Tuesday, June 21, 2011

Letting out the evil vapors

The busy weekend continued with evaluation of "Gus," a 4 year old labrador, who had been vomiting and not eating for 3 days.  He was a typical lab, with a habit of eating anything not nailed down. He had been hospitalized for 24 hours, and was not improving; he had continued to vomit despite lack of food offered to him.  Radiographs from the previous day were suspicious, but not diagnostic for an obstruction.

I assessed Gus, and took him to the ultrasound for further investigation of his abdomen.  Ultrasound was overwhelmingly abnormal.  His loops of intestine were dilated with fluid, and sharp turns were noted, indicating a possible obstruction.  The actual item could not be visualized, but based on these findings, I recommended surgical exploratory.

His electrolytes were performed, and revealed a hypokalemic, hypochloremic metabolic alkalosis; classic for upper GI obstruction, (but also can occur in patients with frequent vomiting).

In Gus' case, the suspicion for a foreign object being lodged in his intestines was increased by his breed, his age, his history and lack of improvement despite therapy, as wells asthe results of radgiographs and ultrasound.  Surgical exploratory was the only way to be sure of the cause of Gus' illness, but in his case (and most others), there is always a risk of performing surgery, only to find nothing.  No obstruction, no foreign object, and no macroscopic reason for the pet's illness.  This is unbelievably frustrating for the client, given the expense of surgery, as well as the pain and recovery time associated with it.  It is also unbelievably frustrating for the veterinarian, who obviously wishes to perform surgery on all the right animals, and not perform surgery on those who don't need it.  On the other hand, the risk of NOT performing surgery on an animal with a GI obstruction is extreme; if the object remains lodged in the intestines, in can result in damage to the intestines, requiring portions to be removed, or in the most severe case,can cause rupture of the GI tract, and an overall much worse prognosis for recovery (or even death).

With these facts in mind, I discussed the recommendations' to Gus' family.  Surgical exploratory did have the small risk of anestheia, as well as the cost and associated healing time, however doing nothing could potentially result in significant worsening of his condition.  They wished to proceed with surgery, and so Gus was prepped for his surgical procedure.

Anesthesia was uneventful, and Gus' vitals all remained normal throught the procedure.  What I found at surgery, however, was just the frustrating finding I had hoped not to see; no foreign object, a negative explore.  Gus' stomach was filled with fluid, his intestines were dilated and had no normal movement, but there was no clear macroscopic reason for his illness.

Frustration washed over me as I evaluated the entire length of his GI tract again, just to be sure. Nothing. No rock, sock, string, or nylons to take out, and no clear reason why Gus had been feeling sick for three days.  The adage you learn in veterinary school is, "If you aren't doing any negative abdominal exploratories, then you aren't doing enough abdominal explores."  This comment, while true, is not comforting when you're staring into a dog's abdomen, wondering why you cut him open.......

The meaning of this comment is based in statistics.  I'll refrain from boring you with the mathematical details, but in summary:  The goal is to never miss a true foreign body (FB), so as to avoid harming the patient (or having one die).  As every patient with a FB can look different, some patients without a FB will mimic those who have a true obstruction.  Essentially, surgical exploratory is called an "exploratory" because, in the right situation, it is not only a therapeutic procedure, but also a diagnostic one. As nobody can be 100% correct every single time, it's better to have a few "negative" explores, than a few patients with an obstruction who are missed, and subsequently die.

Often, patients without foreign objects who undergo surgery do very well afterwards; it's been jokingly referred to as a "therapeutic gut stir" or "letting out the evil vapors."  The pain of surgery typically abates in <24 hours, and they return to happy, healthy lives with their families.  As frustrating as a  negative explore can be, I'd take one every time over a dog who didn't have surgery soon enough.  It's a delicate balance and a difficult decision each and every time.

Anyway, I digress.  I biopsied Gus' intestines, in hopes of determining the cause of his GI illness, and he recovered uneventfully.  He discharged the next day, eating, no longer vomiting and back to his normal self.

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