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Five things that might change how you manage gastrointestinal emergencies

Different indicators can help decide how to approach and manage GI emergencies

Gastrointestinal emergencies are common in general practice and the underlying problem may be overt or subtle. Appropriate effort and time should be given to stabilising a patient on presentation. For example, whilst mortality increases with a delay in a dog presenting with gastric dilatation volvulus (GDV) to the vet, it reduces with a longer time from presentation to surgery. Adequate anal­gesia using a pure mu agonist is often appropriate prior to surgery. A decision to operate is often based on clinical history and physical examination (eg abdominal palpation) but diagnostic imaging is often necessary. Persistent vom­iting which is unresponsive to medical management can increase suspicion of intestinal obstruction and commonly results in hypokalaemia.

1. Consider serum electrolytes carefully

Proximal duodenal and gastric outflow obstruction can cause persistent vomiting with low serum Na, Cl and K; these electrolyte changes should be considered very suspicious even in the absence of imaging findings for obstruction.

Abdominal radiographs should include orthogonal views (a right lateral and a ventro-dorsal or dorso-ventral image). Classic radiographic signs for surgical disease can include the “double bubble” for GDV (Figure 1), two distinct populations of small intestine with obstruction (small and large diameter gut evident with, for example, intussusception, intestinal mass or foreign body; Figure 2) or free abdominal gas with a lack of serosal detail with septic peritonitis. Free abdominal gas can be very obvious (Figure 3) but a more subtle pneumoperitoneum is best recognised using a horizontal beam radiograph with the patient in lateral recumbency (Figure 4). Of course, a lack of radiographic changes does not fully exclude a gastrointestinal emergency and abdominal ultrasound can help to identify the problem or guide further diagnostics (eg abdominocentesis of free abdominal fluid).

Septic peritonitis due to intestinal leakage will result in an effusion with cytological identification of neutrophils and/or bacteria. If intracellular bacteria can’t be definitively identified but there remains a concern for septic peritonitis, glucose and lactate assessment can be helpful.

FIGURE (1) A right lateral plain radiograph showing the classic “double bubble” appearance of a gastric dilation and volvulus and a megaoesophagus in a six-year-old male entire German Shepherd Dog
FIGURE (2) A dilated “sentinel loop” of small intestine, suggesting that there is an obstruction of the gut
FIGURE (3) A severe pneumoperitoneum resulting from perforation of a gastric ulcer in a dog. Highlighting of the serosal surface of the diaphragm is a useful sign to look for if there is a smaller volume of free abdominal gas
FIGURE (4) A horizontal beam radiograph of the cranial abdomen of a dog in lateral recumbency, highlighting a relatively small volume of free abdominal gas following small intestinal leakage

2. Peritoneal fluid biochemistry

Free abdominal fluid glucose and lactate levels can be com­pared to serum levels, and if the lactate is higher and glucose lower in the abdominal fluid it can indicate bacterial anaero­bic respiration. Fluid lactate more than 2mmol/l higher and fluid glucose more than 1.1mmol/l lower than serum should be considered very suspicious for septic peritonitis.

If surgery is required, it is important to consider other procedures that might benefit the animal whilst anaesthe­tised. Biopsies of the intestine or liver may be warranted, and the placement of a feeding tube should always be con­sidered, even if not performed.

3. Feeding tubes should always be considered

Early enteral nutrition reduces hospitalisation time, facilitates intestinal healing and provides an alternate route for medication.

Placing an oesophageal feeding tube is a relatively simple procedure which does not add a significant amount of time to the anaesthetic, is well tolerated by patients post-operatively (generally better than nasogastric tubes) and are useful if an animal has been anorexic prior to surgery or there is notable serosal inflammation or ileus recognised during surgery. Gastric tubes can help decompress the stomach or empty out copious fluid post-operatively and provide a route through which to thread an enterostomy tube (“J through G tube”) without the added complications that direct enterostomy tubes introduce. Animals should be offered food immediately following anaesthetic recovery. The resting energy requirement of a patient (RER) can be calculated and the animal started on a third of that amount per day if it has been inappetant, gradually increasing the amount each day to avoid refeeding syndrome.

4. GDV: the pyloric antrum should be secured to the right body wall via incisional gastropexy

Following de-rotation of gastric volvulus, which is facili­tated by emptying the stomach by orogastric tube or trocar decompression, the stomach is secured to the body wall. An incisional gastropexy of the pyloric antrum to the right body wall will result in appropriately strong adhesions with mini­mal risk of recurrence. Whilst other methods are described, they offer no benefit and increased complications. Left gas­tropexy is only indicated for oesophageal hiatal hernia.

Partial gastrectomy and splenectomy are performed if indicated in the face of gastric necrosis or a compromised spleen. A mild haemabdomen concurrent with GDV is com­mon due to avulsion of the short gastric arteries between the spleen and greater curvature of the stomach; this is also the reason why this region of the stomach is most often affected by ischaemic necrosis.

5. Obstructions: learning to staple can help reduce the risk of complications

Intraluminal or extraluminal occlusion of the gastrointes­tinal tract is most often the result of neoplasia or foreign material. Oesophageal foreign bodies are best removed via endoscopy or fluoroscopy (approximately a 90 percent suc­cess rate). If they can be advanced into the stomach then surgical retrieval via gastrotomy rather than thoracotomy is less complex. Stay sutures are invaluable when performing gastrotomy to minimise the risk of spilling contents into the abdomen. Tissue viability of the intestines is typically assessed visually and by palpation (an experienced sur­geon’s assessment is 85 percent accurate), including identi­fication of vessel pulses (thrombosed vessels are dark and do not blanch when compressed) and whether gut bleeds when incised.

Sutured anastomosis following enterectomy is the most commonly performed method, using full-thickness single-layer simple interrupted or simple continuous suture patterns. The latter is preferable, as it is simpler, uses less material, is quicker and is more leak resistant. Surgical stapling devices can be used to create functional end-to-end anastomoses (Box 1). Practitioners may be reluctant to use these devices based on lack of familiarity and cost but there are numerous advantages over traditional suturing, including considerably shorter surgical/anaesthesia time and a reduced risk of dehiscence in a septic abdomen. Overall, these reduce morbidity and cost.

Box (1) Step-by-step guide to creating a functional end-to-end anastomosis using a linear stapling device and linear-cutter stapling device

FIGURE (5) An enterectomy has been performed and Doyen bowel clamps used to occlude the lumen. Stay sutures are used to manipulate the cut ends of intestine and pull them onto the jaws of the dismantled linear cutting stapler device
FIGURE (6) The linear cutting stapler is closed (halves are pieced together; side handle closed), apposing the intestine ends side-to-side. The sliding toggle on the side of the device is pushed forwards and then pulled back, firing two parallel rows of staples with a sharp cut between them. The intestine now has an appearance of a pair of trousers with an open waist
FIGURE (7A) The belt is placed on the waist of the trousers using a linear stapling device. Offset the previous staple lines…
FIGURE (7B)… rather than apposing them to avoid too many overlapping staples
FIGURE (8) Finally cut the redundant tissue away from beyond the linear stapler and place one or two simple interrupted sutures between the two pieces of intestine in the crotch of the trousers to support a potential weak point in the functional end-to-end anastomosis (literally side-to-side, with a communicating lumen)
FIGURE (9) A linear gastrointestinal anastomosis (GIA) stapler (used for laparoscopic surgery in humans) can be used for small sized animals when the intestinal lumen is too narrow for a standard linear cutting stapler

Septic peritonitis increases the risk of dehiscence of a sutured anastomosis of the small intestine from 8 per­cent to 29 percent, but for a stapled anastomosis the risk increases from 4 percent to only 10 percent. Stapling can therefore prevent this complication in almost 20 percent of dogs with septic peritonitis.

Oversewing the end staple line and placing a support­ing suture in the “crotch” of the adjacent intestinal loops may reduce the risk of leakage further. Regardless of the closure method, the surgical site can be omentalised after­wards. Additional reinforcement can be provided using a serosal patch or even a transversus abdominis onlay flap. Multiple enterotomies may be required to retrieve linear foreign bodies (these have a higher risk of post-operative dehiscence), but these can be minimised by milking the material orad from the most distal enterotomy incision and even attaching the material to a rigid urinary catheter to help feed it along the gut.

Prior to closure, a full examination of the abdomen and copious lavage (estimated to be in the region of 100 to 200ml/kg at a minimum) should be performed using warm Hartmann’s solution or saline. It is highly advisable to use surgical suction to remove fluid to minimise contamination and also to avoid sequestration of bacteria in the abdominal fluid and facilitate phagocyte activity.

Jacqueline Young

Jacqueline Young, BVM&S, MRCVS, graduated from the Royal (Dick) School of Veterinary Studies and is an intern at Wear Referrals. She is interested in diagnostic imaging and surgery and has previously worked in a first opinion practice in British Columbia, Canada.

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Jon Hall

Jon Hall, MA, VetMB, CertSAS, DipECVS, SFHEA, FRCVS, is a European and RCVS Recognised Specialist in Small Animal Surgery and Senior Fellow of the Higher Education Academy. Jon is company director of VetEd Specialists and recently became a Professor of Small Animal Surgery at the University of Nottingham.

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