Peritonitis Sx Flashcards
What layer in the embryo forms the parietal and visceral peritoneum?
Mesoderm
What are the three natural openings between the peritoneum and the pleural cavity?
Esophageal hiatus
Caval hiatus
Aortic hiatus
What is a normal fluid analysis of peritoneal fluid?
Protein <3g/dL
NCC: <300cells/ul
T/F: the peritoneum is a bidirectional membrane allowing for free exchange of peritoneal fluid and plasma
True
T/F: Mesothelial cells in the peritoneum produce surfactant
True
Lymphatic drainage
Occurs through diaphragmatic lymphatics to the mediastinal and sternal LN
Particles cleared from the peritoneal cavity appear in the lungs and systemic circulation very quickly
Peritoneal fluid may gain access to the peural space via the hiatal openings for the esophagus, cava, and aorta
Adhesion formation
Disease or Sx manipulation induces inflammatory cell and fibrin exudation into peritoneum
Adhesions do not persist if vascularity maintained
- Fibrinolysis of fibrinous adhesions occurs in 3-5d
With ischemia, fibrin is infiltrated by fibroblasts
Make collagen and fibrous adhesions
Adhesion prevention
Gentle tissue handling Accurate hemostasis Aseptic technique Prevent tissue dessication Remove blood clots and foreign debris Lavage before closure Do not leave behind gauze or talc! Fortunately, clinically significant adhesions are rare in small animals
Innate defenses
Complement, opsonins
- Natural antibacterial activity in peritoneal fluid
NK cells
Lymphatic drainage
Peritoneal associated lymphoid tissue
Absorption and localization capacity
Omental adhesive, angiogenic, and immunogenic properties
Inflammatory response
Injury or contamination Complement activation Mast cell degranulation N0 chemotaxis M0 phagocytosis Release of inflammatory mediators and cytokines SIRS
Primary peritonitis
Spontaneous inflammmation of the peritoneal cavity No obvious inciting cause Immunocompromise? Feline corona virus - FIP - Hematogenous route? Bacterial rare for primary - Gr + -Hematogenous? Mycobacterial Fungal -Blastomyces - Histoplasma - Candida
Aseptic Secondary Peritonitis
Non-infectious
- Chemical: gastric acid, bile, pancreatic enzymes, urine
- Mechanical and FB: suture, hair, sx swabs, gossypiboma, silk, linen
- Starch granulomatous: surgical glove powder, talc vs corn starch
- Parasitic: toxoplasma, cestodes
Protozoal: Neospora
Septic Secondary Peritonitis
Compromise of the integrity of the GIT
- Direct inoculation with endogenous bacteria
- Perforating intestinal FB
- Gastric rupture in GDV
- Perforating gastric or intestinal ulcers
- Colonic perforation
- Dehiscence of intestinal surgical site
- Iatrogenic perforation
- Trauma: blunt or penetrating
- Torsion or volvulus
- Ruptured viscus: pyo, bladder, gall bladder
- Abscess
Septic Peritonitis Hx
Anorexia, vomiting, lethargy
Trauma or recent Sx
Signalment, including neuter status
Compensated Shock
Tachycardia, bright red mm, rapid CRT, bounding pulses
Decompensated Shock
Tachy/bradycardia, pale mm, prolonged CRT, weak pulses
Septic Peritonitis PE
Temp variable
Painful abd with lack of bowel sounds
Vomiting, diarrhea, PU/PD, pyuria, dysuria, anuria, hematuria, vaginal or preputial discharge, penetrating wounds, hernias, icterus
Septic Abdomen Imaging
Rads: free peritoneal gas, evidence of volvulus or torsion or intestinal obstruction, loss of abd detail (ground glass), mass effect
Contrast: Upper GI, retrograde urethrocystogram, evaluation of gastrostomy or jejunostomy tube site integrity
US: Look around, get some fluid
Dx of Septic Abdomen
CBC: tWBC, band cells, anemia CS: LES, albumin, bilirubin, BUN, Cr, K UA: pyuria, bacteriuria UC: UTI PT/PTT: coagulopathy Lactate/glucose: compare to abd fluid cPLI, fPLI: pancreatitis Blood type: supportive care
Abdominocentesis
Needle tap of the abd cavity
Can be done blindly if large volumes of fluid present, or with US
18-20g needle, over-the-needle catheter, or buterfly catheter, 3-way stop cock, extension tubing, collection basin and sample tubes, culturettes
DPL (Diagnostic Peritoneal Lavage)
Using a peritoneal dialysis catheter or other long, over the needle catheter (14g, 3”)
Catheter into abd 1cm caudal to umbilicus
20-22mL/kg warmed, sterile isotonic or saline solution infused
Gently roll animal
Don’t need to empty entire fluid
Evaluate fluid
Grossly Cytologically Biochemically Microbiologically Once diluted, fluid analysis inaccurate
Abdominal fluid analysis
NCC: PMNs like N0 Protein: level depends on underlying dz Lactate: fluid to blood >+2.0mmol/L - 100% sensitive and specific for dogs, 86% sensitive and 100% specific for septic peritonitis in cats Glucose: F:B >-20mg/dL Bilirubin: F:B >2x Creatinine: F:B >2x Potassium: F:B >1x
Characteristics of a transudate
Decreased oncotic pressure, as with hypoproteinemia <1500 cells/uL, <2.5 protein
Characteristics of normal abdominal fluid
<300cells/uL, <3 protein
Characteristics of a modified transudate
1000-7000cells/uL, 2.5-7.5 protein
Characteristics of an exudate
> 5000cells/uL, >3protein
Abdominal fluid cytology
Numbers and types of cells present N0: degenerate vs non L0 Monocytes/M0 Abnormal cells: reactive cells, neoplastic cells
Treatment of Septic Peritonitis
Stabilize!
- Shock dose colloids/crystalloids, PRBCs, plasma
- ECG, BP
- Discern source of sepsis via imaging
- Abd exploratory
- Monitor: Art line, venous cath, urinary cath
Goals of Sx
Explore, debride, repair, lavage
Drain
- Primary without drainage
- Open peritoneal drainage
- Open peritoneal drainage with vacuum assisted closure
- Primary closure with closed suction abdominal drain
Post-op
Intensive care: BP, vol, electrolytes, nutrition, blood products, pain mgmt
Drain mgmt
Abx: broad spec IV empiric therapy pending C&S, then refine
Prognosis
High mortality
Survival rates 20-80%
Causes of death after septic abdomen
systemic inflammatory response syndrome (SIRS) Vasculitis DIC Bacteremia Pancreatitis Multiorgan Dysfunction Syndrome (MODS)
