Continuing
Education | Medical
Staff | News
| Job
Opportunities

About AEC
| Specialty
Services | Facility
Tour | Your Pets
Health | Kids Corner
| Contact/Directions
| Home

Case Studies

Emergency Critical Care

Case Study:
Gastric Dilatation-Volvulus Syndrome in a German Shepherd

"Sasha" is a 6-year-old neutered male German
Shepherd that presented for making repeated retching motions,
producing only a white foamy fluid. The owners felt that his abdomen
was distended.

Presenting signs
An initial
rapid assessment was made for life-threatening problems (called
primary survey). Sasha's problems included: mental depression, labored
breathing, early decompensatory shock), rapid heart rate (240 beats
per minute), weak, irregular pulses, and significant cranial abdominal
distention. Percussion of the abdomen demonstrated tympany, suggestive
of a gas distended stomach, compatible with
gastric-dilatation-volvulus (GDV) syndrome.

What is GDV?
The GDV syndrome
occurs the stomach rotates at the level of the esophagus within the
abdomen, causing gas accumulation within the stomach and gastric
distension (Figure 1). Blood supply to the stomach and spleen can be
significantly compromised.

Figure 1.
Drawing of stomach
with arrows demonstrating direction of stomach
rotation.

Initial Stabilization
Oxygen was
supplemented, an intravenous catheter placed and blood was taken for
an emergency baseline. Intravenous fluid therapy was started with
rapid infusion of a large volume crystalloids and stroma free
hemoglobin* to resuscitate shock. He was given a narcotic for pain
control. The initial blood tests founs a reduced number of platelets
suggestive of an early problem with coagulation due to the severe
shock.

An electrocardiogram (ECG) was done, revealing a
ventricular tachycardia (Figure 2). He had a rapid heart rate and an
elevated blood pressure of 200/110 mmHg.

Figure 2. ECG showing
ventricular tachycardia

Intravenous lidocaine was given to correct the heart
arrhythmia and then his gas filled stomach decompressed percutaneously
to allow the gas to escape. A new ECG (Figure 3), heart rate and blood
pressure showed that he was stabilized enough to continue with
radiographs and emergency surgical intervention.

Figure 3. ECG after
lidocaine (4 mg/kg)
was given IV showing normal
rhythm

Confirming the Diagnosis
A
radiograph was taken and showed that the stomach was filled with gas
(black coloration) and rotated, with the pylorus now located in a
dorsal position (Figure 4).

Figure 4. Right
lateral radiographshowing a rotated gas filled
stomach.

Emergency surgery was necessary to correct the
stomach rotation, fix the stomach into normal position, and examine
other organs that might be affected. Common complications include:
anesthetic risks, stomach necrosis due to impaired circulation, blood
clots in major vessels, rupture of blood vessels due to the distension
and rotation of the stomach, and splenic damage due to the obstruction
of its blood vessels by the stomach.

Emergency Surgical
Correction
A combination of anesthetic agents were chosen
that had minimal effect on the cardiovascular system and induction and
intubation so that his breathing could be rapidly controlled. The
abdomen was clipped and scrubbed for surgery. An abdominal incision
was made. The stomach was immediately seen to be hugely distended with
gas, rotated and the stomach wall was black due to loss of blood
supply and necrosis (Figure 5). The stomach was de-rotated, a stomach
tube passed for relieving the gas, and the dead area of the stomach
wall was removed. The stomach was then attached to the body wall
(called a “gastropexy”) to prevent rotation in the future. The spleen
was found to have an infarct, and that area was removed. The pancreas
was swollen.

Figure 5. Black
stomach wall
from loss of blood
supply.

Post-operative
Care
Post-operative recovery was prolonged due to
pancreatitis. Procedures that aided recovery included: nasogastric
tube stomach decompression and feeding; plasma transfusions;
administration of crystalloids and colloids to maintain intravascular
volume, antibiotics, and gastric motility stimulants. The dog was
closely monitored in the intensive care unit with blood pressure, ECG
and laboratory tests. Because of the knowledge and skills of the
emergency/critical care team of doctors and nurses, Sasha was able to
go home 5 days after admission.

* Stroma free hemoglobin solution is an oxygen
carrying fluid that is approved for use in dogs.

(click
here to learn more about our specialty ER / CC Services)

Exotic Pets

Popo and one of his
doctors.

Popo is a 5 year old ferret who was brought into
Animal Emergency Clinic for signs of coughing, sneezing and not
feeling well. The owner had been sick with influenza for 2 weeks. She
knew that ferrets are susceptible to the human influenza virus and was
concerned. Popo had not eaten well that day.

A physical examination was done and found Popo to be
depressed, dehydrated, and to have labored breathing. At this time, he
weighed only one pound. He was admitted to the hospital and a catheter
was placed and intravenous fluids and antibiotics were administered.
Blood work was done, confirming dehydration. His other blood
parameters were normal. Radiographs were taken and showed that Popo
had developed pneumonia. The infection had spread to the entire lung
fields on the right side of his chest. This lung pathology was most
likely the reason for his difficulty breathing.

The next day Popo appeared to be getting worse in
spite of the fluids and antibiotics. The owner was contacted and
surgery was recommended to remove the infected lung lobes. It was felt
that the infection was causing lung abscesses and could not be treated
effectively with medications alone. The risks were discussed and the
owner agreed to surgery.

That afternoon Popo was taken to surgery. Because of
his small size, the anesthesia and surgery were very delicate
procedures. The emergency/critical care specialist planned a balanced
anesthesia protocol using both injectable and gas anesthetic.

The Emergency/Critical Care
specialist is administering and monitoring anesthesia for the
<1 pound ferret.

The surgeons were very concerned about performing
chest surgery on such a small animal. Though there had never been any
written reports about chest surgery on a ferret in United States, the
board certified surgeon used her experience with the dog and cat to
plan out the procedure.
The chest was opened and all of the right
lung lobes were found to be completely infected. The surgeons decided
to remove all the right lung lobes knowing that most animals can live
with only 1/2 of the lung lobes in tact. The surgery was very
difficult because of Popo’s small size. The procedure took
approximately 2 hours to perform. A chest tube was placed into the
right side of his chest so that extra fluid and air could be removed
from his chest after surgery. Popo woke up well after the surgery.

The chest tube is
placed and Popo recovered from anesthesia.

Popo is recovering in
the ICU.

Popo was maintained on pain medication, intravenous
fluids and antibiotics in the ICU during his recovery. He went home
with the chest tube in place after three days.

Popo going home with chest
tube and chest wrap.

The owner came back in with Popo one week later to
remove the chest tube. Popo is doing well 1 year after
surgery!!

(click
here to learn more about our specialty Exotic Pets Services)

Dental & Oral Surgery

Case Study:
Dentigerous Cyst
An eight month old, 21.6kg neutered male
Dalmatian/Springer mix, was referred for assessment and treatment of a
15 mm firm mass on the left rostral mandible. The lesion was located
between the mandibular canine (#304) and the second premolar tooth
(#306). Our presumptive diagnosis of the lesion was a dentigerous
cyst.

The preliminary physical examination revealed an
asymmetrical enlargement of the left anterior mandible. The diagnostic
plan included anesthesia for a thorough oral examination, professional
prophylaxis, intraoral radiography and biopsy for
histopathology.

The intraoral radiographs of the clinically affected
area, demonstrated a radiodense tooth structure within an
approximately 13 mm by 16 mm radiolucent area distal to tooth #304
(Figs.2,3). These radiographic findings supported a presumptive
diagnosis of dentigerous cyst. The revised diagnostic and treatment
plan was to surgically explore the mandible and obtain excisional
biopsies for a histopathological diagnosis. The premolars (#305 and
#306) would be extracted and the oral defect was to be reconstructed
using a mucogingival pedicle flap closure. The histopathologic
diagnosis of the lesion was odontogenic keratocyst.

Diagnosis and Treatment of a Dentigerous Cyst in a
Dalmatian/Springer Mix
Dale
Kressin DVM, FAVD, Dipl. AVDC - June, 2005

(click
here to learn more about our specialty Dental & Oral Surgery
Services)

Imaging

"Smokey" was a 6 year old neutered male domestic
long haired cat that ran away from home two days prior to
presentation. Smokey presented to the Animal Emergency Center
emergency service with the following neurologic and physical
abnormalities:

significant mental depression,

circling to the right,

increased extenor tone to the left front and rear
limbs

third eyelid raised on right

small puncture wound typical of a retrobulbar
abscess by the last molar on the right.

Routine blood work did not show any significant
abnormalities. Infectious titers were submitted. Exploration of the
mouth wound found no obvious etiology. Further diagnostics included a
MRI to assess the brain due to the sudden onset and focal right
cortical/subcortical neurologic signs. (see Figures 1 and 2).

The MR showed a lesion in the ventral subcortical
(diencephalons) region of the brain. The lesion was not typical for a
tumor nor for a pyogranulomatous lesion seen with infectious or
granulomatous diseases. Cerebral edema was present.

The likely cause of the sudden onset of neurologic
signs and the lesion found on MR was found the next day when a
cuterebra was found migrating in the tissues in the mouth.

(click here
to learn more about our Specialty Imaging Services)

Oncology

“Comet”

Comet is a 7-year-old Labrador retriever. At the
beginning of February 2007, Comet began having choking episodes and
coughing. He was taken to his veterinary office, where a physical
examination revealed enlarged lymph nodes in multiple locations. A
fine needle aspirate on one of the lymph nodes was taken. This sample
was consistent with high-grade lymphoma.

Lymphoma is a relatively common cancer in dogs. It
is a cancer of lymphocytes (a type of white blood cell) and lymphoid
tissues. Lymphoid tissue is normally present in many places in the
body, including lymph nodes, spleen, liver, digestive tract and bone
marrow. In most cases, we cannot tell what causes lymphoma. The most
common form is involvement of one or more of the external lymph nodes
similar to what Comet had. Many dogs may not feel sick or may have
only very mild signs such as tiredness or decreased appetite. Other
dogs may have more severe signs such as weight loss, vomiting,
diarrhea, excessive thirst or urination, weakness, or difficulty
breathing. The severity of the signs depends upon the extent of the
disease and on whether the cancer has caused changes in organ
function. Often, the only noticeable sign is an enlargement of the
lymph nodes under the neck, behind the knees or in front of the
shoulders. Other organs, such as the liver, spleen and bone marrow can
be involved as well.

Chemotherapy is the mainstay of treatment for
lymphoma. Lymphoma is very sensitive to chemotherapy, and up to 90% of
dogs treated will go into remission when our most effective treatment
protocols are used. The definition of remission is the complete
disappearance of all signs of cancer. A remission is NOT a cure but it
does allow pets to experience a good quality of life. It is important
to remember this because chemotherapy should not be discontinued as
soon as a remission is achieved. The length of remission depends upon
many factors including the primary site, how sick an animal is at the
start of treatment, blood calcium level, and the extent of disease.
For those dogs, like Comet, that have the most common type (external
lymph nodes enlarged) and are treated with the most effective
treatment protocol, the average survival time is about 12-14 months;
approximately 25% of dogs may live longer than 2 years. Unfortunately
without treatment, most dogs will succumb to their disease within 4-6
weeks.

Compared to people receiving chemotherapy, pets
experience fewer and less severe side effects. because we use lower
doses of drugs and do not combine as many drugs as in human patients.
The normal tissues that are most sensitive to chemotherapy are the
intestinal lining, the bone marrow (which makes new blood cells), and
hair follicles. Toxic effects to the digestive tract are responsible
for decreased appetite, vomiting, and diarrhea. In most cases, these
signs are mild and usually resolve on their own or with oral
medication given at home. We seldom see severe side effects; it is
estimated to be less than 5% of all pets receiving chemotherapy will
have a side effect requiring hospitalization.

After discussing options for treatment, Comet’s
owner elected to begin therapy with chemotherapy. Comet’s treatment
will consist of 4 cycles of a combination of chemotherapy medications.
During the first phase of his treatment (called induction), Comet will
get four weekly treatments followed by one week off. This is repeated
for another 4 weekly treatments and then Comet will go to every other
week therapy.

Comet was given his first dose of chemotherapy on
March 2, 2007.

Update:
3/8/2007 - Comet returned today for his
second dose of chemotherapy. He is feeling great and his cough is much
improved. His lymph nodes are much smaller as well, his appetite is
good, and his weight is stable.

4/10/2007 – Comet’s lymph nodes are no longer
enlarged!! He is in complete remission for his lymphoma!! He is
feeling great!

4/24/07 – Comet was given his last weekly injection
today. He will be treated every other week from now on. He remains in
complete remission and is feeling great!

Oncology

“Taj”
A Wonderful Cat with Wonderful
Owners
A Case of Feline
lymphoma

Taj is an 18-year-old Maine Coon. Last August he
presented to the Animal Emergency Center emergency service for fever,
lethargy, weight loss and difficulty using his hind legs. A physical
examination revealed that Taj was thin (6 1/2 lbs). He had a fever
(Temp = 104 F: normal = 101.5 F), was dehydrated, and had difficulty
walking on his rear legs. Taj was admitted to the hospital for
intravenous fluids to help correct his dehydration and help to lower
his temperature. Basic diagnostic tests were preformed to try to
identify the cause of Taj's illness. Blood work revealed a mild anemia
and a mild elevation in kidney enzymes. A urine sample contained
bacteria indicating Taj had a urinary tract infection. Taj was started
on intravenous antibiotics. After one night in the hospital, Taj's
temperature was normal and he was eating again on his own. He was
discharged with oral antibiotics and scheduled to recheck in a few
days.

Taj returned the following evening, now with
vomiting and diarrhea. His temperature was normal at presentation but
he was again dehydrated and lethargic. Repeated blood work showed that
the kidney values were more elevated and his anemia had gotten worse.
The owners allowed more advanced diagnostics. An abdominal ultrasound
was performed to evaluate Taj's kidneys and other organs in his
abdomen. The ultrasound showed that Taj's kidneys were smaller than
normal indicating some kidney disease, most likely associated with
advanced age. Taj also had some enlarged lymph nodes in his abdomen
associated with his intestines. A needle was placed in some of the
lymph nodes and cells were aspirated for examination under the
microscope (cytology). A consultation was obtained with Dr. Rachel
Reiman from the oncology service.

The cells were examined by Dr. Reiman and the
diagnosis of lymphoma (or lymphosarcoma) was made. Lymphoma is one of
the most common cancers diagnosed in cats. It is a cancer of the
lymphocytes (a type of white blood cell) and lymphoid tissues.
Lymphoid tissue is normally present in many places in the body
including lymph nodes, spleen, liver, gastrointestinal tract and bone
marrow. Cats of any age, breed and sex can be affected.

Lymphoma can be divided into several different
forms, which depend upon the predominant location of the tumor (Table
1). Some cats have multiple sites of involvement and do not fit well
into just one category.

Chemotherapy is the mainstay of treatment for
lymphoma. Lymphoma is very responsive to chemotherapy and up 75% of
treated cats will have the complete disappearance of all signs of
cancer (remission). However, microscopic amounts of tumor cells can
remain hidden in the body. A remission is NOT a cure but it does allow
your cat to experience a good quality of life. Because of this,
chemotherapy should not be discontinued as soon as remission is
obtained. The length of remission depends upon many factors, including
the primary site, the degree of illness at the start of treatment,
FeLV status, and the extent of disease.

Most cats tolerate their chemotherapy well with
minimal side effects. Serious side effects are seen in less than 5% of
the cats treated. Side effects might include nausea, vomiting and loss
of appetite, diarrhea, tiredness or infection. If side-effects are
serious or intolerable, steps will be taken to eliminate or reduce
these effects to a tolerable level. Cats do not lose their hair, but
may lose their whiskers and develop a different texture to their fur.

Taj had the gastrointestinal form of lymphoma.
Without treatment most cats will succumb to this disease rapidly. They
will often continue to lose weight, stop eating or have worsening
vomiting and/or diarrhea. Taj's owner elected to begin chemotherapy
treatments with the oncology team. Taj had a high-grade form of
lymphoma so a more aggressive chemotherapy protocol was needed. Taj
was given weekly injections of chemotherapy drugs for the first 8
weeks, and then he was given injections every other week. Taj seemed
to handle these treatments fairly well with only a few episodes of
vomiting and anorexia. Throughout treatment, Taj gained weight very
slowly. In the first month of treatment he went up to seven pounds. He
seemed to hover in this range for most of his treatment.

Taj finished chemotherapy on May 4th, 2006. He comes
in for periodic rechecks and remains in complete remission. He is now
up to 8 pounds!

Table 1. Different
Forms of Lymphoma According to
Location

Digestive tract (Gastrointestinal):
This is the most common form of lymphoma in cats. The
digestive tract includes the stomach, intestines and liver as
well as some of the lymph nodes surrounding the intestines.
Cats with this type of lymphoma may have vomiting, diarrhea,
weight loss or a decreased appetite.

Mediastinal: The mediastinum is a
term used for a special group of lymph nodes in the chest.
Cats with this type of lymphoma are usually younger and
infected with Feline Leukemia Virus (FeLV). Symptoms include
difficulty breathing due to a large mass in the chest or an
accumulation of fluid around the lungs.

Kidney: The kidneys may be the
primary site of involvement. Cats that have this type are
often seen because of signs related to kidney failure
(increased thirst, increased urination, loss of appetite,
vomiting).

Bone marrow: If the cancer is
confined to the bone marrow, we call this leukemia. The signs
that we see in cats are usually related to the decreased
numbers of normal cells (such as red blood cells that carry
oxygen, white blood cells that fight infection and platelets
that help with clotting) which are made in the bone marrow.

External lymph nodes: These cats may
be seen because the owner notes "lumps" (enlarged lymph nodes)
on their cat.

Other sites: Other sites such as the
skin, nose, brain, and spinal cord as the primary site of
involvement.

The type of large
lymphoblastic cells found in
Taj’s lymph nodes, indicating
lymphoma.

The Oncology Team and
Taj
Katie Bratberg, oncology nurse (left)
Dr. Rachel
Reiman
(right)

(click
here to learn more about our Specialty Oncology
Services)

Surgery

Case Study:
External Skeletal Fixator

Kody shortly before his
external
fixator was removed.

Radiograph (also know as an x-ray)
of Kody’s broken leg. The radius and ulna are both broken in the
forearm, just above his carpus (wrist). The yellow arrow identifies the
fractures

Kody is a two year old Husky. This spring, he was
hit by a car, sustaining a broken forearm and multiple abrasions to
the skin. The skin was open at the fracture, increasing the chances of
infection after surgery because of bacterial contamination.

Kody had an external skeletal fixator placed on his
forelimb to stabilize the fractured bones. An external fixator allows
stabilization of the fracture without placing permanent implants in
the limb. Pins and wires are placed through the bone and connect to a
frame outside the limb.

As Kody's bone healed, his owners provided daily
wound care to the sites where pins and wires exited the skin. The
external fixator was bandaged to prevent Kody from catching it on
furniture and to prevent him from hitting people and objects with his
fixator. Restricting his exercise was hard, but Kody's owners did a
great job of limiting his activity to help his bones heal.
Kody did
develop minor pin tract infections which were managed with antibiotic
therapy. As his bone grew stronger some of the pins and wires were
removed from Kody's leg. This procedure is not painful and Kody
tolerated pin removal without any medication.

After 8 weeks, Kody's external fixator is
coming off!

Kody's bones will continue to strengthen as the
fracture site remodels. Restricted exercise for the next 4-6 weeks is
still important after the external fixator is removed to allow the
bone to adapt back to life without the external fixator.

Here is a radiograph of Kody’s leg with the
external fixator in place.

Kody’s leg with the external fixator before it was
removed. Note there is a pin missing from the radiograph
above.

(click here
to learn more about our Specialty Surgery
Services)

2100 W. Silver Spring
Drive | Glendale, WI 53209 | 1.414.540.6710 | © 2004 Animal Emergency
Center