Wednesday 30 September 2020
Case Study: Suspect foreign body in dog
Case Study: Suspect foreign body in dog
History
Max, a 5-year-old German Shorthaired Pointer, presented for acute vomiting of two days duration. The client had been out of town and when she returned, she let Max out into the yard unattended for a few hours. She knows he was eating mulch and yard materials while he was out there. He has no history of eating toys, bones or rawhides, and has had no acute diet change. He normally has a tremendous appetite but currently did not want to eat. The client described a bowing behavior with his front legs extending and stretching downward, with his back legs straight. He has not had a bowel movement for two days and vomits currently every four to five hours. The vomit consists primarily of bile. He is current on all vaccines, including heartworm test and prevention. He is urinating normally.
Presentation
Max was very active during his exam. He was robust and playful. He did not show any signs of nausea, and there was no drooling. His temperature was normal. Soft feces were palpated on rectal examination. Heart and lungs auscultated normally. Abdominal palpation was non-significant with a slight tenseness noted. CRT< 2sec and mm were pink. Hydration appeared normal. Overall, Max did not appear to be in distress.
Differential diagnoses include gastric foreign body with obstruction; gastritis (viral); gastritis (ingestion); metabolic disease; pancreatitis.
Diagnostic tests
Parvo (neg)
Internal organ screen (wnl)
CBC (wnl)
CPL (neg)
Abdominal radiographs (abnormal)
Radiographs of the abdomen showed significant gas throughout the small intestines and colon. The colon contained a significant amount of fecal material. The stomach appeared to be empty. The small intestine contained two radio opaque objects. They were identical, circular and matched to the approximate size of a nickel.
Discussion points to consider
- What is your next step and why?
- After reviewing the films with the client she tells you her mother has been missing a pair of circular earrings for two months. She also reported she was missing some change, some pill bottle lids, nail clippers, and two rings from last year, and wanted surgery performed immediately on her dog. What is your perception of the client's state of mind at this moment and what is your recommendation?
- Max was very rambunctious during his radiographs and light sedation was needed to take the scout films. He was given Torbugesic and valium. Would this have any effect on his radiographs?
- What would be an appropriate fluid rate for Max?
Treatment
Max was started on an intravenous drip of 2.5 % dextrose at two times maintenance. He received 850 mg of cefazolin IV. He was NPO and monitored for vomiting, diarrhea, with TPR performed hourly. The client was advised based on Max's current condition. Immediate exploratory surgery was a possibility but not necessarily indicated at this time. The recommendation was to monitor Max closely and perform serial abdominal radiographs to assess the suspect foreign bodies. Serial films were taken every hour to assess the abdomen.
Throughout the day, Max showed no vomiting and no change in clinical signs. The small intestines continue to show large gas patterns cranial and caudal to the foreign bodies, which were steadily moving through the intestinal tract. The materials reached the colon, and Max was taken for a long walk. He had a large bowel movement and it was examined for suspect foreign bodies.
Examination revealed two completely intact Pepto-Bismol tablets. The stool also contained large amounts of mulch and pieces of sticks. This most likely accounted for the gastritis Max was experiencing. The client stated that she had given them to him the evening before and had not told the doctor because she did not think it was important. Max was given famotidine, continued on fluids for 24 hours and placed on a bland diet. He recovered completely.
Overview
Foreign bodies resulting in obstruction occur commonly in the dog and can cause vomiting without anorexia, depression or anorexia1. Finding a foreign object on a radiograph and clinical signs of obstruction is sufficient for a diagnosis. In this case the question involves whether the suspect foreign body is causing disease or if the ingestion or mulch and other irritants is causing disease without an obstruction. An exploratory laporotomy would be indicated in any patient with this history and radiology results.
The veterinarian needs to be prepared for negative results in exploratory procedures as does the client. In this case based on the friability of the Pepto Bismol tablets it is questionable whether the suspect tablets would be found on a routine run through of the intestinal loops. An accurate history is important to help rule out what may be significant on a radiograph and what may not. Pepto Bismol contains minerals which do appear radiopaque and can be easily confused with other metallic objects.
Case Study: Eosinophilic ulcer (rodent ulcer) in a cat
Case Study: Eosinophilic ulcer (rodent ulcer) in a cat
History
Angie, a 4-year-old Persian cat, presented for a second opinion related to a lesion on her upper lip. She was not eating well and had previously been treated with steroids for her lip condition. The client reported she improved for a week or so after the steroid injection. She was an indoor cat. She was current on her vaccinations as well as deworming and FeLV/FIV (negative). She had been losing weight for about two months. The client reported today that she had begun to vomit her hard food almost immediately after eating.
Presentation
Angie was bright and alert on presentation. She was very thin, weighing 4.2 pounds. Her hydration appeared normal. She had mild dental tartar. Her upper lip was grossly eroded to the point it had begun to expose her nasal cartilage. The erosion was covered in a yellow exudate. Her entire coat had broken hairs and areas of thinning. She had live fleas visible and substantial flea dirt present. Her skin did not appear inflamed or irritated other than the broken hairs which resembled chronic grooming. All other physical exam parameters were normal.
Differential diagnoses includes Flea allergy dermatitis; fungal dermatitis; eosinophilic ulcer; food allergy; skin pyoderma.
Diagnostic tests
FeLV/FIV (neg)
Internal organ function (all values wnl)
CBC (all values wnl)
Skin scrape (neg for mites)
Skin impression (neg)
Fungal culture (neg)
Discussion points to consider
- What supportive measures should be implemented immediately in this case?
- Is there any significance to the breed of cat involved in this study?
- Rodent ulcers have historically been treated with steroids. Are there any possible reasons the treatment has not been effective, i.e., prednisone from previous veterinarians?
- What parameters would you use to determine if this case should be treated or if the cat should be humanely euthanized?
- What is a likely cause of the vomiting episodes?
Treatment
Initially, treatment while waiting for pending blood results involved preparation of an Hill's A/D gruel presented to the cat. The cat ate ravenously but due to the absence of an upper lip, had to eat by sucking in the food. When presented with hard cat food, which the client had used, the cat ravenously used its tongue to throw the food into the back of its mouth. Within 10 minutes, the cat vomited the hard food. It could eat the gruel successfully without any vomiting. Most likely the lack of proper mastication and eating the hard food whole was a cause of the vomiting.
After skin work-up and blood results were determined, the cat was treated with oral Capstar followed by Feline Advantage 24 hours later. Her home was also treated for fleas by a professional company. She was given 20 mg of Depo-Medrol IM, 400 mg of ampicillin SC. She was released on oral clavamox liquid, 80 mg bid. Based on the condition of her mouth, oral medication with pills or tablets was difficult and extremely uncomfortable for the cat.
The cat returned for a recheck one week later. She had gained 3/4 lb. and her coat was improving. No fleas were seen. She was eating the A/D gruel well. At this point she was released with instructions to continue the antibiotics.
She returned two weeks later for a recheck. Her lip was improving and the exudate had resolved with granulation tissue beginning to fill in the area. The scarring, however, led us to believe she may permanently have some prehensile challenges due to the severe nature of her original erosion. The client was educated on the allergic nature of some rodent ulcers and followed through with the recommendation for hypoallergenic diet control. Recommendations were given for Royal Canin feline duck formula. The cat readily adapted to the canned formula and was weaned off of the A/D.
At six month follow-up, the cat had gained a total of 3 pounds. Her hair coat had regrown completely and her lip, although scarred, had regenerated fairly well.
Overview
Indolent ulcers occur on the upper lip of cats at almost any age. Routinely, steroids have been used as the first treatment choice1. There has been evidence that some cats have a genetic predisposition to these ulcers when exposed to specific trigger antigens, particularly fleas2. In this case, the initial steroid treatment may have failed because the underlying flea infestation was not addressed. Atopy can also be a trigger in these cases. For this case, food allergy could not be ruled out as an additional allergen, so once the cat could eat well she was transitioned to a hypoallergenic diet. The recommendation was for lifelong flea control and diet control to help reduce the recurrence of the lesion.
Tuesday 29 September 2020
Case Study: Bladder Stones
Case Study: Bladder Stones
History
Shiloh, a 3-year-old long-haired intact female Chihuahua, presented for frequent urination and hematuria of several days duration. She had been acting normally otherwise and had no prior history of any serious health concerns.
Presentation
Shiloh was quiet and a little shy, but overall was alert and responsive. She urinated on the floor during the exam and the urine was grossly hematuric. Her physical exam was normal except for mild dental calculus, and on abdominal palpation a hard, smooth object was noted in the caudal abdomen.
Differential diagnoses included cystitis, urolithiasis, and neoplasia. Pyometra or metritis were not considered likely possibilities due to the density of the object and its well-delineated borders.
Diagnostic Tests
Urinalysis: Positive for bacteria (cocci), leukocytes and erythrocytes. pH 6.0. No crystalluria noted.
Abdominal radiographs: large, oval mineral radiopacity object in caudal abdomen, consistent with a urolith (Figure 1).
Discussion points to consider
- What is your next step and why?
- Based on the history and the lab findings, what type of bladder stones would you include in your differential list?
- How likely is it that this case would improve with only medical therapy? What would that therapy be?
- What is the likelihood of chronic or recurrent problems in this patient?
Treatment
Surgical removal of the urolith was recommended, but the client could not afford such treatment at the time. Shiloh was prescribed amoxicillin-clavulanic acid 62.5 mg BID PO for two weeks. Her owner was given instructions to observe her closely and present her for a recheck when the course of antibiotics was finished. Shiloh was also prescribed Royal Canin Urinary S/O diet.
Second Presentation
Three weeks later, Shiloh re-presented for lethargy, difficulty defecating and urinating, and discomfort. A physical exam revealed no new findings from the previous visit. Shiloh was hospitalized for the day and showed signs of dysuria, although she was not anuric. Further diagnostic testing was performed.
Diagnostic Tests
Chemistry Profile: WNL
CBC: Increased leukocytes (25,190/µL), otherwise WNL
Discussion Points to Consider
- Does your plan or recommendation change on this second visit?
- How do you communicate your recommendations to the client at this point?
- What are the potential consequences of not performing surgery at this time?
- If the symptoms continue to persist or worsen and the owner cannot afford surgery, what is your recommendation?
Treatment
Based on Shiloh’s symptoms and the results of the lab tests, it was suspected that the large bladder stone was causing pain and discomfort. Shiloh was prescribed 12.5 mg carprofen (1/2 25 mg tablet) PO q24h while the owner decided on further care.
Shiloh’s owner was able to secure finances and authorized surgery. Preanesthetic medications were acepromazine 0.2mg IM and 1.6 mg butorphanol IM. A 22 ga catheter was placed and anesthesia induced with propofol, then maintained with sevoflurane via endotracheal tube. The ventral abdomen was shaved and scrubbed for surgery. An incision was made along the ventral midline in the caudal abdomen, the bladder identified and exteriorized, and stay sutures placed (3-0 PDS). Laparotomy sponges were placed around the bladder to prevent urine leakage into the abdomen. The dorsal body of the urinary bladder was incised and urine evacuated, allowing exposure and exploration of the contents. A single oval urolith was identified and removed (Figures 2, 3). Further exploration and repeated radiographs revealed no additional uroliths. The bladder wall was considerably inflamed and thickened, but no signs of necrosis or other damage were visible. The bladder was closed with a double layer of 3-0 PDS with a simple interrupted pattern. After bladder closure, a leak test was performed with 10cc of sterile saline and no leaks were detected. The abdomen was closed normally with 3-0 PDS; the linea alba, subcutaneous and intradermal tissues were closed using a simple continuous pattern and Vetbond was used for skin closure. Patient recovery was uneventful. Shiloh was sent home with tramadol 25 mg PO BID-TID PRN for pain and amoxicillin-clavulanic acid 62.5mg PO BID for seven days. The post-operative period and recovery were normal.
A piece of the urolith was sent for analysis, which showed it was 40 percent struvite and 60 percent ammonium urate both externally and internally with no nidus.
Overview
Struvite is the most common type of urolith in dogs. Most struvite uroliths form in alkaline urine as a result of urinary tract infections caused by urease-producing organisms. Medical dissolution may be successful in some cases, especially if the uroliths are small. If the urolith is large or the composition is unknown (such as in this case), surgical removal is necessary. Long-term management of struvite uroliths is normally achieved through appropriate use of dietary therapy to encourage dilution of urine and a slightly acidic pH.
Ammonium urate stones often form in Dalmations or dogs with liver dysfunction. However, up to 60 percent of this type of urolith occurs in non-Dalmation dogs and many of these do not have detectable hepatic dysfunction, as was the case with Shiloh. Unfortunately, this means that an underlying cause is not evident in this case. Control of urate stones involves feeding a diet lower in protein to reduce purine, the major amino acid involved in ammonium urate uroliths, as well as alkalinizing the urine slightly.1
The dietary management of this case is complicated by the fact that each type of urolith requires a different pH to prevent the uroliths from re-developing. Several diets are available for control of either struvite or urate uroliths, but no diet is formulated to control both simultaneously. Royal Canin technical services reports that urate stones can develop secondary to long-term presence of struvite stones or crystals, though the underlying cause is unknown.2 Thus, the decision was made to maintain Shiloh on Royal Canin Urinary S/O. It was hoped this would prevent the struvite component of the urolith from recurring and, in turn, prevent recurrence of the ammonium urate urolith.
Case Review: Acute abdominal trauma in a puppy
Case Review: Acute abdominal trauma in a puppy
History
A five month old poodle mix named Scottie presented for evaluation of acute trauma. The pup was current on all vaccines as well as heartworm prevention. He had a history of Coccidia infection a month prior. The puppy was reported as a rescue from a shelter 3 months ago.
Presentation
Scottie was quiet and uncomfortable whether standing or sitting. He had a temperature of 101.5, heart rate of 144 and an increased respiratory rate of 45 breaths/ minute. He clinically appeared approximately 6% dehydrated. His upper canine on the left side was missing. CRT was 2 sec and gums were slightly pale. He had swelling above the right eye and visible bruising and swelling across his abdomen just caudal to his rib cage on the left side. Pulses were strong and regular. No other visible signs of trauma were present. Abdominal palpation was assessed as normal.
Differential diagnosis include acute trauma, respiratory distress cause unknown.
Diagnostic tests
Chest radiographs– mild pulmonary infiltrates present
Abdominal radiographs– food in stomach, suspect enlargement of liver- difficult to assess due to distended stomach. Diaphragm intact. Linea appeared intact.
CBC/Profile–
ALB: 2.8g/dl-range 2.2-3.9
ALKP: 2900 U/L-range 14-192
ALT: 1000 U/L-range 12-115
AMYL: 700U/L- range 500-1400
BUN: 7.0 mg/dl-range 16-33
CA: 10.9mg/dl-range7.9-11.3
CHOL: 183 mg/dl-range 62-191
CREA: 0.500mg/dl-range 0.6-1.6
GLU: 118 mg/dl- range 77-153
PHOS: 6.3 mg/dl-range 4.5-10.4
TBIL: 0.10mg/dl-range 0-0.9
TP: 5.6g/dl-range 5.2-8.2
GLOB: 2.8 g/dl-range 2.8-4.8
WBC: 15.770 10^3/ul -range 6-17
RBC: 5.02 10^6/ul -range 5.5-8.5
HGB: 11.450g/dl-range 12-18
HCT: 33.930% range 37-55
MCV: 68.000fl -range 60-72
MCH: 22.79pg- range 19.5-24.5
MCHC: 33.74g/dl-range 34-38
RDW: 13.92% -range 12-16
PLT: 254 10^3/ul
MPV: 8.71 fl -range 6.1-10.1
Discussion points to consider
- Based on the bloodwork what additional tests would you recommend?
- The owner is visibly distraught about the dog's condition and tells you her husband had an altercation with the dog. What are your legal and moral obligations at this point?
- Financially the owner is limited. What treatment would you recommend for this pet?
- Is there any link between pet abuse and any other dangerous habits?
- The owner asks you what she should do as she is afraid of her husband. How do you respond to her questions?
Treatment
At this point the main concern is liver trauma and possible internal bleeding due to liver damage as well as splenic damage leading to rupture. The owner could not afford hospitalization for the dog. Owner declined a clotting panel. The dog should have been placed on IV 0.9% NaCl at a rate of 1.5 times maintenance with TPR and lung auscultation every 15 minutes as the dog stabilized. The dog was monitored closely at the hospital for 6 hours. TPR remained stable as did CRT and hydration status. Dog was given torbugesic as pain management and sent home with clavamox 2ml bid for one week. The pup was placed on severe exercise restriction to try to avoid any bleeding complications.
The owner was an elementary education teacher and was aware of the relationship between pet abuse and child/spousal abuse.1 The need to report abuse was discussed with the owner. The owner was very fearful of her husband being reported. She claimed this was the first time this had happened. She was given the opportunity to relinquish the puppy to the hospital and declined. The owner's father had worked with puppies in the past and offered to take the puppy. The owner agreed to give up the pup and her father agreed to sign up for puppy training classes and individual consults to reduce any psychological damage to the pup. Both the owner and her father (new owner) agreed if any classes were missed or any more alleged abuse occurred then the information would be turned over immediately to the proper authorities. The client was instructed to seek counseling from a human expert regarding her relationship with her husband.
The puppy left with the father and attended puppy classes for 4 weeks. At that point the original owner returned to the hospital with the puppy for a second time. She informed us they had gone to visit the puppy and her husband claimed it had fallen off of a brick fence when he was left unattended with the dog. Clinically the dog had facial bruising but otherwise appeared normal. The owner relinquished the puppy and he was placed in a foster home through the hospital and recovered uneventfully. The wife reported the two incidences to animal control. To date there has been no additional incidents of abuse.
Overview
Acute abdominal trauma can be dangerous in the dog. In this case the dog's injuries were related to extreme pressure applied to the abdomen by the spouse's knee while he was holding the dog on the ground. Splenic and liver enlargement due to inflammation can result in acute abdominal bleeding.2 Studies have shown a direct correlation between pet abuse and child abuse. Practitioners should use discretionary caution when making allegations of abuse either verbally or in the medical records. Medical records could become discoverable in a court of law if legal action was taken by the authorities or the family members. It best to state medical facts and observation in the medical notes and leave subjective assumptions out of the record.
Monday 28 September 2020
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