SASH : Peritonitis by Dr Nicole Spurlock
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A presentation on veterinary peritonitis by Nicole Spurlock of the SASH vet hospital in Sydney Australia.
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SASH : Peritonitis by Dr Nicole Spurlock
- 1. PERITONITIS Nicole Spurlock DVM, DACVECC Emergency and Critical Care Medicine
- 3. www.sashvets.com Peritoneum • Fenestrated basement membrane • Semi-permeable – Passive diffusion of electrolytes, urea, H20, certain drugs/toxins – Equilibration of concentration and osmotic gradients between peritoneal cavity and intravascular space (peritoneal dialysis) • Large exudative and absorptive area when inflamed
- 4. www.sashvets.com Primary Peritonitis • Spontaneous inflammation of the peritoneum in the absence of underlying intra-abdominal pathology – <1% of cases – Hematogenous spread • FIP – Other routes of entry • Across lumbosacral arches from pleural cavity • From uterus via ovarian bursae • Across GIT (bacterial translocaiton)
- 5. www.sashvets.com Primary – Small Animals JAVMA 2009; 234(7): 906 • 24 cases (1990-2006) • Primary vs. secondary – Less exudative fluid – More likely Gram+ infection – Surgery may do harm to patients with primary peritonitis • Surgery is typically not indicated for humans with primary peritonitis
- 6. www.sashvets.com Secondary Peritonitis • Inflammation of the peritoneum associated with pre- existing abdominal pathology • More common • Infectious • Noninfectious (sterile/aseptic/chemical/traumatic)
- 7. www.sashvets.com Secondary Peritonitis: Infectious Gastrointestinal tract • Necrosis, rupture, perforation • Surgical wound dehiscence • Pancreatic abscess Urogenital tract • Pyometra/uterine rupture • Prostatic abscess • Ruptured urinary bladder with UTI • Renal abscess • Vaginal rupture Hepatobiliary • Necrotizing cholecystitis • Liver lobe torsion • Hepatic abscess Other • Penetrating wounds • Surgical contamination • Evisceration • Splenic abscess • Peritoneal dialysis
- 8. www.sashvets.com Secondary Peritonitis: Compromise of the GIT • 50-60% cases of bacterial peritonitis – Gastric/intestinal perforations secondary to GDV – Surgical wound dehiscence – Perforated small intestinal ulcers – Foreign body – Tumor rupture
- 9. www.sashvets.com Secondary Peritonitis: Sterile • Neoplasia • Pancreatitis • Sterile bile peritonitis • Uroabdomen • Sterile foreign bodies (sponge, talcum powder, suture material)
- 10. www.sashvets.com Pathogenesis • Bacterial/chemical irritants vascular dilatationincreased capillary permeability – Facilitates phagocytosis of bacteria and foreign material • Local deposition of fibrin and plastering of adjacent bowel mesentery (omentum!) to inflamed areas • Walling-off inflammation
- 11. www.sashvets.com Potential Outcomes • Successful walling-off, host defenses resolve infection • Confined suppuration and abscess formation • Diffuse peritonitis
- 12. www.sashvets.com Diffuse Peritonitis: Pathophysiology • Large protein-rich fluid losses (tremendous surface area) hypovolemic shock • Exacerbated by vomiting, diarrhea • Vasodilation relative hypovolemia • Splanchnic edema or vasoconstricton stress ulceration/ischemic damage bacterial translocation • Increased absorption across inflamed peritoneum septicemia, bacteremia, SIRS, sepsis
- 13. www.sashvets.com Course Determination • Virulence of contaminating microorganisms ± presence of certain enhancing substances (bile salts, talc, hemoglobin) • Extent of contamination (volume, rate, duration) • Immunocompetence of host
- 14. www.sashvets.com History & Clinical Signs • Lethargy/depression, • Inappetance, • Vomiting • Diarrhea • ± Acute collapse • Intact female? • Trauma? • Recent surgery? • Abdominal pain ± distention – “Praying position”
- 15. www.sashvets.com Physical Exam: Nebulopathy • Evidence of perfusion impairment – Severe dehydration – Dull mentation – Pallor/injected mucous membranes – +/-Weak femoral/distal pulse quality with BP • Symptoms of SIRS/sepsis: – Hypo/hyperthermia – Brady/tachycardia – Tachypnea – Leukocytosis or leukopenia
- 16. www.sashvets.com Primary Peritonitis – Cats JAAHA 2009; 45: 268-76 • 13 cases • Mortality 31% • Common presentation: Tachypnea, bradycardia, ascites, hypoalbuminemia, anemia • All cats surgically explored
- 17. www.sashvets.com Laboratory Abnormalities • Hemoconcentration/anemia • Hypoglycemia/hyperglycemia • Decreased sodium/potassium ratio • Azotemia • Elevated transaminases • Hyperbilirubinemia • Hypoalbuminemia/panhypoproteinemia • Hypochloremic metabolic alkalosis with hypokalemia • High anion gap metabolic acidosis: – Lactic – Urinary tract • Leukocytosis with a shift to the immature forms on the differential cell count • Absence of leukocytosis or leukopenia
- 18. www.sashvets.com Abdominal Radiography • Loss of intra-abdominal contrast • Ileus with distended loops of bowel • Isolated distended loop bowel or two distinct populations of small intestines • Foreign body • Mass effect • GDV • Free fluid (> 8 ml/kg) • pneumoperitoneum
- 19. www.sashvets.com When to cut: Pneumoperitoneum JAVMA (223)4, Aug 15 2003 JAVMA (225)2, July 15, 2004 Secondary to: – Ruptured hollow viscus – Gas-forming bacteria (abscess) – Penetrating injuries But also secondary to: – Abdominocentesis – Recent abdominal surgery (18 d)
- 20. www.sashvets.com Ultrasound Examination • Free fluid • Abscesses in parenchymal organs • Pyometra • Pancreatitis • Abdominal masses • Abnormalities in organ blood flow – Organ torsion • Intestinal obstruction
- 21. www.sashvets.com FAST JAVMA 225(8), Oct. 15, 2004 • Focused Abdominal Sonogram Trauma • Adapted from human medical field to identify abdominal fluid in dogs following trauma • 4 Views, named for landmarks in R recumbency – DH: diaphragmatico-hepatic – SR: spleno-renal – CC: cysto-colic – HR: hepato-renal • Sensitive, not specific
- 22. www.sashvets.com Abdominal Paracentesis • Patient in L lateral recumbency (spleen!) • Ventral abdomen at the level of the umbilicus clipped and prepared aseptically • Urinary bladder evacuated • Local infiltration with lidocaine? • 4-quadrant centesis – 23 ga needles (4-6) – 1 ml syringe – Slides & sample collection tubes • Closed or open-needle techniques described • Contraindications: coagulopathy; organomegaly; distension of abdominal viscus
- 23. www.sashvets.com Abdominal Paracentesis Bloody fluid that clots: • r/o vessel or organ Effective? • Canines: 5.2-6.6 ml/kg abdominal fluid required for positive results Alternative: • Diagnostic peritoneal lavage?
- 24. www.sashvets.com Evaluation of Peritoneal Fluid • Cytology/culture: Crystals? Microbes? Pigments? • Total protein • Lactate • Glucose • Creatinine • Bilirubin • PCV • Surgical Intervention: – Septic abdomen – Bile peritonitis – Uroabdomen (+/-) – Persistent hemoabdomen
- 25. www.sashvets.com Normal Peritoneal Fluid • < 1mL/kg non-clotting, clear, yellow fluid (straw-colored) • Transudate: – < 3000 nucleated cells/L – 50% macrophages, 50% lymphocytes – < 2.5 g/dL protein (albumin) • Functions – Decreases friction between opposing surfaces – Dissemination of localized inflammation/infection • Drainage – Diaphragmatic lymphatics and thoracic duct to sternal lymph nodes (80%)
- 26. Abdominal effusion Total protein count, total nucleated cell count < 2.5 g/dl protein <1500 nucleated cells/L 2.5-7.5 g/dl protein 1000-7000 nucleated cells/L > 3 g/dl protein > 7000 nucleated cells/L Transudate Modified transudate Exudate Algorithm to Classify Effusions
- 27. Transudate Low serum albumin YesNo Proteinuria YesNo Diarrhea Consider PLN No Yes Consider hepatic insufficiency Consider PLE Abdominal fluid [creatinine] greater than serum creatinine No Yes Consider leakage from intestinal lymphatics
- 28. Modified Transudate Fluid bile-stained, with phagocytized bile pigments NoYes Fluid is red, with phagocytized RBCs NoYes Bile peritonitis Intracavitary hemorrhage Fluid is milky white Yes No Chylous/pseudo- chylous Small lymphocytes predominate Yes No Chylous/pseudo- chylous Lymphoblasts, mast cells, cells w/nuclear criterea for malignancy
- 29. No Neutrophils predominate YesNo Nonexfoliating neoplasia, FIP, chronic inflammation, Diaphragmatic Hernia, Liver Lobe Torsion, other Abdominal fluid [creat] > serum [creat] Yes No Uroperitoneum Organsims present (mycotic, rickettsial, protozoal) Yes No Yes No Neoplasia Heart failure? Yes Infectious pleuritis/peritonitis FIP, tissue inflammation, nonexfoliating neoplasia, other
- 30. Mostly degenerate Yes Bacteria present YesNo Culture Bacterial peritonitis No Bacterial, mycotic, protozoal or rickettsial organisms Yes Infectious peritonitis No Yes Nuclear criterea malignancy No Possible neoplasiaFluid very bloody YesNo Erythrophagocytosis YesNo Intracavitary hemorrhage Bloody tap, organ tap, acute hemorrhage Bile-stained with phagocytized bile pigments Exudate where Neutrophil predominates Neutrophils Yes Bile peritonitis No Abd. fluid [creat] > serum [creat] Uroperitoneum YesNo Infectious, inflammatory, neoplastic
- 31. Exudate where Neutrophil does not predominate No Primarily mast cells Primarily small lymphocytes NoYes Mast cell tumor Chylous/pseudo- chylous Primarily lymphoblasts Yes No Lymphosarcoma Primarily macrophages Yes No Fluid is bile-stained with phagocytized bile pigment Cells with nuclear criterea for malignancy Yes Yes Bile peritonitis No Low-grade chronic inflammation, FIP Yes No Neoplasia? Refer Exudate
- 32. www.sashvets.com When to Cut: Septic Effusions • Non-septic effusions: cut? • Hepatic disease, GI neoplasia, multicentric lymphoma, splenic leiomyosarcoma, pancreatitis, right- congestive heart failure, intact pyometra • Septic effusions: cut! – GI – intestinal neoplasia, foreign body, postoperative enterotomy dehiscence, duodenal feeding tube leakage Other – hepatic abscess, pancreatic abscess, mesenteric lymph node abscess, contamination from urinary bladder
- 35. www.sashvets.com Septic Effusion: Lactate and Glucose Bonzynski et al. JAVMA 2003 • Blood-to-fluid (BFG) glucose difference > 20 mg/dl (1.1 mmol/L) – 100% sensitive and specific for dx septic peritonitis in dogs – 86% sensitive and 100% specific in cats • Blood to fluid lactate difference < 2mmol/L – 100% sensitive and specific for dx of septic peritonitis (dogs) • IV administration of glucose or presence of hemoabdomen may decrease accuracy
- 36. www.sashvets.com Evaluation of post-celiotomy peritoneal drain fluid volume, cytology, and blood-to-peritoneal fluid lactate and glucose differences in normal dogs Vet Surg 2011 40(4) • JP drain placed after abdominal explore in 10 healthy dogs • Peritoneal fluid analyzed q6 x 7 days • Results after day 4: – blood-to-peritoneal glucose concentration differences were consistent with septic effusion based on previously reported values (all dogs) – Blood-to-peritoneal lactate concentration consistent with septic peritonitis (70% of dogs) • Conclusion: post-operative blood to peritoneal fluid glucose & lactate may not be reliable indicators of septic peritonitis when evaluating fluid collected from closed suction drains
- 37. www.sashvets.com When to Cut: Bile Peritonitis • Abdominal fluid – Presence of bilirubin = 100% effective in diagnosis bile peritonitis – Effusion [bilirubin] > serum [bilirubin] – Cytology: bile pigments & crystals may also be seen microscopically – If secondary to ruptured mucocele, these changes may not be present • Gelatinous bile may not disperse intra-abdominally
- 38. www.sashvets.com When to Cut: Uroabdomen • Abdominal fluid [creatinine] to peripheral blood [creatinine] ratio of >2:1 • Abdominal fluid [potassium] to peripheral blood [potassium] ratio of >1.4:1 • Remember: – Bladder palpable in majority (>50%) – Ascites can occur subsequent to severe UO – Some animals with urinary compromise will still urinate & have urine collecting in the abdomen
- 39. www.sashvets.com Pre-op Stabilization • Fluid resuscitation • Blood products (peri-op) • Correction acid/base, electrolyte abnormalities • Euglycemia • Vasopressors for refractory hypotension • Inotropes for documented myocardial failure • 4-quandrant bacteriocidal systemic antibiotics • Pain management • Source control
- 40. www.sashvets.com When to Cut: a Summary • Septic peritonitis – Abdominal abscess – GI obstruction – Ischemic/perforated/ruptured GI • Persistent abdominal hemorrhage – Trauma – Neoplasia • Uroperitoneum (+/-) • Free abdominal gas (non-iatrogenic or associated with pneumomediastinum) • Bile peritonitis
- 41. www.sashvets.com How to know: a Summary – Septic peritonitis: • Intracellular microbes • Blood-to-fluid glucose concentration difference > 1.1 mmol/L • Blood –to-fluid lactate difference < 2 mmol/L – Bile peritonitis: • Effusion [bilirubin] > blood [bilirubin] (usually x2) • Presence of bile pigments or crystals – Uroperitoneum • Fluid creatinine > 2:1 of serum creatinine • Fluid potassium > 1.4:1 serum potassium – Hemoperitoneum • PCV of fluid near peripheral blood (or increasing) • Evaluate with TP: decreasing protein levels indicate hemorrhage
- 42. www.sashvets.com.au twitter: @SASHvets Phone - (02) 9889 0289 Fax - (02) 9889 0431 Level 1, 1 Richardson Place, North Ryde 2113, Sydney, NSW www.sashvets.com.au twitter: @SASHvets Phone - (02) 9889 0289 Fax - (02) 9889 0431 Level 1, 1 Richardson Place, North Ryde 2113, Sydney, NSW
Editor's Notes
- peritonitis is defined as inflammatio of theperitoneal cavity and may be classified according to underlying cause (primary vs. secondary), extent (generalized of localized), or the presence of infectious agents (septic or non-septic)
- Consquence of a perexisting aseptic or septic pathologic intraabdominal condition
- Secondary peritonitis most commonly results from leakage of GI contents from a compromised GIT
- SIRS: Systemic inflammatory response to infectious or noninfectious causes, with 2 or more of the following: Hypo/hyperthermia Brady/tachycardia Tachypnea Leukocytosis or leukopenia Sepsis: SIRS plus known or suspected presence of serious infection Severe sepsis: Sepsis plus evidence of end-organ dysfunction Septic shock: Sepsis with hypotension refractory to fluid therapy Sepsis: SIRS plus known or suspected presence of serious infection Severe sepsis: Sepsis plus evidence of end-organ dysfunction Septic shock: Sepsis with hypotension refractory to fluid therapy
- Many of the symptoms association with peritonitis can be attributed to a wide variety of conditions, but remember that signalment can be a big clue as to underlying cause. Young animals are often associated with foreign body ingestion, for example. An accurate history can also be very important for diagnosis, as well as progression and timing of symptoms This is especially important as many symptoms are vague and inconsistent between patients. You might think, for example, that abdominal pain would be a no-brainer for the majority of these patients. However, one retrospective study focusing on cats with septic peritonitis revealed that roughly 40% of felines did not exhibit pain on abdominal palpation
- Although a full PE should always be performed, a specific area of discomfort cannot be identified. Many animals with peritonitis are systemically ill and exhibit nonspecific clincial signs. Patients may arrive in varying stages of shock, and can have wither injected of pale mm, prolonged CRT or injected, hyperemic mm, and be either hypo or hyper thermic. Even septic will not always exhibit consistent symptoms, though septic cats are more often appreciated to be bradycardic while dogs generally present tachycardic. Often, diagnosing the underlying condition requires multiple diagnostic tests in addition to a through physical & history.
- Just to highlight the fact that it is not possible to distinguish between primary and secondary peritonitis by physical examination alone: many of the c/s are identical. And bringing back a point from an earlier slide: surgical intervention may do harm to patients with primary peritonitis, while many conditions associated with secondary peritonitis require surgery. To complicate matters further, not all cases of secondary peritonitis are appropriate to manage surgically. With nebulous clinical signs and lab findings it is often difficult to know when to cut and when not to. The remainder of this presentation is going to focus on what conditions require surgery and how to differentiate them from those that don’t.
- As I just alluded to, many lab findings will be non-specific. Increased permeability Malnutrition Hepatic dysfunction GI losses Shifting of hepatic synthetic pathways towards production of APPs Patients with peritonitis should have rooutine hematologic, biochemical, and coagulation analysis. many lab abnormalities are (again) non-specific, but some may help narrow your index of suspicious on cause. More importantly, several derangements can be life threatening if not corrected Both hypo and hyperglycemia may relate to sepsis (hyperglycemia in the absence of DM) Hyperkalemia may indicate uroperitoneum, though can also be present with addisons disease Similarily, hyperbilirubinemia may be a result of bile peritonitis or sepsis (or other disease) Hypoproteinemia may be a result of protein loss within the peritoneal cavity Essentially, derangements in the serum chemistry may be reflective of primary organ dysfuction or indicative of hypoperfusion or shock A CBC, though also part of the required baseline, is again not specific to etiology. Absence of leukocytosis or leukopenia can reflect Severe sepsis Immunocompromised Addisonian
- There is no question that patients with suspected peritonitis should be evaluated for peritoneal effusion. Often, one or more imaging modalities are utilized. Plain radiographs may reveal a focal or generalized loss of detail known as the “ground glass appearance”. They may also show mass lesions, evidence of intestinal obstruction, GDV, prostatomegaly, or suggest pyometra (among other things). Remember to conider thoracic radiographs as well: not only is this helpful as a metastatic and pulmonary screen, but the presence pf bicavitary effusion increase the mortality rate in patients roughly 3 fold over patients with peritoneal effusion alone. However, it is important to remember that all abdominal effusions may not be visible on plain radiographs. Small volume effusions may not be appreciated radiographs.
- A pneumoperitoneum suggests perforation of a hollow viscous organ, penetrating trauma, or the presence of gas producing anaerobic bacterial. All of these conditions are indications for surgical intervention as soon as reasonably appropriate. It is very important to remember, however, that recent abdominal surgery and/or abdominocentesis can create free abdominal air. Traumatic pneumoperitoneum managed conservatively???
- Ultrasonography is often useful for determinining the underlying etilology of peritonitis, and is also helpful for localizing and aiding retrieval of small volume abdominal effusions. Keep in mind that little of no fluid may be detected initially if patients arrive early in the disease process or prior to fluid resuscitation. Consider re-imaging once the patient is resuscitated.
- In an emergency situation, a full ultrasound examination is not always an option. Alternatively, a FAST ultrasound can be employed to rapidly & non-invasively assess for free intraabdominal fluid.
- Abdominocentesis is the diagnostic method of choice for confirming peritonitis, and also the key to determining how to manage it As previously mentioned, If your patient is hypovolemic/shocky on presentation, this may not be productive. Try again post resuscitation. Single paracentesis attempts are successful n only 20% of patients with low bolumes of peritoneal effusion (< 3 ml/kg). IF an ultrasound maching is not accessible, a blind tap can be employed.
- A DPL may be considered when peritonitis is suspected despite the absence of detectable effusion or when a minimal volume of effusion makes it difficult to obtain a sample Can perform DPL with a peritoneal dialysis catheter or an over the needle, large bore 14-18 ga catheter. Briefly, the technique is performed by infusion of 22 ml/kg of warmed, sterile isotonic saline solution through the catheter inserted in an aseptically prepared site just caudal to the umbilicus. The sample is then retrieved for analysis. Remember that the lavage solutio will diute the sample and pergaps alter the analysis. I don’t often do this. More sensitive at detection of intra-abdominal pathology than standard abdominocentesis Detects 1.0-4.4 mL/kg fluid PCV > 10% consistent with hemoabdomen
- Again, analysis of abdominal fluid is the key to characterizing the disease process and choosing appropriate therapy. Once obtained, abdominal effusion should be evaluated for the following. If you have only obtained a small amount, prioritize your tests around your clinical suspicions. A slide can be made with only a few drops of fluid and can change everything! Always make a slide for cytology. This slide contians the basics. By evaluating abdominal fluid via these parameters, you will likely be able to determine the correct course of action Surgical dehiscense GI perforation/rupture
- A little more in depth regarding peritoneal fluid. First, lets review normal peritoneal fluid.
- When to cut: transudate?
- Abdominal fluid cytology that reveals degenerative neutorphils and intracellular bacteria confirms a diagnosis of septic peritonitis an is an indication for emergency surgical exploration… However, you may not always be that lucky. Increasing inflammation (numbers of neutrophils or morphologic features of toxicity in these cells) observed in serial samples are also useful in determining proper management. Also remember that dogs receiving antibiotics may have no observable bacteria in peritoneal fluid samples, despite peritoneal contamination
- What else can we use? Remember that Bacteria consume glucose & produce lactate. Glucose concentration of abdominal effusion is a useful predictor of bacterial peritonitis in dogs. A concentration difference of more than 20 ml/dl between paired samples for blood and peritoneal fluid glucose is a reliable predictor of bacterial peritonitis. (IV administration of glucose or presence of hemoperitoneum may decrease the accuracy of this test) Additionally, a blood-to-fluid lactate difference less than 2 mmol/L was predictive of septic peritonitis in dogs (not useful in cats) You may not always see intracellular bacteria, but be highly suspcious of a septic effusion. Evaluate your effusion and build a case (one way or another)
- Consider your history!! Recent surgery?
- Uroabdoment can occur secondary to: Blunt trauma Urethral catheterization Bladder expression Bladder wall pathology But do all cases of uroabdomen require surgical repair? What about small urethral tears? Some of these will heal with a urinary catheter in place over roughly 7 days. bladder ruptures often require surgical repair, though small leaks may heal with continuous decompression provided by a UCS. Urethral trauma is successfully treated conservatively in some cases as well. Definitive surgical treatment for uroabdomen secondary to renal or ureteral injury is generally necessary.
- And speaking of uroabdomen… I think that uroabdomens are the perfect example to highlight the improtance of stabilization prior to surgery. Initial stabilization of the patient with a uroabdomen revolves around correction of acid base derangements (hyperkalemia!!) and shock. In addition to standard interventions, a peritoneal dialysis catheter can facilitate the evacuation of urine from the peritoneal cavity and ther diversion of urine that continues to leak from the disruted UT until the patient is stale and surgical intervention can be performed. Along that same vein: patients with peritonitis are SICK. Before surgical intervention, each patient must be made as hemodynamically and medically stable as possilbe & reasonable. Goals are to restore normal fluid and electrolyte balance and minimize contamination & damage.
- Without a clear indication the clinician must used all infor that can be obtained quitckly to determine if surgery is wattented Intestinal obstruction (foreign body, neoplasia, intussusception)
- Prognosis? Prognosis ranges from good to guarded in patients with peritonitis. Reported survival rates are highly variable and dependent on the etiology and presence of infection. Mortality also depends on appropriate stabilization and care.