Unexplained ruptured proximal duodenum

Re: Unexplained ruptured proximal duodenum

Martin Atkinson — Thu, 05 Jun 2014 09:25:43 GMT

[quote user="Wren"]But what about Cartrophen injections? I'm guessing Trocoxil is a no-no?[/quote]I am a huge fan of Cartrophen at least in early stages of OA in dogs and cats. The one and only dog I put on Troxocil nearly died from acute HGE. The company tried to spin their way out of any probable association but safe to say I've not used it since.

As for the OP's assertion that the dog never had melaena I would just question how this conclusion was reached. Owners are not good at interpreting the colour of the dog's faeces unless its tarry. I had a dog with (probable) gastric ulceration from (unnecessary) corticosteroid therapy from another vet. They described the faces as normal but an occult blood test came up positive. Once we'd got the dog off the steroids and after a while on gastro-protectants/antacids the owner commented on how much paler the faeces were and this was in fact more normal.

Re: Unexplained ruptured proximal duodenum

james herriot lied — Tue, 03 Jun 2014 23:01:30 GMT

Sounds like you covered all the bases pretty well - although the perceived wisdom was ulcer, it could easily have been something else. Glad to hear the dog's doing OK.

Re: Unexplained ruptured proximal duodenum

james herriot lied — Tue, 03 Jun 2014 22:59:36 GMT

[quote user="Rob Davis"]

[quote user="james herriot lied"]In fact, if anybody wants a bit of a gawp at how some human pharma companies operate, I'd say vioxx is a good place to start.[/quote]

"Bad Pharma" by Ben Goldacre is an illuminating, is slightly worrying read...

[/quote]

Yes, read that a while back. But the whole vioxx thing was monumental - when a company sets aside the best part of six BILLION dollars to pay for the mess left behind, something's slightly up.

Re: Unexplained ruptured proximal duodenum

nikki — Tue, 03 Jun 2014 20:47:44 GMT

Histo came back today compatible with ulcer.

I sent the fluid we tapped the day before surgery for culture (pre-antibiotics) and that came back on extended culture with mixed anaerobes sensitive to Metronidazole.

I sent the dog home on amoxyclav and MTZ as well as omeprazole and zantac. How long do you think I should keep her on antibiotics and gastro-protectants?

The dog wasn't lame whilst in with us even once off vetergesic so we're going to monitor and see at what stage lameness returns once we increase her exercise and go from there. Cartrophen is definitely worth a go though.

Re: Unexplained ruptured proximal duodenum

Rob Davis — Tue, 03 Jun 2014 17:33:23 GMT

[quote user="james herriot lied"]In fact, if anybody wants a bit of a gawp at how some human pharma companies operate, I'd say vioxx is a good place to start.[/quote]

"Bad Pharma" by Ben Goldacre is an illuminating, is slightly worrying read...

Re: Unexplained ruptured proximal duodenum

james herriot lied — Tue, 03 Jun 2014 15:55:01 GMT

Thanks, Tim.

I must admit, I've always been dubious on selective anti-Cox 2s (whilst completely buying into the 'preferential' inhibition of meloxicam), and this seemed entirely borne out by the Vioxx debacle. The EMEA report on trocoxil - and how its recommendations were spun by the company - left me a little deflated also.

In fact, if anybody wants a bit of a gawp at how some human pharma companies operate, I'd say vioxx is a good place to start.

Re: Unexplained ruptured proximal duodenum

Tim Charlesworth — Tue, 03 Jun 2014 15:33:01 GMT

[quote user="james herriot lied"]

Thank you for a specialist's reflections, Tim. When you say you close them transversely, do you just do a simple repair? No problems with narrowing or stricture?

Would there be any value at all in swabbing, or would the background noise of competing bugs make any isolates meaningless? The fact that these dogs can often go back on NSAIDs must point to multiple underlying causes.

[/quote]

I've never had a problem with narrowing or stricture but by transverse closure I mean so that the wound runs at 90 degress to the line of the bowel this preserving luminal size more than if the bowel was closed longitudinally. You end up with a couple of tiny "dog ears" in the bowel but not a problems. I always debride the ulcer/lesion (but don't get carried away) and the just close it simply normally using simple interrupted with these. I usually have a sample of the peritoneal fluid obtained preop that we submit for culture (and ideally taken before antibiotics started). The whole NSAID's story is very complicated. There is some evidence that the more COX selective NSAIDs may not be as gastroprotective as we were led to believe. The classic story I see is dog with OA pain on NSAIDs, dog seems more uncomfortable and so owner increases dose of NSAID but the discomfort was actually GI in orgin and ulcer develops etc etc... Fortunately these aren't too common!

Re: Unexplained ruptured proximal duodenum

james herriot lied — Tue, 03 Jun 2014 12:36:33 GMT

Thank you for a specialist's reflections, Tim. When you say you close them transversely, do you just do a simple repair? No problems with narrowing or stricture?

Re: Unexplained ruptured proximal duodenum

Kathryn Burton — Tue, 03 Jun 2014 10:50:06 GMT

How about amantadine - I think you could argue a case for going off licence?

Re: Unexplained ruptured proximal duodenum

Tim Charlesworth — Tue, 03 Jun 2014 10:36:06 GMT

Sorry to come in late on this. Completely agree with the other posts. Prox duodenum classic site. They can be hard to suture but usually can close transversely. The ulcers are usually on the antmesenteric side and so you don't have to worry too much about the common bile duct/pancreatic ducts that come in on the mesenteric aspect of the duodenum. You can augment the repair with a serosal patch but I just tend to omentalise them. Have seen 4-5 in this location and they were all on NSAIDs and none have recurred (to my knowledge) even though some have been placed back onto (different) NSAIDs. Hope all goes well with the case,

Tim

Re: Unexplained ruptured proximal duodenum

Wren — Tue, 03 Jun 2014 09:41:10 GMT

As you know Nikki it's not my specialist subject... But what about Cartrophen injections? I'm guessing Trocoxil is a no-no?

Re: Unexplained ruptured proximal duodenum

Michael Woodhouse — Mon, 02 Jun 2014 23:29:33 GMT

Pardale V? What NSAID was the dog on, is there something more selective with a gastero-protectant that might be ok?

Re: Unexplained ruptured proximal duodenum

nikki — Mon, 02 Jun 2014 23:20:31 GMT

Just a quick update - the dog went home today. She took a little while to regain her appetite but today was playing again and looking much happier. I just hope my repair holds.

Also, need to think about what long term medication she can go on for her elbow OA as clearly not going to touch any NSAIDs again.

Re: Unexplained ruptured proximal duodenum

Kirsten Simpson — Mon, 02 Jun 2014 09:29:21 GMT

[quote user="Jenny Smith"]

I'd be very suspicious re: NSAID induced ulceration too. I've seen one, more of an acute presentation (OOH clinic workload), was scanning through your post to wait and see where you mentioned the NSAID usage!

Do you ever look at the lactate of abdominal fluid as part of the work up on a tap? If (abdo lactate) - (systemic blood lactate) = >2 then it's a big indication for septic peritonitis. I know most clinics don't have handheld lactate meters but you can run it on the vet test

Jenny

[/quote]

You can also use blood glucose as a measurement of septic peritonitis as well. Think abdo BG should be lower than peripheral by a certain amount (only papers I can find are American so diff units).

Re: Unexplained ruptured proximal duodenum

Jenny Smith — Mon, 02 Jun 2014 04:29:28 GMT

Jenny

Re: Unexplained ruptured proximal duodenum

james herriot lied — Sun, 01 Jun 2014 23:10:42 GMT

The only other comment I'd have would be that if you'd trimmed a hole just south of the pyloric sphincter, were you happy with just suturing the defect?

Re: Unexplained ruptured proximal duodenum

Michael Woodhouse — Sun, 01 Jun 2014 17:30:30 GMT

[quote user="Rach"]the lecturer felt that Labradors were over-represented[/quote]

I suspect they are also over represented in the population of dogs with arthritis on NSAIDs!

Re: Unexplained ruptured proximal duodenum

Rach — Sun, 01 Jun 2014 07:48:29 GMT

A very similar case was discussed on my certificate course, the lecturer felt that Labradors were over-represented and said that there is a theory that these patients have underlying inflammatory GI disease, particularly with an eosinophillic component. So would be interesting to see what the histo says and if there has been a history of low grade GI dz?

Re: Unexplained ruptured proximal duodenum

Henry L'Eplattenier — Sat, 31 May 2014 12:09:45 GMT

I agree with what other people have posted. To me this has the typical aspect and location of a ruptured ulcer. Does the dog have a history of medical treatment with NSAIDs or steroids? Taking a biopsy at surgery is a good idea in order to rule out neoplasia. Again I agree with the others: histology should give you the final diagnosis. Your postoperative medical management with antacids and sucralfate is good! Let's hope the dog recovers quickly! Good luck with this case!

Re: Unexplained ruptured proximal duodenum

Utlendigur — Sat, 31 May 2014 10:53:17 GMT

Not duodenum, but a few years ago I saw an Afghan hound that presented looking like a GDV ie with a massive tympanic abdomen - but was bright, wagging its tail and not vomiting. Xray showed huge amounts of free gas in the abdomen, and at ex lap I found a small circular hole in the stomach. No FB despite searching the stomach, guts and abdo cavity. Histo came back as mild inflammation - not even an ulcer (dog wasn't on nsaids). Never knew what caused it - best guess was something perforated it then passed through the guts - but the dog did fine.

Re: Unexplained ruptured proximal duodenum

Kirsten Simpson — Sat, 31 May 2014 09:25:25 GMT

Ulcer. Saw one exactly the same after long term course Metacam. Never seen one before but it was so neat! Just a perfect circle through the intestines! Hers was right around the bile duct + pancreatic duct so luckily a specialist walked in (was OOH) and helped me by doing a serosal patch.

Re: Unexplained ruptured proximal duodenum

Andrew Kent — Sat, 31 May 2014 09:09:30 GMT

The proximal duodenum is the classic site for an NSAID induced ulcer and some dogs have minimal (or no) clinical signs in advance of this. Andy

Re: Unexplained ruptured proximal duodenum

Sammy82 — Fri, 30 May 2014 23:51:43 GMT

My first thought was perforated ulcer, before I even read about the NSAID. Long-term NSAID use could explain why. But hopefully the histo will give you a definite diagnosis.

Re: Unexplained ruptured proximal duodenum

james herriot lied — Fri, 30 May 2014 23:33:51 GMT

It's one of those where histo will probably come up trumps - we recently had a yellow cat with ridiculous bloods and gall bladder distension which was eventually PTSd; a FOC post mortem appeared to show entirely normal tissue - including pancreas. We sent samples off (at our own expense) which came back with chronic pancreatic inflammation and a neoplastic infiltration around the bile duct opening. Had we not done the histo, we'd have had a lot of sleepless nights.