Peritonitis

Question 1

What is the difference between primary and secondary peritonitis?

Answer 1

Primary- inciting cause not found (ex: FIP)
Secondary - trauma, translocation of bacteria, dehiscence, abdominal rupture

Question 2

What is the most common type of peritonitis seen in vet med?

Answer 2

Secondary generalized septic peritonitis

Question 3

What body system are the majority of cases of peritonitis related to?

Answer 3

GI tract (36-73% of cases)

Question 4

Describe the pathogenesis of peritonitis

Answer 4

Injury leads to inflammation which leads to fluid leakage out of vasculature. Immune reaction (mast cell degranulation, cytokine release) causes more leakage and inflammation which then leads to hypovolemia/ ambuminemia and fibrin. If severe can lead to shock, SIRS, DIC

Question 5

What is the common signalment for peritonitis?

Answer 5

There’s not one
-if young animal, foreign body more likely

Question 6

What are some of the common things noted on history in peritonitis cases?

Answer 6

Recent abdominal surgery or foreign body, chronic steroid or NSAID use (can cause ulcers), trauma, intact (pyometra)

Question 7

What are the main clinical signs associated with peritonitis?

Answer 7

Vague- abdominal pain/fluid distention or wave, fever, anorexia, vomiting, diarrhea, lethargy

Question 8

If in hypovolemic shock, what might you see on physical?

Answer 8

Tachycardia, pale MM, delayed CRT, hypotension, severe dehydration, arrythmias, SIRS

Question 8

What diagnostics should you always perform in peritonitis cases?

Answer 8

CBC/chem
-PT/PTT (if times prolonged, think DIC and consider albumin transfusion)
-abdominocentesis (cytology/culture, lactate)

Question 9

What changes do you often see on CBC/chem in peritonitis cases?

Answer 9

Marked neutrophilia with toxic changes, anemia/hypoproteinemia, hypo/hyperglycemia, electrolyte abnormalities (low sodium and chloride if vomiting, low potassium if anorexic), azotemia, liver enzyme elevations

Question 9

What are some signs of peritonitis on Abdominal rads?

Answer 9

loss of serosal detail, ground glass, gas behind diaphragm

Question 10

What does the prognosis in peritonitis cases depend on?

Answer 10

Inciting cause

Question 11

What are some negative prognostic indicators in peritonitis cases?

Answer 11

Refractory hypotension, cardiovascular collapse, respiratory distress, DIC, lactate >2.5, ionized hypocalcemia, MODS

Question 12

What are the main surgical steps in a peritonitis case?

Answer 12

Exploratory laparotomy
- stabilize, administer appropriate antibiotics, control/fix problem, drain the abdominal cavity, consider placing drain or leaving open, consider feeding tubes

Question 13

What drugs are most important pre-op in these cases?

Answer 13

Analgesics- opioids
-shock bolus fluids (1/4 at a time with blood pressure rechecks in between)

Question 14

What is a good first line antibiotic choice in these patients?

Answer 14

Cefoxitin, ampicillin sulbactam (unasyn)
- can culture, but often does not affect treatment

Question 15

Describe the prep for these cases prior to surgery?

Answer 15

Clip HUGE margin, sternum to pubis and very wide
-be sure you have crazy amounts of warm sterile saline available and suction

Question 16

What should you be sure to look at during explore?

Answer 16

Gross observation, run GI tract, kidneys/bladder, pancreas/gall bladder, follow omentum

Question 17

Describe some general principles for GI surgery

Answer 17

Pack off area you are focusing on, remove foreign bodies, close, and always lavage

Question 18

What is the bandaid of the abdomen?

Answer 18

The omentum!

Question 19

When performing enterotomy, how should you close?

Answer 19

Single layer, full thickness, can do simple interrupted or continuous pattern

Question 20

What is important to remember when doing Resection and anastomosis?

Answer 20

Preserve blood supply as much as possible by cutting closer to main branches, need to close mesentery to prevent bowel entrapment

Question 21

What are the options for closure after abdominal surgery?

Answer 21

Primary closure with (2-3 at least) or without drain, or open closure
-if abdomen flushes out well and not too much inflammation, can do without drain

Question 22

What are the indications for leaving cavity open?

Answer 22

Excessive fibrin, debris, necrosis, inflammation