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InFocus

Nursing patients with gastrointestinal emergencies

The GI tract has many different functions which can be affected by obstruction or the presence of a foreign body and it is important to provide rapid treatment for these cases

The gastrointestinal (GI) system comprises the mouth, oesophagus, stomach, small intestines (duodenum, ileum and jejunum) and the large intestine (colon). There are many complications that can arise in these areas which may require emergency intervention.

Foreign bodies

The oesophagus is a muscular structure that connects the mouth to the stomach and can become obstructed by foreign bodies including bone/cartilage or fish hooks: both require emergency treatment. The clinical signs may include regurgitation, a change in posture, drooling (blood may be present), repeated attempts to swallow, anorexia and coughing due to pneumonia (Cook, 2020). Clinical signs and a history from the owner will be highly suggestive of an oesophageal foreign body (FB), radiography will identify fish hooks (due to the high contrast/radiopacity) whereas bone or bulky FBs vary and may appear as an ill-defined soft tissue density in the caudal thorax (Hotston Moore, 2008).

There are a variety of methods that can be used to remove the FB and sometimes it requires a combination of flexible endoscopy, rigid endoscopy and/or surgical intervention. Medical management using endoscopy is the preferred method, with oesophagoscopy allowing for visual­isation of the oesophagus. A retrospective study by Bur­ton et al. (2007) found that the success rates are high for oesophageal foreign body removal by this method. Surgery is indicated if there is an oesophageal perforation or the FB can not be removed via endoscopy.

Endoscopy is not recommended for the removal of a linear foreign body (LFB) due to the material becoming anchored in different parts of the GI tract. LFBs are more commonly found in cats and can consist of a variety of materials, from hair bands to string. Clinical signs of an LFB vary, but can include vomiting, lethargy, abdominal pain, inappetence and anorexia. Sometimes owners may report witnessing the ingestion or seeing the FB within the mouth (Pope, 2003). LFBs are found to have a less favourable prognosis in cats due to multiple incisions being made into the GI tract (Taylor, 2016). However, one study found that the survival rates for dogs with LFBs and non-LFBs were the same at 96 percent (Hobday et al., 2014). If an FB is suspected in a cat, it is always advisable to check under the tongue during the clinical examination where the FB may be seen wrapped around the base of the tongue. An explora­tory laparotomy is recommended with a gastrotomy and enterotomies to remove the foreign body. If intestinal tissue is not viable then an intestinal enterectomy and anastomo­sis may be required.

Gastric dilatation volvulus

A common GI emergency that affects the stomach is a gastric dilatation volvulus (GDV). This involves the stomach filling with gas and twisting, which compromises the blood supply to the stomach and spleen, resulting in cardiogenic and hypovolaemic shock (Homer, 2020). Clinical signs of shock include tachycardia, pale mucous membranes, pro­longed capillary refill time (CRT), weak peripheral pulses and hypotension. A GDV is a life-threatening condition which mainly affects large deep-chested breeds including Boxers, Great Danes, Rottweilers and Irish Setters.

Patients with GDV present with varying degrees of shock. Previously, shock rates using crystalloids of 90ml/kg/hr have been recommended; however, to be able to titrate the intravenous fluid therapy correctly, bolus therapy of 10 to 20ml/kg while monitoring the patient’s response prevents possible complications from over infusion (Poli, 2017).

Gastric decompression can be achieved using a stomach tube or trocharisation to remove gas and stomach contents prior to surgery. Surgery has three goals: repositioning the stomach, evaluating the abdominal viscera and performing a gastropexy by creating a permanent adhesion between the stomach and the body wall (Rosselli, 2017). Benitez et al. (2013) investigated the use of an incisional gastropexy and the prevention of a GDV; they found that no dogs had a recurring GDV but gastric bloat recurred in 8.8 percent of patients that had a gastropexy during surgery for a GDV and 11 percent for those having a gastropexy prophylactically.

Intussusception

Gut motility can be altered by underlying disease processes and can result in an intussusception, where a portion of the GI tract invaginates into the lumen of the adjacent segment; it is commonly recognised in patients less than one year of age (Thomason and Latimer, 2020). Intussusception is diagnosed using ultrasonography and clinical signs, and once diagnosed surgery is recommended. An exploratory laparotomy is performed, with the entire GI tract being examined. Manual reduction may be successful if there are no or minor adhesions present, and the GI tract appears viable. Enterectomy and anastomosis is performed when the intestinal segment cannot be reduced, is perforated or not viable. A 2008 study of 88 dogs showed 82 percent required anastomosis due to necrosis (Barreau, 2008).

Post-operative care

Intravenous fluid therapy is essential not only in stabilising patients prior to surgery but also post-operatively. Fluid losses occur via respiration, urine and faeces at 50ml/ kg/24 hours; patients with gastrointestinal disease may have increased losses through vomiting and diarrhoea. It is important to continue intravenous fluid therapy until the patient can independently replace the fluid loss (Hill and Crompton, 2011) and until the clinical signs resolve.

BOX (1) The patient’s resting energy requirement (RER) should be calculated daily based on the patient’s weight

Post-operative management of cases that have had an oesophageal FB will depend on the degree of mucosal dam­age caused to the oesophagus. Those with minimal mucosal damage will require a combination of a cytoprotective (sucralfate), proton pump inhibitor (omeprazole) or an H2 receptor agonist (ranitidine, famotidine). Those with more severe mucosal damage should have a gastrostomy tube placed for enteral feeding for 5 to 10 days (White, 2014). Feeding tubes that can be used to bypass the oesophagus include gastrostomy or percutaneous endoscopic gastros­tomy (PEG) tubes which are placed into the stomach either surgically or endoscopically. These tubes have a larger diameter than other feeding tubes such as naso-oesopha­geal or oesophagostomy tubes which means specific tube feeding diets can be used or tinned/wet food diets blended with water. The patient’s resting energy requirement (RER) should be calculated daily based on the patient’s weight (Box 1). If the patient requires additional nutrition the daily calorific intake can be increased by 25 percent at a time.

It is important to provide nutrition early post-operatively and different methods may be required to get a patient to eat such as warming food, hand feeding or placement of feeding tubes until the patient is maintaining their daily nutritional requirement independently. Normal motility returns to the small intestine almost immediately after an insult such as GI surgery. However, the stomach and large intestine are compromised for 24 to 36 hours, so using liquid foods to deliver nutrition can help as minimal mechanical digestion is needed. Early enteral nutrition after surgery or hospitalisa­tion has been shown to lower complications, shorten hospital stays and improve patient outcomes (Firth, 2013).

Complications

A possible complication of gastrointestinal surgery is peritonitis (leakage of intestinal contents into the abdominal cavity caused by the breakdown of the intestinal suture line) which occurs around three to five days after sur­gery (Stanley, 2012). A second exploratory laparotomy is performed to find the affected area of intestine; resection and anastomosis is followed by abdominal lavage using copious volumes of crystalloid fluids and placement of a closed abdominal suction drain. Suction drains should be monitored frequently to check for signs of complications or infection around the insertion site (redness, swelling, exu­date and pain). The accumulating fluid should be emptied (wearing gloves) every four to six hours and the volume and appearance of the fluid and any complications recorded each time. Drainage can be affected by fibrin, omentum and blood clots but also by patient interference (Yon, 2020), which can be prevented by using a buster collar or body suit. Any blood clots can be removed by flushing crystal­loid fluids via the tubing connecting to the drain. Removal of a suction drain depends on the quantity and quality of the fluid produced; drains should be removed when the fluid production is less than 0.2ml/kg/hr. It is important to remember that the fluid production will never be zero due to the body identifying the drain as foreign material and inducing fluid production (Van Goethem, 2015).

References

Barraeu, P.

2008

Intussusception: diagnosis and treatment. WSAVA World Congress Proceedings. Dublin

Benitez, M. E., Schmeidt, C.W., Radlinksy, M.G. and Cornell, K.K.

2013

Efficacy of incisional gastropexy for prevention of GDV in dogs. Journal of the American Animal Hospital Association, 49, 185-189

Burton, A., Talbot, C. and Kent, M.

2017

Risk factors for death in dogs treated for esophageal foreign body obstruction: a retrospective cohort study of 222 cases (1998–2017) Journal of Internal Veterinary Medicine, 31, 1686-1690

Cook, A.

2020

Esophageal foreign bodies, Today’s Veterinary Practice, 10, 45-50

Firth, A.

2013

Early enteral nutrition: principles and practice. The Veterinary Nurse, 4, 392-399

Hill, P. and Crompton, S.

2011

Immediate post-operative recovery of the surgical patient – part two. Veterinary Times

Hobday, M. M., Pachtinger, G. E., Drobatz, K. J. and Syring, R. S.

2014

Linear versus non‐linear gastrointestinal foreign bodies in 499 dogs: clinical presentation, management and short‐term outcome. Journal of Small Animal Practice, 55, 560-565

Homer, A.

2020

Cardiovascular monitoring of the canine gastric dilatation volvulus patient. The Veterinary Nurse, 11, 24-28

Hotston Moore, A.

2008

Oesophageal foreign bodies. BSAVA Congress, England

Poli, G.

2017

Focus on GDV, part one: resuscitation. Veterinary Times

Pope, E. R.

2003

Feline intestinal foreign bodies [online]

Rosselli, D.

2017

Gastric dilatation and volvulus: stabilisation and surgery. Today’s Veterinary Practice, 7, 43-50

Schoor, M.

2015

How to manage indwelling feeding tubes in cats and dogs. The Veterinary Nurse, 6, 118-123

Stanley, B. J.

2012

Complication of intestinal surgery. WSAVA/FECAVA/BSAVA World Congress, Birmingham, England

Taylor, S.

2016

Gastrointestinal foreign bodies: Your cat ate what? Veterinary Times

Thomason, M. and Latimer, C.

2020

Intussusception Reduction [online]

Van Goethem, B.

2015

Use of drains (Thoracic, Abdominal). WSAVA World Congress Proceedings, Bangkok, Thailand

White, R.

2014

Oesophageal foreign bodies: treatments and complications. Veterinary Times

Yon, E.

2020

The veterinary nurse’s role in the management of wound drains. The Veterinary Nurse, 11, 264-269

Cathy Woodlands

Cathy Woodlands, RVN, graduated from Bristol University with a degree in veterinary nursing and practice administration. In 2014 she completed the advanced nursing diploma in Clinical and Professional Veterinary Nursing with the RVC. She is Deputy Head Referral Nurse at Bath Veterinary Referrals and has an interest in surgical nursing, anaesthesia and wound management.


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