"Case of the week" discussion

RE: "Case of the week" discussion

Julie Innes — Mon, 20 May 2019 08:49:53 GMT

I'm not one for doing lots of tests, but I stand by my decision to do bloods on this cat. Given it's weight loss it could easily have been hyperthyroid or have CRF or (as in this case) hypoalbuminaemic. Important to know.

That mass you are feeling on the first consult- could be something, could be nothing. Could be a red herring. Given that the cat was fairly stable, I'd get bloods, see what else is going on, get the cat back for another feel a few days later, armed with a little more info. Then discuss next steps.

RE: "Case of the week" discussion

Anthony Todd — Sun, 19 May 2019 15:47:52 GMT

[quote user="Kate Richardson"]Another poss diagnosis[/quote] et seq

Would/should you be able to pick this up by eye or section if you removed it?

[so it would obviously go for histo]

Are they alone or are more lymph nodes affected?

Would they ever cause GI signs and therefore be picked up prior to ex-lap?

How common are they?

RE: "Case of the week" discussion

Kate Richardson — Sun, 19 May 2019 12:10:24 GMT

For an abdominal mass[quote user="Anthony Todd"]

[quote user="Lucy Fleming"]Large cell lymphoma of the ileo-caecal-colic region?[/quote]

I assume this is causing symptoms [of obstruction?] so you'd want to do something to relieve that pretty quickly.

Wouldn't you relieve the symptoms anyway, via an ex-lap independent of the FNA etc.?

[/quote]

I would say rarely does it cause obstruction, as the lymphoma is within the intestinal wall which tends to get thicker without invading the lumen. Am sure in very advanced cases this will cause obstruction eventually.

And in Lucy's case, this cat isn't showing signs of obstruction, he has weight loss, slight lethargy, is eating ok and has diarrhoea.

Another poss diagnosis for an abdominal mass would be mast cell neoplasia, and an FNA may give you reason to think this is the diagnosis and I'd rather know that before surgery. I say may, because although I definitely in the ultrasound and FNA camp, sometimes the FNAs can be non diagnostic. But that's part of the discussion to be had with the owner.

(Can't believe I've just given the ex-lappers some free ammo!!!)

RE: "Case of the week" discussion

Anthony Todd — Sun, 19 May 2019 11:51:23 GMT

[quote user="Lucy Fleming"]Large cell lymphoma of the ileo-caecal-colic region?[/quote]

I assume this is causing symptoms [of obstruction?] so you'd want to do something to relieve that pretty quickly.

Wouldn't you relieve the symptoms anyway, via an ex-lap independent of the FNA etc.?

The diagnosis [and prognosis] would come later surely?

I would offer histo of the mass but say that it is not totally conclusive as to prognosis [as stated on here] and leave the cost/benefit to the owner.

[not sure of the relative costs charged for all this today....]

RE: "Case of the week" discussion

Lucy Fleming — Sat, 18 May 2019 18:06:31 GMT

[quote user="Michael Woodhouse"]I'd throw back in this case - how likely is it that ANY diagnostic test will mean you don't end up in surgery?[/quote]

Large cell lymphoma of the ileo-caecal-colic region?

RE: "Case of the week" discussion

Anthony Todd — Sat, 18 May 2019 17:27:42 GMT

Relevent anecdote alert:

My near neighbour and "rival",TH, on our night rota though, and never a cross word, was admitted to hospital BITD with very intense abdominal pain.

As he lay their moaning and grunting he said "Can't you open me up?

"Oh. you're not nearly sick enough for that" was the dismissive reply... [bile duct obstruction, eventually]

RE: "Case of the week" discussion

Michael Woodhouse — Sat, 18 May 2019 16:53:22 GMT

[quote user="Gillian Mostyn"]

If money was taken out of the discussion what would you do?

If it was your abdomen, would you opt for ultrasound first or straight to ex lap?

[/quote]

In this case it sounds VERY MUCH like an ex lap will be required from the history so if money wasn't an issue I don't think I'd do much differently.

I'm very much of the opinion that we should do a diagnostic test to answer a specific question. Not a fan of fishing missions. Not really a fan of blood profiles, but I do use them simply for cost reasons.

I'd throw back in this case - how likely is it that ANY diagnostic test will mean you don't end up in surgery? Stop delaying and building up a bill. There is no wonder insurance prices keep going up.

Like the classic blocked bladder or pyo. Get on and fix it.

RE: "Case of the week" discussion

Niall Taylor — Sat, 18 May 2019 16:29:04 GMT

All through this thread I've been trying to remember which joke it reminds me of - I've remembered

Four veterinarians are on a duck shoot, one is a medic, one an imaging consultant, one is a pathologist and one a surgeon.

They settle down in the reeds and pretty soon a bird flies over. The medic looks up and says, "that might be a duck, but I can't be certain without full bloods and urinalysis", he lowers his gun. The imaging specialist also hesitates, saying, "it could well be a duck, but how can we tell without x-rays".

Finally, the surgeon stands up, raises his gun, takes aim and lets rip with both barrels. The bird falls to the ground in a mess of blood and feathers. The surgeon picks up the body, throws it at the pathologist and says, "is that a duck?"

Niall

RE: "Case of the week" discussion

Anthony Todd — Sat, 18 May 2019 13:26:42 GMT

I may be corrected but, I don't think we ever factored cost into any therapeutic advice.

We would have quoted a fee after the therapeutic advice was given [and then we were lucky 'cos the Harmsworth, back in the days of Tony Self, was pretty accommodating].

And ex-laps seemed to be much cheaper, comparatively BITD too.

RE: "Case of the week" discussion

Lucy Fleming — Sat, 18 May 2019 10:54:02 GMT

[quote user="Michael Woodhouse"]Bloods, rads, scan, sedate, FNA & histo would cost more in most/all practices than an ex lap - no?[/quote]

We didn't do rads, which had they been included likely would have brought the cost up to more than an ex-lap. Without them (I don't have the exact figures with me so can't be certain) bloods, scan, sedation, FNA and cytology would still probably be a bit less than a "peek and shriek" type ex-lap ending in PTS. Significantly less than a resection and anastamosis of a section of diseased gut, especially if complications were to develop (increased risk of this has been demonstrated in hypoalbuminemia patients). He might fly through surgery and do great, but I think it's important that the owners (and we) are prepared for the worst case scenario as well as the best.

If cost was a limiting factor, we could have skipped bloods, and in this cat, probably managed a blind FNA in consult (not the case with every patient and mass!) and got a diagnosis, it turns out (though we might have equally had a non diagnostic sample)

If cost was a really limiting factor, it would have been a conversation probably about steroids vs euthanasia.

If QOL was the limiting factor at initial presentation (he was surprisingly 'well') then trying to get a definitive diagnosis quickly might have meant going to ex-lap fairly immediately.

There's lots of ways to approach this (one of the reasons I thought it would make an interesting case for discussion) with no one real right or wrong answer. I also found it quite refreshing to be able to gather quite a lot of information which was, while perhaps not essential, still useful. I'm certainly not one for immediately running every test available (if only because my brain likes to move through lists one at a time!) but sometimes cost constraints can leave you feeling like you have one hand tied behind your back.

A popular rhetorical question on here is often "just because we can, does that mean we should?" but perhaps another one is "just because we don't have to, does that mean we shouldn't?"

RE: "Case of the week" discussion

Richard Carter — Sat, 18 May 2019 08:53:23 GMT

My ultrasound skills are not good - we do fnas for in-house and biopsies for histo but if time of essence will prefer to go to ex-lap early. As others have said - Xrays, repeated ultrasounds, barium etc all add up and sometimes when you get in there, it is nothing like what you would have expected from the work-up.

our success rate of removing occluding GI tumours with good short, medium and long outcomes for patient and owners is quite high - yes some are on permanent a/inflam; preds if lymphoma afterwards (haven't had a single client prepared to do COP in a cat, som do try chlorambucil) but we have removed adenomas, adenocarcinomas, mast cell tumours sometimes with affected l/nodes, sometimes closing knowing that the cancer is still in the patient but solving the immediate problem of g/i obstruction, discomfort and deterioration. These are with owners who accept that occasionally we are not going to be able to do anything - masses in mesenteric l/n occluding the efferent GI flow and not in GI tract for eg.

Even then given how many are likely to be lymphoma, trial depomed is usually offered sometimes with amazing results. If it's in a box, then there isn't a chance.

Why ex lap? Having previously misdiagnosed hair impaction as a tumour.....

RE: "Case of the week" discussion

Gillian Mostyn — Sat, 18 May 2019 08:12:59 GMT

[quote user="Michael Woodhouse"]I still kind of agree with him. Bloods, rads, scan, sedate, FNA & histo would cost more in most/all practices than an ex lap - no? I do agree strongly that in 30 mins the mass will be examined, sampled and possibly removed/fixed. I really hope we can manage pain and discomfort associated with abdominal surgery. A biopsy better than FNA. Mark 1 eyeball better than rads.[/quote]

If money was taken out of the discussion what would you do?

If it was your abdomen, would you opt for ultrasound first or straight to ex lap?

I'm happy to go to ex lap if needed, and I hope I can control pain adequately. But I don't see how offering a non-invasive ultrasound etc first can ever be negative thing? Obviously the owner gets final say on refusal, which they can do on cost grounds if they wish, but if it were my pet I'd want it to be offered.

RE: "Case of the week" discussion

Michael Woodhouse — Fri, 17 May 2019 23:14:04 GMT

[quote user="Anthony Dennison"]I do hope you're just trying to bait us Tony, otherwise you haven't learnt anything from this thread. [/quote]

I still kind of agree with him. Bloods, rads, scan, sedate, FNA & histo would cost more in most/all practices than an ex lap - no? I do agree strongly that in 30 mins the mass will be examined, sampled and possibly removed/fixed. I really hope we can manage pain and discomfort associated with abdominal surgery. A biopsy better than FNA. Mark 1 eyeball better than rads.

I don't see merit in spending £100's of pounds and delaying the inevitable. I would open this cat in a heartbeat.

RE: "Case of the week" discussion

Anthony Dennison — Fri, 17 May 2019 16:57:55 GMT

[quote user="Anthony Todd"]Not if you do a quick exlap first, then you'll know and never be wrong[/quote]

I do hope you're just trying to bait us Tony, otherwise you haven't learnt anything from this thread.

RE: "Case of the week" discussion

Anthony Todd — Fri, 17 May 2019 16:03:24 GMT

[quote user="Gillian Mostyn"]But if you euthanase them all, you'll never know. Or ever be wrong[/quote]

Not if you do a quick exlap first, then you'll know and never be wrong

RE: "Case of the week" discussion

Gillian Mostyn — Fri, 17 May 2019 15:40:44 GMT

I've had a large intramural abscess in a middle aged GSD that presented as a palpable mass in its small intestine...with signs of GI blockage. We did go to ex lap (I'm not skilled enough in ultrasound, but would agree this would have been ideal). It was drained and no cause was found on histology...the dog was fine afterwards. Not all GI 'masses' are terminal.

But if you euthanase them all, you'll never know. Or ever be wrong.

RE: "Case of the week" discussion

Rob Loxley — Fri, 17 May 2019 13:58:05 GMT

[quote user="Kate Richardson"]Has everyone forgotten this is 6 year old cat? All doom and gloom. He might have something treatable[/quote]

We've had a couple of diagnoses of Feline Gastrointestinal Eosinophilic Sclerosing Fibroplasia which we would otherwise have been convinced were neoplastic

RE: "Case of the week" discussion

Kate Richardson — Fri, 17 May 2019 12:33:44 GMT

Has everyone forgotten this is 6 year old cat? All doom and gloom. He might have something treatable

RE: "Case of the week" discussion

Julian Earl — Fri, 17 May 2019 11:12:53 GMT

[quote user="Clive Ansell"]ost of the information is there at the initial consultation; a nodular central abdominal mass and that degree of weight loss is almost certainly going to be bad news. The investigations that follow just prove what you already know really, and are just a different direction to the same end point PTS in most cases[/quote]

I've agreed with you there Clive but all cases end up badly sooner or later and not all require PTS of course. I think a lot of the later posts confuse the need for diagnosis with prognosis. A cat like this losing weight appears to be in big trouble regardless of the precise diagnosis. I decided early in my career that any abdominal mass justifies a laparotomy in order to come to asolution whether by removal or simply identifying it as a hopeless case. Pre-op blood tests are only likely to be justifiable if there is a real fear of renal ollapse under GA. But on the other hand, fluids and sedation should permit transcutaneous FNA for a rapid diagnosis at minimal cost c.f. to full laparotomy? The more that I think about this, I think getting a FNA is crucial for satisfactory progress with this cat. That's my 2p-worth!

PS: tangent alert? I think that abdominal palpation is an under-taught skill at university and for our patients should be a day-one core- skill.

Okay 3p-worth! Inflation?

RE: "Case of the week" discussion

Clive Ansell — Fri, 17 May 2019 10:29:43 GMT

Most of the information is there at the initial consultation; a nodular central abdominal mass and that degree of weight loss is almost certainly going to be bad news. The investigations that follow just prove what you already know really, and are just a different direction to the same end point PTS in most cases.

RE: "Case of the week" discussion

Clive Ansell — Fri, 17 May 2019 09:57:39 GMT

I was thinking the same thing; even with an ex-lap it may give a very good idea of what is going on, but there is no definitive diagnosis until the histopathology results are back.

RE: "Case of the week" discussion

Anthony Dennison — Fri, 17 May 2019 09:40:47 GMT

[quote user="Anthony Todd"]All that is assuming your non-invasive tests are diagnostic which an ex-lap pretty always is, as [far as the mass is concerned].[/quote]

[quote user="Anthony Todd"]At least, with an ex-lap, you should get all the information always from the mass.[/quote]

No. You know there is a mass. You know the location of the mass.

You don't know what the mass is, you don't know whether it's malignant or if there are other metastases in other body cavities, or if there is the presence of lymphatic invasion.

We've done ex-laps before being very suspicious of a foreign body and found nothing. So we've just said, 'guess it's a bad gastroenteritis then'. Not a definitive diagnosis, just narrowed down the differentials.

RE: "Case of the week" discussion

Niall Taylor — Thu, 16 May 2019 20:29:56 GMT

[quote user="Anthony Todd"]All that is assuming your non-invasive tests are diagnostic which an ex-lap pretty always is[/quote]

An ex-lap is nowhere near "pretty always" diagnostic. Sure, you get a direct look at the problem, but there is no way of telling in every case exactly what the problem is and whether or not it is likely to have survived with medical treatment. As a bit of an ex-lap fan myself, one has to be honest and admit that some animals are pts prematurely during an ex-lap for conditions which could otherwise have been treated or at least significantly palliated medically.

[quote user="Anthony Todd"]if the cat was nearly OK with the mass then it seems sensible, to me, to remove the mass etc. as necessary and hope the cat improves.[/quote]

Really? - end to end lower bowel anastomoses are far from straightforward to put it mildly, especially with a serum albumen of 19.

This sort of case has no definitive solution in veterinary medicine, it all depends on client choice and preference. There is no single answer.

Niall

RE: "Case of the week" discussion

Anthony Todd — Thu, 16 May 2019 19:40:59 GMT

All that is assuming your non-invasive tests are diagnostic which an ex-lap pretty always is, as [far as the mass is concerned].

Not sure that, with modern, or even BITD techniques, a GA was much of a "put through".

Restraining a cat for a FNA of an intra-peritoneal mass can't be too pleasant for the cat, certainly less pleasant than a I/V induction.

At least, with an ex-lap, you should get all the information always from the mass.

If the cat presented as "unhappy" in any way then PTS on the table would be obvious, but if the cat was nearly OK with the mass then it seems sensible, to me, to remove the mass etc. as necessary and hope the cat improves.

RE: "Case of the week" discussion

Jenny Harris — Thu, 16 May 2019 19:19:02 GMT

I also disagree with use of anon account for this. And also as it’s looking like lymphoma I am not sure exlap indicated either. It won’t fix the problem if this is lymphoma. And at least now knowing neoplasia is most likely and if the owners don’t want further treatment, the patient can be pts now without having to be put through an Exlap. Other practices may charge differently but in my clinic ultrasound and FNA an awful lot cheaper than ex-lap and histo. And may provide the same info. for the record I don’t disagree with others that would take a different approach and go straight to surgery (assuming the options were discussed with the owner). It just wouldn’t be the way I personally would do it.