E2: Spleen, Pancreas and Peritonitis Flashcards

1
Q

The spleen lives within the leaf of the ______ _______and is attached to the stomach via the ______ _______. It’s main blood supply is the ______ artery whose parent is the _______ artery. Blood leaves the spleen via the ______ vein, which flows into the _______ vein and finally out of the ______ vein.

A

The spleen lives within the leaf of the GREATER OMENTUM and is attached to the stomach via the GASTROSPLENIC LIGAMENT. It’s main blood supply is the SPLENIC** artery whose parent is the **CELIAC artery. Blood leaves the spleen via the SPLENIC vein, which flows into the GASTROSPLENIC vein and finally out of the PORTAL vein.

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2
Q

What are these called? What are they made of?

A

Sidertoic plaques

Deposits of irona and calcium in the splenic surface

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3
Q

What is splenomegaly and what are some causes ?

A

Splenomegaly: symmetric enlagement of the spleen

Drugs: Thiopental, acepromazine

Congestion/Torsion

Infiltrative diseases

Immune-mediated diseases

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4
Q

What can cause splenic torsion? What is the most common cause? What dog breeds are predisposed?

A

Most common: With GDV

Stretching of gastrospenic ligament during previous GDV or trauma

Congenital absence of GSp ligament

Breeds: Large and Giant- Great Dane, Greater Swiss Mnt Dog, German Shepherd, English Bulldog

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5
Q

How can you diagnose a splenic torsion?

A

Rads

US + doppler (Mottled/diffuse hypoechoic areas, no flow through vessels

CT (overkill)

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6
Q

What should you perform in conjunction with a splenectomy following a splenic torsion?

A

Gastropexy

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7
Q

You have removed the spleen from a Great Dane, but the owner cannot afford to send the spleen in for biopsy. They are worried about this because they fear it may be cancer. What can you tell them?

A

It is not crucial to send it because neoplasia is very rarely the cause of splenic torsion and this breed is prediposed to the condition

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8
Q

What main vessels are double clamped and transected when peforming an emergency splenectomy in a patient that has active splenic hemorrhage?

A

Splenic artery and vein

Left gastroepiploic artery and vein

(All vessels at the splenic hilus)

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9
Q

A dog comes in following a HBC incident. You are fairly certain due to various diagnostics you have run that there has been trauma to the spleen and it is bleeding. The dog is overall stable, including the PCV. What is your course of action?

A

Compression bandage and monitor closely (esp PCV)

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10
Q

What is the most common splenic neoplasia in dogs? Cats?

A

Dogs: HSA

Cats: MCT

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11
Q

What is the rule of 2/3rds?

A

2/3 of dogs with a splenic mass will have a malignancy

2/3 of those malignancies will be HSA

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12
Q

What does a non-traumatic hemoperitoneum in a large breed dog with a splenic neoplasm indicate? Small breed?

A

Large: That the mass is likely malignant

Small breed: Not associated with malignancy

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13
Q

What small breed dog is predisposed to splenic neoplasia?

A

Wheaten Terrier

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14
Q

What relationship does the size of a splenic mass have with malignancy?

A

Larger heavier masses are more likely to be benign

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15
Q

Why is the prognosis for splenic HSA so poor? What is the prognosis with surgery alone? Surgery and chemo?

A

In nearly all cases microscopic metastasis is present at the time of diagnosis

Sx: 1-3 months

Sx + Chemo: 5-6 months

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16
Q

What is eBAT?

A

Biospecific urokinase angiotoxin designed to inhibit Endothelial Growth Factor Receptor (which is overexpressed in splenic HSA)

(i.e. it is a drug that prevents neoangiogenesis within the HSA)

Not available commercially yet

6 months survival (this drug followed by DOX)

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17
Q

Will performing a splenectomy alter the progression of HSA? Why or why not?

A

No, probably has already metastasized

However, it may provide SHORT TERM relief to allow the owner time for a proper good-bye.

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18
Q

What are the 2 techniques to consider for a complete splenectomy? What are advantages and disadvantages of each?

A

Ligation of individual hilar vessels (Conventional)

(+): Preserve branches to stomach and pancreas, lower risk of post-op hemorrhage

(-): Time consuming

Ligation of the splenic and short gastric arteries

(+): No compromise of blood flow to the greater curvature of the stomach, faster

(-): Higher risk of hemorrhage, more challenging if large mass or omental adhesions distorty anatomy

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19
Q

What vessels are imperative to preserve when performing the splenic artery ligation technique to remvoe the spleen?

A

The branches to left limb of the pancreas (primary blood supply)

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20
Q

What are indications for performong a partial splenectomy?

A

Trauma

Focal abscess

Partial infarction

(ONLY in dogs that are NOT at risk for splenic disease)

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21
Q

What are some complications post-splenectomy? What should you monitor post-op?

A

Ventricular arrythmias (monitor EKG, Holter monitor is best)

Hemorrhage (montior PCV)

Iatrogenic: Pancreatitis/necrosis, Gastric wall compromise (be gentle when handing organs and ligating)

Subclinical hemoparasite infection (Babesia, Bartonella) -rare in animals, common in ppl

Portal vein thrombosis

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22
Q

What is the main duct system in the pancreas of the cat? Dog?

A

Cat- Pancreatic duct (drains right lobe, enters duodenum via major D papilla)

Dog-Accessory Pancreatic duct (drains left lobe, enters at minor D papilla)

23
Q

What pancreas biopsy technique is indicated if dffuse disease is present? Which part of the pancreas is easiest to biopsy?

A

Guillotine (suture fracture) Technique

Sample distal aspect of right limb

24
Q

What pancreas biopsy technique is indicated for tumor removal? How much of the pancreas can you remove if the ducts are patent?

A

Partial pancreatectomy

80% with patent ducts

25
Q

What are the complications associated with partial removal of the pancreas?

A

Most common complication= Pancreatitis

EPI (if drainage obstructed)

Endocrine pancreatic insufficiency (e.g. Diabetes mellitus) (if remove >90%)

Devitalization to duodenum (if damage the caudal pancreaticoduodenal artery branches that supply the duodenum) - prevent by making sure you have good visualiztion, dissect omentum, and isolate and ligate vessels right on the pancreatic parenchyma)

26
Q

What is Dr. Cavanaugh’s preferred dissection/resection tool for pancreatic surgery?

A

Ligasure

27
Q

_______ ________ are a collection of purulent material and necrotic tissue within and extending from the pancreatic parenchyma.

_______ ________are collections of pancreatic secretions and cellular debris enclosed within a wall of granulation tissue or fibrous sac that lacks an epithelial wall.

A

Pancreatic abscesses

Pancreatic pseudocysts/cysts

28
Q

What is the test of choice for diagnosing pancreatic pseudocysts? Can it be used to differentiate a cyst from an abscess? If not, what can?

A

Ultrasound

No, they look the same. Must do FNA to distinguish.

29
Q

What is the first line treatment for pancreatic pseudocysts? What is the treatment of choice if the patient is clinical? How are pancreatic abscesses best managed?

A

Percutaneous aspiration

Debride, drain and omentalize - both for abscesses and cysts

30
Q

What is the approximate morality rate for dogs after pancreatic abscess removal? Cats? What about dogs post-pseudocyts removal?

A

Dogs- 40%

Cats- 25%

Dog-cyst: <25%

31
Q

In addition to adressing the pancreatic pseudocyts or abscess, what do you need to consider for the post-op care of the animal?

A

Post-op nutrition plan

Require post-gastric feeding (ideally), best would be J-G feeding tube (gastrojejunostomy) because it allows you to drain the stomach if gastric paresis has occured as well as giving you access to feed the small intestine (if the stomach is fine, you can feed to the stomach instead)

32
Q

What are the 3 types of pancreatic neoplasia? Which cells are involved?

A

Exocrine pancreatic adenocarcinoma - from acinar or ductular epithelial cells

Insulinoma- functional tumors of B-cells of Islets of Langerhans

Gastrinomas (Zollinger-Ellision Syndrome)- functional tumors of ectopic amine precursor uptake decarboxylase (APUD) cells

33
Q

What do insulinomas cause due to their constant secretion of insulin? Are these usually malignant or benign in dogs?

A

Hypoglycemia

>90% malignant

34
Q

What do Gastrinomas secrete? What does this cause? Are most of these malignant or benign?

A

Gastrin

Hyperacidity- ulcers and erosions

Malignant

35
Q

Are most exocrine adenocarcinomas locally invasve? Do they cause clinical signs? What is the prognosis?

A

Yes, hight metastatic rate and local invasion

Cause vomiting, abdominal pain, weight loss, and signs of EHBO

Poor prognosis: 3 mo in dogs, <7 days inc ats

36
Q

Which pancreatic tumor can cause polyneuropathy?

A

Insulinomas (due to chronic hypoglycemia causing nerve damage)

37
Q

What are the clinical signs associated with hypoglycemia called?

A

Whipple’s Triad

38
Q

How are insulinomas diagnosed?

A

Fastine insulin-glucose ratio

High insulin despite low glucose

Insulin often >70 microIU/mL

39
Q

What drugs are used to medically manage insulinoma?

A

Glucocorticoids

Diazoxide (oral hyperglycemic agent)

40
Q

What is a typical cause for primary peritonitis?

A

FIP in cats

41
Q

What is the most common source of secondary peritonitis? What bacteria are the main offenders?

A

Gastrointestnal

  • E.coli*
  • B. fragilus* (enhances lethal potential of E.coli)
42
Q

What are the two phases of shock?

A

Hyperdynamic phase- early

Hypodynamic phase- late

43
Q

How do cats with septic peritonitis present?

A

No pain

Relative BRADYcardia (<140bpm)

44
Q

What is the classic sign of peritonitis seen on rads and US?

A

Pneumoperitoneum

45
Q

What is the gold standard for diagnostic technique for peritonitis? What is the finding you expect?

A

Peritoneal sampling via US (AFAST)

(alternative: blind 4-quadrant, or diagnostic peritoneal lavage)

Degenerative neutrophils, intracellular bacteria

46
Q

How is septic peritonitis diagnosed using fluid analysis?

A

Compare peritoneal fluid to blood

Peritoneal fluid [GLUC]

Peritoneal fluid [LAC] > Blood [LAC] (2 points higher)

Peritoneal fluid = Blood GLUC - 20

= Blood LAC + 2

More consistent in dogs than cats

47
Q

How is bile peritonitis diagnosed?

A

Fluid analysis:

Peritoneal fluid [bilirubin] > 2.5x serum bilirubin

48
Q

What are the 4 goals of threatment for peritonitis?

A

Provide hemodynamic support (IVF, blood products, ABX, analgesia)

Reduce amount of contamination (Sx ASAP)

Prevent further contamination by controlling the source (ABX, Sx)

Provide effective post-op abdominal drainage

49
Q

What is a typical antibiotic combo for septic peritonitis?

A

Ampicililin + Baytril or Aminoglycoside + Metronidazolle

50
Q

T/F: Lavage with warm saline mixed with chlorhexidine is indicated before closing after a peritonitis surgery.

A

FALSE

Warm isotonic saline lavage is essential but WITHOUT any additives

51
Q

What are the peritoneal drainage options?

A

Primary closure (not for GI-based sepsis, best for parenchymal organ sources)

Open (most efficient but requires more care) - Gravity dependent or VAC

Closed (less risks) - Passive (less good) or Active (closed suction, Jackson Pratt)

52
Q

What are the options for post-op nutritional support?

A

Eosphageal - problem when vomiting

Gastric - problem is gastroparesis

Post-gastric/J tube - higher risk of complication, gastroparesis

Combo/J through G tube

53
Q

What do you call a non-septic chornic peritonitis in which the abnormal organs are “coocooned” in collageanous connective tissue?

A

Sclerosing Encapsulating Peritonitis

54
Q

What risk factors diminish the prognosis for peritonitis?

A

Septic peritonitis (vs bile)

Decreased pre- or intra-op blood pressure

Presence of DIC

Ineffective antibiotics selected before C&S results obtained