Radiograph quiz

Re: Radiograph quiz

mariette asselbergs — Fri, 07 Feb 2014 17:21:42 GMT

"Would others have done a fPLI given it can be positive with partial obs and pancreatitis (wasn't available in any case)? "

No, but now I may.

Thanks for this interesting case!

Mariette

Re: Radiograph quiz

Miriam Lodewyks — Wed, 05 Feb 2014 19:42:40 GMT

Pancreatitis would definitely NOT have been high on my list of differentials, and running a FPI test in the face of "indigence" unlikely. So well done to the day vets for getting it, but I think they got lucky. I'm with David, would have recommended ex-lap.

Re: Radiograph quiz

Anthony Dennison — Wed, 05 Feb 2014 17:43:09 GMT

[quote user="Thomas Johnson"]I do the same, but if I were to see a horse with colic the first thing I would reach for would be an NSAID...[/quote]

Ah, fair point. This is why I only do smallies!

Re: Radiograph quiz

Gillian Mostyn — Wed, 05 Feb 2014 17:37:05 GMT

[quote user="Hannah Wynne Richards"]

Showing my age--again !!!!!!!!!!!!!!!

I actually did Latin at school, and rather enjoyed it - far more logical than French.

[/quote]

I am a couple of years younger than you - and also did Latin! My daughter will also be doing latin in due course....

Re: Radiograph quiz

Hannah Wynne Richards — Wed, 05 Feb 2014 17:34:16 GMT

Showing my age--again !!!!!!!!!!!!!!!

I actually did Latin at school, and rather enjoyed it - far more logical than French.

Wynne

Re: Radiograph quiz

Thomas Johnson — Wed, 05 Feb 2014 17:25:52 GMT

[quote user="Anthony Dennison"]

If money was limited, I would have done exactly as you did with the information you had.

[/quote]

I agree, I would have recommended an ex-lap. Even if I'd had an abnormal Snap fPL I would still have been considering an ex-lap.

[quote user="Anthony Dennison"]

I try to avoid metacam with anything gut related, if it was pancreatitis opioids only.

[/quote]

I do the same, but if I were to see a horse with colic the first thing I would reach for would be an NSAID...

Re: Radiograph quiz

Anthony Dennison — Wed, 05 Feb 2014 17:22:03 GMT

If money was limited, I would have done exactly as you did with the information you had.

I try to avoid metacam with anything gut related, if it was pancreatitis opioids only.

Re: Radiograph quiz

David Mills — Wed, 05 Feb 2014 17:10:46 GMT

So. The answer.

This was an OOH case, presenting on a Sunday night. Like others, I was very worried about this cat and wanted to ex lap ASAP - and this is form me, who people may no am no advocate of the 'ex lap anything remotely abdominal and have it zipped up by tea' brigade. There is a soft tissue/bony density around the rib areas which was very suspicious in my mind and I did not like the look of that gas in conjunction with the clinical signs and history - the suggestions of pneumoperitoneum and retroperitoneal air went through my mind as well. It was my advice to the owner, that, all things being equal, I would recommend ex lap as the way forward regardless of financial status, after a couple of hours on some fluids. Owner refused on cost grounds, and I advised would likely need one the next day at own practice, but likely take rads, more tests etc first.

Cat was hydrated and looking better by the morning, but still dull and painful despite vetergesic and being fully rehydrated. Went back to own practice that day and x-ray showed gas had moved and was now colonic. fPLI was abnormal and amylase and lipase were increased. No ex lap was performed and cat made an uneventful recovery - was discharged that day with an injection of metacam.

So the diagnosis was pancreatitis, with what I suspect was secondary ileus. However, I'm not fully convinced there isn't a partial obstruction here that worked its way through.

The owner subsequently complained about the cost of the treatment and incompetence in not spotting that all the cat needed was a jab of 'painkiller and antibiotic'.

Would others routinely use metacam for pancreatitis? Personally I think it's useless for visceral pain, and I think a lot of the cranial abdominal pain was to do with gut distension rather than pancreatitis, the latter I've never been convinced causes the same acute abdominal pain as in dogs.

Anyway, cat fixed. I still believe an ex lap was indicated on these X-rays - what to do when hamstrung by a client wanting (cheap) crystal ball diagnosis? Would others have done a fPLI given it can be positive with partial obs and pancreatitis (wasn't available in any case)?

Re: Radiograph quiz

Gillian Mostyn — Tue, 04 Feb 2014 23:13:31 GMT

[quote user="David Mills"]That BGS Latin-by-rote education dulling by the day, it seems...[/quote]

It's tragic isn't it?

(my daughter passed the entrance exam last week..... looks like she'll end up not being a good latin scholar either...)

Re: Radiograph quiz

David Mills — Tue, 04 Feb 2014 23:07:53 GMT

[quote user="Neil Wheadon"]

If I learn nothing about the cat, I've learnt 2 new words

Indigence = a state of extreme poverty; destitution (I know everyone wanted to know that, but were too afraid to ask)

Neil

[/quote]

Alas, you always come across with the sophistication of a Latin scholar; no more.

[quote user="Gillian Mostyn"]I asked Dr google.... [/quote]

That BGS Latin-by-rote education dulling by the day, it seems...

Re: Radiograph quiz

Gillian Mostyn — Tue, 04 Feb 2014 23:04:36 GMT

[quote user="Neil Wheadon"]Indigence = a state of extreme poverty; destitution (I know everyone wanted to know that, but were too afraid to ask)[/quote]

I asked Dr google....

Re: Radiograph quiz

mariette asselbergs — Tue, 04 Feb 2014 23:03:10 GMT

Send home with doses of oral vetergesic (cheap), and keep telephone contact about developments. If cat get miserable then use human communicative + vet authorative talents to talk into euthanasia. If all goes well celebrate appropriately! (Just had a dog which everybody was convinced had fb, but owner refused surgery and miraculously got better after 4 days).

Mariette

Re: Radiograph quiz

Neil Wheadon — Tue, 04 Feb 2014 22:59:44 GMT

If I learn nothing about the cat, I've learnt 2 new words

Indigence = a state of extreme poverty; destitution (I know everyone wanted to know that, but were too afraid to ask)

Neil

Re: Radiograph quiz

David Mills — Tue, 04 Feb 2014 22:52:44 GMT

[quote user="Francisco Gomez"]1. A phone call to VDS to see where I stand.[/quote]

No VDS cover at this practice.

[quote user="Francisco Gomez"]3. Once at home, large glass of red wine, preferably Rioja Gran Reserva[/quote]

You finish at 8am...gin and tonic time, personally.

[quote user="Gillian Mostyn"]Is this an actual case?[/quote]

Yes.

[quote user="Gillian Mostyn"]I've had plenty of similar situations, but the owner is always relieved to get the cat euthanased[/quote]

Lancastrians are an unemotional race.

Re: Radiograph quiz

Gillian Mostyn — Tue, 04 Feb 2014 22:36:26 GMT

[quote user="David Mills"]Forgot to add. Owner definitely doesn't want the cat euthanased.[/quote]

If you feel the cat requires immediate euthanasia, but the owner will not agree, then I would need to start to do some research. I'm not sure who has the legal right to seize the cat on welfare grounds - the RSPCA or the Police- but I'd be finding out!

Is this an actual case? I've had plenty of similar situations, but the owner is always relieved to get the cat euthanased to rid themselves of the cat and the problem.

Re: Radiograph quiz

David Mills — Tue, 04 Feb 2014 22:12:55 GMT

Forgot to add. Owner definitely doesn't want the cat euthanased.

Re: Radiograph quiz

Gillian Mostyn — Tue, 04 Feb 2014 22:00:33 GMT

If the owner cannot afford any further treatment, then a decision now has to be made as to what is in the cats' best interests.

If the cat's condition is stable and improving, then continue with conservative treatment.

If the cat's condition, now or later, makes further investigation or surgery necessary (in your opinion), but the owner is not able to afford anything at all, and even a payment plan is not an option, then the patient needs to be euthanased.

Re: Radiograph quiz

Francisco Gomez — Tue, 04 Feb 2014 21:59:41 GMT

[quote user="David Mills"]

In the morning she is hydrated, brighter, but still uncomfortable in cranial abdomen.

Declines further x-ray at your practice; claims indigence.

What now?

[/quote]

I would do three things:

1. A phone call to VDS to see where I stand.

2. If VDS allows, A FOC injection of pain relief, possibly vetergesic and send the tandem owner/cat home, warning that patient might need to be euthansed if becomes unwell again.

3. Once at home, large glass of red wine, preferably Rioja Gran Reserva and a chat with myself about why the h*ll did I start to treat this cat in the first place if the owner couldn't possibly afford to pay the bill.

Re: Radiograph quiz

David Mills — Tue, 04 Feb 2014 21:53:14 GMT

So...most seem to be going for ex lap, or at least thinking this is surgical.

Ex lap after some fluids is recommended to owner. Owner declines on cost grounds. Cat is given 500ml fluids over 12h and vetergesic. In the morning she is hydrated, brighter, but still uncomfortable in cranial abdomen. Not eaten, not vomiting, no change in vitals.

Declines further x-ray at your practice; claims indigence.

What now?

Re: Radiograph quiz

John Flynn — Tue, 04 Feb 2014 20:56:50 GMT

Thanks for the case quiz - nice radiographs

I'm putting pen to paper to make me think and stop me fooling myself into thinking I would have handled just fine once have hindsight of answer!

Thorax looks fine on both views.

Abdomen less so.

On DV view: gas in fundus looks OK, but I do wonder about whether it's outlining a foreigh object/mucosal irregularity caudo-medially.

There is a string of 4 large gas bubbles going from area of pylorus to pelvis just right to midline - lateral to this appears to be foreign materialrunning from the pylorus to L4 and causing some distnetion laterally of right abdominal wall - I don't think this to be faecal material in ascending colon. Looks like a spleen outlined in left lateral abdomen, which always makes me think in a cat could this be something else or is there a reason for splenomegaly.

On lateral view: There is a large air-filled tubular structure in dorsal abdomen, given the DV view, this does not appear to be large intestine and therefore most likely represents seriously distended small intesinal segment(s).

Best guess: linear FB perhaps anchored in stomach?

Irrespective, I'm definitely diving straight into ex lap on this case.

Re: Radiograph quiz

Miriam Lodewyks — Tue, 04 Feb 2014 19:54:54 GMT

I'm with Mariette. Highly suspicious of FB, obstructed, and possibly also perforated? Gas seems peritoneal and given the pain on abdominal palpation, sounds like peritonitis to me. I'd go in sooner rather than later. Awesome word, by the way: impecunious!

Re: Radiograph quiz

mariette asselbergs — Tue, 04 Feb 2014 12:59:44 GMT

The gas is in the stomach and if there is continuation in the small intestine past the pyloris than this intestine is overstretched. Explains the vomiting to me. I would be concerned about fb and if the choice financially is between ivf and analgetics and PTS if not picked up on the one hand, and going in on the other hand, then I would go in now. Quick and if you don't find anything then you no longer need to keep that in your fiff diagnoses, and the cat will only have a zip in his/het abdominal wall, big deal.

Mariette

Re: Radiograph quiz

Francisco Gomez — Tue, 04 Feb 2014 10:40:33 GMT

[quote user="David Mills"]

No money for bloods or ultrasound. Money for ivft and fluids/analgesia. Could stretch to ex lap if sure - absolutely - that required.

[/quote]

impecunious depending of the time of the day...

[quote]

What do you recommend next?

1. Fluids, analgesia, reassess in a few hours

[/quote]

I'd agree with Neil. I don't think is about to die. And I would hate to put this one under the knife and find nothing...

An x-ray later on might answer a lot of questions.

PS. I agree with previous post about free gas in the abdomen, possibly due to leak from intestines.

Re: Radiograph quiz

Kirsten Simpson — Tue, 04 Feb 2014 09:06:24 GMT

Pneumoperitoneum? Never seen it before but I would be worried about that and prep for exlap asap once been bolused with IVFT and more stable. Would take FAST scan and if any FF tap and check. Take bloods + elecs and haematology and check acid base status etc. Looks surgical to me though :S

Re: Radiograph quiz

Robin Grimmer — Tue, 04 Feb 2014 08:17:58 GMT

I don't think the gas is retro peritoneal. I the gas is all in the gi tract. The profuse vomiting suggests a gi obstruction. Is it a gdv? Maybe secondary to some muscle rupture/ hernia? I would go for ex lap as soon as the patient is stable enough.