Small Animal Acute Abdomen Flashcards
Define acute abdomen
Rapid onset of severe symptoms that may indicate potentially life-threatening intra-abdominal pathology requiring urgent surgical intervention.
What is an acute abodment often associated with?
An acute onset of severe abdominal pain
Name GI System differentials for acute abdomen?(12)
- GDV/GD
- necrosis, rupture, perforation
- surgical wound breakdown
- obstruction (complete or partial)
- ulceration
- ileus
- gastroenteritis
- duodenocolic ligament entrapment
- bowel incarceration (hernia, rupture)
- mesenteric torsion/thrombosis
- obstipation
- colitis
Name differentials for acute abdomen in the urogenital system (11)
- pyelonephritis/abscess
- AKI
- urolithisasis
- ureteral obstruction
- urethral obstruction
- cystitis
- uroabdomen
- uterine disease
- dystocia
- prostatic disease
- testicular disease
- Pyometra rupture
- Prostate abscess rupture
Name differentials for acute abdomenin the hepatobilliary system (6)
- acute hepatitis/cholangiohepatits
- abscess
- liver lobe torsion
- biliary rupture & bile peritonitis
- cholelithiasis
- biliary obstruction
- cholecystitis
- portal vein thrombosis
Name differentials for acute abodmen of the spleen (3)
- neoplasia
- torsion
- rupture
Name differentials for acute abdomen of the pancreas (3)
- pancreatitis
- abscess
- neoplasia
Name differentials which do nnot belong to a body system which can cause acute abdomen (4)
- pansteatitis
- migrating foreign bodies
- sclerosing peritonitis
- FIP – can mimic septic peritonitis
Name conditions that might mimic acute abdomen (4)
hypoadrenocorticism
spinal disease
hyperlipidaemia
polymyositis
What differentials of acute abdomen need emergency surgery? (5)
- GDV
- foreign body or other intestinal obstruction
- penetrating abdominal wounds
- septic or bile peritonitis
- presence of pneumoperitoneum (provided there is no iatrogenic cause such as prior GDV trocharization, abdominocentesis or abdominal surgery)
How may age help the differential list?
Younger patients= consider trauma, toxicity more likely
Older patients= consider neoplastic or metabolic disease more likely
How may breed help the differential list?
- pancreatitis eg miniature Schnauzer
- GDV eg Standard Poodle, Great Dane
- avoiding “traps” eg dachshundà spinal disease
- Easy to misdiagnose spinal pain as abdominal pain!
- Don’t want to wait for a spinal patient to go off their bac legs
How may sex/neutering status help the differential list for acute abdomen?
- ruptured pyometra? Always keep this in mind for a FE patient
- prostatic abscess?
What questions should we ask about the clincal history for an acute abdomen?
- Current medication?
- planned or unplanned
- not just prescribed medication
- Any history/possibility of trauma (even if there is no external signs of this)
- What might the patient have eaten
- food?
- toys?
- scavenging?
- Any vomiting or diarrhoea? One or the other?
- What about water intake and urination?
How would we approach the triage for the major body systems?
- GI manifestations
- is the abdomen tympanitic?
- Cardiorespiratory:
- circulation and tissue perfusion
- airway patency and oxygenation
- Shocked or CRS compromise – need to give Oxygen by flow by to increase oxygenation
- Neurological
- any evidence of brain or spinal cord dysfunction?
- don’t confuse spinal pain for abdominal pain
- significant change in mentation?
- Dachsund which is snapping on abdo palpation – check hindlimb reflexes to see if it is the classic dachsy slipped disc
- Urogenital
- renal function and bladder integrity
With an acute abdomen, what should we look at with the cardiorespiratory system?
- Assess the 4 perfusion parameters and auscultate the heart:
- heart rate
- peripheral pulse rate and quality (duration, amplitude, any deficits)
- mucous membrane colour
- CRT
- Looking for evidence of
- hypovolaemic shock (next slide)
- classic hyperdynamic systemic inflammatory response syndrome (SIRS)
- associated with significant inflammatory stimulus
- tachycardia, tall, narrow pulses, bright pink or red mucous membranes, rapid CRT
- cats: severe mental depression, poor or unpalpable femoral pulses, pale mucous membranes, undetectable CRT, inappropriate bradycardia.
- both SIRS & hypovolaemia
- Assess the respiratory system
What is seen in the following areas for mild hypovolaemia?
Heart rate
Mucous membranes
CRT
Pulse amplitude
Pulse duration
Metatarsal pulse
Heart rate - 120-150
Mucous membrane= N, pinker?
CRT = <1 sec
Pulse amplitude = High
Pulse duration =Low
Metatarsal pulse = easy to feel
What is seen in the following areas for moderate hypovolaemia?
Heart rate
Mucous membranes
CRT
Pulse amplitude
Pulse duration
Metatarsal pulse
Heart rate= 150-170
Mucous membranes= pale pink
CRT = around 2 secs
Pulse amplitude = low
Pulse duration =low
Metatarsal pulse =hard to feel
What is seen in the following areas for severe hypovolaemia?
Heart rate
Mucous membranes
CRT
Pulse amplitude
Pulse duration
Metatarsal pulse
Heart rate = 170-220
Mucous membranes = white or grey
CRT = slow above 3 secs
Pulse amplitude = really low
Pulse duration = really low
Metatarsal pulse = absent
Discuss the criteria for SIRS in cats and dogs
Temp
HR
RR
WBC
What 3 things should you assess for th respiratory syste whe there is an acute abdomen?
- Assess the respiratory system
- Respiratory rate
- Increased With abdominal pain?
- Respiratory effort
- Any compromise from ascites?
- Pressure on diaphragm
- Auscultate carefully
- Any suggestion of aspiration pneumonia?
- Crackles in the ventral lung
- Respiratory rate
How should you examine the abdoemen with acute abdomen?
- Observe:
- contour and body shape
- wounds or puncture marks
- Palpate gently but thoroughly
- reassure the patient first
- can you locate normal organs
- often not with abdominal pain!
- move on to deeper palpation
- “splinting” may occur
- try changing position of animal
- FLs up?
- Start gently and then this will give you an idea of how hard to palpate! Start caudually and work cranially
- Auscultation
- Percussion/ballottement
- Look for the fluid thrill
- Don’t forget
- oral exam
- rectal
What is it likely to be if there is generalised abdo pain?
Septic peritonitits
What 5 things are on differentials if there is localised abdo pain?
- FB
- Intussception
- Cranial abdomen- pancreatitis?
- Can give referred pain elsewhere in abdomen
- caudal abdomen- prostatitis?
- focal and repeatable- FB?
What does this show and how do they develop?
Linear foreign bodies
Concern in intestinal FB
They can be anchored at the head end in the mouth, in the intestine they can start to concertina the intestine. Used to be a cassette tape issue!
Can cut through a friable intestine.
Affect a large length of cut
Saw through the lining
See the bunching up of intestine.
Devvelop ascites as they have perforated through
How can we stable the acute abdomen? (4)
- Oxygenate especially if SPO2 <92%
- monitor pulse oximetry?
- keep in sternal recumbency?
- Will never do any harm!!!!
- Establish iv access and collect blood before starting fluids
- don’t wait for blood results to give fluid resuscitation
- Correct hypovolaemia and restore – hartmanns is a good start. Saline may be better if there is acte vomiting where stomach has lost contnt (but hartmans would still be better than nothing)
- Fluid therapy: tailor to the individual to correct hypovolaemia and restore perfusion
- isotonic crystalloid
- up to 60-90ml/kg for dogs (shock dose)
- up to 40-60ml/kg for cats (shock dose)
- Cat lung does not cope as well in shock – more likely to drown
- start with a bolus and monitor response
- often 10-20 mls/kg over 15-20 minutes then review
- Expect to see a significiant improvement in 15 mins
- consider colloids & blood products
- Not available atm. Adverse reactions in people so rarely available!
- Think more about blood products or plasma
- Consider monitoring
- blood pressure
- ECG
Visceral pain of the acute abdomen:
A) What is the source?
B) What is the innervation?
C) What is the localisation?
A) Abdominal viscera
B) I nnervated by autonomic nerves (C & A fibres (ignore this)) responding to
- distention
- muscular contraction—not to cutting, tearing, or local irritation
C) Poor localisation
Visceral pain of the acute abdomen:
A) What is the source?
B) What is the innervation?
C) What is the localisation?
A) Parietal peritoneum
B) somatic nerves (A fibres) responding to
• irritation, infectious, chemical, or other inflammatory processes, ischaemia
C) Sharp and well localized
What other pain is there which is poorly understood in animals?
Referred
What are the advantages of using Pure μ agonist (methadone or fentanyl) for acute abdominal treatment?
- rapid onset of action
- top up doses can be given if analgesia is inadequate
- any worrying adverse effects can be reversed with naloxone
What are the disadvantages of using Pure μ agonist (methadone or fentanyl) for acute abdominal treatment? (1)
Possible adverse effects
- ileus = worsen clinical signs
- high dose might =
- sedation
- bradycardia
- respiratory depression
How can we approch acute abdomen pain management (4)
- Start with methadone and add in CRIs of
- Lidocaine (dogs only)
- Promotility properties can help alleviate ileus
- Ketamine
- Ketamine and lidocaine (work well together)
- Can also use ketamine, lidocaine and methadone
- Consider regional anaesthesia
- Intraperitoneal local anaesthesia or
- Epidural injection via epidural catheter- not a day 1 skill!
- Maropitant may have some analgesic effect in addition to its anti-emetic effects
- Has some general analgesia properties too
- Be flexible- monitor and work with your patient
- Team approach to pain control is crucial
Can we justify antibiotics in acute abdomen cases? (include examples)
- Underlying problem might be septic peritonitis
- try to collect fluid sample for culture before giving antibiotics
- as soon as sample obtained- start treatment iv
- Patient might be at risk of bacterial translocation from the gut
- poor perfusion of the gut = compromised integrity of gut wall
- aerobic and anaerobic gram +ve and gram –ve bacteria
- What might you use?
- penicillin or 1st generation cephalosporin with fluroquinolone +/- metronidazole
- ampicillin or cefazolin + enrofloxacin +/- metronidazole
- ?An exception to our rule not to use enrofloxacin unless we have culture proving we need to
- Acute, critical care abdomen we may reach for it even though we would rather not
What is the minimum data base likely to be for acute abdomen? (5)
- PCV & TS and a blood smear
- Urea and creatinine
- Blood glucose
- Serum electrolytes
- Urinalysis: SG, dipstick +/- sediment/culture
- May tell us they have pyelonephritis
How do we interpret:
High PCV and high total protein?
Hypovolaemia
How do we interpret:
High PCV and normal or low total protein? (3)
Splenic contraction,
polycythaemia, hypoproteinaemia
How do we interpret:
Normal PCV and high normal or low total protein?
Normal hydration with hyperproteinaemia
Anaemia and hypovolaemia
How do we interpret:
Low PCV and high total protein? (2)
Anaemia and hypovolaemia
Anaemia with hyperproteinaemia
How do we interpret:
Low PCV and normal total protein?
Non blood loss anaemia with normal hydration
How do we interpret:
normal PCV and normal total protein? (3)
Normal, Acute haemorrhage
Hypovolaemia & anaemia & hypoproteinaemia
How do we interpret:
low PCV and lowtotal protein? (3)
Blood loss,
Anaemia and hypoproteinaemia
Overhydration
What should we do if we find hypoglycaemia?
Give supplemented fluids
What should we do if we find Hypokalaemia +/- hypochloraemia and metabolic alkalosis in a patient with profuse vomiting?
- 0.9% NaCl initially, then Hartmanns spiked with K+
- many times just restoring perfusion allows the kidneys to sort out acid base imbalance
- Choice of fluid is not always critical
- Profuse vomiting – saline may be better for metabolic alkalosis! (profuse vomiting)
- Hartmanns is otherwise the fluid of choice
What other tests might be useful in the acute abdomen?(6)
- Clotting tests ACT PT/PTT
- think about DIC in critical patients
- Lactate
- Does not replace the 4 perfusion parameters we have on physical exam
- CBC & biochemistry
- any concern about renal or hepatic disease?
- beware of 2ry changes ie consequences of the primary disease
- SNAP PLI
- follow up with SPEC PLI if abnormal
- could it be pancreatitis 2ry to peritonitis or a FB? ie still surgical
- Venous blood gases
- Faecal analysis?
- worth considering in a young patient
What diagnostic imaging should we do? Why?
Abdominal radiography: lateral and VD views
- **avoid the VD view in animals with
- respiratory distress
- severe hypovolaemia especially if abdominal distension = pressure on CVC
- Due to the increased pressure possibly causing cardiac compromise
- more useful than ultrasound in patients with intestinal obstruction +/- FB
- less useful than ultrasound if +++ peritoneal flui
Consider thoracic radiography
- if neoplasia is a differential
- haemoabdomen due to a ruptured liver or splenic mass
- how many thoracic views would you take as a met check?
- if you are worried about aspiration pneumonia
- SIRS might lead to ARDS
Why might we do contrast radiography and what can we use?
•Might be needed to confirm clinical suspicion of ruptured GI tract or urinary tract?
Barium
What is abdominal ultrasound used for? (6)
- Good for detecting free fluid
- For small volumes look between liver lobes and at the apex of the bladder
- Triangular pockets of fluid
- Anechoic?- But can be quite echogenic in septic abdomen case
- U/S guided aspiration
- For small volumes look between liver lobes and at the apex of the bladder
- Look for the underlying cause:
- Pancreatitis
- Pyometra
- Abscesses
- Torsions
- Masses
What equipment is needed in Abdominocentesis? (5)
- Clippers
- Surgical prep for area of interest & gloves
- 1-2 inches caudal to and R&L of umbilicus on the midline
- Needle (hypodermic, spinal or OTN catheter) + syringe
- Plain tube and EDTA tube
- why do you need these?
- What will you do with your abdominal fluid sample?
- Local anaesthetic
- 0.5ml lidocaine per site?
- might not need this if analgesia under control
How ca you do Abdominocentesis? What are the techniques for this?
- Ultrasound guided
- “blind abdominocentesis” – but people will more often have an U/S
- standing if possible? More likely to be successful as you can try and approach ventrally in the right quadrant of the abdomen
- express bladder first if you can do this safely
- 1st site to try: ventral aspect of right cranial quadrant
- why?
- open needle technique= less risk of sucking in omentum and therefore blocking needle
- if this fails try closed needle ie attach syringe
- if still no success try 4 quadrant approach
- Think about the potential for false results and how confusing this could be
- aspirate from spleen
- puncture of dilated gut
- inadvertent cystocentesis
what if I can’t get a sample in abdominocentesis? Include the techniques for this
Diagnostic peritoneal lavage
- worth considering when there is just not enough fluid to sample even with help from ultrasound
- minimal equipment required ie catheters:
- peritoneal dialysis catheter
- over the needle catheter works just as well
- technique:
- infuse 10-20ml/kg of warm isotonic fluid into abdomen
- 20-30 minutes later perform abdominocentesis as before
- See if the luid has just gone and see if the fluid is just somewhere we cant see
- Get the animal to walk around may help the fluid collection
What is this? what can be seen?
Peritoneal effusion of dog with sterile peritonitis
Sterile
Macropahhages
RBC
Pacnreatitis rather than a septic belly
What would your interpretation be for the following DPL evaluation?
A) Clear fluid
B) Opaque & bloody
C) Darker each time repeated
A) No obvious injury/peritoneal dz
B) Haemorrhage
C) Continued haemorrhage
What would your interpretation be for the following DPL evaluation?
A) Turbid or cloudy
B) Bluish/greenish tinge
C) PCV <2 %
D) PCV 3-10%
A) Peritonitis ?
B) Bile leakage? (or upper GI)
C) Mild haemorrhage
D) Moderate haemorrhage
What would your interpretation be for the following DPL evaluation?
A) PCV > 10%
B) White cells > 1000 x 109
C) White cells > 2000 x 109
A) Severe haemorrhage
B) Mild peritoneal irritation
C) Marked peritoneal irritation
What would your interpretation be for the following DPL evaluation?
A) Amylase > serum
B) ALK phosphatase > serum
C) Bilirubin +
D) Creatinine > serum
A) ? Pancreatitis, trauma, small bowel leak
B) Trauma, ischaemia, leakage
C) Leak from biliary tract/ bowel
D) Uroabdomen
What would your interpretation be for the following DPL evaluation?
A) Bacteria
B) Neutrophilia (toxic neutrophils)
C) Plant material
D) Neoplastic cells
E) Triglycerides > serum
A) Bacterial peritonitis
B) Suppurative peritonitis
C) GI leak
D) Neoplasia
E) Chyloabdomen
What does prognosis depend on?
Underlying cause
Why do we need to rapidly assess in acute abdomen?
To have appropriate intervention to manage life threatening complications such as hypovolaemic shock will reduce morbidity and mortality
Discuss whether we remove ascites fluid?
Very rare for us to drain ascites fluid – it is a short term solution as, the cause is more likely to form more fluid
Chronic cases – may wish to drain to allow the patient to feel a bit better
Respiratory compromise – can drain this too
Do we use diuretics in ascites?
Frusemide – doesn’t change what’s happening in the abdomen
Spirolcatone – aldosterone antagonist – can help a bit. But this could worsen the dehydration. So yes in chronic but no in acute unless you were worried about the renal output.
Chronic chyloabdomen patients - can be a relief to the animal. Last ditch attempt
