Help - Surgical or medical?

Re: Help - Surgical or medical?

Pieter Fourie — Sun, 04 Nov 2012 22:36:48 GMT

Has anybody attempted abdominal palpation or is that too oldfashioned as well? Pieter

Re: Help - Surgical or medical?

james herriot lied — Fri, 02 Nov 2012 13:27:20 GMT

[quote user="Rajat"]

They scan a lot of patients with suspect FBs which are scan negative and are kept in the hospital for monitoring and the majority respond to symptomatic treatment.

[/quote]

The majority respond to symptomatic treatment? What about the rest - do they have the FB fished out by ex lap later?

(see, now that was mindless sh*tst*rring....)

Re: Help - Surgical or medical?

Rajat — Fri, 02 Nov 2012 10:46:32 GMT

[quote user="David Mills"]Be interesting to see what comes back[/quote]

I had a response from the author..Jane thanks for pointing our that Dayle is a lady

I asked what the outcome was for the 13 patients excluded from the study and whether by any chance they had a fals epositive rate for US and/or radiography.

Paraphrasing (as closely as I can without copying and pasting)...Dayle recollects that the majority of those 13 did not have radiographic signs of an obstruction and were not suspicious on US for a FB. If they were suspicious on US they would have gone to surgery. none of them 9the 13) represented with a FB following discharge but Dayle says it is possible an FB could have been passed at home without the O noticing though most likely there was none to begin

Dayle's ongling clinical impression is that if there is a high clinical impression of a FB (history rads bloods +/- palpation) then ultrasound will pick it up. They scan a lot of patients with suspect FBs which are scan negative and are kept in the hospital for monitoring and the majority respond to symptomatic treatment. They don't radiograph the majority of these cases any longer (as they are using US) so it is hard to compare radiographic signs to sonographic signs.

Re: Help - Surgical or medical?

jd2008 — Sun, 28 Oct 2012 01:54:45 GMT

Just to clarify a couple of points arising from the first paper Raj referenced:

Melbourne Uni vet hospital has a first opinion general practice and the emergency department sees first opinion emergency cases as well as referred cases.

It is highly likely that most, if not all, the cases in Dayle and Cathy's paper were first opinion cases, not referred.

And Dayle is a she

We see many suspected GI foreign bodies in the ECC dept. A far as diagnosis goes first and foremost palpation is king. However there will always be a subset of patients who are not compliant, too obese or too painful to allow the careful palpation required to identify intestinal FBs.

Next step for me is ultrasound. Out of hours we don't have ready access to our ultrasonographers or their swanky machine. We do however have a perfectly decent Esoate Mylab in our ICU which gives the detail required for emergency imaging of an acute abdomen.

I ultrasound all my suspected GI FBs. It doesn't take long, 10-15 minutes, we charge the client the grand total of $70 for it and it gives what I consider vital information: not just confirming my suspicions, but occasionally identifying other abdominal pathology and also indicating the presence or absence of free peritoneal fluid. Even if you aren't confident about picking up GI obstruction on ultrasound, detecting free fluid is within the grasp of any vet.

Detecting free fluid will change the way the case is managed, the cost estimate and prognosis given and gives the surgeon and anaesthetist a vital heads-up.

It's also interesting to note the number of times the 'FB' palpated turns out to be an enlarged chain of jejunal lymph nodes - another reason for not diving straight into coeliotomy without at least attempting to get a handle on what you're dealing with.

All in, this 'faffing around' takes 15 minutes - 30 if I want radiographs as well. And the cost is small compared to the cost of emergency abdominal surgery.

As far as endoscopy goes we generally only remove oesophageal FBs with this (we see many - most Aussie dogs are fed bones as a regular part of their diet) . Rarely will we consider it for gastric FBs. Fishing around in a soup of ingesta for hours is rarely rewarding.

Re: Help - Surgical or medical?

Simon Neuhoff — Fri, 26 Oct 2012 18:30:22 GMT

[quote user="Anthony Todd"]

[quote user="Simon Neuhoff"] US can also help to avoid egg in the face situations - I've had a few of those![/quote]

Don't want to labour the point but missing a FB, when it would have been found with an ex lap, has to count as an emu egg in the face as far as I'm concerned.

[/quote]

errr yes - as I alluded in my prev post I am not happy to rule out fbs based in my ultrasound skills - that is not what I was talking about.

Re: Help - Surgical or medical?

Anthony Todd — Fri, 26 Oct 2012 17:39:20 GMT

[quote user="Simon Neuhoff"] US can also help to avoid egg in the face situations - I've had a few of those![/quote]

Don't want to labour the point but missing a FB, when it would have been found with an ex lap, has to count as an emu egg in the face as far as I'm concerned.

Re: Help - Surgical or medical?

Simon Neuhoff — Fri, 26 Oct 2012 17:27:23 GMT

[quote user="Anthony Todd"]

[quote user="James Laidlaw"]Ultrasound is also every so slightly less invasive than a GA and ex lap... There are probably a lot of cases that go to the knife un-necessarily - we've all heard or used the line about "releasing the demons" for an uneventful ex-lap. There are benefits to ultrasound in the correct and capable hands and the huge benefit is usually no sedation or GA required, just a bit of a haircut.[/quote]

I'm sure there are some that go to the knife unnecessarily and "releasing the demons" isn't a line many use now....

Remember we're talking about acute abdomens here, not opening up a dog that's off food for a day or so.

And, for sure, there are benefits of an ultrasound, but the 22% missed , in very experienced hands, seems a bit of a disadvantage to me which the poster seems to gloss over, in fact never acknowledge.....

[/quote]

Acute abdomens can include a number of non surgical causes too though - such as pancreatitis, parvovirus to name just two. Similarly ultrasound info may save the client money in terms of NOT going for an exlap when the prognosis is highly likely to be dire - and allow them to pts in a better way than "on the table" with an over the phone consent. US can also help to avoid egg in the face situations - I've had a few of those!

It is a very useful tool - personally I think less useful than many textbooks make it out to be and only every a part of a workup but useful never the less. As James and others have aid it is horses for course - there is no one size fits all approach.

Re: Help - Surgical or medical?

James Laidlaw — Fri, 26 Oct 2012 17:04:20 GMT

OP said "7 yo cocker male neutered, vomiting chronically for years but much worse in last few days"

Not really acute abdomen, but by the by...

Ultrasound in inexperienced hands could also help avoid tapping the stomach/GI tract when doing centesis. I don't think there's a right or wrong approach, and is all going to depend on things on a case by case basis. I feel there are just as many cases where diagnostics are used incorrectly or inappropriately as there are cases that get pushed for treatment or surgery that isn't a certainty...

22% missed in one study of 40 something dogs isn't my experience with "experienced hands" and that definition can vary wildly!!!

Re: Help - Surgical or medical?

Anthony Todd — Fri, 26 Oct 2012 16:41:34 GMT

I'm sure there are some that go to the knife unnecessarily and "releasing the demons" isn't a line many use now....

Remember we're talking about acute abdomens here, not opening up a dog that's off food for a day or so.

Re: Help - Surgical or medical?

James Laidlaw — Fri, 26 Oct 2012 16:18:13 GMT

[quote user="Anthony Todd"]

[quote user="Hannah Wynne Richards"]

Well said Simon

Wynne

[/quote]

Well reading the second paper it looks like the false positive rate with US was 2% and the false negative was 9 out of 41, if you include things that would be, or were, discovered by an ex. lap, that's 22%!

Surely an ex.lap has an error rate of nearly zero as far as a FB is concerned and a positive rate of a lot as far as pancreatitis etc. etc. is concerned.

There doesn't seem any statistical evidence for anything else than an ex.lap as far as I can understand.

Crikey, with US you might miss 5 in 41, and that's only the SI ones! Mind you one was discovered at necropsy and what does that say?

Not a risk I'd take!

[/quote]

Ultrasound is also every so slightly less invasive than a GA and ex lap... There are probably a lot of cases that go to the knife un-necessarily - we've all heard or used the line about "releasing the demons" for an uneventful ex-lap. There are benefits to ultrasound in the correct and capable hands and the huge benefit is usually no sedation or GA required, just a bit of a haircut.

Re: Help - Surgical or medical?

Anthony Todd — Fri, 26 Oct 2012 16:07:53 GMT

[quote user="Hannah Wynne Richards"]

Well said Simon

Wynne

[/quote]

Surely an ex.lap has an error rate of nearly zero as far as a FB is concerned and a positive rate of a lot as far as pancreatitis etc. etc. is concerned.

There doesn't seem any statistical evidence for anything else than an ex.lap as far as I can understand.

Crikey, with US you might miss 5 in 41, and that's only the SI ones! Mind you one was discovered at necropsy and what does that say?

Not a risk I'd take!

Re: Help - Surgical or medical?

Hannah Wynne Richards — Fri, 26 Oct 2012 13:13:43 GMT

Well said Simon

Wynne

Re: Help - Surgical or medical?

Simon Neuhoff — Fri, 26 Oct 2012 13:03:42 GMT

[quote user="Anthony Todd"]

[quote user="Rajat"]If one does not know have access to or skills with said tool, relying on other diagnostics one is more familiar with is more appropriate[/quote]

Or you could just go straight to the "reference standard" or one of them, best not necropsy or a phone call.....

From the second of the papers [can't copy the piece so I've just typed it out]

All 82 dogs underwent abdominal radiography, abdominal ultrasonography and one of the following reference standards; exploratory laparotomy, necropsy, or followup call telephone call to the owner at least 1 month after discharge....

I think I'd still just go straight to the first reference standard meself...

[/quote]

And you'd be wrong to do so sometimes. Like many threads this is becming increasingly more polarised between the "scan every abdomen" and the "exlap only" veiwpoints. The real world of course lies between.

Re: Help - Surgical or medical?

Anthony Todd — Fri, 26 Oct 2012 12:47:08 GMT

[quote user="Rajat"]If one does not know have access to or skills with said tool, relying on other diagnostics one is more familiar with is more appropriate[/quote]

Or you could just go straight to the "reference standard" or one of them, best not necropsy or a phone call.....

From the second of the papers [can't copy the piece so I've just typed it out]

I think I'd still just go straight to the first reference standard meself...

Re: Help - Surgical or medical?

Simon Neuhoff — Fri, 26 Oct 2012 11:25:48 GMT

Rajat it was the "I expect you and David to be hands on with the US" bit that made me think you feel this is of general application - and that is where I disagree with you. Not meaning to discredit my fellow GPs but the ones I have personal experience with are not competent enough to RULE OUT (as opposed to simply picking up) a foreign body on ultrasound.

Re: Help - Surgical or medical?

Rajat — Fri, 26 Oct 2012 11:01:27 GMT

Given this -

[quote user="Simon Neuhoff"]I have done an uktrasound course and do the odd scan[/quote]

You're quite right to say this

[quote user="Simon Neuhoff"]I certainly would never personally rule out a foreign body on the basis on one of my scans[/quote]

Doing an odd scan does not make one competent at it and doing one course is neither here nor there- some people may need a lot of courses, some may need only one. ~What is most important is lots of scanning practice and studying normal anatomy in books videos and most importantly live animals. And then studying some more. Unless one is doing that and getting better at US..one is not going to be competent at it.

[quote user="Simon Neuhoff"]nor would I be comfortable doing so on the basis of any of the GP's I have worked alongside. [/quote]

I've seen many GPs who are very very good with US as they use it regularly, almost if not daily..

If one does not know have access to or skills with said tool, relying on other diagnostics one is more familiar with is more appropriate - and this includes an exploratory laparotomy. I have repeatedly said this- pls see my previous posts.

Re: Help - Surgical or medical?

David Mills — Fri, 26 Oct 2012 10:57:07 GMT

[quote user="Rajat"]

haha I won't argue debate fluid therapy with you now- already off topic... btw did you folks read the second paper with 82 animals and 97% vs 70% success for US?

Oh and since the 13 animals were giving you guys sleepless nights I have emailed the author to see if he can shed some light on it. I expect you and David to be hands on with the US when they email back and say specificity was 100% too..!!!

[quote user="Anthony Todd"]Hypoglycaemic tu? Couple of wines moi![/quote]

[/quote]

Be interesting to see what comes back... don't get me wrong, I do think US is a fantastic tool and I love using it, but it is - apart from surgery perhaps - one of the few things entirely dependent on both the machine you have and the operator, as others have said; and the opportunities for 2nd opinions are limited in GP. I certainly wouldn't rule out an FB after a scan by myself, and I think that is more the general case than the papers involoving specialists - just like you alluded to with Mr Ness and ortho surgery.

Re: Help - Surgical or medical?

Simon Neuhoff — Fri, 26 Oct 2012 10:49:16 GMT

[quote user="Rajat"]

haha I won't argue debate fluid therapy with you now- already off topic... btw did you folks read the second paper with 82 animals and 97% vs 70% success for US?

[quote user="Anthony Todd"]Hypoglycaemic tu? Couple of wines moi![/quote]

[/quote]

Rajat it would still not be applicable to the real world of general practice - where not everyone has an ultrasound machine and the majority that do exist get used infrequently and inexpertly. I have done an uktrasound course and do the odd scan. I can identify gross pathology - but I can NEVER make a diagnosis -even the experts will agree you need a biopsy for that! Yet I consider myself to be at least as good as the majority of GPs I have worked alongside with a scanner - as a serial locum I have seen lots of scanners neglected and dusty in the corner. I certainly would never personally rule out a foreign body on the basis on one of my scans - nor would I be comfortable doing so on the basis of any of the GP's I have worked alongside.

I am not rubbishing diagnostics in general and I personally prefer to do things as thoroughly as finances and faciltieis allow but ultrasound is extremely operator dependent and I really feel the studies you have quoted have no bearing on general practice as I have observed it.

Re: Help - Surgical or medical?

Hannah Wynne Richards — Fri, 26 Oct 2012 10:05:26 GMT

Evelyn With regard to palpating abdomens You and I had the immense good fortune to be taught large animal medicine by someone who had extensive 1st opinion practice experience-and the basic principles have carried over to SA work I would have operated on the evidence of the original radiograph-together with the history

Wynne

Re: Help - Surgical or medical?

Rajat — Fri, 26 Oct 2012 00:30:26 GMT

[quote user="Evelyn Barbour-Hill"]

No.

But if you feel you have to "go in" (we're going in, chaps! (Achtung! Spitfeuer!)) immediately, why not apologise and postpone some of your consultations?

[/quote]

Couldn't agree more

Re: Help - Surgical or medical?

Anthony Todd — Thu, 25 Oct 2012 22:40:27 GMT

[quote user="Evelyn Barbour-Hill"]Doesn't anybody palpate the abdomen any more?[/quote]

Yes, I'd love to see the comparison between a good palpater, a good USographer, a good radiographer and a good surgeon......

Re: Help - Surgical or medical?

Evelyn Barbour-Hill — Thu, 25 Oct 2012 22:34:41 GMT

Doesn't anybody palpate the abdomen any more?

Doesn't anybody use barium any more?

Re: Help - Surgical or medical?

Evelyn Barbour-Hill — Thu, 25 Oct 2012 22:32:23 GMT

[quote user="Rajat"]On another note- is a symptomatic FB causing vomiting as emergent a surgery in everyone's eyes as is say a GDV? Do you go in immediately leaving aside the fact you may have other commitments in 1/2 to one hour like consults?[/quote]

No.

But if you feel you have to "go in" (we're going in, chaps! (Achtung! Spitfeuer!)) immediately, why not apologise and postpone some of your consultations?

Re: Help - Surgical or medical?

Michael Woodhouse — Thu, 25 Oct 2012 21:06:50 GMT

At some point something has to happen. Whether that is death, rupture, devitalisation etc. We'd all agree that if we just did nothing these dogs would eventually die? It's more like a pyo rather than a GDV to me. Maybe doesn't need to be done NOW like a GDV but the sooner it's done the sooner I can relax.

Re: Help - Surgical or medical?

Rajat — Thu, 25 Oct 2012 21:06:13 GMT

haha I won't argue debate fluid therapy with you now- already off topic... btw did you folks read the second paper with 82 animals and 97% vs 70% success for US?

[quote user="Anthony Todd"]Hypoglycaemic tu? Couple of wines moi![/quote]