Lecture 16: Surgery in the vomiting patient Flashcards
1
Q
What are some gastric differentials for vomiting
A
- Dietary indiscretion
- FB
- Volume, speed, anxiety
- Pancreatitis
- GDV
2
Q
what are some SI differentials for vomiting
A
- FB
- AHDS
- Non-specific gastroenteritis
- IBD
- Intussusception
- Mesenteric torsion
3
Q
what would be primary differentials for vomiting in <6 months, 6-18 months vs >24 months
A
< 6 months, 6-18 months: FB
>24 months: other, neoplasia
4
Q
what is common cause of vomiting in miniature schnauzers and shelties
A
pancreatitis
5
Q
what is common cause of vomiting in labs and Rottweilers
A
FB
6
Q
what is common cause of vomiting in GSD
A
GDV
7
Q
what is common cause of vomiting in yorkie, Maltese, cat with copper colored iris
A
PSS
8
Q
How would vomiting be interpreted differently in intact vs neutered male
A
intact male- more likely to ingest something
9
Q
How would vomiting be interpreted differently in intact vs spayed middle to older aged females
A
intact- pyometra
10
Q
ex: 10yr FS shin tzu diagnosed with DM 3 months ago, on insulin therapy. Stopped eating yesterday, vomited 2 times this AM. Likely cause?
A
insulin overdose, hypoglycemia
11
Q
2yr FS lab at family BBQ yesterday, vomiting 6 times over night, likely cause?
A
FB
12
Q
7yr FI chihuahua lethargic, decreased appetite for several days, vomited once. Likely cause?
A
pyometra
13
Q
what is a common sign of abdominal pain
A
prayer position
14
Q
what are some tests you can run for severe vomiting, non-responsive to supportive care
A
- Endocrine tests- cortisol, ACTH stim
- Infectious disease
15
Q
what is included in the big 4
A
PCV, TS, glucose, azo
16
Q
what baseline blood samples should be collected for vomiting patient
A
cbc/chem, canine pancreas specific lipase test, bile acids
17
Q
total protein is increased with and decreased with what
A
Increased with: dehydrated, chronic inflammation
Decreased with: PLE, PLN
18
Q
what is urea increased and decreased with
A
increased with: dehydration, renal failure, blocked urethra, ruptured bladder
Decreased with: low dietary protein, sepsis, liver failure, PSS
19
Q
what is creatinine increased with
A
dehydration, renal dysfunction, blocked urethra, ruptured bladder
20
Q
what increased and decreases hepatic enzymes
A
increases: liver disease
Decrease: cirrhosis
21
Q
what increases lipase
A
acute pancreatitis in dogs, chronic renal failure
22
Q
t or f: lipase is useful to dx pancreatitis in cat
A
false
23
Q
glucose increases and decreases with what
A
increases with: stress, excitement, glucocorticoid therapy, cushings, DM
Decreases with: insulin overdose, insulinoma
24
Q
bilirbuin increases with what
A
fasting, hepatic lipidosis in cats, hemolytic disease, liver dysfunction, biliary obstruction
25
lactate increases with what
anaerobic metabolism, associated with complications and mortality
26
sodium increases and decreases with what
increases with dehydration
Decreases with addisons, renal disease
27
potassium increases and decreases with what
increases: addisons, severe renal failure
Decreases: chronic renal failure, vomiting, diarrhea
28
chloride increases and decreases with what
increases: acidosis, hypernatremia
Decreases: alkalosis, vomiting, hyponatremia
29
total CO2 increases and decreases with that
increases: metabolic alkalosis
Decreases: metabolic acidosis
30
calcium increases with what
dehydration, decreased phosphorus
31
what is primary thing looking for on rads for FB
segmental dilation of small intestines
32
what are 3 basic steps to evaluate rads for obstructive enteropathy
1. Identify colon
2. Identify SI with greater than normal diameter
3. Identify SI with normal diameter
33
what technique was used here to provide better visualization and would you say needs surgery or pass on own
Pneumocolonogram
Already in colon will likely pass on own
34
what is the normal ratio of SI external diameter to height of L5 in dogs
< or = 1.4
35
SI external diameter: height of L5 in dogs <__ unlikely to be obstructed, > __= possible distention, >__= likely obstruction
<1.4, >1.5, >2.4
36
based on intestinal diameter is patient obstructed or not
obstructed
37
SI external diameter ratio to height of cranial end plate of L2 in cats <__mm maximum normal distemper and >__= likely obstruction
12mm, >2x
38
how can you differentiate chronic lower intestinal obstruction with functional mechanical ileus
1. Wait, hospitalize and repeat rads
2. Ultrasound
3. Upper GI contrast study
39
ultrasound of SI what wrong
FB- casts hypoechoic shadow
40
for GI linear FB check under __ in cats
tongue or around base of tongue
41
t or f: for linear FB attempt to pull FB out through mouth
false!
42
What do you do if client declines tx for FB
1. Fluids
2. Repeat rads
3. Check glucose and lactate
4. Check O2 saturation
5. Analgesia
6. Antibiotics
7. Client education
43
what are some GI indications for emergency ex-lap
1. Foreign body not moving on rads
2. Obstruction getting worse
3. Severe GI compromise
44
what are some indications for emergency ex-lap from extra-GI causes
neoplasia causing secondary obstruction, abdominal hemorrhage or peritonitis (GB rupture, prostatic abscess, cysts)
45
what are some causes of severe GI compromise that warrant emergency ex-alp
1. Linear FB
2. Perforating FB or GI rupture
3. Complete intestinal obstruction
4. Peritonitis/sepsis
5. Neoplasms
6. Intussusception
7. Perforating or dissecting ulcer
46
what are the advantages to avoiding perioperative nausea and vomiting
1. Lowered risk for aspiration pneumonia
2. Prevent increase ICP or IOP
3. Improve recovery and post-op feeding
47
what is ASA status of II and some examples
mild systemic disease
Ex: BOAS, non-perforated GI
48
what is ASA status of III and some examples
severe systemic disease
Ex: hepatic, endocrine, perforated GI or UG
49
what is ASA status of IV and some examples
severe systemic disease that is life threatening
Ex: septic peritonitis, septicemia
50
what opioids have been show to increase vomiting when used as pre-anesthetics
morphine, hydromorphone, methadone
51
what is the first and only FDA approved medication for prevention of preop vomiting in dogs
maripotant/ cerebra
52
linear foreign bodies can be anchored proximally at __ or __
tongue base, pylorus
53
linear foreign bodies have potential for severe, diffuse intestinal injury due to trauma to __
mesenteric borders
54
What wrong
plication—> linear FB
55
what wrong
plication—> linear FB
56
describe process of removing linear FB in cats
1. Clamping any visible sublingual length
2. Perform gastrotomy- cut sublingual length and pull out of oral cavity, may attempt to remove intestinal portion- if can’t close gastrotomy
3. Perform enterotomy to remove intestinal part- milk FB into one segmented to limit to one enterotomy if possible
4. Perform resection and anastomosis if any perforated bowel- avoid multiple anastomosis
57
t or f: with linear FB if there is perforation you can simply close the perforation
false- must do resection and anastomosis
58
Describe process of removing linear FB in dogs
1. Check sublingual region but uncommon
2. Isolate stomach with lap sponges and perform gastrotomy in a vascular pre-pyloric region and remove
3. If no FB in stomach- perform enterotomy in middle of placated bowel and remove
59
how do you perform suture anastomosis leak test on bowel
1. Doyen forceps placed 10cm apart
2. Inject 12-15mL saline to create intraluminal pressure >25mmHg
60
what is a very common post-parvo complication
intussusception
61
define intussusception
telescoping of intestine into lumen of another part of intestine
62
what are some causes of intussusception
1. Parasitic enteritis
2. Viral enteritis
3. Linear FB
4. Previous abdominal sx
5. Neoplasia
63
what wrong
meniscus sign- sign for intussusception
64
ultrasound SI- what wrong
Intussusception
65
what is tx for intussusception
1. Sx reduction
2. Resection and anastomosis
66
how can you reduce recurrence of intussusception
1. Resection
2. Enteroplication
67
describe pathomechanics of GDV
1. Fast eating, stress or having one learner meal/day can cause bloat
2. Stomach dilates and twists
3. Compresses vital organs and compromised BF
68
how do you decompress GDV
trochar
69
what are the 3 necessary things in sx to tx GDV
1. Gastric decompression
2. Gastric derotation
3. Gastropexy
70
what is morality for GDDV
15-24%
71
what are negative indicators for GDV
1. Recumbent
2. Depression/coma
3. Dysrhythmias
4. Splenectomy
5. Partial gastrectomy
6. Gastric necrosis
7. Increased lactate
72
what is positive indicator for GDV
time from presentation to surgery
73
what can increase bloat in large breeds and lead to GDV
1. Elevated food dish
2. Fast eating
3. Age
4. Family hx
74
what may not decease risk of GDV
1. Restricting exercise before or after eating
2. Restricting water before and/or after meals
3. Feeding 2 or more meals/day
4. Moistening kibble
75
what can help prevent bloat and GDV
1. Do not elevate food bowls
2. Prophylactic gastropexy
3. Do not breed dogs who had GDV
4. Slow eating
76
In GDV, __ 24hr after initiation of fluid therapy was associated with increased in hospital mortality risk and 1 month post-op
hyperlactatemia
77
what is most common malignant gastric disease and most common location
adenocarcinoma
Location: pylorus
78
what are sx tx for adenocarcinoma
1. Billroth I: pylorectomy
2. Billroth II: gastrojejunostomy
79
what are 4 examples of malignant SI neoplasia
1. Adenocarcinoma
2. Lymphoma (cats)
3. MCT
4. Leiomyosarcoma/GIST
80
GIST vs. leiomyosarcoma: which is c-kit positive
GIST
81
what are some examples of benign intestinal neoplasia
1. Leiomyoma
2. Polyps
3. Pythiosis
82
what is tx for discrete gastric masses vs small cell lymphoma
masses: surgical resection
Small cell Lymphoma: chemo
83
what is prognosis for uncomplicated GI FB
excellent
84
what locations of GI FB can worsen prognosis
duodenocolic ligament
ICCJ
85
what prognosis do linear FB carry and when does it decrease
good prognosis—> decreases with peroration and sepsis to guarded
86
what are poor clinical outcomes/sequela to GI FB
1. Septic peritonitis
2. Short bowel syndrome
87
short bowel syndrome leads to __ following resection of >__% of SI
mesenteric volvulus, 75%
88
what wrong
mesenteric volvulus- global dilation
89
what are some risk factors for septic peritonitis
1. Poor sx technique
2. Unhealthy intestine
3. Pre-op peritonitis
4. FB
5. Hypoalbuninemia
6. Use of blood products
7. Delayed enteral nutrition
90
how do you dx septic peritonitis
1. Rads- difficult
2. AFASt and peritoneal fluid sample— glucose and lactate
91
what should you never use to evaluate rads for septic peritonitis
barium contrast
92
what histopath finding on peritoneal fluid sample indicates sepsis
degenerate neutrophils with intracellular bacteria
93
In septic cases fluid glucose is __than blood glucose due to __
lower due to bacterial utilization
94
what fluid -serum glucose indicates septic peritoneal effusion
difference of 20mg/dL
95
what blood-fluid lactate indicates septic peritoneal effusion
difference of 2mmol/L
96
what is tx for septic peritonitis
1. Ex-lap and correction
2. Obtain samples for bacteriology
3. Resection and anastomosis
4. Post-op drainage
5. Fluids
6. Abx
7. Nutrients
97
what is prognosis and common sequela to septic peritonitis
50% survival
SIRS common
98
what is short bowel syndrome
malabsorption after extensive SI resection
99
short bowel syndrome signs seen with >__% resection and potentially fatal if >__%
50%, 75%
100
what are some lab findings and clinical signs consistent with short bowel syndrome
1. Watery diarrhea
2. Weight loss
3. Electrolyte imbalances
4. Hypoproteinemia
101
what is pathophysiology of short bowel syndrome
1. Decrease mucosal surface area for absorption
2. Decreased transit time
3. GI hypersecretion
4. SI bacterial overgrowth
102
how do you manage short bowel syndrome
1. Adequate nutrition- small, frequent feedings, highly digestible diets
2. Supplement electrolytes and vitamins
3. Control SI bacterial overgrowth: probiotics and appropriate abx
4. Manage diarrhea
103
what were primary causes of death in post-op complications from anesthesia
cardiovascular and respiratory complications
104
why should you express urinary bladder prior to recovery
full or distended bladder can contribute to post-op pain
105
why should you position patient on padded, absorbent bedding in sternal recumbency post-sx
support airway and reverse atelectasis
106
if patient is vomiting or regurgitating in recovery how should you position them
1. Place head below stomach to allow passive drainage
2. Then place head above stomach
107
what do you do if patient regurgitates under anesthesia
1. Flush esophagus with water
2. Suction
3. Extubation ET tube with cuff partial inflated- reduced risk of stricture
