Abdominal pain Flashcards
What is an acute abdominal crisis?
- an animal presented as an emergency, in a more or less severe critical state, and for which medical and possible surgical tx will be necessary
- term often used to describe cases in which some degree of uncertainty remains in regard to the diagnosis
What would be a true emergency?
- probably if either the following:
– hypovolaemic shock (high hr, slow CRT, pale mm)
– septic shock - note- ruminants are stoic animals
Ddx for acute abdominal crisis - GI dz
- Abomasal volvulus
- Abomasal displacement
- Haemorrhagic jejunitis
- Caecal torsion
- Primary/secondary bloat
- Intestinal torsion/intussusception
- Mesenteric torsion
- Peritonitis
Ddx for acute abdominal crisis - non-GI dz
- Uroliths
- Uterine torsion (usually at the end of gestation)
- Pyelonephritis
Signalment and history
- Age
- Sex
- Breed
- Stage of production
- Nutrition
- Management system
- Stage in reproductive cycle
- Previous surgery
- Previous treatments
Clinical examination - CV status
- Heart rate
– Increased - Mucous membrane
– tacky - Capillary refill time
– Prolonged - Dehydration (skin tent)
– prolonged
– skin tent above the eye
– sunken eyes can also tell us about hydration
Clinical exam - abdominal silhouette
- Rear and side
– Abdominal distension - Back position
– flat or arched (cranioabdominal pain or just generalised abdominal pain)
Clinical exam - abdominal exam
- Auscultation
– Rumen contractility
-> Reduced - Percussion
– “pings” = DA
– paralumbar fossa
– can be anywhere from the olecranon to the paralumbar fossa
-> Abnormal - Succussion (ballottement)
– “splashing”
Clinical exam - signs of pain
- Bruxism (grinding teeth)
- Abducted elbows
- Reluctance to dip on withers pinch
– Cranial abdominal pain - Head press, frowned/worried expression
Clinical exam - rectal palpation
- Viscera
– Normal
– Distended
– Turgid - Help rule out none GI?
- Normal RDAs wouldn’t feel on rectal unless really distended
Clinical exam - faeces
- Faecal output
– Reduced - Appearance
– Frank blood
– Melena
– Fibrin and mucus
Rectal sweep - should have room to move when rectal - if tight and not able to move a lot it can mean straining or the rectal wall doesnt want to move due to fibrin attachment on the other side -> peritonitis (e.g. due to calving issues, poorly done c-sections)
Ancillary Diagnostic Tests
Abdominocentesis & peritoneal fluid analysis
- Colour
- Volume
- Turbidity
- Odour (if it smell really bad it’s really bad news)
- Protein content (on refractometer)
Peritoneal tap - need to avoid the rumen so don’t do on the left side.
Hand back from the diploid on the midline to the mammary vein = good area to go in
Imaging- Ultrasonography
- 7.5MHz transrectal probe has its uses
Ultrasonography
- good for scanning reticulum and rumen, esp for tyrewire dz
- don’t need to clip or coupling gel, just lots of surgical spirit
- Reticular contractions
– Located left of midline, caudal to xiphoid
– U shaped structure
– Only wall visible (gas mixed into ingesta in lumen)
– Cranial sac of rumen caudal to reticulum
– Reticulum = biphasic contractions
-> Second moves reticulum dorsally - Also good for adhesions, abscess, fluid accumulation etc
Peritonitis aetiology
- Primary (uncommon): associated with systemic infection
- Secondary (much more common): after abdominal surgery
Peritonitis clinical presentation
- Acute: abdominal discomfort, pyrexia +/- toxaemia (check mm), altered faecal output, look awful
- Chronic: non-specific clinical signs, can be waxing and Maning (around stressors commonly), can just look a bit off
Diffuse peritonitis
- Urethral obstruction (-> bladder rupture -> peritonitis)
- Acute acidosis/rumenitits
- Toxic mastitis
- Postpartum metritis
- Perforated abomasal ulcer
- inflammation and infectious everywhere
- any local cause can easily become diffuse if they spread
Local peritonitis
- LDA/RDA
- Caecal torsion
- TRP
- Uterine torsion/rupture, dystocia, caesarean, vaginal tear
- Intestinal obstruction, volvulus, strangulation, intussusception, perforation
- Splenic/hepatic/umbilical abscess
– Umbilical abscess in calves top of ddx - Fat necrosis (older, fat animals)
Pathophysiology of acute peritonitis
- adhesions (1w-10d in, fibrin + collagen -> to control the infection/keep the infection in)
- toxaemia
- shock and haemorrhage
- pain/tucked up appearance
- paralytic ileus
- exudate (lots of WBCs, neutrophils, day 5 deposit of fibrin)
Diagnosis of acute peritonitis
Withers test: may be reluctant to dip and may produce audible grunt (indicating abdominal pain). ~30% sensitive
Eric Williams test: A quiet grunt may be heard just before the ruminal A wave contraction, due to the pain from the biphasic reticular contraction
Rectal palpation: adhesions may elicit discomfort or a pain response and may be palpated within the abdominal cavity per rectum (particularly in chronic peritonitis)
Clinical pathology: leukopenia and degenerative left shift (increase in immature neutrophils), increased levels of plasma fibrinogens and low plasma proteins to fibrinogen ratio
Abdominocentesis: increased turbidity, increased leukocyte count, increased total protein levels (>3g/dl) +/- bacteria (can be difficult)
Exploratory laparotomy:may allow for identification of the cause of peritonitis and possible correction of the condition is possible.
Gluto-aldehyde test:
Binds to fibrinogen if in blood and will form a blot. if clots within 3 mins it’s a fairly accurate indicator there’s fibrinogen. decent cow side test. for more chronic cases
Treatment of peritonitis
Immediate and conservative:
- Fluid therapy (IV fluids, hypertonic 3-5L, then pump orally)
- NSAIDs (ideally into the vein)
- Antimicrobials (B lactam or tetracycline, Long course (going to be off licence, duration: 2w+)) (procaine penicillin, amoxicillin, oxytet (given IV depending on product))
Surgical:
Debridement, lavage and drainage (don’t have suction in the field so debridement, lavage, draining difficult)
Cows wall off infections well
Localised peritonitis - flushing would spread it and make it diffuse so leave it
Prognosis
Dependent on cause, tx, type, so guarded
Caecal Torsion signalment
- usually early lactation dairy cows
Caecal Torsion aetiology
- poorly understood (increased VFA in intestines -> atony?)
(concentrate heavy diet increases VFAs)
Caecal Torsion presentation
- caecal atony may cause dilatation
- if free end kinds over dilatation -> torsion
Drain fluid into bucket as it’s a prognostic indicator -> >30L poorer prognosis
Caecal torsion tx
- Right flank laparotomy, externalise and empty caecum using purse string suture, reposition
- Oral fluids
- Calcium borogluconate (helps contractions of the mucosal wall, give into the vein)
- NSAIDs (2 days, i.e. ketoprofen), antibiotics (3 days, Procaine benzylpenicillin)
- Fibre to reduce VFAs in diet
