Your Pet's Best Friend

The case of the dog who ate the non-food item.

Eating non-food items is a big problem in pets.  It happens so often that I am amazed at how seldom I have to do surgery to remedy the situation.  Frequently the animal vomits up the item.  Sometimes it passes all the way through.

In September, we were all set to do surgery for an intestinal blockage on a young Saint Bernard.  She had eaten very little food for the past 3 weeks, and had lost 25 percent of her body weight.  I could feel a mass in her abdomen.  The night before her operation, she passed a pair of underpants she had eaten weeks earlier.  Her recovery was uneventful after that.

The most dangerous are items that lodge in mid-intestine, as they are more likely to perforate the bowel, and that is bad news.

Items that sit in the stomach can cause intermittent problems depending on where they lodge.  That's what happened to this little gal (pictured in recovery, post-op).  She had been having problems for 5 days.  At night, she vomited and felt terrible.  The next morning, she seemed fine, ate, drank, kept it down.

On Friday evening, she vomited up some pieces of plastic flower she had consumed at some unknown time.  "She just chews on everything!"  I couldn't help thinking that maybe we need to "pick up everything off the floor". 

Taking an X-ray to look for foreign objects is usually unrewarding, as most of them are not dense enough to be seen.  This is certainly true for plastic.  However, sometimes you can see a flat piece of plastic if you catch it edge-on.  This makes it very thick, as far as the X-ray is concerned, and that's what we see here.  At left is a close-up view of the top picture. There is a white line that is lying flat over the exit valve from the stomach, like a closed door.  Stuff can't pass through, so the dog vomits and feels bad.

The next morning, she feels fine.  The new X-ray (on the right) now shows the white line in a different position.  The foreign object has moved, and the "door is open".  We can't tell what the object is, but we know something is in there.

I had hoped we might be able to retrieve it with the endoscope, using a grasping forceps. There were several long strips of plastic, and we were able to grab these, like so.

Unfortunately, the plastic leaf that was the "door" had become embedded in the exit, and we could not grasp it through the scope.  She wound up having to have surgery after all.

Her prognosis is great, provided she can limit her future intake to food.

Systemic Fungus Infections

What is wrong with this kitten? How did she get this classic "Roman Nose" profile?  She wasn't born with it.  She has an infection called Histoplasmosis, a systemic fungus.

Most folks have heard of "toe-nail fungus" or "athlete's foot" or ringworm. These are fungus infections  of the skin, and they don't go deep into the body.  They are very unlikely to affect any internal organs, or make you sick.  You just get funky-looking itchy places.

Systemic fungus infections are very dangerous indeed.  In our area, the two most common are Histoplasmosis and Blastomycosis.  We are in an endemic area for both (meaning that the fungus is widespread and it's been here for a long time, and it's not going away).

The fungal spores live a very long time in the soil, and it's not really possible to get rid of them.  A specialist once told me that you would have to soak your yard six inches deep with formaldehyde.  Even supposing you were willing and able to do this, it would kill everything in your yard, plus it would be illegal. The stuff is dangerous.  The Department of Natural Resources and the Environmental Protection Agency would be all over you.  So, that's not happening. 

Fortunately, the spores rarely grow into the lifestage of the fungus that is infectious.  We're not sure what stimulates the Blastomyces fungus.  We just know that it thrives in swampy soil.  For us, that means anyplace you could drive to in an hour.  I've seen cases even from high, well-drained sandy areas in southeast Missouri.  Still swampy enough, apparently.

Histoplasma spores are fertilized by bird manure.  Beware of starling roosts, chicken houses, and so forth. If your yard looks like this car, be careful.  If you have to clean up such a place, be sure to wear a respirator so you don't inhale any of the dust. 

I have been told by public health authorities that most people in my area have had enough exposure to this that you can find they have some immunity if you blood-test them.  It may not be enough to overcome massive exposure, though.  Wear that respirator.

Even though the Histoplasma fungus is extremely common in our soil, I rarely see cases of it -- less than half a dozen in over 30 years.  Blastomycosis, on the other hand, we see several times each year.

Both germs can affect lungs, lymph nodes, skin, intestinal tract, even the bones and eyeballs.  Really, the fungus can go about anywhere inthe body.  We suspect a systemic fungus when an infection doesn't respond to antibiotics, as we would expect a bacterial infection to do.

There are certain patterns that develop on the chest X-ray that are more common with a fungus-caused pneumonia than with bacteria or viruses.

 Sometimes you can find the organism in pus if you have an open sore place on the skin. On the left, you see Blastomyces,which looks pretty big next to these white blood cells around it.  It's the double-walled, budding yeast. 

On the right, you see Histoplasma organisms, which in this photo are actually within big white blood cells called macrophages that are trying to eat them and kill them.

In this little kitten's case, we were able to find it when we drew some cells out of a swollen lymph node. Our sample looked a lot like the pictue.   More frequently, you cannot find the organism, so you want to test for it. 

In years past (and sometimes now), we sent out blood samples.  Unfortunately, these often give false negative tests in the early course of the disease.  Now there is a test for the fungus antigens (microscopic pieces of the fungus itself) that uses urine specimens.  Surprisingly, this is more sensitive and more accurate as a general rule.  We send them to MiraVista Labs.

Our patient started out with the swollen nose, and little sore nodules on her eyelids. At first, antibiotics seemed to help, then things got worse, and the lymph nodes began to swell.  We suspected systemic fungus and knew we had something suspicious in those cells from the lymph node.  Treatment with itraconazole was started right away, and we soon had confirmation of Histoplasmosis from the University of Missouri Clinical Pathology laboratory.

This patient has no history of exposure to the bird manure, and she tested negative for the immunosuppressive diseases we see in cats (Feline Leukemia virus and Feline Immunodeficiency virus).  She was very small for her age,  however, so her body defenses may not be all they should be.  So far, she seems to be responding well to treatment.

Even with the right medicine,  it takes two months or more of treatment to eliminate the infection.   With a two-pound kitten like this, that's not so bad.  With an 80-pound Labrador, it is VERY expensive.

It is also possible to become re-infected down the line, so these are really bad diseases.  When they get into the eye, that eye is usually lost. If a testicle is affected, surgical removal is indicated.  Bad stuff.

Fortunately, though the micro-organism is very common in our soil, the infections are rare.  They are best treated as early as possible when they do occur.  If your pet has a persistent infection that doesn't seem to be responding to antibiotics, it's time to consider the possibility of a systemic fungus.

 

 

Big Bladder Stone

 I’ve posted a case like this in the past, but it never ceases to amaze me.  This dog doesn’t look like she feels very happy, and that’s accurate.

“She doesn’t feel very good.   She has to go out a lot, and she’s drinking a lot of water. I think I saw some blood in her urine.”  How long has that been going on?  “Just a couple of days.” 

She is an older female that has never been spayed, so I’m worried about the possibility of a uterine infection.  The first test I want is an abdominal ultrasound.  I really want to get a look at that uterus. 

The uterus looks okay, but there’s this huge acoustic shadow from the bladder makes it hard to get a good look at the uterus.  It takes a minute for me to shift my point of view from this huge shadow being “in my way” to it being “the thing I’m looking for”.  That’s what a huge bladder stone looks like on an ultrasound, because it doesn’t let any sound waves through.

I took an X-ray to get a better look at it.  Wowsers! That’s a big one.  Not only that, but if you look closely you can actually the bladder wall.  It is so thick from chronic inflammation that you can see it on the X-ray.  Normally, you just see a silhouette of the bladder.

The only remedy for this situation is surgery, which is usually pretty straightforward.  Any surgery can have complications, but these usually do quite well.

So here’s the weird thing: this dog has only been showing outward signs noticeable to the owner for a couple of days.  You can see that this thing is pretty doggone big, and very rough.  It looks like a whole bunch of tiny stones packed together, which is what it is.  These are struvite stones (calcium magnesium phosphate) and in dogs they occur secondary to bladder infections.  Something like that takes months to form.

You might say that this dog’s owner just couldn’t have been paying any attention to the dog or he would have noticed this a long time ago.  I might say that, too, except that I have run into this several times before, and with clients that I knew well – people who do NOT ignore their pets.  I don’t know how it can happen that such a long term problem shows no outward signs, but sometimes it does. 

Bottom line, when you first notice that your pet is having problems, it may not necessarily be something that is just starting.  Maybe instead of “watching it for a few days” you need to get it checked out as soon as you can.

Sometimes the very best care is not enough.

We can do so many wonderful things with medicine and surgery that we begin to think we can fix anything.  If we just do the right thing, make the right choices, do the right tests, perform the right treatments, we can make the patient well again.

Well, doing the right thing is certainly better than doing the wrong thing.  It makes me think of the Mad Hatter and the March Hare in "Alice in Wonderland".  They have used butter in an attempt to lubricate a pocket-watch.  Their results are not good, even though "it was the best butter".  They did their best, but it was the wrong thing to do.

Then we have cases like the one I had this week.  We did everything right, but it wasn't good enough.

The kitten came in just not acting right, not wanting to eat much.  He had shown no specific signs of illness, but hadn't felt well for two days.  His temperature was slightly elevated, but nothing to write home about.  Then I felt what I was sure must be the problem: a mass in the middle of his abdomen.  It was nearly two inches thick, and it was in a place where there shouldn't have been any big lumps.

An X-ray confirmed that all the normal stuff was in the normal places, so this was definitely something that shouldn't be there.  With a kitten at Christmas time, and such vague symptoms, and not wanting to eat, and an abnormal "thing" in the belly, I thought I had it figured out.  He must have eaten some non-food item (tinsel, anyone?) and developed an intestinal blockage.  Nothing for it now but an exploratory surgery to fix things.

The thing about an exploratory surgery is this: by definition, you are going exploring, which is to say you are going into unknown territory to find out what is there.  The exploratory was definitely the right thing to do, but I didn't find what I expected.

The big lump was a hugely swollen lymph node.  It was as big as as a hen's egg, when it should have been about the size of a black-eyed pea.  It appeared to be reacting to a marble-sized, angry-looking red lump on a section of small intestine.  There was no way to peel off the lump and be sure to get it all without making a hole in the intestine.

So, I removed a short section of intestine, and I also took a biopsy of the lymph node.  We put the intestine back together and put the cat back together, and started on some heavy-duty antibiotics and supportive therapy.  The lumps went to the pathology laboratory via FedEx within two hours.

The next day, the kitty had some fever, but was eating and looking better and acting better.  Sweet.  We don't want to get in a hurry to send him home, yet, though.  Got to be sure he keeps eating and keeps it down.  AND we want to know what the lump was.

I'm thinking that a six-months old kitten is unlikely to have cancer (though St. Jude's Hospital is full of kids with cancer).  Maybe there was some tiny perforation of the bowel, and the body was trying to wall it off.  That ought to be fixed.

The kitten seemed to continue his recovery over the next couple of days. The fever came down, and the lump in the belly was getting smaller.  I'm feeling great about this.  Then the pathology results come back.

The pathologist says that the most likely diagnosis is FIP.  That's bad, no treatment, gonna die.  Could it be something else?  The internist says, yes, it might be just what I had suspected... or not.  A more definitive test can be done on the tissue, so I order it.

The kitten goes home with mom and dad. He ought to feel better, but he doesn't.  The next morning they call to tell me kitty took a nose-dive during the night.  On presentation, he's starting to turn yellow - liver failing.  He's breathing hard.  X-rays show pneumonia.  He didn't have those problems before, but he's got them now. 

His immune system is shot.  It was FIP after all, and it was killing him.

If you clicked on the FIP link, you know that there's not much we can do to prevent it, treat it, or even detect it accurately (while the patient is still alive, that is).

The owners didn't waste any time, we didn't waste any time here, the kitten would have had the same treatment at a referral institution.  We did everything right, and the patient was still lost.

We can do so much, but sometimes, the best we have is not enough.

Consulting a Specialist

My tag-line that follows my signature on Veterinary Information Network is “I’m lost, but I’m making good time.” When I am putting a puzzling case up for consultation, I have already done one of two things.  One is, I’ve done everything I know how to do, and I’m still stumped.  The second is, I’ve reached a crossroads in the diagnostic plan and I don’t want to put the patient through unnecessary testing. Therefore, I want some input into the best choice as I proceed.

After thirty-four years of doing this, I’m able to handle the majority of cases that walk through my door.  On the other hand, I certainly still have not “seen it all” (and majority means “more than half”).  Of course, it’s impossible to have the expert knowledge of a specialist in every field.  There are no “experts on everything”, though are some people who have that opinion of themselves.

Some things seem obvious.  If I have a terrible eye problem, I want to see an ophthalmologist. 

Some are not so obvious.  If I go to my primary care doctor because I feel bad, I expect him to examine me and make a diagnosis that will enable effective treatment.  When the physical exam and history don’t give him enough information to make the diagnosis, I expect him to perform diagnostic testing.   

If he still doesn’t know what is going on, I expect him to refer me to someone with more specialized expertise.  I really don’t want him to just spitball it and prescribe some medicine just to get me out of the office.

While we are told that seventy percent of our patients will get well if we can manage not to screw them up (i.e. they don’t really need us), still there are those thirty percent that need help.  If I’m one of those, I want the level of help that I need.

For the first two decades of my professional career, I didn’t have the option to refer many patients.  The nearest referral specialists were at the veterinary teaching hospital at the University of Missouri – three hundred miles away.  Most of my clients couldn’t or wouldn’t make the trip.  “What can you do here?”  Well, I can do my best, but I don’t have the expertise and equipment of the specialists who are teaching at the veterinary school. 

Because of this, I attempted procedures that I would rather have referred.  Sometimes they turned out very well, and I learned some techniques that I never would have tried, had the referral option been available.  Of course, sometimes they didn’t turn out so well, but with euthanasia being the only alternative, we gave it a shot.

I generally try to avoid catch-phrases like “paradigm shift”.  So I won’t say that.  I will say that today’s new veterinarians have a completely different mindset about the general practitioner’s scope of practice than we did, lo, these many years ago.

Back when dinosaurs walked the earth, a veterinarian was more or less expected to do it all.  Come in from delivering a calf by C-section, diagnose a horse’s lameness problem, then perform orthopedic surgery to fix a dog’s fractured leg.  I have known many veterinarians who did all that.  Some managed to be better than good at all of it.  Most had their areas of strength and weakness, and eventually  would shift their activities to their strengths.  The problem was, you might be the only game in town.  If you tell people that you aren’t a good man for their problem, you need to have a name for them to call.  When that was not the case, you just had to be honest and say, “This is really not the best way to handle this case, but it is all I have to offer you.  The animal really needs…”

The important thing was to do your best and be honest with the client.  That hasn’t changed.  What has changed is the increased availability of specialists, and the increased availability of attorneys. 

Today’s veterinary students are encouraged to refer anything complicated to a specialist.  The problem is the definition of “complicated”.  Where do you draw the line?  When do you learn some new skill?

A new veterinarian has some of the same problems I did.  Every case you see is your first one.  I was on the phone back to my professors almost every day when I first got out on my own.  The new generation also has the specter of being admonished to offer referral for almost EVERYTHING, lest one be liable for a malpractice suit.  The faculty put the fear of God into them on this subject.

I’m fortunate to have a group of referral specialists only ONE hundred miles away now, and they are some really good doctors.  Still, they are a hundred miles away, and they aren’t cheap.  That means that for many complicated cases, I can’t put the monkey on somebody else’s back.  I’m still in the position of having to do my best right here. 

There is hardly a week that goes by that I am not emailing or telephoning more than one specialist about my cases.  When I have reached my limitations, I know it, and I do my best to get more help for my patients.

What brings this subject to mind was an interesting experience I had this past week.  I was called to testify in a neglect case involving an apparently starving horse.  The horse was emaciated and very weak.  It looked like a skeleton with skin. The owner had sought no medical attention for the horse, and stated that he STILL would not have done so, if not for pressure from the Sheriff’s department.

Now there are only two basic things that can be going on here.  Either the horse didn’t get enough nutritious food, or it had such a severe medical problem that the food could not be utilized. This is not rocket science.  In either case, the horse’s care has been neglected.  It’s a no-brainer.

In court, the defendant objected to my being called as a witness because I am not a specialist in equine medicine.  He had been looking at my website and blog and found “my own admission” that I often consulted specialists when I had a case beyond my expertise.  In his mind, that makes me unqualified.

By contrast, his defense was “I’ve done everything I know how to do, but the horse just keeps losing weight.”  He did NOT seek help or advice, despite the obviously deteriorating situation.  He just kept on doing “everything he knew how to do”, even though it was not working.

If he had spent half as much time researching how to care for his horse as he had on trying to undermine my credibility, he wouldn’t have been in court in the first place.

When your veterinarian says that he (or she) needs to consult a specialist, or wants to refer you to a specialist, I see that as the mark of a responsible doctor, not a declaration of incompetence.  If I need a cardiac bypass, I don’t want my family doctor to learn on me.

Side note:  The horse was confiscated and has been gaining weight, and is feeling much better since getting adequate feed in the last two week.  There is good reason to hope for a happy ending here.

Removing Painful Teeth is Worth the Trouble

I got excited this week.  I got excited because I got the opportunity to fix something that really needed fixing.  You might think that happens all the time, but you don't always see such a great opportunity to handle a painful situation in such a rapid fashion.

This is Dawson.  When his loving owner "inherited" him three years ago, she asked her regular veterinarian about what she could do to help his awful mouth odor.  Unfortunately, that doctor mis-estimated a couple of things:  the owner's commitment to caring for the pet, and how long this dog would live. 

Mama was told that Dawson was too old to anesthetize, and the other doctor periodically prescribed antibiotics to "control the infection".

We saw him on Thursday.  You could smell his mouth across the room.  He was in constant pain, whining, rubbing his mouth, and at last he was hurting badly enough to  quit eating.  "I just have to do something for him".  I felt the same way.  When I touched his mouth during the exam, he really cried.

Amazingly enough, Dawson hadn't gotten any younger in the last three years.  At fourteen, he's still "too old".  He's a little overweight, and you can hear some fine crackles (like emphysema) all over his lungs. 

The owner was happy to let me assess him for anesthetic risk factors.  His chest X-ray was actually pretty clear, no fluid in his lungs and only mild heart enlargement.  His blood chemistries were nearly normal.  His electrocardiogram was just fine.  I called the teaching hospital at the University of Missouri's veterinary college.  An anesthesiologist was happy to advise me about the best course for Dawson.

We set him up for oral surgery the next morning, and sent him home with pain medicine.  He got the best rest he'd had in weeks.

The next day Dawson was successfully anesthetized, meaning he slept through the procedure without evidence of pain, and he woke up again pretty quickly.  Having good monitoring equipment lets us know when he needs more support (which he didn't, much), and sevoflurane gas lets us adjust his anesthesia rapidly.

We removed these nasty snags and sutured up the gums.  He doesn't have a tooth in his head, but he doesn't need them to eat dog food.  He will need some additiona surgery to close up some old sockets that have been open for a long time.  For now, though, his constant pain has been relieved.  He's not too old for that.

 

Diagnostic Workup Success - that almost wasn't.

This is Molly.  A few days ago she was presented for an examination.  She had been limping a little the night before and just didn't feel well.

There was no lameness when she came in, but she didn't have much mojo.  She didn't seem in any distress really, just no energy.  She also had not wanted to eat much.  There was no fever, nothing seemed swollen or out of place, and I couldn't find a sore spot anywhere.

She lives in a fenced yard, so trauma didn't seem likely, even though she shares it with another pretty big dog.   There just wasn't really anything to put your finger on, but you could tell she was unhappy.

I was about to send her home with some anti-inflammatory medicine, thinking she might have slipped and made a bad landing in the mud the night before.  Then her owner said, "You know she usually chews on everything, but she doesn't want anything today."  I asked, "Everything, as in a lot of things that aren't food?"  She replied in the affirmative.

With that piece of information, I thought of all the dogs with foreign body intestinal blockages I have seen who had no specific outward signs -- they just didn't feel good. "Let's take an X-ray of that belly. We probably won't see anything, but I'd hate to miss a ridiculously obvious foreign object."  Okay, let's do it.

The abdominal X-ray looked normal, but there was a little bit of the chest on the film, too.  When I looked at the whole film, the chest part looked "funny" (funny-strange, not funny-haha).  We took pictures of the chest.

There was what appeared to be a significant amount of fluid in the chest.  That will make you feel bad.  We tapped her chest - it was blood.  Internal bleeding will also make you feel bad.  In your chest, it will squish your lungs and eventually keep you from breathing, even if you don't go into shock first.

Even though there was no history of exposure to rat-poison, we filled her full of vitamin-K (the antidote).  That stuff makes the dog a free bleeder, and bleeding into the chest (hemothorax) is not uncommon.  Since my associate is pretty knowledgeable in Chinese medicine, we also started the herbal preparation called Yunnan Baiyao, as it helps to get the body's own clotting mechanisms into high gear.

The alternatives to rat-poison were not happy ones: a bleeding tumor, some other abnormal structure that had begun to bleed, or some other heretofore unnoticed bleeding disorder in the dog.  All of those have a terrible prognosis, not to mention that referral to a surgical specialist was not in the cards.

Thankfully, Molly has responded well to treatment and seems about normal now.   Who takes a full set of X-rays every time a patient just "doesn't feel good"?  Nobody.  A chance remark, a look at the wrong place, and we got an accidental look at the right place.  And I almost sent her home with some pain-killers.  Serendipity, it's called.

Enlarged Spleen of the century

When a dog-owner calls and says that his dog is dribbling a little urine, you think of the usual suspects: weak bladder sphincter, bladder infection, bladder stones, neurological problems.  You do NOT think of an enlarged spleen.

Max (this is his post-surgery photo) is a Mastiff mix.  He's about 8 years old (a guess, as he was a stray originally), and usually weighs in the low 80's.  For several days, he had been dribbling a few drops of urine after he watered the shrubbery, even though he had a good stream when he let fly.  He had also leaked a puddle where he was lying down on a couple of occasions.

With that kind of history, I usually want a urine specimen first.  You usually need to culture the urine, so a voided sample is not good enough for that.  You just can't get an uncontaminated specimen when the dog pees in a cup.  What you need to do is a cystocentesis -- you lay him down on his back, do a surgical prep on his tummy, use the ultrasound to locate his bladder and insert a sterile needle.  Then you withdraw some urine with a syringe and you're ready to do your culture and urinalysis.  The specimen is not contaminated, and you don't have to follow the dog around the yard with a cup.

We lay Max down and scanned his bladder, and found that it was being compressed by a large mass of tissue. Further scanning showed this to be the tail of his spleen.  An X-ray confirmed that his very large spleen was extending from his stomach all the way back to his bladder.  It was so big and heavy that the weight of the organ was compressing the bladder and causing Max to leak urine.  Sort of like a lady with an advanced pregnancy -- when the baby is bouncing on your bladder, you can have an "accident".

Even in a very large dog like Max, the normal size of the spleen would be about one and one-half times the size of my hand -- ten inches long and 1/2 inch thick would be a big one.  This was just unreal.  [It's the long, curvy red spot in the diagram.]

Your first thought would be cancer, but the ultrasound scan showed no masses or changes in texture.  It just looked like a normal spleen... only huge.  And... why is that?   I sent out the usual panels of blood tests and they were all normal.

I spoke with an internist at the Veterinary Teaching Hospital at the University of Missouri and she said, "There is huge list of differential diagnoses."  So huge, apparently, that she just listed a few for me to get started with.  "Screen for tick-borne diseases". [We sent off the blood tests.]  

"It could just be twisted a little, or have a partial thrombus [blood clot] in the splenic vein." [Blood can get pumped in by the arteries, but can't get out as fast, so the spleen gets gradually bigger and bigger by being inflated with blood.] 

"You should still consider cancer.  Try aspirating the spleen." [Stick a needle in it and see what a syringe will suck up.] Since the spleen is structurally a big sponge full of blood, we'd probably just get blood cells, but she assured me it would be safe.  So I did.

"If you don't find anything on your tests, then you need to take a biopsy specimen.  Well, if you're going to do that, just take out the whole spleen." [You can live without it, if you have to.]

So, no tick-borne diseases.  The cytology report on my needle stick says "suspicious for lymphoma", but could just be some kind of inflammatory reaction.  With a needle aspirate, you're looking at individual cells and you don't see any kind of architecture.  It can be misleading.  And it was.

Next step:  exploratory surgery to remove the spleen.

His spleen was 28 inches long and weighed six and a half pounds.  It wasn't twisted.  It was a lot of work to get out.  This picture reminds me of people with their trophy fish.  In fact, I've seen plenty of trophy fish that weren't this big.  We sent several sections to the pathologist, and it's not cancerous. It's just "severely congested" (i.e. really overfilled with blood). 

It was so "over-inflated" with blood that wherever I bumped it with a finger it would break and start bleeding.  I didn't lose any blood from the major vessels as I tied them off, but the rest of it was bleeding like a cartoon character shot with a shotgun.  He was at no small  risk of the organ rupturing and having severe internal bleeding.

The good news is that his prognosis is good.  We still have to check a few things to look for reasons he might have had a blood clot in the first place, but no deal-breakers so far.  The first picture in the post shows him the day after surgery and he already felt better.  Nine days later he is recovering his energy level and seems to feel really good... and he's not wetting himself.

 

 

Mega-Esophagus and "The Third Opinion"

This is Bear.  He's nibbling at the grass here.  For over one year he has had frequent episodes of vomiting.  Sometimes it's just a little fluid, sometimes undigested food, sometimes a little grass, or a combination of the above.

He came to see us after having numerous unsatisfactory attempts at treatment.  "I'm here for a second opinion." Third, actually.  My associate spent a long time getting the past medical history, everything that has been tried and the results (or lack of them) of those efforts.  That's par for the course when you are giving a "second opinion".

The "second opinion" case is not something I really look forward to, at least not when something has been going on for a year.  This suggests that the problem is not simple nor straightforward, and it probably isn't going to "fix itself".  If any of those were the case, I wouldn't be seeing it. 

So, more often than not, you spend a long time extracting the history, and documenting it, and concluding that the other doctor has been very thorough and done everything you can think of and it did not work.  Oh, I can hardly wait to see one of these cases.  They really ought to be seeing a specialist, but they are seeing me instead.  Hard to be a hero on these.

Of course, sometimes you just have a different point of view than the other guy (gal).  After working with a case for a long time, you can get tunnel-vision.  You have made that initial assessment and it biases everything you do after that.  So, a fresh pair of eyes (and ears) sometimes has an easier time finding a fresh perspective on the case.

My associate started over with basic lab tests.  Some had been done before, some hadn't.  At any rate, we needed to see where Bear was at present.  We might get a clue. [In a referral situation, they recommend a "minimum database", which includes  a complete blood count, biochemistry profile of 12 to 20 tests, a stool exam and a urinalysis.]  In this case, there was nothing in the data to suggest a specific diagnosis.

Bear's owner said, "Just keep him a couple of days until you find out what it is. I'm tired of going round and round with this."  So now it's my turn. Hey, no pressure.

Ah, but here was that rare case.  There is a logical progression of diagnostic tests.  I can see what has already been done, I can see what hasn't worked.  I don't have to do any of that over again myself, and there is a clear next step.

Vomiting food that isn't digested.  Maybe it isn't even getting to the stomach.  "Have you tried feeding him with his dish elevated?  Does it make a difference?"  Well, yes they have, and maybe it does.

So, I take an X-ray of his chest.  You can't tell much about his esophagus, but his trachea (windpipe) looks pushed down out of place a little.  Then I mixed a little barium with some dog food and Bear scarfed it right down.

Now, your esophagus is firm, small, muscular tube (when it's normal).  It squeezes the food right on down to your stomach without the aid of gravity.  If you stand on your head, it squeezes the food right on up to your stomach when you swallow. [I tried that in seventh grade.  I used a pillow under my head, and leaned against a wall so I wouldn't fall, and I used a straw to drink the water.  It worked.]  The food goes right on down (or up) in a hurry.  Unless you have mega-esophagus.[Follow the link to a discussion on Veterinary Partner.]

Bear has mega-esophagus.  He's had it all along.  I found it with the first test I ran.  All that food should be in his stomach, not in his chest.  I look like a genius, but it's just the luck of the draw.  It's one of those rare occasions when being the "third opinion" doesn't turn out to be a major frustration.

Since Bear's esophagus is a big flabby sack (instead of a firm, muscular tube), and further testing shows no thyroid problems and no myasthenia gravis (possible causes), he will have to rely on gravity.  From now on, he gets to eat while standing on his hind legs.  Some fun, huh?  Too bad the "genius" can't cure what I diagnosed.

Diagnosing diabetes... among OTHER things.

Here's Mollie. [Sorry the photo is a little out of focus; our timeline got way out of hand and I didn't take time to check the picture before she left.] She's a complicated case and she got me to violate one of my basic rules, to wit: I'm a doctor for the whole patient, not just one complaint. 

By this I mean that each patient gets a complete physical exam and I try to get a complete medical history. I don't want a patient to come in with three problems and leave with two of them undetected. I didn't realize I was violating it when Mollie first came in, but I did it anyway.

I hadn't seen Mollie before and she had a number of complaints.  She is taking two medications for a seizure disorder (a long-term situation).  She has lost weight.  Her belly is kind of big. She has some lameness problems, which appear to be related to this lump on her left hind leg.  The lump was very hard, so we took this X-ray, and it is not pretty.  It's hard to say whether this is bone cancer or bone infection or what, but it's not pretty. With a possibly cancerous lump and weight loss, our next step was a chest X-ray.  If her lungs were already riddled with cancer, then our other testing would not be quite as important.

Fortunately, the chest X-rays looked great.  Next step would be to biopsy that lump.  PLUS, we really need to assess how the rest of the body is doing.  With that weight loss, other organs could be affected.  We need to X-ray the abdomen and get an ultra-sound scan. And, of course, we should really get some blood-work.  The owner looked at the estimate and decided she wanted the biopsy first and the rest could wait, and I acquiesced.

Now friends, I want to take time out to talk to you about what we call the "minimum database".  Actually, it's what the veterinary teaching hospital calls the "minimum database".  Any patient admitted will have a complete blood count, blood chemistry profile, urinalysis, and stool exam.  That might sound more like a "maximum database" instead of a "minimum database".  I certainly don't always have the opportunity to get all that information with every patient.  Of course, with a referral institution, with cases that have already been worked up elsewhere, you surely don't want to miss anything.  That's what makes this their "minimum database".  Let me repeat the key point here: you surely don't want to miss anything.

So, Mollie returns a few days later for her biopsy.  With her age and condition, I feel that we MUST get pre-anesthetic blood-work.  Just for the record, a blood sugar of 500 is not normal.  The dog has diabetes mellitus ("sugar diabetes").  We collected a urine specimen and it was full of sugar, and worse, full of ketones.  Ketones show up in urine when you've been breaking down fat excessively because you can't use the sugar (because you don't have adequate insulin production).  Too many ketones in the bloodstream can put you into a coma.  By the way, her urine also has a substantial amount of pus present.

Urinary tract infections are common in dogs with diabetes: their urine is full of sugar, and bacteria are happy to grow there.  Oddly enough, while the pet has a bladder infection, it is very hard to get their blood sugar regulated.  Thus we need to culture the urine so that we can treat the bladder infection, so that we can be successful in treating the diabetes.

One thing I didn't show you on Mollie's lab-work was her humongo high alkaline phosphatase.  That could be from liver problems, or from bone damage, or maybe even her seizure meds.  It could also be from Cushing's disease, where the adrenal glands overproduce cortisol (the body's natural form of cortisone).  That disease commonly accompanies diabetes mellitus, and it can cause a pendulous abdomen, due to muscle weakening.  Remember Mollie's big abdomen?

Both diseases cause excessive urine output (by different mechanisms), which requires that the dog drink a ton of water to compensate.  I called the owner to tell him about the diabetes and urinary tract infection, and possible Cushing's disease, and that we would be putting off the biopsy until the diabetes was under control.  By the way, had he noticed that she drinks a lot of water? "Oh, man, you can't keep enough water in front of her.  She drinks gallons of water.  She drinks an amazing amount of water."  Weight loss with a good appetite and excessive urination and water-drinking is classical for diabetes.

Now, why didn't I know this already?  Why didn't I find this out in my initial history-taking?  Because I became a "lump doctor" instead of a "dog doctor".  I looked at that lump, and that X-ray, and I tunnel-visioned in on that.  Sure, I recommended more complete diagnostics, but I was all about that cancer (that may or may not be there), and wasn't really looking for "everything".

Here are the hands of Mollie's owner, giving her the first injection of insulin (first of many to come). Her urine culture is at the lab, and she's taking antibiotics while we await the results.  When we get her diabetes under control, we'll get that biopsy, and then we'll look at the Cushing's disease.

The Take-Home Message:  When your veterinarian recommends what looks to you like a LOT of tests, it might be a good idea to go ahead and do it.  I wish I had.  Then I could be writing this and talking about how smart I am, instead of how I figured it out just in time (even though a little on the late side).