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Mesenteric torsion pathology and management

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Mesenteric torsion pathology and management

  1. 1. Case advisors: Dr Sarah Boston, Dr Alexa Bersenas Program advisor: Dr Karol Mathews
  2. 2. History and signalment <ul><li>5 y.o NM Boxer ‘Lennox’ </li></ul><ul><li>Collapsed with profuse rectal hemorrhage </li></ul><ul><li>Hypotensive + tachycardic @ rDVM </li></ul><ul><li>CBC, chemistry, abdominal radiographs performed </li></ul><ul><li>Transferred to OVC </li></ul><ul><li>Arrived 2 ½ hours after initial collapse </li></ul>
  3. 3. Physical exam findings <ul><li>Recumbent, poorly responsive </li></ul><ul><li>T=36.4, HR=220 bpm, RR=42, MAP<60mmHg </li></ul><ul><li>White m.membs </li></ul><ul><li>Abdominal pain+ free fluid, profuse rectal hemorrhage </li></ul><ul><li>QUATS </li></ul><ul><ul><ul><li>PCV=32%, TS=38g/l </li></ul></ul></ul><ul><ul><ul><li>lactate=7.6 mmol/l, AG=16 </li></ul></ul></ul><ul><ul><ul><li>Stress hyperglycemia 11.1 mmol/l </li></ul></ul></ul><ul><ul><ul><li>Hypokalemia 2.7mmol/l </li></ul></ul></ul><ul><ul><ul><li>Mixed metabolic+ respiratory acidosis pH=7.22, BE=-7.6 PCO 2 =45mmHg </li></ul></ul></ul>
  4. 5. Treatment <ul><li>Over the next 60 min </li></ul><ul><ul><li>Fluids </li></ul></ul><ul><ul><ul><li>3 litres PLA (100ml/kg) </li></ul></ul></ul><ul><ul><ul><li>300 ml pentastarch (10ml/kg) </li></ul></ul></ul><ul><ul><ul><li>472ml FFP (17ml/kg) </li></ul></ul></ul><ul><ul><ul><li>405mls whole blood </li></ul></ul></ul><ul><ul><ul><li>300mls PRBCs </li></ul></ul></ul><ul><ul><li>Analgesia </li></ul></ul><ul><ul><li>Potassium CRI </li></ul></ul>
  5. 6. Response <ul><li>Centrally responsive, in sternal, PCO 2 ↓ 35mmHg </li></ul><ul><li>HR=136, membs pink, MAP=98mmHg </li></ul><ul><li>Profuse rectal hemorrhage continuing... </li></ul>
  6. 7. What did we do? <ul><li>Improved perfusion </li></ul><ul><ul><ul><li>Perfused brain now CO 2 responsive- PCO 2 ↓by 10mmHg </li></ul></ul></ul><ul><ul><ul><li>M.membs pink </li></ul></ul></ul><ul><ul><ul><li>Lactate decreased </li></ul></ul></ul><ul><ul><ul><li>Normalised bp, established urine production </li></ul></ul></ul><ul><li>Unmasked anemia + hypoproteinemia </li></ul><ul><ul><ul><li>PCV 15%, TS=2.2 </li></ul></ul></ul><ul><ul><ul><li>BE = +5.2 </li></ul></ul></ul><ul><ul><ul><li>Hypoproteinemia raises BE </li></ul></ul></ul><ul><ul><ul><li>Narrows the anion gap- hides lactate </li></ul></ul></ul>
  7. 8. The bigger picture.... 60 min after admission
  8. 9. So that....
  9. 10. At surgery....before
  10. 11. And after....
  11. 12. Intestinal torsion <ul><li>Surgical emergency </li></ul><ul><li>High mortality rate </li></ul><ul><li>GSD, Great Danes, Neapolitan Mastiff, English Pointers </li></ul><ul><li>Diagnosis on clinical signs </li></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>Abdominal pain </li></ul></ul><ul><ul><li>Abdominal distension </li></ul></ul><ul><ul><li>+/- Hematochezia </li></ul></ul><ul><li>Plain radiographs </li></ul>
  12. 14. Review of veterinary literature <ul><li>Aetiology and incidence unknown </li></ul><ul><li>Mortality rate reported as </li></ul><ul><ul><li>100% 6/6 cases 1984 </li></ul></ul><ul><ul><li>(Harvey, Rendano, Vet Surg) </li></ul></ul><ul><ul><li>89% 8/9 cases 1992 </li></ul></ul><ul><ul><li>(Shealey, Henderson, Vet Surg) </li></ul></ul><ul><ul><li>100% 4/4 cases 1999 </li></ul></ul><ul><ul><li>(Cairo, Font , JSAP) </li></ul></ul><ul><li>58% 7/12 cases 2004 </li></ul><ul><li>(Junius, Appeldorn, JSAP) </li></ul><ul><ul><li>Surgery within 60 minutes of presentation </li></ul></ul>
  13. 15. Comparative aspects <ul><li>Reported in dogs, cats, pigs, cows, horses, humans and whales </li></ul><ul><li>Extensively investigated in humans </li></ul><ul><ul><li>Most commonly presents in infancy </li></ul></ul><ul><ul><li>Can occur in children/ adults </li></ul></ul><ul><ul><li>Presentation- GI malrotation </li></ul></ul><ul><ul><ul><ul><li>Many asymptomatic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bilious vomiting </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Abdominal pain, chronic waxing/waning GI signs, weight loss, reflux </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Acute intestinal volvulus and shock </li></ul></ul></ul></ul>
  14. 16. Aetiology <ul><li>Failure of normal embryological intestinal development </li></ul><ul><li>Shortened distance between dorsal attachments of cecum and duodenojejunal junctions </li></ul><ul><li>Variable dorsal attachment of duodenal jejunal junction </li></ul><ul><li>Narrowed mesenteric root predisposed to twist </li></ul>
  15. 17. Introducing the...Ligament of Treitz <ul><li>Not well known in clinical vet med </li></ul><ul><li>Well characterised in canine applied comparative physiology </li></ul><ul><li>Regulates outflow from duodenum to jejunum </li></ul><ul><li>Physiologic sphincter </li></ul><ul><li>Role in embryologic GI rotation </li></ul>
  16. 18. Treatment- Ladd procedure <ul><li>Counterclockwise derotation of the intestinal twist </li></ul><ul><li>Careful dissection between caecum and ligament of Treitz to mobilise dorsal attachments and widen mesenteric root </li></ul><ul><li>Positioning of duodenum on right and large bowel on left </li></ul><ul><li>Prophylactic appendectomy </li></ul>
  17. 19. Key questions.... <ul><li>Does the syndrome of intestinal malrotation exist in dogs? </li></ul><ul><li>Is there the same variation in distance between the attachment of the ligament of Treitz and the base of the caecum in dogs? </li></ul><ul><li>Does this alteration in the base of the mesenteric root predispose to intestinal volvulus? </li></ul>
  18. 20. Intestinal torsion pathophysiology <ul><li>Mesenteric vein obstructed > artery </li></ul><ul><li>Intestine congests- mucosa sloughs + blood leaks into lumen </li></ul><ul><li>Villi rapidly compromised- ↑susceptibility -countercurrent mechanism </li></ul><ul><li>Tissue hypoxia and ischemia->generalised ileus and pain </li></ul><ul><li>Abdominal fluid </li></ul><ul><ul><ul><li>transudate from venous and lymphatic congestion </li></ul></ul></ul><ul><ul><ul><li>exudate with rupture </li></ul></ul></ul>
  19. 21. Ischemia and re-perfusion injury
  20. 22. Relevance?
  21. 23. Post-op concerns <ul><li>Hypotensive </li></ul><ul><li>Arrhythmias </li></ul><ul><li>Ongoing massive GI losses </li></ul><ul><ul><ul><li>3.5l in first 24 hrs </li></ul></ul></ul><ul><ul><ul><li>NG tube </li></ul></ul></ul><ul><li>Comatose, bilateral miosis </li></ul><ul><li>Respiratory acidosis </li></ul><ul><li>Coagulopathic </li></ul><ul><ul><ul><li>Platelets= 46,000 </li></ul></ul></ul><ul><ul><ul><li>PT=15.1 (5.5-9.8) </li></ul></ul></ul><ul><ul><ul><li>aPTT=25.6 (9.8-19.6) </li></ul></ul></ul><ul><li>Hypoproteinemic </li></ul><ul><ul><ul><li>Alb=12g/l </li></ul></ul></ul><ul><ul><ul><li>COP=9.6mmHg </li></ul></ul></ul>
  22. 24. But... <ul><li>Responsive to pressors and fluid support </li></ul><ul><ul><ul><li>Norepinephrine </li></ul></ul></ul><ul><ul><ul><li>8l fluids </li></ul></ul></ul><ul><li>Oxygenating well </li></ul><ul><li>Urine output>2ml/kg/hr </li></ul><ul><li>PCV=37% </li></ul>
  23. 25. CNS dysfunction in the critically ill <ul><li>Coma </li></ul><ul><ul><ul><li>Global hemispheric dysfunction </li></ul></ul></ul><ul><ul><ul><li>Brainstem RAS </li></ul></ul></ul><ul><li>Disruption to BBB </li></ul><ul><ul><ul><li>Cytokine mediated </li></ul></ul></ul><ul><ul><ul><li>Vasogenic+ cytotoxic edema </li></ul></ul></ul><ul><li>DDx </li></ul><ul><ul><ul><li>Sepsis encephalopathy </li></ul></ul></ul><ul><ul><ul><li>Narcotics </li></ul></ul></ul><ul><ul><ul><li>Electrolyte/ acid base derangement </li></ul></ul></ul><ul><ul><ul><li>Shock </li></ul></ul></ul><ul><ul><ul><li>Thrombosis </li></ul></ul></ul>
  24. 26. Interventions- supportive <ul><li>Naloxone trial </li></ul><ul><li>Intubation and ventilation </li></ul><ul><ul><ul><li>PaCO 2 ↓ to 30mmHg </li></ul></ul></ul><ul><ul><ul><li>Airway protected </li></ul></ul></ul><ul><li>Colloidal support </li></ul><ul><li>Cefoxitin </li></ul><ul><li>GI protectants </li></ul><ul><li>Trickle feeding </li></ul>VS
  25. 27. Response... <ul><li>Regained consciousness/ extubated 35 hours post-op </li></ul><ul><li>Continued hemorrhagic diarrhoea- ↓volume </li></ul><ul><li>Normotensive </li></ul><ul><li>Ileus resolving </li></ul><ul><li>Continued hypoalbuminemia/ low COP </li></ul><ul><ul><ul><li>2 units platelet rich FFP </li></ul></ul></ul><ul><ul><ul><li>Pentastarch CRI 1ml/kg/hr </li></ul></ul></ul><ul><ul><ul><li>Eating spontaneously on day 4 post-op </li></ul></ul></ul><ul><li>Sudden decline in PCV @ day 4 29%->14% </li></ul><ul><li>Marked facial edema </li></ul>
  26. 28. Diffuse facial edema <ul><li>Hypersensitivity reaction </li></ul><ul><ul><ul><li>FFP </li></ul></ul></ul><ul><ul><ul><ul><li>Recipient Abs vs donor plasma proteins </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Within 48 hours of administration </li></ul></ul></ul></ul><ul><ul><ul><li>Drugs </li></ul></ul></ul><ul><ul><ul><ul><li>Antibiotics </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Opiates </li></ul></ul></ul></ul><ul><ul><ul><li>Artificial colloids </li></ul></ul></ul><ul><li>Local venous/ lymphatic obstruction </li></ul><ul><ul><ul><li>Jugular thrombosis associated with central line </li></ul></ul></ul>
  27. 29. Acute decline in PCV <ul><li>Delayed transfusion reaction </li></ul><ul><li>Acute GI bleed </li></ul><ul><ul><li>No clinical signs </li></ul></ul><ul><li>Immune mediated </li></ul>
  28. 30. Delayed transfusion reactions <ul><li>Inciting antigen </li></ul><ul><ul><li>DEA 3,5,7 natural alloantibodies in 5 to 30% dogs </li></ul></ul><ul><ul><ul><li>Only primary transfusion needed </li></ul></ul></ul><ul><ul><li>Any other antigen </li></ul></ul><ul><ul><ul><li>‘ Priming’ transfusion sensitises 3 to 5d prior </li></ul></ul></ul><ul><ul><ul><li>Reaction with any subsequent transfusion </li></ul></ul></ul><ul><ul><ul><li>Acute hemolytic with DEA 1.1, 1.2 </li></ul></ul></ul><ul><ul><ul><li>‘ Delayed’ type with other antigens </li></ul></ul></ul>
  29. 31. Delayed transfusion reactions <ul><li>Delayed </li></ul><ul><ul><ul><li>NOT PREVENTABLE with type/ crossmatch </li></ul></ul></ul><ul><ul><ul><li>3-14d post transfusion </li></ul></ul></ul><ul><ul><ul><li>Multiple manifestations </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Extravascular hemolysis- PCV drop </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fever </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Thrombocytopenia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Post transfusion immunosuppression </li></ul></ul></ul></ul></ul>
  30. 32. Back to Lennox.... <ul><li>Treatment supportive </li></ul><ul><li>Further PRBC transfusion given </li></ul><ul><li>Immunosuppression not indicated </li></ul><ul><li>Discharged 8 days after admission </li></ul><ul><li>Re-admitted for further transfusion support 7d later- icteric </li></ul><ul><li>2 weeks later PCV=38% </li></ul>
  31. 33. <ul><li>And thanks to: </li></ul><ul><li>Dr Ainsley Boudreas </li></ul><ul><li>Dr Judy Brown </li></ul><ul><li>Dr Sylvan Bichot </li></ul><ul><li>ICU technicians </li></ul><ul><li>The blood bank </li></ul>

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