Two Cases of Planned Relaparotomy for Severe Peritonitis Secondary to Gastrointestinal Pathology

Case No. 1

A 12-year-old, 24-kg, spayed female Belgian sheepdog was presented obtunded and laterally recumbent. The dog had a history of a poor appetite and diarrhea for 1 week, and she was currently on cephalexin for superficial pyoderma and deracoxib for osteoarthritis. Rectal temperature was 100.0°F, heart rate was 120 beats per minute, and the femoral pulses were weak and synchronous. The dog’s abdomen was distended and moderately painful upon palpation. Oxygen therapy and lactated Ringer’s solution were started. After a bolus of intravenous (IV) fluids, systolic blood pressure was 100 mm Hg. Purified hemoglobin^a (5 mL/kg IV) and fresh-frozen plasma (10 mL/kg IV) were administered during resuscitation, and hydromorphone^b (0.06 mg/kg IV) was given for pain.

On abdominal ultrasonography, a large amount of free abdominal fluid was present; no pleural or pericardial fluid was evident. Abdominocentesis revealed a dark brown, flocculent fluid, and on cytology a mixed population of extra- and intracellular bacteria and degenerate neutrophils were seen. A diagnosis of septic peritonitis was made. Analysis of a venous blood sample revealed acidemia (pH 7.251; reference range 7.36 to 7.44), significant metabolic acidosis (bicarbonate [HCO₃] 11.4 mEq/L; reference range 18 to 22 mEq/L), and a respiratory alkalosis (partial pressure of venous carbon dioxide [PvCO₂] 25.8 mm Hg; reference range 36 to 44 mm Hg). Lactate was elevated at 7.2 mmol/L (reference range 0 to 2 mmol/L). Other laboratory abnormalities included elevations of blood urea nitrogen (105 mg/dL; reference range 7 to 27 mg/dL) and creatinine (4.5 mg/dL; reference range 0.4 to 1.8 mg/dL), as well as hyponatremia (132.7 mEq/L; reference range 141 to 156 mEq/L), hypoalbuminemia (0.4 g/dL; reference range 2.6 to 4.3 g/dL), and a low-normal blood glucose (79 g/dL; reference range 78 to 126 g/dL). Platelets were slightly decreased at 142,000/μL (reference range 200,000 to 500,000/μL). Prothrombin time (PT) and activated partial thromboplastin time (APTT) were within normal limits. Fifty percent dextrose^c (200 mg/kg) was given as an IV bolus, and ticarcillin/clavulanate^d (67 mg/kg IV), enrofloxacin^e (6.7 mg/kg IV), and famotidine^f (0.6 mg/kg IV) were also started.

Once the dog was stabilized, an emergency exploratory laparotomy was performed. Anesthesia was induced with diazepam^g (0.5 mg/kg IV) and propofol^h (4 mg/kg IV) and was maintained with isofluraneⁱ in oxygen. Upon entry into the abdominal cavity, a large amount of cloudy, brown fluid containing grass and food particles was encountered. A severe, generalized peritonitis with petechiation was noted on all serosal surfaces. Three areas of gastric perforation were detected along the body and pyloric antrum. Partially adhered omentum appeared necrotic, and adjacent gastric tissue was friable and purple to black in color. Demarcation between necrotic and healthy tissues was unclear. The viability of the pyloric area was questionable, which indicated the possible need for a Bilroth procedure. Despite IV administration of lactated Ringer’s solution, fresh-frozen plasma (21 mL/kg), and hetastarch (1.25 mL/kg per hour), systolic blood pressure decreased to 80 mm Hg and did not respond to a hetastarch bolus (6 mL/kg) or dopamine IV. The decision was made to temporarily seal the gastric perforations and lavage the abdomen, with the intention of performing a second laparotomy 12 to 24 hours later. Gastric perforations were closed with 2-0 polydiaxanone^k in a Lembert pattern, and the abdomen was lavaged with warm, sterile saline. The linea alba and skin were sutured with a loose simple continuous suture pattern that provided a 1-cm gap for fluid to drain. A sterile, absorbent bandage was placed around the abdomen, and a nasogastric tube was inserted.

Postoperatively, lactated Ringer’s solution, dextrose, potassium chloride, hetastarch, and dopamine were continued IV. Oxygen saturation measured via pulse oximetry (SpO₂) was 86%, so unilateral nasal oxygen was also started. The nasogastric tube was suctioned every hour to keep the stomach decompressed. Because the packed cell volume (PCV) was low (26%; reference range 38% to 47%), and in order to maximize oxygen delivery to the tissues prior to the second surgery, a transfusion of 2 units of packed red blood cells was initiated. Blood pressure stabilized following the transfusion. Fentanyl^l (5 μg/kg per minute IV) was given for pain control. Intravenous ticarcillin-clavulanate and famotidine were continued.

Fifteen hours after the initial surgery, the abdomen was re-explored. Generalized peritonitis appeared significantly improved from the prior surgery. A large portion of the omentum was necrotic and was resected. The necrotic area of the stomach was well demarcated, and the temporary closures of the gastric wall were within the necrotic area, which encompassed approximately one-third of the stomach (including much of the body and part of the pyloric antrum). Resection of the necrotic portion of the stomach was accomplished using a stapling device.^m As the pylorus appeared viable, a Bilroth procedure was not performed. The abdomen was lavaged with warm, sterile saline; two closed-suction drainsⁿ were placed; and the abdomen was routinely closed.

The dog recovered smoothly from anesthesia and was continued on crystalloid solutions, fentanyl (5 μg/kg per hour IV), and hetastarch (20 mL/kg per day IV). One episode of vomiting occurred postoperatively and was treated with metoclopramide^o (0.56 mg/kg per hour IV). The suction drains initially collected a large amount of serosanguineous fluid, but they were removed 48 hours postoperatively when the amount of drainage decreased and cytology revealed no bacteria. The dog was started on small amounts of a bland diet 36 hours postoperatively and was switched to oral amoxicillin/clavulanic acid^p (375 mg q 12 hours), famotidine^q (10 mg q 24 hours), sucralfate^r (1 g q 8 hours), and metoclopramide^s (5 mg q 8 hours) prior to discharge 4 days after the second surgery.

Case No. 2

A 9-year-old, 60-kg, castrated male bullmastiff with a history of foreign body ingestion was presented as an emergency after being found laterally recumbent and surrounded by vomitus. On presentation, the dog was obtunded and recumbent. Rectal temperature was 99.8°F, heart rate was 160 beats per minute, and respiratory rate was 50 breaths per minute. Laboratory tests revealed elevations of PCV (64%; reference range 37% to 55%), total protein (11 g/dL; reference range 5.8 to 7.9 g/dL), platelets (566,000/μL; reference range 200,000 to 500,000/μL), blood lactate (14 mmol/L; reference range 0 to 2 mmol/L), albumin (4.6 g/dL; reference range 2.6 to 4.3 g/dL), alkaline phosphatase (266 U/L; reference range 23 to 212 U/L), creatinine (2.8 mg/dL; reference range 0.4 to 1.8 mg/dL), calcium (12.7 mg/dL; reference range 7.9 to 12 mg/dL), and cholesterol (460 mg/dL; reference range 110 to 320 mg/dL). Mild hypokalemia (3.04 mEq/L; reference range 4.0 to 5.6 mEq/L) was also found. Prothrombin time was slightly elevated (16 seconds; reference range 8 to 14 seconds), but APTT was within normal limits.

Initial therapy included IV lactated Ringer’s solution, hydromorphone (0.07 mg/kg IV), cefazolin^t (33 mg/kg IV q 8 hours), enrofloxacin (6.7 mg/kg IV q 24 hours), and chlorpromazine^u (0.8 mg/kg SC q 8 hours). Lateral and ventrodorsal abdominal radiographs revealed markedly dilated small intestines and loss of serosal detail in the cranial abdomen. Because of the radiographic findings and a historical suspicion of ingestion of a foreign body, an exploratory laparotomy was performed.

Anesthesia was induced with propofol (4.2 mg/kg IV) and maintained with isoflurane in oxygen. Abdominal exploration revealed multiple gastric foreign bodies and a linear jejunal foreign body that had caused plication from the duodenal flexure to the distal ileum. A diffuse peritonitis was also present. A gastrotomy and four enterotomies were performed to remove the foreign bodies. The viability of the entire small intestine was questionable [Figure 1]. The decision was made to perform a second celiotomy 24 hours later to assess the viability of the bowel, rather than risk short-bowel syndrome secondary to resection of most of the small intestine. The abdomen was lavaged with warm, sterile saline; the linea and skin were loosely apposed; and a bandage was applied as described for case no. 1.

Postoperatively, crystalloids, potassium chloride, and hetastarch were administered IV, as well as an IV infusion of morphine, lidocaine, and ketamine for pain control. Cefazolin, enrofloxacin, and chlorpromazine were continued as before, and metronidazole^v (20 mg/kg IV q 12 hours) was added. Twenty-four hours later, the abdomen was explored a second time. The small intestine, including the enterotomy sites, appeared viable, though a diffuse peritonitis was still present [Figure 2]. Omentum was placed over the most severely discolored serosal sites, and an elective circumcostal gastropexy was performed. The abdomen was lavaged with warm, sterile saline; a closed suction drainⁿ was placed; and the abdomen was closed routinely.

Drug administration continued with IV crystalloids; hetastarch; a continuous infusion of ketamine, morphine, and lidocaine; and cefazolin, enrofloxacin, and metronidazole. Serosanguineous fluid was evacuated from the drain until the drain was removed 2 days later, at which time fluid collection was minimal. Cytology of the abdominal drainage prior to drain removal revealed no infectious organisms. The dog was started on oral feedings 24 hours after the second surgery; but after an episode of vomiting, metoclopramide (0.05 mg/kg per hour IV) and famotidine (0.3 mg/kg per os [PO] q 12 hours) were given. The dog was discharged from the hospital 7 days after the second surgery, with postoperative administration of amoxicillin^w (17 mg/kg PO q 12 hours), metronidazole (21 mg/kg PO q 12 hours), metoclopramide (0.25 mg/kg PO q 8 hours), and enrofloxacin^x (2.3 mg/kg PO q 12 hours). The dog recovered well and had no clinical signs until he was presented 4 months later with another gastric foreign body, which was removed via gastrotomy. During surgery, the intestines were normal in appearance.