Smallies 8 Flashcards
What causes FIP?
A fatal combination of a feline specific coronavirus and an ineffective/inappropriate immune response
How is Feline Enteric Coronavirus transmitted?
Easily transmitted via faeco-oral route
Highly contagious and very common
How does Feline Enteric Coronavirus survive in the environment?
Survives 1-2 days at room temperature or up to 7 weeks in dry environment
Inactivated by most disinfectants, doesn’t often persist in the environment unless there is a cat constantly shedding the virus
What are the signs of a subclinical infection of Coronavirus?
Asymptomatic
What are the clinical signs of Coronavirus infection?
Enteritis
o Mild self-limiting vomiting and/or diarrhoea
o Can persist for weeks to months as chronic low grade GI signs
Mild upper respiratory tract signs
How long does viral shedding of Coronavirus occur?
Viral shedding can occur for 7-18 mths post infection, it can be intermittent or persistent
How many cats with Coronavirus go on to develop the FIP?
5-12% of cats infected with coronavirus
What is typical history and signalment of FIP?
Cats < 3 years of age - most prevalent from 4-16 months, but it can occur in cats of any age (often see a secondary peak in cats >10 yrs)
A disease of multicat households due to increased exposure to virus and higher stress levels
Seen in breeding colonies and shelter cats
A disease of pedigree cats? Genetic susceptibility e.g. Abyssinian, BSHs, Birmans, Burmese
What is wet FIP?
cats which develop ascites and/or pleural fluid associated with vasculitis
What is dry FIP?
cats that develop granulomatous lesions in multiple organs but often no effusion
What are the presenting signs of wet FIP?
Abdominal distension due to ascites - modified transudate/exudate (non-septic, no bacteria within the neutrophils)
Pleural effusion causing tachypnoea, dyspnoea (restrictive breathing pattern) with muffled heart and lung sounds on auscultation
What are the presenting signs of dry FIP?
Mild intermittent fever that waxes and wanes
Poor appetite
Weight loss/stunted growth
Depression
Anaemia - mild, non-regenerative
Jaundice
Abdominal palpation might reveal enlarged mesenteric lymph nodes, irregular and enlarged kidneys/liver and intestinal mass lesions
Ocular signs of FIP include uveitis, chorioretinitis, retinal detachment, hyphaema, hypopyon
Neurological signs (variable) e.g. dull, abnormal mental state, ataxia, nystagmus, seizures
What are some differentials for FIP?
Lymphocytic cholangitis
Lymphoma
Describe the development of clinical FIP
A cat is infected with feline enteric coronavirus
Phase of rapid replication occurs in enterocytes
A mutation occurs allowing virus (feline infectious peritonitis virus) to replicate in macrophages
Sustainable replication in macrophages then triggers a fatal systemic disease
What are characteristic histopathic lesions of FIP?
Vasculitis affecting serosal surfaces causes pleural, peritoneal and pericardial fluid
Pyogranulomatous or granulomatous lesions in multiple organs (macrophage heavy inflammation) e.g. Lymph nodes, liver, kidney, GI tract often affected
What factors increase the risk of FIP developing?
Viral genetics
Host immunity
Environment e.g. close contact
What haematology findings will you see with FIP?
Lymphopenia and neutrophilia (variable, common stress leucogram in cats)
Mild-moderate non-regenerative anaemia
What biochemistry findings will you see with FIP?
Hyperproteinaemia
Low albumin: globulin ratio
High bilirubin (wet FIP)
Why do you get a low albumin:globulin ration with FIP?
High protein due to high globulins (gamma globulins)
Low albumin - Due to renal and/or GI loss, loss in fluid associated with vasculitis, reduced production by liver
What albumin:globulin ratio makes FIP likely and what ratio makes FIP unlikely?
<0.4 = FIP likely, >0.8 = FIP unlikely
What non-specific acute phase protein can be helpful when diagnosing FIP?
serum alpha-1 acid glycoprotein
What will you see in fluid analysis (pleural or peritoneal) in FIP?
Will see quite a few macrophages with a few neutrophils in a background of red blood cells
Clear yellow viscous fluid
High protein (>35g/l) component with a low Albumin:globulin
Cell content can be low but very variable - Non-degenerate neutrophils and macrophages
Rare cases where fluid is a chylous effusion
What might you see on radiography with a FIP case?
Peritoneal, pleural and/or pericardial fluid
o If you can’t see the cardiac outline clearly on a DV view of the thorax, pleural fluid is likely to be the cause
o Will be able to see fluid in the ventral aspect of the thorax in a lateral view
o A loss of serosal detail in the abdomen is indicative of ascites, if the intestines are full of gas they will still be highlighted even with increased surrounding fluid
Enlarged mesenteric lymph nodes
Irregular kidneys, may be enlarged
Intestinal wall lesions
What will you see on kidney biopsy with FIP?
Pyogranulomatous lesions
How is a diagnosis of FIP made?
Cumulative evidence is important when trying to make a diagnosis of FIP, we cannot rely on one single diagnostic test
How useful is serology when confirming a diagnosis of FIP?
Feline CoV serology indicates exposure only
Very high titres support a presumptive diagnosis if very high clinical suspicion
Rising titres not useful unlike other diseases
How useful is tissue PCR when confirming a diagnosis of FIP?
`Cannot differentiate between FIPV and “normal” coronavirus (FECV) but if virus is present in any fluid sample this supports a diagnosis
How useful is immunofluorescence to detect FCoV antigen in macrophages when diagnosing FIP?
FCoV presence in a macrophage shows that the virus has progressed – current best test to prove we have FIP (need an external lab for analysis)
Positive staining is consistent with FIP
Useful test to confirm a strong clinical suspicion
False negatives if low cellularity in effusions
What sample should you use for immunofluorescence to detect FCoV antigen?
Use effusion if possible (but low cell count so may not have enough macrophages as the antigen won’t be in all of the macrophages) or CSF if showing neuro signs
How can we definitivity diagnose FIP?
Histopathology (invasive) to look for typical lesions
Exploratory surgery inevitably does happen in some FIP cases where the diagnosis has been missed in other ways or the disease is mimicking a surgical disease
Post mortem diagnosis
What is seen on histopathology with FIP?
Perivascular pyogranulomatous or granulomatous lesions in multiple organs
Macrophages and neutrophils +/- lymphocytes and plasma cells
When do you need a definitive diagnosis when dealing with a possible FIP case?
A definitive diagnosis is often important if you have a kitten with FIP and need to report back to the breeder. They will want to see enough evidence to prove that one of their animals may be the source of an FIP infection
What is included in the treatment of FIP?
Supportive care e.g. antiinflammatory, appetite stimulants, vitamin B12 (cobalamin), S/C fluids (at home), antioxidants
Feline interferon omega
Euthanasia is a viable option
Can you vacinate against FIP?
No - there is no UK vaccination
How can you prevent FIP?
Reduce transmission of coronavirus by limiting exposure, especially in multicat environments
Early weaning of kittens
What is the definition of an acute abdomen?
Rapid onset of severe symptoms that may indicate potentially life-threatening intra-abdominal pathology requiring urgent surgical intervention
What cases of acute abdomen do not require surgery?
Generalised ileus or acute gastroenteritis (AHDS)
List differentials of an acute abdomen associated with the GIT
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
List differentials of an acute abdomen associated with the urogenital system
Pyelonephritis/abscess AKI Urolithisasis e.g. Ureteral obstruction or Urethral obstruction Cystitis Uroabdomen Uterine disease Dystocia Prostatic disease Testicular disease
List differentials of an acute abdomen associated with the hepatobillary system
Acute hepatitis/cholangiohepatits Abscess Liver lobe torsion Biliary rupture & bile peritonitis Cholelithiasis Biliary obstruction Cholecystitis Portal vein thrombosis
List differentials of an acute abdomen associated with the spleen
Neoplasia
Torsion
Rupture (sometimes not painful)
List differentials of an acute abdomen associated with the abdominal wall
Trauma
Rupture
Penetrating wounds
Evisceration
List differentials of an acute abdomen associated with the pancreas
Pancreatitis
Abscess
Neoplasia
Why is it important to work out if the patient has a surgical acute abdomen?
Undiagnosed surgical conditions can be rapidly life threatening
Unnecessary exploratory surgery can significantly increase morbidity and mortality
What are indications of emergency surgery with an acute abdomen?
GDV (not GD)
Foreign body or other intestinal obstruction, especially if there is perforation
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 does signalment help with the diagnosis of the cause of an acute abdomen?
Age:
o Younger patients - consider trauma, toxicity more likely
o Older patients - consider neoplastic or metabolic disease more likely
Breed predisposition might be helpful for:
o Pancreatitis e.g. miniature Schnauzer
o GDV e.g. Standard Poodle, Great Dane
o Avoiding “traps” e.g. dachshund - misdiagnose spinal pain as abdominal pain
Sex/neutering status:
o Ruptured pyometra – always a consideration in female entire bitches
o Prostatic abscess?
What questions do you need to ask the owner when presented with an aucte abdomen case?
Current medication? o Planned or unplanned o Not just prescribed medication Any history/possibility of trauma? What might the patient have eaten e.g. food? toys? scavenging? Any vomiting or diarrhoea? What about water intake and urination? Acute presentation can be the end stage of a more chronic disease- were there any warning signs before the patient collapsed?
What should be included in the evaluation of major body systems when presented with an acute abdomen case?
GI manifestations
o Is the abdomen tympanitic?
Cardiorespiratory:
o Circulation and tissue perfusion
o Airway patency and oxygenation e.g. flow by or mask
Neurological
o Any evidence of brain or spinal cord dysfunction?
o Don’t confuse spinal pain for abdominal pain
o Significant change in mentation?
Urogenital
o Renal function and bladder integrity
What are the 4 perfusion parameters we can measure?
Heart rate
Peripheral pulse rate and quality (duration, amplitude, any deficits)
Mucous membrane colour
CRT
When assessing the cardiovascular system in an acute abdomen patient, what are we looking for?
Evidence of hypovolaemia shock and signs of SIRS
What are signs of 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
What is the expected heart rate in mild, moderate and severe hypovolaemia?
Mild: 120-150
Moderate: 150-170
Severe: 170-220
What is the expected mm colour in mild, moderate and severe hypovolaemia?
Mild: normaler/maybe pinked
Moderate: pale pink
Severe: white or grey
What is the expected CRT in mild, moderate and severe hypovolaemia?
Mild: <1s
Moderate: approx 2 s
Severe: >3s
What is the expected pulse amplitude in mild, moderate and severe hypovolaemia?
Mild: slightly increased
Moderate: slightly decreased
Severe: severely decreased
What is the expected pulse duration in mild, moderate and severe hypovolaemia?
Mild: slightly decreased
Moderate: slight decreased
Severe: severely decreased
What is the expected metatarsal pulse in mild, moderate and severe hypovolaemia?
Mild: easy to feel
Moderate: hard to feel
Severe: absent
What is the temperature (F) in the SIRS criteria for cats and dogs?
Cats: >103.5 or <100
Dogs: >102.6 or <100.6
What is the heart rate in the SIRS criteria for cats and dogs?
Cats: >225 or < 140
Dogs: >120
What is the respiratory rate in the SIRS criteria for cats and dogs?
Cats: >40
Dogs: >20
What is the WBCC in the SIRS criteria for cats and dogs?
Cats: >19500 or <5000
Dogs: >16000 or <6000
What do you need to look for when visually examining the abdomen of an acute abdomen patient?
Contour and body shape
Wounds of puncture marks
What will you see on radiography with a linear foreign body?
Will see bunching up of intestines on radiography, with air pockets in the lumen. May also see ascites if perforation has occurred
What must you initially do with an acute abdomen patient?
Stablise!
Oxygenate
Establish IV access (take blood sample then give IVFT)
What fluids are suitable for an acute abdomen patient?
Isotonic crystalloids e.g. Hartmanns or saline (better option with acute vomiting)
What is shock rate fluid for a dog?
Dogs: up to 60-90ml/kg
Cats: up to 40-60ml/kg
How do you administer fluids to an acute abdomen patient? (rates etc)
Start with a bolus and monitor response
Often 10-20 mls/kg over 15-20 minutes then review and move onto shock rate
What nerves and stimuli are linked with visceral pain?
Innervated by autonomic nerves (C and A fibres) responding to distention or muscular contraction
What does visceral pain feel like?
Poorly localised, typically vagie, dull and nauseating
What nerves and stimuli are linked with somatic pain?
Innervated by somatic nerves (A fibres) responding to irritation, infectious, chemical, or other inflammatory processes, ischaemia
What are the advantages of using pure μ agonist as analgesic agents for an acute abdomen patient?
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 as analgesic agents for an acute abdomen patient?
Ileus -> worsen clinical signs
High dose might lead to sedation, bradycardia or respiratory depression
o Risk of aspiration pneumonia
What CRIs can you couple with methadone use when using a multimodal analgesic approach to an acute abdomen patient?
Lidocaine (dogs only) - promotility properties can help alleviate ileus
Ketamine
Ketamine and lidocaine
Should you use NSAIDs when planning analgesics for an acute abdomen patient?
Avoid if possible
Can we justify use of antibiotics in acute abdomen cases?
Underlying prolem might be septic peritonitis
Patient might be at risk of bacterial translocation from the gut
Why might there be bacterial translocation in an acute abdomen case?
Poor perfusion of the gut leads to compromised integrity of gut wall
What antibiotics could you use in an acute abdomen case?
Penicillin or 1st generation cephalosporin with fluroquinolone +/- metronidazole
Ampicillin or cefazolin + enrofloxacin +/- metronidazole
What is the minimum data base likely to be for acute abdomen?
PCV & TS and a blood smear Urea and creatinine Blood glucose Serum electrolytes Urinalysis: SG, dipstick +/- sediment/culture
What is the interpretation of increased PCV and increased TP in an acute abdomen case?
Hypovolaemia
What is the interpretation of increased PCV and normal/decreased TP in an acute abdomen case?
Splenic contraction, polycythaemia, hypoproteinaemia
What is the interpretation of normal PCV and increased TP in an acute abdomen case?
Normal hydration with hyperproteinaemia
Anaemia and hypovolaemia
What is the interpretation of decreased PCV and increased TP in an acute abdomen case?
Anaemia and hypovolaemia
Anaemia with hyperproteinaemia
What is the interpretation of decreased PCV and normal TP in an acute abdomen case?
Non-blood loss anaemia with normal hydration
What is the interpretation of normal PCV and normal TP in an acute abdomen case?
Normal, Acute haemorrhage
Hypovolaemia, anaemia and hypoproteinaemia
What is the interpretation of decreased PCV and decreased TP in an acute abdomen case?
Blood loss, Anaemia and hypoproteinaemia
Overhydration
What further tests may be important in the investigation of an acute abdomen case (after the minimum database)?
Clotting tests ACT PT/PTT - think about DIC in critical patients as it maybe better to PTS than surgery if there is a coagulopathy
Lactate
CBC and biochemistry
SNAP PLI - Follow up with SPEC PLI if abnormal
Venous blood gases
Faecal analysis - worth considering in a young patient
When should you avoid the VD view?
Respiratory distress
Severe hypovolaemia especially if abdominal distension
Why should you avoid a VD view in a patient with hypovolaemia and a distended abdomen?
Get increased pressure on caudal vena cava leading to increased cardiovascular compromise
When is radiography more useful that ultrasound with an acute abdomen patient?
More useful than ultrasound in patients with intestinal obstruction +/- FB
When is radiography less useful that ultrasound with an acute abdomen patient?
Less useful than ultrasound if there is lots of peritoneal fluid
When should you consider thoracic radiography with an acute abdomen case?
If neoplasia is a differential
If you are worried about aspiration pneumonia
Why can you justify contrast radiography in the diagnosis of an acute abdomen?
Barium can be used for the GI tract even if risk of perforation as it is a superior study i.e. less chance of missing the crucial diagnosis
Less risk of dilution in abdominal fluid than with iodinated contrast agent - get a more obious contrast leak point rather than just diffusion
Perforation means euthanasia or surgery and therefore leaked barium can be lavaged
Why is ultrasonography useful in the diagnostic work up of an acute abdomen patient?
Good for detecting free fluid
Look for the underlying cause e.g. pancreatitis, pyometra, abscesses, torsions, masses etc
What equipment is needed for abdominocentesis?
Clippers
Needle (hypodermic, spinal or OTN catheter) + syringe
Plain tube and EDTA tube
Local anaesthetic - 0.5ml lidocaine per site (might not need this if analgesia under control)
Where should you surgically prep for abdomincentesis?
1-2 inches caudal to and R&L of umbilicus on the midline
Where is the first site you should try for abdominocentesis?
ventral aspect of right cranial quadrant
What equipment is needed for a diagnostic peritoneal lavage?
Peritoneal dialysis catheter Over the needle catheter works just as well Saline Syringe Clippers
What is the technique for peritoneal lavage?
Infuse 10-20ml/kg of warm isotonic fluid into abdomen
20-30 minutes later perform abdominocentesis as before
Allows ‘flushing’ of parts of the abdomen you can’t access
If the dog will walk, this may help flush the fluid around the abdomen
What are potential reasons for false results from abdominocentesis?
Aspirate from spleen
Puncture of dilated gut
Inadvertent cystocentesis
Why is the open needle technique best for abdominocentesis?
Less risk of sucking omentum
