Peritonitis

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Pyometra with secondary peritonitis in a bitch[1]
Peritonitis in a dog due to intussusception of the small intestine[2]
Laparoscopic view of a dog with encapsulating peritoneal sclerosis, showing how abdominal organs are invisible since they are encapsulated by a thick fibrous membranous tissue[3]

Peritonitis is an umbrella term for any inflammatory or infectious disease of the visceral lining (peritoneum) of the abdomen.

Regardless of cause, peritonitis in dogs usually involves the majority of the abdominal organs including the liver, stomach, intestines, spleen, kidney, reproductive organs and urinary bladder. In early stages, peritonitis is limited to regional inflammation of the serosal lining of affected organs (e.g. the uterus in pyometra), but as the condition worsens, multi-organ dysfunction occurs due to deteriorating hemodynamic changes caused by liberation of bacterial endotoxins.

Academically, peritonitis can be defined as either primary in origin or secondary to perforation of and leakage from gastrointestinal organs. It may also be classified as septic (bacterial, fungal, protozoal) or aseptic (inflammatory, e.g., encapsulating peritoneal sclerosis).

Causes of peritonitis include:

- Canine parvovirus
- Clostridium spp[18]
- Mycobacterium microti[19]
  • Secondary bacterial peritonitis - often secondary to gastrointestinal perforation
- Enterococcus spp
- Escherichia coli
- Pasteurella multocida
  • Secondary fungal peritonitis - commonly seen as post-operative infections
- Nocardia spp - granulomatous peritonitis
- Candida albicans[20]
- Ochroconis gallopavum[21]
- Blastomyces spp[22]
- Neospora spp (usually pups)[23]
- Leishmania spp[24]
- Mesocestoides spp[25]
- Echinococcus alveolaris[26]
- Spirometra spp[27]

Clinically affected dogs typically present with nonspecific symptoms which, depending on the cause, include depression, anorexia, tachycardia, tachpnea, vomiting and pain upon palpation of the abdomen. Fever is an inconsistent feature of this condition, as some patients with septic peritonitis may have progressed to hypothermia due to overwhelming sepsis. Mucous membranes are invariably pale and hypotension may be apparent in advanced cases.

Blood tests usually revealed a marked leucocytosis, neutrophilia (with a left shift or, if very severe, a degenerative right shift), hypoglycemia, hypomagnesemia, hypoalbuminemia and delayed clotting time, characterized by reduced platelet count, prothrombin time and activated partial thromboplastin time[28].

Radiography is usually unreliable, but may reveal evidence of pneumoperitoneum or free abdominal effusion. Thoracic radiography may be indicated to rule out concurrent conditions (e.g., metastatic disease, aspiration pneumonia) as complicating factors.

Percutaneous fluid aspiration (abdominocentesis) of the abdomen or diagnostic peritoneal lavage is frequently diagnostic. Serosanguinous fluid is commonly removed in inflammatory diseases, with an increased in nucleated cells (> 1 X 109 cells/L), presence of intracellular bacteria and elevated protein concentrations (> 25 g/L). The presence of amylase or lipase suggests pancreatitis, and the presence of bile is usually indicative of cholelithiasis or biliary tract rupture. The presence of elevated levels of creatinine and potassium in abdominal fluid may suggest a uroabdomen due to urolithiasis.

The use of serum markers such as C-type natriuretic peptide (serum NT-pCNP) have been shown to be poor indicators of septic peritonitis[29], but lactate concentrations in abdominocentesis fluid >2.5 mmol/L (and higher than the blood lactate concentration) is suggestive of septic peritonitis[30].

A presumptive diagnosis can be established on presenting clinical signs, blood tests, imaging studies (radiography, ultrasoography and CT) and abdominal fluid content. Peritoneal lavage is considered a rapid diagnostic tool in most cases.

In most cases of septic peritonitis, surgery is required. If surgery is not feasible, euthanasia is the most humane option.

Prior to surgical intervention, supportive treatment is critical for long-term survival, and includes nutritional support[31], intravenous fluids (with crystalloid and colloids at 90 mL/kg/hr), aggressive intravenous antimicrobial therapy (e.g. enrofloxacin and metronidazole), oxygen support, analgesia (e.g. buprenorphine at 0.005 - 0.02 mg/kg three times daily), intravenous canine-specific albumin[32] and peritoneal lavage[33].

In severe cases open abdominal drainage and closed suction drainage are required[34].

In certain breeds such as the Collie, Shetland Sheepdog, Australian Shepherd and Old English Sheepdog, a relative adrenal insufficiency may be a complication of septic peritonitis. This may require the administration of physiological levels of glucocorticoids, avoiding large doses which would compromise immunocompetency against bacteremia.

In hypotensive patients, the use of vasopressor agents such as dobutamine (2 - 20 µg/kg/min), dopamine (5 - 20 µg/kg/min) or vasopressin (0.01 - 0.1 U/kg as a bolus, followed by 0.001 - 0.1 U/kg/hr intravenously as constant rate infusion) should be considered. If hypotension persists, norepinephrine should be given at 0.05 - 3.3 µg/kg/min intravenously.

To guard against DIC, use of intravenous plasma (10 mL/kg intravenously over 3 - 4 hours), or low dose heparin may be warranted to replace spent clotting factors. Plasma is less effective than hetastarch for colloidal support alone.

Reliable indicators of survival include marked hyperkalemia, hypoalbuminemia, lymphopenia and intraoperative hypotension tend to have a poorer response[35] due to development endotoxemic shock and DIC.

The prognosis is generally guarded to poor in septic cases with systemic signs of secondary toxic shock[36].

References

  1. Vet Surgery Central
  2. Scialert
  3. Izawa T et al (2011) Encapsulating peritoneal sclerosis associated with abnormal liver development in a young dog. J Vet Med Sci 73(5):697-700
  4. Davis KM & Spaulding KA (2004) Imaging diagnosis: biliopleural fistula in a dog. Vet Radiol Ultrasound 45(1):70-72
  5. Hopper BJ et al (2004) Imaging diagnosis: pneumothorax and focal peritonitis in a dog due to migration of an inhaled grass awn. Vet Radiol Ultrasound 45(2):136-138
  6. Reed S (2002) Nonsteroidal anti-inflammatory drug-induced duodenal ulceration and perforation in a mature rottweiler. Can Vet J 43:971–972
  7. Hylands R (2006) Veterinary diagnostic imaging. Longitudinal intestinal perforation at the level of the proximal duodenum near the pylorus resulting in a septic peritonitis. Can Vet J 46(8):748-750
  8. Kook PH & Reusch CE (2011) Severe gastrointestinal bleeding secondary to lornoxicam in the dog. Schweiz Arch Tierheilkd 153(5):223-229
  9. Case JB et al (2010) Proximal duodenal perforation in three dogs following deracoxib administration. J Am Anim Hosp Assoc 46(4):255-8
  10. Ellison GW (2011) Complications of gastrointestinal surgery in companion animals. Vet Clin North Am Small Anim Pract 41(5):915-934
  11. Penninck D & Mitchell SL (2003) Ultrasonographic detection of ingested and perforating wooden foreign bodies in four dogs. J Am Vet Med Assoc 223(2):206-209
  12. Hickey MC & Magee A (2011) Gastrointestinal tract perforations caused by ingestion of multiple magnets in a dog. J Vet Emerg Crit Care (San Antonio) 21(4):369-374
  13. Beck JJ et al (2006) Risk factors associated with short-term outcome and development of perioperative complications in dogs undergoing surgery because of gastric dilatation-volvulus: 166 cases (1992-2003). J Am Vet Med Assoc 229(12):1934-1939
  14. Saulnier-Troff FG et al (2008) Acute gaseous peritonitis after rupture of a retroperitoneal rectal diverticulum in a dog. J Small Anim Pract 49(7):356-358
  15. Thompson LJ et al (2009) Characteristics and outcomes in surgical management of severe acute pancreatitis: 37 dogs (2001-2007). J Vet Emerg Crit Care (San Antonio) 19(2):165-173
  16. Escobar MC & Neel JA (2011) Pathology in practice. Gallbladder mucocele rupture, bile peritonitis, cholestasis, and liver inflammation and necrosis. J Am Vet Med Assoc 239(1):65-67
  17. Humm KR et al (2010) Uterine rupture and septic peritonitis following dystocia and assisted delivery in a Great Dane bitch. J Am Anim Hosp Assoc 46(5):353-357
  18. McConkey S et al (1997) Liver torsion and associated bacterial peritonitis in a dog. Can Vet J 38(7):438-439
  19. Deforges L et al (2004) First isolation of Mycobacterium microti (Llama-type) from a dog. Vet Microbiol 103(3-4):249-253
  20. Ong RK et al (2010) Candida albicans peritonitis in a dog. J Vet Emerg Crit Care (San Antonio) 20(1):143-147
  21. Singh K et al (2006) Fatal systemic phaeohyphomycosis caused by Ochroconis gallopavum in a dog (Canis familaris). Vet Pathol 43(6):988-992
  22. Nielsen C et al (2003) Diagnostic peritoneal lavage for identification of blastomycosis in a dog with peritoneal involvement. J Am Vet Med Assoc 223(11):1623-1627
  23. Holmberg TA et al (2006) Neospora caninum associated with septic peritonitis in an adult dog. Vet Clin Pathol 35(2):235-238
  24. Adamama-Moraitou KK et al (2004) Sclerosing encapsulating peritonitis in a dog with leishmaniasis. J Small Anim Pract 45(2):117-121
  25. Patten PK et al (2012) Cestode infection in 2 dogs: cytologic findings in liver and a mesenteric lymph node. Vet Clin Pathol Dec 31
  26. Stief B & Enge A (2011) Proliferative peritonitis with larval and cystic parasitic stages in a dog. Vet Pathol 48(4):911-914
  27. Drake DA et al (2008) Proliferative sparganosis in a dog. J Am Vet Med Assoc 233(11):1756-1760
  28. Bentley AM et al (2013) Alterations in the hemostatic profiles of dogs with naturally occurring septic peritonitis. J Vet Emerg Crit Care (San Antonio) 23(1):14-22
  29. DeClue AE et al (2011) Evaluation of serum NT-pCNP as a diagnostic and prognostic biomarker for sepsis in dogs. J Vet Intern Med 25(3):453-459
  30. Levin GM et al (2004) Lactate as a diagnostic test for septic peritoneal effusions in dogs and cats. J Am Anim Hosp Assoc 40(5):364-371
  31. Liu DT et al (2012) Early nutritional support is associated with decreased length of hospitalization in dogs with septic peritonitis: A retrospective study of 45 cases (2000-2009). J Vet Emerg Crit Care (San Antonio) 22(4):453-459
  32. Craft EM & Powell LL (2012) The use of canine-specific albumin in dogs with septic peritonitis. J Vet Emerg Crit Care (San Antonio) 22(6):631-639
  33. Swayne SL et al (2012) Evaluating the effect of intraoperative peritoneal lavage on bacterial culture in dogs with suspected septic peritonitis. Can Vet J 53(9):971-977
  34. Cioffi KM et al (2012) Retrospective evaluation of vacuum-assisted peritoneal drainage for the treatment of septic peritonitis in dogs and cats: 8 cases (2003-2010). J Vet Emerg Crit Care (San Antonio) 22(5):601-609
  35. Grimes JA et al (2011) Identification of risk factors for septic peritonitis and failure to survive following gastrointestinal surgery in dogs. J Am Vet Med Assoc 238(4):486-494
  36. Culp W & Holt D (2010) Septic peritonitis. Compend Contin Educ Vet 32(10):E1-E15
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