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Smallies 9 Flashcards

1
Q

What is the evaluation of clear fluid from a diagnostic peritoneal lavage?

A

No obvious injury/peritoneal disease

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2
Q

What is the evaluation of opaque and bloody fluid from a diagnostic peritoneal lavage?

A

Haemorrhage

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3
Q

What is the evaluation of fluid that gets darker with each attempt when performing a diagnostic peritoneal lavage?

A

Continued haemorrhage

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4
Q

What is the evaluation of turbid/cloudy fluid from a diagnostic peritoneal lavage?

A

Peritonitis

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5
Q

What is the evaluation of bluish/greenish fluid from a diagnostic peritoneal lavage?

A

Bile leakage or upper GI leak

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6
Q

What is the evaluation of finding fluid with a PCV of <2% from a diagnostic peritoneal lavage?

A

mild haemorrhage

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7
Q

What is the evaluation of finding fluid with a PCV of 3-10% from a diagnostic peritoneal lavage?

A

moderate haemorrhage

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8
Q

What is the evaluation of finding fluid with a PCV of >10% from a diagnostic peritoneal lavage?

A

severe haemorrhage

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9
Q

What is the evaluation of finding fluid with white cells >1000x10^9 from a diagnostic peritoneal lavage?

A

mild peritoneal irritation

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10
Q

What is the evaluation of finding fluid with white cells >2000x10^9 from a diagnostic peritoneal lavage?

A

marked peritoneal irritation

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11
Q

What is the evaluation of finding fluid with more amylase than serum from a diagnostic peritoneal lavage?

A

Pancreatitis, trauma, small bowel leak

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12
Q

What is the evaluation of finding fluid with more ALK phosphatase than serum from a diagnostic peritoneal lavage?

A

Trauma, ischaemia, leakage

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13
Q

What is the evaluation of finding bilirubin in the fluid from a diagnostic peritoneal lavage?

A

Leak from biliary tract/bowel

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14
Q

What is the evaluation of finding fluid with more creatinine than serum from a diagnostic peritoneal lavage?

A

Uroabdomen

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15
Q

What is the evaluation of finding fluid with neutrophilia (toxic neutrophils) from a diagnostic peritoneal lavage?

A

suppurative peritonitis

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16
Q

What is the evaluation of finding fluid with plant material from a diagnostic peritoneal lavage?

A

GI leak

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17
Q

What is the evaluation of finding neoplastic cells in the fluid from a diagnostic peritoneal lavage?

A

neoplasia

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18
Q

What is the evaluation of finding fluid with more triglycerides than serum from a diagnostic peritoneal lavage?

A

chyloabdomen

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19
Q

What is GVD?

A

Gastric dilatation volvulus, also known as gastric dilation, twisted stomach, or gastric torsion, is a medical condition that affects dogs in which the stomach becomes overstretched and rotated by excessive gas content

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20
Q

What are the mortality rates with surgery for a GDV patient?

A

10-18%

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21
Q

List extrinsic risk factors of GDV

A 
Diet
Post prandial exercise
Pre-prandial exercise
Single daily feeding
Hospitalisation – increased stress
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22
Q

List intrinsic factors of GDV

A 
Breed (deep-chested)
Body size
Thoracoabdominal dimensions
Gastric volume
Gastric position
Gastric ligament laxity (hepatoduodenal and hepatogastric)
Eructation control
Pyloric canal function
A parent (1st degree relative) who has experienced a GDV – don’t breed from dogs who have had a GDV
Temperament and “happiness”
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23
Q

List breeds predisposed to GDV

A

Great Dane, St Bernard, Weimaraner, Irish Setter, Gordon Setter, Standard Poodle, Basset Hound, Doberman Pinscher, Old English Sheepdog, German Shorthaired Pointer

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24
Q

What is the aetiology of GDV?

A 
Multifactorial
Aerophagia leading to gastric dilation
Abnormal oesophageal motility
Dysphagia
Gas or fluid accumulate in stomach and the normal means of relief (vomiting, regurgitation, pyloric function) have become inoperative
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25
Q

Is clockwise or anti-clockwise rotation more common with GDV cases? And what is the maximum rotation for each way?

A

Clockwise; most common, max rotation of 270-360 degrees

Anti-clockwise; rare, max rotation of 90 degrees

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26
Q

Describe the roation in GDV

A

Generally (in GDV) the stomach rotates in a clockwise manner when viewed from the surgeon’s perspective (dog on its back, clinician at dog’s side facing cranially (rotation can be 90-360 degrees).
Gastric dilatation usually precedes volvulus; twisting occurs passively due to the alteration of anatomical relationships by the progressively ballooning stomach. As the stomach dilates, it pushes dorsal and the pylorus becomes ventralised. Once it has twisted it is not likely to untwist. When the stomach twists, it rotates into the omental bursa.

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27
Q

What will you typically see when you open up a dog with GDV?

A

You will see a single layer of omentum overlying the stomach when you open the dog up

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28
Q

What are the resultant pathophysiological events of a GDV?

A 
Hypovolaemia
Endotoxaemia
Hypoxia
Cardiac dysfunction
Gastric ischaemia and mucosal necrosis
Splenic ischaemia/infarction
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29
Q

What is the pathophysiology of local events at the stomach with a GDV case?

A

Gastric wall blood supply disrupted – avascular necrosis and infarction most likely on the greater curvature of the stomach (Leads to rupture and peritonitis)
As the greater curvature of the stomach is displaced the gastric branches of the splenic artery can avulse
Haemorrhage and ischaemia result
Perfusion pressure falls
Mechanical obstruction to vessels (caudal vena cava and portal vein)
Thrombi (due to clotting) can develop if the blood flow slows down
Gastric necrosis (most commonly greater curvature)

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30
Q

What is the pathophysiology of local events at the spleen with a GDV case?

A

Displaced as greater curvature of the stomach moves
Venous congestion due to compromised venous drainage
Splenic artery avulsions can occur
Infarction (arterial supply decreased due to congestion downstream)
Splenic torsion
Splenomegaly due to congestion can occur

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31
Q

What are the pathophysiological systemic consequences in a GDV case?

A

Blood flow obstruction e.g. caudal vena cava and hepatic portal vein
Venous return decreased and cardiac output falls
Heart rate increases
o Myocardial oxygen demand increases
o Myocardial oxygen delivery is falling
Poor perfusion and stasis
Arrhythmias
Ischaemic reperfusion injury (IRI)
Gastric perforation – adversely affects prognosis (PTS/death likely)
Septic peritonitis
Post-operative disseminatied intravascular coagulation (DIC)
Post-operative Systemic Inflammatory Response Syndrome (SIRS)

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32
Q

What are the presenting signs of a GDV case?

A

Progressively expanding and tympanic abdomen – care with giant breeds, the ribs cover the stomach
Dog depressed, may be recumbent
In ‘shock’, CRT prolonged, pale
Tachycardia, poor pulses, tachypnoea
Dog exhibiting signs of pain
May shown signs of non-productive retching/vomiting (if they can produce vomit this does not mean they don’t have a torsion)
Restless

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33
Q

What should be included in the diagnostic work up of a GDV case?

A 
Clinical signs
Assess severity of shock
Electrolytes
Acid/base status
Electrocardiogram
Radiography
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34
Q

What are the therapeutic goals of GDV?

A

Restore and support the circulation
Provide oxygen to help the oxygen demand on the heart and to the periphery
Decompress the stomach
Work out if it is GD or GDV? Not always clear cut, even with radiography
Surgical planning to untwist the stomach
Prophylactic gastropexy – prevent it happening again (may not be performed at the same time as the fixative surgery)

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35
Q

What does the initial management of GDV consist of?

A 
First priority is to treat shock
Fluid therapy
Decompression
ECG – treat dysrhythmia?
IV corticosteroids – may or may not be beneficial but won’t do any harm as a single injection
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36
Q

What do we what to measure in the blood of a GDV patient?

A

PCV and TS
Electrolytes
Lactate
Venous blood gases

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37
Q

What are we looking for in the venous blood gases of a GDV patient?

A

Metabolic acidosis, tissue hypoperfusion, anaerobic metabolism and lactate accumulation

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38
Q

What type of fluids are suitable for a GDV case?

A

A balanced eletrolyte solution e.g. Hartmanns (first choice) or 0.9% NaCl

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39
Q

What rate should we give crystalloids to a GDV patient?

A

Shock dose (90ml/kg) give a proportion
E.g. 20-25ml/kg over first 10-15 mins
Repeat as necessary (up to 90ml/kg

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40
Q

What can you use as a last resort in a GDV case (aka the dog is dying in front of your eyes)?

A

Give hypertonic saline (7.2%) (1ml/kg/min)

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41
Q

What analgesia is indicated in a GDV case?

A 
A pure mu agonist opioid is indicated
 o Methadone (Comfortan) is licensed for dogs and cats 
 o So is fentanyl (Fentadon) (licensed, shorter acting, more potent, less available)
42
Q

Should you use NSAIDs in a GDV patient?

A

Avoid if possible

43
Q

Is an ECG indicated with a GDV patient?

A

If available, perform an ECG:
• The magnitude of the arrhythmias can be assessed
• Correcting hypoperfusion, pain and electrolyte abnormalities commonly resolves the arrhythmias

44
Q

When should you treat arrhythmias in a GDV patient?

A

Avoid the temptation to treat unless
o Arrhythmia is sustained, paroxysmal or polymorphic ventricular tachycardia (> 150 bpm)
o Pre-existing cardiac disease

45
Q

Why do you get secondary arrhythmias in a GDV patient?

A

As a result of acid base abnormalities, electrolyte disturbances, haemostatic abnormalities and/or reperfusion injury

46
Q

What is the initial managment of a GDV patient once it is stablised?

A

Orogastric tube – put vet wrap into mouth of dog to hold the jaw open and pass the gastric tube through
Percutaneous trocar
Gastrotomy

47
Q

Describe the process of passing a stomach tube?

A

Pre-measure large stomach tube and mark (holes +++)
Sedate with care (opioid or opioid + benzodiazepine) but often not required
Insert bandage roll (e.g. Vetrap) into dog’s mouth and pass lubricated tube through the lumen
If tube will not advance, do not force it – a change in position might help it pass
Lavage and drain, if possible

48
Q

What should you do if a tube cannot be passed in a GDV patient?

A

Perform a percutaneous gastrocentesis

49
Q

What should you use for a percutaneous gastrocentesis?

A

Large bore needle/trocar or OTN catheter (14-16 G)

50
Q

Where should you perform a percutaneous gastrocentesis?

A

Place on most distended side caudal to last rib

Right side is often preferable to help avoid the spleen – but anywhere you can percuss the stomach is suitable

51
Q

When should you radiograph a GDV patient?

A

Once decompression has been achieved and the dog is stabilised

52
Q

Do you always need to radiograph a GDV patient?

A

No - can go straight to surgery if the diagnosis is obvious and the treatment won’t change depending on the image

53
Q

What is the aim of surgery in GDV patients?

A

Correct gastric malposition
Assess and treat ischaemic injury
Prevent recurrence

54
Q

What should you do if you find necrotic tissue when you open a GDV dog?

A

Can invaginate the necrotic part of the tissue and stitch together the healthy part of the tissue
Invagination is not commonly done, more likely to do a gastrectomy to remove the necrotic tissue

55
Q

How can you prevent recurrence with GDV?

A 
Tube gastropexy 
Incisional gastropexy 
Circumcostal gastropexy
Belt loop gastropexy 
Incorporating gastropexy
Laparoscopic gastropexy
56
Q

What types of gastropexy are most commonly performed?

A

Incisional gastropexy

Belt loop gastropexy

57
Q

What is the advantage of a tube gastropexy?

A

The theoretical advantage is that you have a tube in the stomach so if you get another dilation in the post-operative period you can drain the gas.

58
Q

Briefly explain what is done in a belt-loop gastropexy

A

Raise seromuscular flap off the greater curvature, pass through gap made in transversalis muscle and suture back in place.
Use stay suture attached to apex of the flap to pass through loop made through muscle in abdominal wall. Use long lasting, monofilament e.g. PSD. Seromuscular layer and seromuscular layer of flap - no penetration of stomach lumen

59
Q

Briefly explain what is done in an incisional gastropexy?

A

On the pyloric antrum make a linear incision (can be transverse) through seromuscular layer. Make a similar linear incision on the abdominal wall and stitch them together.
Incision made through serosal layer, 8-10cm long, partial thickness (seromuscular incision, only down to submucosa), then touch to abdominal wall to get idea of where stomach needs to sit. Often need assistant to evert lateral wall to get at this easily. Make incision through serosa and underlying transversalis on body wall (single incision). Stitch one side of abdominal wall incision to one side of stomach incision. Do the far side first to make it easier to suture back up. Use monofilament long lasting polydiaxonone eg. PDS

60
Q

Briefly explain what is meant by an incorporating gastropexy?

A

When you exit the ex-lap to put the stomach back in its usual position, incorporate part of the stomach wall into the linear alba as you close it

61
Q

What are the post-operative complications of a GDV case?

A 
Death
Shock
Dysrhythmias - 40% of dogs
Anaemia
Hypokalaemia
62
Q

How do you treat post-op dysrhythmias in GDV patients?

A

Lidnocaine/procainamide

63
Q

What should GDV patients be fed post-op?

A

Low fat, semi-liquid, low protein diet

64
Q

What should you tell the owner after a GDV case?

A

Feed a few small meals per day (better than one or two larger meals)
Avoid stress around the time of feeding
Restrict exercise both before and after feeding
Do not use an elevated food bowl (may encourage aerophagia) – conflicting studies
Do not breed from dogs with a 1st degree relative with a history of GDV
Consider prophylactic gastropexy (?)

65
Q

Why is small bowel torsion rare?

A

Mechanisms in place to prevent this. Fixed points in abdomen prevent twisting and things getting stuck

66
Q

What is the prognosis of small bowel torsion and why?

A

Poor
May get torsion around the mesentery, animal will nearly always die. By the time it presents, bowel will be ischaemic and dead

67
Q

What breed is most likely to get small bowel torsion?

A

GSD

68
Q

What are the ideal suture materials for closure of the stomach, and how long does it last?

A

Polyglyconate - 21 days
Polydioxanone - 28 days
Glycomer 631 - 18 days

69
Q

What are the ideal suture materials for closure of the urinary bladder, and how long does it last?

A 
Glycomer 631- 18 days 
Polyglytone 6211 - 10 days
Poliglecaprone 25 - 14 days
Polyglyconate - 21 days
Polydioxanone - 28 days
70
Q

What are the ideal suture material for closure of the linea alba, and how long does it last?

A

Polyglyconate - 21 days

Polydioxanone - 28 days

71
Q

What are the ideal suture materials for surgery of the pancreas, and how long does it last?

A

Polypropylene - permanent
Polyglyconate - 21 days
Polydioxanone - 28 days

72
Q

What are the ideal suture materials for surgery of the gall bladder, and how long does it last?

A

Glycomer 631 - 18 days
Polyglyconate - 21 days
Polydioxanone - 28 days

73
Q

What are the advantages of balfour abdominal retractors?

A

Three-point retractor – stable once placed
Can be used as a two-point or three-point retractor
Many versions come with a locking nut to prevent the retractor closing once placed

74
Q

What are the disadvantages of balfour abdominal retractors?

A

Large – may not fit in practice autoclave
Expensive
Cannot be used on small patients

75
Q

How are abdominal retractors classified?

A

Hand-held
Self-retaining
Two-point, three-point or circular

76
Q

How do gosset retractors stay open?

A

Self-retaining

Remain open due to friction

77
Q

What is the main disadvantage of gosset retractors?

A

Often close inappropriately

78
Q

What is the main disadvatage of langenbeck retractors?

A

Require a surgical assisstant to hold them

79
Q

What would be a good antibiotic to use for use in a clean/contaminated small bowel enterectomy surgery in small animals?

A

Cephalosporin 1st/2nd/3rd gen e.g. Cefuroxime 20mg/kg Iv

Clavulanate amoxicillin 20 mg/kg IV

80
Q

When would be the best time for antibiotics to be administered peri-operatively?

A

IV every 60-90 min dependent on surgery
Duration of therapy
o Contaminated: 24h
o Dirty: therapeutic - 5d?

81
Q

What safety precautions should be taken when using surgical swabs during open abdominal surgery?

A

Count the swabs prior to performing the procedure
Count the swabs prior to closure of the linea alba
Do not disposed of the swabs until the swab count is correct and the operation is finished

82
Q

What are common foreign bodies in dogs?

A

Bones, Rawhide, Toys and balls, Fish hooks, Clothing

83
Q

What are common foreign bodies in cats?

A

Needles, String, Toys, Hair

84
Q

What are clinical signs of foreign bodies?

A 
Retching
Regurgitation (food &amp; water)
Vomiting 
Ptyalism
Anorexia
Restlessness 
Cervical pain
85
Q

What investigations should be included when working up a foreign body case?

A 
High index of suspicion from clinical history
Plain radiography (in most instances the foreign body will be radio dense or the ingestion was witnessed)
Endoscopy
86
Q

Give examples of foreign bodies which appear radiolucent on radiography?

A

Rawhides and furballs

87
Q

Should you perform constrast radiography in a suspect foreign body case?

A

Avoid if possible - risk of perforation

88
Q

If you have to perform a contrast radiograph on a suspect FB case what should you use?

A

If you need to give one, select a water-soluble iodine agent suitable for swallowing

89
Q

Why should you avoid using barium as a contrast agent in a suspected FB case?

A

Don’t give barium due to the potential risk of oesophageal perforation as the contrast agent will irritate the mediastinum or cause aspiration pneumonia

90
Q

What is the treatment for FB?

A

Emergency surgical removal

91
Q

How are oesophageal FBs usually treated?

A

Endoscopic retrieval

92
Q

How should you treat the 10% of oesophageal FBs than cannot be removed orally?

A

Push them into the stomach - often digested and removal not needed

93
Q

What is the blood supply to the spleen?

A

Blood supply runs down the hilus
Main splenic artery and vein, and an anastomotic supply to the greater curvature of the stomach via short gastric arteries, and left gastroepiploeic arteries
Also has an anastomotic arterial supply from the greater curvature of the stomach

94
Q

What is the most common reason for a spenectomy?

A

Mass

95
Q

How do you prevent bleeding in an emergency splenectomy?

A

In an emergency situation, can perform mass ligation technique - ligate splenic artery, then mass ligation of 3 bites of suture around mesentery and remove en mass

96
Q

What is a problem of mass ligation of spenic vasculature?

A

Will also remove some blood supply to the stomach, but no real issues in the dog as stomach has lots of blood supply

97
Q

How do you perform a spenectomy in a non-emergency case?

A

If not emergency, the slower closure of all vessels around the edge better as this will maintain blood supply to the liver better

98
Q

Describe the blood supply to the stomach

A

There is a blood supply down the great (left and right gastroepiploic) and lesser (right and left gastric) curvature of the stomach

99
Q

What is the risk with gastric perforation?

A

Gastric acid contamination is a bigger worry than bacterial contamination

100
Q

Why would a gastrotomy be indicated?

A

The creation of an artificial external opening into the stomach for nutritional support or gastric decompression

GI2 (27 decks)

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