Intestinal obstruction in small animals


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Intestinal obstruction in small animals

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Intestinal obstruction in small animals

  1. 1. Intestinal Obstruction Management in Small Animals (Dogs & Cats)
  2. 2. General principles of small intestinal surgery <ul><li>Fluid therapy </li></ul><ul><li>-In animals with obstruction, secretion of fluid in to intestinal lumen is increased and reduced absorption of intraluminal fluid and electrolytes leads to reduction in intravascular fluid volume results in dehydration </li></ul><ul><li>-if untreated dehydration result in hypovolemic shock. </li></ul>
  3. 3. Fluid therapy…(continued) <ul><li>profuse vomiting may cause hypochloremia,hypokalemia,or hyponatremia </li></ul><ul><li>Loss of sodium, water, and bicarbonate rich pancreatic secretion leads to metabolic acidosis. </li></ul><ul><li>With high intestinal obstruction, excessive loss of gastric hydrochloride from persistent vomiting may result in metabolic alkalosis. </li></ul><ul><li>Administer balanced electrolytes i/v . </li></ul><ul><li>Crystalloid solution more common. </li></ul><ul><li>If shock-colloids. </li></ul>
  4. 4. 2.Antibiotic prophylaxis <ul><li>Indicated in animals with intestinal obstructions </li></ul><ul><li>Stagnant luminal contents and devitalized wall are excellent growth media </li></ul><ul><li>Opening of intestine results in leakage of microflora and contamination of surgical field. </li></ul><ul><li>Pathogens cause peritonitis after surgery are </li></ul><ul><li>Escherichia coli </li></ul><ul><li>Enterococcus </li></ul><ul><li>Bacteroides </li></ul><ul><li>Coagulase ‘+’ve Staph aureus </li></ul><ul><li>First generation cephalosporin is the choice . </li></ul><ul><li>Redosed 2 hours after the initial dose . </li></ul>
  5. 5. 3.Assessment of intestinal Viability <ul><li>Colour </li></ul><ul><li>Peristaltic waves </li></ul><ul><li>Vascular pulsations </li></ul><ul><li>-subjective factors. </li></ul>
  6. 6. Assessment of intestinal Viability….(continued) <ul><li>Fluoresceine dye </li></ul><ul><li>10 to 15mg /kg </li></ul><ul><li>Intravenously </li></ul><ul><li>Wood lamp </li></ul><ul><li>- mucosal viability </li></ul><ul><li>Surface oximetry </li></ul><ul><li>- for assessment of perfusion. </li></ul><ul><li>Newer techniques include electromyography, Doppler ultrasonic flow probes. </li></ul>
  7. 7. 4.Choice of suture material for enteric closure <ul><li>Monofilament synthetic absorbable ( polydioxnone, polyglyconate) or non absorbable (nylon or polypropylene). </li></ul><ul><li>Chromic catgut-inflammatory process during its dissolution and occurs more quickly when it is exposed to proteolytic action of gastro-intestinal secretions. </li></ul>
  8. 8. 5.Choice of suture pattern for enteric closure <ul><li>Serosa </li></ul><ul><li>Muscularis </li></ul><ul><li>Submucosa </li></ul><ul><li>Holding layer, strongest part,submucosal apposition result in primary intestinal healing </li></ul><ul><li>Mucosa </li></ul>
  9. 9. 6.Suture Line Reinforcement <ul><li>Omentum-called “abdominal police man” </li></ul><ul><li>-has an extensive vascular and lymphatic supply,angiogenic,immunogenic,and adhesive properties –control infection, restore blood supply and lymphatic drainage. </li></ul>
  10. 10. Serosal patch <ul><li>Used after intestinal surgery when closure </li></ul><ul><li>Integrity is questioned or dehiscence is repaired.( in acute emergencies) </li></ul><ul><li>The antimesenteric border of healthy jejunum placed over the questionable suture line and is sutured in place with simple interrupted suture. </li></ul><ul><li>Provide support, a fibrin seal, resistance to leakage, blood supply to damage area, may prevent intussusceptions . </li></ul>
  11. 11. 7.Anesthetic considerations <ul><li>Special consideration for patients with bowel obstructions,ischemia,or perforations </li></ul><ul><li>Enlarged viscera may compress vena cava-circulatory and vascular compromise. </li></ul><ul><li>Viscera displacing diaphragm cranially may compromise respiration. </li></ul><ul><li>Visceral manipulations may induce bradycardia. </li></ul><ul><li>Maintain patients body temperature above 95 ° F </li></ul>
  12. 12. Surgical Anatomy <ul><li>Intestine of dog -5 times the body length(80% is small intestine). </li></ul><ul><li>The duodenum is the most fixed portion(25 cm) </li></ul><ul><li>The jejunum forms most of small intestine coils lying in the ventrocaudal addomen. </li></ul><ul><li>The ilium-15 cm long and has an antimesenteric vessel. </li></ul>
  13. 13. <ul><li>Cranial mesenteric artery is the major source of blood supply. </li></ul><ul><li>Cranial aspect of duodenum receives its blood supply from gastro duodenal artery which originates from celiac artery. </li></ul><ul><li>The innervations of small intestine is by autonomous nervous system.(Vagus and splanchnic nerves) </li></ul>
  14. 14. Intestinal obstruction <ul><li>Interruption in the passage of intestinal contents </li></ul><ul><li>Intestinal obstruction classified as- </li></ul><ul><ul><ul><li>Acute or Chronic </li></ul></ul></ul><ul><ul><ul><li>Partial or Complete </li></ul></ul></ul><ul><ul><ul><li>Simple or Strangulated </li></ul></ul></ul><ul><ul><ul><li>High or Low </li></ul></ul></ul>
  15. 15. Causes of obstruction <ul><li>Extraluminal </li></ul><ul><li>eg:-intussusception ,volvulus,hernia etc </li></ul><ul><li>Intramural </li></ul><ul><li>eg:-intestinal neoplasia, hematoma,granuloma etc </li></ul><ul><li>Intraluminal eg:- foreign objects </li></ul><ul><li>Intestinal Pseudo-obstruction and ileus </li></ul>
  16. 16. Intestinal luminal obstructions <ul><li>Most common indication for laparotomy in dog and cat. </li></ul><ul><li>Clinical signs associated with </li></ul><ul><li>location </li></ul><ul><li>duration </li></ul><ul><li>severity of obstruction </li></ul><ul><li>vomiting, anorexia, depression and abdominal tenderness are common. </li></ul>
  17. 17. Pathophysiological events
  18. 18. Diagnosis <ul><li>History </li></ul><ul><li>Physical Examinations </li></ul><ul><li>Radiography </li></ul><ul><li>The classic sign of mechanical obstruction is the presence of </li></ul><ul><li>multiple loops of gas-dilated small intestine of varying diameters </li></ul>
  19. 19. GI CONTRAST STUDY • confirm suspect disease found on survey radiographs
  20. 20. . <ul><li>Ultrasonography </li></ul><ul><li>Endoscopy </li></ul>
  21. 21. Surgical techniques <ul><li>Enterotomy </li></ul><ul><li>Enterectomy </li></ul><ul><li>Intestinal resection and anastomosis </li></ul><ul><li>Enteroplication </li></ul>
  22. 22. Enterotomy <ul><li>Most common indication is intraluminal foreign body that cause obstructions. </li></ul><ul><li>Intestinal biopsy </li></ul><ul><li>Milk away intestinal content </li></ul><ul><li>Doyen’s clamp </li></ul>
  23. 23. Enterotomy for intestinal biopsy
  24. 24. <ul><li>Enterotomy incision may be </li></ul><ul><li>closed transversely. </li></ul>
  25. 25. <ul><li>Irreducible Intussusception </li></ul><ul><li>Mesenteric volvulus </li></ul><ul><li>Neoplasia </li></ul>Intestinal resection and Anastomosis Recommended for removing ischemic, necrotic segments of intestine . End-to-end anastomosis is recommended .
  26. 26. Technique <ul><li>The affected segment is clamped </li></ul><ul><li>The mesenteric vessels are ligated. </li></ul><ul><li>The triangular piece of mesentery distal to ligature is torn and bowel is divided close to the clamp and removed </li></ul>
  27. 27. Stump closure End-to-end anastomosis <ul><li>There are several ways to eliminate disparity between luminal diameters of the ends to be apposed. </li></ul><ul><li>1. Transecting smaller segment at an angle, creating a lumen of larger diameter. </li></ul>
  28. 28. Stump closure End-to-end anastomosis <ul><li>2. To eliminate marked luminal disparity ,the antimesenteric border of the smaller segment can be incised longitudinally to create a larger opening. </li></ul><ul><li>The first and second sutures are placed in mesenteric and antimesenteric border </li></ul>
  29. 29. <ul><li>3 .Spacing each suture farther apart on the large lumen side </li></ul>
  30. 30. Stump closure-End-to- end anastomosis-suture patterns <ul><li>1.Single layer simple interrupted suture pattern. </li></ul><ul><li>2.Simple continuous suture. </li></ul><ul><li>3. Parker Kerr suture </li></ul><ul><li>-Temp.cont.suture over clamp </li></ul><ul><li>-The free ends of thread pulled </li></ul><ul><li>and clamp withdrawn. </li></ul><ul><li>-united by Lembert’s suture </li></ul><ul><li>-ends of stay suture are drawn out. </li></ul>
  31. 31. <ul><li>4 .Maunsell’s suture </li></ul><ul><li>- M. suture at mesenteric border </li></ul><ul><li>Both eversion and inversion technique. </li></ul><ul><li>One strand from the suture is used </li></ul><ul><li>to insert an inversion suture </li></ul><ul><li>around half of the circumference </li></ul><ul><li>of intestine to the antimesenteric border . </li></ul>
  32. 32. <ul><li>The second strand is used to stitch the other half of the intestinal circumference. </li></ul><ul><li>The knot is then tied to complete the inversion . </li></ul>Maunsell’s suture(contd….)
  33. 33. <ul><li>Criteria in assessing tech. of anastomosis- </li></ul><ul><li>1.Absence of leakage </li></ul><ul><li>2.Minimal occlusion of lumen. </li></ul><ul><li>3.Minimal formation of adhesions. </li></ul><ul><li>4.Fast rate of healing. </li></ul>
  34. 34. Enteroplication <ul><li>Prevent recurrence of intussusception </li></ul><ul><li>Serosa-serosa adhesions are formed by suturing together adjacent loops of intestine. </li></ul>
  35. 35. Post operative Complications <ul><li>Septic peritonitis </li></ul><ul><li>- associated with dehiscence of anastomosis or enterotomy site. </li></ul><ul><li>-clinical signs occur 2-5 days after surgery. </li></ul><ul><li>-Diagnosis-serial complete blood count. increase in band neutrophils </li></ul><ul><li>-Broad spectrum antibiotics,fluids ,supportive therapy + surgical correction Of primary problem.(serosal patch or omental patch) </li></ul><ul><li>- Complete drainage of peritoneal cavity . </li></ul>
  36. 36. <ul><li>Adhesions </li></ul><ul><li>-in human patients </li></ul><ul><li>-Dogs &cats have active active fibrinolytic system prevents this. </li></ul><ul><li>-Peritoneal irrigation with dialysis solution after surgery reduce this. </li></ul>
  37. 37. <ul><li>Short Bowel Syndrome </li></ul><ul><li>- Few cases are reported. </li></ul><ul><li>-Characterized by maldigetion and malabsorption occur after extensive resection. </li></ul><ul><li>Ileus </li></ul><ul><li>-Common complication </li></ul><ul><li>-Reduced motility due to overactivity of sympathetic system caused by manipulation of intestine, long operative time, and extensive resection. </li></ul>
  38. 38. <ul><li>Other causes of </li></ul><ul><li>Intestinal Obstruction </li></ul>
  39. 39. INTUSSUSCEPTION <ul><li>Intussuception is the telescoping or invagination of one intestinal segment (intussuceptum) in to lumen of an adjacent segment. </li></ul>
  40. 40. INTUSSUSCEPTION(contd…) <ul><li>Occur any where ;ileocolic and jejunojejunal intussusceptions are most common. </li></ul><ul><li>Are often associated with enteritis (i.e, parasitism, viral or bacterial infections, dietary change, foreign bodies, masses) or systemic illness. In old animals -neoplasia. </li></ul><ul><li>Also reported after environmental changes and surgery. </li></ul>
  41. 41. INTUSSUSCEPTION(contd…) <ul><li>More common in younger animals ( less than 1 year) </li></ul><ul><li>Clinical signs vary with level and completeness of the obstruction. </li></ul><ul><li>It can progress to a point at which the small intestine protrudes from anus and differentiated from rectal prolapse by easy passage of probe between the prolapsed segment and rectum. </li></ul>
  42. 42. <ul><li>On palpation, a cylindrical mass in the cranial to mid abdomen. </li></ul><ul><li>On plain radiograph, a mass effect or accumulation of gas proximal to intussusception . </li></ul><ul><li>Manual reduction –if enteric </li></ul><ul><li>vessels are patent, intestinal wall </li></ul><ul><li>not look ischemic. </li></ul><ul><li>Gentle traction on intussusceptum </li></ul><ul><li>and pressure on intussuscepiens </li></ul>
  43. 43. Mesenteric volvulus <ul><li>Rare and fatal </li></ul><ul><li>Intestine twists on its mesenteric axis, resulting in strangulating mechanical obstruction of S.I. and compression of cranial mesenteric artery and its branches </li></ul><ul><li>leading to ischemic necrosis. </li></ul>
  44. 44. Intestinal neoplasia <ul><li>Most often occur in rectum and colon in dog and small intestine in cat. </li></ul><ul><li>Commonly affect muscular layer and cause mechanical obstruction . </li></ul><ul><li>Most common is adenocarcinomas and lymphocarcinomas. </li></ul>
  45. 45. Thank You