Abdominal Surgery Flashcards
(183 cards)
1
Q
What are the surgical approaches to abdominal surgery?
A
Ventral midline, paracostal, flank, laparoscopic (needs extra advanced training)
2
Q
What kind of biopsies are done on LN? What about Mesenteric LN?
A
Done in surgery (easiest) or FNA through skin. However, Mesenteric LN’s are really sensitive and you might destroy those if you don’t do it with surgery with a wedge biopsy.
3
Q
What’s special about intestinal biopsies?
A
Treat it like a clean contaminated wound. If you know you’re doing a clean surgery, then do this biopsy last and swap the gloves and instruments when you’re closing up so you don’t get fecal material in the SQ or other spaces. You need lap sponges, to pack the area and be super gentle with the samples (crush injuries from forceps very easy)
4
Q
How do you prevent intestinal contents from flying out after a biopsy?
A
You get an assistant to hold it off
5
Q
How do you do liver biopsies and what are the benefits of each method?
A
Guillotine biopsy: where you tie a monofilament suture around an edge of the lobe and cut it off, punch biopsy: good for lesions that are not near edge of lobe, Laparoscopy: is an easier procedure to recover from cause you don’t open up the entire chest, just send in this arm with a camera and forceps and take a snip of the liver.
6
Q
Which of the 3 liver biopsies techniques is easiest to recover from?
A
Probably the laparoscopy method, unless we have bad coagulopathies, the dog can go home the same day. The biopsy method you could put gel foam in the biopsy spot to seal it up.
7
Q
Give examples of organs (x7) that you need to think twice about biopsies
A
Kidney (higher risk, don’t hit the medulla cause it bleeds a lot), Pancreas (only if there are gross lesions or specific pancreatic conerns, we’re worried about pancreatitis post-op, very temperamental organ, only do if you think you have EPI), Bladder (not a routine exploratory laparotomy), Spleen (not on route ex lap), Adrenal glands (just no), body wall (sometimes), Omentum (guillotine like biopsy)
8
Q
What are some causes of inflammatory peritoneum (peritonitis)?
A
Primary causes: FIP in cats; secondary causes: sequelae of other things like –> Aseptic = foreign body, ruptured neoplasm, pancreatic enzymes, bile, urine, stomach or proximal duodenal contents, diffuse neoplasia (carcinomatosis/sarcomatosis/mesotheliomas) or Septic = bowel perforation or dehiscence, penetrating wounds, surgical contamination, ruptured pyometra or prostatic abscess, urine or bile with bacterial load.
9
Q
What are some clinical signs related to peritonitis? (they’re kinda non-specific)
A
Depression, abdominal pain, nausea, vomiting, anorexia, diarrhea
10
Q
What are some more specific clinical signs of peritonitis?
A
Fever and leukocytosis but are not consistent
11
Q
What might you see on BCHEM and CBC for peritonitis?
A
Leukocytosis with left shift or neutropenia; Elevated BUN, creatinine, potassium possibly due to uroperitoneum; if it is bile peritonitis you might see elevated bilirubin, alk phosph, alanine transaminase; with septic peritonitis you may see hypoglycemia, hyperlactatemia
12
Q
What might abdominal radiographs who in an animal with peritonitis?
A
Free air present in abdomen (but if you’ve opened up the abdomen, it could persist in there for 3 weeks postop), lack of serosal detail suggestive of effusion.
13
Q
What’s the gold standard for peritonitis diagnosis?
A
Obtain peritoneal fluid (US guided), conduct cytology/clin path on it to determine degenerative neutrophils, bacteria = septic, measure the fluid and compare markers of bilirubin, creatinine, glucose, lactate to the blood. Bile crystals = bile peritonitis
14
Q
QUICK TRIAGE, THERE’S SHOCK FROM PERITONITIS, what do we do?!
A
Aggressive patient stabilization like: IV fluids (crystalloid and depends on bloodwork: LRS, plasmalyte are well balanced, NaCl if they’re hypochloremic, hypokalemic so add in K, if they’re hypocalcemic, don’t bolus calcium but have them on plasmalyte and add calcium), pain meds and anti-inflammatories (injectable opioids, ketamine, lidocaine), Antibiotics (i know you want a sample, but prioritize saving hte life- broad spectrums like enrofloxacin, ampicillin, metronidazole, piperacillin tazobactam, cefoxitin), vasopressors/ionotropic meds to help with heart function and BP, blood products if indicated
15
Q
What are the surgical steps to peritonitis?
A
Removal of inciting cause (resect bowel, remove FB, debride abscess, OVH for ruptured pyometra, etc.), lavage abdominal wall (just until it’s not a gross colour and more serosanguinous- fluids can make them realy hypotensive and cold so use it warmed), drainage of peritoneal cavity (closed suction only, open management no longer suggested –> careful of hypoproteinemia, hypoalbuminemia and electrolyte disturbances as well as infection and pain)
16
Q
What’s the general prognosis for peritonitis?
A
Variable but at best it is guarded (50/50), the earlier to I ntervene the better
17
Q
What can penetrating traumas cause internally?
A
Direct perforation of the bowel
18
Q
What can blunt trauma cause in the abdomen?
A
Immediate tears or vascular compromise to organs
19
Q
What’s a good and bad predictor of abdominal trauma cases, diagnostically?
A
Clinical and lab findings are not good predictors, abdominal radiographs or peritoneal lavage (diagnostic) are good predictors
20
Q
What makes a penetrating wound in the abdomen a bad prognosis?
A
Generally, a perforated bowel, major abdominal hemorrhage and perforation of organs worsens the prognosis greatly, it depends on the extend of damage as well
21
Q
T/F: The stomach is a complicated organ to conduct surgery on because of its overabundance of vasculature, it has a lot of complications.
A
False: the stomach has an overabundance of blood supply which is why it can heal so well, it tends to be a straightforwards and low complication rate surgery.
22
Q
Which organs attached to the stomach make it problematic for the stomach?
A
Pancreas, duodenum, gall bladder
23
Q
Why does the stomach need such a large blood supply?
A
It helps with making the mucosa in the stomach so HCl doesn’t melt right through it.
24
Q
What are reasons we would have to conduct surgery on the stomach?
A
Biopsy, foreign body, GDV/prophylactic gastropexy, GI tube placement, neoplasia, outflow obstruction, hiatal hernia, gastroesophageal intussusception
25
IF we had an outflow obstruction of the stomach, what would bloodwork indicate?
Hypochloremia, metabolic alkalosis (losing all your chloride and acid), as the animal gets more sick, this metabolic alkalosis gets less consistent
26
Why is a gastrotomy safer than an enterotomy?
Gastrotomy is safer because of the size of the stomach > intestine, blood supply is more, easy closure, bacterial types are less troublesome and there are less complications
27
What are the two most common indications for a gastrotomy?
Biopsy (IBD or diffuse neoplastic process like lymphoma), foreign body removal (most common)
28
Where should you incise for a gastrotomy?
incise between the greater and lesser curvature in a relatively avascular location
29
What are some mandatory things you need for a gastrotomy?
You need an assistant, suction since there's a lot of fluid, PDS (single continuous or inverted pattern) and evaluate the entire GI tract, don't get tunnel vision
30
What is gastric dilatation and volvulus?
Accumulation of air in the stomach, gastric malpositioning to the point that the CVC is obstructed so blood from legs can't gt to heart and diaphragm obstructing breathing. Volvulus makes it look worse too. Stomach rotates clockwise 180-270 degrees, you get gastric ischemia, necrosis and perforation. Systemically there is obstructive and hypovolemic shock due to everything and splenic effects (bleeding from gastric vessels, congestion, torsion of the spleen too)
31
What are some risk factors of GDV?
Large, giant deep chested dogs, stress, feeding (large amounts or eating too fast or just one type of dry food), increasing age, male, hereditary, previous splenectomy (less anchoring, overall less room), post-prandial exercise
32
How do you diagnose a GDV?
Signalement and history (retching - nonproductive, distended abdomen, restlessness, ptyalism, tachypnea, dyspnea, shock symptoms)
33
What might a dog with GDV indicate on bloodwork?
lactate levels may be increased due to ischemia, check there is no coagulopathies cause you're going to surgery and make sure liver and kidneys are ok.
34
What pain management are we using for GDV?
fentanyl, hydromorphone helps with tachycardia and arrhythmias, Since the pancreas is attached to the stomach, it tells the rest of the body it is mad so VPCs (spleen also contributes)
35
What do we give to the dog to control the VPC's or Vtachs associated with arrhythmias from GDV?
Lidocaine
36
How do we immediately stabiize GDVs?
Trocharize it or add a gastric tube both under anesthesia or sedation to decompress. Provide fluids (at least 2 and bolus on front legs and crystalloids), prepare it for emergency surgery
37
Once GDV dog is stable, what do we do and why?
Abdominal radiographs in RIGHT LATERAL (will see gas distended stomach with compartmentalization, if you think there's a FB do a left lateral first.
38
Describe radiograph of a GDV dog in right lateral
you'll see a fluid filled stomach, super distended, you'll see a curling stone figure, popeyes arm when it's really fluid/gas filled. You'l see a dilated esophagus cause of aerophagia, megaesophagus, look for vena cava cause it'll be so thin
39
What's the next few after right lateral to determine GDV?
DV
40
Briefly describe the surgery for a GDV from positioning of the animal to just before closing
Dorsal recumbency, long ventral midline incision (xiphoid to pubis), don't perforate the stomach cause it's super distended, detrosion (grab duodenum and push stomach ventrally and to left - might need orogastric tube), assess gastric viability, check other organs like spleen and stomach wall, look for FB and concurrent masses/nodules
41
Why might you do a splenectomy during a GDV surgery?
The spleen is torsed around the vascular pedicle, lack of arterial pulsation in mesentery of spleen, if it was congested initially and after you detorse the GDV and it's not getting pinker by end of surgery… then cut it out
42
During the gastrectomy, what indicates a poorer prognosis.. When what is involved?
Poorer prognosis if cardia of stomach is involved and if the stomach is black and white. Sometimes you have to resect the stomach, but itll likely torse towards cardia.. It's a tough call
43
What are indications to due gastropexy on left or right?
Left: hiatal hernia and gastroesophageal intusussception; right: GDV or prophylactic pexy (if you cut a GDV, you have to pexy)
44
What's an incisional gastropexy?
Slit through transversus at pyloric antrum, not full thickness (not through mucosa), attach it to just behind last rib
45
What must you monitor on ECG after post-op?
VPC/Vtach for atleast 24 hours to find arrhythmias
46
T/F: mortality rate of GDV's afer surgery is 10%
TRUE
47
What's the difference between acquired and congenital hypertrophic pylorogastropathy?
Congenital: muscular layer, pyloric stenosis and normally in young (<1yo) brachys. Acquired: mucosal or mucosal and muscular layers, small breed dogs.
48
What does a hypertrophic pylorogastropathy look like coming in to the clinic?
chronic intermittent vomiting with increasing frequency (Ddx is chronic foreign body)
49
What's a good way to diagnose hypertrophic pylorogastropathy?
U/S and CT or barium radiographs but difficult
50
What's a gastroesophageal intussusception and how common is it?
Stomach slides in and out of chest through the esophagus. Need to close the hiatus and pexy the stomach
51
What's type 1-4 hiatal hernia?
Type 1: sliding hiatal hernia, type 2: paraesophageal hiatal hernia (part of fundus slides into thorax along with esophagus), Type 3: combo of 1 and 2, Type 4: herniation of abdominal contents through esophageal hiatus.
52
What's the most common gastric neoplasia in dogs, cats?
Dogs: gastric adenocarcinoma; cats: lymphosarcoma
53
What are two other gastric neoplasias?
Leiomyosarcoma, fibrosarcoma
54
As you move towards the ____ the worst the prognosis of gastric neoplasia placement
Pylorus
55
Which arteries supply part of the duodenum and originates from a branch of the celiac artery?
Hepatic and cranial pancreatic duodenal artery
56
What's one way to tell where the ileum is on the small intestine?
It's the only part that has a visible blood supply (antimesenteric vessels)
57
What exits out the major duodenal papilla?
common bile duct
58
What might you see on bloodwork of small intestinal diseases?
Electrolyte imbalances due to dehydration or vomiting/diarrhea (hypochloremic metabolic alkalosis, hypokalemia, hyper or hyponatremia), erythrocytosis, hyperproteinemia, hyperlactatemia, Sepsis biomarkers (hypoglycemia, hyperbilirubinemia, hyperlactatemia)
59
Why do we do a left lateral radiograph first if we suspect a FB?
Don't want the fluid to enter into the pylorus or the foreign body to get lodged by the FB, so take a left lateral photo first so it's not gravity dependent
60
What are the 3 imaging techniques used for SI disease?
Contrast study (barium studies- if they can't swallow… asipration pneumonia, or if there's a perforation --> peritonitis), US, CT
61
Which lateral view (L or R) will you see a large gas filled pylorus on the ventralish side?
Left lateral
62
Why is fluid therapy important before surgery?
Rehydrate the animal before anesthesia because many FBs can be cut with conservative management, and most animals are at risk for fluid and electrolyte imbalances when undergoing intestinal surgery because they're often suffering diarrhea, anorexia, vomiting and lose a lot of fluids, entering metabolic alkalosis
63
Should we use antibiotic prophylaxis before SI surgery and why or why not?
Yes, gram negative and positive bacteria are in the SI (dirty environment), use Cefazolin and injected 30 min before incision. Single dose or continued dose for max of 24 hours.
64
Which suture types should be avoided and which are ideal for SI surgery?
Multifilament and chromic gut sutures avoided; ideal: those that don't cause inflammation or potentiate inflammation like monofilament, small sized taper needles, pick ones with relatively long absorption times/maintenance of strength. 4-0 PDS (simple interrupted or continuous), 3-0 PDS for very large dogs
65
What's the holding layer of a hollow viscous organ?
SQ
66
What's the recommended suture pattern for closing SI?
Single layer appositional (appose Submucosa), inverting patterns narrow the lumen, 2 layer patterns aren't appositional for submucosa, and everting patterns cause more adhesions.
67
When cutting out a solitary FB, should we cut aboral or oral to it?
Aboral, cut in the healthy prat of intestine longitudinally on antimesenteric border
68
What do you do with necrotized intestinal wall?
You resect and anastomose the healthy sections together. Resect it based on blood supply to bowel
69
What's the goal of the gambee pattern and when do you use it?
If the mucosa everts while you're trying to suture it, you can use the Gambee pattern which tries to keep the mucosa on the inside without trying to have too much eversing
70
What do we do if the intestines are a different size at where you resected?
Cut non=dilated side at a slant, and dilated side straight down, take closer bites on narrower side and farther bites on dilated side.
71
T/F: you can use staples on resection and anastamosis
False: don't use staples, they will destroy the intestines and be super irritating
72
What do you do with the omentum after anastmosis?
Magical bandaid, so do enterotomy --> flush --> throw omentum ontop and protects it
73
Describe the leak test
normal peristaltis pressures in SI of dogs = 15-25 mmHg, so take a needle and inject some saline, don't put too hard
74
Where are two sites that the linear FB gets anchored at?
Base of tongue or at pylorus (cat > dog)
75
What's the pathogenesis of a linear FB?
Peristalsis --> attempts to move FB but intestines accordion along object --> line becomes taut on mesenteric side of intestinal lumen --> irritates and devitalizes intestines --> multiple perforations
76
What might you see on x-rays of a linear FB?
SI plications, small teardrops (luminal bubbles), lacks free fluid and gas sometimes but doesn't mean there's no perforation.
77
Should you use contrast studies for linear FB? Why or why not?
You could, but be super careful incase there are perforations as barium causes terrible peritonitis. Get an US or CT or just explore the abdomen
78
What's the conservative treatment for foreign linear body?
Cut it from tongue and let it pass in 1-3 days, place radioopaque clip and follow it through intestines, never pull it out anally or orally (inexpensive). If this doesn't work, there's a high chance of intestinal perforation. RESERVE THESE for cases with no c/s and no ability to afford surgery
79
What's the surgical treatment of foreign linear body?
isolate bowel, start with anchor point through gastrotomy usually. Dogs usually pylorus, cats is usually tongue. Can tie it to a red rubber catheter and string it to different parts of the tract. Check mesenteric borders.
80
What are examples of benign SI tumors?
Leiomyomas, adenomas, adenomatous polyps
81
What are examples of malignant SI tumors?
Dogs: adenocarcinoma, leiomyosarcoma, GI stomal tumors; Cats: lymphosarcoma; common to both: fibrosarcoma, mast cell tumours
82
When resecting tumors in bowel, how much in cm should you remove as margins?
5-10cm margins and submit for histopath
83
What's the age group of intussusceptions?
< 1 yo
84
What are causes of intussusceptions?
Idiopathic < commonly this one, parasites, viruses (parvo), linear FB, previous surgeries, uncontrolled pain. If older animal then it could be neoplasia
85
What will we see on US of an intussusception?
Concentric rings (alternating hyper and hypo-ehoic) in transverse or parallel lines in longitudinal image. Could be a dynamic process so it disappears
86
What's the treatment for intussusception?
You need to do an ex lap, reduce it if possible and then resect and anastmasose it if possible.
87
What's enteroplication and how does it prevent intussusception?
Decrease probability of recurrence, you lay out all the intestines, then suture them together into one huge sheet of intestines. It has high complication rates
88
What complications does enteroplication cause?
Increase chances of future FB, more likely to have septic abdomen post op
89
What's a mesenteric volvulus and its pathogenesis?
Twisting of bowel on its mesenteric axis (which includes cranial mesenteric artery and branches). Twist --> obstruction of thin walled veins and lymphatics --> edema and engorgement of bowel and sequestration into blood --> mucosa rapidly compromised --> eventual arterial occlusion --> ischemic necrosis.
90
What is mesenteric volvulus reported in association with?
EPI and lymphocytic plasmacytic enteritis
91
What are the c/s of mesenteric volvulus?
Peracute onset of acute abdomen (collapse, rapidly progressing bloat, hematochezia, vomiting or diarrhea, pain may or may not be present)
92
T/F: you can diagnose mesenteric volvulus early with x-rays
With progression, you get gaseous distension of entire bowel, so early on you might not see it
93
What's the treatment for mesenteric volvulus?
Rapid fluid resuscitation to treat shock, surgery asap to remove the twist and may require R/A. Most urgent surgeries in vet. Derotate and reperfuse bowel. If it's dead, don't untorse it cause all the dead cytokines will free into the circulatory system and the animal will die from cytokine storm.
94
Define incarcerated hernia and strangulated hernia
Incarceration: small bowel is herniated and can't be reduced; strangulation: incarcerated bowel with devitalization.
95
Common locations for hernia
Inguinal or scrotal, diaphragmatic, umbilical, failed body wall closure, traumatic body wall hernias, mesenteric rents not closed at surgery.
96
Describe how ileus manifests after SI surgery and how to fix it
It's due to inadequate peristaltic activity and so the animal might vomit, regurgitate (aspiration pneumonia), will have inappetance cause it feels nauseous. Try to give it prokinetics, treat the underlying problems, give it a bit of food (prokinetic), anti-nausea (maropitant), decrease pain meds if comfortable cause opoioids perpetuate ileus
97
Should you do an NG tube for the ileus complication?
Helps with removing food that is backed up.
98
What is short bowel syndrome?
It's a complication of SI surgery, and can develop when 75% of the intestines are resected (over a lifetime). Causes malnutrition, weight loss, diarrhea. Treatment: maintain fluids, nutrition and exogenous vitamins (B12 deficiency likely from jejunum and ileum resection)
99
How do you minimze formation of adhesions after SI surgery?
atrumatic tissue handling, moisten tissues, strict asepsis, remove contaminats (starch, blood, bile, gauze)
100
What days do you usually see dehiscence after closing?
day 3-5 = lag phase of wound healing (neutrophils are done and have debrided tissues at level of incision)
101
What's the 4-4-4 rule?
It's in relation to enterotomies; 4-0 PDS, 4mm between bites, 4 days till dehiscence
102
T/F: the large intestines has poor collateral circulation
True: makes it prone to dehiscence, bowel viability hard to assess, just remove suspected avascularity, don’t perform full thickness biopsy.
103
T/F: the large intestine has few amounts of bacteria:
False, lots of bacteria, mainly gram negative anaerobes
104
What's another name for a congenital megacolon and what is it?
Hirschprung's disease (rare): has no mesenteric ganglionic cells in distal colonic segment --> permanent muscular spasm of affected area --> functional obstruction of bowel. < constipation, laxatives don't work, need R and A
105
Define obstipation
Plugged, mostly in cats, causes chronic constipation and can be due to sevral things but it's most commonly idiopathic
106
What to do if an obstipated cat comes in?
We will try to treat it medically first. Not refer to surgeon yet, but maybe internal med.
107
Let's say you decide to R and A the colon in a cat that has obstipation… what do we do?
You need to preserve the blood supply to both ends = cranial rectal branch. Entire colon is generally dilated, cats usually adapt well to loss of water absorptive abilities
108
Where's the most common site if neoplasia in large intestines of dogs and cats?
dogs = rectum and colon, cats = uncommon
109
What are clinical signs of large intestinal neoplasias?
Blood or mucus in stools, tenesmus (always wanting to poop), dyschezia (constipation)
110
What are two malignant masses found in LI?
adenocarcinoma, leiomyosarcoma
111
What are benign masses found in LI?
Adenomatous polyps, leiomyoma
112
What's a DDx for a GSD?
Colonic torsion
113
What's a risk factor for colonic torsion?
Previous GI disease and abdominal surgery may be a risk
114
Is colonic torsion emergency?
Yes, devitalized colon is bad, rupture is even worse. We need surgery ASAP to reposition colon (left side colopexy) and R and A on affected prats
115
If we're worried about splenic neoplasia, should we do a partial or full splenectomy?
Full splenectomy
116
T/F: splenic surgery is indicated for trauma related injuries
False: rarely need surgery for trauma related injuries
117
What might you see on bloodwork indicating the spleen is injured?
Anemia, platelet count lower, may have prolonged coagulation factors
118
How important are CT and US in spleen disease diagnosis?
Not super, they are complementary tests, with exceptions of big dogs and deep chested dogs which spleen is under the ribs. CT can help elucidate neoplasia that can change prognosis if there is metastasis. A hemoabdomen can be seen with US.
119
What's the 2/3 rule related to hemangiosarcomas on the spleen?
2/3 are splenic masses are malignant, of the above 2/3 are hemaniosarcoma
120
What's the median survival time of a hemangiosarcoma?
MST is 2-3 months with surgery without chemo, 6 months with surgery and chemo. If there are metastasis found at time then the MST is dramatically reduced
121
What's the most common form of splenic tumour in cats?
Mast cell tumours
122
What looks just like a hemangiosarcoma pre-op?
Hematoma
123
T/F: you can tell if it's a hemaniosarcoma or benign hyperplasia on US or grossly.
False: you can't tell this and need a biopsy to be definitive.
124
What are the main sites of ligation for a splenectomy?
Ligate splenic artery and vein + short gastrics (always double ligate these!), careful of the pancreas so double ligate distal to the pancreas. You can also ligate along the hilus of the spleen.
125
What is the animal more at risk of after a splenectomy?
GDV, should consider a gastropexy post splenectomy
126
What other diseases might secondarily cause a splenic torsion and why?
GDV and neoplasia. GDV since it has shifted in location and allowed for the spleen so much more space to move. Neoplasias increases the mass in one location of the spleen which can cause a rotation point.
127
What's the typical presentation of a splenic torsion
Acute abdomen
128
What letter xD does the spleen look like on radiograph for splenic torsion?
a C!
129
what must you not do when you see a splenic torsion in the abdomen during surgery?
Do not detorse the spleen, remove it first cause you risk the splenic vein draining into the portal vein and emboli being released into the systemic circulation
130
What are the 3 major divisions of the 6 liver lobes?
Left division = left lateral and medial lobes; central division: quadrate and right medial lobes (gall bladder between these lobes); right division = right lateral and caudate lobes and surrounds vena cava (as you proceed to the right, the lobes fuse together)
131
What are the anatomic differences between dogs and cats in terms of biliary anatomy?
Both cats and dogs have a common bile duct. Cats CBD and major pancreatic duct fuse into the duodenum at the major duodenal papilla (cats have an extra-hepatic biliary obstruction with pancreatitis); dogs have a separate tube for common bile duct and major pancreatic duct (don't get extra-hepatic biliary obstruction with pancreatitis).
132
What are 3 indications for referral surgery for liver and biliary disease?
Portosystemic shunts, liver trauma, single lobar enlargement due to abscess, neoplasia, torsion
133
The congenital abnormality of PSS is more commonly ______ (intra or extrahepatic) in most small dogs and cats
Extrahepatic; and intrahepatic for larger dogs
134
How might a congenital vs acquired PSS look, when you look into the abdomen?
Acquired: multiple and tortuous; congenital: usually a single large supply avoiding the liver (extrahepatically or intrahepatically)
135
Hepatic encaphalopathy is commonly secondary to PSS, how do we treat this first?
Antibiotics: eliminate ammonia producing bacteria (metronidazole); lactulose: acidifies the gut microflora to trap ammonia within the GIT and also increases urease activity to increase osmotic drag within colon to decrease GI transit time); low meat protein diet: decreases ammonia from diet
136
How do you surgically correct a single PSS?
Complete or partial attenuation redirects the blood into the portal vasculature which might cause bad portal hypertension since the portal vein can't accommodate this. You need to do an ameroid contrictor or cellophane banding. Ameroid constrictors slowly shut and cease blood flow, cellophane banding will cause an inflammatory reaction that will close the shunt by fibrosis over time. There is also interventional radiology for intra-hepatic PSS = coils
137
What are some routine things you should check for on spay/neuter?
Check for PSS and remember there could be urinary calculi if present, also check for concurrent cryptorchids
138
What are some Post-op complications of PSS?
Portal hypertension, seizures and other post-attentuation neuro signs, hypothermia, hypotension, hypoglycemia
139
How prevalent is liver lobe torsions in small animals?
Rare, usually involves one lobe (left lateral lobe is most common)
140
What other mammals will get liver lobe torsions?
Rabbits
141
What does the liver lobe torsion look like on US and CT?
US: hypoechoic or heterogenous liver lobe with decreased or no blood flow; CT: lack of contrast enhancement of affected lobe, abnormal positioning
142
What are some post op considerations of liver lobectomies?
hemorrhage, weight of the mass on vena cava, arrhythmias, blood products are a must, management of pneumothorax if you entered the chest
143
How common are liver lobe abscesses in dogs and cats?
Rare, usually involves one lobe (left lateral lobe is most common)
144
What could cause liver abscesses?
1. necrosis of neoplasms; 2. ascending biliary infection; 3. hematogenous spread.; 4. foreign body migration
145
T/F: liver abscesses can be visualized on CT and US
True; sometimes you can see intraparenchymal gas on radiographs too
146
What's the treatment for bad liver abscesses?
Lobectomy and appropriate antibiotics, need intense perio-operative management
147
What is more common liver neoplasia: metastatic or primary?
Metastatic > primary
148
Give examples of liver neoplasias
Lymphosarcoma, pancreatic adenocarcinoma, hemangiosarcoma
149
T/F: it's common for you to be able to palpate liver masses
True: palpable mass in 50-75% of them
150
What might bloodwork show for liver neoplasias?
Elevated hepatic enzymes (maybe- more common in older dogs): ALT, AST, ALP, hypoalbuminemia, hyperbilirubinemia.
151
What's the most common liver tumor?
hepatocellular carcinoma < it's malignant but has excellent prognosis if surgically resected (biologically benign)
152
What do older dogs tend to have developed on their liver?
Nodular hyperplasia is benign
153
How do you diagnose a extrahepatic biliary duct obstruction?
CT and US
154
What are some differentials of EHBO?
Extraluminal compression of CBD (pancreatitis or neoplasia), intraluminal obstruction of bile flow (choleliths, flukes, GB mucocoele), congenital (atresia), trauma
155
What is a GB mucocele?
It's when material within the gall bladder becomes semisolid to immobile. Not all will look like a kiwi shape. It can lead to extrahepatic bile duct obstruction, disrupt GB wall blood flow causing pressure necrosis
156
What's the most common gall bladder disease?
gallbladder mucocele
157
What's the typical signalement of gallbladder mucoceles?
older tom iddle aged dogs, breed predispositions (shelties, cockers, mini schnauzers, border terriers), very uncommon in cats since there are fewer mucous glands in GB of cats
158
If the gall bladder is obstructed by a mucocele, what would you see?
icterus and abdominal pain ontop of non-sepcifics (anorexia, lethargy, intermittent paint)
159
What happens if the gallbladder mucocele ruptures?
septic shock and bile peritonitis
160
Out of all the liver enzymes, which one predominates in gallbladder mucoceles?
Increased ALP often predominates, then increased ALT, GGT, total bilirubin in symptomatic patients. Cholesterol could be elevated in EHBO patients
161
What are cuases of GB mucoceles?
Not known, could be concurrent endocrinopathies like Cushings and hypothyroidism, hyperlipidemic, genetics, hyperplasia of mucin secreting glands, abnormal gallbladder motility.
162
What are medical managements of GB mucoceles?
Consider low fat diet, ursodiol, SAM-E and treat underlying endocrine disorders.
163
When is surgery clearly indicated for GB mucocoele?
When there is BCHEM signs of hepatobiliary disease or striated/stella appearance of immobile stuff in the gall bladder
164
T/F: the earlier you do surgery for a GB mucocoele, the better the prognosis
True: elective cholecystectomy = 2% mortality, emergency = 20%, ruptured GB = 50%
165
How common is cholelithiasis in dogs and cats?
Rare, usually involves one lobe (left lateral lobe is most common)
166
What are usually the concretions in a cholelithiasis?
Calcium bilirubinate or bilirubin
167
Where is the most common spot for a obstruction due to a cholelithiasis?
common bile duct at duodenal papilla
168
Extrahepatic biliary obstruction can be caused by ______x3 things
Cholelithiasis, pancreatitis, neoplasia
169
How does pancreatitis cause extrahepatic biliary obstruction?
Causes compression of common bile duct with its acute or chronic fibrosis
170
What kind of neoplasias can cause EHBO?
Basically any that cause pressure on the biliary tract like exocrine pancreatic tumors, gastric tumors, proximal duodenal tumors. Cats with inflammatory polyps
171
What is a cholecystoenterostomy?
When the gall bladder is joined to the small intestine
172
What are the short and long term complications of a cholecystoenterostomy?
Bile leakage --> peracute sepsis; chronic cholangiohepatitis --> stenosis of opening created
173
Septic cholecystitis is rare in dogs, but what about cats?
most common in cats
174
What's a common bacterial pathogen for septic cholecystitis?
E.coli
175
What does bile peritonitis surgery aim to do?
Stop the leakage and ensure bile flow can flow from liver to small bowels (cholcystoduodenostomy)
176
What are 3 techniques to biopsy this crazy tempermental pancreas?
Dissection and ligation/guillotine, stapler (left limb mainly (this one is under greater omentum on stomach), bipolar vessel sealing devices
177
What are the only 2 reasons you should take a pancreatitis to surgery?
1. concurrent EHBO and need for a stent; 2. need a longer term feeding tube than NG tube
178
T/F: pancreatic abscesses often happen secondary (most commonly) to extra-pancreatic bacterial infections in dogs
False: most common reported complication of pancreatitis in dogs = pancreatic abscesses
179
How do we diagnose a pancreatic abscess?
clinical signs similar to pancreatitis (vomiting, depression, anorexia, abdominal pain), US and CT --> aspiration fluid, cytology, culture
180
How do you surgically fix a pancreatic abscess?
GO IN THERE AND DEBRIDE, culture, provide drainage, partial pancreatectomy or partial gastrectomy or splenectomy, omentalization < kinda a bad prognosis
181
What's a pseudocyst in the pancreas?
This is a sterile abscess, it's a collection of pancreatic juice and debris enclosed by wall of fibrous or granulation tissue in pancreas. Often an uncommon complication of pancreatitis in dogs and cats.
182
How do you diagnose a pseudocyst?
fluid aspiration (guided by US), cytology (will see low cellularity), high maylase and lipase.
183
How do you manage a pseudocyst?
sometimes you have to keep emptying it, sometimes chemical ablation (alcohol to try and eliminate it but can worsen pancreatitis), if growing then surgery to remove and provide drainage
