Difference between revisions of "Peritonitis - Cats and Dogs"

Revision as of 19:18, 21 July 2010

Fibrinohaemorrhagic peritonitis in infectious canine hepatitis
Septic peritonitis caused by various agents, often Escherichia coli and anaerobic bacteria through perforation of the gut, rupture of urinary bladder or an abscess
Putrid peritonitis in uterine rupture with pyometra or septic metritis
Nocardia infection reults in profuse pink/red fluid due to blood and chronic inflammatory cells
Granulomatous peritonitis caused by fungi, Nocardia and Actinomyces

Cats

Putrid peritonitis in uterine rupture due to pyometra or fetal putrefaction
Peritonitis due to penetrating wounds
Septic peritonitis due to anaerobes in cat bite abscesses
Serous peritonitis in cats with feline infectious peritonitis especially in the wet form but exudate occurs also in the dry form
- Viscous, clear, pale to deep yellow fluid, may contain strands of fibrin

Description

Peritonitis is defined as the inflammation of the peritoneum. The inflammatory response involves vasodilation, exudation of protein-rich fluid, cellular infiltration, pain and, chronically, formation of fibrous adhesion. The disease can be classified into primary and secondary cases.

Primary peritonitis occurs spontaneously without any pre-existing pathological process in the abdomen. In cats, feline infectious peritonitis is the most common cause of primary peritonitis.

Secondary peritonitis occurs as the result of a pre-existing pathological process within the abdomen. It be further classified into septic or non-septic peritonitis, where septic peritonitis results from direct bacterial infection of the peritoneal cavity. Septic peritonitis is the most common form in the dog and its causes include:

Perforation of the gastro-intestinal tract due to foreign bodies, intussuscepta, invasive neoplasia or dehiscence of surgical wounds or biopsy sites. Peritonitis as a result of wound dehiscence is most likely to occur 3-5 days post-operatively.
Penetration of the abdomen by a stick, gunshot or other foreign body.
Rupture of an infected uterus (pyometra), biliary tract or urinary tract.

Non-septic peritonitis may occur due to the leakage of bile, urine or pancreatic enzymes (chemical peritonitis) or due to the presence of foreign substances such as barium or glove powder (physical peritonitis). In some cases of urinary tract or biliary tract rupture, septic peritonitis may occur if the tracts were previously infected.

Diagnosis

Clinical Signs

Abdominal pain
Depressed
Vomiting
Diarrhoea
Hypotension and shock
Hypothermia or hyperthermia

Laboratory Tests

Haematology

Leucocytosis; predominantly neutrophilia ± left shift or neutropaenia
Haemoconcentration
Hypoproteinaemia

Biochemistry

Hypoglycaemia - possible sepsis
Increased lactate concentration
Azotaemia
Hypokalaemia
Metabolic acidosis

Diagnostic Imaging

Radiography

Abdominal radiography may reveal free gas in the abdomen. This is highly suggestive of peritonitis. The visceral details are loss. If radiograph is taken with the patient standing, a fluid line may be seen.
Thoracic radiograph should be assessed for signs of metastatic disease.

Ultrasonography

This is sensitive to detect free fluid in the abdomen.
Possible causes such as abscesses of organs or rupture of gall bladder can be identified.
It can be used to assist abdominocentesis.

Histopathology

Abdominal fluid can be collected for laboratory analysis via abdominocentesis. The fluid should be stained for intracellular bacteria and assessed for:
- amylase and lipase for pancreatitis
- bile for biliary leak
- creatinine for urine
- glucose (<2.8 mmol/l) and lactate (>5.5 mmol/l) for sepsis

Treatment

It is vital to identify cases which require emergency surgical intervention. Any of the following is a major indication:

positive for intracellular bacteria.
free gas visible in the abdominal radiograph.
presence of penetrating injuries in the abdomen.

Medical

Fluid therapy

Aggressive fluid therapy with crystalloid and colloid should be given on initial presentation to improve haemodynamic parameters.
Fluid therapy is also very important in the postoperative period. Both crystalloid and colloid should be continued until the patient is normotensive. However, if hypotension continues, a vasopressor such as vasopressin should be considered.
Supplementaion of glucose and potassium may be needed.
If severe metabolic acidosis is present, bicarbonate may be given.
Septic peritonitis can cause disseminated intravascular coagulation (DIC) and therefore plasma can be given to replace clotting factors.

Antimicrobial

Broad spectrum antibiotics should be given, preferably following culture and sensitivity test. Escherichia coli, Clostridium spp. and Enterococcus spp. are most commonly isolated.

Surgery

This may be indicated if the cause of peritonitis is undetermined or intestinal rupture or intestinal obstruction or mesenteric avulsion is suspected. Abdominal lavage is controversial due to the possibility of dissemination of infection. It is indicated in cases of generalised peritonitis but care has to be taken in cases of localised peritonitis. As much of the fluid used for lavage has to be drained as it will hinder the body’s immune system otherwise.

Prognosis

Guarded. Peritonitis is a multifactorial disease and the consequence is fatal in most cases. A rapid diagnosis and treatment may improve the prognosis.

References

Fossum, T. W. et. al. (2007) Small Animal Surgery (Third Edition) Mosby Elsevier
Nelson, R.W. and Couto, C.G. (2009) Small Animal Internal Medicine (Fourth Edition) Mosby Elsevier.
Tilley, L. P. & Smith, F. W. K. (2007) Blackwell's Five-minute Veterinary Consult: Canine & Feline (Fourth Edition) Blackwell Publishing

For further information on peritonitis see: [1] In Pra

@@ Line 1: / Line 1: @@
-{{OpenPagesTop}}
+{{unfinished}}
-==Introduction==
-'''Peritonitis''' is defined as inflammation of the [[Peritoneal Cavity - Anatomy & Physiology|peritoneum]]. The inflammatory response involves vasodilation, [[Exudate|exudation]] of protein-rich fluid, cellular infiltration, pain and, chronically, formation of fibrous adhesion. The disease can be classified into primary and secondary cases.
-'''Primary peritonitis''' occurs spontaneously without any pre-existing pathological process in the abdomen. In cats, [[Feline Infectious Peritonitis |feline infectious peritonitis]] is the most common cause of primary peritonitis.
+*Fibrinohaemorrhagic peritonitis in infectious canine hepatitis
+*Septic peritonitis caused by various agents, often [[Escherichia coli|''Escherichia coli'']] and anaerobic bacteria through perforation of the gut, rupture of [[Urinary Bladder - Anatomy & Physiology|urinary bladder]] or an abscess
+*Putrid peritonitis in uterine rupture with pyometra or septic metritis
+*''[[:Category:Nocardia species|Nocardia]]'' infection reults in profuse pink/red fluid due to blood and chronic inflammatory cells
+*Granulomatous peritonitis caused by [[Fungi|fungi]], ''[[:Category:Nocardia species|Nocardia]]'' and ''[[:Category:Actinomyces|Actinomyces]]''
-'''Secondary peritonitis''' occurs as the result of a pre-existing pathological process within the abdomen. It can be further classified into '''septic''' or '''non-septic''' peritonitis, where septic peritonitis results from direct bacterial infection of the peritoneal cavity. Septic peritonitis is the most common form in the dog and its causes include:
+===Cats===
-*'''Perforation of the gastro-intestinal tract''' due to foreign bodies, [[Intussusception|intussuscepta]], invasive [[Neoplasia - Pathology|neoplasia]], deep ulceration or dehiscence of surgical wounds or biopsy sites. Peritonitis as a result of wound dehiscence is most likely to occur 3-5 days post-operatively.
-*'''Penetration of the abdomen''' by a stick, gunshot or other foreign body.
-*Rupture of an infected uterus ('''pyometra'''), [[Biliary Tract Rupture|biliary tract]] or urinary tract.
-The bacteria causing septic peritonitis or their products may spread systemically causing sepsis or endotoxaemia.
+*Putrid peritonitis in uterine rupture due to pyometra or fetal putrefaction
+*Peritonitis due to penetrating wounds
+*Septic peritonitis due to anaerobes in cat bite abscesses
+*Serous peritonitis in cats with [[Feline Infectious Peritonitis|feline infectious peritonitis]] especially in the wet form but exudate occurs also in the dry form
+**Viscous, clear, pale to deep yellow fluid, may contain strands of fibrin
-'''Non-septic''' peritonitis may occur due to the leakage of bile, urine or pancreatic enzymes ('''chemical peritonitis''') or due to the presence of foreign substances such as barium or glove powder ('''physical peritonitis'''). In some cases of urinary tract or biliary tract rupture however, septic peritonitis may occur if the tracts were previously infected.
+==Description==
+'''Peritonitis''' is defined as the [[Inflammation - Pathology|inflammation]] of the [[Peritoneal cavity - Anatomy & Physiology|peritoneum]].  The inflammatory response involves vasodilation, [[Exudate|exudation]] of protein-rich fluid, cellular infiltration, pain and, chronically, formation of fibrous adhesion.  The disease can be classified into primary and secondary cases.
-==Clinical Signs==
+'''Primary peritonitis''' occurs spontaneously without any pre-existing pathological process in the abdomen.  In cats, [[Feline Infections Peritonitis (FIP)|feline infectious peritonitis]] is the most common cause of primary peritonitis.
-The clinical signs are related to the presence of severe inflammation within the body cavity, with or without systemic infection.
-*'''Abdominal pain''', manifesting as a reluctance to move due to inflammation of the parietal peritoneum.
-*'''Depression''', anorexia and lethargy and non-specific signs of infection or systemic disease.
-*[[Vomiting|'''Vomiting''']] and [[Diarrhoea|'''diarrhoea''']] may occur due to alterations in intestinal motility and functional ileus.
-*'''Hypotension''' and (septic) [[Shock|'''shock''']] due to effusion of fluid into the peritoneum and systemic vasodilation.
-*'''Hypothermia''' or '''hyperthermia'''.
-==Laboratory Tests==
+'''Secondary peritonitis''' occurs as the result of a pre-existing pathological process within the abdomen.  It be further classified into '''septic''' or '''non-septic''' peritonitis, where septic peritonitis results from direct bacterial infection of the peritoneal cavity.  Septic peritonitis is the most common form in the dog and its causes include:
-===Haematology===
+*'''Perforation of the gastro-intestinal tract''' due to foreign bodies, [[Intussusception|intussuscepta]], invasive [[Neoplasia - Pathology|neoplasia]] or dehiscence of surgical wounds or biopsy sites.  Peritonitis as a result of wound dehiscence is most likely to occur 3-5 days post-operatively.
-As with any severe inflammatory process, '''leucocytosis''' will occur. Initially, this is caused by '''[[neutrophilia]]''' which may have a left shift or, if very severe, a degenerative right shift. Severe localised inflammation may stimulate a '''leukaemoid response''' with massive mobilisation of neutrophils from the bone marrow pools.
+*'''Penetration of the abdomen''' by a stick, gunshot or other foreign body.
+*Rupture of an infected uterus ('''pyometra'''), biliary tract or urinary tract.
-'''Haemoconcentration''' (causing a raised packed cell volume (PCV) and total protein concentration) may occur due to loss of extracellular fluid.
+'''Non-septic''' peritonitis may occur due to the leakage of bile, urine or pancreatic enzymes ('''chemical peritonitis''') or due to the presence of foreign substances such as barium or glove powder ('''physical peritonitis''').  In some cases of urinary tract or biliary tract rupture, septic peritonitis may occur if the tracts were previously infected.
-===Biochemistry===
+==Diagnosis==
-'''Hypoproteinaemia''' may occur due to loss of plasma proteins into the inflammatory [[Exudate|exudate]].
+===Clinical Signs===
+*Abdominal pain
+*Depressed
+*[[Stomach and Abomasum Consequences of Gastric Disease - Pathology|Vomiting]]
+*[[Diarrhoea|Diarrhoea]]
+*Hypotension and [[Shock - Pathology|shock]]
+*Hypothermia or hyperthermia
-'''Hypoglycaemia''' may occur in cases of septic peritonitis.
-Dehydration (which is also responsible for the haemococentration) may also result in pre-renal [[Azotaemia|azotaemia]], increased tissue '''lactate''' production and '''metabolic acidosis'''.
+===Laboratory Tests===
+====Haematology====
+*Leucocytosis; predominantly neutrophilia ± left shift or neutropaenia
+*Haemoconcentration
+*Hypoproteinaemia
-'''Hypokalaemia''' may occur as a result of chronic vomiting and it may contribute to the intestinal ileus which often develops in cases of peritonitis.
+====Biochemistry====
+*Hypoglycaemia - possible sepsis
+*Increased lactate concentration
+*Azotaemia
+*Hypokalaemia
+*Metabolic acidosis
-==Diagnostic Imaging==
-===Radiography===
-'''Plain radiographs of the abdomen''' may reveal the presence of free gas in the abdomen ('''pneumoperitoneum''') due to intestinal perforation or bacterial production. The normal serosal detail may be effaced due to the presence of an abdominal effusion and, if a horizontal beam decubitus radiograph is made, a '''fluid line''' may be apparent.
-In cases where neoplasia is thought to be the cause of the inflammatory process, thoracic radiograph should be assessed for signs of metastatic disease.
+===Diagnostic Imaging===
+====Radiography====
+*Abdominal radiography may reveal free gas in the abdomen.  This is highly suggestive of peritonitis. The visceral details are loss.  If radiograph is taken with the patient standing, a fluid line may be seen.
+*Thoracic radiograph should be assessed for signs of metastatic disease.
-===Ultrasonography===
+====Ultrasonography====
-This modality has a high sensitivity for the detection of free fluid in the abdomen and it may be used to identify some specific causes of peritonitis, including abscesses of organs or [[Biliary Tract Rupture|rupture of the biliary tract]].
+*This is sensitive to detect free fluid in the abdomen.
+*Possible causes such as abscesses of organs or rupture of [[Gall Bladder - Anatomy & Physiology|gall bladder]] can be identified.
+*It can be used to assist abdominocentesis.
-Ultrasound scans can also be used to guide '''abdominocentesis'''.
-===Other Tests===
+===Histopathology===
-Free abdominal fluid can be collected under ultrasound guidance and submitted for cytological analysis. If fluid cannot be obtained on aspiration, '''diagnostic peritoneal lavage''' can be performed by instilling a small volume (~20 ml/kg) of warmed isotonic crystalloid into the abdomen, agitating the abdomen and then re-aspirating this fluid. Grossly, the fluid may contain vegetable fibres if the gastro-intestinal tract has ruptured or it may be evidently green (indicating the presence of bile) or haemorrhagic. On cytological examination, the sample should be assessed for the presence of neutrophils (and other leucocytes) with intracellular bacteria. If motile organisms are observed when examining your sample microscopically, this is a good indication that you have accidentally taken a sample of intestinal contents.
+*Abdominal fluid can be collected for laboratory analysis via abdominocentesis.  The fluid should be stained for intracellular bacteria and assessed for:
+**amylase and lipase for [[Pancreatitis - Dog and Cat|pancreatitis]]
+**bile for biliary leak
+**creatinine for urine
+**glucose (<2.8 mmol/l) and lactate (>5.5 mmol/l) for sepsis
-Further possible tests include:
-*Measurement of '''amylase''' and '''lipase''' where the cause is suspected to be [[Pancreatitis|pancreatitis]]
-*'''Bile''' where [[Biliary Tract Rupture|biliary tract rupture]] is suspected.
-*'''Creatinine''' and '''potassium''' if the effusion is thought to be a uroabdomen; creatinine levels in a peritoneal sample that are higher than serum concentrations indicate uroperitoneum.
-*'''Glucose''' and '''lactate''' should be measured; where their values are <2.8 mmol/l and >5.5 mmol/l respectively the inflammation is likely to be septic.
-Lactate levels are indicative of a hypoxic crisis and levels are occasionally used as a prognostic indicator - rising levels in the face of vigorous treatment of peritonitis seem to be anecdotally  more prognostically useful than absolute cut off values. NB. Measurement of lactate on some machines such as hand held blood gas analysers may require a heparin sample.
-*Culture is indicated where a bacterial infection is suspected, and should include an anaerobic culture.
-In cats with [[Feline Infectious Peritonitis]], the effusion usually has a high protein content (>35g/l) with a high globulin: albumin ratio.  There is a variably high cellularity mainly composed of lymphocytes.
 ==Treatment==
-It is vital to identify severe cases promptly as these will require emergency surgical intervention. Any of the following criteria is a major indication for surgery:
+It is vital to identify cases which require emergency surgical intervention.  Any of the following is a major indication:
-*Presence of intracellular bacteria in leucocytes in the abdominal exudate
+*positive for intracellular bacteria.
-*Pneumoperitoneum
+*free gas visible in the abdominal radiograph.
-*Presence of penetrating injuries to the abdomen.
+*presence of penetrating injuries in the abdomen.
-===Medical Management===
+===Medical===
-====Fluid Therapy====
+====Fluid therapy====
-Aggressive [[Principles of Fluid Therapy|fluid therapy]] with [[Crystalloids|crystalloid]] and [[Colloids|colloid]] should be given on initial presentation to improve haemodynamic parameters and this should be maintained into the peri- and post-operative periods where appropriate and until the patient is normotensive. If the patient remains hypotensive, the use of a vasopressor such as [[Interventional_Agents#Dobutamine|dobutamine]], [[Interventional_Agents#Dopamine|dopamine]] or even [[Interventional_Agents#Vasopressin|vasopressin]] should be considered as animals in septic shock are likely to have systemic peripheral vasodilation.
+*Aggressive fluid therapy with [[Crystalloids|crystalloid]] and [[Colloids|colloid]] should be given on initial presentation to improve haemodynamic parameters.
+*Fluid therapy is also very important in the postoperative period.  Both crystalloid and colloid should be continued until the patient is normotensive.  However, if hypotension continues, a vasopressor such as [[Vasopressin|vasopressin]] should be considered.
+*Supplementaion of glucose and potassium may be needed.
+*If severe metabolic acidosis is present, bicarbonate may be given.
+*Septic peritonitis can cause [[Disseminated Intravascular Coagulation|disseminated intravascular coagulation (DIC)]] and therefore plasma can be given to replace clotting factors.
-Glucose and potassium should be supplemented where these parameters are found to be abnormal and, in cases of severe metabolic acidosis, the use of sodium bicarbonate may be considered. This product should be used with care as overdoses may result in overshoot metabolic alkalosis, tissue anoxia due to a left-shift of the haemoglobin-oxygen dissociation curve and paradoxical cerebral acidosis as carbon dioxide (not bicarbonate) crosses the blood brain barrier.
+====Antimicrobial====
+*Broad spectrum antibiotics should be given, preferably following culture and sensitivity test.  [[Escherichia coli|Escherichia coli]], [[:Category:Clostridium species|Clostridium spp.]] and Enterococcus spp. are most commonly isolated.
-Septic peritonitis can cause [[Disseminated Intravascular Coagulation|disseminated intravascular coagulation (DIC)]] which represents a very large therapeutic challenge. Plasma may be administered to replace used clotting factors and some authors advocate the use of low doses of heparin to prevent further coagulation.
+===Surgery===
+This may be indicated if the cause of peritonitis is undetermined or intestinal rupture or intestinal obstruction or mesenteric avulsion is suspected.   Abdominal lavage is controversial due to the possibility of dissemination of infection.  It is indicated in cases of generalised peritonitis but care has to be taken in cases of localised peritonitis.  As much of the fluid used for lavage has to be drained as it will hinder the body’s immune system otherwise.
-====Antimicrobial Drugs====
-Broad spectrum bactericidal antibiotics should be administered and, where possible, the choice of product should then be guided by culture and sensitivity of samples of peritoneal fluid. [[Escherichia coli|''Escherichia coli'']], [[:Category:Clostridium species|''Clostridium spp.'']] and ''[[Enterococcus faecalis]]'' are the species most commonly isolated in cases of septic peritonitis.
-===Surgical Management===
+==Prognosis==
-Surgical intervention is indicated if the cause of peritonitis is undetermined or if it has been caused by intestinal rupture, intestinal obstruction or mesenteric avulsion. Abdominal lavage is a controversial procedure as it carries a risk of disseminating infection throughout the body and it is therefore indicated in cases of generalised peritonitis but should be used with care in cases of localised peritonitis.  A volume of around 200 ml/kg fluid should be used to lavage the abdomen and as much of this fluid as possible should be re-aspirated as its continued presence will hinder the immune system by diluting bactericidal factor and preventing leucocyte migration.
+Guarded.  Peritonitis is a multifactorial disease and the consequence is fatal in most cases.  A rapid diagnosis and treatment may improve the prognosis.
-It is beneficial to maintain peritoneal drainage after lavage by either '''open''' or '''closed''' drainage. Open drainage involves leaving part of the abdominal wall loosely sutured so that peritoneal fluid can leak out under gravity. The wound must be dressed under sterile conditions and there is a high risk of ascending infection and of continued protein loss with this technique.
-Closed drainage involves implanting a drain into the abdomen (often a '''Jackson Pratt drain''') to which suction can be applied to aspirate fluid from the peritoneal cavity. The drain usually has multiple fenestrations along its length so that it does not become blocked by omentum or fat.
-==Prognosis==
-Guarded. Peritonitis is a multifactorial disease and the consequence is fatal in most cases. A rapid diagnosis and treatment may improve the prognosis but it is generally poor in cases of septic peritonitis.
-{{Learning
-|Vetstream = [https://www.vetstream.com/felis/search?s=peritonitis Peritonitis]
-|literature search = [http://www.cabdirect.org/search.html?q=title%3A%28peritonitis%29+AND+od%3A%28cats%29+ Peritonitis in cats publications]
-[http://www.cabdirect.org/search.html?q=title%3A%28peritonitis%29+AND+od%3A%28dogs%29+ Peritonitis in dogs publications]
-}}
 ==References==
-*Ettinger, S.J, Feldman, E.C. (2005) '''Textbook of Veterinary Internal Medicine''' (6th edition, volume 2) Elsevier Saunders Company
 *Fossum, T. W. et. al. (2007) '''Small Animal Surgery (Third Edition)''' ''Mosby Elsevier''
 *Nelson, R.W. and Couto, C.G. (2009) '''Small Animal Internal Medicine (Fourth Edition)''' ''Mosby Elsevier''.
 *Tilley, L. P. & Smith, F. W. K. (2007)  '''Blackwell's Five-minute Veterinary Consult: Canine & Feline (Fourth Edition)''' ''Blackwell Publishing''
-For further information on peritonitis see the following In Practice article on SA Peritonitis: [http://inpractice.bvapublications.com/cgi/reprint/26/7/358 maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=haemoabdomen&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT]
+For further information on peritonitis see: [http://inpractice.bvapublications.com/cgi/reprint/26/7/358?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=haemoabdomen&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT] In Pra
+[[Category:Peritoneal_Cavity_-_Inflammatory_Pathology]]
-{{review}}
+[[Category:To_Do_-_James]]
-{{OpenPages}}
-[[Category:Peritoneal_Cavity_-_Inflammatory_Pathology]]
-[[Category:Expert Review]][[Category:Peritoneal Cavity Diseases - Cat]][[Category:Peritoneal Cavity Diseases - Dog]]