Tobias Chapter 86 Peritoneum And Retroperitoneum

Front 1

what are the nine regions the abdomen can be divided into?

Back 1

the right and left hypochondriac regions
the epigastric or xyphoid region
the umbilical region
the right and left lateral regions (including the flanks and paralumbar fossae)
the right and left inguinal regions,
the pubic region.

Front 2

what area is important in allowing passage of thoracic dz into abd and vice versa.

what passes thru this area?

Back 2

Paired slitlike openings dorsal to the diaphragm and ventral to the psoas muscles separate the pleural and peritoneal cavities only by a thin layer of fused endothoracic and transversalis fascia.

The sympathetic trunk and splanchnic nerves also enter the abdominal cavity in this area.

Front 3

Back 3

describe the portions of the omentum:

1.bursal portion
2. The splenic portion of the greater omentum extends to the hilus of the spleen to form the gastrosplenic ligament.
3.The smallest portion of the greater omentum is the veil portion containing the left limb of the pancreas.

Front 4

what is the omental bursa?

what is the epiploic foramen?

Back 4

The omental bursa is a potential space between these layers.

The omental bursa is a closed sac except for its large opening, the epiploic foramen, bounded dorsally by the caudal vena cava and ventrally by the portal vein.97

Front 5

what is the surgical significance of the epiploic foramen?

Back 5

Bleeding from the liver can be temporarily arrested by placing a finger through the epiploic foramen just cranial to the pylorus and curling the finger ventrally to occlude the hepatic artery and portal vein.

Migration of loops of small intestine through the epiploic foramen is rare but may result in intestinal strangulation

Front 6

where is the lesser omentum located?

Back 6

It lies between the lesser curvature of the stomach and porta hepatis, becoming continuous with the mesoduodenum.

Front 7

what are milky spots?

Back 7

aggregations of cells that are a source of neutrophils, macrophages, and lymphocytes and are important components of peritoneal defense mechanisms

Front 8

what organs are retroperitoneal?

Back 8

The kidneys,
ureters for most of their length,
adrenal glands
The aorta, caudal vena cava,
lumbar lymph nodes are also retroperitoneal.

Front 9

what is the peritoneum?
what types of cells does it contain?

Back 9

serous membrane composed of a single layer of squamous cells of mesothelial origin.

The cell surface is covered with microvilli

The mesothelial cells are supported by a connective tissue stromal layer composed of elastic and collagen fibers, macrophages, lymphocytes, mast cells, glycosaminoglycans, and adipose cells

Front 10

what are stomata?

Back 10

the peritoneum of the visceral surface of the diaphragm has fenestrations of the basement membrane, the stomata, of variable size

Mesothelial cell processes regulate stomata size, increasing the size in peritonitis.

In dogs and cats, these fenestrations are considered large, generally in the 4- to 16-µm diameter range or larger.

These fenestrations and special lymphatic collecting vessels, the lacunae, are important in clearance of fluid and particles from the peritoneal cavity.--drain to the sternal lymph nodes.

Front 11

name all of the ligaments that are formed by fold is the omentum

Back 11

Front 12

what is the colloid osmotic pressure of normal peritoneal fluid.

Back 12

28 mm Hg

Front 13

what is the normal protein and cellularity of peritoneal fluid?

what cells are normally in peritoneal fluid?

Back 13

<3g/dL
<300cells/mm
macrophages, mesothelial cells, lymphocytes

Front 14

list the normal cell counts and protein numbers in normal peritoneal fluid, transudate, modified transudate, and exudate?

Back 14

Normal


Transudate


Modified Transudate


Exudate

Cells/µL


<300


<1500


1000–7000


>5000

Protein (g/dL)


<3


<2.5


2.5–7.5


>3

Front 15

which side of the diaphragm has more lymphatics

Back 15

The right side of the diaphragm has a much greater distribution of lymphatics than the left side

Front 16

in a study comparing drainage of contrast material from the abdomen via open drainage and penrose, what was found?

Back 16

Most of the contrast medium drained within 6 hours with open peritoneal drainage and within 24 to 48 hours with sump–Penrose drainage.

Front 17

how much fluid can the abdominal cavity absorb?

Back 17

at a rate of 3% to 8% of body weight per hour.

Front 18

what is the normal range for IAP in dogs?

Back 18

2.0 to 7.5 cm H2O (mean, 4.50 ± 0.44 cm H2O)

Front 19

what is an indirect method of IAP measurement?

Back 19

indwelling transurethral urinary bladder catheter.

Front 20

in a study evaluating increased IAP is pigs, what were the effects?

Back 20

IAPs of 15 mm Hg (20.4 cm H2O) in pigs induced by CO2 insufflation caused:
increased heart rate
increased mean arterial pressure
increased systemic vascular resistance
decreased cardiac output
decreased mesenteric arterial blood flow
decreased intestinal mucosal blood flow,
increased bacterial translocation

Front 21

how is the clinical diagnosis of acute abdominal compartment syndrome in humans is made?

Back 21

when high peak inspiratory pressure is accompanied by oliguria and an apparent tight abdomen.

Urinary bladder pressure measurement greater than 20 to 25 cm H2O is suggestive

Front 22

at what IAP should surgical decompression be considered?

Back 22

Surgical decompression should be considered when IAP nears 30 cm H2O, particularly in oliguric animals.

Front 23

what treatment was given experimentally in pigs with IAP of 15mmHg to improve intestinal circulation?

Back 23

Low-dose infusion of dobutamine (5 µg/kg/min) corrected intestinal mucosal hypoperfusion induced by moderately increased IAP (15 mm Hg or 20.4 cm H2O IAP) experimentally in pigs

Front 24

what agents have been shown to reduce adhesion formation in horses?

in lab animals?

Back 24

lactated Ringer's solution
intraoperative and postoperative administration of heparin
hyaluronate–carboxymethylcellulose membrane implantation

intraperitoneal 0.4% hyaluronic acid solution subcutaneous administration of TNP-470
intraabdominal administration of fibrinolytic agents

Front 25

what physical techniques have been advocated to decrease adhesion formation?

Back 25

omentectomy and physical barriers,

Front 26

what are the mechs of immune function of the peritoneum?

Back 26

mediated by the complement system.

Specifically, release of C3a and C5a stimulates neutrophil chemotaxis and degranulation of basophils and mast cells.

Other innate defenses include absorption of bacteria through diaphragmatic lymphatics,

phagocytosis by resident leukocytes and macrophages, abscess formation,

activity of resident natural killer cell

Front 27

what pro-inflammatory cytokine has been asstd with a poor prognosis in primates?

Back 27

a primate model of peritonitis, persistent elevation of IL-6 was a poor prognostic sign, with a mortality rate of 42%

Front 28

what intraperitoneal substances are known adjuvants in peritonitis?

Back 28

gastric mucin, bile salts, hemoglobin, and barium
Peritoneal fluid volume

Gastric mucin polysaccharide has a heparin-like anticomplement effect, which inhibits phagocytosis.

Bile salts lower surface tension, altering cell adhesion and lysing RBCs, releasing hemoglobin.

Hemoglobin interferes with phagocytic cell chemotaxis, phagocytosis, and intracellular killing.

Hemoglobin may also play an adjuvant role by providing the iron required by some microorganisms.Hemoglobin also inhibits bacterial clearance from the peritoneal cavity by interfering with lymphatic clearance mechanisms.

Front 29

In canine models of septic shock what happens to intestinal mucosa?

Back 29

In canine models of septic shock, adrenergic stimulation increases intestinal venous pressure, injuring the mucosal barrier of the gut and promoting translocation of gut bacterial flora across the intestinal wall.

Front 30

what role does fever play in infection?

Back 30

The mechanisms of the beneficial effects of fever are unclear but appear to relate to enhanced host defenses through enhancement of cytokine expression, particularly TNF-α and IL-1β. Pharmacologic suppression of an animal's febrile response may be deleterious.

Front 31

What was found in the following study:
Kenney, EM, Rozanski, EA, Rush, JE, et al.: Association between outcome and organ system dysfunction in dogs with sepsis: 114 cases (2003–2007). J Am Vet Med Assoc. 236, 2010,

Back 31

MODS has recently been reported in a large, multicenter, retrospective series of dogs treated surgically for septic peritonitis secondary to gastrointestinal tract leakage.

Fifty percent of dogs in this study had MODS. The mortality rate was 70% for dogs with MODS and 25% for those without MODS.

Front 32

what organ besides the peritoneum also absorbs bacteria and other particulate matter

Back 32

The omentum also absorbs bacteria and other particulate matter; it is the only organ in addition to the peritoneum capable of doing so

Front 33

how does peritoneal inflammation induces gastrointestinal ileus?

Back 33

Peritoneal inflammation induces gastrointestinal ileus by sympathoadrenergic reflex inhibition.

These inhibitory reflexes completely block myenteric cholinergic neurons,

Front 34

what was shown regarding intestinal motility in a dog model of acute peritonitis by “appendiceal” ligation

Back 34

, spike activity was significantly decreased by 3 hours, motility was inhibited by 6 hours, and complete adynamic ileus was established by 9 hours.2

Front 35

what is reflex rigidity?

Back 35

Peritoneal irritation causes reflex rigidity of the abdominal and diaphragmatic muscles.

Diaphragmatic rigidity impedes respiratory movements. Diaphragmatic rigidity and decreased respiratory movement reduce intraperitoneal circulation and decrease lymphatic clearance of fluid and particulate matter through the diaphragm

Front 36

what was found in the following 2 studies regarding abd pain with septic peritonitis:

Costello, MF, Drobatz, KJ, Aronson, L, et al.: Underlying cause, pathophysiologic abnormalities, and response to treatment in cats with septic peritonitis: 51 cases (1990–2001). J Am Vet Med Assoc. 22, 2004

Parsons, KJ, Owen, LJ, Lee, K, et al.: A retrospective study of surgically treated cases of septic peritonitis in the cat (2000–2007). J Small Anim Pract. 50, 2009

Back 36

In two recent retrospective studies of septic peritonitis in cats, signs of pain during abdominal palpation were reported in only 38% to 64%

Front 37

how is Peritonitis is most commonly classified ? what type is most common in small animals?

Back 37

Peritonitis is most commonly classified as primary or secondary, acute or chronic, localized or generalized, and septic or aseptic.

In small animal practice, acute generalized secondary septic peritonitis is a relatively common occurrence

Front 38

what is the major difference between primary and secondary peritonitis?

Back 38

Primary peritonitis is spontaneous inflammation of the peritoneum in the absence of an evident intraabdominal source of infection or history of penetrating peritoneal injury.

In contrast to secondary peritonitis, primary peritonitis is monobacterial in most cases.

Front 39

what is the proposed route of infection in primary peritonitis?

Back 39

has been postulated to be primarily hematogenous, but bacterial translocation across the intact intestinal mucosa and bacteremia in portosystemic shunting have also been implicated

Front 40

Primary bacterial peritonitis in dogs and cats: 24 cases (1990–2006). J Am Vet Med Assoc. 234, 2009

were infections in animals with primary septic peritonitis mono or polybacterial?

what type of bacteria?

what was mortality rate?

Back 40

A recent retrospective study of primary bacterial peritonitis in 15 dogs and nine cats over a 16-year period revealed monobacterial infection in 56% of canine and 100% of feline cases.

Eighty percent of the bacteria cultured in dogs and 60% of bacteria cultured in cats in this study were gram-positive organisms.

Seven of 15 dogs (46.6%) and four of nine cats (44.4%) survived to discharge from the hospital.

Front 41

some pathogens asstd with primary peritonitis in dogs (small number of each):

Back 41

Salmonella typhimurium
Chlamydia psittaci
Clostridium limosum
Mycobacterium microti
Citrobacter freundii
Blastomyces dermatidis
histoplasmosis
candidiasis

Front 42

what was the mortality rate in the following study?

Ralphs, SC, Jessen, CR, Lipowitz, AJ: Risk factors for leakage following intestinal anastomosis in dogs and cats: 115 cases (1991–2000). J Am Vet Med Assoc. 223, 2003

Back 42

In one study, 85% of dogs that developed intestinal anastomotic leakage died despite aggressive treatment.

Front 43

how can you diagnose a surgical sponge retention?

Back 43

Ultrasonography and ultrasound-guided fine needle aspiration may assist diagnosis.

Surgical swab granuloma is sonographically characterized as a hypoechoic mass with an irregular hyperechoic center.

Cytology may reveal mononuclear inflammatory cells and multinucleate giant cell along with fibers.

The combination of survey abdominal radiographs and sonography enabled detection of retained surgical sponges in six of seven dogs (86%) in one study

Front 44

how is the diagnosis of starch-induced peritonitis made
what is the Treatment
how can you prevent contamination of the peritoneal cavity

Back 44

diagnosis of starch-induced peritonitis can be made by iodine staining or polarized light microscopic examination of peritoneal fluid.

Treatment with corticosteroids is recommended.

To prevent contamination of the peritoneal cavity with surgical glove powder, gloves should be washed or wiped with sterile saline before entering the abdomen.

Front 45

can you use chlorohex in the peritoneum?

Back 45

Povidone–iodine solutions in 3% and 10% concentrations cause intense peritoneal irritation and marked diffuse hemorrhagic peritonitis.

Even normal saline solution causes mild peritoneal inflammation, possibly because of its acidity.

Front 46

what is sclerosing peritonitis?

why does it happen?

how is it diagnosed?

how is it treated?

Back 46

It is a chronic form of peritonitis in which the abdominal organs become encased in thick, “cocoon-like” layers of collagenous connective tissue.

Peritoneal fluid may show large numbers of RBCs, macrophages with erythrophagia, mixed inflammatory cells, reactive mesothelial cells, and fibroblasts.

In the first three dogs reported, etiologic agents and pathogenesis of the lesions was not apparent.

Four of five animals in the second report had potential causes of the lesions, including steatitis and fat necrosis in the cat, fiberglass ingestion in one dog, bacterial peritonitis in one dog, and chylous effusion in one dog.

Surgical exploration and biopsy from multiple abdominal organs is recommended.

In one dog, fluid accumulation resolved with lavage and Penrose drainage for 11 days.

Corticosteroid therapy may reduce inflammation, slow progression, and control ascites.

Surgical dissection resulted in multiple sites of intestinal wall disruption and euthanasia of the dog.

Front 47

what types of parasitic peritonitis have been reported?

Back 47

Toxoplasma gondii
nymphal pentastomiasis
Porocephalus crotali.
Mesocestoides spp.
leishmainia

Front 48

what was the general source of peritonitis in the following study?

Hosgood, G, Salisbury, SK: Generalized peritonitis in dogs: 50 cases (1975–1986). J Am Vet Med Assoc. 193, 1988

Back 48

In a retrospective study of 50 dogs with generalized peritonitis, the gastrointestinal tract was the source of contamination in 60% of the dogs, most commonly secondary to surgical wound dehiscence

Front 49

Costello, MF, Drobatz, KJ, Aronson, L, et al.: Underlying cause, pathophysiologic abnormalities, and response to treatment in cats with septic peritonitis: 51 cases (1990–2001). J Am Vet Med Assoc. 22, 2004

what was the cause of peritonitis in this study

Back 49

Leakage from the gastrointestinal tract was the cause of septic peritonitis in 47% of 51 cats in a retrospective study.

Front 50

what was the cause of peritonitis is dogs in this study?

Winkler, KP, Greenfield, CL: Potential prognostic indicators in diffuse peritonitis treated with open peritoneal drainage in the canine patient. J Vet Emerg Crit Care. 10, 200

Back 50

In another retrospective study of the outcome of open peritoneal drainage in dogs with peritonitis, leakage from the gastrointestinal tract was the cause in 12 of 19 (63%) participants

Front 51

what were risk factors for anastomotic leakage identified in the following study

Back 51

In a retrospective study of risk factors for leakage after intestinal anastomosis in 90 dogs and 25 cats, preoperative peritonitis was identified as a significant risk

Other factors associated with anastomotic leakage in this study include hypoalbuminemia and intestinal foreign body

Front 52

what was the incidence of leakage with GI FB in the following study?

Hayes, G: Gastrointestinal foreign bodies in dogs and cats: a retrospective study of 208 cases. J Small Anim Pract. 50, 2009

Back 52

In a retrospective study of dogs and cats treated surgically for gastrointestinal foreign bodies from a first-opinion charity practice in which cases with preexisting peritonitis were excluded, 5% of the animals developed postoperative peritonitis presumably secondary to gastrointestinal dehiscence and leakage.

None of these animals survived.

In this study:
a longer duration of clinical signs
the presence of a linear foreign body
multiple intestinal procedures were associated with significantly increased mortality

Front 53

what was the % leakage in this study? what were the risk factors?

Shales et al.: Complications following full-thickness small intestinal biopsy in 66 dogs: a retrospective study. J Small Anim Pract. 46, 2005

Back 53

Enteric wound breakdown and septic peritonitis was diagnosed in 12% of 66 dogs with full-thickness small intestinal biopsy studied retrospectively, with no parameters predictive of enteric wound dehiscence identified.

Front 54

what was the dehischence rate in this study?

Gorman, SC, Freeman, LH, Mitchell, SL, et al.: Extensive small bowel resection in dogs and cats: 20 cases (1998-2004). J Am Vet Med Assoc. 228, 2006

Back 54

In dogs undergoing resection of greater than 50% of the length of small intestine secondary to foreign body, enteric wound dehiscence was reported in 2 of 13 (15%) of dogs, both of which were euthanized

Front 55

hats a major complication of gastrostomy tubes?

Back 55

In a retrospective study of gastrostomy tubes for nutritional management of renal failure in 56 dogs, peritonitis was a complication in 5%, resulting in the death of one dog.94

Front 56

what is the incidence of ruptured uterus with pyometra?

Back 56

In a retrospective study of 183 cases of pyometra in cats, the uterus was ruptured in seven cats, with fatal septic peritonitis in four.

Septic peritonitis appears to be rare in dogs with pyometra. In a retrospective study of 80 cases of pyometra (73 dogs), only one bitch was described with ruptured uterus and peritonitis

Front 57

how frequent does bile culture positive?

Back 57

In a retrospective study of gallbladder rupture in 45 dogs, 11 of 40 dogs had positive bacterial cultures, with aerobic organisms isolated in 10 dogs and anaerobic organisms isolated in only one dog.

Bile is a known adjuvant in peritonitis, and conventional wisdom suggests sterile bile peritonitis will progress to septic bile peritonitis. However, sterile biliary effusions of 30 days or more duration have been described

Front 58

what is the prognosis asstd with bile peritonitis?

Back 58

Survival in patients with sterile bile peritonitis was 100%, but survival in those with septic bile peritonitis was only 27% in one study.

A 79% mortality rate was reported in a retrospective study of hepatic abscesses in 14 cats, with septic peritonitis diagnosed in 67% by cytology.

In another study of variables associated with outcome in 60 dogs undergoing extrahepatic biliary surgery, the mortality rate was 55% in dogs with septic bile peritonitis compared with 13% in dogs with sterile bile peritonitis.

Front 59

what was survival in this study?

Crews et al.: Clinical, ultrasonographic, and laboratory findings associated with gallbladder disease and rupture in dogs: 45 cases (1997–2007). J Am Vet Med Assoc. 234, 2009

Back 59

In a more recent retrospective study, an 82% survival rate was reported for dogs with bacterial bile infection and gallbladder rupture

Front 60

what is a major complication of peritoneal dialysis?

most common isolate?

Back 60

Septic peritonitis secondary to peritoneal dialysis accounted for 4% of cases of generalized peritonitis in dogs in one retrospective study.

In a retrospective study of 27 dogs and cats treated with peritoneal dialysis, eight animals developed bacterial peritonitis.

The most common isolate was Klebsiella spp

Front 61

what is the incidence of peritonitis in dogs undergoing sx for gdv?
Ralphs, SC, Jessen, CR, Lipowitz, AJ: Risk factors for leakage following intestinal anastomosis in dogs and cats: 115 cases (1991–2000). J Am Vet Med Assoc. 223, 2003

Back 61

In a retrospective study of 166 dogs treated surgically for gastric dilatation and volvulus, peritonitis was a complication in 4.8% and was a risk factor for mortality.

Front 62

are there mostly aerobes or anaerobes in the colon?

Back 62

The colon has very dense bacterial concentration, with obligate anaerobes in excess of aerobes by approximately 1000 : 1.

Front 63

what 2 species of bacteria predominate in the peritoneal cavity in bowel perforation,

Back 63

E. coli and Bacteroides fragilis

Front 64

what toxin increases the virility of e.coli in the peritoneal cavity?

Back 64

α-Hemolysin is a common exotoxin of E. coli postulated to play a key role in facilitating the pathogenicity of E. coli in the peritoneal cavity.

α-Hemolysin is toxic to many mammalian cells,

α-Hemolysin:
decreases intraperitoneal pH,
lyses intraperitoneal erythrocytes
reduces recoverable viable leukocytes when present in the peritoneal cavity.

The presence of α-hemolysin markedly increases patient mortality and increases likelihood of recovery of E. coli and B. fragilis.

Front 65

what types of bacteria are most commonly isolate in septic peritontiis?

multiple or single
aerobic or anaerobic?

Back 65

In a retrospective study of 23 cases of septic peritonitis in dogs, there were multiple organisms identified in 14 of 28 cultures, including anaerobic organisms in 26% of the cases.

Front 66

what type of fungal infection is most common from bowel leakage?

Back 66

fungal secondary peritonitis is most often a result of infection with Candida albicans and is related to leakage of the stomach or duodenum. Candidal infection of the peritoneal cavity carries a grave prognosis

Front 67

what volume of peritoneal fluid can be palpated?

Back 67

Peritoneal fluid volume of 10 mL/kg body weight can be detected on physical examination by ballottement

Front 68

are cats with septic peritonitis usually hyperthermic?

Back 68

Cats with septic peritonitis are more commonly hypothermic

Front 69

how often do you see SIRS with septic cats?

Back 69

Cats with septic peritonitis are more commonly hypothermic

Front 70

SIRS criteria in Cats?

Back 70

Rectal temperature
>39.7° C (103.5° F) or <37.8° C (100° F)

Heart rate
>225 bpm or <140 bpm

Respiratory rate
>40 bpm

WBC (cells/µL)
>19,500 or <5000

Band neutrophil
>5%

Front 71

SIRS criteria for dogs

Back 71

Rectal temperature
>39° C (104° F) or <38° C (100.4° F)

Heart rate
>120 bpm

Respiratory rate
>20 bpm

WBC (cells/µL)
>18,000 or <5000

Front 72

how many SIRS criteria need to be met?

Back 72

3 or more for cats
2 or more for dogs

Front 73

what factors are associated with an increased risk of dehiscence in this study?

Allen, DA, Smeak, DD, Schertel, ER: Prevalence of small intestinal dehiscence and associated clinical factors: a retrospective study of 121 dogs. J Am Anim Hosp Assoc. 28, 1992

Back 73

in a retrospective of intestinal dehiscence, there was a significantly increased incidence of dehiscence when enterotomies or anastomoses were performed for traumatic injuries and foreign body entrapment.

Thus, a history of recent enterotomy for trauma or foreign body warrants a still higher index of suspicion

Front 74

can you use barium if you suspect a gastro- intestinal perf?

Back 74

Iodinated water-soluble contrast agents should be used in preference to barium when leakage from a hollow viscus or foreign body entrapment is suspected.

Leakage of intestinal contents plus barium into the peritoneal cavity is associated with higher mortality rate than either contaminant alone

Front 75

what is "double effusion"?
what diseases are asstd?
what are the proposed mechs?

Back 75

he rate of double effusions was highest in peritonitis or pleuritis caused by infectious agents and in pancreatitis. The presence of double effusion was associated with a 3.3 times increased risk of death. The mechanism of double effusion was considered an extension of abdominal disease through the diaphragmatic hiatus to the pleural space and vice versa or as a sequela to disseminated intravascular coagulopathy.304

Front 76

what biochemical parameters have been associates with survival in dogs?

Back 76

Significant differences in alanine transaminase (ALT) and gamma-glutamyltransferase (GGT) values were noted between survivors and nonsurvivors in a retrospective study of diffuse peritonitis in dogs.

Front 77

what effect does effusion volume have on obtaining diagnosis?

Back 77

single abdominal paracentesis results are reported to be positive in 20% of animals with a peritoneal effusion volume of 3 mL/kg and in 80% of animals with a 10-mL/kg effusion volume.

Experimentally, intraperitoneal fluid volume of 5.2 to 6.6 mL/kg was required for positive results of needle paracentesis, but only 1.0 to 4.4 mL/kg was necessary for positive results using a peritoneal dialysis catheter to obtain the sample