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SA Sx - Gastric Sx Disorders 1

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drraythe's version from 2017-09-13 19:51

Intro + FB

Question Answer
Most common Sx disorder of stomach?Foreign body
What are the 2 forms of Pyloric stenosis / hypertrophy?Congenital or acquired
4 main surgical disorders of the stomach?Foreign bodies
Pyloric stenosis / hypertrophy
Neoplasia
Hiatal hernia
1 of the most common foreign bodies is...?Bone
Where’s the 1st place you should check for foreign bodies?Look at mouth 1st, bones tend to get stuck btwn 2 molars & cz pressure necrosis/ulcers of the palate
Why should you be wary of occasional vomiting?Gastric foreign bodies may be clinically silent, remaining in the stomach for prolonged periods & czing only occasional vomiting
Most common PTx for foreign bodies?More common in young animals, more common in dogs than cats (except linear foreign bodies)
Where do linear bodies usually get stuck & what gets the most damage from them?(Usually cats w/ thread or string)
Usually stuck under tongue or in pyloris, cz the most damage to the intestines
CSs of a gastric foreign body?Abdominal pain
Vomiting (from irritation)
Anorexia & weight loss (variable)
Loss of electrolytes
Blood in stool
How often can you palpate a FB?Very seldom
CSs of an Incomplete or intermittent obstruction?Less frequent vomiting (could be gastric or pyloric vomiting), water & electrolyte loss is less severe, anorexia & weight loss may be predominant signs
If you see melena or hematemesis, what might you suspect is happening w/ the foreign body?Mucosal erosion, ulceration or necrosis (this occurs occasionally)
If you need to use contrast gastrography (radiology), what should you keep in mind??Can use radiopaque or contrast media... dont use barium w/ perforations = czs granulomatous rxns
How might Laboratory data appear if there is a gastric foreign body? Why is this?Metabolic alkalosis
Hypochloremia
Hypokalemia (due to vomiting or diarrhea)
*Stabilize PTx before anything else!
When would you prolly do Endoscopy for a gastric FB?Small, light-weight, soft material (i.e. fabric)
When would you prolly do gastrotomy for a gastric FB?Smooth or heavy objects, sharp or rough-surfaced objects (i.e. balls, bones, toys)
Why might you see distended bowels on a rad for a GASTRIC FB?Distended bowel can be due to pain bc pain czs ileus
Can you do a water test in the stomach?Nearly impossible
When does stomach serosa heal the best?12-24h
Where is it hard to get FBs out of the stomach w/ your hands?Hard to get them out of fundus w/ hands
How many views should you take before attempting to surgically remove a FB?Take 2 views, sometimes 3 bc it helps to better see the FB CANNOT do single view before Sx, cant get a good Dx
What is the prognosis of a gastric foreign body?Usually excellent, Good even if mucosal damage is present
If you see an inflated ball in the stomach, what can you do to try to remove it?Pop it w/ an endoscope 1st
How many views should you do for a FB?3
what is going on in this picture & why?Ileus due to FB. Intestine has stopped, gas accumulates
Chronic vomiting
Abdominal wall pushed up against spine
PTx is thin.
If you want to add a little contrast to your radiograph w/o using contrast medium to determine more about the FB, what can you do?Tube to put gas in - neg contrast technique
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Pyloric Hypertrophy/Stenosis

Question Answer
Who does pyloric hypertrophy usually happen to?Occurs predominantly in dogs and, less commonly, in cats
What is the etiology of Pyloric Hypertrophy/Stenosis?Unknown
Difference in what is affecting in Congenital VS acquired hypertrophyCongenital form involves muscular layer of pylorus. Acquired form is hypertrophy of mucosa or muscular(one or both) layer of pylorus & sometimes of pyloric antrum
What is the most common signalment of an animal suffering from CONGENITAL pyloric hypertrophy/stenosisPuppy or kitten, usually 6-8 weeks old. Brachycephalic breeds of dog & Siamese cats have higher incidence
What is the Hx like for a PTx presenting for CONGENITAL pyloric hypertrophy/stenosis? (What has been happening to them?)Hx of vomiting following ingestion of solid food, manifested at weaning, Vomiting occurs at regular period up to 24 hours after eating. May have Hx of ravenous appetite.
If you have PTx that you suspect has pyloric hypertrophy/stenosis & they are pyrexic, what might you suspect?DDx aspiration pneumonia
CSs of CONGENITAL Pyloric Hypertrophy/Stenosis?Emaciation
Stunted growth
Dehydration
Occasionally fever & increased lung sounds 2° to aspiration of vomitus
How can you diagnose CONGENITAL pyloric hypertrophy/stenosis?Hx & signalment
Especially age at onset (around weening, 6-8wk)
CSs
Lab data
Radiography
How does Radiography look like (plain & pos contrast) w/ CONGENTIAL pyloric hypertrophy/stenosis?Plain radiographs: enlarged stomach filled w/ food & fluid. Positive contrast gastrography: delayed gastric emptying - presence of barium in stomach beyond 8-12 hours is abnormal
Laboratory abnormalities for an animal who has pyloric hypertrophy/stenosis?Malnutrition leads to hypoproteinemia, anemia, low BUN, hypoglycemia. Pyloric vomiting leads to dehydration, hypochloremic metabolic alkalosis. Elevated white blood cell count if aspiration pneumonia occurs
What is the Hx of an animal w/ ACQUIRED pyloric hypertrophy/stenosis?Intermittent vomiting, not always associated w/ feeding, that increases in frequency over mos. Weight loss. Occasionally anemia, depression, decreased activity
How do you Dx ACQUIRED pyloric hypertrophy/stenosis?Hx
Signalment & physical examination findings
CSs
Laboratory data
Radiography
Signalment of a dog w/ ACQUIRED pyloric hypertrophy/stenosis? (Breed disposition?)Middle aged excitable small breeds of dogs, especially Lhasa Apso & Shih-tzu. RARE in cats
CSs of ACQUIRED pyloric hypertrophy/stenosis?Pale mucous membranes, Weakness, Emaciation, Dehydration, Hypochloremic metabolic alkalosis
How does radiography look w/ ACQUIRED pyloric hypertrophy/stenosis? (What contrast do you use?)Pos contrast gastrogram, Delayed gastric emptying, Irregular mucosa w/in pylorus or pyloric antrum, Filling defect in pylorus
How does acquired pyloric hypertrophy/stenosis look like w/ endoscopy?Narrow lumen in pylorus, *mucosal/submucosa hypertrophy
What are the different kinds of Tx available for pyloric hypertrophy/stenosis?Medical Tx not effective - need Sx!!
Pyloromyotomy
Pyloroplasty
Gastroduodenostomy/Gastrojejunostomy
3 commonly used surgical procedures used to treat pyloric h/s?FREDET-RAMSTEDT pyloromyotomy
HEINEKE-MIKULICZ pyloroplasty
Y-U antral advancement flap pyloroplasty
What is the procedure that would be considered radical for treating pyloric h/s?Billroth I gastroduodenostomy
Explain the FREDET-RAMSTEDT pyloromyotomy (is it used for congenital or acquired? what is the surgical technique?)Used for CONGENITAL. Partial thickness longitudinal incision from pyloric antrum to duodenum across pylorus. Seromuscular layer incised to allow mucosa to bulge into incision & expand pylorus (mucosa not cut)
What technique is this, what is it used to Tx?FREDET-RAMSTEDT pyloromyotomy, for CONGENITAL pyloric h/s
Advantages of the FREDET-RAMSTEDT pyloromyotomy?Quick & easy to perform, Lumen of pylorus not opened (use stay sutures)
Disadvantages of the FREDET-RAMSTEDT pyloromyotomy?Effective only in congenital stenosis, Effect may be temporary – stenosis may recur as seromuscular incision heals (tend to heal & give you reoccurrence of the Dz)
How should you take the stomach out & why is it difficult to expose the stomach properly?take stomach out w/ fingers, Babcock’s, or stay sutures. Hard to expose stomach properly due to gastrohepatic lig
What are the indications for a HEINEKE-MIKULICZ pyloroplasty? What is the surgical technique like?For CONGENITAL OR ACQUIRED pyloric hypertrophy/stenosis, biopsy. This is a full-thickness LONGITUDINAL incision crosses the ventral surface of the pylorus. The incision is closed transversely in 1 layer of simple interrupted sutures
If the gastrohepatic ligament is preventing you from getting good exposure of the pylorus, what can you do?When severing gastrohepatic lig, do it halfway to give your good exposure of the pylorus, too far through lig = intro the bile duct
What is best to get the stomach out?Babcock’s better than stay sutures
During the HEINEKE-MIKULICZ pyloroplasty, you cut a full thickness line through part of the pylorus. Often, mucosa "mushrooms" out w/ full thickness luminal incisions. What can you do about this excess mucosa?If mucosa redundant = can trim it
If you are doing a HEINEKE-MIKULICZ pyloroplasty & you need more exposure, what can you do?Blunt dissection around mucosa/submucosa w/ a hemostat
What technique is this? When can it be used? HEINEKE-MIKULICZ pyloroplasty, can use for CONGENITAL OR ACQUIRED pyloric h/s
What type of closure do you use on a HEINEKE-MIKULICZ pyloroplasty & why?Single layer apposition only! Cant use 2 layers bc it reduces the lumen size too much.
What are the advantages of the HEINEKE-MIKULICZ pyloroplasty?Exposure of mucosa for biopsy
Less likelihood of recurrence than pyloromyotomy.
What are the disadvantages of the HEINEKE-MIKULICZ pyloroplasty?Lumen is opened, not usually effective w/ acquired pyloric hypertrophy
What are the indications for a Y-U pyloroplasty? What is the surgical technique?Acquired pyloric hypertrophy, resection of mucosa / submucosa
TECHNIQUE: Make a longitudinal full-thickness pyloric incision. Extend it into the pyloric antrum making 2 diverging incisions (Y). The incised gastric wall is closed by suturing into a U shape
What technique is this? When is it used? Y-U pyloroplasty, good for acquired pyloric hypertrophy
What type of suture pattern is used for the Y-U pyloroplasty? Suture?Single apposition (as to not narrow the lumen) & absorbable suture
What are the advantages of the Y-U pyloroplasty?Good exposure of mucosa
Redundant mucosa & submucosa can be resected (use 1 layer closure)
Greater expansion of pylorus
What are the disadvantages of the Y-U pyloroplasty?Lumen is opened, More lengthy procedure
When is a Pylorectomy & Gastroduodenostomy (Billroth I) indicated? (What is it basically?)Severe acquired~ pyloric hypertrophy, necrosis of pylorus
Neoplasia (end to end anastomoses of duodenum & stomach )
(note: have to reestablish enterohepatic circulation to keep bile going into duodenum - but then bile is free flowing constantly)
(Pylorectomy & Gastrojejunostomy (Billroth II)-what is going on?)(Side to side anastomosis of jejunum bowel loop to stomach. incision should be not less than 3-4 cm bc shrinkage can occur during healing process up to 50%. pylorus & part of duodenum are gone. duodenum is a stump. jejunum attached to body of stomach. prob - jejunum not used to acidity of stomach - so anastomoses can become ulcerated)
What are the indications for a partial gastrectomy?Neoplasia, ischemic injury (GDV) or penetrating injury (ulcer or trauma)
Where does ischemic injury usually occur in the stomach?Commonly occurs at the greater curvature
When is a PTx NOT suitable for Sx (partial gastrectomy)?If there is ischemic injury involving both curvatures
Explain the INCISIONAL partial gastrectomy techniqueBranches of the gastroepiploic vessels to the affected area are ligated, A continuous suture may be run concurrently w/ resection. The incision is closed in 2 layers
What technique is this? Partial gastrectomy
If you are trying to find where the necrotic tissue from an ischemia ends, how can you tell which tissue is alive?Knick it a bit & see if it bleeds
What is the layer w/ the main blood supply to the stomach?Submucosa - may bleed throughout Sx
When ligating vessels during a partial gastrectomy, what must you be careful about?Do not cut off blood supply to spleen
Partial gastrectomy w/ STAPLES technique?Branches of the gastroepiploic vessels to the necrotic area are ligated, the tissue to be resected is drawn into the jaws of the TA (55 or 90) stapler, the tissue is stapled, then excised. (staples cut & close at same time)
Diff btwn fever & hyperthermia?Hyperthermia is a CS fever is a syndrome (many CSs)
How could you help reduce the recurrence of pyloric h/s after a FREDET-RAMSTEDT pyloromyotomy procedure? (Why is there recurrence?)Recurrence can happen bc 2 layers which were cut can heal back together (muscularis & serosa) → recurrence of Dz. do pylorectomy - remove a little strip of pylorus - (muscularis) to prevent reoccurrence. Lumen is NOT penetrated
For any procedure, where do you want to avoid your suture going?Avoid curvatures - might compromise blood supply w/ sutures
After a Y-U pyloroplasty, how should you feed your PTx?Dont over feed PTx - need small frequent meals
What is a "TA" stapler?Thoracic abdominal stapler
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