Surgical diseases of the abdominal cavity Flashcards
(82 cards)
1
Q
What are dfdx for ascites?
A
- Hypoalbuminemia
- Heart failure
- Portal hypertension
2
Q
Dfdx for fluid from a hollow viscera
A
- Urine
- Bile
- GI contents
- Chyle
3
Q
Dfdx for peritonitis
A
- Inflammation or infection
4
Q
Dfdx for hemoabdomen
A
- Trauma
- Coagulopathy
- Torsion (spleen, stomach, liver)
- Neoplasia
- Non-neoplastic mass in vascular tissue
5
Q
What determines clinical signs for hemoabdomen?
A
- Rate and cause of blood loss
6
Q
What are signs of hemorrhagic shock?
A
- Weak pulses
- Prolonged CRT
- Pale mucous membranes
- Tachycardia
- Tachypnea
- Hypotension
7
Q
What diagnostics may be indicated for hemoabdomen?
A
- Abdominocentesis
- CBC/chem/UA
- Coagulation tests
- Imaging of abdomen and thorax
- EKG (looking for VPCs)
8
Q
Extravascular blood: It DOES or DOES NOT clot?
A
- DOES NOT clot
9
Q
Intravascular blood: it DOES or DOES NOT clot?
A
- Does clot
10
Q
What should you do with bloody fluid obtained by abdominoctenesis?
A
- Put in a red top tube
- Compare PCV of fluid to peripheral fluid
- DO a cytology (look for concurrent peritonitis or neoplastic cells)
11
Q
Treatment for an unstable patient with hemoabdomen: 1st step
A
- Start with medical management
- O2, fluids, transfusions, abdominal wrap
- Vit K if coagulation issue suspected
12
Q
How does most traumatic bleeding stabilize on its own?
A
- With medical management
- Even if it involves the liver or spleen
13
Q
Hemoabdomen: What to do if condition stabilizes and the primary cause is trauma?
A
- No sx if remains stable (often liver or spleen;)
14
Q
Hemoabdomen: What to do if condition stabilizes and the primary cause is mass?
A
- Consider surgery to biopsy or resect
15
Q
Hemoabdomen: What to do if condition stabilizes and the primary cause is coagulopathy
A
- Determine underlying cause
16
Q
Hemoabdomen: What to do if condition does NOT stabilize and the primary cause is trauma or mass?
A
- Emergency surgery
17
Q
Hemoabdomen: What to do if condition DOES NOT stabilize and the primary cause is coagulopathy other than DIC due to surgical condition?
A
- No surgery (unless it’s DIC secondary to something in the abdomen)
18
Q
What are three potential causes of peritonitis?
A
- Pure inflammation
- Infection
- Chemical (e.g. from bile or urine)
- OR it could be a combination of the above
19
Q
What is peritonitis?
A
- Localized or diffuse inflammatory process involving the peritoneum
20
Q
What is the most common source of contamination for a septic abdomen?
A
- GIT
- Either due to dehiscence or perforation (e.g. due to FB, tumor, or trauma)
21
Q
What are other causes of septic abdomen?
A
- Abscess (hepatic, renal, prostate, pancreas, etc.), pancreatitis, cholecystitis, and penetrating injury
22
Q
Describe the pathophysiology of how peritonitis leads to hemoconcentration?
A
- Inflammation –> massive fluid and protein shift into the peritoneal cavity
23
Q
Describe the pathophysiology of how peritonitis leads to hypovolemic shock
A
- Inflammation –> massive fluid and protein shift into the peritoneal cavity
24
Q
Describe the pathophysiology of how peritonitis leads to hypoproteinemia?
A
- Inflammation –> massive fluid and protein shift into the peritoneal cavity
25
Describe the pathophysiology of how peritonitis leads to Visceral vasculature vasodilation
- Inflammation leads to endotoxin release
26
Describe the pathophysiology of how peritonitis leads to neutrophils in the abdomen
- Inflammation leads to endotoxin release
27
Describe the pathophysiology of how peritonitis leads to high hepatic energy demand?
- Combination of hemoconcentration, hypovolemic shock, hypoproteinemia, vsiceral vasculature vasodilation, and neutrophils into the abdomen
28
Describe the pathophysiology of how peritonitis leads to metabolic acidosis
- Combination of hemoconcentration, hypovolemic shock, hypoproteinemia, vsiceral vasculature vasodilation, and neutrophils into the abdomen
29
Describe the pathophysiology of how peritonitis leads to septic shock
- Combination of hemoconcentration, hypovolemic shock, hypoproteinemia, vsiceral vasculature vasodilation, and neutrophils into the abdomen
30
Describe the pathophysiology of how peritonitis leads to multi-organ failure
- Combination of hemoconcentration, hypovolemic shock, hypoproteinemia, vsiceral vasculature vasodilation, and neutrophils into the abdomen
31
Signs of peritonitis based on history
- Vomiting, diarrhea, lethargy, anorexia, distended abdomen, weight loss
32
Signs of peritonitis based on PE
- Ascites
- Abdominal pain
- fever
- Dehydration
- Tachycardia
- Tachypnea
- Hypotension
- Pale mucous membranes
- Prolonged CRT
33
What are the signs that equate hypovolemic shock with peritonitis?
- Tachycardia
- Tachypnea
- Prolonged CRT
- Pale MM
- Hypotension
34
How long can it take for signs of peritonitis to show after the initial insult?
- Days to weeks
35
Abdominocentesis results of septic peritonitis
- Degenerative neutrophils +/- bacteria
36
In septic peritonitis, the glucose in the blood will be HIGHER or LOWER than glucose the abdominal fluid. Why?
- Higher because bacteria in the abdomen are consuming the glucose in the abdomen
37
What is the equation suggesting septic peritonitis based on blood and abdominal fluid glucose?
- BG > abdominal fluid glucose + 20 mg/dL
38
In septic peritonitis, the lactate in the blood will be HIGHER or LOWER than the lactate in the abdominal fluid. Why?
- Lower in the blood because there are bacteria producing lactate in the abdominal fluid
39
What is the equation suggesting septic peritonitis based on blood and abdominal fluid lactate?
- Abdominal fluid lactate > blood lactate + 2mmol/L
40
How to stabilize a patient's condition pre-op for septic peritonitis (three primary components)?
- Fluids
- Antibiotics
- Analgesia
Also: improving oncotic pressure, vasopressors, correcting acid/base and electrolyte imbalances
41
Qualities for antibiotics given for septic peritonitis, and what route?
- Broad spectrum
- Given IV
- E.g. Unasyn and enrofloxacin
- e.g. 2nd or 3rd generation cephalosporin
42
Spectrum of unasyn
- Anaerobic and aerobic gram positive and gram negative
43
MOA of Unasyn
- Beta-lactam that inhibits cell wall synthesis (cidal)
| - Sulbactam binds to beta-lactamases
44
Spectrum of enrofloxacin
Gram negative aerobes
45
MOA of enrofloxacin
- Fluoroquinolone
- Bactericidal
- Inhibits DNA gyrase
46
Spectrum of 2nd gen or 3rd gen cephalosporin
- Gram negative and gram positive anaerobes
47
MOA of 2nd or 3rd gen cephalosporin
- Beta-lactam that inhibits cell wall synthesis (cidal)
48
Can most causes of peritonitis be managed medically or surgically?
- Most require emergency surgery as soon as the patient's condition has been optimized to the extent possible or when it's apparent that the patient won't improve until you do surgery to address the underlying problem
49
What should be done during surgery in addition to treating the cause of septic peritonitis?
- Culture
- Debride
- LAVAGE
- Establish drainage (omentum, closed suction drain, negative pressure wound therapy)
50
How much fluid should be used for lavage?
- 200-300 mLs/kg as a baseline
51
What should you consider intra-op that relates to post-op nutrition for animals with septic peritonitis?
- Strongly consider putting in a feeding tube, as these animals are often very compromised and won't eat post-op, and nutrients are needed for healing
52
What is the prognosis for peritonitis?
- 50-85%, with increased mortality seen if very young or very old animals, delayed diagnosis, highly virulent organisms, immunosuppression, malnutrition (thus consider feeding tube), systemic disease, multi-organ dysfunction
53
What is a hernia?
- Protrusion of tissue from its normal cavity through a natural or unnatural defect
54
What is the procedure called to repair a hernia?
- Herniorrhaphy
55
How should you describe a hernia?
- Anatomical site (e.g. inguinal, perineal, diaphragmatic)
- Acquired (e.g. secondary to trauma or disease) or Congenital (if latter, look for other congenital issues and don't breed)
- Whether contents are reducible or irreducible
- What organs or tissue are involved
- Whether contents are obstructed (e.g. intestine or bladder) or strangulated (blood supply cut off) (EMERGENCY)
- Other characteristics as for any mass: size, shape, density, appearance, location, mobility, and painful or not
56
Dfdx for a hernia
- Abscess, foreign body reaction, lipoma, neoplasia, cellulitis, hematoma, seroma, lymphadenopathy
57
How do you diagnose a hernia?
- History, palpation, imaging (rads/ US)
| - FNA but only after you're pretty sure what's in the ernia
58
How do you do a herniorraphy?
- Reduce hernia contents
- If full celiotomy was performed, so a full abdominal explore for damaged viscera that may have once been in the hernia
- Close the hernia ring
59
What should you do if the hernia contents don't fit through the ring?
- Enlarge the ring if needed; don't force the contents through the rings
60
What do you do with viable vs nonviable tissues through a herniorraphy?
- Return viable tissues to their normal location
| - Resect nonviable tissues
61
How to close the hernia ring
- Obliterate dead space or redundant tissue
- Minimize tension
- Be sure of the holding power of the tissues - are they healthy and strong?
- Be prepared to use alternative closure techniques or refer to a surgeon
62
Alternative closure techniques for a hernia
- Muscle or fascial flaps, ECM bioscaffold, synthetic mesh
63
What causes an umbilical hernia?
- Umbilical aperture fails to close or is abnormally formed/too large
- Common congenital abnormality in dogs (occasional in cat) but can be acquired if the umbilical cord was transected too close
64
Clinical significance of most umbilical hernias
- Usually just fat and is of little clinical significance
65
For up to what age can a small umbilical hernia in a young dog spontaneously close?
- up to 6 months
66
Conservative treatment for an umbilical hernia
- If small hernia not causing any issues, you can wait to repair when the patient is neutered
67
What are two reasons why surgery might be indicated sooner for an umbilical hernia?
1. Hernia ring is greater than the size of the intestinal loop
2. Hernia contains abdominal organs
68
Where does the hernia occur with an inguinal hernia?
- Herniation through the inguinal ring
69
Who gets a congenital inguinal hernia more frequently?
- More common in males (associated with delayed testicle descent) than females
70
Who gets acquired form of inguinal hernia more frequently?
- More common in females because their inguinal canal is shorter and larger diameter than males
71
Why do females tend to get acquired inguinal hernias more frequently?
- Inguinal canal is shorter and larger diameter than males
- Estrus/pregnancy/obesity may lead to a change in connective tissue strength and enlarged canal
- Traumatic
72
What are the three options for herniorrhaphy for an inguinal hernia, and which are preferred?
- Option 1: incise over the hernia itself (only lets you assess currently herniated tissue; if that tissue needs to be resected, may be difficult via this approach)
Option 2 (preferred): Ventral abdominal midline incision to access and repair hernia from inside; allows full explore of abdomen for tissue s that had previously been damaged by herniation but had been reduced by time of surgery
- Option 3 (preferred): Combo of option 1 and 2
73
What's the most common cause of incisional hernia?
- Error in surgical technique
74
How can you prevent incisional hernia?
1. Use appropriate suture material
2. Tie square knots
3. If abdominal incision is off the linea, engage the external rectus fascia with sutures
4. Tightening suture in the direction you are suturing after every bite
75
How long after surgery do incisional hernias usually occur, and why?
- Within 3-5 days post-op
| - End of inflammatory phase, so there is maximal debridement
76
Which patients are more likely to get an incisional hernia?
- More common if patient is obese, geriatric, or debilitated
77
Treatment for an incisional hernia
- Do you approach through a new incision or the old incision?
- Treatment is herniorrhaphy
| - Approach through original incision
78
Traumatic abdominal hernia info
- Skin is often intact, so if no tissues have herniated yet, may not detect without good palpation.
- Hernia may be masked by severe bruising and swelling of skin, SC tissue, and muscle
- Actual herniation may occur weeks after trauma due to deterioration of tissues instead of healing
79
Why might you want to delay herniorrhaphy (2-5 days)?
- If no obstruction/strangulation, may delay herniorrhaphy x 2-5 days (want to decrease inflammation, edema, bruising)
80
Under what circumstances should hernia repair NOT be delayed?
- Obstruction or strangulation
81
WHat is the concern if you wait >7 days to repair a traumatic hernia?
- I'm guessing contracture and fibrosis
82
Common sites for traumatic herniorrhaphy
- flank, cranial pubic ligament (prepubic tendon), paracostal)
- Skin often intact
