Surgical Complications/Peritonitis

Question 1

What organs are retroperitoneal?

Answer 1

kidneys

ureters (for most of their length)

adrenal glands

aorta

caudal vena cava

lumbar lymph nodes

Question 2

How do small particles (<10um) move from the peritoneal fluid into the systemic circulation? Which small particles?

Answer 2

diaphragmatic lymph→ mediastinal l.n.→thoracic duct→systemic circulation

RBC, bacteria, & neoplastic cells

Question 3

What are the two types of peritonitis?

Answer 3

1. aseptic:
   
   1. endogenous chemical contamination of the peritoneum (sterile bile, urine, lymph, or pancreatic enzymes)
   2. Exogenous chemical contamination (talc or irritating lavage solutions and mechanical irritation from manipulation of organs during sx)
2. Septic: associated with infection

Question 4

What are the two types of septic peritonitis?

Answer 4

1. Primary: spontaneous inflammation of peritoneum
2. Secondary: associated with intra-abdominal leakage of bacteria into the peritoneum or disruption of the body wall resulting in the introduction of external bacteria. Rupture,

perforation, or leakage of bacteria from the gastrointestinal tract is the most common cause in small animals.

Question 5

Which part of the immune system does the peritoneum depend on mainly for absorbing and localizing infections?

Answer 5

innate

Question 6

What blocks fluid reabsorption in peritoneal inflammation?

Answer 6

fibrin (occludes peritoneal drainage)

Question 7

Components of normal peritoneal fluid?

Answer 7

relatively acellular

(some macrophages, mesothelial cells, lymphocytes)

Question 8

Can peritoneal fluid clot? Why?

Answer 8

no, does not contain fibrinogen

Question 9

What is the pathogenesis of septic peritonitis?

Why is there an influx of protein rich fluid?

Answer 9

Question 10

How does peritoneal contamination injury result in death?

Answer 10

multiple organ dysfxn

• kidney
• pancreas
• liver

Question 11

What are the beneficial actions of the omentum?

Answer 11

• isolate and seal the source of contamination by formation of an omental adhesion in response to fibrinous exudate
• absorb bacteria and other particulate matter
• rich blood supply to the lesion, high absorptive capacity, and pronounced angiogenic activity to further assist resolution.

Question 12

What are the SIRS criteria for dogs?

Answer 12

Question 13

What are the SIRS criteria for cats?

Answer 13

Question 14

Clinical signs of septic peritonitis?

Answer 14

Question 15

Differentiate the expected abdominocentesis results for a septic vs. aseptic abdomen vs. ascites vs. uroperitoneum vs. chyloperitoneum?

Answer 15

Question 16

When performing an abdominocentesis, what is the best location to insert the needle?

Answer 16

caudal to the umbilicus ~1cm in

Question 17

What would be the different indications if intracellular vs. extracellular bacteria were present in the peritoneal fluid?

Answer 17

intracellular: septic peritonitis
extracellular: perforated bowel w/ collection needle

Question 18

What would be diagnostic for uroabdomen in the peritoneal fluid?

Answer 18

peritoneal fluid creatinine in excess of serum creatinine

peritoneal fluid potassium in excess of serum potassium.

Question 19

What would be dx for bile in peritoneal fluid?

Answer 19

peritoneal fluid bilirubin >2x serum bilirubin

golden-green granular pigment

or a basophilic mutinous material is the predominant

cytologic finding

Question 20

What is the recommended abx tx for septic peritonitis?

Answer 20

third generation cephalosporin & metronidazole (anaerobes)

Question 21

What is the general flow for peritonitis DX & TX?

Answer 21

Question 22

Why does peritonitis pre-dispose anastomoses to dehis?

Answer 22

peritonitis causes strong proteolytic activity that degrades collagen and extracellular matrix and may predispose intestinal anastomoses and enterotomies to dehiscence.

Question 23

What are the different SX techniques than can be used with a septic peritonitis?

Answer 23

debridement

lavage

serosal patching

omental wrapping

drainage: open vs. closed

Question 24

What type of drain is used for a closed drainage?

Answer 24

Jackson-Pratt drain

Question 25

What are the key parts of post-op management for peritonitis?

Answer 25

monitoring

nutrition

transfusion/fluids

CV support

abx (based on C/S)

Question 26

What are poor prognosis indicators for peritonitis?

Answer 26

Refractory hypotension, cardiovascular collapse,
respiratory distress and DIC are indicators of poor
prognosis

Question 27

What is protein-malnutrition associated with?

Answer 27

immunocompetence, depletion of energy stores, weakness, delayed wound healing, and organ failure

Question 28

What is the preferred source of nutrition: enteral or parenteral in peritonitis cases?

Benefits?

Answer 28

enteral

Benefits:

directly beneficial to enterocytes

decreases bacterial translocation across the intact gut wall

maintains intestinal structure and function, decreases mucosal permeability to bacteria and endotoxin

preserves secretory IgA concentrations in biliary tract secretions.

Question 29

Why is CV support need post-op for peritonitis?

Answer 29

cardiovascular support drugs (such as dopamine or dobutamine) may be required to maintain cardiac output and support systemic arterial blood pressure