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Step-by-Step Approach to Patient Care
Garret Pachtinger, VMD, Diplomate ACVECC

cute gastrointestinal (GI) distress and abdominal t Arched back or “prayer position” (Figure 1)
pain require prompt evaluation and immediate t Abdominal distension (Figure 2)
intervention to prevent further morbidity and mor- t GI signs, including vomiting, diarrhea, hypersalivation,
tality. The most important question is: Does the patient retching, or anorexia
require medical or surgical management? If surgical t Poor perfusion parameters, including pale mucous
management is warranted, the clinician will need to time membranes (Figure 3), prolonged capillary refill time,
the surgery to decrease further morbidity and maximize and poor pulse quality
survival. t Tachypnea and/or tachycardia.
Acute abdominal pain is associ-
ated with a variety of underlying
causes (Table 1), and results from:
t Stimulation of pain fibers—A-del-
ta and c-nociceptors—within the:
» GI tract (ie, submucosa, mus-
cularis or peritoneal lining of
hollow viscera)
» Abdominal organs (ie, capsule
distension and stretching of
spleen and liver)
» Nerves, muscle, fascia, and skin
associated with the abdominal
t Pain referred from extra-abdom-
inal sites.1

STEP 1. Determine if clinical 2

signs are associated with acute Figure 1. Abdominal stretching or the classic
abdominal pain. “prayer position”
Clinical signs associated with acute Figure 2. Severe abdominal distension due to
abdominal pain may include:2 ascites
t Restlessness and/or guarding or Figure 3. Pale mucous membranes
splinting of the abdomen

14 Today’s Veterinary Practice September/October 2013


TABLE 1. Acute Abdominal Pain:

Differential Diagnosis List2 TABLE 2. Patient Status: Examples of
Abdominal t Abscessation/infection Diagnoses & Therapeutic Approach
Lymph Node t Neoplasia
External GI/ t Fasciitis
Abdominal t Herniation (umbilical, inguinal, Nonsurgical
Structures abdominal wall) Acute pancreatitis r IV fluid therapy
t Intervertebral disk disease Gastritis r Medications, including
t Myositis Gastroenteritis analgesics, antiemetics,
t Steatitis gastroprotectants, and
GI Tract t Gastric dilatation–volvulus prokinetics
Lesions t GI neoplasia, obstruction, Emergent
perforation, or ulceration Cardiovascularly stable Surgical candidates that
t Intestinal torsion hemoabdomen can:
t Intussusception Intestinal obstruction with- r Tolerate a delay in anes-
t Mesenteric thrombosis or torsion out evidence of peritonitis thesia and surgery
t Pyloric outflow obstruction
Uroabdomen, with place- r Require medical therapy
Pancreatic t Infarction of the pancreas ment of temporary urinary to optimize health status
Disease t Pancreatic abscess or peritoneal dialysis cath- prior to anesthesia and
t Pancreatitis eter surgery
Peritoneal t Bile peritonitis Critical
Cavity t Hemoperitoneum
Gastric dilatation–volvulus Patients that require:
Disease t Pneumoperitoneum
Mesenteric torsion r Rapid assessment and
t Septic peritonitis
Septic peritonitis treatment
t Uroperitoneum
Uncontrolled hemorrhage r Immediate emergency
Reproductive t Pyometra abdominal surgery; delay
Tract Disease t Testicular abscess or torsion will increase morbidity
t Uterine rupture or torsion and mortality
Reticulo- Hepatobiliary Disease
endothelial t Biliary tract rupture, mucocele,
System or obstruction STEP 2. Categorize patient as nonsurgical, emergent,
t Hepatic abscess, hepatitis, or or critical.
cholangiohepatitis When a patient presents with concern for GI distress and acute
t Liver lobe torsion abdominal pain, I try to place them into 1 of 3 categories:
t Neoplasia nonsurgical (medical), emergent, or critical (Table 2).
Splenic Disease Some cases are fairly straightforward; for example, the
t Fracture
4-year-old standard poodle that presents with acute onset
t Hematoma
t Neoplasia of panting, pacing, nonproductive retching, and distended
t Thrombosis abdomen. Gastric dilatation–volvulus (GDV) is the most likely
t Torsion diagnosis. However, other cases present with clinical signs
consistent with acute abdomen but too vague to identify a
Urinary Tract Prostatic Disease
t Prostatic neoplasia specific diagnosis without further evaluation.
t Prostatitis/prostatic abscess Therefore, use your well-tuned examination and diagnos-
Renal Disease tic skills to determine whether patients require a medical or
t Avulsion surgical approach.
t Calculi
t Infarct STEP 3. Perform triage evaluation and address any life-
t Neoplasia threatening abnormalities.
t Pyelonephritis Triage History
Urethral/Ureteral Disease Important triage information includes:3
t Obstruction t Signalment
t Passage of calculi
» Age: Younger patients may have a different differential list
t Rupture
Urinary Bladder Disease
(eg, trauma, poisoning) compared with older patients (eg,
t Cystitis neoplasia, metabolic disease)
t Neoplasia » Sex: Intact patients may also have a different differential
t Obstruction list (eg, pyometra, prostatic abscess) than that of neutered
t Rupture patients.
» Breed: Breed variations may help guide examination and

September/October 2013 Today’s Veterinary Practice 15


diagnostics, such as a standard poodle with GDV or

TABLE 3. Physical Examination: hypoadrenocorticism versus a dachshund with inter-
Assessment & Findings vertebral disk disease
t Presenting complaint
Cardiovascular r $BQJMMBSZ SFGJMM UJNF t Progression since initial onset.
r .VDPVT NFNCSBOFT Triage Examination
r 1VMTF RVBMJUZ A triage examination is a brief, focused, physical evalua-
r #PEZ UFNQFSBUVSF tion that is critical to assess major body systems, which
Respiratory r 3FTQJSBUPSZ SBUF FGGPSU include the cardiovascular (ie, circulation and tissue per-
POTENTIAL FINDINGS fusion), neurologic (ie, brain or spinal cord dysfunction),
respiratory (ie, airway patency, oxygenation), and uro-
Abdominal r "TDJUFT
genital (ie, renal function and urinary bladder integrity)
r %JTUFOEFE BCEPNFO XJUI systems. Failure to recognize an abnormality in any system
tympany on percussion (GDV) can result in immediate, life-threatening deterioration of
r 0SHBOPNFHBMZ STEP 4. Obtain detailed history and perform thorough
Eyes, Ears, r %FOUBM PDVMBS PS PUJD EJTFBTF physical examination.
Nose, Throat r )BMJUPTJT Once the initial assessment is completed and any life-
(EENT) r 4USJOH GPSFJHO NBUFSJBM VOEFS UIF threatening abnormalities addressed, obtain a more thor-
tongue ough history and perform a complete physical examina-
r 6MDFSBUJPO tion.
discomfort Acute Abdomen History
Musculo- r 'SBDUVSFT In patients with GI distress and acute abdominal pain, his-
skeletal/ r +PJOU TXFMMJOH tory should address:
Neurologic r .VTDMF BUSPQIZ t Medication history (both prescription and over the
Skin r &DDIZNPTFT CSVJTJOH t Access to foreign material (indoors and outdoors)
(Integument) r )FNPSSIBHF JO BSFB PG VNCJMJDVT » Abnormal/new food
(Cullen’s sign); may indicate he- » Garbage
moabdomen » Recent abdominal surgery
Respiratory r #SPODIPWFTJDVMBS TPVOET » Toys (both children and pet)
t Trauma
t If vomiting present, differentiating it from regurgitation,
r 1SPTUBUF QBJO PS FOMBSHFNFOU coughing, or retching.
r 4VCMVNCBS MZNQIBEFOPQBUIZ t If diarrhea present, characterizing it as large or small
bowel based on color, frequency, and consistency and
Urogenital r Females: Pregnancy, mammary
supplementing with rectal examination.
masses, or vaginal discharge
r Males: Enlarged prostate or pre-
putial discharge Physical Examination Evaluation
Following the triage examination, perform a thorough
physical examination (Table 3).
TABLE 4. Opioid Medications for Acute Abdomen
STEP 5. During history and physi-
Medication Dose Range Frequency Route
cal examination, begin monitor-
Buprenorphine 0.01–0.02 mg/kg Q 4–6 H SC, IM, IV ing patient.
Fentanyl 3–10 mcg/kg/H Constant rate IV An effective veterinary team has
(2–5 mcg/kg initial IV bolus) infusion mastered the art of multitasking.
Fentanyl patch < 10 kg: 25-mcg patch Q 3–4 days; Transdermal To facilitate efficient patient assess-
10–20 kg: 50-mcg patch onset of effect ment, ask support staff to:4
20–30 kg: 75-mcg patch 12–24 H after t Place peripheral IV catheter(s)
> 30 kg: 100-mcg patch application t Initiate intermittent or continu-
Hydromorphone 0.05–0.2 mg/kg Q 4–6 H SC, IM, IV ous electrocardiography for car-
Methadone 0.1–0.4 mg/kg Q6H SC, IM, IV
diac monitoring
t Monitor pulse oximetry and
Morphine 0.5–2 mg/kg Q 4–6 H SC, IM blood pressure

16 Today’s Veterinary Practice September/October 2013


t Evaluate packed cell volume, total protein, blood glucose,

lactate, and electrolytes; determine if azotemia is present.
STEP 6. Initiate primary treatment based on findings.
Based on physical examination and initial diagnostic results,
primary treatments may include:
t IV fluid therapy to correct hypovolemia and improve perfu-
sion; administer:
» Balanced isotonic crystalloids (10–30 mL/kg) in incremen-
tal boluses
» Synthetic colloids (hydroxyethyl starch, 3–5 mL/kg) in
incremental boluses
t Supplemental oxygen, if there is labored breathing or abnor-
mal perfusion
t Analgesic therapy:5
» Opioid therapy is most commonly used (Table 4). 5
» Nonsteroidal anti-inflammatory drugs (NSAIDs) should be
used with caution until the underlying cause is identified.
Their usefulness is limited in hypoperfused patients due
to side effects (renal and GI compromise) and potential
need for surgery.

STEP 7. Perform secondary survey as well as additional

Laboratory Analysis
t Complete blood count: White blood cell, red blood cell, and
platelet counts
t Serum biochemical profile: Important organ values, blood 6
glucose, and electrolytes
t Pancreatic testing: Pancreatic lipase immunoreactivity test,
lipase, or amylase can be used to evaluate possible pancre-
t Coagulation profile: Prothrombin time, partial thromboplas-
tin time, platelet count, and D-dimers
t Urinalysis and urine sediment: Urine specific gravity, pres-
ence of bacteria, and other abnormalities
t Fecal examination: Fecal float and cytology

Imaging Analysis
Radiography to identify or evaluate (Figures 4 through 6):
t GDV or pneumoperitoneum 7
t Presence of foreign material or intestinal pattern consistent
with obstruction, such as small intestinal plication or dila-
tion (Note: Distention of bowel up to 1.6 the height of the
body of L5 is reportedly normal in dogs).
t Poor contrast and detail due to:
» Ascites (eg, carcinomatosis)
» Lack of abdominal fat (eg, cachectic or juvenile patient)
» Mass effect (eg, pyometra or stump pyometra, splenic mass)
» Peritonitis (eg, septic effusion due to ruptured intestinal
Abdominal ultrasound to identify (Figure 7):
t GI obstruction Figure 4. Gastric dilatation–volvulus
t Pancreatitis Figure 5. Severe gastric distension due to “food
t Peritoneal effusion bloat”
t Pyometra Figure 6. Large urinary bladder stones
t Specific organ enlargement Figure 7. Ultrasound appearance of small intestinal
t Urinary tract obstruction. intussusception

September/October 2013 Today’s Veterinary Practice 17


8 9 10

Figure 8. Septic suppurative inflammation diagnosing a septic abdomen

Figure 9. Gross surgical appearance of a small intestinal intussusception
Figure 10. Dehiscence of a small intestinal resection and anastomosis

Cytologic Analysis 9. Elevated bilirubin levels compared to peripheral serum

Effusion can be obtained by:6,7 levels
t Abdominocentesis (ultrasound-guided or 4-quadrant 10. Free gas on abdominal radiographs (if radiographs
technique) taken prior to abdominocentesis and patient has not
t Diagnostic peritoneal lavage (for small volume effusion had recent abdominal surgery)
or if ultrasound is unavailable). Once a diagnosis is made, the critical question is: How
Cytologic evaluation of the effusion should include soon should surgery be performed? This decision depends
(Figure 8): on 2 factors:
t Identification of degenerate neutrophils, neoplastic 1. How stable is the patient?
cells, and/or intracellular bacteria 2. What is the underlying diagnosis?
t Nucleated cell count and differentiation among transu- Most patients presenting with an acute abdomen will
date, modified transudate, or exudate require some degree of stabilization prior to anesthesia
t Detection of food material and surgery. For example, in patients with acute abdominal
t Measurement of:8,9 pain and GI distress with hypovolemia, common findings
» Lactate and glucose (compared to plasma in evaluation are acid–base or electrolyte abnormalities, which should
of sepsis) be addressed prior to anesthetic induction.
» Creatinine and potassium (compared to plasma in Clinical judgment is needed to determine the appropriate
evaluation of urinary tract rupture) balance between presurgical stabilization and the amount of
» Bilirubin (compared to plasma in evaluation of biliary time taken before the problem can be surgically corrected.
tract rupture).

STEP 8. For emergent and critical patients, consider

TABLE 5. Broad-Spectrum Antibiotic
indications for surgery: Combinations for Critical Patients
Indications for immediate surgical intervention in critical
patients include (Figures 9 and 10):
Cefazolin, or 20–30 mg/kg Q 8–12 H; IV
Abdominal Conditions Ampicillin 22 mg/kg Q 8 H; IV
1. Complete bowel obstruction Enrofloxacin 10–15 mg/kg Q 24 H; IV
2. GDV Metronidazole 10 mg/kg Q 12 H; IV
3. Inability to medically stabilize intra-abdominal hemor-
4. Mesenteric volvulus Ampicillin/ 20–30 mg/kg Q 8 H; IV
5. Penetrating abdominal injury sulbactam
6. Splenic torsion Enrofloxacin 10–15 mg/kg Q 24 H; IV
Metronidazole 10 mg/kg Q 12 H; IV
Diagnostic Findings
7. Cytologic evidence of intracellular bacteria or plant/ COMBINATION 3
food material in abdominal fluid Cefotaxime 30–50 mg/kg Q 6 H; IV
8. Elevated creatinine and potassium levels compared to Clindamycin 8–11 mg/kg Q 8–12 H; IV
peripheral serum levels

18 Today’s Veterinary Practice September/October 2013


1. Franks JN, Howe LM. Evaluating and
TABLE 6. GI Protectants & Antiemetic Medications managing acute abdomen. Vet Med
2000; 95(1):56-69.
DOSE RANGE, FREQUENCY, & 2. Macintire DK. The acute
MEDICATION DRUG CLASS abdomen—differential diagnosis and
ROUTE management. Semin Vet Med Surg
Chlorpromazine Alpha-2 and D2 0.1–0.5 mg/kg Q 8 H; IM, SC, (Small Anim) 1988; 3(4):302-310.
3. Kirby R, Rudloff E. Acute abdomen.
antagonist suppository In Morgan R (ed): Handbook of
Dolasetron 5-HT3 0.5–1 mg/kg Q 12–24 H; SC, IV Small Animal Practice, 3rd ed.
Philadelphia: WB Saunders, 1997.
4. Mann FA. Acute abdomen:
Famotidine H2 receptor 0.5–1 mg/kg Q 12–24 H; IV, PO, Evaluation and emergency
antagonist SC treatment. In Bonagura JD (ed):
Kirk’s Current Veterinary Therapy
Maropitant NK-1 antagonist 1 mg/kg Q 24 H; SC XIII. Philadelphia: WB Saunders,
2 mg/kg Q 24 H; PO 2002, pp 160-164.
5. Mathews K. Management of pain.
Metoclopramide D2 antagonist 0.2–1 mg/kg Q 6 H; IM, PO, SC Vet Clin North Am Small Anim Pract
1–2 mg/kg/day; CRI 2001; 30:4.
6. Crowe DT. Diagnostic abdominal
Omeprazole Proton pump 0.7–1 mg/kg Q 24 H; IV, PO paracentesis and lavage in the
inhibitor evaluation of abdominal injuries
in dogs and cats: Clinical and
Ondansetron 5-HT3 0.1–0.3 mg/kg Q 6–24 H; IV, PO experimental investigations. JAAHA
antagonist 1976; 168:700.
7. Rudloff E. Abdominocentesis
Pantoprazole Proton pump 0.7–1 mg/kg Q 24 H; IV and diagnostic peritoneal lavage.
inhibitor In Ettinger S, Feldman E (eds):
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Prochlorpera- Alpha-2 and D2 0.1–0.5 mg/kg Q 8 H; IM, SC, Medicine: Diseases of the Dog
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Saunders, 2005, pp 269-270.
Ranitidine H2 receptor Dog: 2 mg/kg Q 8–12 H; IV, PO
8. Rizzi TE, Cowell RL, Tyler RD,
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Cat: 3.5 mg/kg Q 12 H; PO thoracic, and pericardial fluid.
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STEP 9. For all patients, implement appropriate 9. Bonczynski JJ, Ludwig LL, Barton
LJ, et al. Comparison of peritoneal fluid and peripheral blood pH,
medical therapy. bicarbonate, glucose, and lactate concentration as a diagnostic tool
In addition to fluid therapy, electrolyte correction, for septic peritonitis in dogs and cats. Vet Surg 2003; 32:161.
and potential surgical correction, other therapies to 10. Crowe D, Devey J. Assessment and management of the
hemorrhaging patient. Vet Clin North Am Small Anim Pract 1994;
consider include: 24:1095.
11. Herold L, Devey J, Kirby R, Rudloff E. Clinical evaluation and
management of hemoperitoneum in dogs. J Vet Emerg Crit Care
Antibiotic Therapy 2008; 18(1):40-53.
Translocation of gram-positive and gram-negative aer- 12. Saxon W. The acute abdomen. Vet Clin North Am Small Anim Pract
obes and anaerobes may occur following a period of 1994; 24(6):1207-1224.
poor perfusion and alteration to the integrity of the
GI tract. Common broad-spectrum antibiotic combi- Garret Pachtinger, VMD,
nations I use in critical patients are listed in Table 5. Diplomate ACVECC, is a
veterinarian at the Veterinary
GI Therapy Specialty and Emergency
For persistent GI upset, administer gastroprotectants Center in Levittown,
and antiemetics (Table 6). Pennsylvania, and COO of
VetGirl, LLC, a subscription-
IN SUMMARY based podcast service offer-
ing RACE-approved veterinary
Ultimately, the prognosis for patients with acute abdo-
CE. While in practice, he helped develop the emer-
men depends on the underlying disease process.12
gency room and intensive care unit at VSEC as well
Many diseases are treatable with fluid resuscitation,
as develop their emergency and critical care intern-
pain control, and exploratory laparotomy. Rapid ship program. Dr. Pachtinger is actively involved
evaluation and treatment of life-threatening complica- with the American College of Emergency and
tions, such as hypovolemic shock, decreases morbid- Critical Care and is a consultant for the Veterinary
ity and gives the astute clinician time to determine a Information Network. He has published numerous
diagnosis and develop a therapeutic plan. n scientific articles and book chapters and lectures
nationally and internationally. Dr. Pachtinger received
GDV = gastric dilatation–volvulus; GI = gastrointestinal; his degree from University of Pennsylvania.
NSAID = nonsteroidal anti-inflammatory drug

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