dogs and cats 13 Flashcards

Question 1

Q

diffusion barriers (sucralfate) when used, what are they, effect, indications and administration

Answer

A

chronic vomiting
- Sulphated sucrose and polyaluminium hydroxide
- In acidic environment cross polymerises to form viscous gel
○ Binds to necrotic tissue like a liquid band-aid
○ Also stimulates prostaglandin production, absorption bile salts and inactivation gastric pepsins
○ Stimulates mucosal defences
- Indications
○ Treatment of gastric ulceration (doesn’t prevent) and reflux oesophagitis
- Administration
○ Apart from food and other drugs (30 minutes except for digoxin, tetracyclines, fluroquinolones, its 2 hours)

Question 2

Q

histamine H2 receptors anatagnoists when used, action, indications, examples and how often need to give

Answer

A

Action
○ Competitively inhibits gastric acid secretion by 70-90% (by binding H2 receptors site on parietal cell)
Indications
○ Treatment of gastric ulceration due to NSAID, uraemia and other causes
○ Does not prevent NSAID-ulceration
Examples and how often need to give
○ Cimetidine (tagamet) q 6-8 hours
○ Ranitidine (zantac) q 12 hours
○ Famotidine (pepcid) q 24 hour
○ Nizatidine (tazac)
Reduce dose by 50% if impaired renal function

Question 3

Q

proton pump inhibitor action, 2 main examples, when used and indications

Answer

A

Inhibits gastric acid secretion by irreversibly binding proton-transporting enzyme at luminal surface of parietal cell
Complete inhibition of gastric acid secretion
○ More effective than H2 antagonists
example
1) omeprazole - mast cell tumours
2) pantoprazole - suspected or confirm gastric ulceration
Indications -> ONLY WHEN STRONGLY SUSPECTED GI ULCERATION

Question 4

Q

prostalgandin E1 analogues main example, effect, wen used and efficacy

Answer

A

○ Misoprostol (cytotect)
○ Synthetic replcaement for PGE1 and therefore promotes gastric mucosal defence mechanisms
○ Used for prophylaxis against NSAID gastric mucosal injury (not effective as treatment)
○ Efficacy not proven in small animals

Question 5

Q

gastric acid suppression drugs for chronic vomiting what two drugs don’t need to give together and when should use

Answer

A

No need to give proton pump inhibitors AND histamine H2 receptor antagonists
So when should we use these drugs?
- WHEN HAVE - documented/strongly suspected GI ulceration
- NOT just cause vomiting and inappetant and primary have diarrhoea
○ Pancreatitis, cirrhosis, chronic kidney disease, gastritis, NSAID prophylaxis (only effective when 2 x dose and leads to side effects)
○ UNLESS-> these lead to GI ulceration

Question 6

Q

What are the 6 main GI causes of chronic vomiting and list the 3 main common first

Answer

A

Inflammatory bowel disease/chronic enteropathy (diarrhoea (dogs), Vomiting (cats))
Dietary intolerance/sensitivity
Intestinal lymphoma (cats&raquo_space;dogs)
Chronic pancreatitis
Structural (pyloric stenosis)
Other neoplasia

Question 7

Q

What are the 6 main non-GI differential diagnosis of chronic vomiting

Answer

A

Hyperthyroidism (cats)
1. Renal failure
2. Liver disease
3. Heart disease
4. Hypercalcaemia
5. Hypoadrenocorticism

Question 8

Q

Haematemesis what is it, is it significant and common cause

Answer

A

Digested blood = coffee grounds
○ Significant gastric ulceration or bleeding -> not always have melena (can be delayed)
Often concurrent melena but can be delayed
Significant haematemesis, especially if weight loss is also present, should ALWAYS be investigated
ulcerated disease

Question 9

Q

what are the GI phyiological protections against ulceration

Answer

A

○ Gastric mucus and bicarbonate to form gel layer
○ High epithelial cell turnover (high energy requirements)
○ Tight junctions and lipoprotein layer of cells
○ Rich vascular supply
○ Protective prostaglandins (PEG and PGI2)

Question 10

Q

gastric ulceration what caused by and main consequences/clinical signs

Answer

A

Caused by anything that disrupts mucosal barrier or causes excessive acid secretion
Signs of melena, haematemesis, weight loss, pain and other associated disease
Consequences of GI ulceration
Hypoproteinaemia
Anaemia
Electrolyte loss
Metabolic alkalosis
Pain -> due to reflux, oesophagitis, regurgitation
Anorexia
Decreased gastric motility -> GO reflux -> oesophagitis -> regurgitation

Question 11

Q

gastric ulceration what are the main causes

Answer

A

Primary GI disease
- gastritis, neoplasia (gastric carcinoma) - common in dogs, outflow obstruction
drugs - common - NSAIDS, corticosteroids
Systemic disease - liver disease, DIC, pancreatits (not as commo), hypoadrenocorticisim
gastric hyperacidity - gastrinomas, mast cell tumours

Question 12

Q

if suspect gastric ulceration for chronic vomiting what is the main approach

Answer

A

Rule out drugs
Rule out systemic disease
Rule out inflammatory intestinal disease
Rule out neoplastic disease (abdomen and elsewhere)
○ Any nodule find need to aspirate (mast cell tumour)

Question 13

Q

what inital tests to run in a chronic vomiting investigation

Answer

A

Haematology
Serum biochemistry and electrolytes
Urine analysis
T4 in cats
Survey abdominal radiographs (thorax if regurgitation)
○ Ultrasound instead for cats as wanting to rule out lymphoma

Question 14

Q

what is the main reasons cats vomiting and why is diagnosis more difficult in cats

Answer

A

Why would cats vomit?
- Common with concurrent disease due to anatomy
○ Intestine, pancreas and biliary tree are very close leading to disease in one resulting in disease in others
Why is diagnosis more difficult in cats?
- All chronic inflammation in gut will lead to lymphocytic-plasmacytic inflammation
○ Difficult to differentiate inflammation from small cell lymphoma
- Often chronic history
- Diarrhoea not always observed
- Pruritis may be manifested as vomiting of hair balls
○ Owner may think that is normal however for some cats if just start vomiting hairballs when normally don’t then abnormal
- Only severe disease will cause weight loss

Question 15

Q

What are the 6 main differentials for chronic vomiting in cats

Answer

A

Metabolic disease - thyroid and kidney - rule out first
Dietary sensitivity/food intolerance/dietary responsive enteropathy
Antibiotic responsive enteropathy
Inflammatory bowel disease (steroid responsive enteropathy)
Intestinal lymphoma
Chronic pancreatitis

Question 16

Q

dietary sensitivity in cats types, other signs related how test and what generally occurs

Answer

A

True sensitivity is Type I mediated
Usually concurrent pruritis, young cats
Protein most antigenic
GI signs resolve within 1-2 weeks and should recur with rechallenge
HOWEVER only about 50% of dogs signs recur with rechallenge suggesting other reason for improvement on diet
○ Fibre may alter intestinal microflora -> soluble fibre also increases faecal water contents
○ Insoluble fibre increases faecal dry matter and highly fermentable fibre may increase methane production and worsen motility
○ High fat diets or poorly digestible starches may prolong gastric emptying and cause vomiting

Question 17

Q

inflammatory bowel disease in cats definition and the 3 types - EXAM

Answer

A

Definition
○ Chronic (>3 weeks) clinical signs with inflammation within the GI tract and no identifiable cause
○ Usually lymphocytic-plasmacytic
○ Loss of tolerance to antigens
Due to confusing nomenclature, now classified as:
○ Food responsive (not food allergy)
○ Antibiotic responsive (not speicific infection)
○ Immunosuppressive responsive (only true IBD)

Question 18

Q

Feline lymphoma what generally presents as, what are the 2 types, which good and which bad

Answer

A

present as chronic vomiting

a. Small cell lymphocytic -> one found in the gut, lymphocytes look normal
b. Large cell (lymphoblastic) -> large granular cells - BAD

Question 19

Q

Small cell lymphocytic lymphoma in cats general presentation, type of cell, diagnosis, predilection site

Answer

A

§ Well, older cat with chronic vomiting
§ Usually T lymphocytes extending up from bottom to top villus
§ Cells small, with minimal features of malignancy
§ Immunohistochemistry and PCR clonality testing to help distinguish from IBD
§ Predilection site: distal ileum

Question 20

Q

small cell lymphocytic lymphoma diagnostic difficulties and potential causes

Answer

A

§ Diagnostic difficulties
□ Not always changes on ultrasound and if so not pathognomonic (inflammation or neoplasia)
□ Where to biopsy and how
□ How to interpret the biopsy -> PARR testing useful
§ Potential causes
□ Genetic predisposition
□ Any chronic inflammation -> IBD, helicobacter
□ Cigarette smoke exposure
□ FIV

Question 21

Q

Large cell (lymphoblastic) lymphoma what cells, age, results in/character and prognosis

Answer

A

§ B and T lymphocytes, no effect on prognosis
§ Cats of any age
§ Rapidly progress, and form transmural masses and spreads to lymph nodes
□ Cats are sicker than with small lymphoma, signs of intestinal obstruction
§ Large granular lymphocytes highly malignant and metastasise to other sites
§ Poorer prognosis

Question 22

Q

Crhonic pancreatitis in cats, what generally reported with, clinical signs and diagnosis

Answer

A

Up to 100% reported with concurrent disease
○ Hepatomegaly, thickening intestines
Cause or consequence
Even more vague clinical signs
○ Anorexia, lethargy, vomiting, diarrhoea, weight loss, jaundice
Diagnosis
○ Little to no change bloods (no change lipase and amylase, TLI and PLI not helpful)
○ No real sensitivity in ultrasound
○ Pancreatic biopsy -> only way

Question 23

Q

What are the 5 main clinical priorities when presented with well but vomiting cat

Answer

A

Examine to ensure no physical abnormalities
Obtain full dietary history
Rule out metabolic disease if indicated
○ Hyperthyroidism
○ Renal disease
○ Cholangiohepatitis/cholescystitis
○ Pancreatitis
Treatment trial (work from top down)
- diet
- antibiotics
- immune suppressive
diagnosic investigation if treatment trial don’t work

Question 24

Q

treatment diet trail for well but vomiting cat which diet, when should see response and 3 possible outcomes and what to do

Answer

A

§ Which diet
□ Hydrolyzed or novel protein source
□ High soluble fibre content
□ Restrict access to other food
§ Should see response in 1-2 weeks
□ If do, continue diet for 6 months if completely balanced, and then can try other or previous diets
® Approx 50% won’t relapse
□ If partial response
® Can try alternative hydrolyzed or hypoallergenic diet -> may be variable individual response
□ If no/minimal response to diet
® Is cat still well, no loss in weight or dropping albumin
® Is there an increase in liver enzymes (cholangiohepatitis, but ruled out hyperthyroidism)
® OPTIONS -> Antibiotics, alternative diet or diagnostic pathway (if owner wants to know what is going on)

Question 25

Q

Treatment trail antibiotics for a well but vomiting cat which use, when respond and what if don’t

Answer

A

§ Amoxicillin 20 mg/kg bid for up to 6 weeks
§ Metronidazole 10mg/kg bid for maximum 3 weeks
§ Again should respond within 1-2 weeks and after 3-4 week course may only need dietary management
§ IF STILL NO RESPONSE TO DIET - need to ‘support’ the cat and happy with diagnosis move onto BELOW

Question 26

Q

Treatment trail with immune suppressive for well but vomiting cat what is the main thing to use, why and options for administration

Answer

A

§ Nutrition, micronutrient and fluids
§ Cobalamin
□ Supplementation improves clinical signs in cats with GI disease
□ This is regardless which diagnosis and treatments
□ Options
® Treat and measure response or
® Treat empirically (250ug injection once weekly for 4-6 weeks)

Question 27

Q

Diagnostic investigation if treatment trail don’t work or want to find out exactly what is happening on a well but vomiting cat what are the 3 main options, what good and bad about each

Answer

A

Ultrasound
○ May be normal or show loss of layering with IBD, small cell lymphoma
○ May show masses, lymphadenopathy, focal intestinal thickening or effusion and can get samples
Endoscopy
○ Limitation access to biopsy - good quality biopsy takes experience and training
○ Gastric good
○ Overlap with IBD in intestine
○ Tricky to get ILEUM -> access from the colon
Exploratory laparotomy
§ Increased morbidity
§ Increase yield
§ Can assess disease outside of intestine
§ Can biopsy ileum easily

Question 28

Q

what are the 4 main options for treatment of IBD

Answer

A

1) prednisolone
2) other corticoteroids - not as effective - dexamethasone, budesonide
3) other immunosuppressives - chlorambucil
4) other therapies - not properly evaluted - mega-3 fatty acids, probiotics - don’t use

Question 29

Q

treatment for IBD prednisolone, when taper, what use with and side effects

Answer

A

○ Start to taper every 3-4 weeks until reach minimum effective dose
○ Continue diet and continue antibiotics for first 2 weeks of prednisolone
○ Side effects
§ PU/PD and alopecia (minimal)
§ Development of diabetes is a risk

Question 30

Q

treatment for IBD otehr corticosteroids what are the 2 main ones when give and main issue

Answer

A

not as effective as above
○ Dexamethasone
§ Only if cannot give oral medication and not eating well enough to place in food
§ 1/6th to 1/8th the oral pred dosage q 36-48
§ Profound immune suppression
○ Budesonide
§ Not evaluated in cats

Question 31

Q

Other immunosuppressives for treatment of IBD when use, what are the 2 options and which is better and why

Answer

A

○ Only if histologic diagnosis 
1. Chlorambucil 
§ Current choice as add on 
§ Generally well tolerated 
2. Ciclosporin 
§ Be careful with latent toxoplasmosis 
§ Not evaluated in feline IBD

Question 32

Q

treatment for IBD other therapies what are the 2 main options, when use or not

Answer

A

not properly evaluated
1) Omega-3 fatty acids
§ May interfere with palatability of diets, and cause diarrhoea
2) Probiotics - waste - DON’T USE
§ Lack of translational benefits in people
§ Well tolerated in cats
§ Recent abstracts suggests not effective in feline IBD

Question 33

Q

small cell lymphoma in cats, prognosis in terms of response to therapy and median remission

Answer

A

This is a ‘good’ tumour
Response to therapy 75-90%
Majority of cats alive and in remission at 2 years
○ Median remission 897 days

Question 34

Q

treatment of small cell lymphoma

Answer

A

Still support (cobalamin)
Still antibiotics and diet
Initial therapy
○ Prednisolone 3mg/kg once daily, reducing to 1-2mg/kg once daily when have clinical remission
○ Chlorambucil 2mg q 48 hours, 15mg/m^2 q 24 x 4 q 3 weeks, 20mg/m^2 q 2 weeks
same as IBD

Question 35

Q

If treat IBD and small cell lymphoma the same do we need to differentiate?

Answer

A

DIFFERENTIATE VIA -> Immunohistochemistry and PAR sample

- Important due to prognosis -> IBD better prognosis than small cell lymphoma

Question 36

Q

what is a common concurrent disease to IBD in cats and treatment

Answer

A

Cholangiohepatitis/cholecystitis - most common
○ Antibiotics
○ Vitamin K if severe

Question 37

Q

large cell lymphoma prognosis in terms of remission, median time, when good

Answer

A

Complete remission in 50-75%
Overal median remission 4-8 months, overall MST 6-8 months
Have longer survival if initial good response
Often unwell, so need nutritional support
Recent study shows bacteraemia in cats with LC lymphoma

Question 38

Q

large cell lymphoma in cats treatment basics and main options

Answer

A

Treatment basics 
- Cobalamin 
- Antibiotics 
- Nutritional support 
Treatment options 
- Palliative prednisolone 
- Palliative surgery 
- Multi-agent chemotherapy 
- Radiation therapy

Question 39

Q

patient preparation for GIT surgery what are the 4 main considerations

Answer

A

1) Common disturbances:
○ Dehydration
○ Electrolyte imbalances:
§ Hypochloraemia, Hyponatraemi, Hypokalaemia
○ Acid-base disturbances:
2) Treatment/correction of these pre-op problems important to:
○ Optimise outcomes
○ Prevent complications
3) Fasting for elective procedures can minimise risk of spillage but decreases gastric fluid pH
4) If gastro-oesophageal reflux anticipated –consider H2 antagonist or proton pump inhibitor
○ Rapid induction and airway control if vomiting reflux likely (prevent aspiration)

Question 40

Q

what are the 5 regions of the stomach and why important in surgery

Answer

A

Cardia - terminal part of oesophagus, gastro-oesophageal sphincter
Fundus - can be affected during GDV
Body - largest part
Pyloric Antrum - funnelling down into smaller cylinder -> WHERE DO GASTROPEXY
Pylorus - outflow of stomach, muscular sphincter into proximal duodenum

Question 41

Q

what are the 7 main branches off the aorta

Answer

A

Hepatic branch
1. Splenic artery
2. Celiac artery
3. Cranial mesenteric artery - supplies all intestines
4. Renal artery
5. Testicular/ovarian
Caudal mesenteric - colon

Question 42

Q

drainiange of the GI tract, where go, why important in PSS

Answer

A

DRAINIAGE -> all to the portal vein -> liver -> recirculation of bile salts
- Important with porto-systemic shunts -> portal vein and caudal vena abnormal communication -> bile salts and other facts bypass liver -> hepatic encephalopathy

Question 43

Q

what are halsteads principles for surgery

Answer

A

Gentle tissue handling
Accurate apposition of tissue layers
Preservation of vascular supply
Accurate haemostasis
Prevention of contamination
Recognition and appropriate treatment of contamination

Question 44

Q

surgical appraoch to GI surgery what is needed, incision, equipment and approach

Answer

A

Adequate visualisation of the entire abdomen is important:
Ventral midline coeliotomy:
○ Xiphoid to pubis
○ Balfour Abdominal Retractors - self-retaining -> hold abdominal wall apart
○ Laparotomy Sponges
○ Suction - poole suction tip -> prevent contamination of GI content
Examine the ENTIRE gastro-intestinal tract:
○ Systematic -> cranial left first
○ Visual & Tactile –pulses, peristalsis, colour
Don’t miss the second lesion

Question 45

Q

Antibiotic use in GIT surgery what used for what, is it continued post op

Answer

A

§ Agents present in tissues at time of incision (30 mins)
§ Selected for efficacy vs expected organisms
§ 1st generation Cephalosporins OK for gastric and small intestinal procedures
§ 2nd generation for colonic procedures (also mixed infections generally)
§ Not continued > 24 hrs post-operatively unless break in asepsis

Question 46

Q

what is the bacterial load within stomach, small and large intestine therefore what antibiotics to use

Answer

A

§ Stomach 102/ gram - FIRST GENERATION
§ Small Intestine 104 / gram - FIRST GENERATION
§ Large Intestine 1010 / gram –also ^ No’s Anaerobes - SECOND GENERATION

Question 47

Q

Spillage of GI contents within GI surgery what results in and 4 main ways to reduce contamination

Answer

A

○ Clean contaminated -> contaminated - DUE TO BREAK IN ASEPSIS
§ Without appropriate treatment -> peritonitis, death -> broad-spectrum antibiotics
- Techniques to reduce gross contamination / spillage:
a. Orogastric intubation -> help with feeding after surgery - PLACE PRE SURGERY
b. Isolation –moistened laparotomy sponges
c. Stay sutures –large full thickness bites
d. Suction

Question 48

Q

What are the 4 steps that need to perform once gross contmaination of GI surgery has occurred

Answer

A

Prophylactic antibiotic therapy becomes therapeutic antibiotic therapy
Therapeutic therapy initiated with empirically selected agents based on expected organisms BUT MODIFIED based on microbial CULTURE & SENSITIVITY from sample taken AFTER LAVAGE
Debridement of gross materials/contaminants
Lavage 200-300ml/kg (Seim1995)
○ Reduction in bacterial load
○ Removal of adjuvant materials
○ Removal of inflammatory mediators

Question 49

Q

peritoneal lavage when done, when change gloves and equipment, what use at what temp

Answer

A

Perform routinely prior to abdominal closure if hollow viscus entered
Change gloves prior to lavage
Use separate instruments to close post-lavage
Lavage fluids 37-39 degrees C:
○ Cooler fluid exacerbate hypothermia
○ Warmer fluids result in vasodilation →hypotension and increases adhesions
○ isotonic
All natural fluid and irrigation fluid is removed following lavage:
○ Residual fluid reduces immune clearance of debris and micro-organisms and is an adjuvant for peritonitis
○ Poole Suction tip

Question 50

Q

Gastrotomy/gastrectomy what are the main indications and where cut stomach and why

Answer

A

- Indications:
○ Removal of Gastric Foreign bodies
○ Removal of neoplastic lesions
○ Removal of severe focal mucosal erosive lesions
○ Removal of necrotic stomach wall (GDV can occur) 
○ Obtain Biopsy samples
- Ventral Stomach Wall:
○ Relatively avascular area
○ Long axis vs short axis
○ Position influenced by indication

Question 51

Q

Suture material and patterns used in stomach

Answer

A

Synthetic monofilament absorbable materials are preferred: - swayed on
○ Reduced tissue trauma from tissue drag
○ Reduced wicking
Taper point needle–smaller holes vs cutting
2-layer simple continuous appositional closure:
○ Mucosa/Submucosa - higher collagen content -> appositional simple continuous or interrupted
○ Serosa/muscularis

Question 52

Q

what are the 3 main indications of using stapling in stomach, how works, advantages and 2 types

Answer

A

- Indications:
○ Gastrotomyclosure (rare)
○ Gastrectomy(reduces spillage)
○ Anastamosis
- Deploy 2 or more rows of titanium staples:
○ Rows of staples may be of same or different sizes
○ +/-integrated knife for tissue division
- Advantages:
○ Rapid
○ Consistent spacing and closure
- Types 
1. Linear Staplers
2. circular staplers

Question 53

Q

What is the most important post-operative consideration with gastrotomy, what decreases this and therefore results in

Answer

A

Want to get them eating as soon as possible
Gastro-intestinal motility can be reduced by:
○ Handling
○ Desiccation
○ Incision –Disturbs myoelectricalconduction from pacemaker
○ Opioids AVOID
○ Pain
○ Recumbency/lack or early ambulation
○ Lack of enteral nutrition
Poor motility results in:
○ Pain
○ Anorexia
○ Vomiting
○ Gastric distension

Question 54

Q

What are the 4 main post-operative therapies for gastrotomy

Answer

A

Analgesia
IVFT to:
○ Replace ongoing loss
○ Supply Maintenance
○ Maintain perfusion
Prokinetic Therapy:
○ Cisapride, Ranitidine, Metoclopramide, Erythromycin
Enteral (into staomch) or parenteral (into bloodstream (bypass stomach)) nutrition

Question 55

Q

What are 4 main indications for immediate enteral or parenteral nutrition

Answer

A

○ Patients without adequate nutrition for 3 or more days
○ Evidence of more than 10% weight loss
○ Inadequate mm mass
○ Serum albumin < 2.5 g/dLin cats / <2.1 g/dLin dogs

Question 56

Q

Enterotomy what is it, indications and technique

Answer

A

opening of the small intestines
- Indications: - determined via clinical signs, history, imaging
○ Foreign body removal
○ Access to the major duodenal papilla for common bile duct cannulation
○ Tissue biopsy
- Technique
1. Isolation of affected segment:
§ Moistened laparotomy sponges
§ Milk chyme away from incision
§ Assistant finger clamps or Doyen intestinal forceps
2. Anti-mesenteric incision through UNAFFECTED intestinal wall
3. Suction to remove luminal fluid

Question 57

Q

Enterotomy closure pattern, what include, bites and size, what also used to closure commmonly

Answer

A

Closure
○ Single layer appositional (simple continuous, simple interrupted, staples) -> start above the incision site
○ Submucosa provides suture holding strength
○ Everted mucosa may be trimmed if required
○ Sutures must engage submucosa–full thickness passage easiest.
○ 3mm bites –Full thickness -3mm apart
○ 3/0 for larger dog, 4/0 for cat or smaller dog
Omentalisation:
○ Perform routinely
○ Vascular supply, seals leaks

Question 58

Q

intestinal biopsy what needed, 2 techniques and complications

Answer

A

Full thickness samples for histopathology:
○ (if endoscopic bxfails or location unsuitable)
○ Multiple sites (Gastric, duodenum, jejunum, LN)
○ Colon generally not sampled routinely due to increased risk of more significant complications
Techniques:
○ Suture Lift Wedge
○ Dermal punch biopsy - full thickness of the wall
Not benign procedure –12% incidence of peritonitis and death (Shales 2005)
○ Attention to technique important

Question 59

Q

Enterectomy what is it and 4 main indications

Answer

A

intestinal resection and anastomosis 
- Indications:
○ Severely damaged intestine
○ Damage to segmental vascular supply
○ Intestinal neoplasia
○ Segmental incarceration/strangulation

Question 60

Q

enterectomy what is the 6 steps within

Answer

A

Isolate segment and identify good mesenteric vessels
Milk chyme from site
Doyen intestinal forceps
Ligate vasculature
Excise tissue –ensure sufficient tissue extends from Doyen forceps to increase ease of closure
closure - Suture onto mesenteric side, knot OUTSIDE OF LUMEN, second suture on antimesenteric side (simple interrupted)

Question 61

Q

What are the 3 main closure techniques for enterectomy

Answer

A

1) end to end - most common
2) side to side - functional end to end
3) mucosal eversion

Question 62

Q

end to end closure in enterectomy what is involved

Answer

A

□ Most commonly performed technique
□ Appositional patterns recommended:
® Inverting patterns narrow lumen
® Everting patterns increase adhesions
® Apposition -> Primary healing & rapid bridging of the mucosal defect
® Single layer appositional closure:
◊ Simple continuous –separate each side i.e.180 degrees then180 degrees
-> avoids purse-string effect
◊ Simple interrupted
} Correct tension produces apposition without crushing tissues.

Question 63

Q

Side to side clousyre in enterectomy what equipment needed and how occurs

Answer

A

□ GIA staplers x2 or 1
□ Antimesenteric border -> puts row of staples down combining the two ends, cut in the middle of the 2 suture rows to create an opening between the two side, then staple up the top off and cut (creating pants)

Question 64

Q

what are the 3 ways to manage luminal disparity within enterectomy

Answer

A

§ Vary spacing of sutures - mild sparsity only
§ Transect smaller segment a an angle (sort side is anti-mesenteric to preserve blood supply)
§ Spatulation of smaller segments -> linear incision along antimesenteric border to increase lumen diameter

Answer 65

A

stitch intestines together
- Indications:
○ Prevention of recurrence of intussusception (Oakes 1994)
○ Performed over small intestine from jejunum to ileum:
§ Recurrence at site distant from original site
§ Avoid kinking and sharp bends
§ Sutures must penetrate submucosa
- Controversial
○ Rate of complications > rate of recurrence (Applewhite2001)
○ High experimental morbidity in cats (Nash 1998)

Answer 66

A

1) gastro-oesophageal reflux
2) septic peritonitis
3) adhesions
4) short bowel syndrome
5) ileus

Answer 67

A

○ May be silent
○ Reported in 57% of orthopaedic cases (Wilson 2006)
○ Likely higher in GIT surgical cases -manipulation
○ Results in oesophagitis and if severe potentially stricture
○ Shorter periods of fasting may increase gastric fluid pH

Answer 68

A

○ When occurring in the post-operative setting –most commonly assoc with enterotomyor anastamotic dehiscence
○ 7-16% incidence (Hosgood1988, Allen 1992, Ralphs 2003)
○ 12% incidence after full thickness biopsy (Shales 2005)
○ Risk Greatest in debridement phase 3-5 days post-op
§ Risk Factors:
□ Pre-operative peritonitis
□ Presence of a Foreign body
□ Hypoalbuminaemia
□ Delayed enteral Feeding

Answer 69

A

○ Less common in dogs/cats than in humans and horses due to active fibrinolysis
○ Contributing factors:
§ Ischaemi- Haemorrhage
§ Foreign Bodies
§ Infection
○ May result in obstruction

Answer 70

A

○ Malabsorption from lack functional length of small intestine:
§ Reduced surface area
§ Gastric and intestinal hyper-secretion
§ Bacterial Overgrowth
§ Decreased transit time
○ Risk if > 50% length resected
○ Proximal resection better tolerated vs distal
○ Results in persistent diarrhoea, steatorrhea, weight loss, electrolyte disturbances

Answer 71

A

○ Appropriate treatment and time -> adaptation:
§ Increase in villus length and crypt depth (over 3 mths)
§ Fluid and electrolyte therapy
§ Early enteral nutrition:
□ Fibre is a key component:
® Stimulates adaptation, modulates motility, ^ water absorption, Binds bile salts -> reduces secretory diarrhoea
□ Glutamine –preferred energy source for enterocytes
§ If unsuccessful –loperamide/ antimicrobials
○ Prognosis –variable (length resection, presence ICV)

Answer 72

A

○ Common after GIT surgery -> Careful handling
○ High sympathetic tone
○ Clinical Signs:
§ Pain, Vomiting, Regurgitation, Abdominal Distention (NB similar to peritonitis)
○ Treatment/prevention
1. Correct underlying causes:
□ Sepsis
□ Electrolyte disturbance
□ Uraemia
□ Pain
2. Prokinetics
□ Metoclopramide, Ranitidine, Cisapride
3. Early Enteral Nutrition

Answer 73

A

1) peritoneal defecnce mechanisms compromised
2) intense inflammation reaction
3) pro-inflammatory mediations -> PG’s -> increase vascular permeability
4) third space of fluid, albumin, clotting factors
5) protein loss -> coagulopathy
6) systemic inflammation and microthrombi - SIRS
7) fluid loss and vasodilation -> decrease CO
8) reduced perfusion - anaerobic metabolism
9) acidosis secondary
10) catecholamine and cortisol response -> increase O2 demand
11) poor perfusion, disruption mucosal barriers -> bacterial translocation
12) endothelial damage and circulatory stasis promoter hypercoagulable state

Answer 74

A

○ Poor perfusion of organs
○ Poor renal perfusion inhibits renal buffering mechanisms
○ Reflex rigidity inhibits ventilation

Answer 75

A

○ Gastric mucin –anti-complement effect
○ Bile salts –lower surface tension and lyse RBC’s releasing Hb
○ Haemoglobin –Hb interferes with phagocytic cell chemotaxis and phagocytosis and provided Fe for bacterial metabolism
○ Barium

Answer 76

A

○ Primary Peritonitis:
§ Peritonitis without identified cause
§ FIP, monobacterial infections (Culp 2009)
○ Secondary:
§ Most common –leakage of intraluminal content from GIT or urogenital tracts.
§ Polymicrobial
§ Mortality rates up to 85% (Ralphs 2003)
○ Aseptic/Sterile Peritonitis:
§ Inflammation without infection (pancreatitis, desiccation, surgical biomaterials, gossypiboma (retained surgical sponge), Chemical –urine and non-septic bile)

Answer 77

A

a. Identify and correct cause
b. Reduction bacterial load
c. Removal of gross contaminants and inflammatory mediators
d. Prevention of recurrence
e. Provide route for enteral nutrition

Answer 78

A

GIT perforation/leakage most common cause (47-63%)
Previous abdominal surgery is a significant cause of Septic peritonitis (46% cases had surgery in 2 weeks prior to presentation)
Risk factors for peritonitis after surgery:
○ Pre-operative Peritonitis
○ Hypoalbuminaemia
○ Intestinal FB
Leakage rates from full thickness biopsy 12%
○ Increase total bacterial load and percentage of anaerobes aborad

Answer 79

A

1) necrosis from GDV
2) penetrating FB
3) trauma
4) ulceration with perfusion - NAIDS
5) feeding tube leakage
6) pancreatitic abscess
7) pyometra

Answer 80

A

1) midline laparotomy
2) debridement - removal of source
3) lavage
4) omentalisation
5) serosal patching
6) closure and drainge
7) post operative support

Answer 81

A

○ Xiphoid to pubis

○ Full and systematic examination of the peritoneal cavity (see previous lecture on laparotomy)

Answer 82

A

Debridement - remove the source
○ Removal / repair of source: (examples)
§ Cholecystectomy
§ GIT Resection and anastomosis
§ Liver lobectomy
§ Ovariohysterectomy (Pyometra)
○ Suture biomaterials with prolonged absorption profile
Lavage
○ Reduction in bacterial load, removal of adjuvant materials and inflammatory mediators
○ 200-300ml/kg
○ Addition of AB or antiseptics has no reported benefit and may result in chemical peritonitis
○ Intraperitoneal iodine induces toxicity and chemical peritonitis in dogs

Answer 83

A

○ Described for prostatic abscesses, pancreatic cyst and pseudocysts
○ Successfully used for plugging 20mm duodenal defects
§ Healing complete at 8 weeks
○ Omental wrapping:
§ Seal small leaks
§ Provide drainage & immunocompetent cells
§ Vascular supply and angiogenenic potential
§ Wrapping to prevent omentalisation resulted in leakage and septic peritonitis (McLaughlin 1973)

Answer 84

A

○ Peritonitis associated with increased risk of dehiscence (Crowe 1984)
○ Proteolytic activity results in collagen degradation
○ Serosal patching recommended for anastomoses and areas of hollow viscusorgans with potential for leakage (Crowe 1984):
§ Placement of serosa of healthy small intestine loops over focal regions of hollow viscous organs suspected of being unhealthy
○ Reduced mortality in a canine experimental model

Answer 85

A

1) primary closure without drainage
2) primary closure with drainage
3) open peritoneal drainage
4) VAC laparostomy

Answer 86

A

® Primary problem identified and addressed
® Bacterial load reduced and residual contamination minimal
® Mortality rate 46%
® ICU care and plasma not available –preclude open abdominal drainage

Answer 87

A

Jackson-Pratt drains most common - negative pressure resulting in fluid flow from abdomen 
□ Potential problems:
® Nosocomial infection
® Occlusion of drains with omentum
® Ineffective drainage
□ Benefits include:
® Reduced risk evisceration
® Reduced risk nosocomial infection
® No need for second sxprocedure to close abdomen –but cannot inspect viscera

Answer 88

A

□ Benefits reported:
® Improved removal of bacteria, foreign material and inflammatory mediators
® Improved O2 tension –reduces anaerobe survival
® Affords early planned, serial re-exploration
□ Technique
a) Cranial 1/3-2/3 of the linea alba left partially open with a loose simple continuous monofilament suture pattern (1-6 cm gap)
b) Falciform ligament excision
c) Tack omentum to areas of leakage to prevent occlusion of opening
d) Sterile technique for bandage changes –in surgical suite under GA –allows serial re-inspection
e) Bandages weighed to assess fluid loss□ Mean open drainage duration 4 days in retrospective clinical studies (Greenfield 1987, Woolfson1986)

Answer 89

A

□ Criteria for closure unclear but recommendations: (Woolfson1986)
® Improvement in colour and clarity of drainage fluid
® Reduction in volume drainage fluid
® Absence bacteria on cytology
® Repeat culture at closure –40% patients had different MC&S results (Greenfield 1987) and positive results increased mortality (Woolfson1986)
□ Nosocomial infection recognised complication
□ Superiority of open drainage not established in any trials in clinical reports in either humans or animals
→ Not done very commonly

Answer 90

A

® Visceral protective layer (?)
® Open cell foam
® Suction catheter
® Circumferential Occlusive film seal
® Continuous Negpressure -75-125mmHg via Suction unit
® Changed q 48 hrs
□ Time to closure: 2 days
□ Reduced morbidity &amp; Mortality in Humans vs Open Drainage - CHOOSE THIS OVER OPEN DRAINAGE

Answer 91

A

a. Analgesia
b. Enteral nutrition –maintain protein, glutamine maintains enterocyte health
c. Maintenance fluid, electrolyte, acid-base balance
§ Protein energy imbalance major contributor to mortality (Tennant 1993)
d. Feeding tube placement as proximal as possible to maximise physiology unless a contraindication for proximal GIT use exists
○ Jejunostomy has the highest rate complications 17-42% (Orton 1986)

Answer 92

A

Mortality rates remain high 20-70% (Hosgood1988) 85% Ralphs
Published survival rates:
○ Open drainage 52-80%
○ Primary closure 54%
○ Closed suction drainage 70%
○ Vacuum 50%

Answer 93

A

Fasting leads to:
- Intestinal mucosal atrophy
- Increased enterocyte apoptosis
- Change in mucin composition
- Decreased glutamine and arginine transport
Role of nutrition
- Prognosis is poorer if negative nitrogen balance
ENTERAL NUTRITION is best for intestinal mucosal health
- Decrease cytokine production
- Increase mucosal blood supply and stimulate local growth factors

Answer 94

A

Partial parenteral nutrition - only supplies part of nutrition and energy - not common
Total parenteral nutrition
Assisted enteral nutrition - most common

Answer 95

A

Requires central venous catheter
○ Strict asepsis required - longer length of time - gloves, aseptic technique needed
Gradual introduction to full RER
○ At least 40 mEq/L potassium to prevent refeeding syndrome
Also amino acids (not taurine), dextrose and lipids
○ Not calcium or fat soluble vitamins
○ Lipid reduced if high serum triglycerides
○ Protein content reduced if hepatic/renal disease

Answer 96

A

Mechanical
- Phlebitis
- Thrombosis
- Septic
- Metabolic
- Gut atrophy - most common

Answer 97

A

BEST ONE TO USE
○ Reduction inflammatory markers
○ Reduction intestinal permeability
○ Improved survival
○ Improved morbidity
What about post intestinal surgery?
Balancing act
Concern about healing intestinal incision
-Best way for intestine to heal is to be healthy
Best way for intestine to be healthy is to be fed

Answer 98

A

Principles
- Ensure all other treatments adequate
○ Fluid/electrolyte
○ Analgesia
○ Anti-emetic
- Ensure no coagulopathy
- Assess anaesthetic risk
How long for?
○ Short-term if end-end anastomosis or post GDV (max 24 hours)
○ Short-term fine (< 48 hours) in mild-moderate cases pancreatitis
○ Majority of mild-moderate cases will resolve
- If able to eat, and wants to eat then feed a low-fat food
- Don’t stop feeding if one break-through vomit
- Avoid food aversion in hospital by force feeding

Answer 99

A

1) NO - nasooesophageal tube
- needs to be long enough to sit in distal 1/3 oesophagus
- Oxygen catheters or soft infant feeding tubes - very small so small amount of food
- Will need to feed Ensure or equivalent in Aust/NZ supplemented with whey protein after first 24-48 hours
2 )Oesophagostomy tubes
- My technique of choice with ≥ 3 days no food including pre-hospital)
- Technically easy to place
- Allows for thicker liquid and blended foods
- Well tolerated
- Can commence feeding immediately
- Requires general anaesthesia for placement - PLACE IN DURING SURGERY
- Can lead to SEVERE gastric reflux if placed into the stomach
○ Don’t feed when animal recumbent and feed slowly

Answer 100

A

12-14 F cats
16-18 F larger dogs
Management
Clean and change bandage daily for 3 days then q 2-3 days
Can use as soon as awake
Check position before feeding and flush before and after feeding
Can remove easily -> just remove sutures and remove

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dogs and cats 13 Flashcards

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