vs cats with septic peritonitis
blood lactate to fluid lactate < 2.0 mmol/L was 67% SN/ 100% SP for septic peritonitis in dogs and 84% accurateNOT reliable in cats
53
fluid rates recommended 24-72 hours after surgery for post op septic ab
10-12 ml/kg/hr recommended post op were required to maintain hemodynamic stability may develop hypoalbuminemia
54
antimicrobial drug recommendations for empirical therapy of septic peritonitis
cidal for both gm + and - and anaerobes1. ampicillin, gentamicin, metronidazole2. extended spectrum cephalosporins3. ampicillin, amikacin4. cefazolin, aminoglycoside5. fluoroquinolones
55
% of animals with bacterial septic peritonitis that may be placed on inappropriate Ab
26%
56
bacterial culture results and antibiotic sensitivity patterns in 23 dogs with septic peritonitis
80% gm - and 100% gm + SENSITIVE AMINOGLYCOSIDES50% gm - and 30% gm + sensitive fluoroquinolones
57
lavage amount for patients with septic abdomen
200-300 ml/kgor continued until the returning fluid is clear
58
why is intraperitoneal antimicrobial therapy NOT recommended
Causes:--adhesions--chemical peritonitis--allergic reactions--catabolism --delayed anastomotic healing
59
other rx considered for septic peritonitis patient
--pentoxyfylline: improves survival and decreases adhesions and abscess formation(rats)--Vit E--Ab with an iron chelating agent--immunoglobulin
60
surgical considerations for septic abdomen
1. ID underlying cause2. debride and fix3. lavage (intra op, post op intermittent, open ab, PL)4. augmentation techniques (serosal patch, omentalization, fascial or muscle grafts, fibrin sealant)5. Open vs Closed ab +/- drains
61
mortality rate reported in 28 dogs treated surgically for septic peritonitis WITHOUT abdominal drainage
50%
62
According to Staatz et al Vet surgery 2002 with animals treated surgically for septic peritonitis OPEN ab drainage vs primary closure what was the survival difference
NO SIGNIFICANT DIFFERENCE in survival btwn groupsoverall survival rate 71%open group did have a significantly longer hospital stay though
63
benefits to open abdominal drainage
--ability to provide ample drainage--perform early, planned re-exploration--can be used in patients with anaerobic bacterial peritonitis---can treat patients with abdominal compartment syndrome
64
Disadvantages of open abdominal drainage
--potential for secondary infection--evisceration--bowel desiccation--hypoproteinemia--frequent labor intensive bandage changes that may require sedation or anesthesia--inability to quantify fluid production
65
criteria for closing a peritoneal cavity from open peritoneal drainage
1. gross improvement in color, clarity2. decreasing volume3. decreasing cellular toxicity4. absence of bacT on cytologyconsider explore, lavage at the time of closure
66
concerns with closed peritoneal drainage techniques
1. ineffective drainage2. early occlusion3. nosocomial infection
67
percentage of RETURN of infused saline with methylene blue using a sump-penrose drain vs penrose vs tube vs sump drain
sump-penrose SUPERIOR 72%sump 60%penrose 40%tube 40%
68
Mueller et al JAVMA 2001% complications with closed suction drainage in animals with septic peritonitis
50% complicationsmostly anemia and hypoproteinemia
69
post op management of septic abdomen
1. nutrition2. analgesics3. transfusions therapy (albumin, blood products, plasma)4. ECG/BP cardiovascular monitoring with art line 5. +/- oxygen therapy6. continued fluids for maintenance of perfusion/hydration7. indwelling ucath (1-2 ml/kg/hr)8. low dose heparin9. low dose lasix CRI if edematous
70
which amino acid is considered essential during catabolic illness
glutamine
71
T/Fepidurals are contraindicated for patients with septic peritonitis
TRUEepidurals are contraindicated based on decreased survival times, decr cardiac and renal function, and deleterious effects of sympathetic blockade
72
benefits of low dose heparin therapy for post op septic ab
--improve clotting fx--improve clearance of peritoneal bacT--decr fibrin formation--decr abscess formation--potentially improve survival
73
human serum albumin transfusion to healthy dogs
type III hypersensitivitysignificant morbidity and mortality
74
prognosis and survival rates for general septic ab, open ab drainage, closed ab drainage and primary closure
generalized 20-70% (50%)open ab drainage 50-80%close ab drainage 70%primary closure 54%INTERPRET WITH CAUTION
75
bacteria most common in peritoneal or retroperitoneal abscesses
bacteriodes fragilis
76
the most common retroperitoneal tumor in domestic animals
lipoma
77
define fistula
abnormal communication or connection btwn epithelial lined structures

Peritonitis (2 decks)

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