GI III

Created by kenzo19 

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clinical signs

intestinal FB - _______ determined by: location of FB, degree of obstruction, moving vs stationary, integrity of intestinal wall (ulceration or perforation)

linear foreign bodies

intestine - more common in cats; sewing thread, yarn, string, tinsel; clinical signs occur when the foreign body becomes fixed at some point cranially typically around tongue or at pylorus

tongue pylorus

two typical locations for linear foreign bodies to become fixed

linear foreign bodies

clinical signs and physical exam findings - vomiting, depression, abdominal pain (posture, gait, guarding on palpation), palpable bunching of intestines in central abdomen, check under tongue

oral exam

linear FB - ______ - examine oral cavity closely - FB can become embedded in mucosa and not be easily visualized

linear foreign body

intestinal plication with eccentric air bubbles

linear foreign body

sx mgmt - free FB cranially by removing from base of tongue or performing gasrotomy; examine mesenteric border of intestine for perforations; remove FB through enterotomy(ies)

red rubber catheter

may be an option for small diameter linear foreign bodies - if you can ID the proximal and distal ends - minimizes the number of enterotomies req'd

perforation

linear foreign body - if there is a rough appearance to intestines - look for _________

linear foreign bodies

complications - impaired intestinal fxn secondary to inflammatory changes; short bowel syndrome with extensive resection

non linear foreign bodies

sx mgmt - complete exploratory; removal through enterotomy aboral (distal) to foreign body most commonly recommended, but if it is easier to remove proximal, do it

pinch intestine to stimulate peristalsis

what is most reliable method to evaluate intestinal viability?

intussusception

more common in dogs; young (<1 yr); identify underlying cause; clinical signs influenced by location and degree of obstruction

intussusceptum

part of the intussusception that telescopes into the other

intussuscipiens

part of the intussusception that telescopes over the other

ileocolic jxn

most common location for intussusception to form

intussusception

common locations - ileocolic jxn, ileum, jejunum, cecum (inversion), duodenum, colon

intussusception

sx mgmt - attempt manual reduction; assess viability if successful; resection and anastomosis (irreducible, nonviable)

fibrin seal development

what process in the pathology of an intussusception will make it hard to manual reduce it?

tear

complication of manual reduction of intussusception

intestinal plication

prevent recurrence of intussusception; plicate entire small intestine; avoid tight turns; complications - obstruction, strangulation, perforation

intestinal plication

suture intestinal loops together at 3-5 cm intervals with interrupted sutures placed along lateral wall; use absorbable suture material such as poliglecaprone 25 (monocryl)

opioids

lower rates of recurrence of intussusception recently may be due to increased use of ________

25%

intussusception recurrence rate up to _____ without plication

intestinal plication

____________ considerations - caution in very young patients with significant growth potential remaining; if done, plicate from duodenocolic to ileocolic jxn; surgeon preference

colorectal

most common location for intestinal neoplasia in the dog?

small intestine

most common location for intestinal neoplasia in the cat?

leiomyoma/sarcoma adca lsa

(3) most common intestinal neoplasias in dogs

duodenal polyps Adca lsa

(3) most common intestinal neoplasias in cats

chemotherapy

preferred tx for LSA

regional lnn liver

intestinal neoplasia staging is done by checking (2)

surgical excision

with the exception of LSA what is the treatment of choice for intestinal neoplasias

focal

intestinal neoplasia - which form of LSA has a better prognosis?

excellent

what is the prognosis for benign intestinal neoplasia with complete excision?

10 months

MST for intestinal AdCA in dogs

2 years

MST for intestinal AdCA in cats

1 year

MST for intestinal leiomyosarcoma

intestinal

principles of ________ sx - minimize contamination - pack off affected area, occlude intestine proximal and distal with intestinal forceps or fingers (if intestines are empty occlusion is not mandatory and decreases manipulation / trauma; decompress dilated bowel loops; local lavage unless generalized contamination; gentle tissue handling

viability

intestine - assessment of ________ - pink, moist glistening color; pulsation of mesenteric vessels; bleeding from cut surface; peristalsis - pinch test; Fluoroscein dye injected IV

intestines

suturing principles - sutures must penetrate submucosa, modified gambee pattern, simple interrupted or simple continuous pattern, monofilament absorbable suture material

intestinal

______ biopsy - full thickness biopsy wide enough that all layers remain intact - 3-4 mm wide; techniques - longitudinal biopsy w/ longitudinal closure, longitudinal biopsy w/ transverse closure (dont do), TRANSVERSE BIOPSY, dermal punch

transverse wedge biopsy

intestines - full thickness wedge 3-4 mm wide taken perpendicular to long axis of intestine; wedge should not be >20-25% of circumference

resection and anastomosis

principles of intestinal ___________ - pack off affected segment, determine extent of excision and ligate blood supply, occlude proximal and distal segments as atraumatically as possible, minimize mucosal eversion, begin anastomosis at mesenteric border, interrupted or continuous suture pattern, close rent in mesentery, wrap anastomosis with omentum

more control more traumatic

adv / disadv of using scissors to cut intestines

angling cut

intestinal R&A - ______ enlarges lumen size initially to acct for the 10-20% narrowing which typically occurs during healing

mucosal eversion

intestines - minimize manipulation - to minimize _____________ - which increases risk of infection and adhesion formation

mesenteric

intestinal R&A - begin anastomosis at _________ border; leakage most common at this site - no serosa; fat in mesentery impairs visualization

close tightly at tips

important quality of staples when doing an intestinal R&A

angle

intestinal R&A - cutting the smaller diameter segment at an ______ may reduce disparity and facilitate anastomosis

omentum

the ________ is very important in reducing the risk of wound healing problems after intestinal surgery

serosal patch

done when omentum is not available; reinforcement of suture lines in questionable tissue - enterotomy, colotomy, urinary bladder; induces permanent adhesion much stronger than omentum

large intestine

sx of the _________ - principles same as small intestine but differences - high bacterial population, healing, blood supply

collagenase

due to high _______ population the LI heals differently than the SI - sutures will be the only thing holding it together for the first few days

cecum

dz of the _____ - cecal inversion, cecal dilatation, cecal impaction, neoplasia

cecal inversion

cecal intussusception; chronic diarrhea with hematochezia (melena)

cecal inversion

tx - attempt manual reduction, expose through colotomy if irreducible; typhlectomy

megacolon

increased diameter associated with chronic constipation (obstipation); causes - colonic inertia, outlet obstruction

idiopathic megacolon

most common in cats; middle to old age; colonic smooth muscle dysfunction

idiopathic megacolon

dx - hx - increased time in litter box; PE - wt loss, poor coat, ADR, grossly distended colon; radiography, rule out medical causes of colonic inertia

idiopathic megacolon

tx - deobstipate; dietary modification; stool softeners; motility modifiers - cisapride from compounding pharmacies; subtotal colectomy

subtotal colectomy

goal is to remove as much colon as possible - colocolostomy, ileocolostomy

subtotal colectomy

post operative course - diarrhea (4wks to months, may persist in dogs); soft formed stools; increased frequency of defecation; potential complications - SIBO with ileocolostomy, intermittent constipation

intestinal

post op care of ________ sx patients - taper fluid and electrolyte therapy as oral intake returns to normal; offer food and water the day after sx unless contraindicated; pain mgmt

GI

post op monitoring of ____ sx patients - most complications first 3-5 days; general attitude, MM, abdominal palpation, temperature BID to TID, cbc, abdominocentesis or DPL (diagnostic peritoneal lavage), US, re-exploration

intestinal

complications following ______ sx - ileus, adhesions, obstruction - intussusception, entrapment, stenosis, dehiscence, peritonitis, short bowel syndrome

dehiscence

risk factors for ________ after intestinal sx - multiple intestinal procedures, pre-existing peritonitis, underlying cause (trauma, FB), lack of omentum

dehiscence

intestinal - overall rate <10%; mortality rate >80%; not influenced by: suture material, suture pattern

rectum

dz of the _______ - rectal prolapse, rectal stenosis / stricture, neoplasia

anus and perianal area

dz of the ___________ - anal sac (impaction, inflammation/abscess, neoplasi), anus (imperforate anus, stenosis/stricture), perianal (inflammation [fistula], hyperplasia, neoplasia)

complete

rectal prolapse - all layers

incomplete

rectal prolapse - only mucosa

rectal prolapse

secondary to tenesmus - rectal / anal disease, urogenital disease

prolapsed intussusception

what is the primary differential for rectal prolapse?

rectal prolapse

tx - identify and treat underlying cause, reduce and place purse-string suture if viable, amputate if nonviable, coloplexy if recurrent

amputation

_____ of rectal prolapse - need to control inner portion; use a tube inserted with straight needle passed through to prevent it from sucking back into rectum; interrupted sutures to allow for stretch

amputation

complications after rectal prolapse ________ - infection, dehiscence, stricture, recurrence

coloplexy

indications - recurrent rectal prolapse, perineal hernia; techniques - suture - absorbabl / non absorbable; for incisional, use absorbable

incisional coloplexy

descending colon - apply cranial traction; similar to incisional gastropexy; incision through seromuscular layers of colon and transversus abdominus of body wall; can perform in more than one spot on descending colon

adenomatous polyps leiomyoma fibroma

benign colorectal neoplasia (3)

adca leiomyosarcoma lsa

malignant colorectal neolplasia (3)

rectal adenomas

c/s - hematochezia, tenesmus / dyschezia, visible mass (may be intermittent); presentation - most occur in distal rectum - polyploid, sessile, multiple

rectal adenomas

diagnosis - direct observation, rectal palpation, proctoscopy / colonscopy; biopsy - incisional v excisional - always submit excised masses even when pre-op biopsy is performed - up to 25% will come back as a more aggressive tumor (carcinoma in situ, invasive Adca)

rectal adenoma

tx - sx excision - transanal, dorsal approach, mucosal resection; cryosurgery - cant evaluate margins, cant confirm dx

rectum colorectal jxn

surgical approaches to the _______ and ________ - transanal, dorsal approach, rectal pull-through (modified, swenson's pull-through [lesions that extend beyond peritoneal reflection into abdominal cavity])

transanal approach

epidural block; limited to lesions in the caudal 4-6 cm of the rectum

rectal

complications of ______ sx - dehiscence, infection, stricture, incontinence (sphincteric, sensory)

anal sac dz

________ - anal sac impaction, anal sacculitis, anal sac abscess; common problem, small dogs (poodles, chihuahua); rare in cats

anal sacculectomy

manage infected or abscessed glands medically until inflammation resolves; anal sacs lie within external anal sphincter; open and closed techniques

closed anal sacculectomy

use blunt probe or instrument; paraffin injection; catheter - to delineate it, make incision parallel to muscle fibers

open anal sacculectomy

insert one blade of scissors into sac; apply upward pressure to tips to minimize tissue cut OR insert groove director or probe through duct into anal sac; incise over instrument with caudal tension on instrument to minimize damage to sphincter; dissect anal sac from anal sphincter

anal sacculectomy

complications - infection, draining tracts - incomplete removal of anal sac, must excise to resolve; fecal incontinenc

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