To exlap or not exlap 2?

RE: To exlap or not exlap 2?

Silvia Maldonado — Tue, 20 Oct 2015 00:23:02 GMT

No worries, Anthony. Too much info at once, I reckon.

And not so used to seeing a vet nurse happy to go to surgery in the dead of night, but you can bet that selfies are pretty much on fashion...

Love night shifts!

RE: Exlap or not exlap 2

Anthony Todd — Mon, 19 Oct 2015 23:34:32 GMT

[quote user="Silvia Maldonado"]The 1st exlap was done 5-6 weeks before[/quote]

Sorry, my mistake, should read the case notes again before firing off!

RE: Exlap or not exlap 2

Stephen Courtney — Mon, 19 Oct 2015 23:10:17 GMT

This is a great thread, highlighting the problems of making the right choices, indeed as did the first Ex Lap thread!

I think life was simpler pre ultrasound - an ex lap answers so many questions, and often resolves the situation either by revealing the problem or letting the evil spirits out.....all findings are useful and have diagnostic value, even normal ones! The most difficult FBs are the ones that stick a bit, move a bit, and leak fluid round he edges...like this bag.

I think perhaps many of us who are not natural surgeons worry about performing surgery that turns out to be unneccessary or perhaps ending up in over our heads...

RE: Exlap or not exlap 2

Silvia Maldonado — Mon, 19 Oct 2015 19:47:01 GMT

[quote user="Anthony Todd"]

Can I suggest someone should have had a good look for the bag during the first Ex Lap, as I have said so often it'll be the best chance of looking at everything.

Will a plastic bag show on Xray or ultrasound or, palpation even?

Would the pancreas have been inflamed at the first ex-lap and why is it now? [unless it is a mild peritonitis?]

Ironically [hind sight is 20:20 etc] the bag may well have just sailed through eventually, even on B12 and Betsolan, but was it ever worth the risk?

I say always not!

[/quote]

Oh, no, sorry for the misunderstanding, no. The 1st exlap was done 5-6 weeks before, and a rubber toy was removed. The bag was chewed 12 days before the 2nd exlap was done. My guessing is that it was passing through the small GI fine until it reached the enterotomy zone and, either because it was inflammated, or narrower (although no cushing suture was done, just interrupted simple sititching), or any other reason, the thing is that just cranially to it, the bag "decided" not to pass. The pancreatitis, was it due to 3 days vomiting? mmm... maybe!

Latest news, the dog was sent home this afternoon, he's been in hospital for 5 days.

Occam's razor... William of Occam was the character played by Sean Connery in "the name of the rose", and used to say that "in most situations, the simplest reasoning is the correct answer", like look for the most logical answer and you'll likely be right

RE: Exlap or not exlap 2

Anthony Todd — Mon, 19 Oct 2015 18:00:17 GMT

Occam's razor

ˈɒkəmz/

noun

the principle (attributed to William of Occam) that in explaining a thing no more assumptions should be made than are necessary. The principle is often invoked to defend reductionism or nominalism.

I'm no more the wiser but it's a nice one to toss in when the patricians get uppity.

RE: Exlap or not exlap 2

Anthony Todd — Mon, 19 Oct 2015 17:56:03 GMT

[quote user="Evelyn Barbour-Hill"]As Anthony and I have banged on about in the past........[/quote]

Hold on, hold on, I thought you were in the more barium camp.....

Can I suggest someone should have had a good look for the bag during the first Ex Lap, as I have said so often it'll be the best chance of looking at everything.

Will a plastic bag show on Xray or ultrasound or, palpation even?

Would the pancreas have been inflamed at the first ex-lap and why is it now? [unless it is a mild peritonitis?]

Ironically [hind sight is 20:20 etc] the bag may well have just sailed through eventually, even on B12 and Betsolan, but was it ever worth the risk?

I say always not!

RE: Exlap or not exlap 2

Evelyn Barbour-Hill — Mon, 19 Oct 2015 14:26:11 GMT

[quote user="Silvia Maldonado"]Lesson learned, "Occam's razon", a good abdominal palpation might be all I need,[/quote]

As Anthony and I have banged on about in the past........

[quote user="Silvia Maldonado"]and barium passing all the intestines doesn't rule out a FB.[/quote]

but a) delayed gastric emptying is always suspicious, and b) if you radiograph at the right time you should be able to see the FB outlined by barium.

Sez me. Not a gut expert.

Anyway, thanks for an interesting thread Silvia

RE: Exlap or not exlap 2

Silvia Maldonado — Mon, 19 Oct 2015 13:41:44 GMT

My goodness! how many good arguments! On hindsight I do realize how complex the case was. Where should I start?

Exactly, Anthony! Why bloods are normal? Wouldn't I expect high K in a duodenal blockage? what about lipase and amylase? Why he was still vomiting after 3 days on cerenia? why vomiting only food, and not immediately? Where was the bag? still in the stomach, after 9 (now 12) days? was it one of those biodegradable ones? how big it was after being chewed? Linear FB? Did the dog pass it indeed? Was that really the problem?

Evelyn rightly pointed out her concerns, if barium was indeed passing, but delayed, or some retained, and why not having more different views as well as recording times.

As Nicole asked, and a very good question, "why giving him barium again?". My plan was restart the barium test. Because, as Mark suspects, what if the bag is half blocking? would it pass? is it already in the large intestine? is it still in the stomach?

Only that, recalling the problems I had myself during the only night I had him (Sunday) that I could not performed a proper abdominal palpation, I had the feeling that the other vets would have had the same problem. So this time I sedated him (bupre+midazolam, then propofol) and did a proper, good abdominal palpation. That's why, Nicole and Evelyn, I didn't upload any more images, because at this point I did feel a mass in the abdomen, about 6-8cms long, and 2-3cms wide, cranial to the bladder, too ventral to be a kidney, not so dorsal to rule out the spleen or the previous enterotomy? My plan was restart the barium+xrays, but now I changed my plan.

Thomas and Grumpyoldman, in this case ultrasound did help me. Not to look for gas or free fluid, but determining if the mass palpated was in fact a FB or an organ (recent enterotomy? spleen?) To be sure I was not palpating an organ or a extremely swollen and granulomatose enterotomy, I grabbed a probe, and it is much easier to see it in live, but here are some freeze images

First and second images were of just small intestine, I also found an homogenous spleen, nice liver, quite full bladder... The last one was the mass I had in my hand, not allowing the waves to penetrate. That way I ruled out I had grabbed an organ.

I called his owner by 23:00h, sorted out some appointments we had (sole charge with just a VN alone), get all ready, and started exlap by 00:30h

Maybe for some days the bag was allowing the food to pass, but at this point only fluids were going through the folds that run parallel to the intestine. The bag was stuck just cranial to the enterotomy he had recently had at the ileum, well passed all duodenum, and I guess the recent surgery narrowed the intestinal lumen (he was not taking any NSAID either). Also found out that pancreas was very inflammated.

Endoscopy would have deffinitely been useful if it hand been in the stomach. I was also wondering if the plastic bag was in the large intestine, which would have been more consistent with the history. Can anyone tell if it would have been useful and endoscopy? better trying enemas? or exlap and milking it through manually?

I'm sharing my experience as a way of thanking you all for sharing yours and helping me making decisions. Lesson learned, "Occam's razon", a good abdominal palpation might be all I need, and barium passing all the intestines doesn't rule out a FB. Hope you find it useful as well.

RE: Exlap or not exlap 2

Anthony Todd — Mon, 19 Oct 2015 10:34:05 GMT

[quote user="Mark Hedberg"]

What if the plastic bag is still in the stomach and some of the barium got stuck in the bag?

[/quote]

My thoughts exactly, but I wonder how many bariums and Xrays are needed to confirm this, if it hasn't shown by now?

Perhaps endoscopy would be better as the problem seems to be centring on the stomach? Probably able to pull the plastic bag out and the same time too?

RE: Exlap or not exlap 2

Mark Hedberg — Mon, 19 Oct 2015 10:21:15 GMT

What if the plastic bag is still in the stomach and some of the barium got stuck in the bag?

RE: Exlap or not exlap 2

Thomas Johnson — Mon, 19 Oct 2015 08:38:59 GMT

[quote user="grumpyoldman"]

some different views maybe useful a DV or the other lateral ? The barium will not affect an ultrasound too much .

[/quote]

I'm guessing ultrasound's not going to be very useful as it had an ex-lap 10 days previously, so there's probably still some free gas in the peritoneal cavity.

RE: Exlap or not exlap 2

Evelyn Barbour-Hill — Mon, 19 Oct 2015 00:05:29 GMT

[quote user="Anthony Todd"] I might change to metoclopramide as it has this claimed gut motility normalising function.[/quote]

This dog's had all sorts of drugs any of which might have an adverse effect on gastric emptying. I'd try to take it off all drugs for a bit, if possible.

[quote user="Anthony Todd"]I can't see much purpose in continuing the barium though.[/quote]

I don't quite know what you mean. If you mean continuing to administer barium, no, of course not. If you mean continuing to radiograph, there's every reason to continue. This dog appears at the moment to have delayed gastric emptying, and we want to find out if that is really the case, and we want to try to get a clue as to why. If we keep a careful watch on it, the appearance of the residual barium may even give us the answer.

[quote user="Anthony Todd"]Where's the plastic bag?[/quote]

That's what we all want to know.

RE: Exlap or not exlap 2

grumpyoldman — Mon, 19 Oct 2015 00:04:58 GMT

some different views maybe useful a DV or the other lateral ? The barium will not affect an ultrasound too much . The last pre second barium pic does look like pyloric retention could be gastritis or a rolled up sock ? Is there a preliminary plain film ?

RE: Exlap or not exlap 2

Anthony Todd — Sun, 18 Oct 2015 23:42:24 GMT

[quote user="Silvia Maldonado"]I was really confused, and remembering the last post "exlap or not exlap"..[/quote]

Come on you lot, this is an odd one, help the previous posters out here, including me.

Where else can one turn except to the accumulated wisdom on vetsurgeon.org!

RE: Exlap or not exlap 2

Silvia Maldonado — Sun, 18 Oct 2015 22:10:04 GMT

Yes, the bloods should have shown some amylase or lipase alteration, but both were wnl. I guess the pancreatitis suspicion was based on the pain on cranial abdomen. K+ also was wnl. Done a comprenhensive profile, Na was normal, Cl was unknown, and no tCO₂

The dog didn't vomit the barium. He was vomiting his chicken, hours after ingesting it. The plastic bad, nobody knew were it was. According to the owners, he had not passed it yet. At the time I saw him, he was also vomiting bile, with an empty stomach. However, he had been vomiting for 3 days by then. He had been given cerenia on Sunday, Monday and Tuesday. To make things worse, some barium had passed in the stools, and the day before, Monday, he produced a normal, solid stool.

I was really confused, and remembering the last post "exlap or not exlap"...

RE: Exlap or not exlap 2

Anthony Todd — Sun, 18 Oct 2015 21:20:14 GMT

[quote user="Silvia Maldonado"]Suspecting pancreatitis[/quote]

Shouldn't the bloods have picked that up?

Where's the plastic bag? Er, not still in the stomach?

What does the dog vomit? [barium, FB, bile etc?]

Not one I'd jump in and ex lap againat this stage, too many positives going on, except the vomiting.

How long after cerenia does does the dog vomit? As it's such a powerful anti-emetic that makes me a bit undecided, together with the fact that the dog is eating, has some bowel movement and is BAR.

Couldn't just be a gastritis? I might change to metoclopramide as it has this claimed gut motility normalising function.

Might pay to give small meals frequently, warmish water and watch carefully.

I can't see much purpose in continuing the barium though.

Let us know what happens!

RE: Exlap or not exlap 2

Evelyn Barbour-Hill — Sun, 18 Oct 2015 16:05:07 GMT

I am NOT a gut expert but:

I'm thinking the bulk of the barium went through with normal appearances (but more intermediate pictures would have been helpful), yet some is retained in the stomach, which is not really normal. So in a way it's a pity you gave more barium, because it has confused the picture, but never mind. I'd be wanting after that to take repeat pictures every couple of hours, until it's all in the large intestine: or, until you find that a lot of it is in the large intestine but some is retained in the stomach. Both left and right laterals so that you have views both with pylorus up and pylorus down. (And record the times, to assist in your interpretation).

Do I understand that the dog is still vomiting? If so, can you get endoscopy done?

RE: Exlap or not exlap 2

Silvia Maldonado — Sun, 18 Oct 2015 15:33:07 GMT

I started my shift at 21:30h, and the dog was admitted by 16h-ish. Seen by 2 vets, one ending her shift by 17h and handing over her cases to the second one.

I gave him more barium because I didn't know when it was given, what time the xrays were done (within 1h? within 4h?) and did know he had passed some barium in his stools by 17-18h.

RE: Exlap or not exlap 2

Nicola Cole — Sun, 18 Oct 2015 15:06:20 GMT

I know you mentioned you haven't got exact times of post barium radiographs-but do you have a rough idea?

Also, was there a reason more barium was given before the last radiograph?