Lecture 7: Hemoperitoneum/Peritonitis (Exam 1) Flashcards
Define Hemoperitoneum/hemoabdomen
Abnorm accumulation of blood in the peritoneal cavity
What are the traumatic origins of hemoperitoneum
- HBC
- Kicks
- Falls
What is the #1 cause of hemoperitoneum in dogs & cats
Neoplasia
What is are other nontraumatic reasons for hemoperitoneum
- Non traumatic rupture of the adrenal gland
- Non malignant disease
What is the signalment of hemoperitoneum
- Younger are more likely to be trauma related (esp males)
- Older is more likely to be neoplasia
What can be found in the hx of a px w/ hemoperitoneum
- Trauma/suspected trauma
- Neoplasia is usually non specific
- Prev hemorrhage
- Access to toxins/rodenticide
- Prev dx of a mass
- Prev sx or dx procedure
- Rx
What does the PE of a px w/ hemoperitoneum look like
Anything from clinically norm to severe hemorrhagic shock
What can be seen in radiographs of a px w/ hemoperitoneum
Loss of abdominal detail w/ focal or generalized “ground glass” appearance
What is an AFAST exam
Abdominal focused assessment w/ sonography for trauma
What are the four views of an AFAST Eoxam
- Diaphragmaticohepatic (DH)
- Splenorenal (SR)
- Cystocolic (CC)
- Hepatorenal (HR)
T/F: Clinicopathologic abnorms in dogs w/ hemoabdomen are typically diff regardless of the cause of the abdominal bleeding
False; typically similar regardless of the cause
How is hemoperitoneum dxed
Finding nonclotting bloody fluid in the abdomen by the abdominocentesis or Dx peritoneal lavage (DPL)
Describe the use of DPL & FAST exam
The use of DPL in trauma is declining while the use of the FAST exam is rapidly replacing it
Why is the use of DPL decreasing
- Invasive
- Low specificity
- High rate of nontherapeutic laparotomies
- False negs
When do trauma px w/ hemoabdomen don’t need sx
When they stabilize after medical management often dont req sx
What is medical management of hemoabdomen
- IV fluid replacement therapy
- Blood transfusion
- Tight ab wrap during stabilization
- O2 therapy
What should be done during pre op
- Shock
- Correct abnorms before ax
- Blood transfusion if PCV < 20%
Describe anesthesia during sx for hemoperitoneum
- Anemic px need O2
- Avoid barbiturates
- Avoid acetylpromazine
- Hypotension due to volume depletion
What are the indication for sx
- Undetermined source of hemorrhage
- Uncontrolled hemorrhage
- Evaluation/removal of intra abdominal neoplasia
Define primary generalized peritonitis
Spontaneous inflammation of the peritoneum w/ no obvious intra abdominal reason for leakage of bacteria
Define secondary generalized peritonitis
Occurs in conjunction w/ an intra abdominal reason for the inflammation/infection (infectious & non infectious)
Describe secondary generalized peritonitis
- Predominant form in dogs
- Usually caused by bacteria
- Most originate from contamination from the GI tract
Why is differentiating primary peritonitis from secondary generalize important
B/c surgery is not routinely performed in primary generalized but is req in secondary generalized
Describe the bacterial association in peritonitis
- Gram + more common in primary
- Gran - more common in secondary
- Primary is more likely to be mono while secondary is more likely to be polybacterial
What is the signalment of peritonitis
Any age but younger animals are more common
What is the hx of peritonitis
- Often nonspecific
- Delayed onset of signs may be seen w/ trauma, mesenteric avulsion, & bile peritonitis
- Have had prev GI sx
What is the presenting complaint of a px w/ peritonitis
- Most = lethargy, anorexia, vomiting, diarrhea, &/or abdominal pain
- Cats = lethargy, depression, & anorexia
What should sick intact female dogs be evaluated for first
Pyometra
What can Radiographs show for a px w/ peritonitis
- Intestinal tract may be dilated w/ air, fluid, or both
- Free abdominal air
- Localized peritonitis can cause sentinel loop by making the duodenum appear to be fixed & elevated
What will show up in an ultrasound w/ peritonitis
- Collecting fluid
- Organ eval
- Pain is often the limiting factor for ultrasound
What is the classic description of radiographs in a px w/ peritonitis
Loss of abdominal detail w/ focal or generalized “ground glass” appearance
What is the most common lab findings in peritonitis
- Leukocytosis
- Neutrophil count may be norm or low
- Left shift is often present but not always
What is a prognostic indicator of peritonitis in cats
- Lactate levels
- Higher levels = poorer prognosis
What are the goals of medical management w/ peritonitis
- Eliminate cause of contamination
- Resolve the infection
- Restore norm fluid & electrolyte balance
What is the preferred dx method for abdominocentesis
Ultrasound
What are indication for abdominocentesis
- Shock w/ no cause
- Undx ab dx
- Suspicion of post op GI dehiscence
- Blunt or penetrating abdominal injury
- Abdominal effusion
- Undx ab pain
Describe an intraoperative peritoneal lavage
- Controversial
- Warmed isotonic saline is the most appropriate lavage fluid (~ 200 mL/kg)
- No evidence that adding antiseptics/antibiotics to lavage fluid is of benefit
- Not been shown to be of benefit in px w/ severe pancreatitis
What is an open abdominal drainage
- A small section of the abdominal incision is left open & sterile wraps are placed around the wound
- Not commonly used due to time & effort req
What are the advantages of OAD
- Improved metabolic condition
- Fewer ab adhesions
- Fewer abscesses
- Access for repeated inspection/exploration
What are the disadvantages of OAD
- Hypoalbuminemia
- Hypoproteinemia
- Anemia
- Nosocomial infections
When is closed suction drainage effective in dogs & cats
- Generalized peritonitis
- If effusion is serous in nature
T/F: Nutrition is a critical factor in pre op management
True
Describe the steps of an abdominocentesis
- Insert 18 - 20 g 1 1/2 in over the needle catheter (w/ added side holes) @ the most dependent point
- Don’t attach the syringe
- Allow fluid to drip rom the catheter
- If fluid does not drip use a 3 CC syringe w/ gentle suction
Describe a dx peritoneal lavage
- Make 2 cm skin incision caudal to umbilicus
- Hemostasis to avoid false pos
- Small incision into the linea alba
- Hold edges of incision while the peritoneal lavage catheter is installed (w/out trocar)
- Direct the catheter caudally into the pelvis
- Gently aspirate
- If neg aspiration attach the catheter to IV line w/ bag of warm sterile saline & infuse into the abdominal cavity
- Roll px gently side to side to disperse fluid
What is a warning about diagnostic peritoneal lavage
This tech does not reliably exclude significant retroperitoneal injury or hemorrhage
Describe the steps of the open abdominal drainage
- When closing the abdomen leave a portion of the abdominal incision open
- Usually big enough to insert your gloved hand
- Close the cranial & caudal aspects of the incision (monofilament absorbable suture in a cont pattern)
- Place a sterile laparotomy pad over the opening
- Change the wrap @ least 2 daily w/ the px standing
When should the ab incision that was used for open abdominal drainage be closed
- When bacterial #s have decline & neutrophils are no longer degenerative
- Usually @ 3 to 5 D post op
Describe the steps of closed suction drainage
- Attach suction reserve bulb to tubing w/ vacuum applied
- Place sterile protective bandage around the tube-skin interface
- Empty the bulb using aseptic tech & record the vol of fluid collected
- Remove the drain by cutting the suture & applying gentle traction
Describe the suture material used in peritonitis cases
- Use monofilament nonabsorbable suture or slowly absorbable suture
- Don’t used braided suture
- Don’t use suture that is rapidly degraded
What should be done post op
- Fluid therapy cont esp if OAD
- Monitor electrolytes, AB, serum protein & correct them as req
- Nasal oxygen if sepsis
- Ensure adeq caloric intake
- Consder plasma if hypoproteinemic
- Give analgesia
What is the prognosis of peritonitis sx
- Generalized = guarded
- Many survive w/ aggressive therapy
- ~50%
- Dogs w/ primary who underwent sx were less likely to survive than those w/ secondary
