dog radiograph help

Re: dog radiograph help

Joyce Whitehead — Fri, 04 Apr 2014 19:10:06 GMT

Interesting thought Jennifer, but I really don't know the answer! And thanks for the humble pie but I'm still glad I didn't ex lap her in the circumstances, her insurance (animal friends) would have been further dimished with no help!

Re: dog radiograph help

Anthony Todd — Fri, 04 Apr 2014 15:52:19 GMT

[quote user="David Mills"]some people like to go fishing with hand grenades[/quote]

When you get nothing you know, for sure, you must try somewhere else straight away.

Re: dog radiograph help

Anthony Todd — Fri, 04 Apr 2014 15:49:20 GMT

[quote user="Anthony Todd"]

What happened with the referral?

[/quote]

Humble pie is being consumed as I speak, although the elimination of the abdominal cavity on day would have got to the chest earlier.

Re: dog radiograph help

Joyce Whitehead — Fri, 04 Apr 2014 14:27:28 GMT

Apologies for the slow reply but I finally have news of this little dog. She had a thoracotomy at the referral practice, which revealed a tumour in the right caudal lobe, with some pleural involvement, but the surgeon felt he had got all he could see out with reasonable margins. The histo results have been reported today, and it is a bronchialveolar carcinoma with a high mitotic index, but well encapsulated. So a rather guarded outlook but the owners are happy they have done all they could. I have spoken to them today, and she is eating better than before although likes "special" food, and has recovered well from surgery. Thanks for all advice here. Fingers crossed!

Re: dog radiograph help

Anthony Todd — Mon, 31 Mar 2014 08:22:43 GMT

What happened with the referral?

Re: dog radiograph help

Joyce Whitehead — Wed, 19 Mar 2014 18:23:29 GMT

Update on this case - the FNA came back as (surprisingly) epithelial in origin with some cells filled with apparently sebaceous material, and some cells with basophilic staining. The comment from the lab was that this was more typical of a dermal lesion, but there was evidence of it being neoplastic ( sorry I don't have the lab report here to read). I am, by the way, happy that I got well into the tumour as I could clearly see where I was on the ultrasound. It at least means that liver herniation is off the agenda. The upshot of this is that the owners have decided to go for referral and likely thoracotomy. I will update once I have more news! Thanks again for the assistance.

Re: dog radiograph help

Joyce Whitehead — Sat, 15 Mar 2014 21:26:07 GMT

No not at all egg sucking Tim, and really useful advice thanks. I think if the FNA isn't something really aggressive then I will be able to persuade them toward referral and surgery. I have already done an ultrasound but via abdomen, as this was pre radiography, but I plan to scan intercostally for the FNA. It certainly looked fairly solid and walled off on the initial scan. Thanks again for your advice.

Re: dog radiograph help

Tim Charlesworth — Sat, 15 Mar 2014 19:12:13 GMT

[quote user="Joyce Whitehead"]Today's update. I have had a chat with the owners, and discussed the options. Bess has never had a trauma of any sort, apparently the most traumatic incident the owner could remember was a bee sting. So unless this is congenital, it makes the hernia somewhat less likely. They are not keen to send her for thoracotomy at this stage, as if it is something really nasty they don't want surgery. However they have agreed to biopsy or FNA, so she is booked in for next week to do this, hopefully under ultrasound guidance. I will let you know once we have any results.

[/quote]

Hi Joyce, might be worth sending them for a chat with a referral surgeon to discuss thoractomy (without obligation to proceed) if a primary lung lobe problem is confirmed. Dogs really do recover very quickly from an intercostal thoracotomy (which is how this would be tackled unless CT etc dictates otherwise) with most dogs going home the day after surgery. Many owners worry about sending their dogs for thoracic surgery but lung lobectomies are regarded as relatively "routine" in referral centres.

FNA should yield a diagnosis. Usually safest to GA the dog so you can induce a "breath hold" and then take the FNA (quickly) without worrying about lung movement. The risk of pneumothorax should be very low as the lobe/mass does not look aerated. Worth checking that this is not fluid filled with ultrasound as if it is an abscess then the FNA could introduce pyothorax. Sorry if this is egg-sucking and fingers crossed for the dog!

Tim

Re: dog radiograph help

Joyce Whitehead — Sat, 15 Mar 2014 16:14:35 GMT

Today's update. I have had a chat with the owners, and discussed the options. Bess has never had a trauma of any sort, apparently the most traumatic incident the owner could remember was a bee sting. So unless this is congenital, it makes the hernia somewhat less likely. They are not keen to send her for thoracotomy at this stage, as if it is something really nasty they don't want surgery. However they have agreed to biopsy or FNA, so she is booked in for next week to do this, hopefully under ultrasound guidance. I will let you know once we have any results.

Re: dog radiograph help

Anthony Todd — Fri, 14 Mar 2014 23:06:35 GMT

[quote user="Joyce Whitehead"]that often an ex lap is a great solution[/quote]

[quote user="Joyce Whitehead"]But not always.[/quote]

I think I suggested it after the Xray, around the time Tim commented.

The x rays were with the first post.

Re: dog radiograph help

Joyce Whitehead — Fri, 14 Mar 2014 22:29:05 GMT

And I would agree that often an ex lap is a great solution. But not always. And not to the exclusion of ruling out more common causes of anorexia, such as renal or hepatic disease. I am completely in favour of (in some cases) letting the abdominal demons out!

Re: dog radiograph help

Robin Grimmer — Fri, 14 Mar 2014 22:19:12 GMT

Exactly. Let's not forget that Prince Phillip had an ex lap recently and he's in his 90s! If it's good enough for him..

Re: dog radiograph help

Anthony Todd — Fri, 14 Mar 2014 21:44:25 GMT

[quote user="Joyce Whitehead"]I'm not quite sure how I was expected to get to the chest on day one, when all the signs did not have a hint of an chest issue.[/quote]

I don't think anyone would have.

I'm sorry if you took all my discussions personally; they certainly are never directed at the person.

Reading the latest history makes me think I may have leapt in with an exlap a bit quick, but you were looking for a diagnosis and I still think an exlap would have got you to the chest much quicker and may yet yield an abdominal answer...

There has, in my view, been a gradual but relentless change in vet.med which seems to me to be based on the ethos that the diagnosis will be guaranteed as long as enough tests are done, no matter if the likelihood of discovering anything diagnostic from most of the tests is remote.

Whereas those of my generation [or perhaps it's only me] would rather look at the area in the flesh as it were [with some exceptions such as lungs....] using the ex lap and gain much more direct information much more positively and accurately.

I find this illogical and frustrating,

There have been so many threads on here of cases where loads of tests are done, all not diagnostic, all expensive and all delaying the diagnosis whereas the old style exlap, and chest tap seem to be either ignored or regarded as too extreme.

It's still widely practised in human medicine though which is a bit of an anomaly.

Re: dog radiograph help

Anthony Todd — Fri, 14 Mar 2014 21:32:52 GMT

[quote user="David Mills"]If your favourite tool is a hammer, then everything is a nail. Or, some people like to go fishing with hand grenades. Thank goodness for retirement.

[/quote]

I guess this is directed at me.

Be interested in the final result.

Re: dog radiograph help

Joyce Whitehead — Fri, 14 Mar 2014 20:53:37 GMT

Could I just say thanks for all the helpful comments, I am going to discuss the next steps with the owners tomorrow (day off today). I'm not quite sure how I was expected to get to the chest on day one, when all the signs did not have a hint of an chest issue. Yes I could have X-rayed her before, but this dog, aside from having a poor appetite, has been enthusiastically going for a walk, and otherwise living a happy life. The owners have also been distracted by the other dog, I have not been seeing this dog every day. I am not a young inexperienced vet (rather a bit of an old codger these days) but if I was, I think by now I would have retreated to a safe distance and would not post asking for advice again with some of these comments. Please think before you post Anthony, I don't think suggesting that all this dog needs is a an ex lap is actually all that helpful. And the tests I have done have not been made up but have followed a logical course. (To my mind at least). I will, however bear in mind all the useful comments in my discussion with the owners. Sorry for the lack of paragraphs, I am on an iPad.

Re: dog radiograph help

karen jones — Fri, 14 Mar 2014 20:49:31 GMT

After a week like I've had retirement would be lovely.....

Re: dog radiograph help

David Mills — Fri, 14 Mar 2014 20:46:43 GMT

If your favourite tool is a hammer, then everything is a nail. Or, some people like to go fishing with hand grenades. Thank goodness for retirement.

Re: dog radiograph help

Anthony Todd — Fri, 14 Mar 2014 19:24:59 GMT

Yeah but your's showed loads of respiratory signs and no abdominal signs.

What's your point?

Where's the connection?

Even I, or all of my colleagues, bumbling along, but not needing to make it up ,would have got to the chest quicker than is apparent in the case here; probably on day one.

And, even I, might not have done an ex-lap and might even have considered a non-invasive Xray, although a quick chest tap, in my experience often yielded cancer cells....... [may have been a good idea in the one under argument]

Re: dog radiograph help

Martin Atkinson — Fri, 14 Mar 2014 18:55:52 GMT

I had a similar case just last week also a middle aged JRT bitch. Vague history of a cough that responded to antibiotic last November. Been OK since but was then presented two weeks ago losing weight and vomiting although she had been obese and was now a normal weight. The owner requested blood tests which were all normal. In passing a soft cough was mentioned but she didn't want to investigate that at the time due to cost restraints. She was presented as an emergency last week anorexic, dyspnoic and coughing worse. X-rays showed pulmonary oedema and cardiomegaly, ECG also supported cardiac enlargement and there was a marked neutrophilia. She was treated with frusemide, pimobendan and antibiotics until we could arrange echocardiography and awaited results of NT proBNP. Her breathing improved and subsequent X-rays after the oedema had improved showed a fluffy density in the right diaphragmatic lung lobe and a radiodense lesion in the left cranial lung lobe. Lungworm was now suspected so Fenbendazole was started. Her breathing waxed and waned and subsequent X-rays showed no signs of improving, NTproBNP came back as normal so she was referred for further investigation. CT scans confirmed the presence of a mass and FNA showed a lung carcinoma. Her condition deteriorated and she was PTS.

Re: dog radiograph help

Anthony Todd — Fri, 14 Mar 2014 18:43:12 GMT

[quote user="Hannah Wynne Richards"] Ex-lap, find it's thoracic, refer, and 2nd GA in a short time - I think not![/quote]

Oh, come on, a quick, well oxygenated GA, or faffing around with tests and "could be"s for days, gimme a break.

Which will do most harm??

Re: dog radiograph help

Hannah Wynne Richards — Fri, 14 Mar 2014 18:38:33 GMT

Ex-lap, find it's thoracic, refer, and 2nd GA in a short time - I think not!

David, we can agree at times ! I think a bit like the Conservatives who've paid tribute to Tony Benn - I mean, I disagree with everything he said, but I would respect him for being honest (which is more than can be said of most politicians)

Wynne

Re: dog radiograph help

Anthony Todd — Fri, 14 Mar 2014 17:58:16 GMT

[quote user="David Mills"]The days of bumbling through making it up as you go along are, thankfully, more and more consigned to history. FWIW I think this is either middle R lung lobe - prime area for FB - or liver herniation which happens at this place most commonly.[/quote]

Conversely, I would say, in the days of bumbling through, without the various opinions now presented, the patient would have had it's ex lap probably on day 1 and have still been referred but only if necessary, with all involved knowing that the abdomen was normal.

Not many of us made up the results of a quick ex-lap up as we went along.....

The ex-lap would have taken no more than 30 minutes, given all that information, and the referral vet would have known far more accurately, what he/she had to deal with, should referral be needed [ie the chest needed opening]

That's without insurance too, so you really had to make each pound add diagnostic information.

It sounds a if there's a fair chance that it'll have to have an ex-lap anyway to be sorted; finally.

Re: dog radiograph help

Bob Russell — Fri, 14 Mar 2014 15:54:52 GMT

I posted similar radiographs from a JRT about a year ago. Cannot find them on here now. My case is fine when on antibiotics but deteriorates when they stop. The owner is unwilling to investigate. My case (and response to treatment) suggests a FB.

Re: dog radiograph help

David Mills — Fri, 14 Mar 2014 14:27:49 GMT

[quote user="Hannah Wynne Richards"]

It's one I would definitely refer. That's not insurence dictating diagnostics - it's insurence enabling the best veterinary surgeon(s) to deal with a complicated , and potentially problemtic case. - only common sense.

Wynne

[/quote] Wowsers, Ms Richards and I agree. Ethically, in any situation that the VS is inexperienced in the procedure such as this, then referral to someone more experienced is the only 'right' option. If that is not affordable then a compromise can be made. The days of bumbling through making it up as you go along are, thankfully, more and more consigned to history. FWIW I think this is either middle R lung lobe - prime area for FB - or liver herniation which happens at this place most commonly.

Re: dog radiograph help

Tim Charlesworth — Fri, 14 Mar 2014 11:07:58 GMT

[quote user="Anthony Todd"]

[quote user="Tim Charlesworth"] if that seemed a sensible thing to do.[/quote]

How would that fit with all the apparent gastrointestinal signs and the absence [?] of respiratory signs?

[/quote]

The main presenting sign seemed to be reduced appetite/anorexia which could certainly be attributed to this mass. There did not seem to be much in the way of GI signs in the original post and these could also be attributed to the mass or the lung mass (presuming this is what is is) could be an incidental finding and there happens to be some gut-rot of some sort going on..

The absence of respiratory signs certainly does not exclude pulmonary neoplasia, most dogs will develop a cough +/- dyspnoea at some point but we have seen a fair few animals who did not have any of the above yet had primary lung neoplasms. Will be interesting to find out what happens in the end...