PRESENTATION 1
A 4-year-old neutered male Irish setter was presented for anorexia of 3 days’ duration and acute intractable vomiting for the past 24 hours. The dog has a history of pica but does not usually develop clinical signs. The client suspected that the dog may have ingested a dish cloth about a week ago. Vaccines and heartworm preventative treatment were up to date.
Related Article: Diagnostic Peritoneal Lavage
Physical Examination
The patient was quiet, alert, and responsive. The mucous membranes were tacky and the abdomen was tense on deep palpation. A suspected foreign body was palpable cranially.
- Weight: 34.6 kg
- Temperature: 101.7⁰F
- Pulse: 180 bpm (synchronous pulses; fair quality)
- Respiration: 48 bpm
Diagnostics
Blood analysis (abnormal values)
- RBCs: 9.75 × 106/μL (range, 4.8–9.3)
- Hematocrit: 71.4% (range, 36–60)
- Hemoglobin: 22.1 g/dL (range, 12–20.3)
- Platelets: 134 × 103/μL (range,170–400)
- Albumin: 2.5 g/dL (range, 2.7–4.4)
- Glucose: 148 mg/dL (range, 70–138)
- Total bilirubin: 0.7 mg/dL (range, 0.1–0.3)
Abdominal radiographs: Suggestive of a small intestinal obstruction, with small intestinal to L5 ratio of 2.0, multiple distended small intestinal loops, and a mixed population of normal and abnormally distended loops.
Treatment
A ventral midline celiotomy and abdominal exploratory revealed a midjejunal foreign body. Marked intestinal gas distention and bruising were noted from the cranial area to the foreign body, which was removed by an aboral enterotomy. Omental patching was performed, and the abdominal cavity was flushed with approximately 2.5 liters of sterile saline. A Jackson-Pratt drain was placed, and the abdomen was closed routinely.
- Anesthesia
- Premedication: hydromorphone (1.7 mg IV)
- Induction: propofol (140 mg IV, to effect); diazepam (10.4 mg IV)
- Maintenance: isoflurane inhalant anesthesia
- Intraoperative therapy
- Plasma-Lyte* (350 mL/hr CRI), Normosol-R bolus (790 mL × 1, over 10 min)
- Hetastarch (62 mL bolus) for hypotension
- Ampicillin (770 mg IV)
- Morphine (8.4 mg/hr) and lidocaine (105 mg/hr) added to CRI of fluids
- The patient regurgitated during recovery; administered:
- Metoclopramide (1 mg/kg IV; then by CRI [2 mg/kg q24h])
- Postoperative treatment/instructions
- Plasma-Lyte* + KCl (20 mEq/L) + metoclopramide (16 mg/L) + lidocaine (500 mg/L) + morphine (33 mg/L) CRI at 90 mL/hr
- Hetastarch (30 mL/hr)
- Famotidine (0.5 mg/kg IV q24h)
- Maropitant (1 mg/kg SC q24h)
- Dexmedetomidine (2 μg/kg IV prn) for anxiety
- JP drain evacuations q4h; evaluate fluid q24h; removed drain on day 2
- The dog developed mild hypoproteinemia and was initially inappetent. With improvement in clinical signs, the patient was discharged after 2 days with the following plan:
- Apply cold/warm packs to incision
- Tramadol (2 mg/kg q24h)
- Famotidine (0.75 mg/kg q24h)
- Small frequent meals
- Activity restriction x 2 weeks, e-collar at all times
- Recheck in 10 to 14 days for suture removal
PRESENTATION 2
The patient presented 1 day after discharge (3 days after enterotomy) for lethargy, decreased appetite, polydipsia, and diarrhea.
Physical Examination
- The patient was bright, alert, and responsive. Abdomen unremarkable on palpation. Incision appeared within normal limits.
- Temperature: 102.7⁰F
- Heart rate: 124 bpm
- Pulses: strong and synchronous
Diagnostics
- Brief abdominal ultrasound showed scant abdominal effusion with moderate diffuse ileus.
Treatment
- Recommended bland diet, frequent walks to promote gastric motility.
- Recommended continued monitoring and, if inappetence/lethargy persists, return for full abdominal ultrasound.
PRESENTATION 3
Seven days after the enterotomy, the patient was presented for serosanguineous discharge from the incision line over the past 2 to 3 days. The patient exhibited no changes in appetite, no vomiting or diarrhea, normal stools, and normal activity levels.
Physical examination
The abdomen was tense under palpation but not overtly painful. The incision was swollen with crusting along the incision and down the medial thighs. Serosanguineous fluid continued to drain from the incision.
- Weight: 35 kg
- Temperature: 103.9⁰F
- Pulse: 120 bpm
- Respiratory rate: 24 bpm
- Mucous membranes: mildly tacky
Diagnostics
- FAST (focused abdominal sonography for trauma) scan: free abdominal fluid
- Paired samples of fresh whole blood and abdominal fluid
- Whole blood: lactate 1.3 mmol/L (range, <2.5); glucose 105 mg/dL (range, 70–138)
- Abdominal fluid: lactate 7.2 mmol/L; glucose 50 mg/dL
- Cytology of abdominal fluid
- Few neutrophils with intracellular cocci
- Marked degenerate neutrophils (>5–10/hpf)
- Red blood cells/macrophages in moderate numbers
- Packed cell volume: 43% (range, 37–55)
- Total protein: 5.4 g/dL (range, 5.2–7.8)
Treatment
The original midline celiotomy was opened and an abscess was noted in the subcutaneous space along the caudal third of the incision. Approximately 200 mL of purulent fluid was suctioned from the peritoneal cavity. Multiple fibrous adhesions were present, attaching the jejunum to the original incision at the linea alba and the abscess to the omentum, linea incision, midjejunum, and previous enterotomy site. The gastrointestinal tract and pancreas were severely inflamed with no peristalsis noted. Multiple areas of jejunum contained small serosal tears but leak test was negative. The previous enterotomy site showed evidence of leakage and the original closure was resected with 1-millimeter margins and closed transversely. The abdomen was lavaged with 8 liters warm saline and the fluid was cultured. Omental wrapping was performed at all areas of serosal damage and at the enterotomy site. Two intraabdominal Jackson-Pratt drains were placed (caudally and cranially) as well as a third Jackson-Pratt drain along the linea. The remainder of the abdomen was closed in routine fashion. Peritoneal culture showed Escherichia coli susceptible to most broad-spectrum antibiotics.
- Anesthesia
- Premedication: fentanyl 1.7 mm patch (2 μg/kg IV)
- Induction: propofol 5 mg/kg (105 mg) IV to effect, diazepam 0.3 mg/kg (10.5 mg) IV
- Maintenance: isoflurane inhalant
- Intraoperative therapy
- Plasma-Lyte* (350 mL/hr), fentanyl 10 mL/hr (increased to 25 mL/hr during procedure) CRI
- Crystalloid (62 mL bolus × 2) for hypotension
- Cefazolin (770 mg IV)
- Postoperative treatment/instructions
- Plasma-Lyte* + KCl (20 mEq/L) + metoclopramide (22 mg/L) at 130 mL/hr
- Fentanyl (3 μg/kg/hr)
- Famotidine (0.5 mg/kg q24h IV)
- Ampicillin/sulbactam (1050 mg q12h IV)
- Enrofloxacin (350 mg q24h IV)
- Dexmedetomidine (2 μg/kg prn IV; then 0.27 mg/L CRI) for anxiety
- JP drain evacuations q2h; evaluate fluid q24h
- Calculate input/output based on fluid losses from drains; replace with lactated Ringer’s solution q2h
- Apply warm packs to incision q6h
The patient developed mild hypoproteinemia and was initially inappetent. After improvement in clinical signs, the drains were removed on postoperative day 3 and the patient was discharged on postoperative day 4, with the following plan:
- Tramadol (2 mg/kg q24h)
- Famotidine (0.75 mg/kg q24h)
- Enrofloxacin (4 mg/kg q24h)
- Small frequent meals
- Activity restriction × 2 weeks; e-collar at all times
- Recheck/suture removal in 10 to 14 days
OUTCOME
Patient exhibited no complications to enrofloxacin treatment. The incision healed with no further discharge and patient is doing well (eating, drinking, no vomiting or diarrhea) at home. The sutures were removed on postoperative day 11 and the dog was returned to normal activity/diet.
*A multiple electrolyte intravenous solution