Medical management of pneumoperitoneum, gastric pneumatosis, and hepatic venous gas secondary to 3% hydrogen peroxide toxicity in a dog

OBJECTIVE

To describe the medical management and outcome of a dog suffering severe hydrogen peroxide toxicity.

CASE SUMMARY

A 3-year-old neutered female Bichon Frise was presented to an emergency and referral practice after ingestion of 10-20 mL/kg 3% hydrogen peroxide. On presentation, the dog was obtunded, was tachypneic, and had severe gastric tympany. Abdominal radiographs revealed pneumoperitoneum, gastric pneumatosis, and hepatic venous gas. The dog was managed conservatively with supportive care and oxygen therapy. Repeat radiographs 6 hours later showed complete resolution of all gas inclusions. While hospitalized, the dog developed severe hematemesis, and abdominal ultrasound revealed severe gastric wall thickening. Subsequent endoscopy confirmed severe gastric mucosal necrosis without evidence of deeper ulceration and relatively mild petechiation of the esophagus. The dog was ultimately discharged after 5 days of hospitalization and continued to do well at home. Recheck ultrasound 5 weeks postdischarge showed normal gastric wall appearance.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first reported case of pneumoperitoneum secondary to hydrogen peroxide toxicity and the first description of the clinical course of severe toxicity in dogs.

Sonographic features of the uncomplicated postoperative abdomen in dogs treated for pyometra by ovariohysterectomy

Pyometra is a prevalent disease in intact bitches and the standard treatment is ovariohysterectomy (OHE). Published descriptions of normal sonographic findings after OHE are currently lacking. The aims of this prospective observational study were to describe and compare postoperative abdominal sonographic features for three timepoints following OHE in a group of dogs with pyometra and an uneventful recovery. A total of 22 dogs had sequential focused abdominal ultrasound examinations on days 1, 4-6, and 10-15 postsurgery. Recorded sonographic features for each examination time point and characteristics of the cervical stump and the mesovarium, size, and echogenicity of medial iliac lymph nodes (MILNs), presence of free peritoneal fluid, and pneumoperitoneum. The cervical stump appeared as a heterogenous area with a hypoechoic center surrounded by hyperechogenic tissue in all dogs. The cervical stump transverse-sectional area was larger on day 4-6 compared with day 1 and day 10-15 (P = .0009). Mesovarium ligature reactions were identified as heterogeneous and hyperechoic areas with central and/or edge shadowing in all dogs. The size and echogenicity of MILNs and the mesovarium reactions did not significantly differ among time points. Free peritoneal fluid was detected in 45%, 41%, and 9% and pneumoperitoneum in 95%, 82%, and 14% of dogs at sequential time points. Findings from this sample of dogs with an uneventful recovery following OHE due to pyometra can be used to assist veterinarians in interpreting postoperative abdominal ultrasonographic characteristics in future dogs treated surgically for pyometra.

Is pneumothorax secondary to pneumoperitoneum a real risk in dogs undergoing total laparoscopic gastropexy?

Background: There were described in veterinary literature the possibility of pneumothorax as a complication of laparoscopic surgery in dogs undergoing laparoscopic ovariectomy associated with total laparoscopic gastropexy. Aim: To assess if spontaneous pneumothorax secondary to pneumoperitoneum is a real risk in dogs undergoing total laparoscopic gastropexy. Methods: Dogs undergoing totally laparoscopic gastropexy received chest x-rays (CXR) in lateral (left and right) and ventro-dorsal projection before and after the surgery. Two veterinary radiologists reported the x-rays and indicated the presence or not of pneumothorax. Result: Postoperative pneumothorax was not detected on postoperative CXR in the total of 76 dogs of the study. Conclusion: The odds risk of pneumothorax after total laparoscopic gatropexy surgical procedure is low.

Cardiovascular and respiratory effects of carbon dioxide pneumoperitoneum in the domestic rabbit (Oryctolagus cuniculus)

The objective of this study was to evaluate the effect of intra-abdominal pressure (IAP) on cardiorespiratory parameters during pneumoperitoneum with carbon dioxide in domestic rabbits. Six juvenile female New Zealand white rabbits were assigned to randomized sequences of IAP (0, 4, 8 mmHg) in a crossover study. The following parameters were measured at each IAP: direct arterial blood pressure (ABP); cardiac output, (CO), cardiac index, and stroke volume index (CI, SVI); heart rate; end-tidal carbon dioxide (ETCO₂); arterial blood gases (PaCO₂, PaO₂); peak inspiratory pressure (PIP); and peripheral oxygen saturation (SpO₂). Between IAPs, the abdomen was desufflated for a 5-minute washout period. Mixed linear regression models were used for statistical analysis. Heart rate, SpO₂, and ABP were not significantly affected by IAP, although there was a positive increase in ABP with IAP. Partial pressure of carbon dioxide (PaCO₂) was increased at an IAP of 8 mmHg and ETCO₂ and PIP were greater with each IAP applied. Cardiac output and CI were significantly decreased with IAP and, although SVI showed the same trend, it was not statistically significant. In conclusion, pneumoperitoneum with carbon dioxide causes an increase in ETCO₂, PaCO₂, and PIP, whereas cardiac output and CI decrease. These cardiorespiratory changes should be considered when determining the optimal IAP for laparoscopic procedures in rabbits.

Large-volume pneumoperitoneum and septic peritonitis secondary to splenic abscess rupture in a dog

An 11-year-old spayed female American pit bull terrier mixed breed dog was presented because of hyporexia and abdominal distension. The dog had large-volume free peritoneal gas on imaging and septic neutrophilic exudate on abdominocentesis. Exploratory laparotomy revealed a ruptured splenic mass draining purulent material. A splenectomy was performed and the abdomen was lavaged. Culture samples grew an anaerobic Gram-positive rod. The dog was discharged 4 days after surgery with no residual problems noted 1 week later. To our knowledge, this is the first report of large-volume pneumoperitoneum and septic peritonitis secondary to rupture of a splenic abscess.

Tension Pneumoperitoneum Due to Gastric Perforation in a Cat

A 14-year-old spayed female cat weighing 2.3 kg developed tension pneumoperitoneum that progressed for 6 hr. Abdominocentesis was performed and 1.3 L of gas was aspirated after which the cat's respiratory condition improved. The next day, the cat's abdomen redistended, and laparotomy was performed. A gastric perforation was noted and sutured after the margin was resection. The cat showed a good physical condition without any gastrointestinal signs at 6 months after surgery.

Outcome of and prognostic indicators for dogs and cats with pneumoperitoneum and no history of penetrating trauma: 54 cases (1988–2002)

OBJECTIVE

To determine the outcome of and prognostic indicators for dogs and cats with pneumoperitoneum and no history of penetrating trauma.

DESIGN

Retrospective study.

ANIMALS

43 dogs and 11 cats.

PROCEDURE

Medical records of dogs and cats with radiographic evidence of pneumoperitoneum and no history of penetrating trauma were reviewed. Information collected included signalment, previous medical problems, initial complaint, duration of illness, physical examination findings, radiographic findings, laboratory abnormalities, abdominocentesis results, bacterial culture results, concurrent diseases, hospitalization time, and outcome. Abdominal radiographs were reviewed, and radiographic severity of pneumoperitoneum was classified. For those animals that underwent exploratory laparotomy, time from admission to surgery and results of histologic examination of biopsy specimens were recorded.

RESULTS

24 (44%) animals survived and were discharged from the hospital, but none of the variables examined was associated with whether animals survived. Rupture of the gastrointestinal tract was the cause of pneumoperitoneum in 40 animals. However, cause and location of gastrointestinal tract rupture was not associated with whether animals survived. Twenty-three of 40 (58%) animals that underwent exploratory laparotomy survived, compared with only 1 of 14 animals that did not undergo surgery.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that pneumoperitoneum in dogs and cats without any history of penetrating trauma is most commonly associated with rupture of the gastrointestinal tract and requires immediate surgical intervention. Even when appropriate treatment is instituted, the shortterm prognosis is only fair.

Pneumatosis in Canine Gastric Dilatation-Volvulus Syndrome

Retrospectively, 243 dogs with radiographic evidence of gastric dilatation-volvulus (GDV) were studied for radiographic signs of pneumatosis (intramural gas), pneumoperitoneum, splenomegaly, and severity of gastric distention. The sensitivity, specificity, and predictive value of these imaging signs as predictors of gastric wall necrosis, as determined by visual inspection at surgery or necropsy, were determined. The sensitivity and specificity of gastric pneumatosis were 14.1% and 92.7%, respectively. The prevalence of gastric wall necrosis was 26.6%. The positive and negative predictive values of gastric pneumatosis for predicting gastric necrosis were 40.9% and 74.9%, respectively. Gastric pneumatosis and pneumoperitoneum were identified together in four dogs. Pneumoperitoneum, either alone or in conjunction with pneumatosis, yielded similar results as a test for gastric necrosis. Splenomegaly and severity of gastric distention were insensitive and nonspecific for gastric wall necrosis. Splenomegaly did not predict the need for splenectomy at surgery. Although pneumatosis and pneumoperitoneum are relatively specific signs of gastric wall necrosis, the utility of these signs as a test for gastric necrosis is limited in clinical practice. The significance of pneumatosis should be taken into consideration with previous treatments for gastric decompression, as percutaneous gastric trocharization or orogastric intubation may increase the number of false-positive results.

Pneumoperitoneum in dogs and cats: 39 cases (1983-2002)

OBJECTIVE

To identify the most common causes of pneumoperitoneum in dogs and cats and determine history, clinical features, and outcome of affected animals.

DESIGN

Retrospective study.

ANIMALS

31 dogs and 8 cats.

PROCEDURES

Medical records were reviewed for signalment; history; abnormal physical, clinicopathologic, and radiographic findings; results of cytologic analysis and bacterial culture of abdominal fluid; gross and histologic findings at surgery or necropsy; and outcome.

RESULTS

Pneumoperitoneum was classified as spontaneous in 25 animals and traumatic in 14. Causes of traumatic pneumoperitoneum included vehicular impact, gunshot wounds, abdominal dog bite wounds, and iatrogenic pneumothorax. Spontaneous pneumoperitoneum was caused by gastrointestinal tract perforation in 23 animals; underlying causes included neoplasia, nonsteroidal anti-inflammatory drug administration, and corticosteroid administration. Two animals developed spontaneous pneumoperitoneum after bladder rupture. Animals with spontaneous pneumoperitoneum were significantly older and had clinical signs of longer duration than those with traumatic pneumoperitoneum. Sixteen animals survived, including 15 of 23 animals that underwent surgery. Animals that survived had significantly higher serum albumin concentrations than did animals that died or were euthanatized.

CONCLUSIONS AND CLINICAL RELEVANCE

Although pneumoperitoneum is most often attributable to perforation of a hollow viscus, other causes do exist. Early exploration is recommended for diagnosis and treatment of the underlying condition.

Tracheal gas isufflation-aided mechanical ventilation during carbon dioxide-induced pneumoperitoneum in rabbits

Despite numerous benefits of laparoscopic procedures, the serious hypercapnia and respiratory acidosis in hypercapnic patients with decreased pulmonary compliance during carbon dioxide-induced pneumoperitoneum (CDP) may be developed. Tracheal gas insufflation (TGI) has been shown to be a useful adjunct to controlled mechanical hypoventilation. This study was undertaken to identify whether TGI superimposed on controlled mechanical ventilation (CMV) improve ventilatory efficiency during CDP in rabbits. Sixteen paralyzed and anesthetized rabbits were used. The animals were assigned to two groups-CMV group: CMV alone; TGI group: CMV superimposed by TGI with flow rate of 2L/min. The animals were insufflated to intra-abdominal pressure of 8 mmHg with CO2 gas. Then, tidal volume (V(T)) was changed to maintain the set peak inspiratory pressure (PIP) value, while other ventilatory settings were kept constant. The set PIP value corresponding to 30, 60, and 90 min after the start of peritoneal insufflation of CO2 were 15, 22, and 25 cm H2O, respectively. During CDP with TGI, PaCO2 decreased significantly (p<0.01) from CMV without TGI of 82.1 +/- 14.1 to 47.5 +/- 5.5, 58.1 +/- 9.9 to 40.0 +/- 4.6, 47.1 +/- 9.4 to 32.7 +/- 5.1 mmHg at PIP of 15, 22, and 25 cm H2O, respectively. The inspired V(T) decreased significantly (p<0.05) from CMV without TGI of 18.4 +/- 3.9 to 12.8 +/- 2.8 ml at PIP of 15 cm H2O. TGI superimposed on CMV is more effective than CMV alone in enhancing ventilatory efficiency during CDP in rabbits.

Pneumoperitoneum secondary to a perforated gastric ulcer in a cat

A 7-year-old domestic cat was examined because of a history of weight loss, intermittent diarrhea, and anorexia of 6 months' duration. Results of physical examination were normal except for marked abdominal tension. Results of a CBC and serum biochemistry profile were unremarkable. Severe pneumoperitoneum was noted radiographically, and abdominocentesis yielded 640 mL of air. Abdominal distension recurred 1 day after abdominocentesis. Exploratory laparotomy was performed 3 days after recurrence of abdominal distension and revealed a gastric perforation along the greater curvature of the stomach with omental and pancreatic adhesions at the site of perforation. Mild local peritoneal inflammation was also noted. A partial gastrectomy was performed to resect the lesion, and histologic examination confirmed a severe perforating ulcer. The gastric wall adjacent to the ulcer was histologically normal. Aerobic and anaerobic bacteriologic cultures of abdominal swab specimens were negative for bacterial growth. The cat was discharged 4 days after surgery and clinically normal at suture removal.

Cardiopulmonary, blood and peritoneal fluid alterations associated with abdominal insufflation of carbon dioxide in standing horses

REASONS FOR PERFORMING STUDY

Abdominal insufflation is performed routinely during laparoscopy in horses to improve visualisation and facilitate instrument and visceral manipulations during surgery. It has been shown that high-pressure pneumoperitoneum with carbon dioxide (CO2) has deleterious cardiopulmonary effects in dorsally recumbent, mechanically ventilated, halothane-anaesthetised horses. There is no information on the effects of CO2 pneumoperitoneum on cardiopulmonary function and haematology, plasma chemistry and peritoneal fluid (PF) variables in standing sedated horses during laparoscopic surgery.

OBJECTIVES

To determine the effects of high pressure CO2 pneumoperitoneum in standing sedated horses on cardiopulmonary function, blood gas, haematology, plasma chemistry and PF variables.

METHODS

Six healthy, mature horses were sedated with an i.v. bolus of detomidine (0.02 mg/kg bwt) and butorphanol (0.02 mg/kg bwt) and instrumented to determine the changes in cardiopulmonary function, haematology, serum chemistry and PF values during and after pneumoperitoneum with CO2 to 15 mmHg pressure for standing laparoscopy. Each horse was assigned at random to either a standing left flank exploratory laparoscopy (LFL) with CO2 pneumoperitoneum or sham procedure (SLFL) without insufflation, and instrumented for measurement of cardiopulmonary variables. Each horse underwent a second procedure in crossover fashion one month later so that all 6 horses had both an LFL and SLFL performed. Cardiopulmonary variables and blood gas analyses were obtained 5 mins after sedation and every 15 mins during 60 mins baseline (BL), insufflation (15 mmHg) and desufflation. Haematology, serum chemistry analysis and PF analysis were performed at BL, insufflation and desufflation, and 24 h after the conclusion of each procedure.

RESULTS

Significant decreases in heart rate, cardiac output and cardiac index and significant increases in mean right atrial pressure, systemic vascular resistance and pulmonary vascular resistance were recorded immediately after and during sedation in both groups of horses. Pneumoperitoneum with CO2 at 15 mmHg had no significant effect on cardiopulmonary function during surgery. There were no significant differences in blood gas, haematology or plasma chemistry values within or between groups at any time interval during the study. There was a significant increase in the PF total nucleated cell count 24 h following LFL compared to baseline values for LFL or SLFL at 24 h. There were no differences in PF protein concentrations within or between groups at any time interval.

CONCLUSIONS

Pneumoperitoneum with CO2 during standing laparoscopy in healthy horses does not cause adverse alterations in cardiopulmonary, haematology or plasma chemistry variables, but does induce a mild inflammatory response within the peritoneal cavity.

POTENTIAL RELEVANCE

High pressure (15 mmHg) pneumoperitoneum in standing sedated mature horses for laparoscopic surgery can be performed safely without any short-term or cumulative adverse effects on haemodynamic or cardiopulmonary function.

Spontaneous pneumoperitoneum in two cats

Spontaneous pneumoperitoneum is an infrequently observed presentation in cats. This report details two cases of pneumoperitoneum in the cat. The first case was suspected to have been caused by a gastric perforation secondary to gastric lymphoma. The second case was caused by a perforated gastric ulcer in a cat that had been recently treated with corticosteroids and a non-steroidal anti-inflammatory drug.

Idiopathic pneumoperitoneum in a dog

A 13-year-old, neutered male standard poodle with tachypnea and abdominal distension was diagnosed with pneumoperitoneum. Pneumoperitoneum can be due to a perforated gastrointestinal tract, penetrating abdominal wounds, gas-producing bacterial peritonitis, or it can be iatrogenically introduced during surgery. Idiopathic pneumoperitoneum is a condition diagnosed in humans after exclusion of perforated gastrointestinal tract and other known causes of free intra-abdominal gas. This report suggests that dogs may suffer from a similar syndrome.

Subcutaneous emphysema, pneumoperitoneum, and pneumoretroperitoneum after gastrostomy tube placement in a cat

A 17-year-old spayed female domestic shorthair cat developed subcutaneous emphysema, pneumoperitoneum, and pneumoretroperitoneum during endoscopic placement of a gastrostomy feeding tube after gastric insufflation and cannula insertion. The cat underwent exploratory laparotomy to investigate the possibility of gastric rupture but only a 2- to 3-mm defect was found in the gastric fundus at the site of cannula insertion. Pasteurella multocida and Enterobacter spp were cultured aerobically from the peritoneal cavity. The cat recovered without complications.

Pneumoperitoneum and gastric perforation in a minimally clinically affected dog

A 13-year-old female sheepdog had a reduced appetite, depression, vomiting and moderate tympanic abdominal distension. A severe pneumoperitoneum was detected radiographically. The cause of the pneumoperitoneum was a small perforation in the gastric cardia secondary to necrosis. This report describes severe pneumoperitoneum due to gastric perforation in a minimally clinically affected patient.

Concurrent abomasal displacement and perforating ulceration in cattle: 21 cases (1985-1996)

OBJECTIVE

To evaluate the association of physical examination and clinicopathologic findings with surgical findings in cattle with concurrent abomasal displacement and perforating ulceration, to determine short- and long-term survival rates in these cattle, and to determine whether degree of peritonitis (focal vs diffuse) influences survival rates.

DESIGN

Retrospective study.

ANIMALS

21 cattle with concurrent abomasal displacement and perforating ulceration and 42 cattle with uncomplicated abomasal displacement.

PROCEDURE

Information on signalment, stage of lactation, physical examination findings, clinicopathologic data, surgical diagnosis, procedure(s) performed, and necropsy findings were retrieved from medical records of all cattle included in this study. Differences between physical examination findings of cattle with concurrent disease and those of cattle with uncomplicated displacements were evaluated, as were differences between survival rates in cattle with focal versus diffuse peritonitis.

RESULTS

Cattle with concurrent disease had a greater probability of having pneumoperitoneum and signs of abdominal pain identified on physical examination than did cattle with uncomplicated diseases. There was no relationship between clinicopathologic data and survival time. Short-term survival rate was 38%, and degree of peritonitis significantly influenced survival time in cattle with concurrent abomasal displacement and perforating ulceration. Long-term survival rate in these cattle was 14%.

CLINICAL IMPLICATIONS

Cattle with concurrent displaced abomasum and perforating ulceration have a poor chance for survival. In addition to detection of displaced abomasum, physical examination findings that can help lead to a presurgical diagnosis of this syndrome are pneumoperitoneum and signs of abdominal pain.

The identification of structures and conditions responsible for right side tympanitic resonance (ping) in adult cattle

In review of the case records of all cattle greater than or equal to 2 years of age admitted to the Large Animal Hospital of the New York State College of Veterinary Medicine in a 3-year-period, 366 were identified as having areas of right side tympanitic resonance (ping) due to gas distention of intra-abdominal structures. The source of the ping was identified as abomasum in 137 cattle, various segments of the intestinal tract in 157 cattle, and peritoneal gas in 2 cattle. In 70 cattle, no identification was made as to the source of the ping. In 151 (41%) of the cattle with areas of ping, both the clinical and definitive (surgical or necropsy) identification of the source of the ping was recorded. In these cattle, the sensitivity and predictive value of the clinical identification were determined for each structure. The sensitivity and predictively; for cecum and/or ascending colon, the sensitivity and predictive value were both 87%. Of all cattle in which a right side ping was recorded, the principal final diagnoses were: left displacement of the abomasum (116), right displacement of the abomasum (77), abomasal (and omasal) and volvulus (60), other gastrointestinal conditions (73), nongastrointestinal conditions(40).