Exploratory surgery

The dog was anesthetized, and an emergency exploratory laparotomy was performed. A copious amount of white-to-yellow purulent fluid was removed from the abdominal cavity. Adhesions were noted between the bladder and abdominal wall, between various loops of bowel, and between the bowel and bladder. A stick had penetrated the jejunal wall and entered the abdominal cavity. The stick was removed, and the affected regions of bowel were resected and anastomosed. The integrity of the anastomosis site was evaluated by intraluminal injection of sterile saline solution and found to be secure. The abdomen was thoroughly lavaged with warm sterile saline solution. A Jackson-Pratt closed suction drain was applied, and the patient recovered from anesthesia without complications. Aggressive postoperative antibiotic therapy and support measures were instituted.

Postoperative test results

Nine days after the surgery, the dog's temperature, and pulse and respiration rates were normal, but a CBC revealed a PCV of 32%, a fibrinogen concentration of 700 mg/dl (reference range = 100 to 400 mg/dl), and a total WBC count of 56,120/μl characterized by a neutrophilia with a marked left shift back to myelocytes with 2+ to 3+ toxic neutrophils. These CBC findings indicated a more dramatic response to the apparent infectious process. The serum chemistry profile revealed increased ALP (353 U/L) and AST (109 U/L) activities and total bilirubin concentration (12.1 mg/dl; reference range = 0 to 0.4 mg/dl) and decreased concentrations of albumin (1.8 g/dl) and calcium (8.7 mg/dl). The elevated bilirubin concentration was likely the result of functional cholestasis (sepsis-associated cholestasis). The hypocalcemia was again attributed to the low albumin concentration.

Outcome

Despite aggressive fluid and antibiotic therapy after the surgery, the dog developed acute vascular shock and cardiac arrest late on postoperative day 9. The patient was successfully resuscitated; however, it was euthanized a few hours later in accordance with the owner's wishes because of a poor prognosis, resulting from the clinical presumption of sepsis and suspected progression of the abdominal adhesions observed previously during surgery. A necropsy examination revealed evidence of leakage from the intestinal anastomosis site with diffuse peritonitis and adhesions in the cranial abdomen involving most of the small intestine and omentum.

DISCUSSION

Rapidly identifying barium sulfate free within a body cavity is essential in prompting emergency procedures that might prevent deleterious effects and, possibly, death. In this case, initial radiographic findings at the referring veterinary clinic did not indicate leakage of barium into the peritoneal cavity. This lack of noticeable leakage could be due to the possibility that the stick had not yet perforated the gastrointestinal tract.

Effects of barium sulfate suspension

Barium sulfate suspension in an animal's abdominal cavity causes a devastating peritonitis with mortality rates that rapidly increase in a quantity-dependent fashion.^2-4 Barium sulfate quickly agglutinates and adheres to peritoneal surfaces.⁵ In experimental studies in dogs and rabbits, intraperitoneal barium sulfate suspension injections resulted in high mortality secondary to diffuse hemorrhagic peritonitis with numerous adhesions and granulomas throughout the abdominal cavity.^3,4

When mixed with intestinal contents, barium sulfate has a synergistically deleterious effect—the intestinal contents and bacteria become trapped within granulomas that rapidly form in response to the barium sulfate.^3,4 Visceral adhesions from fibrinous exudate form within six hours, and after three to five days, the barium sulfate becomes encapsulated within the fibrinous adhesions.⁵

In this case, marked fibrous adhesions developed throughout the mesentery and involved multiple bowel loops. Presumably, these adhesions caused delayed healing at the surgical anastomosis site and resulted in the leakage observed at necropsy.

Prevention and treatment

If contrast imaging is necessary in an animal with signs of peritonitis or if intestinal perforation is a differential diagnosis, it is best to use an iodinated contrast medium because of its lower propensity to incite peritoneal irritation. However, as seen in this case, sometimes perforations are not identified or suspected before contrast media administration.

Assuming barium sulfate was used in a gastrointestinal study, cytologic identification of this contrast media within an abdominal effusion confirms the leakage of gastrointestinal contents and should alert you to pending septic peritonitis. Since the combination of barium sulfate and intestinal contents free within the abdominal cavity results in time-dependent, synergistically deleterious effects, aggressive therapeutic treatment is warranted. More than routine abdominal lavage may be required to physically remove the contaminants, so gently rub the peritoneal surfaces with sterile gauze, and vigorously lavage the abdomen with warm sterile saline solution.

Even with rapid treatment, a patient's prognosis is guarded. However, prompt recognition and immediate treatment are essential in maximizing the chance of restoring health.⁶

Mark D. Dunbar, DVM
A. Rick Alleman, DVM, PhD, DABVP, DACVP
Department of Physiological Sciences
College of Veterinary Medicine
University of Florida
Gainesville, FL 32610

REFERENCES

1. Bonczynski JJ, Ludwig LL, Barton LJ, et al. Comparison of peritoneal fluid and peripheral blood pH, bicarbonate, glucose, and lactate concentration as a diagnostic tool for septic peritonitis in dogs and cats. Vet Surg 2003;32(2):161-166.

2. Henrich MH. [Barium peritonitis in animal experiments (rat, dog)]. Chirurg 1986;57(12):801-804. German.

3. Cochran DQ, Almond CH, Shucart WA. An experimental study of the effects of barium and intestinal contents on the peritoneal cavity. Am J Roentgenol Radium Ther Nucl Med 1963;89:883-887.

4. Sisel RJ, Donovan AJ, Yellin AE. Experimental fecal peritonitis. Influence of barium sulfate or water-soluble radiographic contrast material on survival. Arch Surg 1972;104(6):765-768.

5. Thomas JC. The disposal of barium sulfate in the abdominal cavity. J Pathol Bacteriol 1936;43:285-298.

6. Gfeller RW, Sandors AD. Naproxen-associated duodenal ulcer complicated by perforation and bacteria- and barium sulfate-induced peritonitis in a dog. J Am Vet Med Assoc 1991;198(4):644-646.