Abdominal Disease Flashcards
1
Q
Causes of cranial abdominal pain
A
Liver (hepatitis)
Gall bladder (obstruction)
Stomach (gastritis/GDV)
Spleen (splenitis)
Pancreas (pancreatitis)
Diaphragm?
2
Q
Causes of dorsal abdominal pain
A
Kidneys (pyonephritis/AKI)
Spine
Spleen (splenic torsion/rotation)
Radiating pain from other organs
3
Q
Causes of caudal abdominal pain
A
Bladder
Uterus
Colon
Prostate (prostatitis/prostatic abscess)
4
Q
Where can spinal pain be transferred to?
A
Pain on palpation of whole abdomen as palpation affects posture
5
Q
Endocrine disease that can present with acute abdominal pain
A
Addison’s
6
Q
Meaning of ‘acute abdomen’
A
Acute abdominal pain
(Shock, collapse due to shock, vomiting could be related to pain/shock/cause)
7
Q
Types of shock seen with acute abdomen
A
Hypovolaemic
Distributive
Obstructive (reduced cardiac output due to obstruction of blood vessels)
Cardiogenic (reduced cardiac output due to abnormal heart)
8
Q
How to identify type of shock in an acute abdomen?
A
POCUS (mushroom view for ejection fraction, caudal vena cava should be bounding, cardiac tamponade, DCM, abdominal fluid)
9
Q
Which fluid types may be present in the abdomen?
A
Blood
Urine
Inflammatory exudate
(Bile)
(Transudates)
10
Q
What ultrasound finding in the abdomen is an emergency?
A
Free fluid
11
Q
Laboratory tests for the acute abdomen
A
Haematology (neutrophilia, PCV)
Biochemistry (ALT/ALP, urea/creatinine, albumin)
Lactate (assess tissue perfusion)
12
Q
Will abdominal fluid have the same PCV as blood in the acute or chronic situation?
A
Acute
13
Q
Diagnostic tests for the acute abdomen
A
Ultrasound
Radiograph
Haem/biochem
Blood pressure
ECG
Blood gas analysis
14
Q
Metabolic acidosis
A
Low pH
Caused by lactate/urea
15
Q
Fluid choice for metabolic acidosis
A
Hartmann’s (alkanising)
16
Q
Metabolic alkalosis is pathognomic for what?
A
Pyloric obstruction
17
Q
Fluids for metabolic alkalosis
A
Saline (NaCl and water, dissociates to NaOH and HCl)
18
Q
Typical prognosis for ascites
A
Poor
19
Q
What would you be suspicious of if a dog had abdominal distension, abdominal discomfort, dyspnoea and lethargy?
A
Ascites
20
Q
Differentials for abdominal distension
A
Organomegaly
Abdominal mass
Ascites
Pregnancy
Bladder distension
Obesity
Gastric distension
21
Q
Diagnosis of ascites
A
History
Clinical exam
BCS
Ballottment
Ultrasound
Tap fluid
22
Q
Opaque and foul smelling abdominal fluid
A
Septic fluid
23
Q
Diagnostics when identifying abdominal fluid type
A
Gross appearance/smell
Cellularity (smear, microscope)
Protein content (refractometer, TP scale)
24
Q
What fluid type is clear/colourless/pale straw colour, TP<20, TNCC<1.5 with neutrophils, macrophages and some mesothelial cells?
A
Protein poor transudate
25
What fluid type is yellow/blood tinged/turbid, TP>20, TNCC<5 with macrophages, mesothelial cells and increasing neutrophils and small lymphocytes?
Protein rich/modified transudate
26
What fluid type is turbid, various colours, TP>20, TNCC>5 with neutrophils and sometimes macrophages?
Exudate
27
Investigations when protein poor transudate is found in abdomen
Biochemistry (confirm hypoalbuminaemia)
Urinalysis (look for kidney failure)
Ultrasound (liver disease)
28
Differentials for protein poor transudate
Protein-losing enteropathy
Protein-losing nephropathy
Hepatic failure
29
Pathophysiology of protein poor transudate in abdomen
Hypoalbuminaemia = decrease in plasma colloid oncotic pressure
30
Pathophysiology of protein rich transudate
Increased hydraulic pressure in blood/lymph circulation = protein leaks from permeable capillaries = ascites develops when resorptive capacity of lymphatics is overwhelmed
31
Differential diagnoses for protein rich transudate
Cardiovascular disease
Chronic liver disease (post hepatic portal hypertension)
Neoplasia
Thrombosis (rare)
32
Investigation of protein rich transudate
Ultrasound (heart and liver)
Radiography (thorax metastasis)
Biochemistry
33
Exudate pathophysiology
Inflammatory process (septic or non-septic) = high TNCC, increased vascular permeability
34
Septic causes of exudative ascites
Penetrating wound
Surgical complication
Rupture of infected lesion
Bacteraemia (rare)
35
Does ascites with a septic cause have a better or worse prognosis than other ascites?
Better (there is something to 'fix')
36
Non-septic causes of exudative ascites
Neoplasia
Uroperitoneum
Bile peritonitis
FIP
37
Differentials for a lymphatic abdominal effusion
Cardiac disease
Hepatic disease
Neoplasia
Steatitis (inflammation of fat)
38
Pathogenesis of gastric dilation and volvulus
Aerophagia (swallow more gas than usual)
39
Risk factors for GDV
Eating quickly
Stress/anxiety/pain
Exercise (oesophagus opens after feeding)
Thoracic width to depth ratio (Red Setters, GSDs, Dobermanns, Dashchunds)
40
Pathophysiology of gastric dilation and volvulus
Gas distension
Pylorus pivots (180/360 degrees, 90% rotate clockwise)
Space occupying: pressure on vena cava = obstructive shock, gastric vessel occlusion = necrosis, gastric blood supply linked to spleen = spleen engorges and twists)
41
Type of shock in GDV
Obstructive
42
Treatment of obstructive shock in GDV
Oxygen therapy
Analgesia
IVFT bolus in cephalic vein
ECG +/- treat ventricular tachycardia with lidocaine
43
Reason for IVFT bolus in cephalic vein with GDV
No hypovolaemia but no blood returning to heart due to CVC obstruction = hypovolaemia cranially
44
Why is an ECG required in GDV management?
Hypoxic damage to heart = arrhythmias, most commonly ventricular tachycardia
45
Medical treatment of obstruction in GDV for temporary stabilisation
Orogastric (large)/nasograstric (small) tube to decompress stomach
Percutaneous decompression with Trocar/needle/catheter if tube can't be placed
46
Anaesthetic considerations in GDV
High ASA grading
Avoid alpha 2s (CV compromise)
Methadone for pain
Co-induce with Midazolam and propofol (anaesthetic sparing affect)
Antibiotics? (Long surgery/damage to gastric mucosa)
Monitor lactate/blood gas analysis/ECG (acidosis likely)
Monitor cardiac output (blood pressure)
Monitor perfusion (ventilate, capnography)
47
Advised surgical technique for GDV
Decompress stomach fully
Incisional gastropexy (de-rotate stomach, incise pylorus serosa and abdominal wall, stitch together)
Remove spleen if damaged
48
Surgical methods for GDV
Belt loop
Circocostal version
Tube gastropexy
Incisional gastropexy
49
Post operative care for GDV
Monitor cardiac output for 24-48h as there is risk of repurfusion injury (ECG, blood pressure)
Oxygen therapy?
50
Radiographic appearance of 'bloat' (gastric dilation, no volvulus)?
'Double bubble'/'boxing glove'
51
How to differentiate between 360 degree rotation of stomach and bloat?
Patient with bloat is less critical
Cannot stomach tube patient with volvulus
52
Surgical management of bloat
Gastropexy is indicated as there is a future risk of GDV
53
Benefits of a prophylactic gastropexy
Can be done at same time as castration/spay (reduced cost)
54
Risks of a prophylactic gastropexy
Surgical risk
Surgical time/cost
(Mesenteric torsion)
55
What could red fluid on abdominal tap be?
Blood (haemoabdomen) or serosanguinous
56
How can you differentiate a serosanguinous abdominal fluid from a haemoabdomen?
Very low PCV compared to blood = serosanguinous discharge
57
How do you determine whether a haemoabdomen is acute or chronic?
PCV
Acute = blood
Semi-acute >blood
Chronic
58
How do you stabilise a neoplastic bleed?
Measure perfusion (blood pressure and lactate)
IVFT if necessary
Blood transfusion (auto-transfusion, whole blood or pRBCs)
59
Treatment of neoplastic bleed
Surgery (remove mass)
Chemotherapy(/radiotherapy)
Euthanasia
60
Causes of haemoabdomen
Neoplastic bleed
Blunt force trauma
Penetrating wound trauma
Coagulopathy
61
Stabilisation of haemoabdomen due to trauma
Measure perfusion (blood pressure, lactate)
Fluids or blood transfusion (autotransfusion must be filtered due to microaggregates, whole blood, rRBC with plasma)
Tranexamic acid (fibrinolytic)
62
Should you operate on patients with haemoabdomen due to trauma?
Blunt trauma: avoid operating, will be bleeding from multiple vessels/sources
Penetrating wound: surgery to stop bleeding
63
Most common cause of haemoabdomen due to coagulopathy
Warfarin poisoning
64
Stabilisation of patient with a haemoabdomen due to a coagulopathy
Measure perfusion (blood pressure, lactate)
Fluids or transfusion (fresh frozen plasma rich in clotting factors, pRBCs, whole blood last choice, no microaggregates in autotransfusion but must give plasma too)
65
Which haemoabdomen patient should you never operate on?
Coagulopathy
66
How do you diagnose a uroabdomen?
POCUS to identify free fluid
Bubble study US
(Contrast radiograph)
Tap fluid
67
Biochemistry of fluid in uroabdomen
Creatinine >2x blood
Potassium >1.4x blood
(Urea may be similar)
68
Why should you use ECG monitoring in patients with uroabdomen?
Hyperkalaemia = atrial standstill (no P wave, QRS wide and abnormal/escape complex)
69
Test for hyperkalaemia in uroabdomen
Blood gas
(Biochemistry)
70
Treatment of uroabdomen
Drain bladder with urinary catheter (allow bladder to rest and inflammation reduce before surgery/may resolve)
Surgery
Stimulate transport of sodium into cells as potassium will be co-transported, preventing hyperkalaemia: glucose bolus (stimulate insulin production), bicarbonate, beta-2 agonist (Salbutamol), Hartmann's (alkalising)
71
Hernia
Protrusion of an organ/part of an organ through a defect in the wall of the anatomical area in which it normally lies, generally consists of a hernial ring or sac
72
How is a rupture different to a hernia?
No ring or sac
73
Are all hernias reducible?
No, sometimes the ring closes behind the prolapsed tissue
74
Aims of surgical repair of ruptures and hernias
Return hernia content to normal location
Secure closure of neck of sac
Obliterate redundant tissue in the sac
Try to use the patients own tissue for repair
75
How is a hernia surgically reduced?
Incise over site (ensure adequate exposure)
Breakdown adhesions
Check viability of herniated tissues, resect non-viable tissues
76
Defect closure after surgical hernia reduction
Direct opposition
Don't compromise vasculature
Sufficiently strong suture material (polydioxanone, polypropylene)
Monofilament to avoid sinus formation
77
Type of hernia often found in young animals which is usually congenital due to failed embryogenesis
Umbilical
78
Should you breed from an animal that had an umbilical hernia?
No, it is thought to be inherited
79
Which condition can an umbilical hernia be associated with?
Cryptorchid dogs
80
Typical presentation of umbilical hernia
True hernia (lined by peritoneal sac)
Soft, painless swelling at umbilicus
Normally contain fat/omentum, occasionally intestine (V+/D+)
81
What should you check when an animal has an umbilical hernia?
Diaphragm and heart
82
How is an umbilical hernia diagnosed?
Palpation
83
Management of umbilical hernia
May resolve spontaneously or can be corrected at neutering
84
How is an umbilical hernia surgically closed?
Reduce, incise over hernia, excise sac, repair muscle edges
Remove skin that has stretched over site
Bunch ligate fat
Don't debride margins
Close with synthetic, absorbable, monofilament suture (polydioxanone)
85
What hernia develops when surgical closure of a body cavity fails?
Incisional hernia
86
Where does an incisional hernia most commonly occur?
Linea alba
87
How soon after surgery does an incisional hernia occur?
Normally within 7 days, can be chronic
88
Cause of incisional hernia
Incorrect technique
Incorrect suture material/pattern
Entrapped fat between wound edges
Infection
Steroids/cushings
Poor post op care
89
Signs of incisional hernia
Oedema, inflammation and serosanguinous fluid often pre-empt
Soft painless swelling
Palpable defect
Exposed viscera
90
Investigation of incisional hernia
Commonly obvious
Ultrasound, x rays or advanced imaging might be useful
91
Treatment of incisional hernia
Repair ASAP, evisceration is an acute abdominal emergency
Lavage
Resect non-viable tissues, anastomose bowel if necessary
Re-open and repair entire wound
Debride edges if infected/non-viable
Suture external sheath of rectus abdominis (strongest holding layer)
Monofilament suture (long lasting, appropriate size)
92
Why might traumatic abdominal rupture be missed?
Swelling/bruising
93
How is a traumatic abdominal rupture repaired?
Same principles as hernia repair
Lots of lavage and avoid mesh if contaminated
Identify free edge of abdominal wall and reattach to cranial pelvic brim if there is prepubic tendon rupture
94
What might enter subcutaneous space with an inguinal hernia?
Most commonly omentum
Intestine, bladder or uterus
95
Cause of inguinal hernia
Congenital inguinal ring abnormality or trauma
Can be spontaneous
Can be associated with pregnancy/obesity
Probably inherited, consider neutering
96
Signalment for non-traumatic inguinal hernia
Intact female middle aged dogs or male dogs <2y
Small breeds e.g. Cairn/WHWT
97
Is an inguinal hernia usually painful
No unless incarcerated contents
98
Treatment of inguinal hernia
Surgical closure
99
Are scrotal hernias common or rare?
Rare
100
What is the main cause of scrotal hernias?
Castration in small mammals with large inguinal rings and open methods (guinea pigs)
101
Causes of diaphragmatic rupture
RTA
Congenital (hernia)
102
Pathogenesis of diaphragmatic rupture
Abdominal pressure and open glottis
Tear usually in muscular part of diaphragm (weakest)
Radial or circumferential tears
103
Clinical signs of diaphragmatic rupture
Present shortly after trauma, shocked
Pale/cyanotic
Tachypnoeic/dyspnoeic
Tachycardic
Occasional cardiac arrythmias
Hydrothorax
104
Clinical signs of chronic diaphragmatic rupture
Exercise intolerance
Dyspnoea
Vomiting
Weight loss
105
Diagnosis of diaphragmatic hernia
Radiograph (can put water soluble contrast in abdomen)
Ultrasonography (especially chronic)
106
Radiographic findings with diaphragmatic hernia
Loss of diaphragmatic line
Loss of cardiac silhouette
Gas filled structure in thorax
Atelectasis
Displaced abdominal organs
107
Treatment of diaphragmatic hernia
Oxygen/IVFT/warm patient
Prophylactic antibiotics (toxin release from strangulation)
ECG
Surgery (open heart surgery once abdomen opened)
108
Causes of increased mortality in diaphragmatic hernia surgery
Surgery performed <24h following injury
Patient >1y
109
What causes this presentation?
Perineal hernia
109
Signalment for perineal hernia
Normally entire older male dog, occasionally bitch/cat
110
Clinical signs of perineal hernia
Bulging perineal hernia
Faecal tenesmus
Dysuria
111
Causes of perineal hernia
Progressive weakening of pelvic diaphragm
Hormonal influence
Tenesmus
Congenital/acquired weakness
Colitis/prostatomegaly
112
Muscles that provide lateral support to the anus (bilateral disruption = perineal hernia)
Levator ani
Coccygeus
External anal sphincter
(Together referred to as pelvic diaphragm)
113
Diagnosis of a perineal hernia
Reducible perineal swelling
Absence of pelvic diaphragm on rectal
Assess sphincter tone
Ultrasound/contrast urethrography to highlight bladder
114
Why is bladder retroflexion an emergency?
Stranguria
Hyperkalaemia
Azotaemia
Avascular necrosis
115
Treatment of perineal hernia
Cystocentesis through perineum if bladder retroflexed and cannot pass urethral catheter
IVFT (check K+ levels)
Herniorrhaphy (type of muscle repair)
Castrate
116
Complications after perineal hernia surgery
Faecal incontinence (poor suture placement/chronic)
Urinary problems
Infection
Rectal prolapse (if continuing to strain after surgery)
Sciatic nerve entrapment
Recurrence (if not castrated, due to excess testosterone)
117
Hernia that is commonly seen in brachycephalic breeds and shar peis
Hiatal hernia (congenital defect)
118
What is a hiatal hernia?
Abnormal movement of part of the stomach from its normal position in the abdomen into the chest
119
Clinical signs of hiatal hernia
Regurgitation
Hypersalivation
Visceral discomfort
Low BCS
120
Diagnosis of hiatal hernia
Contrast radiography (soft tissue opacity in dorso-caudal thorax adjacent to diaphragm, swallow barium and take radiograph quickly)
Fluroscopy
Endoscopy
121
What radiographic abnormality is this?
Hiatal hernia
122
What is a hiatal hernia clinically similar to?
Oesophagitis
123
Treatment of oesophagitis in hiatal herniation
Antacid
Sucralfate
Prokinetic (peristalsis from cranial to caudal end)
Antibiotics (aspiration pneumonia)
124
Surgical approach to hiatal hernia
Ventral midline coeliotomy
Reduce hernia at oesophageal hiatus and close
Pexy oesophagus to diaphragm
Pexy stomach to body wall
125
Congenital communication between pericardial sac and abdomen
Peritoneopericardial diaphragmatic hernia (PPDH)
126
Clinical signs of peritoneopericardial diaphragmatic hernia
Asymptomatic
GI/respiratory signs (V+/D+, anorexia, weight loss, wheezing, dyspnoea)
127
Aetiology of peritoneopericardial diaphragmatic hernia
Faulty development of septum transversum
Often associated cardiac/sternal deformity
128
Signalment of peritoneopericardial diaphragmatic hernia
Weimaraner/Cocker Spaniel
129
Diagnosis of peritneopericardial diaphragmatic hernia
Radiography +/- contrast (enlarged cardiac silhouette, dorsally displaced trachea, gas opacities in pericardial sac, contrast radiography)
Ultrasound
130
Surgical management of peritoneopericardial diaphragmatic hernia
Ventral midline coeliotomy
Incise sternum if necessary
Reduce viscera
Suture diaphragm (no need to close pericardium)
131
Causes of septic peritonitis
GI perforation
Hematogenous (GI disease)
External penetration
Iatrogenic
Ascending urinary tract infection (prostatitis/prostatic abscess)
132
Causes of aseptic peritonitis
Inflammatory disease in abdomen (hepatitis, nephritis, cholangitis, pancreatitis, splenic abscess)
Abdominal fluid (bile, blood, gastric perforation, urine)
133
When is a gastric perforation not aseptic?
Treatment with omeprazole (neutralisation of stomach acid)
134
Important history considerations for septic peritonitis
Distributive disease
Foreign body (GI perforation)/external penetration
Recent surgery
Urinary issues (reduced volume, increased frequency, stranguria/dysuria, haematuria, pain)
135
Important history considerations with aseptic peritonitis
Localised pain, vomiting and PUPD may indicate acute abdomen/organ inflammation
Bile is very painful in short term (chronic biliary disease e.g. weight loss/inappatence, jaundice = obstruction, no jaundice = traumatic)
Gastric perforation (painful, sudden lack of pain with rupture, then increasing pain as peritonitis is stimulated)
136
Investigation of peritonitis
POCUS (free fluid)
Tap fluid (if not enough fluid then do diagnostic peritoneal lavage with saline)
137
How can you differentiate a septic or aseptic cause of abdominal fluid in peritonitis?
Colour may indicate issue (yellow = neutrophils)
Bacteria respiring using glucose = glucose lower than blood
Bacteria respiring producing lactate = lactate higher than blood
Smear/cytology for intracellular bacteria
138
Medical management of peritonitis
Remove fluid
Fluid therapy
Analgesia
139
When would you opt for surgical management in peritonitis?
Remove the problem (source control)
Surgical closure (GI perforations) or surgical removal (when appropriate)
140
What structure should not be surgically removed even if it is causing peritonitis? What is the alternative?
Pancreas
Place abdominal drain +/- lavage
141
When should antibiotics be administered in peritonitis?
Septic peritonitis (start as soon as possible then switch based on C&S) although technically not needed with good source control
142
Antibiotic choices for treating septic peritonitis
Amoxicillin clavulanate or metranidazole (if GI origin) and marbofloxacin (fluroquinolone)
143
Characteristics of a good contrast media
Not toxic/harmful
Quickly eliminated from body (but slow enough to image)
Coat lining of organ
144
Substances commonly used as contrast media
Barium (+, liquid or on spear, can be mixed with food)
Iodine (+, IV or in bladder, tastes bad, draws liquid into GI tract = diluted)
Air (-)
145
Uses of contrast media
Highlight structures
Differentiate between soft tissue and fluid
Identify blockages/obstruction
Identify perforation/rupture
Assess blood supply (IV contrast)
Transit time
146
Which structure is being outlined by the contrast medium and which contrast material was used?
Renal pelvis
IV (iodine) urethrogram
147
Which structure is being outlined by the contrast medium and which contrast material was used?
Bladder
Air up urinary catheter (pneumocystogram)
148
Which structure is being outlined by the contrast medium and which contrast material was used?
Bladder
Iodine and air (urinary catheter, air first)
149
Which structure is being outlined by the contrast medium and which contrast material was used?
Stomach/SI
Barium impregnated polythene spheres (BIPS)
150
Which structure is being outlined by the contrast medium and which contrast material was used?
Caudal colon/rectum
Barium
Per rectum/enema
151
Functions of endoscopy
Visual examination
Minimally invasive biopsy
Minimally invasive interventions
152
What type of gastropexy is this?
Incisional
