Peritonitis management - drainage question

Re: Peritonitis management - drainage question

Ronan Doyle — Tue, 09 Mar 2010 10:37:16 GMT

Hi Charlotte,

I've never used heparin so have no experience with it, but on the otherhand I have never had to use it. The fibrin buildup is a normal response to peritonitis - it is the peritoneal response to try to wall off the area from the rest of the peritoneal cavity but once the peritonitis is generalised the fibrin gets in the way. To ultimately deal with the fibrin I would feel you need to deal with the source of the peritonitis.

I would give the galbladder a squeeze when you are in surgery to see if you can see a source of leakage from the bilary tree - ligation of this may then be very challenging as it will depend on where the leakage is from - if it is a lobar bile duct then ligation would be fine but be careful of surrounding lobar vessels. If it is the common bile duct then this probably requires ligation and then bypass of the common bile duct with a cholecystoduodenostomy or possibly stent the common bile duct (this option isunproven in dogs however). If it is the cystic duct/gallbladder then ligate it and/or remove the gallbladder (this can be trickier then it initially looks and it is essential to stay very close to the gallbladdder when dissecting it off the quadrate lobe).

Re: Peritonitis management - drainage question

Charlie Lyon — Mon, 08 Mar 2010 20:20:44 GMT

Oooh - and reading up about managing peritonitis in fossum it mentioned heparin to help with fibrin build up. Is this any use?

Lavaged the abdomen really well and managed to remove most of the 'gunk' so hoping drains will stay relatively clear

Re: Peritonitis management - drainage question

Charlie Lyon — Mon, 08 Mar 2010 20:13:55 GMT

Thanks for the input. We don't have 24hr nursing so this is why we are reluctant to go for open peritoneal drainage - worried enough about a closed system! Will go for placing the drain up the liver end. The penrose drain is working quite well at the moment but know these can block easily.

I do think there is a problem with the bile system - a ruptured duct or something - but don't have the surgical knowledge or experience to fix it. Everything around the liver\stomach\duodenum is all adhesed to each other which is making things much more difficult. Her proteins are WNL at the moment, but I do fear the prognosis is poor - very frustrating!!!

Re: Peritonitis management - drainage question

Ronan Doyle — Mon, 08 Mar 2010 17:47:33 GMT

Hi Charlotte,

Sounds like a very challenging case.

Although you didn't see signs of leakage I would still be very suspicious that this is a bile peritonitis (your surgical description is very suggestive but cytologic examination of the fluid may help confirm this) and ultimately I would worry that this is still leaking. These can be very small leaks which may not be evident for a week or more due to a slow build-up of bile. The leak may be difficult to see especially as there is now established peritonitis. The risk now is that this is very susceptible to become a septic peritonitis as the pre-existing peritonitis strongly predisposes to this occurring and unfortunately surgery may introduce the bacteria. Other possibilities would be a duodenal ulcer - although you probably would see bacteria in your in-house cytology and the dog probably would have deteriorated more quickly. Bottom line though is that is very unlikely to be only due to a mild chemical peritonitis after the bladder rupture. The underlying cause will have to be dealt with to ultimately manage the peritonitis along with dealing with all the systemic problems associated with the peritonitis - no easy task!

Regarding the closed suction drain - I prefer a Jackson Pratt catheter attached to a suction grenade. The drain is placed in an area where the omentum can't easily block it (although this type of drain is quite resistant to blockage) - I usually place it in front of the liver, behind the diaphragm and then exit the tube mid abdomen.

Hope this helps

Ronan

Ronan Doyle MVB CertSAS MRCVS DipECVS

RCVS and European Specialist in Small Animal Surgery

Davies Veterinary Specialists

Manor Farm Business Park, Higham Gobion, Herts, SG5 3HR, United Kingdom

Tel: +44 1582 883950 Fax: +44 1582 883946

E-mail: rsd@vetspecialists.co.uk http://www.vetspecialists.co.uk

Re: Peritonitis management - drainage question

Rob Reid — Mon, 08 Mar 2010 17:39:07 GMT

Hi Charlotte

I am not sure how successful a closed drainage system will be if there is a lot of 'gunk' present. My concern would be that the drain would block with all the fibrin etc you are getting. Also theoretically closed drainage tubes aren't great for draining the whole peritineal cavity, much better for localised things I find - prostatic abscesses for example. And of course don't forget the whole issue of effectively having a foreign body in the abdomen...

You may be better to consider open peritoneal drainage if going for any drainage system, though if cost is an issue this can run up a sizeable bill with all the dressing changes, nursing care etc. If you are going for this, I tend to loosely suture the linea alba, leave the skin open and then use laparotomy swabs to dress the wound. To hold it all in place disposable nappies can be very useful depending on the size of the dog. Dressings need to be changed 2-4 times daily depending on how much discharge there is present. Your main complication with this tends to hypoalbuminaemia.

Obviously any case of peritonitis involves dealing with an removing the underlying cause which may be the issue in this case by the sound of things - does sound like a bile peritonitis in which case if you are going for a closed drain need to make sure you get it in the right spot - for reasons stated earlier. So I am not sure how successful any drainage system will be in this case if this can't be resolved. I tend to reserve peritoneal drainage for cases of contamination. Have you sent any of the abdominal fluid away for cytology? This can be quite helpful in getting to the bottom of the exact cause of the problem.

Sounds like a tough case, what with the pelvic fracture and all. Hope this helps.