 |
Case Studies
Case Study: Gastric Dilatation-Volvulus Syndrome in a German Shepherd
"Sasha" is a 6-year-old neutered male German Shepherd that presented for making repeated retching motions, producing only a white foamy fluid. The owners felt that his abdomen was distended.
Presenting signs
An initial rapid assessment was made for life-threatening problems (called primary survey). Sasha's problems included: mental depression, labored breathing, early decompensatory shock), rapid heart rate (240 beats per minute), weak, irregular pulses, and significant cranial abdominal distention. Percussion of the abdomen demonstrated tympany, suggestive of a gas distended stomach, compatible with gastric-dilatation-volvulus (GDV) syndrome.
What is GDV?
The GDV syndrome occurs the stomach rotates at the level of the esophagus within the abdomen, causing gas accumulation within the stomach and gastric distension (Figure 1). Blood supply to the stomach and spleen can be significantly compromised.
Figure 1.
Drawing of stomach with arrows demonstrating direction of stomach rotation.Initial Stabilization
Oxygen was supplemented, an intravenous catheter placed and blood was taken for an emergency baseline. Intravenous fluid therapy was started with rapid infusion of a large volume crystalloids and stroma free hemoglobin* to resuscitate shock. He was given a narcotic for pain control. The initial blood tests founs a reduced number of platelets suggestive of an early problem with coagulation due to the severe shock.An electrocardiogram (ECG) was done, revealing a ventricular tachycardia (Figure 2). He had a rapid heart rate and an elevated blood pressure of 200/110 mmHg.
Intravenous lidocaine was given to correct the heart arrhythmia and then his gas filled stomach decompressed percutaneously to allow the gas to escape. A new ECG (Figure 3), heart rate and blood pressure showed that he was stabilized enough to continue with radiographs and emergency surgical intervention.
was given IV showing normal rhythmConfirming the Diagnosis
A radiograph was taken and showed that the stomach was filled with gas (black coloration) and rotated, with the pylorus now located in a dorsal position (Figure 4).
Emergency surgery was necessary to correct the stomach rotation, fix the stomach into normal position, and examine other organs that might be affected. Common complications include: anesthetic risks, stomach necrosis due to impaired circulation, blood clots in major vessels, rupture of blood vessels due to the distension and rotation of the stomach, and splenic damage due to the obstruction of its blood vessels by the stomach.
Emergency Surgical Correction
A combination of anesthetic agents were chosen that had minimal effect on the cardiovascular system and induction and intubation so that his breathing could be rapidly controlled. The abdomen was clipped and scrubbed for surgery. An abdominal incision was made. The stomach was immediately seen to be hugely distended with gas, rotated and the stomach wall was black due to loss of blood supply and necrosis (Figure 5). The stomach was de-rotated, a stomach tube passed for relieving the gas, and the dead area of the stomach wall was removed. The stomach was then attached to the body wall (called a “gastropexy”) to prevent rotation in the future. The spleen was found to have an infarct, and that area was removed. The pancreas was swollen.
from loss of blood supply.Post-operative Care
Post-operative recovery was prolonged due to pancreatitis. Procedures that aided recovery included: nasogastric tube stomach decompression and feeding; plasma transfusions; administration of crystalloids and colloids to maintain intravascular volume, antibiotics, and gastric motility stimulants. The dog was closely monitored in the intensive care unit with blood pressure, ECG and laboratory tests. Because of the knowledge and skills of the emergency/critical care team of doctors and nurses, Sasha was able to go home 5 days after admission.* Stroma free hemoglobin solution is an oxygen carrying fluid that is approved for use in dogs.
(click here to learn more about our specialty ER / CC Services)
Popo is a 5 year old ferret who was brought into Animal Emergency Clinic for signs of coughing, sneezing and not feeling well. The owner had been sick with influenza for 2 weeks. She knew that ferrets are susceptible to the human influenza virus and was concerned. Popo had not eaten well that day.
A physical examination was done and found Popo to be depressed, dehydrated, and to have labored breathing. At this time, he weighed only one pound. He was admitted to the hospital and a catheter was placed and intravenous fluids and antibiotics were administered. Blood work was done, confirming dehydration. His other blood parameters were normal. Radiographs were taken and showed that Popo had developed pneumonia. The infection had spread to the entire lung fields on the right side of his chest. This lung pathology was most likely the reason for his difficulty breathing.
The next day Popo appeared to be getting worse in spite of the fluids and antibiotics. The owner was contacted and surgery was recommended to remove the infected lung lobes. It was felt that the infection was causing lung abscesses and could not be treated effectively with medications alone. The risks were discussed and the owner agreed to surgery.
That afternoon Popo was taken to surgery. Because of his small size, the anesthesia and surgery were very delicate procedures. The emergency/critical care specialist planned a balanced anesthesia protocol using both injectable and gas anesthetic.
The surgeons were very concerned about performing chest surgery on such a small animal. Though there had never been any written reports about chest surgery on a ferret in United States, the board certified surgeon used her experience with the dog and cat to plan out the procedure.
The chest was opened and all of the right lung lobes were found to be completely infected. The surgeons decided to remove all the right lung lobes knowing that most animals can live with only 1/2 of the lung lobes in tact. The surgery was very difficult because of Popo’s small size. The procedure took approximately 2 hours to perform. A chest tube was placed into the right side of his chest so that extra fluid and air could be removed from his chest after surgery. Popo woke up well after the surgery.
Popo was maintained on pain medication, intravenous fluids and antibiotics in the ICU during his recovery. He went home with the chest tube in place after three days.
The owner came back in with Popo one week later to remove the chest tube. Popo is doing well 1 year after surgery!!
(click here to learn more about our specialty Exotic Pets Services)
Case Study: Dentigerous Cyst
An eight month old, 21.6kg neutered male Dalmatian/Springer mix, was referred for assessment and treatment of a 15 mm firm mass on the left rostral mandible. The lesion was located between the mandibular canine (#304) and the second premolar tooth (#306). Our presumptive diagnosis of the lesion was a dentigerous cyst.The preliminary physical examination revealed an asymmetrical enlargement of the left anterior mandible. The diagnostic plan included anesthesia for a thorough oral examination, professional prophylaxis, intraoral radiography and biopsy for histopathology.
The intraoral radiographs of the clinically affected area, demonstrated a radiodense tooth structure within an approximately 13 mm by 16 mm radiolucent area distal to tooth #304 (Figs.2,3). These radiographic findings supported a presumptive diagnosis of dentigerous cyst. The revised diagnostic and treatment plan was to surgically explore the mandible and obtain excisional biopsies for a histopathological diagnosis. The premolars (#305 and #306) would be extracted and the oral defect was to be reconstructed using a mucogingival pedicle flap closure. The histopathologic diagnosis of the lesion was odontogenic keratocyst.
Diagnosis and Treatment of a Dentigerous Cyst in a Dalmatian/Springer Mix
Dale Kressin DVM, FAVD, Dipl. AVDC - June, 2005(click here to learn more about our specialty Dental & Oral Surgery Services)
"Smokey" was a 6 year old neutered male domestic long haired cat that ran away from home two days prior to presentation. Smokey presented to the Animal Emergency Center emergency service with the following neurologic and physical abnormalities:
- significant mental depression,
- circling to the right,
- increased extenor tone to the left front and rear limbs
- third eyelid raised on right
- small puncture wound typical of a retrobulbar abscess by the last molar on the right.
Routine blood work did not show any significant abnormalities. Infectious titers were submitted. Exploration of the mouth wound found no obvious etiology. Further diagnostics included a MRI to assess the brain due to the sudden onset and focal right cortical/subcortical neurologic signs. (see Figures 1 and 2).
The MR showed a lesion in the ventral subcortical (diencephalons) region of the brain. The lesion was not typical for a tumor nor for a pyogranulomatous lesion seen with infectious or granulomatous diseases. Cerebral edema was present.
The likely cause of the sudden onset of neurologic signs and the lesion found on MR was found the next day when a cuterebra was found migrating in the tissues in the mouth.
(click here to learn more about our Specialty Imaging Services)
“Comet”
Comet is a 7-year-old Labrador retriever. At the beginning of February 2007, Comet began having choking episodes and coughing. He was taken to his veterinary office, where a physical examination revealed enlarged lymph nodes in multiple locations. A fine needle aspirate on one of the lymph nodes was taken. This sample was consistent with high-grade lymphoma.
Lymphoma is a relatively common cancer in dogs. It is a cancer of lymphocytes (a type of white blood cell) and lymphoid tissues. Lymphoid tissue is normally present in many places in the body, including lymph nodes, spleen, liver, digestive tract and bone marrow. In most cases, we cannot tell what causes lymphoma. The most common form is involvement of one or more of the external lymph nodes similar to what Comet had. Many dogs may not feel sick or may have only very mild signs such as tiredness or decreased appetite. Other dogs may have more severe signs such as weight loss, vomiting, diarrhea, excessive thirst or urination, weakness, or difficulty breathing. The severity of the signs depends upon the extent of the disease and on whether the cancer has caused changes in organ function. Often, the only noticeable sign is an enlargement of the lymph nodes under the neck, behind the knees or in front of the shoulders. Other organs, such as the liver, spleen and bone marrow can be involved as well.
Chemotherapy is the mainstay of treatment for lymphoma. Lymphoma is very sensitive to chemotherapy, and up to 90% of dogs treated will go into remission when our most effective treatment protocols are used. The definition of remission is the complete disappearance of all signs of cancer. A remission is NOT a cure but it does allow pets to experience a good quality of life. It is important to remember this because chemotherapy should not be discontinued as soon as a remission is achieved. The length of remission depends upon many factors including the primary site, how sick an animal is at the start of treatment, blood calcium level, and the extent of disease. For those dogs, like Comet, that have the most common type (external lymph nodes enlarged) and are treated with the most effective treatment protocol, the average survival time is about 12-14 months; approximately 25% of dogs may live longer than 2 years. Unfortunately without treatment, most dogs will succumb to their disease within 4-6 weeks.
Compared to people receiving chemotherapy, pets experience fewer and less severe side effects. because we use lower doses of drugs and do not combine as many drugs as in human patients. The normal tissues that are most sensitive to chemotherapy are the intestinal lining, the bone marrow (which makes new blood cells), and hair follicles. Toxic effects to the digestive tract are responsible for decreased appetite, vomiting, and diarrhea. In most cases, these signs are mild and usually resolve on their own or with oral medication given at home. We seldom see severe side effects; it is estimated to be less than 5% of all pets receiving chemotherapy will have a side effect requiring hospitalization.
After discussing options for treatment, Comet’s owner elected to begin therapy with chemotherapy. Comet’s treatment will consist of 4 cycles of a combination of chemotherapy medications. During the first phase of his treatment (called induction), Comet will get four weekly treatments followed by one week off. This is repeated for another 4 weekly treatments and then Comet will go to every other week therapy.
Comet was given his first dose of chemotherapy on March 2, 2007.
Update:
3/8/2007 - Comet returned today for his second dose of chemotherapy. He is feeling great and his cough is much improved. His lymph nodes are much smaller as well, his appetite is good, and his weight is stable.
4/10/2007 – Comet’s lymph nodes are no longer enlarged!! He is in complete remission for his lymphoma!! He is feeling great!
4/24/07 – Comet was given his last weekly injection today. He will be treated every other week from now on. He remains in complete remission and is feeling great!
“Taj”
A Wonderful Cat with Wonderful Owners
A Case of Feline lymphoma
Taj is an 18-year-old Maine Coon. Last August he presented to the Animal Emergency Center emergency service for fever, lethargy, weight loss and difficulty using his hind legs. A physical examination revealed that Taj was thin (6 1/2 lbs). He had a fever (Temp = 104 F: normal = 101.5 F), was dehydrated, and had difficulty walking on his rear legs. Taj was admitted to the hospital for intravenous fluids to help correct his dehydration and help to lower his temperature. Basic diagnostic tests were preformed to try to identify the cause of Taj's illness. Blood work revealed a mild anemia and a mild elevation in kidney enzymes. A urine sample contained bacteria indicating Taj had a urinary tract infection. Taj was started on intravenous antibiotics. After one night in the hospital, Taj's temperature was normal and he was eating again on his own. He was discharged with oral antibiotics and scheduled to recheck in a few days.
Taj returned the following evening, now with vomiting and diarrhea. His temperature was normal at presentation but he was again dehydrated and lethargic. Repeated blood work showed that the kidney values were more elevated and his anemia had gotten worse. The owners allowed more advanced diagnostics. An abdominal ultrasound was performed to evaluate Taj's kidneys and other organs in his abdomen. The ultrasound showed that Taj's kidneys were smaller than normal indicating some kidney disease, most likely associated with advanced age. Taj also had some enlarged lymph nodes in his abdomen associated with his intestines. A needle was placed in some of the lymph nodes and cells were aspirated for examination under the microscope (cytology). A consultation was obtained with Dr. Rachel Reiman from the oncology service.
The cells were examined by Dr. Reiman and the diagnosis of lymphoma (or lymphosarcoma) was made. Lymphoma is one of the most common cancers diagnosed in cats. It is a cancer of the lymphocytes (a type of white blood cell) and lymphoid tissues. Lymphoid tissue is normally present in many places in the body including lymph nodes, spleen, liver, gastrointestinal tract and bone marrow. Cats of any age, breed and sex can be affected.
Lymphoma can be divided into several different forms, which depend upon the predominant location of the tumor (Table 1). Some cats have multiple sites of involvement and do not fit well into just one category.
Chemotherapy is the mainstay of treatment for lymphoma. Lymphoma is very responsive to chemotherapy and up 75% of treated cats will have the complete disappearance of all signs of cancer (remission). However, microscopic amounts of tumor cells can remain hidden in the body. A remission is NOT a cure but it does allow your cat to experience a good quality of life. Because of this, chemotherapy should not be discontinued as soon as remission is obtained. The length of remission depends upon many factors, including the primary site, the degree of illness at the start of treatment, FeLV status, and the extent of disease.
Most cats tolerate their chemotherapy well with minimal side effects. Serious side effects are seen in less than 5% of the cats treated. Side effects might include nausea, vomiting and loss of appetite, diarrhea, tiredness or infection. If side-effects are serious or intolerable, steps will be taken to eliminate or reduce these effects to a tolerable level. Cats do not lose their hair, but may lose their whiskers and develop a different texture to their fur.
Taj had the gastrointestinal form of lymphoma. Without treatment most cats will succumb to this disease rapidly. They will often continue to lose weight, stop eating or have worsening vomiting and/or diarrhea. Taj's owner elected to begin chemotherapy treatments with the oncology team. Taj had a high-grade form of lymphoma so a more aggressive chemotherapy protocol was needed. Taj was given weekly injections of chemotherapy drugs for the first 8 weeks, and then he was given injections every other week. Taj seemed to handle these treatments fairly well with only a few episodes of vomiting and anorexia. Throughout treatment, Taj gained weight very slowly. In the first month of treatment he went up to seven pounds. He seemed to hover in this range for most of his treatment.
Taj finished chemotherapy on May 4th, 2006. He comes in for periodic rechecks and remains in complete remission. He is now up to 8 pounds!
Table 1. Different Forms of Lymphoma According to Location
- Digestive tract (Gastrointestinal): This is the most common form of lymphoma in cats. The digestive tract includes the stomach, intestines and liver as well as some of the lymph nodes surrounding the intestines. Cats with this type of lymphoma may have vomiting, diarrhea, weight loss or a decreased appetite.
- Mediastinal: The mediastinum is a term used for a special group of lymph nodes in the chest. Cats with this type of lymphoma are usually younger and infected with Feline Leukemia Virus (FeLV). Symptoms include difficulty breathing due to a large mass in the chest or an accumulation of fluid around the lungs.
- Kidney: The kidneys may be the primary site of involvement. Cats that have this type are often seen because of signs related to kidney failure (increased thirst, increased urination, loss of appetite, vomiting).
- Bone marrow: If the cancer is confined to the bone marrow, we call this leukemia. The signs that we see in cats are usually related to the decreased numbers of normal cells (such as red blood cells that carry oxygen, white blood cells that fight infection and platelets that help with clotting) which are made in the bone marrow.
- External lymph nodes: These cats may be seen because the owner notes "lumps" (enlarged lymph nodes) on their cat.
- Other sites: Other sites such as the skin, nose, brain, and spinal cord as the primary site of involvement.
Taj’s lymph nodes, indicating lymphoma.
Katie Bratberg, oncology nurse (left)
Dr. Rachel Reiman (right)
(click here to learn more about our Specialty Oncology Services)
Case Study: External Skeletal Fixator
external fixator was removed.Radiograph (also know as an x-ray) of Kody’s broken leg. The radius and ulna are both broken in the forearm, just above his carpus (wrist). The yellow arrow identifies the fractures
Kody is a two year old Husky. This spring, he was hit by a car, sustaining a broken forearm and multiple abrasions to the skin. The skin was open at the fracture, increasing the chances of infection after surgery because of bacterial contamination.
Kody had an external skeletal fixator placed on his forelimb to stabilize the fractured bones. An external fixator allows stabilization of the fracture without placing permanent implants in the limb. Pins and wires are placed through the bone and connect to a frame outside the limb.
As Kody's bone healed, his owners provided daily wound care to the sites where pins and wires exited the skin. The external fixator was bandaged to prevent Kody from catching it on furniture and to prevent him from hitting people and objects with his fixator. Restricting his exercise was hard, but Kody's owners did a great job of limiting his activity to help his bones heal.
Kody did develop minor pin tract infections which were managed with antibiotic therapy. As his bone grew stronger some of the pins and wires were removed from Kody's leg. This procedure is not painful and Kody tolerated pin removal without any medication.After 8 weeks, Kody's external fixator is coming off!
Kody's bones will continue to strengthen as the fracture site remodels. Restricted exercise for the next 4-6 weeks is still important after the external fixator is removed to allow the bone to adapt back to life without the external fixator.
Here is a radiograph of Kody’s leg with the external fixator in place.
Kody’s leg with the external fixator before it was removed. Note there is a pin missing from the radiograph above. (click here to learn more about our Specialty Surgery Services)
