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Gastrointestinal > Peritonitis Sx > Flashcards

Peritonitis Sx Flashcards

1
Q

What layer in the embryo forms the parietal and visceral peritoneum?

A

Mesoderm

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2
Q

What are the three natural openings between the peritoneum and the pleural cavity?

A

Esophageal hiatus
Caval hiatus
Aortic hiatus

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3
Q

What is a normal fluid analysis of peritoneal fluid?

A

Protein <3g/dL

NCC: <300cells/ul

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4
Q

T/F: the peritoneum is a bidirectional membrane allowing for free exchange of peritoneal fluid and plasma

A

True

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5
Q

T/F: Mesothelial cells in the peritoneum produce surfactant

A

True

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6
Q

Lymphatic drainage

A

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

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7
Q

Adhesion formation

A

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

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8
Q

Adhesion prevention

A 
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
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9
Q

Innate defenses

A

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

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10
Q

Inflammatory response

A 
Injury or contamination
Complement activation
Mast cell degranulation
N0 chemotaxis
M0 phagocytosis
Release of inflammatory mediators and cytokines
SIRS
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11
Q

Primary peritonitis

A 
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
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12
Q

Aseptic Secondary Peritonitis

A

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

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13
Q

Septic Secondary Peritonitis

A

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
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14
Q

Septic Peritonitis Hx

A

Anorexia, vomiting, lethargy
Trauma or recent Sx
Signalment, including neuter status

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15
Q

Compensated Shock

A

Tachycardia, bright red mm, rapid CRT, bounding pulses

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16
Q

Decompensated Shock

A

Tachy/bradycardia, pale mm, prolonged CRT, weak pulses

17
Q

Septic Peritonitis PE

A

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

18
Q

Septic Abdomen Imaging

A

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

19
Q

Dx of Septic Abdomen

A 
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
20
Q

Abdominocentesis

A

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

21
Q

DPL (Diagnostic Peritoneal Lavage)

A

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

22
Q

Evaluate fluid

A 
Grossly
Cytologically
Biochemically
Microbiologically
Once diluted, fluid analysis inaccurate
23
Q

Abdominal fluid analysis

A 
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
24
Q

Characteristics of a transudate

A

Decreased oncotic pressure, as with hypoproteinemia <1500 cells/uL, <2.5 protein

25
Q

Characteristics of normal abdominal fluid

A

<300cells/uL, <3 protein

26
Q

Characteristics of a modified transudate

A

1000-7000cells/uL, 2.5-7.5 protein

27
Q

Characteristics of an exudate

A

> 5000cells/uL, >3protein

28
Q

Abdominal fluid cytology

A 
Numbers and types of cells present
N0: degenerate vs non
L0
Monocytes/M0
Abnormal cells: reactive cells, neoplastic cells
29
Q

Treatment of Septic Peritonitis

A

Stabilize!

  • Shock dose colloids/crystalloids, PRBCs, plasma
  • ECG, BP
  • Discern source of sepsis via imaging
  • Abd exploratory
  • Monitor: Art line, venous cath, urinary cath
30
Q

Goals of Sx

A

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

31
Q

Post-op

A

Intensive care: BP, vol, electrolytes, nutrition, blood products, pain mgmt
Drain mgmt
Abx: broad spec IV empiric therapy pending C&S, then refine

32
Q

Prognosis

A

High mortality

Survival rates 20-80%

33
Q

Causes of death after septic abdomen

A 
systemic inflammatory response syndrome (SIRS)
Vasculitis
DIC
Bacteremia
Pancreatitis
Multiorgan Dysfunction Syndrome (MODS)

Gastrointestinal (12 decks)

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