Thursday, March 12, 2009


every now and then i have one of those cases where i'm left slack-jawed with amazement at what transpires. last night was one such case.

the patient was a beautiful, sweet-natured intact female pit bull. her owner said that at 1pm, she'd been totally normal. she'd gone from that to lethargic, depressed, and dehydrated. he had fed her a giant ham bone with a TON of ham left on the bone itself. while with my technician, she vomited a massive amount of frothy fluid filled with ham.

my physical exam revealed a small amount of bloody feces with bony fragments, fairly significant dehydration, a mildly subnormal temperature (98.8), and screaming abdominal pain. when i tried to palpate her belly, she yelped and tried to bite.

i discussed my concerns with the owner: pancreatitis, foreign body obstruction with the bone, etc. i recommended bloodwork and xrays, which he agreed to do. bloodwork was absolutely normal other than evidence of dehydration (elevated PCV). xrays were more interesting. all of the intestines were shoved into the cranial abdomen, being displaced by a large, soft tissue density object taking up the mid and caudal abdomen. gas opacities were contained within this mass.

i sent the rads to the radiologist for review, and then whisked the dog to ultrasound. i was disturbed to find 2 things i could not explain: MASSIVELY (golf ball sized) dilated intestinal loops and free fluid in the abdomen. it wasn't a ton, but it was definitely there and worrying me.

in the meantime, my xray report had come back - and the radiologist called it a pyometra. this set off warning bells. pyometras are infections of the uterus (the uterus fills up with pus). it starts about 3 weeks after the end of a heat cycle usually. it didn't fit for my pit bull. she'd only been out of heat for a week, she was only 2 (usually a disease of older dogs), she didn't have vulvar discharge, and a host of other things!

i went to the owner with the recommendation that we go to surgery immediately to find out exactly what was going on in that nasty looking abdomen. he agreed reluctantly and to surgery we went.

as i made my nick through the linea alba into the abdomen, a smell came wafting out. it was the smell of rotting. NEVER a good sign. as i enlarged my abdominal incision, i saw something purple-black pushing up out of the abdomen. as i opened it up, i realized what i was seeing. dead intestines. lots and lots and lots and lots of dead intestine. i carefully packed off the abdomen and then pulled the GI tract out. to my amazement, i was looked at a mesenteric rent and small intestinal torsion. that means that for some odd reason, there was a hole in the fat that surrounds and cushions the intestines. the intestines themselves had moved through this hole. once through, they had squeezed and peristalsed and become completely 360 degrees rotated - cutting them off from their blood supply. as a result, they had died.

this was no "cut out an inch of dead intestine and attach the ends of the healthy stuff." greater than 3/4ths of the small intestine was completely dead. there was no fixing it. sure, i could have cut it out - leaving the dog with less than 1/4th of normal small intestinal absorption space...but she would have suffered from short bowel syndrome (inability to absorb nutrients and water from the intestines), she likely would have become septic (or already was), and all other kinds of complications. i gave her owners a prognosis of <10% for survival and quality of life, as well as several more days in the hospital, and an estimate of $3000-5000 for her care.

i euthanized her on the table.

her owners were distraught, obviously - and kept asking me was it something that they had done. explaining to them that the cause couldn't be elucidated was difficult. it was a very sad, very random case. a perfectly healthy happy dog, playing with her ball only 12 hours ago...

i think i'm going to try and write this up as a case report - that's how weird it was.