One of the things I enjoy about emergency work is dealing with the more challenging cases that do not always have a straightforward answer. The process of medicine sometimes requires a detailed diagnostic plan to define the problem and decide on the best treatment course. Sometimes the answer is obvious and no or minimal investigation is required.
Charlie was one of those cases that needed just a little more work up than usual and had an interesting outcome. He presented to me one night after being a bit off colour for a couple of days. His appetite had dropped in the previous 2 days and on this particular day he was not interested in any food. He’d had a couple of small vomits in the morning but did not bring up anything remarkable. Charlie and his sister had apparently been destroying some bedding at home, but at the age of 6 years old, he was not known to eat the things he should not be eating.
When I examined him, his belly was tense and a little tender toward to front of his abdomen, around the stomach area. Nothing obvious stood out and I certainly did not appreciate any swelling of the stomach. He appeared dehydrated so he was admitted into the hospital for treatment with intravenous fluids while further investigation was performed.
As I mentioned in the post on Simba, sometimes deciding on the most appropriate diagnostic test is not clear, and several may need to be performed to obtain an answer. I ran a blood panel on him initially to determine if he had any inflammation of his liver or pancreas. Blood tests are often very useful, sometimes for what they don’t reveal. His organ function was normal, but the electrolyte component of his blood showed all the main ones to be very low (Sodium, Chloride and Potassium). A low potassium and chloride level can suggest an obstruction around the stomach or top of the small intestine, but the low sodium level did not really fit the picture.
We decided the next step should be an abdominal ultrasound. Now here we could have opted for an x-ray first, however, from the history obtained we figured if he had an obstruction, it was likely to be some sort of material. Material does not show up so well on x-rays, so we felt that an ultrasound was more likely to tell us if there was an obstruction, where it was and what the best plan would be for removal. The abdominal ultrasound was helpful but still left us with some questions. Everything in the abdomen looked normal aside from the stomach which was distended with an unusual layering of material that moved back and forth with the stomach rather than separately to it. So it was not certain that this was a foreign body, though highly likely. And if so, what was it?
A single x-ray was taken and proved to us that surgery was indeed necessary to remove the obstruction in Charlie’s stomach:
After speaking to Charlie’s family, permission was obtained to proceed with surgery. Once under anaesthetic, it became quite obvious that Charlie had a distended stomach, and I was surprised that I could not palpate this earlier. He was just too uncomfortable. Surgery was performed and Charlie’s stomach was carefully emptied. The photo below will help you understand why it took a while to empty Charlie’s stomach! An attempt at reconstruction suggested that the contents of Charlie’s tiny stomach (keeping in mind he is about a 10kg dog) was two whole man-sized, leather gardening gloves! They must have been tasty! His stomach was closed and the rest of his intestinal tract was examined to ensure there were no other pockets of obstruction.
Charlie recovered really well from surgery that night and I heard that he was brighter and eating the next morning and so went home to his family the following night. I spoke to one of his owners a week later and was pleased to learn that he was doing well and back to his normal bouncy and boisterous self, news we always like to hear. He was so bright that his Dad was having trouble keeping him settled so as to recover fully from his surgery!