Abdominal pain

Question 1

What is an acute abdominal crisis?

Answer 1

• an animal presented as an emergency, in a more or less severe critical state, and for which medical and possible surgical tx will be necessary
• term often used to describe cases in which some degree of uncertainty remains in regard to the diagnosis

Question 2

What would be a true emergency?

Answer 2

• probably if either the following:
  – hypovolaemic shock (high hr, slow CRT, pale mm)
  – septic shock
• note- ruminants are stoic animals

Question 3

Ddx for acute abdominal crisis - GI dz

Answer 3

• Abomasal volvulus
• Abomasal displacement
• Haemorrhagic jejunitis
• Caecal torsion
• Primary/secondary bloat
• Intestinal torsion/intussusception
• Mesenteric torsion
• Peritonitis

Question 4

Ddx for acute abdominal crisis - non-GI dz

Answer 4

• Uroliths
• Uterine torsion (usually at the end of gestation)
• Pyelonephritis

Question 5

Signalment and history

Answer 5

• Age
• Sex
• Breed
• Stage of production
• Nutrition
• Management system
• Stage in reproductive cycle
• Previous surgery
• Previous treatments

Question 6

Clinical examination - CV status

Answer 6

• Heart rate
  – Increased
• Mucous membrane
  – tacky
• Capillary refill time
  – Prolonged
• Dehydration (skin tent)
  – prolonged
  – skin tent above the eye
  – sunken eyes can also tell us about hydration

Question 7

Clinical exam - abdominal silhouette

Answer 7

• Rear and side
  – Abdominal distension
• Back position
  – flat or arched (cranioabdominal pain or just generalised abdominal pain)

Question 8

Clinical exam - abdominal exam

Answer 8

• Auscultation
  – Rumen contractility
  -> Reduced
• Percussion
  – “pings” = DA
  – paralumbar fossa
  – can be anywhere from the olecranon to the paralumbar fossa
  -> Abnormal
• Succussion (ballottement)
  – “splashing”

Question 9

Clinical exam - signs of pain

Answer 9

• Bruxism (grinding teeth)
• Abducted elbows
• Reluctance to dip on withers pinch
  – Cranial abdominal pain
• Head press, frowned/worried expression

Question 10

Clinical exam - rectal palpation

Answer 10

• Viscera
  – Normal
  – Distended
  – Turgid
• Help rule out none GI?
• Normal RDAs wouldn’t feel on rectal unless really distended

Question 11

Clinical exam - faeces

Answer 11

• Faecal output
  – Reduced
• Appearance
  – Frank blood
  – Melena
  – Fibrin and mucus

Rectal sweep - should have room to move when rectal - if tight and not able to move a lot it can mean straining or the rectal wall doesnt want to move due to fibrin attachment on the other side -> peritonitis (e.g. due to calving issues, poorly done c-sections)

Question 12

Ancillary Diagnostic Tests

Answer 12

Abdominocentesis & peritoneal fluid analysis
- Colour
- Volume
- Turbidity
- Odour (if it smell really bad it’s really bad news)
- Protein content (on refractometer)

Peritoneal tap - need to avoid the rumen so don’t do on the left side.
Hand back from the diploid on the midline to the mammary vein = good area to go in

Imaging- Ultrasonography
- 7.5MHz transrectal probe has its uses

Question 13

Ultrasonography

Answer 13

• good for scanning reticulum and rumen, esp for tyrewire dz
• don’t need to clip or coupling gel, just lots of surgical spirit
• Reticular contractions
  – Located left of midline, caudal to xiphoid
  – U shaped structure
  – Only wall visible (gas mixed into ingesta in lumen)
  – Cranial sac of rumen caudal to reticulum
  – Reticulum = biphasic contractions
  -> Second moves reticulum dorsally
• Also good for adhesions, abscess, fluid accumulation etc

Question 14

Peritonitis aetiology

Answer 14

• Primary (uncommon): associated with systemic infection
• Secondary (much more common): after abdominal surgery

Question 15

Peritonitis clinical presentation

Answer 15

• Acute: abdominal discomfort, pyrexia +/- toxaemia (check mm), altered faecal output, look awful
• Chronic: non-specific clinical signs, can be waxing and Maning (around stressors commonly), can just look a bit off

Question 16

Diffuse peritonitis

Answer 16

• Urethral obstruction (-> bladder rupture -> peritonitis)
• Acute acidosis/rumenitits
• Toxic mastitis
• Postpartum metritis
• Perforated abomasal ulcer
• inflammation and infectious everywhere
• any local cause can easily become diffuse if they spread

Question 17

Local peritonitis

Answer 17

• LDA/RDA
• Caecal torsion
• TRP
• Uterine torsion/rupture, dystocia, caesarean, vaginal tear
• Intestinal obstruction, volvulus, strangulation, intussusception, perforation
• Splenic/hepatic/umbilical abscess
  – Umbilical abscess in calves top of ddx
• Fat necrosis (older, fat animals)

Question 18

Pathophysiology of acute peritonitis

Answer 18

• adhesions (1w-10d in, fibrin + collagen -> to control the infection/keep the infection in)
• toxaemia
• shock and haemorrhage
• pain/tucked up appearance
• paralytic ileus
• exudate (lots of WBCs, neutrophils, day 5 deposit of fibrin)

Question 19

Diagnosis of acute peritonitis

Answer 19

Withers test: may be reluctant to dip and may produce audible grunt (indicating abdominal pain). ~30% sensitive

Eric Williams test: A quiet grunt may be heard just before the ruminal A wave contraction, due to the pain from the biphasic reticular contraction

Rectal palpation: adhesions may elicit discomfort or a pain response and may be palpated within the abdominal cavity per rectum (particularly in chronic peritonitis)

Clinical pathology: leukopenia and degenerative left shift (increase in immature neutrophils), increased levels of plasma fibrinogens and low plasma proteins to fibrinogen ratio

Abdominocentesis: increased turbidity, increased leukocyte count, increased total protein levels (>3g/dl) +/- bacteria (can be difficult)

Exploratory laparotomy:may allow for identification of the cause of peritonitis and possible correction of the condition is possible.

Gluto-aldehyde test:
Binds to fibrinogen if in blood and will form a blot. if clots within 3 mins it’s a fairly accurate indicator there’s fibrinogen. decent cow side test. for more chronic cases

Question 20

Treatment of peritonitis

Answer 20

Immediate and conservative:
- Fluid therapy (IV fluids, hypertonic 3-5L, then pump orally)
- NSAIDs (ideally into the vein)
- Antimicrobials (B lactam or tetracycline, Long course (going to be off licence, duration: 2w+)) (procaine penicillin, amoxicillin, oxytet (given IV depending on product))

Surgical:
Debridement, lavage and drainage (don’t have suction in the field so debridement, lavage, draining difficult)
Cows wall off infections well
Localised peritonitis - flushing would spread it and make it diffuse so leave it

Prognosis
Dependent on cause, tx, type, so guarded

Question 21

Caecal Torsion signalment

Answer 21

• usually early lactation dairy cows

Question 22

Caecal Torsion aetiology

Answer 22

• poorly understood (increased VFA in intestines -> atony?)
  (concentrate heavy diet increases VFAs)

Question 23

Caecal Torsion presentation

Answer 23

• caecal atony may cause dilatation
• if free end kinds over dilatation -> torsion

Drain fluid into bucket as it’s a prognostic indicator -> >30L poorer prognosis

Question 24

Caecal torsion tx

Answer 24

• Right flank laparotomy, externalise and empty caecum using purse string suture, reposition
• Oral fluids
• Calcium borogluconate (helps contractions of the mucosal wall, give into the vein)
• NSAIDs (2 days, i.e. ketoprofen), antibiotics (3 days, Procaine benzylpenicillin)
• Fibre to reduce VFAs in diet

Question 25

Caecal dilatation tx

Answer 25

- Calcium borogluconate (helps contractions of the mucosal wall, give into the vein) - NSAIDs - Fibre to reduce VFAs in diet

Question 26

Haemorrhagic jejunitis

Answer 26

= haemorrhagic bowel syndrome

Question 27

Haemorrhagic jejunitis signalment

Answer 27

- Usually (but not always) early lactation

Question 28

Haemorrhagic jejunitis aetiology

Answer 28

- Unknown. Link with Clostridium perfringens type A? Links to Salmonella also?

Question 29

Haemorrhagic jejunitis presentation

Answer 29

- clots -> obstruction -> colic - red - dark black blood in faeces - often fatal

Question 30

Haemorrhagic jejunitis tx

Answer 30

- surgery? - supportive (NSAIDs, fluids, etc), but isn't usually enough as need something to move the clot along - massaging the clot through is a potential option

Question 31

Other intestinal issues

Answer 31

- Strangulation: rare -- Prolapse of SI through mesenteric tear -- Persistent urachus - Volvulus: rare -- Torsion of root of mesentery - Intussusception: rare - Intestinal obstructions: rare aetiology unknown

Question 32

Other intestinal issues - clinical presentation

Answer 32

Severe abdominal pain, circulatory compromise, abdominal bloat _ death in hours

Question 33

Other intestinal issues - diagnosis

Answer 33

- rectal palpation - ex lap - US in calves can find intussusceptions

Question 34

Other intestinal issues - surgical tx

Answer 34

- Right flank approach - Principles as for other species

Question 35

Traumatic Reticulopericarditis

Answer 35

- Pericardium and reticulum are anatomically closely located - FB is ingested into rumen -> drops into reticulum -> penetrates reticular wall = reticulitis - Penetrates further to pericardial sac (through diaphragm) = pericarditis

Question 36

Analgesia in acute abdominal crisis

Answer 36

- Pain = GI hypomotility - GI pain = ↑ sympathetic tone = GIT inhibition - Peritoneal inflammation = involved in ileus initiation in several species BUT - NSAIDs in anorexic patients can induce ulcers - NSAIDs may impact on clinical signs used for decision making Choice based on: - Experience, cost , legislation etc But benefit of giving pain relief (and NSAID only real class we have) outweighs risk, also usually 7d course rather than extended over weeks and weeks. Ensure can give into the vein as most appropriate/useful for the v sick animal.