Principals: If you want to open the intestines, WHERE do you do it?
EXTERIORIZE the intestines, and then pack off abd cavity
principals: you should engage WHICH layer with all sutures?
SUBMUCOSA (its the holding layer of the GI)
principals: in general, what kinda suture?
Use small size, monofilament synthetic absorbable or nonabsorbable suture swaged on taper needles (big suture=microtrauma)
principals: after ur done with sx, what do you wanna cover the sx site with?
Cover surgical site with omentum or with a serosal patch (check with water test- if needs more help, attach omentum)
principals: before closing, always..
what level of contamination/sterility is intestinal sx considered? what precautions should you take because of this?
either Clean-contaminated, or contaminated! So, Replace contaminated instruments and gloves before closing abdomen (change instruments and gloves!), and Use prophylactic antibiotics
Recommended prophylactic antibiotics for sx, depending on location?
(1) Upper and middle sm int: 1st generation cephalosporins (cefazolin). (2) Lower small intestine and large intestine: 2nd generation cephalosporins (cefoxitin) [he noted you could add metronidazole if you were worried about anaerobes (clostridium natural anaerobe of ileum), but for no longer than 48-72 hr]
what bad problem comes with a complete intestinal obstruction?
pressure on the wall--> necrosis--> perforation--> peritonitis
exs of things which can cause intestinal obstruction?
Foreign body, Intussusception, Ileus(mechanical vs functional), Neoplasia(carcinoma=napkin ring lesion causing obstruction), Pythiosis(hunting dog gulf states), trauma, Mesenteric torsion, herniation
who is more prone to mesenteric torsion? what is the characteristic look of these on rads? how quickly do you need to solve this prob?
GSD, young animals, hunting dogs more prone. Characteristic "cinnamon bun" look on rads. Need to solve w/in 60min of intake (SUPER HIGH mortality rate...and reperfusion injuries)
Severity of signs depends on what 3 things? (which combination leads to the most severe probs?)
(1) completeness (2) location (3) blood supply [Complete, high or strangulated obstruction results in more severe signs]
explain the "completeness" of an obstuction- what are the two types of completeness and which is more severe?
Can be either complete of incomplete. A complete is a more severe problem (pressure necrosis), incomplete is sometimes hard to dx bc a little food DOES get past, and might mimic or hide things
explain the "high vs low" obstruction, and which is more severe
a high obstruction is more severe, keep in mind loss of electrolytes with the location of the blockage (high=alkalosis or and low=acidosis)
blood supply--> strangulated vs non-strangulated: which is more severe? how might appearance of this vary?
strangulated more severe-- must consider if arteries are blocked, or veins, or both. If just veins blocked, aa keep trying to bring blood to tissues, tissues become super edematous
which types of FBs are a cat prob, which are a dog prob?
CATS: linear FBs (esp if thread, look out for needle puncturing root of tongue), dogs basically everything else
who is Intussusception most common in? why?
young dogs! often bc of heavy parasite burden- even after de-wormed, should do a re-check to make sure you got them all. If heavily parasitized, intestines trying to push it through, inc peristalsis--> intuss.
how can you dx intusseption via palpation? cautions?
feels like a hard/semi hard cigar structure that suddenly tapers into normal bowel loop (dont squeeze too hard or can rupture).
who is Mesenteric torsion most common in?
Adult dog, especially German shepherd
If you see there is mesenteric torsion and the bowel loops are black, what should you do? not do?
DONT UNTWIST IF BLACK. resect but look out for short bowel syndrome. look out for any reperfusion injury
two types of ileus?
Post-operative or post-obstruction
usual signalmant of a pt with intestinal neoplasia?
Middle-aged and old dogs and cats
If you see this, what is prolly going on? what is this radiographic look called? how might you go about trying to see things better?
This is the "ground glass appearance" often seen with peritonitis/fluid in abdomen. so abdominocentesis-- drain fluid to take another survey rads. careful with contrast studies- if fluid removed shows things that hint toward perforation, dont do contrast (do US or exploratory)
sensitivity to hypoxia--> which structures are hurt when/at what time? (4 steps of destruction)
(1) superficial villus injury after 20 min (2) destruction of villus after 60 min (3) transmucosal necrosis after 4 hours (4) transmural infarction after about 8 hours
If you see "ground coffee" in the intestines after hypoxia, what do you know?
mucosa sloughed off
Grossly, wall edema and hemorrhage and mucosal sloughing are apparent within...(time)
After__(time)_________ the affected segment of intestine is turgid, and whole blood collects within the lumen
At _________(time)_________ the affected gut appears black, distended, and elongated
Gross necrosis is evident by__(time)_________
Gaseous bowel distention develops within the initial _________(time)_________ after obstruction, and is followed by the loss of fluid into the intestinal lumen.
without any tx, death due to hypovolemia occurs in about..
in short, list the order in which things die from hypoxemia (dont bother with times, other flashcards for that)
superficial villus injury--> destruction of villus--> transmucosal necrosis--> transmural infarction--> wall edema and hemorrhage and mucosal sloughing are apparent--> affected segment of intestine is turgid, and whole blood collects within the lumen--> affected gut appears black, distended, and elongated--> Gross necrosis--> Gaseous bowel distention--> loss of fluid into the intestinal lumen--> death due to hypovolemia
picture explaining the pathophysiology of intestinal obstruction
If the tissue is very edematous, are you concerned about suturing it?
oh yeah..its like suturing jello
according to come pics, which part of the sm int tends to get torsion?
vomiting more common when _________(where)_________ is obstructed, as opposed to diarrhea which is..
So you open the abd of a dog and you see that the omentum is adhered onto a piece of intestine. What do you think happened?
greater omentum = police= trying to patch and bring blood supply, and bring nourishment, and get rid of debris (does adhesion by itself)
Pyloric/proximal duodenal obstruction leads to what acid-base imbalance?
Mid-duodenal to ileal obstruction leads to what acid-base imbalance?
fluid loss due to obstruction happens through what 3 ways?
(1) Vomiting (2) Sequestration in intestinal lumen (increased secretion and decreased absorption) (3) Edema of intestinal wall, especially with venous occlusion of intestine
A strangulating obstruction is a simple obstruction+occlusion of the blood supply and results in what 4 problems?
(1) bacterial overgrowth (2) inc bowel permeability (3) perforation and escape of bowel contents (4)-->peritonitis
why does strangulating obstruction lead to bact overgrowth?
bact replicate rapidly, and no peristalsis to keep them away from abd wall-- without peristalsis, get bacterial translocation after necrosis (going outside of lumen)--> localized peritonitis--> generalized peritonitis
5 possible causes of strangulating obstructions?
Intussusception, Mesenteric torsion, Strangulated hernia, Some foreign body obstructions, Adhesions / bands
what are some things that inc the chances of adhesions? what might help avoid adhesions?
if leave ovarian pedical too long, if you let viscera get dry, adhesions. So makes sure to keep tissue moist by squirting/lavaging abd to help prevent
what problems can come from hairpin adhesions?
peristalsis not working well---food accumulation-- obstruction (pt in pic had OVH a few months before- must not have kept abd moist)
how would you describe what is going on in these pics?
Ileus and dilation (as result of obstruction)
main clinical signs of intestinal obstruction?
Vomiting, Dehydration, electrolyte imbalance, acid-base abnormalities, Abdominal pain, Distended loops of intestine, Palpable abdominal mass
b-day said...where do most FBs get stuck?
usually in jejunum or duodenum (usually not near ileocolic valve, if get that far, will prolly pass.)
if FB in lower sm int, where does telescoping usually take place?
usually telescoping at ileocolic junction.
first part of tx is stabalizing pt- how are some ways to do this?
Correct acid-base, fluid and electrolyte abnormalities, IV abx, tx for shock if necessary
If the FB gets to the colon, what are you thinking?
prolly will pass (monitor tho)
what are the two "worst enemy" FBs?
BBQ skewers (perforate easily), tampons (expand a lot and are difficult to get out)
UNDER THE TONGUE. always check under cats tongues! ESP if you feel bunching of viscera. Other place it can get stuck is at the level of the pylorus
If you see the linear FB under the cats tongue, what SHOULD you do? what SHOULDNT you do?
DO release the attachment from the tongue. (pick up, DONT pull, cut in half). DO NOT ATTEMPT TO PULL IT OUT FROM THE MOUTH
If you see linear FB coming out of anus, dont...
DONT pull it out!
how can a linear FB cause a perforation?
if gets embedded in mesenteric side of intestine and starts serrating and cutting through bc peristalsis against an immobile object--> can cause performation
omg! you see a small thin enlongated linear looking object near the thoracic inlet in a cat and you suspect a linear forign body. Before you attempt surgery to remove this "needle" what should you keep in mind?
DO NOT REMOVE THE CLAVICLE THINKING IT IS A NEEDLE.
If there is a needle attached to a FB in a cat, what other structure might you be super worried about?
communication behind last molar into the floor of the orbit- CAN MOVE FROM MOUTH TO EYE
two unique radiographical signs of linear FBs?
(1) Intestine plicated in cranial abdomen (2) Teardrop shape of gas bubbles in intestine
what's this? what usually causes this?
intestinal plication, usually caused by linear FBs
WHICH border of the intestine is usually lacerated by linear FBs?
MESENTERIC border (MUST explore and assess it)
how should you approach doing an enterotomy if the linear FB in the intestines is long?
dont do one super long enterotomy- do mult normal sized ones
If the intestine is perforated by a linear FB, what is the recc course of action?
Intestinal resection and anastomosis is indicated if the intestine is perforated
once you have removed linear FB and the intestines are still plicated, how can you try to return them to their normal position?
try to "milk" them back into place
so along with the linear FB pics, there was a pic of a STOMACH being held up with stay sutures...why?
bc need to CHECK PYLORUS for where the FB initially got stuck
what is the anderson technique?
once FB has been freed up, thread it /pass though tip of red rubber feeding catheter. try to push through normal digestive direction, and push path and you are stretching intestine. make sure no damage to mesenteric border or might get perforation. (milking cath from outside)
woah! what's going on in this radiograph?
if you press down on abd with a paddle you dec width and then get a more clear pic
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