Lecture 7: Hemoperitoneum/Peritonitis (Exam 1)

Question 1

Define Hemoperitoneum/hemoabdomen

Answer 1

Abnorm accumulation of blood in the peritoneal cavity

Question 2

What are the traumatic origins of hemoperitoneum

Answer 2

• HBC
• Kicks
• Falls

Question 3

What is the #1 cause of hemoperitoneum in dogs & cats

Answer 3

Neoplasia

Question 4

What is are other nontraumatic reasons for hemoperitoneum

Answer 4

• Non traumatic rupture of the adrenal gland
• Non malignant disease

Question 5

What is the signalment of hemoperitoneum

Answer 5

• Younger are more likely to be trauma related (esp males)
• Older is more likely to be neoplasia

Question 6

What can be found in the hx of a px w/ hemoperitoneum

Answer 6

• Trauma/suspected trauma
• Neoplasia is usually non specific
• Prev hemorrhage
• Access to toxins/rodenticide
• Prev dx of a mass
• Prev sx or dx procedure
• Rx

Question 7

What does the PE of a px w/ hemoperitoneum look like

Answer 7

Anything from clinically norm to severe hemorrhagic shock

Question 8

What can be seen in radiographs of a px w/ hemoperitoneum

Answer 8

Loss of abdominal detail w/ focal or generalized “ground glass” appearance

Question 9

What is an AFAST exam

Answer 9

Abdominal focused assessment w/ sonography for trauma

Question 10

What are the four views of an AFAST Eoxam

Answer 10

• Diaphragmaticohepatic (DH)
• Splenorenal (SR)
• Cystocolic (CC)
• Hepatorenal (HR)

Question 11

T/F: Clinicopathologic abnorms in dogs w/ hemoabdomen are typically diff regardless of the cause of the abdominal bleeding

Answer 11

False; typically similar regardless of the cause

Question 12

How is hemoperitoneum dxed

Answer 12

Finding nonclotting bloody fluid in the abdomen by the abdominocentesis or Dx peritoneal lavage (DPL)

Question 13

Describe the use of DPL & FAST exam

Answer 13

The use of DPL in trauma is declining while the use of the FAST exam is rapidly replacing it

Question 14

Why is the use of DPL decreasing

Answer 14

• Invasive
• Low specificity
• High rate of nontherapeutic laparotomies
• False negs

Question 15

When do trauma px w/ hemoabdomen don’t need sx

Answer 15

When they stabilize after medical management often dont req sx

Question 16

What is medical management of hemoabdomen

Answer 16

• IV fluid replacement therapy
• Blood transfusion
• Tight ab wrap during stabilization
• O2 therapy

Question 17

What should be done during pre op

Answer 17

• Shock
• Correct abnorms before ax
• Blood transfusion if PCV < 20%

Question 18

Describe anesthesia during sx for hemoperitoneum

Answer 18

• Anemic px need O2
• Avoid barbiturates
• Avoid acetylpromazine
• Hypotension due to volume depletion

Question 19

What are the indication for sx

Answer 19

• Undetermined source of hemorrhage
• Uncontrolled hemorrhage
• Evaluation/removal of intra abdominal neoplasia

Question 20

Define primary generalized peritonitis

Answer 20

Spontaneous inflammation of the peritoneum w/ no obvious intra abdominal reason for leakage of bacteria

Question 21

Define secondary generalized peritonitis

Answer 21

Occurs in conjunction w/ an intra abdominal reason for the inflammation/infection (infectious & non infectious)

Question 22

Describe secondary generalized peritonitis

Answer 22

• Predominant form in dogs
• Usually caused by bacteria
• Most originate from contamination from the GI tract

Question 23

Why is differentiating primary peritonitis from secondary generalize important

Answer 23

B/c surgery is not routinely performed in primary generalized but is req in secondary generalized

Question 24

Describe the bacterial association in peritonitis

Answer 24

• Gram + more common in primary
• Gran - more common in secondary
• Primary is more likely to be mono while secondary is more likely to be polybacterial

Question 25

What is the signalment of peritonitis

Answer 25

Any age but younger animals are more common

Question 26

What is the hx of peritonitis

Answer 26

* Often nonspecific * Delayed onset of signs may be seen w/ trauma, mesenteric avulsion, & bile peritonitis * Have had prev GI sx

Question 27

What is the presenting complaint of a px w/ peritonitis

Answer 27

* Most = lethargy, anorexia, vomiting, diarrhea, &/or abdominal pain * Cats = lethargy, depression, & anorexia

Question 28

What should sick intact female dogs be evaluated for first

Answer 28

Pyometra

Question 29

What can Radiographs show for a px w/ peritonitis

Answer 29

* Intestinal tract may be dilated w/ air, fluid, or both * Free abdominal air * Localized peritonitis can cause sentinel loop by making the duodenum appear to be fixed & elevated

Question 30

What will show up in an ultrasound w/ peritonitis

Answer 30

* Collecting fluid * Organ eval * Pain is often the limiting factor for ultrasound

Question 31

What is the classic description of radiographs in a px w/ peritonitis

Answer 31

Loss of abdominal detail w/ focal or generalized "ground glass" appearance

Question 32

What is the most common lab findings in peritonitis

Answer 32

* Leukocytosis * Neutrophil count may be norm or low * Left shift is often present but not always

Question 33

What is a prognostic indicator of peritonitis in cats

Answer 33

* Lactate levels * Higher levels = poorer prognosis

Question 34

What are the goals of medical management w/ peritonitis

Answer 34

* Eliminate cause of contamination * Resolve the infection * Restore norm fluid & electrolyte balance

Question 35

What is the preferred dx method for abdominocentesis

Answer 35

Ultrasound

Question 36

What are indication for abdominocentesis

Answer 36

* Shock w/ no cause * Undx ab dx * Suspicion of post op GI dehiscence * Blunt or penetrating abdominal injury * Abdominal effusion * Undx ab pain

Question 37

Describe an intraoperative peritoneal lavage

Answer 37

* Controversial * Warmed isotonic saline is the most appropriate lavage fluid (~ 200 mL/kg) * No evidence that adding antiseptics/antibiotics to lavage fluid is of benefit * Not been shown to be of benefit in px w/ severe pancreatitis

Question 38

What is an open abdominal drainage

Answer 38

* A small section of the abdominal incision is left open & sterile wraps are placed around the wound * Not commonly used due to time & effort req

Question 39

What are the advantages of OAD

Answer 39

* Improved metabolic condition * Fewer ab adhesions * Fewer abscesses * Access for repeated inspection/exploration

Question 40

What are the disadvantages of OAD

Answer 40

* Hypoalbuminemia * Hypoproteinemia * Anemia * Nosocomial infections

Question 41

When is closed suction drainage effective in dogs & cats

Answer 41

* Generalized peritonitis * If effusion is serous in nature

Question 42

T/F: Nutrition is a critical factor in pre op management

Answer 42

True

Question 43

Describe the steps of an abdominocentesis

Answer 43

* Insert 18 - 20 g 1 1/2 in over the needle catheter (w/ added side holes) @ the most dependent point * Don't attach the syringe * Allow fluid to drip rom the catheter * If fluid does not drip use a 3 CC syringe w/ gentle suction

Question 44

Describe a dx peritoneal lavage

Answer 44

* Make 2 cm skin incision caudal to umbilicus * Hemostasis to avoid false pos * Small incision into the linea alba * Hold edges of incision while the peritoneal lavage catheter is installed (w/out trocar) * Direct the catheter caudally into the pelvis * Gently aspirate * If neg aspiration attach the catheter to IV line w/ bag of warm sterile saline & infuse into the abdominal cavity * Roll px gently side to side to disperse fluid

Question 45

What is a warning about diagnostic peritoneal lavage

Answer 45

This tech does not reliably exclude significant retroperitoneal injury or hemorrhage

Question 46

Describe the steps of the open abdominal drainage

Answer 46

* When closing the abdomen leave a portion of the abdominal incision open * Usually big enough to insert your gloved hand * Close the cranial & caudal aspects of the incision (monofilament absorbable suture in a cont pattern) * Place a sterile laparotomy pad over the opening * Change the wrap @ least 2 daily w/ the px standing

Question 47

When should the ab incision that was used for open abdominal drainage be closed

Answer 47

* When bacterial #s have decline & neutrophils are no longer degenerative * Usually @ 3 to 5 D post op

Question 48

Describe the steps of closed suction drainage

Answer 48

* Attach suction reserve bulb to tubing w/ vacuum applied * Place sterile protective bandage around the tube-skin interface * Empty the bulb using aseptic tech & record the vol of fluid collected * Remove the drain by cutting the suture & applying gentle traction

Question 49

Describe the suture material used in peritonitis cases

Answer 49

* Use monofilament nonabsorbable suture or slowly absorbable suture * Don't used braided suture * Don't use suture that is rapidly degraded

Question 50

What should be done post op

Answer 50

* Fluid therapy cont esp if OAD * Monitor electrolytes, AB, serum protein & correct them as req * Nasal oxygen if sepsis * Ensure adeq caloric intake * Consder plasma if hypoproteinemic * Give analgesia

Question 51

What is the prognosis of peritonitis sx

Answer 51

* Generalized = guarded * Many survive w/ aggressive therapy * ~50% * Dogs w/ primary who underwent sx were less likely to survive than those w/ secondary