Septic Peritonitis in an Adult Horse - PowerPoint Presentation

Slide1

Septic Peritonitis in an Adult Horse

Benjamin

Davids

University of Florida

College of Veterinary Medicine

Gainesville, FL

Mentors: Sarah Reuss, VMD, DACVIM;

Liz Nelson

BVSc

Slide2

Signalment

and Clinical Presentation

13 year old

Paint Horse Gelding

Bright and alert on admission

Presenting for gastroscopy due to history of chronic, intermittent, low-grade colic

Slide3

History

3 day low-grade colic

Similar episode ~1 month prior and 5 days prior

Responded to one dose of

flunixin

meglumine

each time

Dietary indiscretion 6 weeks prior to admission

Dirt

Garbage

6 weeks prior:

Dietary

indiscretion

4 weeks prior:

2-3 day low-grade colic

5 days prior:

1 day low-grade colic

3 days prior:

Low grade colic and

inappetence

ongoing

Slide4

Physical Examination Findings

Bright, alert, and responsive

Heart rate 40 bpm

Normal: 28-40

Respiratory rate 36 rpm

Normal: 12-18

Mucus membranes pink

Capillary refill <2 seconds

No murmurs, arrhythmias

ausculted

Normal

bronchovesicular

sounds

ausculted

Coat dirty from repeated rolling

Slide5

Initial Bloodwork

Test

Results

Ref

Range

Hematocrit

30.6%

30-44

Total Protein

8.7 g/

dL

6.1-8.4

Albumin

3.0 g/

dL

2.7-4.5

Globulin

5.7 g/

dL2.4-4.9Creatinine1.5 mg/dL1.1-2.0

BUN15 mg/dL9-22GGT16 U/L17-50SAA1975 mmol/L<200

TestResultsRef RangeWBC9.91 K/uL5.6-11.6#Neut

8.53 K/uL2.6-6.7#Lymph0.87 K/uL1.1-5.7# Mono0.25 K/uL0-0.7#Eos0.21 K/uL

0-0.6#Baso0.03 K/uL0-0.2Fibrinogen1000 mg/dL

100-400

Slide6

Rectal palpation: No significant findings

Gastroscopy: No ulceration in squamous or glandular mucosa, one stomach wormAbdominal ultrasound: No significant findings

Abdominal

Radiographs: Multiple mineral opaque structures within the ventral colon

Initial Diagnostic Findings

Slide7

Gastroscopy Images

Gastroscopy images showing no evidence of squamous or glandular mucosa ulcerations

Slide8

Radiographs

Slide9

Initial Problem List

Hyperfibrinogenemia

Hyperproteinemia characterized by hyperglobulinemia

Increased SAA

Mild neutrophilia

Gastric parasitism

Possible

enteroliths

or sand accumulation in dependent ventral colon

Slide10

Differential Diagnoses

Radiographic findings:

Enterolithiasis

Sand accumulation

Intestinal foreign bodies

Bloodwork findings:

Secondary colonic inflammation

Peritonitis

Gastric Parasites

Draschia

megastoma

Habronema

spp.

The Glass Horse Equine Colic. Glass Horse LLC. Athens, GA.

Slide11

Initial Therapeutic Plan

3 pounds psyllium fiber + mineral oil via nasogastric tube

1 pound each, q8hr

Monitor for pain or signs of colic

Repeat radiographs in 24 hours

Overnight update

Sternal

recumbency

+ flank watching post 3

rd

psyllium administration

Slightly depressed mentation

550 mg flunixin meglumine IV was administered and morning food withheld

Slide12

24 hour post radiographs

No evidence of

enterolithiasis

or sand

Slide13

Updated Diagnostic Plan

Abdominocentesis

Discordant increase in SAA for the ease of passage of sand

The Glass Horse Equine Colic. Glass Horse LLC. Athens, GA.

Slide14

Serum Amyloid A

Positive acute phase protein

Increase correlates to active infection or inflammation

Short half life

Early response and increase in concentration

Reliable indicator of return to health

Rapid decrease in concentration in response to treatment

“Serum Amyloid A (SAA).”

Tridelta

Development LTD, 2011

.

http://

www.trideltaltd.com

/the-basic-

science.html

Slide15

Abdominocentesis

Gross evaluation

Pink (“strawberry milkshake”)

Turbid

Cytology

TP 5.1 g/

dL

WBC: 257,800/

uL

,

93% neutrophils, 2% lymphocytes, 5% mononuclear phagocytes

RBC: 920,000/

uL

Consistent with a septic exudate with rare intracellular cocci

Slide16

Cytology Photograph

100x oil objective image, stained with Wright’s

Giemsa

courtesy of

Drs. Sarah Beatty, DACVP and Tracie Guy.

Cytology image of peritoneal fluid obtained during

abdominocentesis

.

Intracellular

cocci

can be seen within the yellow circle.

Slide17

Updated Diagnosis

Repeat abdominal ultrasound

No evidence of

abscessation

Septic Peritonitis

Updated Plan

Exploratory

celiotomy

Slide18

Exploratory

Celiotomy

Findings

3 areas of gross inflammation and abnormal intestinal plication were visible

Jejunum-jejunum adhesions

Focal perforations

12 feet of affected jejunum was resected

Routine resection and anastomosis

Copious lavage with >10L sterile LRS

“Belly Jelly” (

carboxymethylcellulose

)

Closed in routine fashion

Unremarkable recovery from anesthesia

Slide19

Intra-operative Photographs

Areas of adhesion and perforation noted by the yellow circles

Slide20

Post-operative Dissection

Areas of adhesion and perforation noted by the yellow circles

Slide21

Post-operative Dissection

Slide22

Post Operative Management

Potassium penicillin 22,000 IU/kg IV q6hr

Gentamicin 6.6mg/kg IV q24hr

Flunixin

meglumine

1.1 mg/kg IV q12hr

Plasmalyte

@ 1L/

hr (50mL/kg/day) IV CRID/C after 24 hours

Lidocaine 0.05mg/kg/min IV CRI

Loading dose 1.3 mg/kg IV over 10 minutes

Discontinued after

approx

24hr

Hand walk for 5 minutes with 30s grazing q6hr

Increased to 5min grazing after 24 hours

½ scoop equine senior concentrate q12hr started when grazing increased

Pentoxifylline 10mg/kg PO q12hr started 24hr post-op500kg dose Ivermectin PO for stomach worm

Slide23

Additional Diagnostic Findings

Microbial culture of peritoneal fluid

85%

Streptococcus

equi

ssp

zooepidemicus

15% Gram negative coccobacilli

Surgical Pathology of Jejunum

Intestinal perforation with necrosis and

intralesional

cocci, acute, locally extensive, transmural

Fibrinous

serositis

and necrotizing

jejunitis

Consistent with longstanding inflammation

Chong BF, Blank, LM, Mclaughlin R, et al: “Microbial hyaluronic acid production.” App Micro Bio.

Slide24

Surgical Histopathology

Jejunum

serosa and mucosa, respectively, histopathology

stained with H&E stain showing hemorrhage and necrosis consistent with

jejunal

perforation. 60x

magnification.

Slide25

Histopathology Gram Stain

Jejunum histopathology stained with Gram stain showing the presence of Gram positive bacteria consistent with cultured

Streptococcus

equi

ssp

zooepidemicus

Slide26

Outcome

Patient was discharged 6 days post-op

No post-operative complications while in hospital

Discharged with the following medications:

Ceftiofur

sodium 2.2mg/kg IM q24hr for 14 days

Pentoxifylline

10mg/kg PO q12hr for 3 days

Instructions to be kept on strict stall rest for 30 days with hand grazing 15 minutes q8-12hr

Patient doing well since discharge, but still within the 30 day stall rest period at time of case submission

Slide27

Putting it all together…

Ingested foreign material/body

that caused

jejunal

perforations

Inflammatory response within the jejunum and peritoneum

Adhesions formed within jejunum to wall off perforations

Due to adhesions, inflammation, and abnormal plication, patient experienced recurrent bouts of low grade colic

Presented for chronic colic workup where SAA increase was inconsistently high compared to other clinical findings

Exploratory

celiotomy

, resection and

anastamosis

Recovery and return to food and oral water

Discharge!

Abdominocentesis

revealed septic peritonitis

Slide28

Additional Reading

Belgrave RL, Dickey MM,

Arheart

KL,

et al.

Assessment of serum amyloid A testing of horses and its clinical application in a specialized equine practice. J Am Vet Med

Assoc.

2013;243

:113-9. Jacobsen S, Anderson PH. The acute phase protein serum amyloid A (SAA) as a marker of inflammation in horses. Equine Vet Educ. 2007;9:38-46.

Hawkins JF, Bowman KF, Roberts MC, et al. Peritonitis in horses: 67 cases (1985-1990). J Am Vet Med

Assoc. 1993;203

:284-8.

Dabareiner

RM.

Peritonitis

I

n Horses

. In: Large Animal Internal Medicine, 4th ed. Ed: Smith BP, Elsevier, St Louis, MO, 2009, pp 761-7

Slide29

Acknowledgements

Surgery: Alison Morton, DVM,

MSpVM

, DACVS, DACVSMR; Elyse

Durket

, DVM

Clinical Pathology: Sarah Beatty, DVM, DACVP; Tracie Guy, DVM

Surgical Pathology: Heather

Grodi

, DVM