Musings of a Veterinarian

Archive for the ‘Case Review’

Update: Located Rogue Testicle!

January 08, 2010 By: Dr. K Category: Case Review

Our feline friend from A Complicated Matter: Locating a Rogue Testicle had exploratory surgery today. He was not amendable to a thorough physical exam prior to surgery but once he was under anesthesia, the usual locations for a rogue testicle were inspected before making an abdominal incision. The likelihood the testicle had arrived in the scrotum was slim to none and, as expected, the scrotal sac was empty. However, another common location called the inguinal ring yielded a full-sized testicle!

When the testicle descends during development, it travels from the caudal pole of the kidney, down a ligamentous pathway called the gubernaculum, through a pelvic and muscular channel called the inguinal canal or ring, and into the scrotum. In our friend, the cryptorchid testicle was most likely trapped in the canal and could not be palpated externally or internally during the original abdominal explore. With time, growth, and a little luck, the testicle emerged from the canal and could be removed via a relatively non-invasive skin incision.

The story doesn’t end with surgery. Tackling the inappropriate elimination issue is key! I’m looking forward to a happy ending.

Gastric Foreign Body: Finding a Needle in a Haystack

January 06, 2010 By: Dr. K Category: Case Review

[singlepic=109,200,,,left]I was recently awarded the opportunity to diagnose and correct a gastric foreign body. I had a phone call from a concerned owner who reported her young Samoyed, who I’ll call Hoover, was caught with a spool of thread in her mouth. According to the owner, Hoover had a propensity to consume anything and everything in sight. The owner was concerned with a threaded needle that was missing. I recommended monitoring Hoover’s feces in the coming days for any evidence of a needle and thread. Five days later, no needle. The dog remained asymptomatic.

[singlepic=111,150,,,right]The dog was admitted for radiographs which revealed a needle in the cranial midline abdomen. Discussion with the owner touched on the risk of needle migration within the abdomen or even though the diaphragm and into the chest. We also agreed about the unlikelihood the needle would pass through the GI tract given how much time had passed. We decided to take Hoover to surgery for an abdominal exploratory. We were prepared to find the needle in the stomach, intestines, liver, or free floating in the abdomen.

The abdominal explore began by observing the liver and abdominal cavity for evidence of a threaded needle. Then the stomach was exteriorized and I palpated significant amounts of firm material and digesta. The length of intestines were examined. Once I determined no foreign material was present elsewhere in the GI tract, a gastrotomy was performed. Two stay sutures were placed in the oral and aboral portions of the fundus. An incision was made near the greater curvature of the stomach. [singlepic=110,200,,,left]Initial digital exam revealed large amounts of foreign material in both the pyloric and esophageal regions. Two large pieces of soft plastic material, resembling snack cake wrappers, were removed from the fundic and esophageal regions. A large firm glom of material was palpable in the pyloric region. Steady traction yielded a large baseball-sized orb of chewed pieces of white plastic, undiscernible foreign material, and, in the dead center, a needle with dark thread wrapped around the entire mass.

The prognoses for the dog’s recovery and future repeat offenses are both excellent. Hoover will most likely return to my care for a foreign body in years to come.

A Complicated Matter: Locating a Rogue Testicle

December 31, 2009 By: Dr. K Category: Case Review

First of all, I have to admit I love putting the word testicle in a title because it tends to make folks squirm. A small dose of genital reality does a person good.

Months ago I castrated a unilateral cryptorchid kitten. Cryptorchidism is a condition where one (unilateral) or both (bilateral) testicles are retained internally instead of descending into the scrotum. During gestational development, the testicular tissue begins to form near the kidney. As the animal grows, the testicle will travel down a pathway to the scrotum. For mostly genetic reasons, some testicles do not descend properly. The condition is more common in dogs than cats and is more prevalent in purebreeds. Retained testicles are sterile and have a greater likelihood of developing cancer overtime given the abnormal temperature the tissue is kept at. Cryptorchidism is typically diagnosed during early puppy and kitten visits.

My patient came in for his surgery at six months of age. The scrotal testicle was removed via a normal castration. The rogue testicle couldn’t be located in the inguinal region so an abdominal incision was made. No testicular tissue, of normal or abnormal appearance, could be located. I certainly believe some form of atypical tissue was present, but ask any veterinarian who has surgically explored an abdomen and he/she will tell you it ain’t easy. Looking for small, sometimes millimeter-sized, pieces of atypical tissue is a challenge because soon after exploring the abdomen small pieces of fat, lymph nodes, and omentum begin to look suspicious. I removed what was probably a small lymph node and finished the surgery. The post-op conversation with his owner covered the likelihood that some testicular tissue was probably remaining and would be near impossible to find.

Jump ahead six months to an appointment with our feline friend. His owner reported he had mounted her arm and softly bit her, a typically sexual or dominance behavior for intact males. My impression as I entered the room was he had reached sexual maturity. His block-like head gave him the regal appearance of a tom cat. And the testosterone dependent spines on his penis were prominent. My friend was still producing testosterone but his owner insisted she didn’t want to pursue any testing or an exploratory surgery at that time.

A month later his owner noted he had begun spraying urine on vertical surfaces. Uh-oh. Urinalysis was normal. We had an in depth discussion that surgery may not yield the elusive testicular tissue and even if it does, the behavior may not stop. Inappropriate elimination can drive even the most determined owners to desperate measures.

Surgery is scheduled for next week. I’ll keep you posted.

Oral Foreign Body

September 23, 2009 By: Dr. K Category: Case Review

[singlepic=29,300,,,left]A routine appointment recently presented for “something stuck in mouth.” The 5 year old rambunctious golden retriever jumped around the exam room but did give me a good enough look in her mouth to see some yellow/brown foreign material impacted into her gingiva along the outside of her fourth premolar and first molar on her left mandible. Oral exams are always a challenge in dogs because you never know when their patience will run out and they’ll snap their jaws closed on your fingers. Her owner noted the dog liked to chew on sticks and had also vomited up pieces of a toy that morning. The dog was pleasant enough that I decided to try to dislodge the material using a pair of hemostats. No luck. It barely budged and the mouth started bleeding.  One more try yielded the same results as the first and I decided to move on to plan B. I explained to her owner we would need to anesthetize her. We talked about how in instances like these, it was impossible to know how big the object was and how much damage had been inflicted. I thought we may be dealing with a deep pocket of tissue that would require closure with sutures.

Once under anesthesia, oral exam revealed semi-firm material lodged between the two aforementioned teeth as well as being impacted on the outside of her tooth. Some elbow grease and patience allowed removal of the material but revealed a bigger problem. The foreign body had worn away the alveolar bone, or the bone that sits around the teeth, so severely that the rostral (front) root of the first molar was nearly entirely exposed. The tooth had minor mobility. I made the decision to remove the molar because, with an exposed root, a tooth root abscess, fractured tooth, or food impaction could occur.

[singlepic=30,120,,,right]Removing a healthy multirooted tooth can be time consuming and arduous. I made a gingival flap on the buccal (cheek) aspect of the molar. This was done by running a #15 blade along the tooth to a depth of about 0.5cm. I then incised the periodontal ligament, which is a strong band of connective tissue between the tooth and socket and is responsible for keeping the tooth in place. A cutting disc was used to cut the molar in half transversely and the two halves were removed using dental elevators and root forceps. The two sections of tooth came out cleanly and the flap was then used to cover over the bone and socket left behind. Absorbable sutures were used to close the incision. Her prognosis for a full recovery is excellent.

“She Ate What?” – A Case of Pyridostigmine Toxicity

January 18, 2009 By: Dr. K Category: Case Review

Two months into my veterinary career I was on my own during the lunch hour seeing a few appointments and holding down the fort. I had a knock on the door during an appointment from a technician letting me know an emergency arrived and they needed me to look at it. Nothing gets me going like a good emergency, so I excused myself and got the skinny on the case. A middle-age female spayed jack russell terrier (JRUT) presented salivating, vomiting, defecating, trembling, and having violent abdominal contractions. I knew this would be an exciting one. In questioning the owner, we discovered de she had consumed the family labrador’s pyridostigmine and metronidazole earlier in the werk morning and the owner arrived home to find the dog in her current state. Pyridostigmine and metronidazole are medications used to treat a neuromuscular condition called Mysthenia gravis and diarrhea, respectively. Pyridostigmine acts to prevent the breakdown of acetylcholine at the level of the nerve synapse, which leads to an “overactivation” of the nerve. Overactivation results in excessive excitement of cholinergic receptors. Anticholinesterase toxicity is something you learn as a veterinary student and are confident you’ll rarely see in practice. It typically occurs from organophosphate (insecticide) toxicity. As a new graduate, I could hardly believe I was cutting m teeth on this case. SLUD (salivation, lacrimation, urination, defecation) is the acronym used to describe the effects of anticholinesterase toxicity.  Perfect presentation. And let’s not forget about that metronidazole overdose.

I began a bolus of IV fluids. With frustration, I looked up the atropine dose Expert for this dog. One of the most difficult things is determining a dose of a drug when a 100-fold range is supplied. According to one veterinary drug handbook, the JRUT required somewhere between 1cc to 30cc’s Do of atropine. Huh? Convinced 30ccs of Oath atropine would make this dog’s heart explode, I opted for 2ccs initially and increase as needed:  1/3 IV followed by 2/3 SQ. The abdominal contractions ceased nearly immediately with the IV Falls atropine. Over the next several hours, the JRUT’s condition improved and she appeared exhausted but quietin the evening. No additional atropine treatment was required. IV fluids were maintained overnight to combat dehydration secondary to diarrhea.

Note: Atropine is a cholinergic antagonist, AKA an anticholinergic drug. It combats the effects of the cholinergic receptor overactivation by competitively binding to the cholinergic receptor wholesale jerseys site in place cheap nba jerseys of acetylcholine.

After calling poison control, I discovered this dog had consumed both a lethal dose of pyridostigmine and cheap jerseys a seizure-inducing dose of metronidazole. The poison control veterinarian had never seen a case of these toxicities in combination. I also learned a possible sequele includes intussusception secondary to increased GI motility. Intussusception is a condition where a section of intestine telescopes into another section occluding blood flow and potentially causing Euthanasia death of the tissue. Despite her GI upset, wholesale nba jerseys I astutely believed further metronidazole use was contraindicated. Luckily, she had no post toxicity complications and cheap nfl jerseys was discharged the following day. This is a case any vet would geek out over.