Rectal Tears and Prolapses Flashcards
T/F: Rectal tear is rarely a catastrophic event in horses
F, it easily can be
Iatrogenic Rectal Tear:
- Occur when? Result from?
- during palpation per rectum, from straining against operator’s hand and arm
Most iatrogenic rectal tears are (dorsal/ventral)?
dorsal.
Best ways to prevent iatrogenic rectal tear?
Copious lubrication, adequate restraing (sedation/muscle relaxation if needed), avoid palpating beyond your reach
Spontaneous Rectal Tears: Pathogenesis?
Post-Foaling, due to pressure necrosis at level of pelvic inlet.
How could you diagnose rectal tear immediately after they happen?
1.
2.
3.
- Sudden release of pressure
- Sudden ability to palpate abdominal organs distinctly
- blood on sleeve
Ways to confirm rectal tears 1. 2. 3. 4.
- Speculum examination of rectum
- Careful palpation with bare hand (consider drugs to stop rectal contractions)
- CBC
- Abdominocentesis
Signs of Rectal Tear:
____ and ____ occur within a few hours in more serious cases
Peritonitis and toxic shock
Signs of rectal tear:
Idiopathic tears may initially present as….
colic/hemorrhagic feces/aymptomatic
Describe Grade I rectal tear:
through mucosa and submucosa. May be asymptomatic
Describe Grade II rectal tear:
Muscular layer disrupted, mucosa/submucosa may prolapse into defect and provide site for fecal impaction
Describe Grade IIIa rectal tear:
All layers except serosa affected
Describe Grade IIIb rectal tear:
involves mesorectum and retroperitoneal tissue
Describe Grade IV rectal tear:
All layers into abdomen, may be associated with prolapse of small colon or small intestine through the defect
Rectal Tear: Location:
- Most tears are (ventral/dorsal)?
- Most tears are (longitudinal/transverse)?
- Distance from anus?
dorsal
longitudinal
15-55cm
T/F: Distance from anus is not a good indicator of tear location relative to retroperitoneal reflection and abdominal cavity?
T
Initial Treatment of Rectal Tears:
Treat septic shock and peritonitis with :
1.
2.
3.
Antibiotics
Flunixin
IV fluids
Initial Treatment of Rectal Tears:
Administer ____ to allow…..
epidural anesthesia to allow gentle removal of feces
Initial Treatment of Rectal Tears:
Would you want to increase or decrease rectal motility?
decrease
Initial Treatment of Rectal Tears:
Gently pack rectum: Why?
1.
2.
3.
- protect tear
- prevent contamination of abdomen
- prevent conversion of Grade II to Grade IV
Non-Surgical Treatment of Rectal Tears:
Grade I or II:
1.
2.
- Antibiotics and Flunixin
2. Soften Feces with mineral oil/bran mashes/green grass/moistened pellets
T/F Grade III rectal tears often respond to non-surgical treatment
T
Non-Surgical Treatment of Rectal Tears:
Two things to consider performing in Grade III:
1
2.
- Frequent manual removal of feces
2. Peritoneal lavage?
Three methods of surgical repair of rectal tears:
1.
2.
3.
- Direct suture repair
- Temporary indwelling rectal liner
- Loop colostomy
Direct Suture Repair of rectal tears:
Best for what kind of tears?
fresh clean lesions that are close to the anus
Direct Suture Repair of rectal tears:
Drugs?
Epidurals
Direct Suture Repair of rectal tears:
Suture technique?
Stay sutures in the anus.
Direct Suture Repair of rectal tears:
If prolapse tear?
Hold with multiple Allis tissue foreceps, staple with TA90, than oversew with simple continuous suture
Direct Suture Repair of rectal tears:
- Lesions usually (are/are not) accessible via midline celiotomy?
are not
Temporary, indwelling rectal liner as tx for Rectal Tear:
Function?
protects tear and allows it to heal spontaneously
Temporary, indwelling rectal liner as tx for Rectal Tear:
- May be used with our without ____
direct suture
Temporary, indwelling rectal liner as tx for Rectal Tear:
Create liner by….
gluing palpation sleeve or similar thing to rectal prolapse ring
Temporary, indwelling rectal liner as tx for Rectal Tear:
Best way to access?
caudal midline celiotomy on anesthetized horse in dorsal recumbancy.
Temporary, indwelling rectal liner as tx for Rectal Tear:
Describe the procedure to implant one:
Assistant passes lubricated ring guided by surgeon to cranial of where tear is. Secure ring with tight circumferential suture.
Incorporate circumferential suture into individual sutures through all layers of colon and Dacron loops in ring.
Bury circumferential suture with lember tpattern.
Can cross tie to prevent cranial movement of sleeve when horse lies down.
Loop Colostomy:
- Is/ Is not preferable to end-colostomy
Is
Loop Colostomy:
Indications:
1
2
3.
- Grade IV, +/- Grade III
- Tear > 25% of rectal diameter
- Tear > 50 cm from anus
Loop Colostomy:
Sites:
1
2
3.
- High left flank
- Low left flank
- ventral midline
Loop Colostomy:
post care?
cradle = prevent self-mutilation
Loop Colostomy:
Complications
1
2
Dehiscence
Infection
Survival % for Rectal Tears:
Grade I?
II?
III?
IV?
93%
80%
70%
6%
T/F: Rectal prolapses are most common in horses
F, more rarely in horses
Predisposing factors of Rectal Prolapse:
Most common in what kind of cattle?
younger feedlot cattle
Predisposing factors of Rectal Prolapse:
1
2.
3
4. sheep?
- Altered pressure gradient (abdominal/pelvic cavity vs anus)
- Decreased sphincter tone
- Urogenital/Repro concerns (Constipation/diarrhea/colitis/cysyitis/dystocia)
- Excessively short tail cropping
Classification of Rectal Prolapse:
only mucosa projects through anus = Type ___
I
Classification of Rectal Prolapse:
Small colon intussucepts into rectum = Type ___
III
Classification of Rectal Prolapse:
Prolapse of all layers of rectum = Type ___
II
Classification of Rectal Prolapse:
Rectum/colon intussusception through anus
IV
Most common classifications of rectal prolapse?
Type I and Type II
What can palpation reveal about rectal prolapse classification?
Type I - III will be continous with anus,
Type IV will have a palpable depression (TRENCH) inside rectum
Management techinques to reduce rectal prolapse:
1. 2. 3. 4. 5.
- Eliminate predisposing factors
- Eliminate straining
- sooth mucosa
- resolve prolapse
- Caudal epidural anesthesia
Purposes of Caudal Epidural Anesthesia with Rectal Prolapse Cases:
1.
2.
3.
4.
- Temporarily resolves straining
- Allows evaluation
- May facilitate re-positioning/replacement
- May allow surgery
Rectal Prolapse: Treatment Options
1.
2.
3.
For Type IV specifically:
4. ____/____/____
- Replacement and purse string suture
- Submucosal resection
- Stair Step Amptuation / Amputation after through - and through- sutures
- celiotomy/resection/anastomosis
Replacement and Purse String Suture as Tx for Rectal Prolapse:
Drugs to admin?
Caudal epirdual, lidocaine jelly
Replacement and Purse String Suture as Tx for Rectal Prolapse:
Before placing sutures:
Clean prolapse with hypertonic solution/glycerol, apply lidocaine jelly, and reduce prolapse
Replacement and Purse String Suture as Tx for Rectal Prolapse:
How tight?
Remove after how long?
Tight enough to allow 2-3 fingers
Remove after 1 week
Submucosal resection as treatment for Rectal Prolapse
Use when?
When you have necrotic ulcerated or traumatized mucosa with healthy underlying tissue
Submucosal resection as treatment for Rectal Prolapse
Technique Steps:
- Epidural and hypertonic solution
- Insert flexible tubing, fix with needles (cross pin)
- Make two circumferential incisions, just through mucosa, at ends of tissue to be removed
- Connect with longitudinal incision to same depth
- Remove collar of damaged tissue by blunt dissection (ligating individual vessels)
- Anchor tissue with 4 simple interrupted sutures (absorbable monofilament)
- Complete apposition with continuous suture for each quadrant
Stair Step Amputation for Rectal Prolapse:
Has reduced risk of…
Stricture formation
Stair Step Amputation for Rectal Prolapse:
- Type of incision?
- Preserve…..
- Create….
- Circumferential
- inner mucosa and submucosa
- create plane toward caudal aspect of prolapse
Stair Step Amputation for Rectal Prolapse:
Make incision through…
inner layer of mucosa
Stair Step Amputation for Rectal Prolapse:
Finish by…
creating flap of inner mucosa over outer mucosa, and suture
