On initial presentation 3 days after enterotomy, the patient workup appears adequate, resulting in proper surgical exploration. Resection of the dehisced enterotomy site is the indicated procedure, followed by thorough abdominal lavage. A common question is whether primary closure is sufficient or either closed drainage or an open abdomen should be employed. The literature is also contradictory on this point, with no single technique proven superior.4-7 An open abdomen is racked with complications and does not accrue any benefit over closed drainage; therefore, this author does not recommend that technique. Because minimal morbidity is associated with a closed suction drain, it is best to err on the side of caution and place a drain, although it is not an absolute. Fluid production after peritonitis depends on the amount of peritoneal inflammation associated with the initial cause, and it is much more difficult for intestinal incisions to heal in the face of abdominal fluid due to its effect on the inflammatory/lag phases of healing. Mild, focal peritonitis frequently does not produce much fluid and does not require a drain. More diffuse inflammation leads to voluminous fluid production.
The bloodwork abnormalities (elevated bilirubin, ALT, and ALP) at the time of presentation suggest sepsis and thus proper antibiotic coverage is critical (which was implemented). It would have been reasonable to check the PT/PTT to get a baseline prior to surgery. This factor was checked on the second postoperative day and clotting time was beginning to elevate. This development, combined with low platelets on day 2, is pathognomonic for DIC. Fresh frozen plasma is the treatment of choice for affected patients, as it is able to supply oncotic pressure and all clotting factors except von Willebrand. The DIC was likely caused by the progressive septicemia, as evident from the continued elevation of bilirubin and liver enzyme values, along with reductions in albumin and white blood cells.
Loss of albumin into the forming abdominal effusion is also a cause of hypoalbuminemia. Hypoalbuminemia as a cause of intestinal dehiscence is also controversial, as there are contradictory study results.8 However, hypoalbuminemia leads to interstitial edema, which does impede healing, and also slows blood flow at the capillary beds, which can worsen the effects of hypotension and septicemia as well as increase lactate production, leading to acidosis.
On the day of euthanasia, there was an increase in abdominal fluid. What we do not know is whether this fluid was hypoproteinemic ascites or recurrent septic peritonitis, because we do not have documentation of abdominocentesis with cytology or paired glucose tests. However, there is evidence of worsening DIC and sepsis despite aggressive management.
The survival rate for septic peritonitis ranges from 30% to 70%, with an average of 50%.1 The overall management of this patient pre- and postoperatively was aggressive and proper. While it is possible to question some of the decisions made in the treatment, the literature is not in agreement on many of the questions that would be posed, so it is difficult to make absolute recommendations as to what (if anything) could have changed the outcome in this case.