E2- Peritonitis Flashcards
Perinoneal circulation: focal contaimation can do what?
QUICKLY inoculate entire peritoneum
caudal to cranial flow
***Primary classification of peritonitis****
spontaneous inflam in the absence of intraperitoneal source
corona virus→ FIP (cats)
hematogenous/lymphogenous bact spread, transmural bacterial migration from GI tract, or bact spread from oviducts
Gram + organisms more common and usually MONOBACTERIAL
***Secondary classification of peritonitis****
consequence of an underlying primary dz process
bowel leakage/translocation, urine/bile/blood extravasation, neoplastic invasion, pancreatitis
Gram - organisms more common and usually POLYMICROBIAL
_____ peritonitis- infectious etiologies present (usually bacterial)
septic
Why is it important to differentirate b/t primary Vs secondary peritonitis?
Surgery is NOT routinely indicated for primary but is requisite for secondary
Septic peritonitis from GI origin causes
cause= 38-75% of cases
mecahnical perforation (FB), trauma, ruptured neoplasia, vascular disruption leading to ischemia/necrosis (GDV), surgical dehiscence after R&A, drug induced
Septic peritonitis from GI origin: location of perforation dictates ____
bacterial demographics
aboral = higher total bacterial counts, increased anaerobes, increased mortality
Septic peritonitis from GI origin: two main offenders from the bowel?
E. Coli (57-74% of cases) = alpha hemolysin endotoxin
Bacteroides fragilus (anaerobic)- enhances lethal potential of E. Coli
Septic peritonitis from **hepatobiliary** causes
Ruptured gall bladder mucocele
necrotizing cholecystitis
abscess (+/- tumor)
Serptic peritonitis from **Urogenital** causes
pyometra
prostatic abscess
ovarian cyst
pyelonephritis/renal abscess
retained testicle
ruptured bladder
Other causes of septic peritonitis?
pancreatic
splenic
penetrating trauma- bite wounds
lymph node
iatrogenic
Peritonitis pathophysiology: local manifestations
Peritonitis Pathophysiology: Systemic manifestations
trickle down effect
***have a good understanding of this***
What are the terminal effects of peritonitis?
DIC- disseminated intravascular coagulation
SIRS- systemic inflam response syndrome
MODS- multiple organ dysfunction syndrome
Clinical signs of peritonitis
variable- depend on etiology, duration, signalment and severity
classic= painful, vomit, fever, distended abdomen +/- shock (acute abdomen)
Two phases of shock in peritonitis?
-
Hyperdynamic
- vasomotor dysfunction, cytokine-induced peripheral vasodilation, tachycardia, hyperemic (brick red) MM’s w/ rapid CRT, bounding pulses and hyperthermia
-
Hypodynamic
- decreased contractility and CO = pale MM w/ CRT >2sec, weak peripheral pulses, hypothermic, increased RR,HR, dehydration, dull mentation
Septic peritonitis in cats
NO pain on abdominal palpation
relative BRADYCARDIA = <140bpm
Diagnostic imaging of peritonitis
Abdominal US- pneumoperitoneum and ID pathology
Radiographs- pneumoperitoneum and loss of serosal detail
How long can residual free air remain after abdominal surgery?
up to 30 days
Preferred diagnostic technique for peritonitis in people?
CT imaging
differentiating surgical vs non surgical
What is the GOLD standard dx for peritonitis?
CYTOLOGY
US guided- aFAST (focused assessment w/ sonography for trauma)
blind 4 quadrent abdominocentesis
diagnostic peritoneal lavage (DPL)
What is seen on cytology that is diagnostic for peritonitis?
degenerative neutrophils w/ intracellular bacteria***
How accurate is cytology?
only 57-87% accurate****
In dogs with septic effusion, peritoneal fluid glucose concentration will ALWAYS be _____ than the blood glucose concentration
LOWER
In dogs, Glucose is _____ points lower in belly fluid than blood
20 points
bc glucose is used up by bacteria and phagocytic cells
In dogs, Lactate is ____ points higher in belly fluid than blood
2 points
anaerobic metabolism and lactic acid production by bacteria in peritoneum
How does glucose sensitivity compare to cats vs dogs
cats only 86% sensitive, dogs 100% sensitive
so we rely more on lactate for cats
Diagnosis of fluid analysis for peritonitis: uroperitoneum
Urogenital source- peritoneal fluid creatinine conc > serum creatinine conc = dx for uroperitoneum
Diagnosis of fluid analysis for peritonitis: Bile peritonitis
peritoneal fluid bilirubin conc ****>2.5X*** serum bilirubin conc is 100% dx for bile peritonitis in dogs and cats
Treatment of peritonitis
provide hemdynamic support: fluids, blood products, antibiotics, analgesia
emergency surgery!!!
- reduce amount of contamination
- prevent further contamination by controlling source
- provide postop abdominal drainage
Antimicrobial selection for peritonitis
increased rate of bact resistance with ampicillin, cefazolin, fluoroquinolones
lower rates of resistance with aminoglycosides and 3rd gen cephalosporins
combo therapy to start: FOUR QUADRANT:
- iv ampicillin/aminoglycoside/metro, careful w/ P that have poor perfusion = can lead to acute renal failure
- iv ampicillin/baytril/metro -classic “go to” choice
For peritonitis surgery- you must repair or remove the ____
inciting cause= intestinal resection and anastomosis, cholecystectomy, liver lobectomy, partial cystectomy, nephrectomy
What is important in peritonitis surgery?
LAVAGE w/ warm isotonic saline
suction
Do NOT overlook the need for ____ with peritonitis sx
PO enteral nutrition- these animal need feeding tubes!!
PO ___ critical with peritonitis sx
drainage
____ closure- if source of infection has been isolated and completely controlled in peritoneal sx
primary
Two types of open peritoneal drainage
gravity dependent- dressing packed w/in open incision
vacuum assisted closure
Two types of closed peritoneal drainage
passive- multi luminal, penrose or column disk catheters
**active**- closed suction (jackson pratt)- requires external vacuum to create neg pressure w/in cavity
Pros of open peritoneal drainage
most effecient way to drain
limits anaerobic bacterial growth
Cons of open peritoneal drainage
labor intensive bandage management
risk of nosocomial contamination
anemia, hypoproteinemia and electrolyte imbalances
2nd sx procedure to close abdomen
Pros of closed peritoneal drainage
lower risk of nosocomial bact contamination
decrease potential for evisceration
less intensive PO bandage care
no additional sx to close abd
Cons of closed peritoneal drainage
occlusion (omentum/clots)
ascending bacterial contamination
Open Vs Closed peritoneal drainage: which one is significantly better?
NO SIGNIFICANT difference
Open Vs Closed peritoneal drainage: which requires more intensive care?
OPEN
blood, plasma, enteral nutrition
Open Vs Closed peritoneal drainage: which one requires a longer hospital stay?
6 days- open
3.5 days closed
Cav’s choice for abdominal drainage?
closed suction- Jackson pratt
