The Case: A Vomiting, Prayerful Borzoi
History
A 4-year-old castrated male borzoi was presented for a single episode of vomiting, which occurred shortly after eating. The owner had noted occasional posturing in prayer position for 3 weeks.
Physical Examination
The patient was quiet, alert, and responsive and exhibited lip licking.
Heart rate: 150 bpm, tachycardia; pulses were strong and synchronous
Blood pressure (noninvasive/Doppler): 134 mm Hg systolic, normotension
Weight: 30.5 kg
Palpation: Large, firm cranial abdominal swelling/mass detected
Diagnostics
Three-view abdominal radiographs
Decreased serosal detail
Large soft tissue opacity caudal to stomach with dorsal and caudal displacement of small intestines, consistent with a splenic mass
No displacement of gastric axis evident
Otherwise radiographically normal abdomen.
Three-view thoracic radiographs: unremarkable
FAST<sup†sup> scan of abdomen for free fluid: unremarkable
Serum chemistry panel/electrolytes (in-house Antech point of care machine)
Alanine aminotransferase: 116 IU/L (range, 10–100)
Glucose: 124 mg/dL (range, 74–143)
Otherwise unremarkable
CBC/serum chemistry panel (Antech)
Total protein: 4.9 g/dL (range, 5.0–7.4)
Alkaline phosphatase: 140 IU/L (range, 5–131)
Glucose: 143 mg/dL (range, 70–138)
Total calcium: 8.5 mg/dL (range, 8.9–11.4)
Electrocardiogram: normal sinus rhythm
Plan
Overnight hospitalization with supportive care
Abdominal ultrasound planned for following morning
Splenectomy, pending results of abdominal ultrasound
Overnight Treatments and Progress
Fluids: 10 mL/kg Plasmalyte* bolus, then 90 mL/hr with 20 mEq sodium chloride
Buprenorphine: 0.01 mg/kg q8h IV
Aminocaproic acid: 25 mg/kg q8h IV (in anticipation of surgery the following day)
Tachycardia persisted: (heart rate: 140–160 bpm) despite fluid therapy/buprenorphine
Additional Diagnostics
Abdominal Ultrasound
Markedly enlarged spleen with rounded margins; no splenic nodule or masses
Decreased to absent venous return in splenic vasculature noted on B mode ultrasound. Color Doppler consistent with splenic torsion
Moderate peritoneal effusion
Hyperechoic mesenteric fat adjacent to spleen, consistent with peritonitis
Otherwise ultrasonographically normal abdomen
Prothrombin/partial thromboplastin time: normal, PT 14 seconds (range, 11–17)/PTT 10 seconds (range, 9.1–15.6)
Packed cell volume/total protein: 39% (range, 35–55)/4.2 g/dL (range, 5.0–7.4)
Platelet estimate: 112 X 103/µL (range, 175–500)
Abdominal Exploratory Surgery & Splenectomy
A 360⁰ splenic torsion with tearing of short gastric vessels and thrombosis of major splenic/omental vessels was noted. Sanguineous peritoneal fluid (200 mL) was removed from the abdomen. Splenectomy and prophylactic gastropexy were performed.
The patient was stable under anesthesia.
Outcome
The patient did well postoperatively and was discharged with tramadol 4 mg/kg q8h PO for postoperative pain the following day.
*A multiple-electrolyte solution† Focused assessment with sonography in trauma
The Specialist’s Opinion
Lisa Corti, DVM, DACVS, CCRP
This report provides a great opportunity to discuss the rare occurrence of splenic torsion in dogs. While the patient was a borzoi, Great Danes and German shepherd dogs have been reported to be at greater risk for splenic torsion than others.1 This patient had a history of chronic abdominal pain (posturing in prayer position for 3 weeks) followed by an acute episode of vomiting, presumptive nausea (lip licking), and tachycardia. Splenic torsion typically presents as a chronic disorder, with vague signs such as lethargy, anorexia, vomiting, and abdominal pain. Approximately one third of chronic cases present for an acute episode that requires emergency treatment,1 as happened here. Several things stand out in this case.
Tachycardia & Hemoabdomen
The tachycardia on presentation persisted through the night despite fluid therapy and buprenorphine administration. In a retrospective study of dogs with hemoperitoneum, tachycardia––which can be caused by hypotension, hypovolemia, pain, heart disease, and other conditions––has been shown to be a perioperative factor associated with death and failure to be discharged from the hospital.2 Radiographs in this case revealed a cranial abdominal mass with decreased serosal detail, perhaps indicative of peritoneal effusion. An abdominal focused assessment with sonography in trauma (FAST) scan was, however, unremarkable and the patient was deemed to be free of abdominal effusion. As such an exam is user dependent, the decreased serosal detail on radiographs combined with presence of an abdominal mass and tachycardia should have raised suspicions for the presence of a hemoabdomen.
More aggressive treatment of the patient’s tachycardia, therefore, was warranted. By my calculations, the initial bolus (300 mL) and overnight crystalloid administration (1.5 times maintenance) could have been enhanced to address the tachycardia with more aggressive fluid therapy.
Pain & Nausea
In addition, the patient may still have been in pain. The buprenorphine dosage (0.01 mg/kg q8h IV), in my opinion, is somewhat low, as the dose cited most commonly in the literature is 0.02 mg/kg. Every patient is different, however, and using a pain scale, such as the Glasgow Composite Pain Score, to assess the patient’s level of pain can lead one to increase the dose or frequency or switch to a different analgesic.
The patient’s nausea was also not treated throughout the night. In addition to the discomfort that nausea brings, the patient could have progressed to vomiting, leading to potential volume and electrolyte abnormalities before surgery. Maropitant, metoclopramide, famotidine, and ondansetron are medications that can be useful.
Epsilon Aminocaproic Acid
Interestingly, epsilon aminocaproic acid (EACA) was given “in anticipation of surgery the following day.” EACA is a strong inhibitor of fibrinolysis, as it prevents the activation of plasminogen into plasmin on the surface of blood clots. A retrospective study determined that 28% of retired racing greyhounds that received an amputation for bone cancer had evidence of delayed postoperative bleeding, and those greyhounds that did not receive EACA before surgery were 5.7 times more likely to bleed than the dogs that did receive EACA.3 Whether sight hounds other than greyhounds can have delayed postoperative bleeding, and whether EACA would prevent that bleeding, remains to be seen. Nonetheless, it was with good foresight that EACA was used in this case.
Definitive Treatment
Definitive treatment for splenic torsion is splenectomy, as was done here. The splenic pedicle should not be untwisted, as toxic substances and microemboli can be released into the systemic circulation,1 and can lead to death. Two to three encircling ligatures of heavy nonabsorbable suture can be used around the twisted pedicle before it is transected, making sure to place the ligatures close to the spleen in order to avoid the pancreas. Alternatively, the vessels along the hilus of the spleen can be individually ligated, stapled, or cauterized.
The cause of splenic torsion remains unknown but it is conjectured to be associated with gastric dilatation/volvulus syndrome and splenic neoplasia.1 A gastropexy, which was appropriately carried out in this case, should be performed at the time of splenectomy. The spleen should be submitted for histopathology to rule out any underlying pathology that might have led to the torsion.
Final Notes
The prognosis for dogs with chronic splenic torsion is good. The prognosis for acute torsions depends upon the adequacy of treatment for the hemodynamic changes that occur with cardiovascular collapse.1 The outcome in this case was a positive one, with the patient discharged the following day. It is noted that tramadol was dispensed for pain. Dogs’ inability to produce the metabolite of tramadol that acts at the mu opioid receptor, tramadol’s apparent decrease in oral bioavailability over time, and the lack of clinical studies supporting its use for postoperative pain4 have led this reviewer to prescribe it infrequently. Alternatives for treating at-home postoperative pain include nonsteroidal antiinflammatories with or without gabapentin, transdermal fentanyl, and cold packs on the abdominal incision.
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.
The Generalist’s Opinion
Barak Benaryeh, DVM, DABVP
Although splenic torsions are rare, abdominal emergencies that involve the spleen are fairly common. The clinician(s) in this case did an excellent job of identifying this uncommon disorder and treating it successfully. We can divide the case down to initial presentation/diagnosis, monitoring/treatment, and follow-up to identify some specific learning points from each of these phases.
To Cut or Not to Cut
The first question when dealing with any abdominal emergency is whether or not the case warrants surgery. Radiographs, a serum chemistry panel, and a CBC are the starting points and may be diagnostic in themselves. Often, however, an ultrasound is needed to make a more definitive diagnosis. Indications for immediate surgery include penetrating wounds to the abdomen, evidence of phagocytized bacteria and degenerative neutrophils from abdominal fluid, free gas in the abdomen, and hemorrhage.1 In this case a FAST (focused assessment with sonography in trauma) was performed. FAST scans are very dependent on the individual skill and experience of the sonographer. If there is no obvious and immediate need for surgery, one must consider the stability of the patient, other diagnostic modalities that might be indicated, and how long the patient will need to wait. This dog was tachycardic but normotensive, had no evidence of ongoing losses, and appears by description to have been stable. Waiting for a complete ultrasound was the right call.
Abdominocentesis
The FAST scan done showed no evidence of free fluid. Often with splenic disease (including torsions) there is some free abdominal fluid. If the spleen is hypoxic, one would expect secondary edema and fluid leakage. An abdominal tap can help narrow the differential list. Any evidence of intracellular bacteria in free abdominal fluid is always an indication for surgery.
One additional diagnostic tool that is rarely used but may be helpful in some cases is a peritoneal lavage: sterile saline is introduced into the abdominal cavity and then aspirated for diagnostic purposes.
Watch Those Numbers
Rechecking packed cell volume, total solids, and electrolytes at some point in the night would have provided an extra measure of safety. This dog’s hematocrit was not decreased but the total protein was slightly low (4.9 g/dL [range, 5.0–7.4]). Decreasing total solids is often a better indicator of recent blood loss than PCV as splenic contraction can falsely elevate the red blood cell count.2 Continuing to monitor values throughout the night may reveal changes that might not be clinically apparent.
Following Up
Performing a gastropexy during the surgery was an excellent call. Borzois are a deep-chested breed and at increased risk for gastric dilatation/volvulus. One curious aspect of the case is that the owner noted that the dog had been posturing occasionally (prayer position) for 3 weeks. Splenic torsions are generally considered an acute emergency. It would seem unusual that the source of pain for this dog was the spleen for the last several weeks. This may be a red herring but might be worth pursuing.
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.