Exam 1: Lecture 7 - Hemoperitoneum / Peritonitis Flashcards
what is the definition of hemoperitoneum or hemoabdomen
abnormal accumulation of blood in the peritoneal cavity
what are the traumatic causes of hemoperitoneum
HBC, kicks, or falls
what is the #1 cause of non-traumatic hemoperitoneum
neoplasia
what are the 2 types of neosplasia that are most common for hemoperitoneum
splenic neoplasia and other tumors
what are some other causes of hemoperitoneum
non-traumatic rupture of the adrenal gland or non-malignant disease (GDV, splenic torsion, liver love torsion, vitamin K antagonists aka rat poison)
what do we look at to diagnose hemoperitoneum
- clinical presentation (signalment and history)
- PE
- diagnostic imaging
- lab testing
if there is a younger patient presenting for hemoperitoneum is it more likely to be trauma or neoplasia
trauma
if there is an older patient presenting for hemoperitoneum is it more likely to be trauma or neoplasia
neoplasia
what is the usual history for patients presenting with hemoperitoneum
- trauma or suspected trauma
- neoplasia is usually non specific
- previous hemorrhage
- access to toxins or rodenticide
- previous dx of a mass
- previous sx or diagnostic procedure
- reaction
what do we usually see on PE for hemoperitoneum
- external signs of trauma
- abdominal distention +/- fluid wave
- abdominal tenderness
- contusion / discoloration of abdominal wall
- bulging umbilicus
T/F: We can see anything from clinically normal to severe hemorrhagic shock with hemoperitoneum
true!! they can be acting normal to on their death bed
what do we see on radiographs for hemoperitoneum (IMPORTANT)
classic description is loss of abdominal detail with focal or generalized “ground glass” appearence
what is an AFAST exam
abdominal focused assessment with sonography for trauma
is ultrasound or rads more sensitive with small quantities of fluid
ultrasound
What is this classic description of this radiograph
loss of abdominal detail with focal or generalized “ground glass” appearence
how many views do we do with an AFAST exam
4 views - diaphragmaticohepatic, splenorenal, cystocolic, and hepatorenal
T/F: CT can be helpful in diagnostics because it can locate the mass
true!
T/F: Clinicopathologic abnormalities in dogs with hemoabdomen are not similar
false, they are typically similar regardless of the cause of abdominal bleeding!
how is hemoperitoneum diagnosed
by finding non-clotting bloody fluid in the abdomen by abdominocentesis or diagnostic peritoneal lavage (DPL)
What is important to note about the use of diagnostic peritoneal lavage
its use in trauma is declining while the use of FAST exam is replacing it
why are the disadvantages of the DPL method
invasive, low specificity, high rater of nontherapeutic laparotomies, and false negatives
what is the medical management for hemoperitoneum
- IV fluid replacement therapy
- blood transfusion
- tight abdominal wrap?? used during stabilization (not always used but tries to create pressure for clotting)
- oxygen therapy
T/F: Trauma patients with hemoabdomen that are stabilized after medical management still need suregery
FALSE, the often do NOT require sx
what do we do if the patient is in shock prior to sx
make sure to stabilize them !
what should we do preoperatively before anesthesia
- correct fluid abnormalities
- correct acid-base abnormalities
- correct electrolyte abnormalities
- correct cardiovascular abnormalities
when should we consider a blood transfusion for hemoperitoneum
- if PCV <20%
- hypoxic from anemia or respiratory depression
- if ongoing bleeding is expected
what should consider for anesthetizing patients with hemoperitoneum
- anemic patients need O2 prior to induction and during recovery
- avoid barbiturates (cause splenic congestion)
- avoid acetylpromazine (has RBC sequestration, hypotension, and impact on platelet function)
- hypotension due to volume depletion
what are the indications for hemoperitoneum sx
undetermined source of hemorrhage, uncontrolled hemorrhage, and eval/removal of intra-abdominal neoplasia
what type of incision do we do for hemoperitoneum sx
a routine abdominal incision
what type of surgery do we do for hemoperitoneum
an exploratory sx (look ESP at kidneys, liver, and spleen)
what are some clotting agents that may help control liver bleeding
platelet gel, surgicel, gel foam
what is the prognosis for hemoperitoneum
it really depends on the CAUSE of the hemoabdomen
what is primary generalized peritonitis
spontaneous inflammation of the peritoneum with no obvious intra-abdominal reason for leakage of bacteria
what is secondary generalized peritonitis
occurs in conjugation with an intra-abdominal reason for the inflammation/infection (can be infectious or non-infectious)
what are the causes of secondary generalize peritonitis
- predom form in dogs
- usually caused by bacteria
- most originate from contamination from GI tract via surgical wound dehiscence or GI neoplasia
what are 10 other causes for secondary generalized peritonitis
- galbladder perf, rupture, or neoplasia
- gastric or intestinal FB
- intussusception
- mesenteric avulsion
- GDV
- cystocentesis
- necrotizing cholecystitis
- pancreatic abscess
- prostatic abscess
- FB penetration of the body wall
what is the cause of primary generalized peritonitis
it is of unknown origin
what is the DIFFERENCE between primary and secondary generalized peritonitis
sx is not routinely performed in primary but is REQUIRED in secondary
is primary or secondary peritonitis more likely to be monobacterial
primary
is primary or secondary peritonitis more likely to be polybacterial
secondary
what is the usual signalment of patients with peritonitis
any age but younger is more common
what is the usual history for peritonitis
- often non-specific
- delayed onset of signs may be seen with trauma, mesenteric avulsion, or bile peritonitis
- previous GI sx
how much of a delay do we see with traumatic peritonitis
3-4 hrs
how much of a delay do we see with mesenteric avulsion peritonitis
5-7 days
how much of a delay do we see with bile peritonitis
weeks
what are the usual presenting complaints for peritonitis
most presented for lethargy, anorexia, vomiting, diarrhea, and abdominal pain
how do cats present differently from dogs
they are more likely to present with lethargy, depression, and anorexia rather than abdominal pain
T/F: You should always eval any sick intact female for a pyometra
true!!
what are the common PE findings of peritonitis
- abdominal palpation often causes pain
- vomiting
- diarrhea
- abdominal distention
- pale mm
- prolonged CRT
- tachycardia may indicate shock
- dehydration and arrhythmias may occur
what do we usually see on rads with peritonitis
- intestinal tract may be dilated with air, fluid, or both
- free abdominal air (from ruptured hollow or gas producing anaerobic bacteria)
- localized peritonitis, secondary to pancreatitis may cause a “sentinel loop”
what is a “sentinel loop” on rads
makes the duodenum appear to be fixed and elevated
what do we use ultrasound for
collecting fluid, organ eval
what is usually the limiting factor for ultrasound when trying to diagnose peritonitis
pain is usually the limiting factor
what is the most common lab finding with peritonitis
it is a marked leukocytosis (left shift)
what can we see with neutrophils on lab findings with peritonitis
neutrophil count being normal or low
T/F: Left shift is always present with peritonitis
false! It is often present but not ALWAYS present
other than leukocytosis, what are other lab findings we can see with peritonitis
- anemia
- thrombocytopenia
- dehydration
- hypo-glycemia or hyper-glycemia
- hyperbilirubinemia
- electrolyte and acid-base abnormalities
why should we do an abdominocentesis if there is effusion present with peritonitis
to examine for uroabdomen, bile peritonitis, toxic neutrophils with intracellular or extracellular bacteria
T/F: early peritonitis before onset of clinical signs is difficult to diagnose as primary or secondary
true!!
what are the 3 goals of medical management of peritonitis
- eliminate cause of contamination
- resolve the infection
- restore normal fluid and electrolyte balance
other than the 3 main goals of medically managing peritonitis, what else should we do
withhold food if vomiting, IV fluid therapy, and broad spectrum abx
what are the 6 indications for abdominocentesis with peritonitis
- shock with no apparent cause
- undiagnosed abdominal disease
- suspicion of post-op GI dehiscence
- blunt or penetrating abdominal injury
- abdominal effusion
- undiagnosed abdominal pain
what is the preferred way to do an abdominocentesis
ultrasound guided
what procedure is happening in this picture
diagnostic peritoneal lavage
when is exploratory surgery indicated for peritonitis
- cause of peritonitis cannot be determined
- bowel rupture
- intestinal obstruction
- mesenteric avulsion is suspected
what is the focus of surgical therapy for peritonitis
it is focused on either repair or removal of the inciting cause
T/F: intraoperational peritoneal lavage is controversial
true! But generally indicated with diffuse peritonitis
T/F: we do not have to worry when peritonitis is localized because we cant spread infection doing intraoperative peritoneal lavage
false!!! we should use caution because if the peritonitis is localized to one area we can disseminate the infection with lavage
T/F: as much of the fluid we put into the abdomen should be removed because fluids inhibit the bodies ability to fight off infection (aka macrophages DONT swim)
true!!
what is the most appropriate lavage fluid
warmed isotonic saline
T/F: there is evidence that adding antiseptics to lavage fluids is beneficial
false! no evidence
what is open abdominal drainage (OAD)
a small section of the abdominal incision is left open and sterile wraps are placed around the wound
what are the complications of open abdominal drainage (OAD)
- persistent fluid loss
- hypoalbuminemia
- weight loss
- adhesion of abdominal viscera to bandage
- contamination of the abdominal cavity with cutaneous organisms
what are the advantages of open abdominal drainage
- improved metabolic condition
- fewer abdominal adhesions
- fewer abscesses
- access for repeated inspection/exploration
what are the disadvantages of open abdominal drainage
- hypoalbuminemia
- hypoproteinemia
- anemia
- nosocomial infections
T/F: Open abdominal drainage is not commonly used due to time and effort required
true!
T/F: OAD may be more effective than closed suction drainage with highly exudative effusions
true!!
what type of drain is this
jackson-pratt drainage catheter
what situations is closed suction drainage effective for
generalized peritonitis and if effusion is serous is nature
closed suction drainage takes ____ time and ______ effort than OAD
less time and less effort
what are the surgical techniques for peritonitis
- abdominocentesis
- diagnostic peritoneal lavage
- exploratory celiotomy
- open abdominal or closed suction drainage
how do we do an abdominocentesis
- insert 18-20g 1/2 inch needle but do not attach syringe
- allow fluid to drip from catheter (collect in sterile EDTA tube and submit samples for cultures)
- if fluid does not drip use a 3-cc syringe with gentle suction
what is a giant warning for when we diagnostic peritoneal lavage
this technique does not reliably exclude significant retroperitoneal injury or hemorrhage
T/F: When bacterial numbers have declined and neutrophils are no longer degenerative, close the abdominal incision
true!! usually at 3-5 days post op
in cats and small dogs, where do we place the drain for close suction drainage
place one drain between the liver and diaphragm
in large dogs, where do we place the drain for close suction drainage
place a second drain into to caudoventral abdomen
where should we exit the drain tubes for closed suction drainage
through the body wall thru a paramedian stab incision
how should we suture the closed suction drains into the abdominal skin
with a roman sandal or chinese finger trap
how do we close the abdomen for closed suction drainage
as normal
what type of suture materials should we use for peritonitis cases
monofilament non-absorbable suture or slowly absorbable suture
what suture should we NOT use for peritonitis cases
do NOT use braided suture or suture that is rapidly degraded
what 6 things should we do post op for peritonitis
- continue fluid therapy
- monitor electrolytes, acid-base, serum, protein, and correct as needed
- nasal oxygen if sepsis
- ensure adequate caloric intake
- consider plasma if hypoproteinemic
- analgesia
what is the prognosis for generalize peritonitis
guarded, many survive with aggressive therapy
______% mortality in cats in one study with peritonitis
54% mortality in cats
______% mortality in dogs in another study with peritonitis
53% mortality in dogs
T/F: Dogs with primary peritonitis who underwent surgery were less likely to survive than those with secondary peritonitis
true!!
how do we do a diagnostic peritoneal lavage
- make 2cm skin incision caudal to umbilicus
- direct catheter caudally into pelvis
- gently aspirate
- if negative, attach catheter to IV line with bag of warm sterile saline and infuse into abdominal cavity
- roll patient gently side to side
- when closing the abdomen leave a portion of the incision open for drainage
