The peritoneal cavity is the inside of the belly (abdomen) that houses vital organs such as the stomach, intestines, spleen, liver, kidneys and bladder. A very thin membrane called the peritoneum covers these organs.
By definition, characteristics of inflammation include redness, swelling, pain and discharge. Peritonitis is inflammation of the lining of the abdominal cavity. The most common cause of peritonitis is bacterial infection, which is introduced into the abdomen from an external wound, or more commonly from a perforation of an internal organ. The intestines or stomach may perforate and leak bacteria into the peritoneal cavity as a result of a tumor of the intestines or stomach, which weakens and ruptures the bowel. A perforating stomach or intestinal ulcer and associated peritonitis can be caused by an adverse reaction to certain types of medications (steroids and nonsteroidal anti-inflammatory). Other causes of peritonitis may include liver abscess, inflammation of the pancreas (pancreatitis), rupture of the gallbladder or bile duct, rupture of the bladder, rupture of an infected uterus (pyometra), previous abdominal surgery and viral infection in cats (feline infectious peritonitis). Primary bacterial septic peritonitis is a very uncommon condition in dogs and cats in which there is no identifiable underlying source of bacterial infection in the abdomen. It is possible that this type of infection is transferred from the mouth via the blood stream to the abdomen in these patients.
In many cases, the patient will be seemingly well and then suddenly become very ill. Signs that may be noted at home include weakness, rapid respirations, vomiting, loss of appetite, diarrhea, black stools, and unwillingness to lie down or assuming a “praying position” (hind end elevated and front end and head lying on the ground). Signs that may be noted by your veterinarian may include fever, low body temperature, pale gums, jaundice, rapid heart rate, low blood pressure, fluid in the abdomen, pain upon palpation of the abdomen and potentially a mass in the abdomen.
The diagnosis of peritonitis is based on clinical findings and analysis of fluid from the abdomen. Ultrasound guidance may be needed to collect fluid from the abdomen. The fluid will contain inflammatory cells called neutrophils and in some cases bacteria. Tests done prior to surgery may include a complete blood count, blood chemistry profile, and urinalysis to evaluate the health of the internal organs. Chest x-rays and abdominal ultrasound may be recommended to identify the presence of absence of cancer.
The day of surgery
Peritonitis should be treated on an emergency basis, as a “wait and see” approach will result in further debilitation of the patient and worsening of the prognosis. Our anesthesia and surgical team will prescribe a pain management program, both during and after surgery that will keep your companion comfortable. This will include a combination of general anesthesia, injectable analgesics, epidural analgesia, oral analgesics and anti-inflammatory medication. Your pet's surgeon will contact you after the surgical procedure has been completed.
Exploratory surgery and correction of the underlying problem (ruptured bowel, ruptured gallbladder, ruptured bladder, etc) is the treatment for peritonitis. If no underlying cause of the peritonitis is found, the peritoneal cavity is rinsed with sterile saline to help eradicate the infection. At the discretion of the surgeon, one or two drains may be placed in the abdomen. In some cases, the abdomen may still be temporarily left open (with a bandage applied to keep the organs in place) to allow the infection to efficiently drain. A feeding tube may be placed in some cases. After surgery, intravenous fluids and antibiotics are administered. Commonly, plasma transfusion or administration of artificial plasma is needed to help your companion recover. Most patients remain in the hospital for 3 to 7 days after surgery, during which the drainage tubes will be removed.
Chemotherapy may be recommended if a malignant tumor is removed from the abdomen. This treatment is typically started two weeks after surgery. This medication will be administered every two to three weeks via intravenous injection by our oncologist for a total of four to five treatments. Each treatment, which may take 90 mintues to complete, is typically done on an outpatient basis. Unlike humans, most dogs do not lose their hair and usually have only mild side effects from the medication. These side effects may may include transient loss of appetite and vomiting.
After surgery, you can continue to give your pet a prescribed pain reliever to minimize discomfort. It’s also extremely important to limit your dog’s activity and exercise level for three weeks after surgery. The incision should be checked daily for signs of infection. Two weeks after surgery, the surgeon will monitor the healing process and if indicated, our oncologist will initiate chemotherapy.
Complications following surgery may include persistence of infection and death of the patient. If the patient has cancer, it may metastasize to other internal organs, which ultimately will cause death.
Below is a summary of patient survival following treatment of septic peritonitis:
||64% in early group; 57% in later group
- Bentley AM. Comparison of dogs with septic peritonitis: 1988-1993 versus 1999-2003. J Vet Emerg Critical Care 17 (4):391-398, 2007
- Ruthrauf CM, Smith J, Glerum L. Primary bacterial septic peritonitis in cats: 13 cases. J Am Anim Hosp Assoc 45:268-276, 2009
- Staatz AJ, Monnet E, Seim HB. Open peritoneal drainage versus primary closure for the treatment of septic peritonitis in dogs and cats: 42 cases (1993-1999). Vet Surg 31:174-180, 2002
- Greenfield CL, Walshaw R: Open peritoneal drainage for treatment of contaminated peritoneal cavity and septic peritonitis in dogs and cats: 24 cases (1980-1986). J Am Vet Med Assoc 191:100-105, 1987
Frequently Asked Questions After Surgery
When should my dog have the first bowel movement after surgery?
- Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
- Reasons that a dog will not have regular bowel movements after surgery include:
- The dog has been fasted prior to surgery
- Dogs do not eat well during the hospital stay
- They frequently do not eat well when they go home
- They are fed highly digestible food that produces little stool
- Pain medication that contain narcotics (such as morphine, fentanyl patches, and tramadol) can be constipating
- If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed
- Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable
My pet had surgery and will not eat. What can be done?
- Most pets will not eat their regular dog food after surgery, especially if it is kibble.
- Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source. The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked). The carbohydrate can be pasta, potato or white rice.
- Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
- Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
- Try Hill's A/D diet available at most veterinary hospitals
- Hand feeding: place a small amount of food in the mouth so that your dog gets the flavor
- Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
- Remember that most pets will not eat the first day or two after they get home from surgery
- Offer smelly foods that contain fish such as tuna or smelly cat foods
- Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
- Hand feeding: with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth
- Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature; it should be only luke-warm
- Some cats will only eat dry food, try kibble if your cat normally has been fed that food
- Petting and stroking your cat frequently will help to stimulate appetite
- Remember that most pets will not eat the first day or two after they get home from surgery
- Appetite stimulants such as cyproheptadine may be helpful
- If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop
My pet is vomiting. What can be done?
- The first thing for you to discern is whether your pet is vomiting or regurgitating. Both will result in fluid or food being brought up. Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus. Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled. Usually the regurgited material will be clear or brown colored fluid.
- Next is to identify the cause of the vomiting or regurgitation.
- Causes and treatment of vomiting after surgery
- When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
- Medications such as antibiotics, narcotics or nonsteroidal anti-inflammatory medication commonly cause vomiting after surgery. In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart. Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to. The antibiotic in some cases may be changed to a different one, or may be discontinued.
- Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days.
- An uncommon cause of vomiting after surgery is internal organ failure. Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
- If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present. Do not ignore this sign.
- Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days. In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days. Metoclopramide and Cerenia are good anti-vomiting medications for dogs and cats. You should always consult a veterinary healthcare professional before administering medication.
- Causes and treatment of regurgitation after surgery
- The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia. Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis. This results in poor motility of the esophagus, therefore water and food will accumulate in this structure. In most cases, esphagitis is self-eliminating and will resolve within two or three days.
- If the esophagitis is severe the esophagus may develop one or more strictures. A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week. This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope). If an esophageal stricture is chronic surgery is needed.
- Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other). Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.
How do I know that my dog is in pain following surgery?
- Signs of pain include
- biting if you get near the surgical site
- grimacing (lips are pulled back and the the dog looks anxious)
- tragic facial expression
- restlessness and unable to sleep; pacing
- if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
- the worst pain will be for the first 2 to 3 days after surgery
What can I do to control my dog's pain?
- Narcotic medications that control pain: tramadol, butorphanol, Duragesic (fentanyl patch)
- Anti-inflammatories used to control pain: Deramaxx, Rimadyl, Previcox, or Etogesic
- If an orthopedic surgery has been done cold packing the surgical site may be helpful
- A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack. An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern. Cooling the surgical site helps to numb the area.
How do I know that my cat is in pain following surgery?
- Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain
- Signs of pain in a cat include the following:
- biting if you get near the surgical site
- growling or deep cry
- not wanting to eat
- hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)
What can be done for pain at home for my cat?
- Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
- Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
- Anti-inflammatories can be used, but the dose is much less than dogs
Is it okay for my pet to lick the incision?
- If a dog licks the incision, the healing process may be delayed.
- Licking can remove stitches and cause the incision to open
- Licking can become a severe habit that is difficult to break
- Licking can cause infection as the mouth has many bacteria
- Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
- To stop your pet from licking the following can be tried:
- Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
- Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
- A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.
- A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.
- Bitter apple can be applied around the incision; many dogs will continue to lick after application of this topical
- Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
- Antipsychotic medication in some cases is needed