Cases with answers! To ex lap or not?

Re: Cases with answers! To ex lap or not?

John Flynn — Sun, 17 Nov 2013 20:10:12 GMT

[quote user="mariette asselbergs"]

When I was looking at the 24 hr x-rays as compared to the first ones, it looked like a lot of faeces had moved and there was no sign of overinflated intestines, so I thought that was pretty much against the possibility of a foreign body. Am I wrong to think that (I am quite new to reading radiographs).

Mariette

[/quote]

That was my interpretation also, Mariette.

On the first set of radiographs (apologies for lack of side markers), the stomach looked normal with a little gas and fluid present, while the duodenum, containing a normal amount of gas, looks displaced medially (away form the right abdominal wall) on the VD view, while on the left lateral is perhaps marginally displaced ventrally. This could indicate pancreatic disease (but typically displaces duodenum laterally), or (less likely) hepatic enlargement; with hindsight it was an incidental/artifactual finding. The pancreatic region is probably too cranial to assess fully, but no evidence of changes in serosal detail to indicate localized pancreatitis. The colon contains a moderate amount of feces, and given the site of pain clinically, I wondered if could be constipated, so I gave an enema and decided to wait until the morning (also thought might see better if cleared the faeces out). The gas-filled segment of intestine in the middle of the abdomen and slightly to the right at the level of L2 to L5 in the VD view was probably normal caecum/colon, but wasn't confident to rule out distended small intestinal loop - while there was no convincing evidence of small intestinal obstruction, carpet-like FB or intussusception were still very much in my mind as differentials I didn't want to miss.

The second set of radiographs showed the gas containing segment to have changes in size, the feaces to mostly have passed and generally no indication of mechanical of functional ileus. Something wasn't right though, and I felt an ex lap was in order as it would be worse to miss a surgical lesion such as a bit of carpet FB than to ex lap the dog and find nothing; there was also the added "excuse" that I could remove the intra-abdominal testicle even if I didn't find anything else, so wouldn't be a waste of time, the thought that this could be a non-neoplastic intra-abdominal testicular torsion was only a fleeting one and I didn't seriously expect this.

I guess everyone's a winner on this case (well, OK, Neil really wins ) as if you did an immediate ex lap you sorted the case out pronto and didn't get past page 1, while if you figured that there was no evidence of a GI obstruction based on the radiographs then you were also correct.

If you decided to ultrasound (and were nifty with the probe), then here's what you might have found:

"The ultrasonographic appearance of testicular torsion depends on the duration of the torsion. In a study on experimentally induced testicular torsion in dogs, there was an immediate increase in the size of the spermatic cord. Enlargement of the epididymis was observed in most dogs within minutes of testicular torsion. All affected testes had decreased echogenicity within 15 to 60 minutes after torsion. Enlargement of the affected testis and epididymis and hypoechogenicity of the testicular parenchyma are predominant features of acute torsion (< 6 hours) in experimental as well as clinical settings.4 After 24 hours, echogenicity of the testis becomes heterogeneous, a sign of loss of viability. Doppler (color flow or power) ultrasonography provides physiologic information about the vascular integrity of the testis. Diminished or absent blood flow is the most accurate sign of testicular torsion, but the presence of blood flow does not exclude torsion." (JAVMA, Vol 238, No. 1)

[This is becoming a bit of a choose-your-own-adventure thread!]

Finally, if you are a smarty-pants and learned nothing else, then you can take away the piece of trivia that juvenile Boxers seem to be over-represented in case reports of non-neoplastic intra-abdominal testicular torsion

Re: Cases with answers! To ex lap or not?

mariette asselbergs — Sat, 16 Nov 2013 23:39:30 GMT

PS and thanks for posting this very interesting case plus discussion!

Re: Cases with answers! To ex lap or not?

mariette asselbergs — Sat, 16 Nov 2013 23:38:14 GMT

Mariette

Re: Cases with answers! To ex lap or not?

Anthony Todd — Sat, 16 Nov 2013 21:28:13 GMT

[quote user="Gillian Mostyn"]However, I don't see how deliberately posting very little information, and omitting something that would (should) have been found in the first examination, is useful? Usually the release of information would be equivalent to what would be found with further treatment/diagnostics.[/quote]

But if you just whip in and do an ex-lap it doesn't matter 'cos, when you're in there, all should be revealed and fixed if you can.

Re: Cases with answers! To ex lap or not?

Anthony Todd — Sat, 16 Nov 2013 21:20:06 GMT

Surely just another example of the value of a [quick], early, cost-effective and patient sparing ex-lap?

And the last nail in the coffin of all that faffing around, discussions, suggested diagnoses, examinations, tests and costs is that no one even thought of it, although the nurse gave the clue and an ex-lap got it.

Explains why the morphine helped though....

Re: Cases with answers! To ex lap or not?

jd2008 — Sat, 16 Nov 2013 21:02:45 GMT

[quote user="Neil Wheadon"]

[quote user="Malcolm Ness"]

???

in a dog wi†h an palpable intestinal fb and signs including those consistent with sepsis and bowel perforation, I can't see any merit in delaying surgery.

[/quote]

Septic or not, you still need to treat the underlying cause. Akin to a grass seed down the ear, you need to remove the primary cause. I think Jane means that the dog needs to be stabalised before surgery by sorting out blood pH changes and perfusion issues first

Neil

[/quote]

Thanks Neil. Sorry, maybe I wasn't clear. I'm not suggesting surgery won't be performed or would be delayed for a substantial period of time. The last septic abdomen we saw was coagulopathic (as well as being haemodynamically unstable) on presentation. Our surgeons appreciated us starting FFP and our anaesthetists appreciated us improving it's haemodynamic parameters prior to cutting. We did this all whilst theatre was being prepared so no time wasted in this case. Sometimes we've taken a couple of hours to get the dog to a state where it had a better chance of surviving anaesthesia.

One thing I forgot to mention: knowing your patient is septic prior to surgery gives the owner the chance to euthanase the patient before it's in theatre when 1) it would be PTS under GA with no chance for the owner to say goodbye and 2) costs have gone up substantially

Re: Cases with answers! To ex lap or not?

jd2008 — Sat, 16 Nov 2013 20:56:19 GMT

[quote user="Gillian Mostyn"]

[quote user="Jane Adams"]The presence or absence of vomiting tells us little[/quote]

surely if the main differential is a GI FB then an absence of vomiting is a valid piece of information?

[/quote]

As Neil has said, GI FB cases sometimes don't vomit (or, at least, not in your or the owner's presence!) so I wouldn't rule out FB on the basis of no vomiting. It might move a little further down my differential list though, depending on what other signs are present.

Re: Cases with answers! To ex lap or not?

jd2008 — Sat, 16 Nov 2013 20:53:28 GMT

[quote user="Neil Wheadon"]

[quote user="Jane Adams"]we simply don't have enough information to decide whether emergent ex lap [/quote]

Agreed, but like the lactate, a dog in pain will have an increased HR and RR, but admit the pulse quality, colour of M/N, CRT will give good clues.

One question.

The crucial question is to eliminate a foreign body, as regardless of sepsis you are going to need to retrieve this. How would you detect a foreign body?

Neil

[/quote]

Generally I don't rely on one test. First diagnostic is good palpation. Even if I'm sure I can feel a foreign body I'll, at the very least, perform a brief ultrasound to confirm (and look for fluid/other pathology). We have an ultrasound in our ICU so it's no big deal to do this.

If I can't palpate anything or palpation results in only a suspicion I'll radiograph.

Radiographs are often inconclusive so, if the patient is stable, I'll repeat radiographs after anywhere between 2-6 hours.

I'll also, whenever possible, get the opinion of a colleague.

It's not a one size fits all approach and nor should it be. I suppose I've been round the block often enough to have seen almost every permutation of abdominal pathology and the almost infinite ways they can present. My desire is to reach the right diagnosis for that patient.

Taking a more simplified or formulaic approach might work perfectly 99 times out of 100 but where does that leave that poor 1 patient out of 100?

Re: Cases with answers! To ex lap or not?

Gillian Mostyn — Sat, 16 Nov 2013 19:55:54 GMT

[quote user="John Flynn"]My observant nurse has noted that only has one scrotal testicle and that might explain mass felt yesterday.[/quote]

Ya think?

Shame it took a nurse to notice!

To the red star person: These types of threads are usually very helpful and someone putting in the time to post them is generous and much appreciated. However, I don't see how deliberately posting very little information, and omitting something that would (should) have been found in the first examination, is useful? Usually the release of information would be equivalent to what would be found with further treatment/diagnostics.

Re: Cases with answers! To ex lap or not?

Vet2Vet — Sat, 16 Nov 2013 19:09:03 GMT

Re: Cases with answers! To ex lap or not?

Neil Wheadon — Sat, 16 Nov 2013 18:52:39 GMT

Well thankyou very much. One of the most enoyable posts on Vetsurgeon ever.

Read this whilst Streetviewing South Africa for a cycle trip next year, including the Argos, huge Sportive - blatent plug - one space for a lady left

Neil

Re: Cases with answers! To ex lap or not?

John Flynn — Sat, 16 Nov 2013 18:42:43 GMT

http://www.vetsurgeon.org/members/Jazz/files/ex+lap+or+not+case1/24hrs+on+-+ex+lap+or+not+case1/The+answer+-+no+peeking_2100_/Exlap-case1-answer.bmp.aspx

Re: Cases with answers! To ex lap or not?

Vet2Vet — Sat, 16 Nov 2013 18:41:10 GMT

And................................................

Re: Cases with answers! To ex lap or not?

John Flynn — Sat, 16 Nov 2013 18:37:51 GMT

OK, I wasn't happy leaving unexplored over the rest of the weekend in case there was a surgical lesion I wasn't seeing on the radiographs, so I unzipped earlier on this afternoon (with a view that I could remove a retained testicle if nothing else...).

Re: Cases with answers! To ex lap or not?

Anthony Todd — Sat, 16 Nov 2013 18:07:10 GMT

[quote user="John Flynn"]Should I open up now? [referral or ultrasound not possible today, i'm afraid][/quote]

You'd have had it done and having your first of the day, if you'd stopped posting and started cutting.

[and keep it on the morphne with a clear conscience and all those horrible possibilities eliminated]

Re: Cases with answers! To ex lap or not?

Anthony Todd — Sat, 16 Nov 2013 18:01:13 GMT

[quote user="Neil Wheadon"] If the dog is in shock due to sepsis or fluid shifts between intra and extracellular spaces, then the peripheral pulses will disappear, colour won't be 'pink' anymore and the respiratory rate will alter not due to the pain but because of the change in pH of the blood.[/quote]

I'd rather do my ex lap well before it get to that though, so I'd say pain relief probably masks more than it helps at this diagnostic stage.

Remember we're talking about things we do before we've got a diagnosis.

Re: Cases with answers! To ex lap or not?

Neil Wheadon — Sat, 16 Nov 2013 17:54:27 GMT

[quote user="Michael Woodhouse"]I bet their vet wished they'd opened that dog up sooner[/quote]

Hindsite, wish I had a crystal ball

I can hear all your Yorkshire Folk now

'Eee that vet down the road may as well insert a zipper for me dog'

Neil

Re: Cases with answers! To ex lap or not?

Neil Wheadon — Sat, 16 Nov 2013 17:51:28 GMT

[quote user="Anthony Todd"]But it's on morphine.... so ,they wouldn't change would they?[/quote]

Depends on how often it's given and if it's controlling the pain

Also it's a pain killer and won't alter perfusion. If the dog is in shock due to sepsis or fluid shifts between intra and extracellular spaces, then the peripheral pulses will disappear, colour won't be 'pink' anymore and the respiratory rate will alter not due to the pain but because of the change in pH of the blood.

Neil

Re: Cases with answers! To ex lap or not?

Michael Woodhouse — Sat, 16 Nov 2013 17:18:12 GMT

(I remember a lovely working ESS brought in to ECC one moring about 8am @ RVC. Had a linear FB and own vets had been radiographing, giving metoclopromide and fluids for a few days. They opened it up but was such a mess the dog was PTS on the table. I bet their vet wished they'd opened that dog up sooner......)

Re: Cases with answers! To ex lap or not?

Anthony Todd — Sat, 16 Nov 2013 17:10:05 GMT

[quote user="Michael Woodhouse"]I'm not especially bothered if I open something up and don't find anything (but I would say that was easily less than 1 in 5). Dogs get over it remarkably well and 3 days post op they are wanting to do far more than they are allowed.[/quote]

+ 1, remember it's an exploratory laparotomy, with emphasis on the exploratory and, in these days of litigation and someone to blame, the owner should be made to understand.

And think of all the things you have positively and definitely eliminated with your "negative" laparotomy.

At least no one can say you should have done a laparotomy on Friday, not Monday.... or even worse when the referral centre surgeon says just that.

Re: Cases with answers! To ex lap or not?

Anthony Todd — Sat, 16 Nov 2013 17:04:23 GMT

[quote user="Neil Wheadon"]

Clinical parameters unchanged overnight

[/quote]

But it's on morphine.... so ,they wouldn't change would they?

Re: Cases with answers! To ex lap or not?

Michael Woodhouse — Sat, 16 Nov 2013 16:23:02 GMT

I would maybe wait, but if it was Friday now I'd be itching to get in there..........

Keeping an animal hospitalised, re-examined, repeat bloods, repeat rads etc etc really ads up. Early ex lap can reduce in a much reduced bill.

I'm not especially bothered if I open something up and don't find anything (but I would say that was easily less than 1 in 5). Dogs get over it remarkably well and 3 days post op they are wanting to do far more than they are allowed.

Re: Cases with answers! To ex lap or not?

Neil Wheadon — Sat, 16 Nov 2013 16:14:54 GMT

Torsioned Testicle?

Would explain, the lack of deterioration overnight as not causing systemic illness, but more comfortable on morphine. Lack of deterioraton in systemic signs, presume dog on fluids/hydrated, so yes I'd have a look (Zebra hunting)

Radiographs show contrast in the abdomen, so peritonitis not there.....yet

Neil

PS Zebra is a reference to if you hear a clop of hooves outside the window, most people say horse as common things are common

Re: Cases with answers! To ex lap or not?

Neil Wheadon — Sat, 16 Nov 2013 16:08:34 GMT

[quote user="Gillian Mostyn"]Obviously decisions are based on more than one single symptom, but most FBs will are vomiting....[/quote]

Precisely

Not vomitting

Clinical parameters unchanged overnight

No pancreas snap test done

Awfully easy to dive in and have a look, but........................

Neil

PS I'm not ruling out a pancreatitis secondary to foreign body (based on age mostly) but think John (his posts are quite informed) has thrown this carpet thing in as most owners have a habit of doing, but no evidence yet.

Re: Cases with answers! To ex lap or not?

John Flynn — Sat, 16 Nov 2013 16:05:35 GMT

[quote user="Neil Wheadon"]Blood smear?, [/quote]

not done, i.m afraid

[quote user="Neil Wheadon"]Peripheral pulses?[/quote]

palpate normally

[quote user="Neil Wheadon"]Any deterioration at all overnight?[/quote]

Actually is probably brighter by this afternoon, and certainly hasn't deteriorated noticeably, but not eaten.

Sedated for further abdominal palpation and still area of distinct discomfort dorsal mid-to-caudal abdomen even when flat out under decent dom/torb dose.

My observant nurse has noted that only has one scrotal testicle and that might explain mass felt yesterday.

Have taken more radiographs while sedated to see if things were moving... and now I'm off to chat to the owner again while I get some colleagues to offer an opinion. http://www.vetsurgeon.org/members/Jazz/files/ex+lap+or+not+case1/24hrs+on+-+ex+lap+or+not+case1/default.aspx

Should I open up now? [referral or ultrasound not possible today, i'm afraid]