Gastrointestinal Flashcards
What is the holding layer of the GIT?
Submucosa
List some surgical diseases of the stomach.
Foreign body, obstruction, ulceration, neoplasia, oomycosis, GDV
What will you see with an animal that has ingested a foreign body that is stuck in its stomach?
Distended abdomen, dehydrated, melena, azotemia, acid/base disturbance, hypokalemia, hypochloremia, leukocytosis
How do you treat a gastric foreign body?
Stabilize patient with fluids, gastroprotectants, removal of object
What are some ways to remove a gastric foreign body?
Conservative, endoscopy, gastrotomy, emesis
How do you approach a gastric foreign body surgery?
Ventral midline incision from xiphoid to pubis
T/F: Stomach heals slowly
False. RAPIDOO
What are the two gastric closure options you can use?
Traditional - cushing with lembert
Alternative - simple continuous in submucosa with cushing in seromuscular OR simple cont in serosa, muscle, and submucosa with cushing in seromuscular
When would you perform a single payer closure on the stomach and what patterns would you use?
Pyloric outflow tract, reduced gastric volume, thickened gastric wall.
Use simple interrupted or simple continuous
What happens with congenital pyloric stenosis and gastric outflow obstruction?
Hypertrophy of circular muscles
What are the CxS with gastric outflow obstruction?
Intermittent vomiting, abdominal distension but PAINLESS
What is the best diagnostic tool for gastric outflow obstruction/ congenital pyloric stenosis?
Ultrasound - tells you the layer thickness and differentiates neoplasia
What are the treatments used for congenital pyloric stenosis and which one is better?
Fredet-Ramstedt pyloromyotomy (better) - seromuscular layer, no lumen exposure
Heineke-Mikulicz Pyloroplasty - full thickness, exposes lumen
What do you see with chronic hypertrophic pyloric gastropathy?
Mucosal & muscular hypertrophy, intermittent vomiting
What do you see with DI with CHPG?
Rads - gastric distension, delayed gastric emptying
U/S - pyloric wall and muscle thickness
What can the endoscopy see with CHPG, what can it not se?
Sees hypertrophy of mucosa, but not the muscular layer
What are the grades of CHPG?
Grade 1 muscular hypertrophy
Grade 2 muscular and mucosal
Grade 3 muscular and mucosal with submucosal inflammation
What are the treatment options for CHPG?
Transverse pyloroplasty, Y-U pyloroplasty, Billroth 1, biopsy
What does a Y-U pyloroplasty do? How do you do it?
Creates a wider pylorus
Create a Y incision to transpose antral wall to pyloric region. suture antral flap with simple pattern
What ligament do you want to avoid with Y-U pyloroplasty and why?
Hepatoduodenal ligament because it can damage the common bile duct
What happens with a Billroth 1 procedure?
You excise a portion of the pylorus and suture that to the duodenum
What is the most common form of gastric neoplasia?
Adenocarcinoma
T/F: Gastric adenocarcinoma is rare in cats
True
Where will you expect gastric adenocarcinoma to metastasize to?
Regional lymph nodes, liver
How can gastric neoplasia be presented?
Infiltrative and diffuse, ulcerated, or discrete polypoid
What is the preferred test for gastric neoplasia?
Endoscopy
How do you treat gastric neoplasia?
Aggressive excision >5 cm margins, removal of regional lymph nodes
What surgical techniques are used for gastric neoplasia?
Billroth 1, billroth 2, gastrectomy
When would you perform a billroth 2?
When the resection of the stomach is too proximal where it limits end to end anastomosis
What are some complications with billroth 2?
Alkaline gastritis, blind loop syndrome, marginal ulceration
What does a roux-en-y anastomosis helps resolve in regards to billroth 2 complications?
Avoids alkaline reflux and likelihood of blood loop sydrome
Where is gastric leiomyosarcoma more common located?
In the cardia
T/F: Gastric leiomyomas are very fast growing and fatal
False. Slow growing and incidental findings
What organism causes pythiosis?
Pythium insidiosum
What happens with pythiosis?
Rapid growth and extensive infiltration of organism to the submucosa and muscularis of stomach and SI
What are the CxS with pythiosis?
weight loss, vomiting, diarrhea, hematochezia
What will you find on histopathology of pythiosis?
Eosinophilic pyogranulomatous inflammation
What test can you run to diagnose pythiosis?
ELISA for antibodies
How do you treat pythiosis?
Surgical excision with 3-4 cm borders. Combine with antifungal meds and immunotherapy.
What is the prognosis for pythiosis?
Guarded to poor
Define Gastric-Dilatation-Volvulus
The distension of the stomach and rotation of it on its mesenteric axis
What direction, clockwise or counterclockwise, does the stomach usually turn with GDV? How can you tell?
Clockwise rotation is more common and can be determined by visualization of the greater omentum.
Counter-clockwise rotation will not have a visible greater omentum
List some predisposing factors for GDV.
Large/giant breeds, deep chested, fast eater, post prandial activity, raised food bowls, temperament
How does GDV affect the heart?
Decreased preload, afterload, CO, BP. Compression of veins.
T/F: Reperfusion injuries can occur leading to absent tissue flow despite GDV correction.
True
T/F: GDV cases will exhibit respiratory alkalosis
False. acidosis
What metabolic effects are seen with GDV?
Cellular hypoxia, anaerobic metabolism, increased lactate, metabolic acidosis
T/F: Potassium levels with GDV is low
True, but not always due to electrolyte shifts and sequestration. It is unpredictable
T/F: You will always see hypoglycemia with GDV
True
What renal effects are seen with GDV?
Decreased GFR, olig/anuria, acute renal failure
What PE findings are noted with GDV?
Distended, painful, tympanic abdomen. Retching, pytalism, tachypnea, tachycardia, collapse
What kind of leukogram will you see with GDV?
Stress leukogram
With the hepatocellular damage done with GDV, what values from the chemistry will you monitor?
ALT
What values are monitored for renal damage?
BUN/creatinine
T/F: Due to the damage to the body and hypoxia, you will see decreased bilirubin on the chemistry panel.
False. Increased
Why is a VD radiographic view contraindicated with GDV?
It may lead to reflux and aspiration
What angle/position/view of the patient with GDV most diagnostic on radiographs?
Right lateral
How do you initially treat a GDV patient?
Fluids, decompression, pain management, antibiotics -> surgery
What are the best types of fluids to use for GDV?
Crystalloids and colloids, hypertonic saline
What are some ways to decompress the stomach in a case with GDV?
Orogastric intubation, trocharization, emergency gastrostomy
What type of steroids do you give to a patient with GDV?
Glucocorticosteroids
What meds can you give to aid in the occurrence of any reperfusion injuries with GDV?
Free radical scavengers - vitamin C, vitamin E, deferoxamine, lidocaine, acetylcysteine
How do you perform a GDV surgery?
Ventral midline celiotomy, retract incision, decompress stomach, derotation
What are the names of the retractors used in GDV surgery?
Balfour
How can you assess the viability of the gastric wall with GDV?
Peristalsis, serosal color, friability, vessels, bleeding
What are some surgical techniques to treat GDV?
Partial gastrectomy, gastric invagination (faster, less contamination)
What is pexied with a gastropexy?
Pyloric antrum to the right lateral body wall
What are the different methods for gastropexy?
Incisional, belt loop, circumcostal, tube, incorporatin, laparascopic-assisted, endoscopic-assisted
What suture do you use for gastropexies?
2/0 or 3/0 antibacterial sutures
What is different with the belt loop gastropexy?
Ties the peritoneum to the muscle
Which gastropexy requires uses a purse string suture in the stomach and a mushroom tip catheter?
Tube gastropexy
T/F: Incorporating gastropexies are the most recommended
False. NOT recommended
What are the common post-operative causes of death with GDV?
Shock, gastric necrosis, reperfusion injury, arrhythmias
What are some post-operative therapies for GDV?
NPO and fluids for 24 hours, H2 blockers, prokinetics (vomiting), gastric protectors, analgesics
What is the most common type of arrhythmia with GDV? When should you treat it?
VPCs. Only treat with there are poor pulses
What test can you run to determine prognosis of GDV?
Lactate levels.
> 6 mmol/L - bad
<6 mmol/L - good
What can you have the owner do to prevent GDV reoccurrence?
Feed moist food, fish, egg, water added, outdoor activity, gastropexy, non-stressful environment
What pathophysiological phenomenons occur with intestinal foreign bodies?
Proximal gas and fluid accumulation leading to edema, wall ischemia leading to tissue loss and bacterial translocation
What are the CxS seen with intestinal foreign bodies?
Vomiting, anorexia, depression, abdominal pain, diarrhea
How can you determine the likeliness of obstruction in the intestines with radiographs?
Ratio of small intestine to the height of the L5
<1.6 is no obstruction
>2 is likely
What are some surgical procedures used to treat intestinal foreign bodies?
Enterotomy, R/A, Serosal patching, Enteroplication
How can you evaluate the viability of the intestinal tissue?
Peristalsis pinch test
Color
Blood vessel characterization
Wall thickness/texture
How do you perform an enterotomy to treat FBs?
Identify and isolate the affected area and pack off with sponges, occlude the area proximal and distal, longitudinal incision, close with suture, leak check, omentalize
What suture do you use and what pattern with enterotomies?
3/0 monofilament with simple patterns
What does R/A stand for, and how do you perform it?
Resection and Anastomosis. Remove necrotic, traumatized, neoplastic tissues by occlusion of affected segments, removal of mesentery, excision, close, omentalization
How can you enlarge the lumen size when cutting the intestine for an R/A?
Cut at an angle
What materials are used to close off intestines for surgery?
Monofilament* sutures
Surgical staples
T/F: Like bladder surgery, double layer closure of the intestines is recommended
False, poorer apposition
What are some suture patterns used in intestinal surgery?
Simple continuous, simple interrupted, modified gambee (inverts the mucosa which is good because you don’t want mucosal eversion)
What should you do before injecting saline to test for a leak check after intestinal anastomosis?
Occlude intestine proximally and distally
How far should your staples be placed from one another in an intestinal surgery?
3 mm apart
What methods of intestinal surgery are there that utilize staples?
Anastomosis with staples
Skin stapler
Inverting end-to-end
Side-to-side with GIA stapler
What will you see with linear foreign bodies?
Vomiting, anorexia, abdominal pain, clumping and pleating of intestines
What do you see on contrast radiograph study?
Teardrop shaped air bubbles
How can you surgically manage linear foreign bodies?
Remove from base of tongue (rare)
Gastrotomy(multiple)
How does the catheter technique work in removing a linear foreign body?
Tie FB to catheter and milk it down the intestines to be removed easier through incision or through the anus
What are some post-op intestinal surgery complications?
Septic peritonitis, adhesion, dehiscence
ILEUS
Short bowel syndrome
What occurs with short bowel syndrome?
The body cannot compensate for the loss of mucosa in the gut and it leads to hypersecretions from the GIT and less intestinal transit time -> diarrhea, malnutrition, weight loss
How do you treat short bowel syndrome?
Nutritional support, wait for the body to adapt (may never)
What is the #1 cause of intussusception in small animals?
Viral enteritis
What CxS is seen with proximal intussusception? Distal?
Proximal - vomiting
Distal - tenesmus
If the tissue from an intussusception is necrotic, how do you manage it?
R/A!
How can you prevent reoccurrence of intussusception?
Enteroplication
How long do you want the intestines to be when performing an enteroplication?
3-5 cm intervals
What happens if the cranial mesenteric arteries are compressed for too long? (disease: mesenteric torsion)
Ischemic necrosis of all the intestines occurs
What do you see with mesenteric torsion?
Abdominal distention, hematochezia, collapse, death, shock
T/F: Mesenteric torsion has a very poor prognosis
True, but immediately surgery might work
T/F: Most intestinal neoplasias are malignant
True
What is the most common neoplasia in the dog intestine?
Adenocarcinoma.
Lymphoma for cats
How large are the borders when removing a malignant intestinal mass? Benign?
4-8 cm borders for malignant
Minimal borders for benign
What is the preferred method of obtaining an intestinal biopsy?
Full-thickness layer that is 3-4 mm wide. Use a transverse wedge biopsy
What complication can occur with an U/S guided biopsy of the intestine?
Tumor seeding
When do you use antibiotics for intestinal surgery?
Only at time of surgery, no more than 24 hours after.
Prox intestine = 1st gen ceph
Distal large = 2nd gen
What are the some large intestinal surgical procedures done?
Colopexy, colon R/A, typhlectomy, colostomy
What are the blood vessels that supply the large intestine and colon?
Ileocolic, cran and caudal mesenteric
What do you see with cecal intussusception (inversion)?
Diarrhea, hematochezia, tenesmus
What is the best way to diagnose cecal inversion?
Endoscopy
How do you treat cecal inversion?
Typhlectomy. First ligate the arterial supply, open, milk out, transect and suture
What are the most common types of cecal neoplasia?
Leiomyoma/sarcoma
T/F: Megacolon is more common in dogs than cats
False.
What signs are seen with megacolon?
Chronic constipation
How does megacolon happen?
Feces are retained and dehydrates -> pain -> colonic distention -> muscle and nerve damage -> intertia -> bacterial absorption
What is the most common type of megacolon?
Idiopathic megacolon
How can you surgically treat megacolon?
Subtotal colectomy
T/F: You do not need to prep the bowel before performing a subtotal colectomy
True!
What suture material and pattern do you use for subtotal coletomy?
3/0 PDS with simple pattern
What is the most common congenital abnormality of the anus?
Atresia ani
How do you treat an anal prolapse?
Manually reduce and place a purse string, treat underlying cause
How can you differentiate between a rectal prolapse and a prolapsed intussusception?
You cannot insert your finger into a rectal prolapse
What are some ways to treat a recurrent prolapse?
Non-incisional colopexy
Incisional colopexy
What is the most common benign tumor in the rectum? Malignant?
Benign - adenomatous polyps
Malignant - adenocarcinoma
How do you surgically prep a patient with rectal neoplasia?
Withhold food for 1-2 days prior, prophylactic antibiotics
What are some surgical approaches to the rectum?
Transanal, dorsal, rectal pull through, ventral, lateral (rare)
