BIPS - Useful or not?

RE: BIPS - Useful or not?

Jill Butterworth — Tue, 06 Apr 2021 17:42:15 GMT

I liked to do a Barium swallow (syringe fed, not a meal). I was a sole practitioner and saw quite a few, so any persistently vomiting dog was a FB until proven otherwise in my book, and Ba really helps you to rule in or out obstruction, when plain radiographs are inconclusive, you can't palpate anything, and are still undecided after ultrasound (or don't think you are good enough). In this instance any leak of Ba is minimal because you are on to it with radiography and can proceed to surgery without delay.

On Fridays and Saturdays the pressure was on to decide if cases should be opened up or not to try to avoid sending them to the OOH clinic half way through being worked up or because the costs were an issue. I'd far rather do a quick negative exlap and take a biopsy or two, than risk a client trying to hang on until Monday with a very sick dog if they were put off by OOH fees. Defensive medicine, sure, and it helped that it was my practice, so I could charge/discount accordingly, if I felt I was opening the dog up for peace of mind. I was lucky to have worked at practices with a similar philosophy. It's a balance, but a prolonged undiagnosed obstruction will be far more likely to die/be severely ill when it eventually gets to surgery.

Bad luck with the complaint, it's a tricky thing to communicate, and a big bill is often what triggers it. The dog survived and that's the important thing (which clients seem to forget!). I would usually make a comment about wishing I was clairvoyant to underline the uncertainty.

Not sure if this helps, but I almost always got the client (or whole family sometimes, because second hand info can be poorly explained) back in to show and explain the radiographs before opening the dog up. My reasoning was that it is a graphic illustration of the areas of concern and helps to communicate the dilemma and risks far better than a phonecall, when I worry that they can sense uncertainty and can misinterpret it. ie I want to actually 'show' them what I am worried about, not make them worried about me doing my job.

RE: BIPS - Useful or not?

ADRIAN TANASE — Mon, 05 Apr 2021 20:04:21 GMT

I had a dog with history of GI signs in the past, scavenger, presented with profuse vomiting for 3 days especially after trying to eat (weight loss, etc) and the sickness continued during hospitalisation, thickened intestine on palpation, plain x-ray showed one particular intestinal loop filled with gas 3 x bigger than all the others, US gastric dilatation and huge fluid dilation of stomach and duodenum, low peristaltism, rest of intestine wnl, vomiting persisted despite treatment, no faeces passed. will you open him ? I did. It was Functional Ileus due to chronic GI in the past; with a lot of constant treatment , was better in 6 days. Thanks God I informed the owner about what an ex lap means and that might not find anything. She still made a formal complain.

RE: BIPS - Useful or not?

Julie Innes — Tue, 05 Feb 2019 15:58:17 GMT

It's nothing I've ever really used, but I guess that is just because none of the practices I worked in ever used them! Have used barium, but more commonly to visualise the outline of the stomach/ movement of GIT. We would usually look at plain films and clinical signs. Interested in the idea of using ultrasound- we have it, but it's not a tool I've really associated with looking for FBs, I do worry that I'm not skilled enough.

Another very unscientific "alert" to me is the Foreign Body Face! Dogs with FBs just have a particularly mournful look about them that always sets my Spidey senses tingling! Rarely been wrong!

RE: BIPS - Useful or not?

Glen McIntosh — Tue, 05 Feb 2019 07:27:18 GMT

Havent used BIPS, or barium for that matter, in the last 7-8 years.

I don’t believe that all FB obstructions can be identified on plain radiography, but it can give you a lot of clues.

Mostly we rely on 1. clinical signs, 2. palpation (palpable fb and clinical signs would be diagnostic), 3. Plain radiographs, 4. Ultrasonography.

Ultrasonography is very useful - marked gastric dilation and marked fluid dilation of a portion of proximal small intestine and with normal small intestine distally, with intractable vomiting (esp in the absence of diarrhoea), will almost always warrant an exlap. If I am not seeing those things then I would usually be waiting and seeing, maybe repeating rads and u/s in 12 hours or so. These signs are extremely easy to identify, even for inexperienced ultrasonographers.

We get some referral cases sometimes where barium has been used. The only time it seems to make any difference to decision making is when it has passed through the git uneventfully, thereby excluding obstruction.

If we didn’t have U/s available then barium/BIPS would probably be useful, but I think it isnt needed when u/s is available, which should be just about everywhere now?

Some people are call ultrasound the stethescope of the 21st century and advocate its use, esp in the form of AFAST and TFAST, as part of the routine work up in any sick patient. I tend to agree.

But, like anything, you can still get false positives, so if I cant palpate the FB or see it on plain radiographs, the owners will be forewarned and advised that they will need to accept the possibility of a negative exlap before I am willing to proceed.

RE: BIPS - Useful or not?

Alistair Graham-Evans — Tue, 05 Feb 2019 04:29:54 GMT

I find the most common cause for delay in treatment of GI obstructions with inconclusive X-rays is when they improve so much clinically after initial fluid stabilisation, anti-emetic drugs and analgesia. Then unfortunately surgery done a day too late when they start to deteriorate again and ectomy rather than otomy required.

I have found BIPS of some use in the past with some vague cases to convince myself of medical vs surgical approach though stethoscope & exam usually gives me information needed. We also insist on 3 views on X-ray. I have been guilty of anaesthetising an animal with dilated gas loops on X-ray only to have it stink the theatre out with diarrhoea when it relaxes!

I don't tend to do limited laparotomies as I prefer to have a damn good look around and biopsy lots while there if no FB. A xyphoid to pubis wound heals at the same rate as a small one and I can always use staples or a student if bored closing.

RE: BIPS - Useful or not?

Evelyn Barbour-Hill — Mon, 04 Feb 2019 19:57:24 GMT

[quote user="Anthony Dennison"]Issue is, we're often waiting for a BIPS study and then still doing an unnecessary laparotomy when it's a functional ileus from severe GE rather than a physical blockage.[/quote]

It should be possible, usually, to tell a difference.

RE: BIPS - Useful or not?

Beats — Mon, 04 Feb 2019 19:29:50 GMT

I've never used BIPS (insomuch as I remember), but I've thought about it on occasions.

I do like to have a can of barium available, but it very rarely gets used (I tend to give acepromazine, wait 40 minutes, give iv midazolam, whisper quietly while taking left lateral and VD, then try to get barium+/-food in without aspiration, then take further radiographs over course of day (how long depends on how long patient stays amenable to being radiographed without manual restraint).

Mostly, sedate iv wth medetomidine and butorphanol, take left lateral and VD (and often right lateral and DV too) abdominal radiographs at first suspicion of possible GI obstruction. I look at them, but tend to go more on history though when it comes to deciding whether to do an exploratory coeliotomy or not. Unless suspicion heavy, then I typically manage medically until next day and then repeat the plain radiographs. I find this helpful both because the signs can often be a give-away (profuse diarrhoea then starting may suggest that the dog presenting with 24 hours of vomiting is not a GI obstruction for instance), and the change (or not) in appearance of radiographs fills me with more confidence than interpretation of the first ones alone. I will also confess that I find it generally more efficient than my barium approach.

I am happy to do an exploratory surgery to rule-out the presence of a GI obstruction; sometimes I think the more hardcore medical management afterwards (without further sedations or starvings for imaging) can justify this (say in a case that I would otherwise be hesitant to give more anti-emetics to for fear of missing a GI obstruction). Surgical exploration does not have to be an all-or-nothing approach either, it is quite rational to make a limited incision, check through the intestines (and feel stomach), and close it again without any biopsies or huge incision for detailed abdomianl exploration, if the question you area looking to answer is "does this cat/dog have an obstructive GI lesion" rather than "why is this dog/cat unwell"?

RE: BIPS - Useful or not?

Kate Richardson — Mon, 04 Feb 2019 19:25:54 GMT

Do you use ultrasound to assess motility at all? I've not used BIPS, so can't comment on them. My personal feeling is I use the demeanour and heart rate a lot to determine if obstruction is likely, probably stems from my time in equine work where the heart rate and changes in it was key to determining if a surgical colic or not. Plus gut instinct (pardon the pun). Not wanting to raise an old discussion, but I think the decision to ex lap or not often depends on how keen a surgeon you are as well.

RE: BIPS - Useful or not?

Anthony Dennison — Mon, 04 Feb 2019 17:20:11 GMT

Thanks Evelyn.

[quote user="Evelyn Barbour-Hill"]I'd rather wait for a BIPS study than do an unnecessary laparotomy.[/quote]

Issue is, we're often waiting for a BIPS study and then still doing an unnecessary laparotomy when it's a functional ileus from severe GE rather than a physical blockage.

[quote user="Evelyn Barbour-Hill"]Well, before your final radiographs. There's nothing to stop you also taking some sooner and you may have obstruction identified sooner.[/quote]

Quite. Last Friday morning I got a phone call to say that because I was on call that night I would need to come over to x-ray a dog at 7pm to check for obstruction. I didn't want the dog to wait that long, especially if there was a foreign body so came over at lunchtime to radiograph it. The spheres were passing all the way through the intestines already, just 3 hours after administration.

RE: BIPS - Useful or not?

Evelyn Barbour-Hill — Mon, 04 Feb 2019 16:18:36 GMT

1. Yes. And yes. Just be aware of the limitations. They are not the same as a barium meal.

2. Yes. Well, before your final radiographs. There's nothing to stop you also taking some sooner and you may have obstruction identified sooner.

3. Yes.

Maybe a foreign body can always be picked up on radiographs (or was Mr. Hall showing off?) but other obstructions or partial obstructions may be only suspected or not detectable. A barium meal would show them up, sure, but BIPS are a great deal easier to administer especially to a cat. And a BIPS finding of normality is reliable and reassuring. I'd rather wait for a BIPS study than do an unnecessary laparotomy.

[quote user="Anthony Dennison"]a way of passing the buck to the next vet along[/quote]

I wouldn't know about that. The next veterinary surgeon along is...... still me.