Peritonitis

Question 1

What is peritonitis

Answer 1

Inflammation of the peritoneum and/or peritoneal cavity. The peritoneum is a serous membrane with a parietal and visceral layer, < 1ml/kg peritoneal fluid and is semi permeable.

Question 2

Briefly describe primary peritonitis

Answer 2

This is also know as spontaneous bacterial peritonitis because there is no identifiable source and the route of infection is hematogenous or bacterial translocation. This is not surgical and typically caused by gram positive bacteria

Question 3

Secondary Peritonitis can be caused by __ leakage of bacteria, infection or __ and __ causes such as neoplasia or surgical FB’s

Answer 3

Secondary Peritonitis can be caused by intra-abdominal leakage of bacteria, infection or abscess and non infectious causes such as neoplasia or surgical FB’s

Question 4

Tertiary Peritonitis

Answer 4

Severe persistent or recurrent infection after secondary peritonitis

Question 5

Sclerosing encapsulating peritonitis can be treated by trying to remove __ and resecting and anastomosing __ but has __ treatment success

Answer 5

Sclerosing encapsulating peritonitis can be treated by trying to remove adhesions and resecting and anastomosing intestines but has poor treatment success

Question 6

The etiology of peritonitis is typically of __ origin

Answer 6

The etiology of peritonitis is typically of GI origin

Question 7

Briefly describe the pathophysiology of peritonitis

Answer 7

Irritant -> vascular dilation -> increased capillary permeability -> phagocytosis

The omentum and mesentery is there to wall off and increase blood flow and lymphatics so when this fails = systemic inflammatory response

Question 8

History and clinical signs of a dog with peritonitis

Answer 8

Fever, anorexia, vomiting, diarrhea, lethargy, abdominal pain, abdominal dissension (fluid wave) , prayer position in dogs

Question 9

What might a physical exam of a dog with peritonitis look like?

Answer 9

There will be evidence of perfusion impairment that presents as dehydration, dull mental ion, mucous membrane color, weak PQ and/or blood pressure. There may also be indicators of SIRS/sepsis.

Question 10

When diagnosing peritonitis, what should you look for on rads or AUS and what would you see?

Answer 10

Expect to see pneuomperitoneum for up to 18-21 days

Question 11

Bloodwork for a patient with peritonitis

Answer 11

marked leukocytosis (toxic neutrophils), anemia, hypoproteinemia, electrolyte imbalances, acid-base abnormalities, pre- renal azotemia

Question 12

__ is the most helpful diagnostic for peritonitis

Answer 12

Abdominocentesis

Question 13

Briefly describe normal peritoneal fluid

Answer 13

• <1ml/kg non-clotting, clear, yellow fluid (straw colored)
• transudate should be <3000 nucleated cells/ul, 50% macrophages, 50% lymphocytes, <2.5 g/dL protein

Question 14

Transudate

Answer 14

<2.5g/dL protein
<1500 NC/ul

Question 15

Modified transudate

Answer 15

2.5-7.5 g/dL protein
1000-7000 NC/uL

Question 16

Exudate

Answer 16

> 3 g/dL protein
7000 NC/uL

Question 17

Uroabdomen

Answer 17

Transudate or modified transudate
Abdominal creatinine > serum 2x
Abdominal potassium > serum 1.4x

Question 18

Bile peritonitis

Answer 18

Modified transudate or exudate
Bile staining +/- phagocytized bile pigements
Abdomen bilirubin > serum 2x

Question 19

Septic abdomen

Answer 19

Intracellular bacteria
Abdominal fluid glucose > serum (1.1mmol/L)

Question 20

Treatment goals for peritonitis

Answer 20

DILUTION IS THE SOLUTION TO POLLUTION

-Correction of fluid and electrolyte imbalances
- stop the source of sepsis with exploratory laparotomy and copious lavage
- appropriate antimicrobial therapy
- drainage

Question 21

Medical management of peritonitis

Answer 21

• fluid replacement
• correct electrolytes and glucose imbalances
• antibiotics
• nutritional support (increased metabolic demand, protein loss, directly benefit to enterocytes and GIT, decreases bacterial translocation)

Question 22

Antibiotics for peritonitis currently include __ and __

Answer 22

Antibiotics for peritonitis currently include unasyn (amoxicillin) and cefoxitin

Question 23

Surgical management of peritonitis is done by a __ in which your goal is to stop the source of contamination. What common procedures would you perform during this?

Answer 23

Surgical management of peritonitis is done by a exploratory laparotomy in which your goal is to stop the source of contamination. Common procedures include debridement, drainage of abscess, resection and anastomosis

Question 24

What is the holding layer of the GI tract

Answer 24

Submucosa

Question 25

How might you provide nutrition support by surgical management of peritonitis?

Answer 25

Gastrostomy tube
Jejunostomy tube -> giving stomach a break
Esophagostomy tube -> food aversion, GI tract is fine
Total or parietal parental nutrition

Question 26

Pros and Cons of open peritoneal drainage

Answer 26

Pros: improves abdominal drainage, abdominal evaluation, increases oxygen (macrophage and neutrophil function), decreases bacterial burden, reduces adhesions and intraabdominal pressure

Cons: hypoproteinemia, electrolyte imbalances, potential herniating risk, increased hospitalization, risk of nosocomial infections

Question 27

Jackson Pratt is an __ system drainage

Answer 27

Closed

Question 28

Negative prognostic factors of peritonitis

Answer 28

Refractory hypotension
Cardiovascular collapse
Respiratory distress
Disseminated intravascular coagulation
Plasma lactate >2.5 mmol/L
Ionized hypocalcemia
Multiple organ dysfunction syndrome

Question 29

Mortality rates of peritonitis

Answer 29

26-68%, very variable