Melaena - the next step?

RE: Melaena - the next step?

Anthony Todd — Mon, 01 Mar 2021 18:21:50 GMT

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228835#228835"] I'm serious in that[/quote]

So was I, and this time I think the ex lap was right. I assume it was totally negative on palpation. which makes it even more likely that an ex-lap would help.

Was there any bleeding into the abdomen? if there was an abdo tap might have given a better clue, although an ex-lap would probably be the next step any way

Love to know what the bill was [definitely more than a quick ex-lap,!] hope the dog is Ok and we get the histo which might change things,

I wonder sometimes whether "informed consent" is actually to justify and "explain" the cost of all the ancillary investigations???

RE: Melaena - the next step?

Neil Wheadon — Mon, 01 Mar 2021 13:40:46 GMT

Now please Anthony, no 'I told you so' because yes this was an option - I'm serious in that

A midline laparotomy was performed. A mid to distal jejunal mass was identified and a side-to-side anastomosis was performed with linear GIA and TA30 staplers. Biopsies were also taken from the ileum and an enlarged mesenteric lymph node.

His PCV has increased to 22%

Neil

RE: Melaena - the next step?

Neil Wheadon — Sat, 27 Feb 2021 18:02:03 GMT

[quote userid="5012" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228741#228741"]

Neil Wheadon said:
Bloods and clinical examination showed a PCV of 15% and regenerative

Was that in-house or externally with a haematologist?

[/quote]

Internally 18%

Externally 15%

Neil

RE: Melaena - the next step?

Neil Wheadon — Sat, 27 Feb 2021 18:01:08 GMT

Operated on, in Langford on Wednesday, I should get a report next week

Neil

RE: Melaena - the next step?

Anthony Todd — Sat, 27 Feb 2021 17:56:04 GMT

Eight days on and no answers so what happened to the patient?

RE: Melaena - the next step?

Clive Ansell — Tue, 23 Feb 2021 12:59:14 GMT

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step"]Bloods and clinical examination showed a PCV of 15% and regenerative[/quote]

Was that in-house or externally with a haematologist?

RE: Melaena - the next step?

Clive Ansell — Tue, 23 Feb 2021 12:58:16 GMT

[quote userid="6765" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228718#228718"]

We would do Xrays, scan and endoscopy (Australian GP clinic)

Cost without path fees about $1200-S1500

UK equivalent about £800

[/quote]

About the same as where I'm working at the moment, including a GA.

Obvious varies practice to practice, area to area, but ballpark about right and perfectly reasonable.

RE: Melaena - the next step?

Anthony Dennison — Tue, 23 Feb 2021 11:42:29 GMT

[quote userid="5904" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228705#228705"]I, and most of my comtemps, never mentioned or thought of money when diagnosing a presented patient and we only recommended what was necessary and essential which, it must be said, would have benefited sometimes, but not all times, from the "toys" now available.[/quote]

As you've mentioned, you've retired now. One of the biggest sources of complaints we have is either financial or lack of communication (eg discussing estimates). We have to give owners enough information so they can give informed consent. Which includes costings. The same thing happens now - tests and procedures are done only if they're deemed necessary. We don't just do them for the fun of it.

[quote userid="5904" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228705#228705"]How often on this forum is lack of funds mentioned, sometimes almost as a diagnosis, usually as a reason[/quote]

Because if this is mentioned early enough focus can be on low cost options for treatments and investigations rather than discussing referral/MRI etc

[quote userid="5904" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228705#228705"]Often vets post, "bo money so no tests" so no diagnosis so [of course] no treatment[/quote]

No, treatment is still provided but it is symptomatic and may not deal with the underlying cause. It may help until the animal sorts itself, similar to your approach of...

[quote userid="5904" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228705#228705"]"B12 and betsolan" certainly seemed to help an awful lot of vague signs and symptoms....[/quote]

Yes, because you're suppressing the body's response to whatever is going on and giving a form of support in the B12 so often mild issues it will sort itself out.

[quote userid="5904" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228705#228705"]Finally, too late for me, but let us know!!! I can't learn but others will!![/quote]

Lets focus on this case in had rather than you generalising. If you want to discuss approaches, how about tangenting this thread to discuss it rather than turbopost on this one and derail it.

RE: Melaena - the next step?

Alistair Graham-Evans — Mon, 22 Feb 2021 21:57:29 GMT

We would do Xrays, scan and endoscopy (Australian GP clinic)

Cost without path fees about $1200-S1500

UK equivalent about £800

Sounds like your fees are rather higher over there - to be honest our endoscopy procedures are not profitable but it adds diagnostic value, is interesting and creates a better all round service. We don’t have a useful local referral facility.

RE: Melaena - the next step?

Clive Ansell — Mon, 22 Feb 2021 19:01:04 GMT

I would never say that.

I usually advise what I consider to be best clinical practice (that may differ from what others feel is best). I rarely suggest running every known test, but usually prefer a stepwise approach. Often I just treat what I see, then reassess the response to treatment. I discuss the options with the client and help them decide.

Times change, not necessarily for the better, but they do change. Clients are more demanding than they used to be; they sometimes want/demand a diagnosis aided by Dr Google of course. We also live in an increasing and extreme consumeristic society; folk think because they pay they can demand almost anything, and if they don't get it they complain and sue us. Gone are the days when the vet can just bluff and inject an emulsion of dex/B12/amox in the same syringe.

RE: Melaena - the next step?

Julian Earl — Mon, 22 Feb 2021 16:20:02 GMT

What about that Christmas Pudding. Are not all those raisins and sultanas packed in there toxic to dogs and maybe cause haemmorrhagic inflammation?

I realise this seems to have been eaten after the signs started but a bit odd if given as a recovery-type diet??

RE: Melaena - the next step?

Anthony Todd — Mon, 22 Feb 2021 15:20:19 GMT

This is, IMHO, the biggest change in vet practice since I retired and is why there are hardly any "retired" vets posting on here, which is sad and not really helping .

I wish more dinovets would come on here!

I, and most of my comtemps, never mentioned or thought of money when diagnosing a presented patient and we only recommended what was necessary and essential which, it must be said, would have benefited sometimes, but not all times, from the "toys" now available.

How often on this forum is lack of funds mentioned, sometimes almost as a diagnosis, usually as a reason,

I keep asking for "hit rates" after testing ie [from which a firm, helpful, diagnosis can proceed to treatment] but hardly ever, if ever, get a reply.

Often vets post, "bo money so no tests" so no diagnosis so [of course] no treatment where a silly example like "B12 and betsolan" certainly seemed to help an awful lot of vague signs and symptoms....

Finally, too late for me, but let us know!!! I can't learn but others will!!

RE: Melaena - the next step?

Clive Ansell — Mon, 22 Feb 2021 09:23:40 GMT

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228698#228698"]I can see lots of possibilities here, none are definitive[/quote]

Yep, no right or wrong answers really, and depends on many factors mostly finances

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228698#228698"] Personally I think a referral would be a good idea, not least because they have a bigger selection of toys.[/quote]

In most of the practices I work, that are in poorer areas, this isn't an option I usually have.

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228698#228698"]an ex-lap is an option in my opinion[/quote]

Agree entirely, and I've done many.

RE: Melaena - the next step?

Neil Wheadon — Sun, 21 Feb 2021 23:42:24 GMT

Thankyou everyone

I can see lots of possibilities here, none are definitive

I'll have a chat with the client and see where we go with this. Personally I think a referral would be a good idea, not least because they have a bigger selection of toys.

Without wanting to fuel a fire here, in a client with limited funds, an ex-lap is an option in my opinion

Neil

I'll follow this up as this is a regular practice

RE: Melaena - the next step?

Anthony Todd — Sun, 21 Feb 2021 12:58:36 GMT

[quote userid="10320" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228688#228688"]there isn't necessarily anything wrong with an early ex-lap[/quote]

And there isn't much post-op pain with a negative either. and you can then be very sure too.

"25% is way too high, IMHO, but someone thinks it is better to be very sure than very sorry..

I'm out.

RE: Melaena - the next step?

Lucy Fleming — Sun, 21 Feb 2021 11:45:31 GMT

[quote userid="5904" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228679#228679"]An ex-lap is not a very high risk procedure![/quote]

Not necessarily, but it isn't without risk (more so if enterotomy/ enterectomy carried out) and it's also relatively invasive and will result in significant post-operative discomfort, and relatively high cost compared to most other investigations. Obviously not a high cost if you manage to diagnose (and even better, cure) the presenting problem, but a fairly high cost in the owner's eyes if nothing much is gained.

They absolutely have their place, and there isn't necessarily anything wrong with an early ex-lap (you'll note no-one in the thread suggested that), depending on your clinical suspicions, but equally not something to rush to without consideration of whether you can achieve the same (or a better) result by a different means. I remember seeing a comment from a surgical specialist on a different disucssion board that if you weren't getting about 25% negative explores, then you weren't doing enough abdominal explorations. I'm not sure those figures would quite sit right with me - if I'm going to take an animal to surgery I'd like a better idea that I'm going to get a useful outcome, not either find nothing at all, or find something that is completely out of the realm of my surgical skills to manage.

Anyway, to avoid this thread going in the same direction of so many before, I'll not get further into this discussion again...

RE: Melaena - the next step?

Marianne Thomas — Sat, 20 Feb 2021 21:52:16 GMT

This makes sense.

Would the client go for chemo if it was an option? If no, you've got far less to lose by trying conservative management. If yes, that suggests to me they can afford referral for (perhaps) endoscopic biopsy? I always tell clients referral has the best chance of a successful outcome without invasive procedures, but can end up with the same outcome as in house, & with covid travel there's an extra complication

RE: Melaena - the next step?

Anthony Todd — Sat, 20 Feb 2021 19:18:07 GMT

[quote userid="5012" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228676#228676"]Would you have done an ex-lap without any imaging, back in the day?[/quote]

Yes, and apart from the fact that there was no imaging, [apart from a usually inconclusive X-ray , in most cases], delay might be fatal and certainly not

helpful. This is the query FB/melaenia case,I assume??

An ex-lap is not a very high risk procedure!

I keep requesting "hit-rates" for [usually inconclusive] bloods or imaging, the whippet for spay is a classic example!

.I wouldn't demur if someone, sooner or later, would quote a case which was ONLy diagnosed by a routine blood/scan/Xray in a normal animal but not many/any? so far.....

There must be some stats somewhere of significant parameters discovered on routine bloods in "normal" "healthy" animals??

RE: Melaena - the next step?

Clive Ansell — Sat, 20 Feb 2021 18:11:43 GMT

In my regular practices, most clients are limited financially and don't have insurance. Therefore my default approach would be keep it simple and step by step. I would image in house to start with; rads and US scan, endoscopy if available.

Depending on findings may then advise ex-lap, or referral.

One of the last medicine cases I referred, hepatic disease, was £3500 for investigation alone without any treatment. Many of the clients I see, go into to debt to but groceries.

RE: Melaena - the next step?

Clive Ansell — Sat, 20 Feb 2021 17:58:34 GMT

[quote userid="5904" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228648#228648"]Back in the day the now scorned ex lap would give the most answers quickest. and cheapest and the most comprehensive.[/quote]

Would you have done an ex-lap without any imaging, back in the day?

RE: Melaena - the next step?

Lucy Fleming — Fri, 19 Feb 2021 16:54:07 GMT

[quote userid="5904" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228654#228654"]Or you could just use the Mk 1 eyeball when you exteriorise the the gut and look at all the organs, peritoneum etc.[/quote]

Yes, definite benefit of ex-lap over endoscopy. However, mucosal disease causing bleeding might not necessarily be "visible" or even palpable from the mucosal surface of the GI tract seen at ex-lap. That would be where endoscopy would hold the advantage. If disease/ lesions are patchy then biopsies taken "blindly" at ex-lap might miss them.

RE: Melaena - the next step?

Anthony Todd — Fri, 19 Feb 2021 16:49:39 GMT

[quote userid="10320" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29678/melaena---the-next-step/228653#228653"]It still might very well, provided whatever is in there is large/ solid enough to be palpated and located externally and then dealt with.[/quote]

Or you could just use the Mk 1 eyeball when you exteriorise the gut and look at all the organs, peritoneum etc.

You can be pretty sure you aren't missing anything you can do something about too.

RE: Melaena - the next step?

Lucy Fleming — Fri, 19 Feb 2021 16:40:52 GMT

It still might very well, provided whatever is in there is large/ solid enough to be palpated and located externally and then dealt with.

A more diffuse enteropathy might not be palpable/ detectable externally, but appropriate biopsies taken at ex lap should find it, but for that GI scope and biopsies might be another option.

Ultrasound might locate "something" and possibly allow for FNA sampling of that "something" but may not give loads more information.

I'd be inclined towards scope if possible, or ex-lap, or possibly gastroprotectants and maybe a hydrolysed diet and wait, but there probably is a risk of the wheels falling off with the latter approach.

RE: Melaena - the next step?

Anthony Todd — Fri, 19 Feb 2021 15:46:51 GMT

Back in the day the now scorned ex lap would give the most answers quickest. and cheapest and the most comprehensive.

Probably if anything could be done it would be and any histo taken.

But I remember my colleague and great neigbour, T H, in hospital with severe abdominal pain relating his anguished cry "can't you open me up or something!"

"Oh, your not sick enough for that" was the doctor's reply"

"How sick do you have to be?" Tony groaned!

And, to be honest, he did recover and didn't have an ex-lap..... but 99/100.....

RE: Melaena - the next step?

Clive Ansell — Fri, 19 Feb 2021 14:59:07 GMT

Depends very much on client and finances I guess.

Given the history, could be ulceration/erosion? but being a Boxer neoplasia would be high on my ddx list.

Options:

treat conservatively, antacids, protectants etc, then reasses
imaging in house within the limitations of first opinion practice x-ray/US/endoscopy. may or may not be helpful.
referral