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48 Cards in this Set

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  • Back
What is included in the pre-op work-up of an animal with stomach problems? (4)
1) Complete history and PE
2) Minimum database (CBC/ chem/ UA)
-electrolytes, acid/base status
3) Abdominal imaging,
Rads, aus, CT/MRI
4) Further testing based on initial results
What are the 4 general principles to operating on stomach/ GDV cases?
1) Stabilize patient pre-op
-dehydrated? anemic?
2) Peri-op antibiotics
-cefazolin
3) Post-op antibiotics only if indicated (continued source of contamination, gross spillage of ingesta etc.)-do culture!
4) Don't contaminate peritoneum
What are 4 ways to prevent contamination of peritoneum during abdominal surgery/ GDV repair?
1) Stay sutures
2) Lap sponges
3) Lavage
4) Separate instruments
Why is it so important to empty out the fluids used for lavage during abdominal surgery?
Neutrophils can't swim
What are 4 ways to assess the integrity of the GI tract?
1) Pink
2) Peristalsis
3) Palpation
-thick & edematous= not normal= biopsy
-thin=necrotic=perforates
4) Perfusion
-can you see pulsation?
What type of closure is used in the stomach? (include suture pattern)
Two layer closure
-simple continuous oversewn with inverting suture (lembert, cushing)
Where and how do you want to make your incision to remove a gastric foreign body?
-Gastrotomy in hypovascular area (pick area w/ less vessels)
-Stab with scalpel and extend w/ metzenbaums
What are the 2 layers the stomach separates into?
Serosal muscularis and mucosa/submucosa
Is a physical cause of a gastric ulceration very common? What are some examples?
No, they are very rare and ulceration only results if there's sustained significant trauma
-FB, implants
What are 6 examples of more common causes of gastric ulceration?
1) NSAIDs
2) steroids
3) shock
4) Helicobacter
-controversial
5) gastrinomas
6) Mast cell tumor
Compare the physical damage that results from a full VS partial thickness gastric ulceration?
-Full thickness--> expect septic peritonitis & ill patient
-Partial thickness--> anemia due to chronic blood loss (usually treat w/ medical management)
What is the treatment for a gastric ulceration that is too severe to treat with proper medical management?
Partial gastrectomy
-just cut around ulcer and sew together
What should always be on your mind when you see a penumoperitoneum on an X-ray? What diagnostic should you perform?
GI perforation
-Can tap the belly w/ 22g needle and if get gastric contents= diagnosis
What are the 4 most common types of neoplasia in the stomach******?
1) Adenocarcinoma
2) Lymphoma
3) Leiomyo(sarco)ma or fibrosarcoma
4) Mast cell tumors (less likely)
*What is the most common type of neoplasia in the canine stomach? Cats?
Adenocarcinoma= dogs
Lymphoma= cats
What do you need to make sure to differentiate a gastric leiomyosarcoma from?
GIST (gastric interstitial stromal tumor) because look very similar
-can use a stain to differentiate
*What is a biliroth 1 procedure?
a gastroenterostomy with no biliary re-routing (cholecystoenterostomy)
What is a biliroth II?
Gastroenterostomy with biliary re-
routing
-much more extensive resection
-high morbidity & mortality
*scares even good surgeon= refer
What breeds of dogs most commonly get gastric dilation & volvulus (GDV)?
Deep chested, large breed dogs
Others: Shar pei, bassets, cocker spaniels
What age of dogs are most affected by gastric dilation & volvulus?
Middled aged dogs (4,5,6+)
What are 7 common findings in the history of a dog with a GDV?
1) restlessness
2) retching
3) Non-productive vomiting
4) Hypersalivation
5) Distended abdomen
6) Weakness
7) collapse
*history= highly variable, anything from wagging tail to dead
What do you normally find on a physical exam of a dog with GDV? (several possibilities..)
-may be normal (abdomen may not be THAT distended, femoral pulses may be ok, may even be wagging tail)
-collapsed, in shock or dead
-or anywhere in b/w
What are the 4 standard clinicopathologic diagnostics used when you suspect a GDV?
1) Right lateral abdominal radiograph
-should also obtain an orthogonal view (VD)
2) CBC/ chem
3) Coagulation profile
5) BP & EKG
-consider 3 view thoracic rads
What do you see on a radiograph of a dog with GDV?
Backwards smurf
Why does the stomach get bruising (discoloration) when they have a GDV?
Because there are a bunch of vessels that are connected to the stomach and spleen and these tear---> spleen becomes hypovascular, thrombosis
What are the 4 primary ways that a GDV effects the body?
1) Thoracic and diaphragm impingement
-everything is distended--> decreased tidal flow --> V/Q mismatch
2) Decreased blood flow through caudal vena cava and portal vein (--> decreased CO)
3) Gastric ischemia --> perforation--> peritonitis
4) Intestinal ileus, atony --> fluid sequestration & electrolyte imbalance
What treatment should be done pre-op in a serious GDV case?
Stabilization--> IV CRYSTALLOIDS AND COLLOIDS
-antibiotics?
-anti-arrhythmics?
-analgesia/ premeds
What is the shock dose of crystalloids? Colloids?
Crystalloids: 60-90 mL/kg
Colloids: 20-30 mL/kg
Either before or after you open up the abdomen, what do you do need to do before entering the stomach?
Decompress the stomach
-either use a needle or stomach tubing to release air
What are the 3 main steps to surgically treating a GDV?
1) Gastric repositioning
2) Evaluate abdominal viscera
-if indicated perform splenectomy
-if indicated, perform partial gastrectomy
*when stomach twists it cuts off blood supply to spleen and stomach
3) Perform right sided gastropexy
If you pass a stomach tube before operating on a GDV patient, then the stomach is in the right position, should you still perform a gastropexy?
YES!
**When surgically treating a GD you should maintain vigilant monitoring of what?
Response to treatment and adjust fluid therapy as needed by monitoring BP and EKG monitoring are essential
What should you think if you open up the abdomen and all you see is a bunch of omentum?
Omentum should not be covering stomach, think of GDV bc stomach twisted
How is repositioning of the stomach performed in most cases of gastric dilation & volvulus?
Standing on the dog's right side and:
-pushing the fundus (which is nearest to you) dorsally and to the dog's left
-Pulling the pylorus (which is away from you, near the dog's left side) ventrally and towards you
-use a gentle but confident application of force
-often helpful if stomach is decompressed
How do you verify that you have correct positioning of the stomach after repositioning in cases of GDV?
By carefully palpating the esophageal hiatus
-some may have experienced a counter clockwise volvulus
When should you perform a splenectomy during repair of a GDV?
If spleen is thrombosed or vascularly devitalized
When should a partial gastrectomy performed during a GDV repair?
If stomach wall palpates thin, is excessively dark/black/ or white/grey = partial gastrectomy
Why doesn't Dr. Milovancev recommend a gastric invagination instead of a partial gastrectomy?
bc associated with chronic recurrent bleeding gastric ulcers and clinical anemia
What is the most common method of performing a right sided gastropexy?
Incisional
Should you avoid when performing an incisional ride sided gastropexy?
White fat line bc can cut into diaphragm
How do you perform an incisional right sided gastropexy?
Make incision through transverse abdominis and suture the serosa muscularis to the transverse abdominis muscle
What treatments should be occurring during the continuum of care from pre-op to intra-op to post-op in a GDV patient?
Aggressive volume expansio
-crystalloids at 90 ml/kg/day
-Hetastarch 30 ml/kg/day
-+/- plasma or other blood products
What type of monitoring needs to be performed post-op for a GDV patient?
-EKG, BP, emesis
-Bloodwork and lytes
-consider coags (DIC)
What analgesics should be used post-op in a GDV patient?
Opioids
-AVOID NSAIDS
What medication other than analgesics should be considered for a GDV patient post-op?
-Gastroprotectants (sucralfate +/- famotidine and/or omeprazole)
-antibiotics if suspect risk of bacterial translocation (if perforation otherwise not worth it bc causes vomiting)
-anti-emetics
What should be your post-op suggestions for feeding a post-op patient?
Encourage small frequent meals as soon as they can tolerate it
What is the prognosis for GDV?
Guarded to fair
-~30% mortality
What are 4 considerations of performing a prophylactic gastropexy?
1) Previous episode of GD?
-likelihood of GDV after episode is ~85%
2) Familial history of GDV?
3) At risk breed?
4) Working/ valuable dog?