Wednesday, July 20, 2011

Them bones, them bones...

I had an ultimately unrewarding and very sad case this past weekend/early week that has left me questioning my medical decisions and management.

Over the weekend, I was presented with a 10 year old, female spayed sighthound breed named Lori. She had been fine that morning. She ate her breakfast, went for a walk, and seemed normal. Then she became restless, needed to go outside frequently. The owners walked her and noticed that she seemed to be straining. They thought she was straining to urinate. She would not rest. So they brought her to us.

On physical exam, she was a fit dog. Vitals were totally normal. The only significant finding was a very, very painful caudal abdomen. I could not feel her bladder she was so painful and tense. My initial thoughts were urinary tract infection, bladder stones, or bladder cancer of some sort. I recommended a urinalysis and xrays of the abdomen.

Urinalysis showed absolutely nothing. Xrays, on the other hand, were quite interesting. Lori's small intestines were massively dilated. The radiologist (and I) thought she was suffering some sort of obstruction. But what? She wasn't a chewer, she had no evidence of what was obstructing her bowel? Bloodwork and vitals were totally normal.

Based on the xrays, I recommended exploratory surgery. We discussed that we could wait, try IV fluids, pain medications, and simethicone for gas, but since Lori was currently so stable, the owners wanted to proceed with ex-lap. I agreed with this decision.

What I found was so out of the realm of my experience that I was forced to call in an older, much more experienced veterinarian. In the middle of Lori's small intestine was a 1.5 foot section of massively dilated bowel. It was healthy, it was pink, and it had normal peristalsis. It ended in a blind sac (a diverticulum)! Out of the diverticulum came normal intestines, continuing on their merry way. It all looked healthy and like it had been present Lori's whole life. I had never seen anything like it.

After much discussion with the other doctor and weighing of pros/cons and other options, I elected to remove this area of intestines and send it for histopathology. I carefully anastamosed the ends of the jejunum together and patched them with omentum.

Lori recovered well from surgery. She was awake and alert within about 40 minutes. She spent the night with us and went to her veterinarian the next morning, doing well.

The rest is to be continued...


ellipsisknits said...

I'm having trouble picturing what you describe.

Do you mean there was a blind alley coming out the middle of normal intestines like a 'T' (or, I suppose, an extra appendix), or that there was a point where the intestines had just grown closed completely, so nothing could get from point a to point b via any path?

Either way, it sounds profoundly weird. I'm very curious for part two.

Elizabeth said...

always leaving them wanting more...