Friday, August 29, 2008

not such a useless surgery?

on sunday night, i was presented with a 2 year old dog that had sudden onset of vomiting and diarrhea. she had incredibly bloody, watery diarrhea leaking out of her, as well as intractable vomiting. the owners reported that she had been vomiting all day and couldn't even hold down water.

on my physical exam, she was depressed and significantly dehydrated, as well as painful in her abdomen. i couldn't find anything else of note. i discussed with the owners the full panel of diagnostics that we usually recommend in these cases: bloodwork, xrays (to insure that no foreign body was ingested), and hospitalization for treatment. after giving them the V and D spiel, i told them that honestly, i expected her to be a simple case of gastroenteritis. i recommended running bloodwork and treating the symptoms. if she responded - great. if not, we could proceed with xrays.

the owners agreed to my estimate (for bloodwork and 1-2 nights hospitalization) of $600-800. i whisked the patient off to the back. bloodwork was pristine, other than mild signs of inflammation on the CBC. i started her on anti-emetics and high dose fluid therapy.

i monitored her all night, and she never really responded as i would have liked her to. she continued to be dehydrated, despite heavy rehydration efforts. she continued to be nauseated, despite injectable anti-emetic (Cerenia) and Reglan in her fluid bag.

when i left that morning, i told the day clinician that xrays were probably warranted to ensure that there was no obstruction.

i came back that evening to the dog being prepped for surgery. a barium study was done by my colleague, showing gastric obstruction. without questioning this, i gloved up and went to surgery, expecting to find a wad of plastic blocking the pylorus. no luck. there was no obstruction, in the stomach or elsewhere. i took biopsies of the stomach and the intestines (which were not moving and looked angry) and closed her back up - crossing my fingers as i did so. cutting a piece out of the intestines and suturing it back together always scares me...

and then the news came back to me. i glanced at the xrays. they had showed nothing significant, so a barium study was done. a barium study is conducted using a radio-opaque dye that is put is force fed to the animal. when xrays are taken, it shows up incredibly bright white. it takes the stomach about 4 hours (in a normal animal) to empty. for some reason, the study on this dog was done in 1 hour - and a gastric obstruction assumed because the barium didn't leave the stomach. but that was normal, i realized - far too late to stop from going to surgery, obviously.

when the owner realized where the bill was (on top of having an incorrectly done barium study, she was also GROSSLY underquoted for surgery) - she politely told me that she couldn't pay for it. i understood her frustration. obviously, i deducted the barium study, as it was done wrong. i messed around with other figures, and we eventually came to a settlement on what her bill was. still $500 more than she had expected.

and then i spent the next 2 days beating myself up for doing a needless surgery.

and then my biopsies came back. IBD (inflammatory bowel disease). IBD is an idiopathic (don't know what causes it) disease of cats and dogs in which the intestines become infiltrated with white blood cells like plasma cell and lymphocytes. these set up a nasty inflammatory reaction and lead to the clinical signs of abdominal discomfort, vomiting, and diarrhea. treatment is varied from dietary changes to a novel protein source like kangaroo or duck or rabbit (some people theorize that underlying food allergies cause this disease) to things like steroids and probiotics.

wow. my biopsies were actually useful. my patient was treated and placed on a new diet and sent home.

seems my surgery wasn't quite so useless (thankfully).


Tayaki said...
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Tayaki said...

as always, thank you so much for posting some of your cases. i hope that you're remaining strong and aren't beating yourself up about mistakes that i'm sure *anyone* can make. i'm glad that you were able to find out about the IBD. hang in there, and again, thanks for posting. it definitely keeps me sane when i have to face hours upon hours of studying in the library. :)