GI 36 Peritonitis - Phillips
lab evaluation of septic abdomen**
-CBC: bands (overwhelming response), anemia -chem: LES, albumin, bilirubin, BUN/Cr, K -UA: pyuria, bacteriuria -UC: UTI -coagulopathy (tend to go into DIC when using up clotting factors) -lactate/glucose: comparing abdominal fluid to blood levels -PLI: increased with pancreatitis -blood type: for supportive care
organs that can be torsed and lead to septic peritonitis
-GDV -mesenteric -colonic -liver lobe -spleen -uterus (can get into abdomen through ovarian bursa)
how to prevent adhesions during surgery**
-GENTLE tissue handling, avoid disruption of serosal surface and superficial tissues* -accurate HEMOSTASIS; tips down on BV, tips up for pedicle* -ASEPTIC technique* -prevent tissue desiccation -remove clots -LAVAGE before closure* -do not leave behind gauze/FB
different contents that can be found in the fluid of septic abdomen**
-NCC: polymorphonuclear cells (neutrophils) -protein -lactate -glucose -bilirubin -creatinine -potassium
properties of omentum that make it a defense organism
-adhesive -angiogenic (forms new BV) -immunogenic "Abdominal Policeman"
common history of septic peritonitis case
-anorexia, vomiting, lethargy -trauma/recent surgery -signalment important
what sort of more sophisticated monitoring may need to occur with surgery of septic patient
-arterial catheter: measure paO2 and arterial blood gas -central venous catheter: aid in fluid volume and requirements for vasopressor agents -urinary catheter: allows assessment of urine production and monitor of fluid needs
two classifications of secondary peritonitis
-aseptic (non-infectious) -septic (more common?)
how does torsion or volvulus cause septic peritonitis
-bacterial translocation or hematogenous spread when GIT wall is compromised from torsion
characteristics of peritoneal fluid**
-balance of production and absorption -normal in small amounts to lubricate organs and prevent friction -hypoproteinemic (<3 g/dL) and acellular (NCC<300 cells)**
how to perform abdominocentesis**
-blind with large volumes (5-6 ml/kg) -US guided if available -18-20 gauge needle -3 way stop cock -4 quadrant tap
causes of aseptic peritonitis**
-chemical: urine, bile -mechanical/FB: suture, hair -starch granulomatous: surgical glove powder -parasitic: toxoplasma, cestodes -protozoal: neospora
two types of shock that can be present with septic peritonitis
-compensated: tachycardia, bright red mm, rapid CRT, bounding pulses progresses too... -uncompensated: bradycardia, pale mm, prolonged CRT, weak pulses
general causes of septic peritonitis**
-compromised integrity of GIT (most common)* -trauma -torsion/volvulus -ruptured viscus -abscess -iatrogenic**
causes of compromised integrity of the GIT resulting in septic peritonitis**
-direct inoculation with endogenous bacteria -perforating intestinal FB -gastric rupture in GDV -colonic perforation -perforating GIT ulcers -dehiscence of surgical site
how does the peritoneum gain adhesions
-disease -surgical manipulation induces cell and fibrin exudation
what is often required to stabalize a septic peritonitis patient
-doses of crystalloids of colloids to combat shock +/-vasopressor support beyond fluid resuscitation -attempt with imaging to discern sepsis
lymphatic system of peritoneum
-drainage through diaphragmatic lymphatics to mediastinal and sternal LN -a lot of the drainage from the abdomen goes to LN in the chest
natural openings of the peritoneum
-esophageal hiatus -caval hiatus -aortic hiatus unnatural: congenital or acquired diaphragmatic hernia
usefulness of abdominal ultrasound or CT for septic abdomen**
-evaluate GI tract, hepatobiliary, repro, urinary tracts -evaluate for masses, abscesses, FB -guided abdominocentesis -better than rads**
main goals of septic abdomen surgery
-explore -debride -repair -lavage -drain eliminate the source of contamination!
radiograph features of septic abdomen**
-free peritoneal gas (should never see gas free floating in abdomen unless had sx in past 28d) -volvulus or torsion or obstruction -loss of abdominal detail ("ground glass") -abdominal mass effect
how do adhesions become permanent
-good vascularity allows for fibrinolysis within 3-5 days -ISCHEMIA allows for infiltration of fibroblasts which make collagen and fibrous adhesions fibrinous (stringy) > fibrous (tough, more chronic, dense, firm)!
how to evaluate fluid obtained from abdomen**
-grossly (color, character) -cytologically -biochemically -microbiologically
locations of abscesses that can caused septic peritonitis
-hepatic* -pancreatic -mesenteric -splenic* -prostatic* -umbilical
two systems of defense of the peritoneum
-innate: complement, opsonins, NK cells, lymphatic drainage, PALT, absorption, omentum -inflammatory: complement, mast cell degranulation (histamine), neutrophil chemotaxis, macrophage phagocytosis, inflammatory mediators and cytokines, SIRS
post-op coonsiderations with septic abdomen patients
-intensive care: monitor BP, volume, electrolytes, nutrition, pain -monitor fluid ins and outs -abdominal drain management -antibiotics
prognosis of septic abdomen
-mortality remains high -median survival 20-80% post-op
what can be analyzed on abdominal fluid cytology with septic abdomen**
-numbers and cell types -neutrophils (degenerative vs. non-degenerative)** -lymphocytes -monocytes/macrophages -abnormal cells: reactive, neoplastic
trauma that can cause septic peritonitis
-penetrating abdominal wounds (bite wounds, gunshot, impalement) -blunt abdominal trauma (HBC or fall induced herniation); uncommon for actual GIT to rupture but can see things like gall bladder rupture
diseases of the peritoneum
-primary peritonitis: spontaneous, bacterial, mycobacterial, fungal -secondary peritonitis: aseptic (non-infectious), septic abdomen
ruptured viscus that can lead to septic peritonitis
-ruptured pyometra (e.coli, gram negatives) -ruptured urinary bladder with UTI -ruptured GB with cholecystitis
causes of primary peritonitis
-spontaneous inflammation -bacterial gram positive (rare) -mycobacterial -fungal: blasto, histo, candida primary peritonitis is very rare!
how to treat septic peritonitis
-stabilize -surgery to eliminate source
iatrogenic causes of septic peritonitis**
-surgical site contamination (hair, broken glove, failure of aseptic technique) -retained surgical equipment -peritoneal dialysis (can help or hurt) -can be AVOIDED
specific causes of death in cases of septic abdomen
-systemic inflammatory response syndrome (SIRS)** -vasculitis** -DIC** -bacteremia** -pancreatitis -multiorgan dysfunction syndrome (MODS)
PE of septic peritonitis case
-temp (hypo cats, hyper dogs) -abdominal palpation: painful, lack bowel sounds -variable clinical signs dependent on cause
three fluid types based on cell and protein contents**
-transudate: low cell (<1500), low protein (2.5-3); NOT consistent with septic abdomen -modified transudate: mild cells, mild protein; increased hydrostatic pressure -exudate: high cells (>5000), high protein (>3); CONSISTENT WITH PERITONITIS
what is contrast radiography useful for in terms of septic abdomen
-upper GI evaluation -retrograde urethrocystogram -evaluation of gastrotomy (g-tube) or jejunostomy (j-tube) tube site integrity
options for drainage in septic abdomen cases
1. primary closure without drainage (unadvised) 2. open peritoneal drain 3. open peritoneal drain with vacuum assisted closure 4. primary closure with closed suction abdominal drainage (most common)* flush aggressively; 300 ml/kg
how often is single abdominocentesis tap diagnostic**
20% of the time
what technique can be used if not enough fluid for simple abdominocentesis**
DPL: diagnostic peritoneal lavage catheter inserted 1 cm caudal to umbilicus, 20 ml/kg warm saline infused, gently roll "wash" animal from side to side, obtain fluid back out helpful when not enough fluid to get a tap; when not enough fluid most likely because animal is dehydrated
name for mechanical gauze left behind forming secondary peritonitis
Gossypiboma
concern with overwhelming infectious response with bands
all mature neutrophils are used up and recruiting bands from the bone marrow - should be concerned for animal to be going down the SIRS road
antibiotics needed for septic abdomen
broad spectrum IV empiric therapy pending culture results
causes of transudates
decreased oncotic pressure i.e. hypoproteinemia
causes of modified transudate
increased hydrostatic pressure
significance of bilirubin in abdominal fluid with septic peritonitis**
indicative of bile peritonitis bilirubin in abdominal fluid 2x greater than in blood
significance of creatinine and potassium in abdominal fluid with septic peritonitis**
indicative of uroabdomen Cr: abdominal fluid 2x greater than blood K: abdominal fluid 1x greater than blood
what is peritonitis
inflammation of the peritoneum primary or secondary peritonitis
causes of exudates**
inflammatory, immune mediated or infectious disease - SEPTIC ABDOMEN
what organ is known to be retroperitoneal
kidneys! adrenal gland, urinary bladder, ureters, rectum, ovaries, uterus, aorta, caudal vena cava
what analyte is 100% specific and sensitive for septic peritonitis in dogs (86% in cats)**
lactate! lactate in abdominal fluid greater than in the peripheral blood by > 2 mmol/L
significance of glucose and lactate with septic peritonitis*
lactate: abdominal fluid 2x greater than that in the peripheral blood with peritonitis glucose: abdominal fluid 20x lower than than in the peripheral blood with peritonitis
what is NCC
nucleated cell count; mostly PMC's like neutrophils
problems with DPL**
ratios of bilirubin and CR etc. are diluted can not use these ratios more of a salvage procedure
what is the peritoneum**
serous membrane (parietal and visceral) lining the cavity of the abdomen and covering the abdominal organs bidirectional membrane that allows free exchange of peritoneal fluid and plasma
what is SIRS
systemic inflammatory response syndrome
importance of inflammatory response of the peritoneum
without inflammation, do not progress well through other phases of healing can be a problem with overreaction/systemic inflammation - so overwhelming that it can not be controlled