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The Case: Persistent Inappetence

Clinician's Brief

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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


The Generalist’s Opinion
Barak Benaryeh, DVM, DABVP

The veterinarian(s) involved in this case clearly practices a high level of veterinary medicine. The response to this complication was appropriate and thorough and the dog survived due to the excellent care it received. What we can learn from this case lies not just in where things went wrong but where they went right.

Leak Test
In describing the initial surgery, it is not stated whether a leak test was performed on the intestine after closure. The typical way to perform a leak test is to inject saline into the gut lumen with a 25-gauge needle. The intestines are then closed off on either end while slight pressure is applied to ensure that there are no leaks. Even in the best of cases, a small amount of leakage is possible. In this case, an omental patch was placed to provide backup protection against leakage.

Drains
A Jackson-Pratt drain was placed after the initial surgery. It’s not clear why. When surgery is free from contamination, there should be no need for a drain. A closed suction drain is an effective way to monitor any exudative fluid while minimizing the chance for an ascending infection, but no drain is without potential problems. Complications with drains have been reported to be as high as 35%1 and include falling out, being chewed out, detaching from the patient, and losing suction. In the case of a straightforward enterotomy, placing a drain can create a potential complication rather than prevent one. In a contaminated surgery, such as the second procedure, a drain is appropriate.

FAST (Focused Abdominal Sonography for Trauma or Focused Assessment with Sonography for Trauma)2
The practitioners used the FAST system, originally introduced in human medicine as a way to identify abdominal hemorrhage from trauma. It is a rapid, safe, noninvasive imaging technique that can easily be learned by nonradiologist veterinarians. The abdomen is scanned in 4 specific areas, each in 2 opposing planes. The use of this scan enabled the clinicians to recognize the need for surgery and act accordingly. In summation, the slight improvements that could have been made in this case were being sure to perform a leak test and avoid using a drain in a clean procedure. The use of appropriate diagnostics, good surgical intervention, and drains in the second, contaminated procedure turned the case around and ultimately saved the dog’s life.

Barak Benaryeh, DVM, DABVP, is the owner of Spicewood Springs Animal Hospital. He graduated from University of California–Davis School of Veterinary Medicine in 1997 and completed an internship in Small Animal Medicine, Surgery, and Emergency at University of Pennsylvania. Dr. Benaryeh has also taught practical coursework to first-year veterinary students and was a primary veterinary surgeon for the Helping Hands Program, which trains assistance monkeys for quadriplegic people. Dr. Benaryeh is certified by the American Board of Veterinary Practitioners in Canine and Feline Practice.


The Specialist’s Opinion
Lisa Corti, DVM, DACVS, CCRP

This case reinforces the point that sometimes no matter what we do or how well we do it, we will still confront complications as a result of factors inherent to our patients. Some precautions can be taken to avoid less than optimal outcomes, in this case, the development of leakage from an enterotomy incision.

Fluid Therapy
This patient received appropriate fluid therapy during the first surgery, but it is very important to provide fluid resuscitation before surgery. Adequate preoperative fluid resuscitation makes for a better anesthetic candidate, can improve bowel perfusion, can turn a potential resection and anastomosis into an enterotomy, and can even improve peristalsis to allow a foreign body to pass without further intervention. Rechecking blood values (eg, packed cell volume/total protein [PCV/TP], lactate, pH, BUN, and creatinine) after fluid resuscitation can help assess whether the fluids provided have been adequate. I often take my patients with foreign bodies to surgery with postfluid PCV and TP in the upper 30s (%) and upper 5 (g/dL) values, respectively.

Drain Placement
I’m not sure why a Jackson-Pratt drain was placed in the absence of a septic effusion. Drains can decrease healing and increase risk of infection and should therefore be used only when the benefits outweigh the risks.

Intraoperative Hypotension
Intraoperative hypotension, reported here during the first surgery, is significantly associated with development of postoperative septic peritonitis,1 so every effort should be made to prevent any decrease in blood pressure during surgery. Aggressive fluid therapy with crystalloids and colloids before and during surgery, providing balanced anesthesia and analgesia, minimizing surgical time, and the use of vasopressors can all help in this regard.

Regurgitation
The patient regurgitated during recovery, which unfortunately is not uncommon. Hydromorphone was given as premedication. A recent study revealed that maropitant, when given 1 hour prior to premedication with hydromorphone, prevented vomiting, retching, and nausea.2 Nausea, regurgitation, and vomiting can delay the onset of food intake after surgery, and early oral food intake, in my opinion, is extremely important after surgery to remove a foreign body, as it stimulates intestinal healing and motility and speeds patient recovery. Prolonged anesthesia can also lead to ileus and nausea, and postoperative morphine can cause nausea and thereby a delay in onset of eating. I prefer a fentanyl CRI or intermittent buprenorphine. Maropitant and famotidine were administered to control nausea in this patient; other medications that might have helped with inappetence are metoclopramide, ondansetron, and mirtazapine.

Hypoproteinemia 
Mild hypoproteinemia is stated to have developed postoperatively as well. Hypoproteinemia is a risk factor for developing postoperative septic peritonitis.2 A fresh frozen or frozen plasma transfusion can be considered to replenish protein levels in the hypoproteinemic patient.

The Initial & Ultimate Outcome
This patient had several factors working against full recovery. When he was returned 3 days postoperatively for lethargy and a decreased appetite, I would have been more aggressive with my diagnostics. The so-called “magic window” for gastrointestinal dehiscence is day 3 to day 5, when the inflammatory phase of healing is progressing to the repair phase. A thorough abdominal ultrasound, tapping the fluid noted, or performing a diagnostic peritoneal lavage would have been advisable. I also would recommend performing repeat blood analysis at this time: Evaluating for dehydration and electrolyte abnormalities might have explained the ongoing ileus, and evaluating for anemia, continued hypoproteinemia, and an elevated white blood cell count—all risk factors for death after GI surgery1—might have led one to believe that the patient was indeed compromised despite the normal findings of the physical examination. The presence of hypotension during early sepsis can also be determined by checking blood pressure, which was not mentioned here. In this case, the patient was discharged, and in addition to the recommendations that were made, I would have added metoclopramide and mirtazapine to the list of at-home medications.

At postoperative day 7, it was clear that the patient needed to undergo exploratory surgery. In one study 33% of patients undergoing GI surgery with preexisting septic peritonitis died.1 In this same study, approximately 10% of patients that did not have preoperative septic peritonitis also died, so  this is what I currently tell clients: Despite our best efforts, approximately 10% of these patients won't go home. I’m glad that in this case the final outcome was a good one.

Lisa Corti, DVM, DACVS, CCRP, is a surgeon at Massachusetts Veterinary Referral Hospital in Woburn, Massachusetts. After earning her veterinary degree from Tufts University, she completed a 1-year internship in medicine and surgery at Rowley Memorial Animal Hospital in Springfield, MA, and a 3-year residency in surgery at Iowa State University. Board certified by the American College of Veterinary Surgeons, Dr. Corti is PennHip certified and certified to perform tibial plateau leveling osteotomies (TPLO). She also completed the University of Tennessee course in canine rehabilitation and physical therapy and became certified in December 2006.

References

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