Abdominal radiograph - yes this has an answer too

Re: Abdominal radiograph - yes this has an answer too

Anthony Todd — Wed, 20 Nov 2013 14:42:54 GMT

[quote user="Martin Atkinson"]But it made me think[/quote]

While basking in the sun from another quick ex-lap I still think I'd try and establish whether the uterus was ruptured without rushing in and ending up with an infected lap. wound, possibly for nothing.

I still think that careful low-pressure, low volume [via the flow-meter] oxygen would flatulantly demonstrate a rupture and avoid an unnecessary ex-lap into a compromised cavity.

You'd put your drip up, take a blood for BUN and PCV, at least, and have the patient in a much better state by the time you'd got the team organised to do the ex-lap if necessary. Could even finish the consults while everyone is getting it all together.....

Re: Abdominal radiograph - yes this has an answer too

Martin Atkinson — Wed, 20 Nov 2013 10:52:07 GMT

[quote user="Neil Wheadon"]The ex lap revealed a torn uterus and there was peritonitis with pus in the abdomen. No sign of any puppies.[/quote] OK so you didn't throw us a red herring after all, so much for thinking outside the box!

But it made me think, that given that the uterus is a normally a sterile environment in an uncomplicated whelping, how many times a rupture occurs and heals spontaneously with no complications?

Re: Abdominal radiograph - yes this has an answer too

Neil Wheadon — Wed, 20 Nov 2013 09:35:56 GMT

The ex lap revealed a torn uterus and there was peritonitis with pus in the abdomen. No sign of any puppies.

The comments are interesting and thankyou to everyone prepared to stick their neck out.

1) There looks to be a ground glass appearance ventral to the enlarged uterus. However I had the advantage of knowing what I was looking at. The X-Ray is also easier to see on viewer. David points out the difficulty in interpreting abdominal X-Rays and guess this does show this in part

2) Ultrasound would have been better, looking for free fluid in this case. - Incidentally I had a collapsed Rottewiller last night that had a temperature of 36.6, RR20 (breathing deeply) and the abdomen 'looked full' Doing a FAST scan (basically putting a probe on the abdomen in 4 places) free fluid was easily found that was aspirated as a transudate and a resulting tumour in the chest found by X-Ray. In this case ultrasound was the tool of choice

3) The BUN strip after surgery showed 14mmol/L and yes again agree with David that it's a blunt tool. However it does show the degree of pre-renal azotaemia that these patients are suffering from, where not diving in immediately and performing an ex lap may be a good idea, as by rehydrating and perfusing better you are reducing the effects of an anaesthetic, and improving subsequent recovery.

Any more abdomenal X-Rays out there?

Neil

Re: Abdominal radiograph - yes this has an answer too

James Laidlaw — Wed, 20 Nov 2013 08:14:32 GMT

Can I ask for a VD view?

Re: Abdominal radiograph - yes this has an answer too

Virginia Campbell — Tue, 19 Nov 2013 23:34:17 GMT

I guess ectopic mummified pup. Saw one once, stuck to the spleen. Bitch had a concurrent pyo. Not my case but v cool.

Re: Abdominal radiograph - yes this has an answer too

Michael Woodhouse — Tue, 19 Nov 2013 18:51:11 GMT

A bladder wall is very compliant. I can assure you a bovine uterus with metritis isn't. I've done a couple of spays with bellies full of dead pups and the tissue is in an awful state.

I'd be aware you'd create a rupture.

Re: Abdominal radiograph - yes this has an answer too

Anthony Todd — Tue, 19 Nov 2013 15:17:09 GMT

[quote user="Michael Woodhouse"]

Much safer would be iodine contrast medium, if you wanted do do such things.

[/quote]

We do pneumocystograms and the air allows visualisation of denser structures, so why not in a uterus, which may have a [dense] pup or pus etc. in it which could be masked by the contrast medium??

Re: Abdominal radiograph - yes this has an answer too

Michael Woodhouse — Tue, 19 Nov 2013 13:40:44 GMT

Much safer would be iodine contrast medium, if you wanted do do such things.

Re: Abdominal radiograph - yes this has an answer too

Anthony Todd — Tue, 19 Nov 2013 13:38:21 GMT

[quote user="Michael Woodhouse"]I wouldn't in a friable uterus[/quote]

No, but if it didn't stay in the uterus it would be diagnostic; I didn't expect it'd be pumped up......

Is it ever done? Logically sounds like the way to eliminate a rupture? Also it many delineate a retained pup?

You could use a suitably sized endotracheal tube and O2 gently, with your hand on the abdomen??

Re: Abdominal radiograph - yes this has an answer too

Michael Woodhouse — Tue, 19 Nov 2013 13:25:12 GMT

[quote user="Anthony Todd"]Can you ever do a pneumometrogram [or pneumouterogram]?[/quote]

I wouldn't in a friable uterus

Re: Abdominal radiograph - yes this has an answer too

Anthony Todd — Tue, 19 Nov 2013 12:18:09 GMT

[quote user="Martin Atkinson"]Don't see any evidence of ruptured uterus/peritonitis though.[/quote]

Can you ever do a pneumometrogram [or pneumouterogram]?

Re: Abdominal radiograph - yes this has an answer too

Martin Atkinson — Tue, 19 Nov 2013 11:56:04 GMT

Largely on the basis that we're being thrown a red herring here I suspect the whelping has nothing to do with it and there are multiple soft tissue intestinal foreign bodies, What is odd is the gas filled viscous in the colon - it is completely walled off not like its free gas in the rectum/colon. Left kidney also looks small and more radio-dense than I would expect, - pyelonephritis perhaps. Doesn't explain the purulent vaginal discharge but there may just be a low grade metritis. On the other hand there could be mummified pups which died before skeletal development and didn't whelp which are now causing metritis. Don't see any evidence of ruptured uterus/peritonitis though.

Re: Abdominal radiograph - yes this has an answer too

Linda Filshie — Tue, 19 Nov 2013 11:00:19 GMT

Lack of serosal detail so either free fluid in there of some description (prob peritonitis given hx) or dog is lacking fat. I make out the soft tissue density that Mariette thinks might be a pup but I don't think that it's convincing.

I'd be going for a u/s at this stage if available, abdominocentesis if not.

Re: Abdominal radiograph - yes this has an answer too

mariette asselbergs — Tue, 19 Nov 2013 10:56:43 GMT

Am I just imagining it or do I see a puppy lying backwards. Looks big for the dog is it a toy like breed? Puppy swollen up and rotten?

Mariette

Re: Abdominal radiograph - yes this has an answer too

David Mills — Tue, 19 Nov 2013 01:04:39 GMT

I'd go with retained pup or retained membranes leading to pyometra. Unsure whether 7 days would be long enough for skeletal resorption but suspect not. Could also be due to some uterine inertia at whelping but less likely. Twisted uterus possible but not common. Not seeing any sign of any peritonitis on this rad.

Re bloods, just think - are they going to make a difference to your initial management?

And how useful are bloods to judge resuscitation? Interestingly, there is no evidence - including those from some pretty decent American trials - that show a surival benefit in reducing urea, PCV, TS. There is an interesting ethical question as to whether we should be using these routinely (and charging clients for them). Lactate reduction does show some survival benefit.

Urea sticks are also notoriously poor at characterising high urea accurately so cannot be faithfully used to monitor reductions in levels.

The X-ray/US debate is interesting, and I agree, I think its a generational thing, though at college (08 grad) we were given no US training but plenty of radiography practice. With this case, I would have been scanning first largely because the sensitivity of xrays for abdominal disease is pretty poor.

Re: Abdominal radiograph - yes this has an answer too

Neil Wheadon — Mon, 18 Nov 2013 23:34:44 GMT

[quote user="Laurence Webb"]Neil do Vets Now ever take bloods at admission in case they are later required even if they are not run at the time[/quote]

Vets Now do take bloods on admission yes, to do a minimum database. PCV, Total Solids, Glucose on a glucometer, BUN on strips and lactate. Very little is needed and these do give an indication of where we are and when repeated where we are going. For such a simple series of tests I think they are very useful.

I also take extra bloods for member practices if I think it would be useful.

This case wasn't a Vets Now case, so yes hindsite says take bloods but they were checked after 5 times maintanance and rehydrated a touch.

There's nothing clever in this X-Ray. As an older graduate I'm not as good as newer graduates at ultrasound, but I do find many newer grads aren't as confident in X-Rays and it's pattern recognition (with an answer) that helps, hence posting this one

Neil

Re: Abdominal radiograph - yes this has an answer too

Utlendigur — Mon, 18 Nov 2013 23:23:42 GMT

Loss of serosal detail and has that "look" of peritonitis, so I'm going for that +/- ruptured uterus. I saw a ruptured uterus a last year which didn't have a huge amount of fluid in the abdomen (poor thing was so dehydrated I don;t think there was much spare fluid to 3rd space), was about the same time period post whelping and the xray looked similar. Was an abdomenocentesis done (cheap diagnostic )?

Re: Abdominal radiograph - yes this has an answer too

Michael Woodhouse — Mon, 18 Nov 2013 23:08:59 GMT

If money is an issue I'm more interested in bloods afterwards if dog not responding. It becomes almost academic measuring a raised urea and creatinine and increased PCV in a dehydrated dog, if they are corrected by a couple of litres of fluid.

I am quite used to taking bloods before Tx and seeing what happens (do it routinely with downer cows etc)

Re: Abdominal radiograph - yes this has an answer too

Francisco Gomez — Mon, 18 Nov 2013 23:04:49 GMT

[quote user="Laurence Webb"]

Sometimes because of financial constraints, other times because I don't think I need them initially but I if things go wrong I can forsee that having pre-treatment samples may be useful.

[/quote] Sorry, I'm not perfect either, maybe I was being too harsh...

Re: Abdominal radiograph - yes this has an answer too

Laurence Webb — Mon, 18 Nov 2013 23:01:44 GMT

Not sure I'd go for a ruptured uterus as, although detail in the caudal abdomen isn't great, I'd expect a ruptured uterus to result in lots of fluid and much more of a white out on X-ray.

I agree that checking bloods post fluids is not optimal but we all have cases where the money doesn't stretch as far as we'd like.

Neil do Vets Now ever take bloods at admission in case they are later required even if they are not run at the time? It is something I do occasionally (though not as often as I should). Sometimes because of financial constraints, other times because I don't think I need them initially but I if things go wrong I can forsee that having pre-treatment samples may be useful.

Re: Abdominal radiograph - yes this has an answer too

Miriam Lodewyks — Mon, 18 Nov 2013 23:00:43 GMT

Retained placenta?

Re: Abdominal radiograph - yes this has an answer too

Francisco Gomez — Mon, 18 Nov 2013 22:16:20 GMT

I understand that diagnostics were limited, but not really an excuse for managing the case back to front... Not trying to critisize, its just that if you take the bloods after you use an unknown amount of fluids, it makes it a 'guessing game', rather than a 'clinical' one. Im going to say 'ruptured uterus' that got infected maybe

Re: Abdominal radiograph - yes this has an answer too

Michael Woodhouse — Mon, 18 Nov 2013 22:15:18 GMT

I'm not convinced that is a puppy. I think metritis and peritonitis, but no pups.

I am crap at finding puppies on rads.......