GI Surgery Flashcards
1
Q
Why is healing delayed with the esophagus?
A
there is no omentum around the esophagus
2
Q
What layer is missing in the esophagus?
A
serosal layer
3
Q
What are the causes of Gastric Foreign Bodies?
A
Ingested by patient
Penetrating wound
4
Q
What are the common Gastric Foreign bodies for dogs?
A
Rocks
Toys
anything
5
Q
What are the common Gastric Foreign Bodies for cats?
A
Trichobezoars
Needle
String
6
Q
What disease predispose to Gastric Foreign body ingestion?
A
Pancreatic exocrine insufficiency
Hepatic encephalopathy
Iron deficiency
7
Q
What is the cause of anemia in Gastric Foreign Body?
A
Bleeding
8
Q
What is the cause of Azotemia in Gastric Foreign Body?
A
dehydration
9
Q
What is the cause of Alkalosis in Gastric Foreign Body?
A
Vomiting
10
Q
What is the cause of Acidosis in Gastric Foreign Body?
A
Dehydration
11
Q
What is the cause of Hypokalemia in Gastric Foreign Body?
A
Not Eating and Vomiting
12
Q
What is the cause of Hypochloremia in Gastric Foreign Body?
A
vomiting and not eating
13
Q
What are the laboratory findings in gastric foreign body?
A
Anemia Azotemia Alkalosis or acidosis Hypokalemia Hypochloremia Leukocytosis
14
Q
What is a noninvasive way to remove and view Gastric Foreign Body?
A
Endoscopy
15
Q
What are the 4 ways to treat gastric foreign body?
A
- Treat with fluids, gastro-protectants and antiemetics and hope the foreign body passes
- Remove the endoscopy
- Induce emesis for removal
- Perform surgery to remove the foreign body immediately
16
Q
What specific treatments are for Lead and Zinc foreign bodies?
A
Chelating agents
17
Q
-otomy
A
cutting into
18
Q
-ectomy
A
cutting a section out
19
Q
-ostomy
A
making a hole
20
Q
What is the function of the gastric pacemaker?
A
controls normal gastric contractions
21
Q
What approach do you make for a Gastric Foreign Body surgery?
A
Dorsal recumbency
Ventral midline approach
22
Q
What forceps should you NOT use on a gastrotomy?
A
Babcock forceps
23
Q
Why do you need to change gloves and instruments when removing a gastric foreign body?
A
they are contaminated with stomach contents
24
Q
What is the layer of strength in the stomach?
A
Submucosa
25
Why is serosa to serosa contact important?
Creates a fibrin water tight seal
26
What is the traditional 2 layer closure for the stomach?
Cushing pattern oversewn with Lembert
27
What are the two alternative techniques for stomach closure?
Simple continuous in submucosa and a cushing pattern in seromuscular layers
Simple continuous in serosa and cushing pattern in seromuscular layers
28
What is the problem with the Lembert pattern?
no serosa to serosa apposition
29
What is the difference between the Connell and the Cushing pattern?
Connell - Full thickness
| Cushing - not full thickness
30
What is the problem with the simple continuous pattern in the serosa and the cushing pattern in the seromuscular layer?
inverts the tissue more and reduces gastric volume
31
What type of pattern do you not want to use with a pyloric stenosis?
No inverting patterns
32
What causes Congenital Pyloric Stenosis?
Hypertrophy of circular muscles
33
What breeds are predisposed to Congenital pyloric stenosis?
Brachiocephalic breeds
| Siamese Cats
34
What layer of the pylorus is affected by congenital pyloric stenosis?
Muscular layer
35
What are the clinical signs of Congenital Pyloric stenosis?
Intermittent vomiting
Dietary modification alters signs
Normal to decreased body condition
Abdominal distension but no pain
36
If clinical signs improve with a liquid diet what is the diagnosis?
Congenital Pyloric Stenosis
37
What sign will you see on contrast radiography with Pyloric Stenosis?
"Beak or Apple core" sign
| Delayed gastric emptying
38
What is the number one way to diagnose Pyloric Stenosis?
Ultrasound
39
What are the different treatments for Pyloric Stenosis?
Fredet-Ramstedt Pyloromyotomy
| Heineke-Mikulicz Pyloroplasty
40
What is the advantage of the Fredet-Ramstedt Pyloromyotomy?
Limited contamination
41
What is the disadvantage of Heineke-Mikulicz Pyloroplasty?
goes into the lumen of the pylorus
42
When would you perform the Fredet-Ramstedt Pyloromyotomy?
Congenital Pyloric Stenosis
43
What is a Grade 1 Acquired Pyloric Stenosis?
Muscular hypertrophy
44
How would you treat a Grade 1 Acquired Pyloric Stenosis?
Heineke-Mikulicz
45
What is a Grade 2 Acquired Pyloric Stenosis?
Mucosal and Muscular Hypertrophy
46
What is a Grade 3 Acquired Pyloric Stenosis?
Submucosal, Mucosal, and Muscualr hypertrophy
47
What is the signalment for Acquired Pyloric Stenosis?
Small breeds: Lhasa Apso, Shih Tzu
Excitable or vicious
Middle aged males
48
What is the most useful diagnostic modality for Chronic Hypertrophy Pyloric Gastropathy?
Ultrasound
49
What are the clinical signs of Chronic Hypertrophy Pyloric Gastropathy?
Intermittent vomiting
Vomiting frequency increases over time
Dietary modification affects frequency
50
What do you see on Radiography with Chronic Hypertrophy Pyloric Gastropathy?
Gastric Distension
| Delayed gastric emptying
51
What do you see on Ultrasound with Chronic Hypertrophy Pyloric Gastropathy?
Pyloric wall and muscle thickness
52
Describe the Y-U pyloroplasty
Transposes antral wall to pyloric region
creates a wider pylorus
Suture antral flap to base
53
What pattern would you use in the Y-U Pyloroplasty?
Simple continuous
| Simple Interrupted
54
What is an advantage of the Y-U pyloroplasty?
Transection of gastrohepatic ligament provides better exposure
55
Why must you suture back the defect in the Y-U Pyloroplasty?
provides protection from gastric ulceration
56
When would you perform a Pylorectomy with Gastroduedenostomy?
Severe acquired pyloric stenosis in middle aged animals
57
What suture do you use with a Pylorectomy with Gastroduedenostomy?
3-0 monfilament PDS or monocryl suture
58
What forceps do you use with a Pylorectomy with Gastroduedenostomy?
Doyen Forceps
59
Doyen Forceps
Non traumatic forceps to decrease contamination from the GI contents
60
What are the advantages to the Billroth 1?
Abnormal tissue completely removed
| Large increase in gastric outflow
61
What are the disadvantages to the Billroth 1?
Technically difficult
Longer procedure
Increased risk of leakage
Resecting a lot of tissue and higher risk of dehiscence, leakage, and contamination
62
What is the most common Gastric Neoplasia in dogs?
Adenocarcinoma
63
What is the most common gastric neoplasia in cats?
Lymphoma
64
What are the clinical signs of Gastric outflow obstruction?
```
Vomiting
Anorexia
Regurgitation
melena
hematomesis
pain
weight loss
abdominal distension
```
65
What are the laboratory findings of Gastric Neoplasia?
Anemia
Acidosis
Hypochloremia
Hypokalemia
66
What is the signalment for Gastric Adenocarcinoma?
Older Males
67
Where is Gastric Adenocarcinoma usually located?
Pyloric antrum
| lesser curvature
68
Where does Gastric Adenocarcinoma usually metastasize?
Regional Lymph nodes
| Liver
69
What are the different types of Gastric Adenocarcinoma?
Infiltrative
Ulcerated mucosal plaques
Discrete polypoid
70
What are the most common forms of Gastric Adenocarcinoma?
Infiltrative
| Ulcerative mucosal plaques
71
Linitis plastica
a thickened tissue that is a line of demarcation of the tumor
72
What can you see on contrast radiographs with Gastric Adenocarcinoma?
Filling defects
Delayed gastric emptying
loss of rugal folds
mucosal thickening
73
What should you evaluated with ultrasound with Gastric Adenocarcinoma?
Liver and lymph nodes
74
What is the preferred test for diagnosis of Gastric Adenocarcinoma
Endoscopy
75
What are the treatments for Gastric Adenocarcinoma?
Aggressive surgical excision: Gastrectomy, Billroth 1, Billroth 2 or Cholecystoenterostomy
76
What is wrong with Billroth 2?
High Morbidity and aggressive
77
When is Gastrectomy indicated?
Neoplasia
Ischemic injury
Ulcer
Trauma
78
Billroth 2
Gastrectomy with gastrojejunostomy
79
What are the complications of Billroth 2?
Alkaline gastritis due to Bile and pancreatic secretions flowing into stomach
"Blind loop" syndrome - gastric contents move orally and putrefy
Marginal ulceration of the jejunum mucosa due to acid
80
What is the advantage of Roux-en-Y Anastomosis?
Avoids alkaline reflux gastritis and decreases likelihood of blind loop syndrome
81
What is still a problem with Roux-en-Y Anastomosis?
Marginal ulceration still an issue
82
What is the signalment for Gastric Leiomyosarcoma?
Middle aged
83
Where is the most common place for Gastric Leiomyosarcoma?
Cardia
| Pylorus
84
What is the signalment of Gastric Leiomyoma?
Older patients
85
How would you treat Gastric Leiomyoma?
Gastrotomy incision into the mucosa and scoop out the tumor from the submucosa
86
What time of year do you see Pythiosis?
Fall
| Winter
87
Where do you find Pythiosis?
aquatic environment
88
What is the signalment for Pythiosis?
young large breed working dogs
89
What layers of the stomach are affected by Pythiosis?
Submucosa and muscularis
90
What are the clinical signs of Pythiosis?
```
Weight loss
vomiting
diarrhea
hematochezia
palpable abdominal mass
```
91
How do you diagnose Pythiosis?
ELISA Snap Test
92
How do you treat Pythiosis?
Surgical excision
medical treatment
Itraconazole and Terbinafine
93
What is the prognosis for Pythiosis?
guarded to poor
94
GDV
Gastric Dilatation Volvulus
95
Acute Gastric Dilation
Stomach is in the normal position but distended
96
Chronic Gastric Volvulus
Slight malposition of the stomach
97
How do you treat Acute Gastric dilation?
Emesis and wait for digestion
98
How do you confirm GDV?
Contrast Studies
99
Gastric Dilation Volvulus
Distension of the stomach and rotation of the stomach on its mesenteric axis
100
What is the pathophysiology of GDV?
Stomach distension through gas, fluid or fermentation that limits eructation and emptying causing further distension, clockwise rotation of the stomach and pylorus
101
What are the different types of GDV?
Clockwise
| Counterclockwise
102
Clockwise GDV
70-360 degree rotation of the stomach
103
What is the key to identifying a Clockwise GDV?
Greater omentum covers stomach
104
Counterclockwise GDV
Limited to 90 degrees rotation
105
Which GDV is more symptomatic?
Clockwise GDV
106
What are the predisposing factors of GDV?
```
Large and Giant Breeds
Deep chested dogs
First degree relative
Faster eating
Larger volumes daily
Raised Food Bowls
Post prandial activity
Fats and oils
Restricting water before/after feeding
Egg or fish decreases risk
```
107
Why is age a predisposing factor?
ligaments of the stomach are stretched
108
What is the #1 cause of death in GDV patients?
Hypovolemic Shock
109
What are the cardiovascular effects of GDV?
```
Compression of low pressure veins
Decreased pre load, afterload, CO, BP
Catecholamines causing vasoconstriction, tachycardia, and increased BP
Arrhythmias
Myocardial hypoxia
Metabolic acidosis
Myocardial depressant hormone released
```
110
What is the most common Arrhythmia caused by GDV?
VPCs
111
What happens with Reperfusion injury?
Accumulation of toxic waste products from Anaerobic metabolism released into general circulation causing Capillary permeability, Altered vascular tone, platelet activation, vascular occlusions, Fever, Negative Inotrope
112
What are the respiratory effects of GDV?
```
Impingement on diaphragm
Decreased excursions
Decreased TV
Increased CO2
Respiratory acidosis
```
113
What are the GIT effects of GDV?
Gastric distension
Vascular compromise of stomach mucosa
Mucosal hemorrhage and necrosis
114
What are the metabolic effects of GDV?
```
Poor tissue perfusion
Cellular hypoxia
Anaerobic metabolism
Increased Lactate
Metabolic acidosis
```
115
What are the immune effects of GDV?
```
Hypoxemia causes mucosal ischemia
Loss of protective barrier
Bacterial translocation
Damage to mucosal associate lymphatics
Portal hypertension
```
116
What happens to Potassium with GDV?
Potassium shifts outside of the cells
Catecholamines shift potassium intracellular
Potassium sequestered in gut and lost from vomiting
117
What happens to Glucose with GDV?
Decreased perfusion causes Anaerobic metabolism and inefficient glucose utilization causes Hypoglycemia
118
What are the Renal effects of GDV?
Profound vasoconstriction causes increased BP and decreased GFR
Oliguria/Anuria
Acute renal failure
119
What are the physical findings of GDV?
```
Distended painful tympanic abdomen
Active retching
Hypersalivation
Tachypnea
Tachycardia
Collapse
```
120
What are the laboratory findings of GDV?
```
Increased WBC (stress leukogram)
Increased ALT
Increased bilirubin
increased BUN/Creatinine
Hypokalemia
Increased lactate
Decreased clotting times become increased clotting times and DIC
```
121
What radiographic view is diagnostic for GDV?
Right Lateral
122
What do you see on radiographs for GDV?
Gastric dilation with compartmentalization
Malposition of pylorus
"Double bubble" sign
123
What is the first treatment for GDV?
Fluids
124
What are the treatments for GDV?
Fluids
Decompression
Pain Management
Antimicrobials and free radical scavengers
125
Why do you give antibiotics for GDV?
Bacterial translocation due too sloughing and hemorrhage of the GI tract
126
What does free radical scavengers treat with GDV?
reperfusion injury
127
What fluids do you use with the treatment of GDV?
Combination of
| Crystalloids and Colloids
128
What is a prognostic indicator of GDV?
Lactate
129
Why do you use Colloids in the treatment of GDV?
decrease third spacing from reperfusion injury
130
What vein is the less desirable for the fluid administration in the treatment of GDV?
Saphenous
131
What is a possible complications from Gastric Decompression?
Esophageal perforation
| CV instability from endotoxins
132
What are the different types of Gastric decompression?
Orogastric intubation
Trocharization
Emergency gastrostomy
133
What is the advantage to Gastric Decompression?
Improves cardiac and respiratory function
134
What do you perform when you are unable to pass a orogastric tube?
Trocharization
135
What is a complication of trocharization?
Puncturing the spleen
| Lacerating the stomach causing peritonitis
136
What is the last procedure you perform after trocharization and orogastric intubation have failed for gastric decompression?
Emergency Gastrostomy
137
What approach do you make for an Emergency Gastrostomy?
Right Paracostal Approach
138
Describe the Emergency Gastrostomy
Incision through the abdominal Muscles to isolate the stomach. Suture the stomach to the incision and incise the stomach
139
What is the disadvantage of the Emergency Gastrostomy?
Will have to do more repaire when you reach surgery and some reconstruction
140
What are some other important treatments for GDV?
Oxygen therapy
Pain control
Correct electrolyte imbalance
141
What should you AVOID in GDV treatment?
Glucocorticosteroids
142
Why should you avoid Glucocorticosteroids in GDV treatment?
They are immunosuppressive, delay healing, and ulceragenic
143
What are the free radical scavengers used in GDV treatment?
```
Acetylcysteine
Vitamin C and E
Selenium
Deferoxamine - iron chelator
Lidocaine
```
144
Why is it good to use Lidocaine for GDV treatment?
Treats arrhythmias
Free radical scavenger
Pain control
145
What are the goals of surgical treatment of GDV?
Determine gastric and splenic viability
Correct gastric and splenic positioning
Prevent gastric malposition recoccurence
146
What increases the mortality of GDV patients?
Gastric wall necrosis
147
How do you approach a GDV surgery?
Vental midline celiotomy
148
What will occur when you derotate the stomach?
Reperfusion episode
149
How do you assess gastric wall viability?
```
Peristalsis
Serosal color
Palpate for thinning or friability of the stomach wall
Pulsation of vessels
Bleeding of cut surfaces
```
150
What do you perform on a stomach with gastric necrosis?
Partial Gastrectomy
151
Where do you normally find gastric necrosis?
Greater curvature of the stomach
152
What layer must you engage for stomach apposition?
submucosal layer
153
When would you perform a Gastric Invagination?
If the stomach necrosis is small or questionable
154
What is a disadvantage of performing a Gastric Invagination?
High risk of obstructing gastric outflow at the pylorus
Stomach becomes smaller
Risk of gastric ulceration
155
What is an advantage of gastric invagination?
decreases contamination
156
What should you do before closing a patient after GDV surgery?
Evaluate the spleen
157
What should you evaluate the spleen for?
Venous congestion
vessel thrombosis
Spenic torsion
158
What should you do if you see splenic torsion in a patient with GDV?
Remove the spleen
159
What will happen if you have vessel thrombosis of the spleen?
shedding of Clostridial organisms
160
What do you suture in a Gastropexy?
Pyloric antrum/right lateral body wall
161
Why perform a Gastropexy?
decreases recurrence rate
162
What does Gastropexy not prevent?
dilation
163
What are the different types of Gastropexy?
Incisional
Belt Loop
Circumcostal
Tube Gastropexy/Gastrotomy
164
What type of suture do you use for a Gastropexy?
3-0 or 2-0 monofilament absorbable suture
165
What is the disadvantage of the Belt Loop and Circumcostal Gastropexy?
Takes longer than the incisional method
166
What is the advantage of a Tube Gastropexy/Gastrostomy?
Allows the patient to be fed through the tube after surgery
| Maintains decompression of the stomach
167
When do you perform a Tube gastropexy/Gastrostomy?
when a patient has severe necrosis and will not be eating well after surgery
168
What is the pathophysiology behind Intestinal Foreign Body?
Proximal gas and fluid accumulation
| Wall Ischemia
169
What causes distension?
Accumulation of secretions proximal to the obstruction
170
What complications come from distension?
venous congestion
mucosal sloughing
bacterial translocation
peritonitis
171
What are the clinical signs of Intestinal Foreign Body?
```
Anorexia
vomiting
depression
abdominal pain
diarrhea
```
172
What do you see on radiographs with and intestinal foreign body?
Multiple loops of gas filled dilated intestines
| Ratio-small intestine diameter/ L5 height
173
What is the treatment for Intestinal Foreign Body?
Explore the entire abdomen
Enterotomy
Evaluate viability of the Intestines
174
How do you evaluate Intestinal viability?
```
Peristalsis-pinch test
Color
Pulsation of vessels
Wall texture/thickness
Fluorescein infusion
Surface oximetry
```
175
What is the incision used in Enterotomy?
Longitudinal incison
176
What suture do you use with an Enterotomy?
3-0 monofilament
177
What suture pattern do you use with an Enterotomy?
Simple continuous
| Simple interupted
178
What is important to do with an Enterotomy?
Ometalize
179
Why do you Omentalize?
```
Angiogenic
Immunogenic
Adhesive
Controls infection
Lymph drainage
```
180
What are the indications for Resection and Anastomosis?
Removal of necrotic or ischemic intestines
Removal of irreducible intussusceptions
Removal of traumatized intestine
Removal of neoplasms
181
What forceps do you use during an Enterotomy?
Doyen Forceps
182
What suture would you use during an Enterotomy that is less susceptible to infection?
Monofilament synthetic absorbable or non absorbable
183
What are the different Suture choices for closing an Enterotomy?
Monfilament suture
| Surgical staples
184
What are the complications for Multifilament absorbable suture in an Enterotomy?
More tissue drag
| Potentiates infection
185
What is the layer of strength in the intestine?
Submucosa
186
What is the reason for apposing the submucosa in the intestinal surgery?
Water tight seal
| Better healing
187
What suture pattern is not used for Intestinal surgery?
Inverting pattern
| Double layer closure
188
What are the complications for using double layer closure and inverting pattern in an enterotomy?
decrease lumenal size
predispose to obstruction
compromise blood supply to that segment and less likely to get submucosal apposition
189
What is the best suture pattern for an enterotomy?
Modified Gambee
190
What are the four ways to Manage Lumen Disparity?
1. Angle the smaller segment to increase the surface area to attach to the larger diameter
2. place sutures in a more strategic manner to corrugate and suit the other diameter
3. "fish mouth" the smaller diameter to attach to the other segment
4. suture part of the larger diameter to make it smaller to attach to the smaller segment
191
Serosal Patching
Securing a antimesenteric border of small intestine over a suture line or defect
192
What are the indications for Serosal Patching?
When omentum is not available
Closure integrity is questionable
Non resectable duodenal defects
Enterotomy, Colotomy, Urinary bladder
193
What is a linear Foreign Body?
```
Thread
Nylone
Stocking
Rope
String
```
194
What species are Linear Foreign Bodies common in?
Cats
195
Where does Linear Foreign Bodies anchor?
Base of tongue
| Pylorus
196
What is the complications of Linear Foreign Bodies?
embed in mesenteric border
| perforate intestines
197
What are the clinical signs of Foreign Bodies?
```
Vomiting
Anorexia
depression
Abdominal pain
Clumping and pleating of intestine
```
198
What do you see on Radiographs with Linear Foreign Bodies?
Plicated intestines
| Bunched in central abdomen
199
What do you see on Contract study with Intestinal Foreign Body?
Obvious pleating
| Teardrop shaped air bubbles
200
What is the treatment for Linear Foreign Bodies?
Free FB from under the tongue
| Enterotomy
201
What are complications of Intestinal surgery?
Septic peritonitis
Adhesions
Dehiscence risk factors
202
What risk factors cause Dehiscence?
Technical errors
Multiple Intestinal procedures
Pre-existing peritonitis
Lack of omentum
203
What causes Intestinal Ileus?
Stimulation of sympathetic nervous system
Rough tissue handling
Long surgical time
Extensive resection
204
What are the clinical signs of Intestinal Ileus?
Regurgitation
vomiting
pain
205
How do you treat Intestinal Ileus?
Fluids
electrolytes
prokinetics
206
How do you avoid Short bowel syndrome?
Provide nutritional support to allow the bowel to adapt
| Allow intestinal adaptation
207
What is the problem with Short Bowel Syndrome?
May never resolve
208
Intussusception
Invagination of one portion of bowel loop into an adjacent segment
209
What is the etiology of Intussusception?
Previous illness: virus, bacteria or parasites
| Recent intestinal surgery
210
What is the clinical signs of proximal intussusception?
vomiting
| Abdominal pain
211
What is the clinical signs of Distal Intussusception?
Tenesmus
| Abdominal pain
212
What do you see on radiographs with Intussusception?
Abdominal mass effect
| Gas accumulation proximally
213
What is the surgical management for Intussusception?
Attempt manual reduction
resection and anastomosis of necrotic bowel
Perform enteroplication
214
Mesenteric Torsion
Intestine twisting on mesenteric axis
215
What are the possible causes for Mesenteric Torsion?
Lymphocytic enteritis
Ileocolic carcinoma
GIT foreigns body
216
What are the clinical sign sof Mesenteric torsion?
Abdominal distension
Hematochezia
Collapse and death
217
How do you treat Mesenteric Torsion?
Fluid resuscitation
| immediate surgery: untwist the torsion and resection/anastomosis
218
What is the most common intestinal malignancy in dogs?
Adenocarcinoma
219
What is the most common rectal neoplasia in dog?
Adenomatous polyp
220
What is the most common neoplasia in cats?
Lymphosarcoma
| Adenocarcinoma
221
What is the clinical signs of Intestinal neoplasia?
```
Depression
Anorexia
lethargy
vomiting
weight loss
diarrhea
```
222
How do you treat intestinal neoplasia?
Resection
223
What are the techniques for surgical intestinal biopsy?
Longitudinal biopsy with longitudinal closure
Longitudinal biopsy with transverse closure
Transverse biopsy
Dermal Punch
224
What are the advantages of Ultrasound Guided biopsy?
Obtain sample from any part of the intestine
Safe and quick
Can sample lymph nodes or other masses
225
What are the disadvantages of Ultrasound Guided biopsy?
Insensitive in detecting mucosal lesions
can miss focal lesions
tumor seeding
226
What is the advantage of flexible endoscopy biopsy?
Least Invasive
| Able to visualize mucosa
227
What is the advantage of Laparoscopic assisted Biopsy?
Can biopsy jejunum and other organs
| Full thickness biopsies
228
What is the disadvantage of Laparoscopic assisted Biopsy?
Cannot visualize mucosal lesions
229
What antibiotic would you choose for the Proximal Small intestine?
1st generation cephalosporin
230
What antibiotic would you choose for the Distal and large intestine?
2nd generation cephalosporin
231
What is the post op care for intestinal surgery?
Taper fluid and electrolyte therapy as oral intake returns
Offer water 8-12 hours post op
If no vomiting offer bland food the day after surgery
Pain management
232
What should you monitor in GI surgery patients?
```
General attitude
MM
Abdominal palpation
Temp
CBC
Abdominocentesis
```
233
What is the function of the spleen?
Reservoir for platelets, phagocytes, RBC
Lymphocyte production and storage
Extramedullary hematopoeisis
Filtration of blood: removal of abnormal RBCs, infectious organisms, denatured hemoglobin
234
What is the diagnostic of choice for the Spleen?
Ultrasound
235
What are the differntials for a Hyperechoic Spleen?
Nodular hyperplasia
Neoplasia
Hematoma
236
What is a Hypoechoic rim with a Hyperechoic center on Ultrasound of the spleen?
Malignancies
237
What suture would you use for Splenorrhaphy?
4-0 monofilament absorbable suture
238
What is the suture pattern for Splenorrhaphy?
Interrupted mattress pattern
239
How would you control hemorrhage of the spleen?
direct pressure
240
What is the advantage of Partial Splenectomy?
Preserves function
241
What are the indications for Partial Splenectomy?
Focal abscesses
| Focal injury
242
What are the contraindications for a Partial Splenectomy?
Neoplasia
243
What are the indications for Total Splenectomy?
Neoplasia
Torsion
Severe trauma
IMHA refractory to medications
244
How would you approach a Total Splenectomy?
Ventral Midline
245
Why must you handle the spleen gently during a Total Splenectomy?
Iatrogenic rupture
246
Where on the Spleen must you perform a double ligation during a Total Splenectomy?
Hilus
247
What is the advantage of approaching the spleen from the ometal bursa during a Total Splenectomy?
Fewer ligatures
Less Manipulation
Zone of Resection
248
What causes a symmetrical generalized Splenomegaly?
Inflammation: Bacteria, Viral, Fungal, parasitic
Immune Reaction
Congestion: RHF, Portal Hypertension, VAscular outflow obstruction, or Drugs
Infiltration: Neoplasia
249
What causes an asymmetrical Localized Splenomegaly?
```
Nodular Hyperplasia
Segmental infarction
Siderotic plaques
Splenosis
Neoplasia: Benign or Malignant
```
250
What is a complications of Nodular Hyperplasia?
Rupture causes Hemoabdomen
251
What causes splenic infarction?
Thrombosis or hypercoagulable states: Renal Disease, Hyperadrenocorticism, Neoplasia, DIC, Heart Disease,
Prior Splenic Torison
252
Siderotic Plaques
Tan or rust colored plaques on the margin primarily of iron or calcium caused by aging
253
What causes Splenosis?
Congenital or traumatic
254
Splenosis
Multiple nodules of normal splenic tissue in the abdominal cavity caused by trauma or congenital
255
What are the surgical treatments for Splenic Trauma?
Splenorrhaphy
Partial Splenectomy
Total Splenectomy
256
What are the diagnostic measures for Splenic Trauma?
Serial PCV/TP
| Measure abdominal circumference
257
Splenic Torsion
Twisting of the spleen on its vascular axis
258
What are the possible etiologies for Splenic torsion?
Abnormality or trauma of gastrosplenic or splenocolic ligament
Maybe GDV
259
What are the clinical signs of Acute Splenic torsion?
Acute abdominal pain and distension
Arrhythmias
DIC
Collapse
260
What are the clinical signs associated with Chronic Splenic torsion?
Lethargy
Anorexia
Intermittent vomiting and Diarrhea
Weight loss
261
What is the treatment for Splenic Torsion?
Splenectomy
| Gastropexy
262
What are the clinical signs of Splenic Hemangiosarcoma?
```
Decreased appetite
Anorexia
Lethargy
Weight loss
Abdominal distension
Acute collapse
```
263
What is the treatment for benign Splenic Masses?
Splenectomy and Histopathology
264
What is the treatment for Splenic Hemangiosarcoma?
Stabilize the patient
| Splenectomy
265
What are the complications of Splenectomy?
```
Improper ligation
other abdominal tumors
Ligation proximal to pancreatic artery
Splenic torsion
VPCs
Myocardial hypoxia from hypertension and anemia
MDF from pancreas
```
266
What are the functions of the pancreas?
Digestive secretions
Insulin
Gastrin
267
What is the complications of removing the Pancreas?
the dog becomes diabetic and loss of exocrine function
268
What are the indications for a partial pancreatectomy?
Pancreatic abscess
Pseudocyst
Isolated mass
Focal trauma
269
What is important in a Partial Pancreatectomy?
maintain ducts!
270
What is the treatment for Pancreatic Abscess?
Drainage
Debride
Omentalize
271
Pancreatic Pseudocyst
Pancreatic secretions and debris within fibrous sac
272
What is the treatment for Pancreatic Pseudocyst, if it is asymptomatic and single cyst?
Monitor by Ultrasound
273
What is the treatment for Pancreatic Pseudocyst if greater than 4cm and symptomatic?
Ultrasound guided aspiration
274
What is the treatment for Pancreatic Pseudocyst if it reoccurs or signs persist after aspiration?
Resect if possible
| Debride and drain
275
What is the most common Exocrine Pancreatic Neoplasia of Dogs and Cats?
Adenocarcinoma
276
Where does Adenocarcinoma originate from in the Pancreas?
Acinar cells or ductal epithelium
277
What is the treatment of Exocrine Pancreatic Neoplasia?
Surgical resection
| Palliative (Billroth 2)
278
What is the problem with Insulinoma?
Secrete insulin despite Hypoglycemia
279
What is the medical management of Insulinoma?
```
Frequent small meals
Restrict exercise
Glucocorticosteroids
Diazoxide - oral hyperglycemic
Streptozocin - destroys beta cells
```
280
What are the surgical treatments for Insulinoma?
Allows resection
| Partial pancreatectomy
281
How can you find the insulinoma and identify islets?
IV methylene blue
282
Gastrinoma
Tumor of non Beta islet cells
Secretes excessive gastrin
Increased gastric acid secretion
Leads to gastric ulceration
283
How do you treat a Gastrinoma?
Exploratory
| Resection
284
What is the treatment for Trauma of the liver?
Ligate severed vessels
Partial Lobectomy
Complete Lobectomy
Pringle manuever
285
What is the Pringle Maneuver?
Temporary occlusion of portal vein and hepatic arteries to aid in identification of source of bleeding and plan repair
286
What are the most common primary tumors of the Liver?
Hepatocellular
| Cholangiocellular
287
In what species are Liver tumors more common?
Dogs
288
What are the 3 forms of Hepatocellular tumors?
Massive
Nodular
Diffuse
289
Massive Hepatocellular tumors
Good prognosis with complete surgical excision
290
Nodular Hepatocellular tumors
Metastasis more likely
| Complete excision unlikely
291
Diffuse Hepatocellular tumors
Poor prognosis
| Metastasis to LNs, peritoneum, and Lungs
292
In what species are Cholangiocellular tumors more common?
Cats
293
How do you treat Cholecystitis/Cholangiohepatitis?
Treat medically if not ruptured
| Cholecystectomy
294
W\hat are the possible etiologies of Biliary Mucoceles?
Hyperplasia of mucus-secreting cells and excessive mucus secretion
Alterations in gallbladder motility
Accumulation of inspissated bile
295
What endocrinopathies are Biliary Mucoceles associated with?
Hyperadrenocorticism
| Hypothyroidism
296
What is a complication of Biliary Mucoceles?
Gallbladder rupture
297
What is the signalment for Biliary Mucoceles?
Shetland Sheepdoogs, Cocker Spaniels, and Miniature Schnauzers around the age of 9
298
What is the treatment for Biliary Mucoceles?
Choleretics
Cholecystectomy
Antibiotics
299
Choleretics
increased the flow and increase the turnover of bile - thinning the bile
300
What causes Intraluminal Biliary obstruction?
```
Inflammatory disease
Choleliths and Choledocholiths
Neoplasia
Inspissated bile
Parasites
```
301
What causes Extraluminal Biliary obstruction?
Pancreatic disease
| Duodenal disease
302
When is a Cholecystotomy indicated?
decompress gall bladder and/or antegrade catheterize of bile duct prior to cholecystectomy
303
Choledochotomy
Bile duct exploration/reconstruction
304
What is the importance of the Central division of the liver?
Caudal vena cava goes through the liver and the gallbladder is located here
305
What artery supplies the gallbladder?
Cystic artery
306
Complete lobectomy of the liver
Removal of lobe near to or at the level of the hilus
307
What division of the liver is more accessible for complete lobectomy?
Left division
308
What division is more difficult to perform a complete lobectomy?
Central and right
309
What are the Liver Biopsy Techniques?
```
Fine needle aspirate
Tru-cut needles
Laparoscopic
Skin biopsy Punch
Guillotine Technique
```
310
What is the thickness you should not exceed with a Punch Biopsy?
1/2 the thickness of the liver
311
When is a Partical and Complete Lobectomy indicated?
```
Biopsy
Neoplasia
Trauma
Abscess
Cysts
```
312
When should you perform a Complete Liver Lobectomy?
Should only be used for Left lateral and left medial liver lobectomy
313
What technique results in the most blood loss with the liver?
Partial Lobectomy
| Parenchymal Fracture and ligation
314
Choledochal Stenting
most commonly done to relieve obstruction due to extraluminal compression secondary to pancreatitis
315
What is used for Choledochal Stenting?
Red Rubber Catheter
316
When do you perform a Cholecystotomy?
suspected temporary biliary obstruction
| Pancreatitis
317
Describe a Cholecystotomy
a catheter is places laproscopically or surgically to divert bile flow externally through the body wall caudal to the last rib on ventral abdominal surface
318
What are the indications for Cholecystectomy?
```
Necrotizing cholecystitis
Chronic Cholecystitis
Biliary mucocele
Cholelithiasis
Neoplasia
Trauma
```
319
What must you perform before a Cholecystectomy?
duodenotomy with catheterization of bile duct to confirm patency of bile duct
320
What is the complication of excising the gallbladder?
getting into the bile duct resulting in a transection of small hepatic ducts leading to bile peritonitis
Bleeding due to failure to ligate the cystic artery
321
When would you perform a Biliary Diversion?
Irreparable obstruction or trauma of common bile duct
322
Cholecystoduodenostomy
Attaching the gallbladder to the duodenum
323
Cholecystojejunostomy
Attach the gallbaldder to the jejunum
324
What is a complications of a Cholecystoduodenostomy?
risk of the gallbladder becoming impacted with ingesta causing cholecystitis and/or cholangiohepatits
325
What are the complications associated with Biliary diversion?
Leakage
Stroma stricture
Ascending infections - Cholangiohepatitis
326
What is an advantage to using the Thoracoabdominal stapling technique?
Fast
| Results in minimal hemorrhage
327
Portosystemic Shunt
Anatomic anomaly resulting in abnormal communication between the portal vasculature and the systemic vasculature
328
Patent Ductus Venosus
Failure of closure results in left side intrahepatic shunt
329
What are the classifications of Portosystemic Shunts?
Macrovascular
| Microvascular
330
How do you treat microvascular Portosystemic Shunts?
Liver transplant
331
How does trauma cause the formation of Portosystemic Shunts?
a vessel is damaged and heals back to another vessels the wrong way
332
What breeds are predisposed to Extrahepatic PSS?
```
Yorkies
Shih Tzu
Maltese
Poodle
Schnauzer
Dachshund
Pugs
```
333
Extrahepatic Shunts
Veins that should join the portal vein enter the caudal vena cava or azygous vein instead
334
What veins are most commonly involved in Extrahepatic Shunts?
Left Gastric Vein
| Splenic Vein
335
What breeds have Intrahepatic PSS?
Large breeds: Labrador retriever, Golden Retriever, Australian Shepherd
336
Intrahepatic Portal Vein Hypoplasia
Microvascular shunting within the liver
337
What is a laboratory test for Portal Vein Hypoplasia?
Protein C
338
What is the treatment for Portal Vein Hypoplasia?
Medical management: Diet
339
What diseases cause Multiple Extrahepatic PSS?
Cirrhosis
Non-cirrhotic portal hypertension
Hepatic A-V malformation
340
Multiple Extrahepatic Shunts
Vestigial embryonic communications that can "open up" preventing lethal portal hypertension from developing
341
What are some physical exam findings in cats with Multiple Extrahepatic Shunts?
Ptyalism
Copper Colored irises
Aggressive behavior
342
What can you perform to diagnose a portosystemic shunt?
Portography
| Nuclear Scintigraphy
343
Where do you inject for a Portography?
Mesenteric Vein
344
What is the gold standard for diagnosing Portosystemic Shunt?
CT Angiography
345
What is the medical management for Portosystemic Shunts?
```
Diet with reduced protein
Lactulose
Antimicrobials
Control Intestinal parasites
Seizure control/prevention
```
346
What is a poor prognostic indicator for improvement after surgery with portosystemic shunts?
Lack of improvement in clinical signs from medical management
347
What are the surgical options for Extrahepatic PSS?
Acute ligation/attentuation
| Gradual attenuation: Ameroid Constrictors, Cellophane Banding
348
Describe an Ameroid Constrictor
Hygroscopic casein ring surrounded by metal or plastic sheath
349
What are the complications of Acute occlusion?
Rapid closure
| kinking
350
What are the complications of Chronic occlusion?
Incomplete occlusion
Acquired shunts
Implant migration
351
What is the surgical management for Intrahepatic Shunts?
Extravascular occlusion
| Inravascular occlusion
352
What are the acute postoperative complications for surgery for Intrahepatic shunts?
```
Portal hypertension : Hypovolemic Shock, Hypothermia, Weak pulses, Abdominal pain and swelling, vomiting, diarrhea
Hypoglycemia
Seizures
Hemorrhage
Electrolyte disturbances
Portal vein thrombosis
```
353
What are the chronic postoperative complications for surgery for Intrahepatic shunts?
Recurrence of signs
354
Name some Immediate Postoperative Management for surgery of Intrahepatic Shunts?
```
Fluid therapy
Early food intake
Monitor vitals
Monitor for portal hypertension
Monitor for seizures
Avoid hypothermia
```
355
When is the minimum time for a recheck on surgery from intrahepatic shunts?
4-8 weeks
356
What is the post op monitoring for intrahepatic shunt surgery?
Routine blood work
Liver function tests: Protein C
Repeat imaging: Ultrasound, nuclear scintigraphy and/or angiography
357
Omentum
Peritoneal fold between greater and lesser curvature of stomach
358
Describe the properties of the Omentum
```
Rich blood supply
High absorptive capacity
Pronounced angiogenic activity
absorbs bacteria
Plays role in isolating and sealing of contamination source: abscess or intestinal perforation
```
359
Peritonitis
Inflammation of the peritoneal lining
360
What is the pathophysiology of Peritonitis?
Inflammation --> Vasodilation --> Hypovolemia --> SIRS/DIC/MODS
361
What factors can worsen the severity of inflammation and clinical signs of peritonitis?
High levels of bacterial contamination
Virulence of organism
Presence of adjuvants
Adequacy of local and systemic immune responses
362
What adjuvants can worsen the severity of peritonitis?
Gastric mucin
Bile
Foreign material
Blood/ Hemoglobin
363
How do you classify Peritonitis?
Primary vs. Secondary
364
Primary Peritonitis
Source of inflammation is outside of abdomen
365
Secondary Peritonitis
Source of inflammation is within the abdomen
366
Aseptic Peritonitis
Absence of infectious organisms within peritoneal fluid
367
Septic Peritonitis
Presence of infectious organisms within peritoneal fluid
368
What is an example of Primary Aseptic peritonitis in Cats?
Feline Infectious Peritonitis
369
Describe Primary Septic Peritonitis
Hematogenous or lymphatic spread of bacteria; translocation from GI tract and possibly oviduct
370
Examples of Secondary Aseptic Peritonitis
Chemical Peritonitis: Bile Peritonitis, Pancreatitis, Uroperitoneum
Peritoneal Foreign body
Mechanical peritonitis: Sclerosing encapsulating peritonitis
371
What is the most common source of infection in Secondary septic peritonitis?
GI tract
372
What are the early non-specific clinical signs of Septic Peritonitis?
Vomiting
Lethargy/Depression
Inappetance
Abdominal Pain
373
What are the signs of more severe systemic illness that occur with worsening condition of Septic Peritonitis?
```
Hyper- or Hypothermia
Weakness/collapse secondary to hypotension
Tachycardia
Injected or pale MM
Abdominal effusion
```
374
What 2 or more changes indicate SIRS?
Heart Rate
RR
Temperature
WBC
375
What do you see on CBC with Septic Peritonitis?
Leukopenia or leukocytosis
Left Shift
Thrombocytopenia
Anemia or Hemoconcentration
376
What do you see on Chemistry with Septic Peritonitis?
```
Hyperbilirubinemia
Hypoalbuminemia
Hyponatremia
Hyperkalemia
Hypoglycemia
Azotemia
```
377
What are some diagnostic tests for Septic Peritoneum?
Radiographs
Ultrasound
Abdominocentesis
Diagnostic Peritoneal Lavage
378
What Diagnostic Results are suggestive of septic peritonitis?
Pneumoperitoneum
| Abdominal effusion with intracellular bacteria and toxic/degenerate neutrophils
379
What are the systemic changes consistent with Sepsis/SIRS?
```
Hypotension
Elevated lactate
Tachycardia
Metabolic acidosis
Increeased ALT and T. Bili
Hypoglycemia
Hypoalbuminemia
Leukopenia or leukocytosis
Presence of bands with toxic changes
```
380
What is the treatment for Septic Peritonitis?
Exploratory celiotomy
| Stabilize the patient and correct the primary disease!!
381
What are the goals of Fluid therapy for Septic Peritonitis?
Improve perfusion
Treat hypotension
Improve metabolic acidosis
Correct electrolyte abnormalities
382
What types of fluid should be used for Septic Peritonitis?
Crystalloids and colloids
383
How do you treat Septic Peritonitis?
```
Fluid Therapy
Antibiotics
Analgesia
Pressors for treatment of hypotension
Dobutamine for CV support
Antiemetics
Blood products
Gastroprotectants/Antacids
```
384
What is the optimal Administration of Analgesia for Septic Peritonitis?
CRIs
385
What is the main treatment of Septic Peritonitis?
Surgery
386
What are the main goals of surgery for septic peritonitis?
Correct and contain the primary source of bacteria
Reduce peritoneal bacteria load
Remove foreign material, inflammatory mediators
387
How do you achieve the goals of surgery for Septic Peritonitis?
Repair/Remove source of bacterial contamination
Lavage
Debride tissues that are necrotic or cannot be decontaminated
Abdominal drainage
388
What should not be used in the abdomen?
Antiseptics
389
What is a complication of using Povidone Iodine in the abdomen?
Metabolic acidosis and can lead to complication rates
390
What is a complication of using chlorohexidine in the abdomen?
Interferes with normal healing process
391
What does Abdominal drainage allow in the treatment of septic peritonitis?
Allows for continuous removal of suppurative material from abdomen
Allows for continued evaluation of fluid character and cytologic changes
392
When would you consider putting in an abdominal drainage for septic peritonitis?
Moderate to Severe Peritonitis
393
What are the indications for Open Peritoneal Drainage?
Severe generalized peritonitis
Ongoing contamination
Extensive fibrinous adhesions
394
What are the advantages of Open Peritoneal drainage?
"Drain" entire abdomen
"Second look" opportunities
Repeated lavage
395
What are the disadvantages of Open Peritoneal Drainage?
Very high maintenance
Fluid/electrolyte/protein losses
Nosocomial infection
396
Why do you need to implement Enteral feeding after septic peritonitis surgery?
High metabolic demands due to massive protein losses
397
What are the feeding options for Septic Peritonitis?
Nasoenteric
Esophagostomy tube
Gastrostomy tube
Jejunostomy
398
What is the preferred method of feeding for a patient with septic peritonitis surgery?
Enteral feeding
399
What is commonly associated with vehicular trauma?
Uroabdomen due to bladder rupture
400
Is surgery always necessary for the treatment of uroabdomen?
NO!
