Month: October 2014

A Lively Liver Tango

Hero was a very handsome German Shepherd and at seven years of age, he visited our hospital every six months for routine preventive care. He was current on heartworm and flea prevention, was well trained, and had a surgery as a four year old for a ruptured ACL ligament in his right knee. His annual blood work was always unremarkable. He is a charming dog that behaves beautifully and handles life with grace. Today, though, Hero wasn’t feeling so great. His head was dropped down, he didn’t wag his tail when the nurses chattered at him, and he walked with an odd, hitching gait. Mr. and Mrs. Davis were worried about Hero. He was fine the evening before, playing with the neighbors dog, ate his normal evening meal, and went to bed. He seemed a bit restless overnight and this morning her refused his breakfast. Mrs. Davis was adamant that something was wrong with Hero, and Mr. Davis called off work to bring Hero to the hospital. I rubbed Hero’s ears and he gazed into my eyes with the most piteous look. His eyes were a bit sunken and his gums were sticky to the touch, indications of dehydration. His gums were darker than usual, a sign of decreased blood flow. Hero’s heart was beating a bit too fast. His joints had normal range of motion with no pain on palpation and a rectal exam was unremarkable. As I pressed my fingers into his abdomen I was surprised to feel a large mass, just before Hero cried out. He tolerated me pressing into his lower abdomen; his intestines and bladder felt normal.

I relayed my physical examination findings to Mr. and Mrs. Davis and stressed that we needed to do further diagnostics, but Hero might need emergency surgery. The Davises were visibly upset and Mr. Davis said “Doc, we don’t have much money.” I felt dread welling up in my stomach; finances and hearts often diverge in veterinary medicine. I took a deep breath and explained that we needed to start with blood work and IV fluids. I provided an estimate and asked them to approve the initial costs so that we could start helping Hero feel better. I promised that we would help them figure out finances as soon as we had Hero’s blood work and fluids started. While a nurse drew blood and placed an IV catheter, I considered the possibilities. The possibilities in an adult German Shepherd were numerous; gastric bloat with possible torsion, toxin ingestion, pancreatitis, foreign body, gall bladder disease, liver disease, and diaphragmatic hernia. After giving Hero an injection of pain medications and while we waited for the results of Hero’s blood work, I explained the possibilities and talked about funding. The Davises applied for Care Credit, a deferred interest rate credit card for medical care. I’m not a fan of deferred interest rate cards because of the high interest rate that takes effect if the balance isn’t paid in full by the end of the interest-free term, but often don’t have better options for owners. The Davis’s qualified for Care Credit but were very concerned about taking on such debt. We talked about Hero and how everyone in the neighborhood knows Hero. It’s hard, as a veterinarian, to talk to owners about money, and it is hard for folks like the Davises to ask for financial help. Sometimes, when the stakes are high, we do things that aren’t so comfortable. We encouraged the Davises to visit their neighbors, share their story, and see if anyone was able to help out. We also provided the Davises with a list of charitable organizations that might be able to provide some assistance.

Hero’s blood work revealed mild elevations in liver enzymes and increases in white blood cells. We also took radiographs (x-rays) of Hero’s abdomen, which showed mild gas distension in Hero’s stomach but no evidence of gastric dilation volvulus or bloat, where the stomach swells with air and twists upon itself damaging organs and cutting off blood flow. The lines of the tissues in the radiograph were blurred by excess fluid in Hero’s abdomen. The lines around Hero’s liver were blurred and his liver seemed enlarged. We discussed emergency surgery, the risks to Hero, and the possibility of not being able to solve his condition. The Davises agreed to surgery and headed home to make phone calls and try to raise funds. We prepped Hero for surgery by shaving his entire belly from sternum to pubic bone then scrubbed him for surgery. This type of surgery is called an exploratory; we don’t actually know what we will find when we enter the abdomen, but we hope for answers and wish for cures. Just before we opened Hero’s abdomen up, we ran antibiotics into his blood stream to help reduce the risk of infection.

Long incisions aren’t as simple as they appear; I braced my left hand against Hero’s sternum (covered by a sterile drape) and placed my finger and thumb on either side of the midline of his belly to draw the skin tight towards the sternum and away from the midline. I gripped the scalpel in my right hand and extended my index finger over the top to rest on the back of the blade, then placed it between my left finger and thumb and drew back with mild pressure, opening the skin from sternum to pelvic bone in a single long slice. The skin pulled slightly away from the incision and subcutaneous tissue, mostly fat, peeked from beneath. With the scalpel set aside, I used a pair of forceps that appear similar to large tweezers to draw the subcutaneous tissue up and cut it away from the body wall beneath the skin with a pair of surgical scissors.

The motion is similar to trimming fat from a turkey while skinning it for a holiday dinner. This leaves the linea alba, a fibrous connective tissue that runs between the sets of abdominal muscles, exposed. Cutting through the linea alba leaves those muscles intact and gives us access to the peritoneal, or abdominal, cavity. To cut into the peritoneal cavity, we pull up on the linea alba near the pubic bone with the forceps and, turning our scalpel blade upwards, stab into the linea alba while trying to avoid damaging any organs. Some doctors will use the blade then to cut the linea alba from pubic bone to sternum, but I prefer to replace the blade with surgical scissors called Metzenbaums. I can actually use the scissors to draw the linea alba up and free from the underlying organs then cut, similar to slicing through wrapping paper.

When I performed my first abdominal surgery, I expected the variations in color and the movements of organs, but I was surprised by the heat of the body. Hero’s internal organs appeared darkened, almost as if I were wearing sunglasses under the bright surgical lights. These organs contrasted with bright red blood that was oozing from the top of the liver. The blood pooled around Hero’s intestines, which were stiller than usual. Dogs have seven liver lobes resting above and draping around the stomach and gall bladder. Hero’s left most liver lobe, the left lateral lobe, was large, dark, and the surface was slowly oozing blood. As I felt around the top edge of the left lateral liver lobe where my fingers encountered something that felt like a twisted cord; Hero’s liver had twisted on its own vessel. I resisted the urge to untwist the liver lobe as doing so would release toxins from the dying tissue of his liver lobe back into his blood stream, which would send him into shock. Hero’s liver had danced a tango and twisted about in his abdomen.

My fingers tucked thick suture material around the vessels and tissues where the torsion originated, far into the abdominal cavity in a space I couldn’t see, where the surgery light wouldn’t reach. My fingers rotated the line of the suture, tucking the right line beneath the left, then the left beneath the right, repeating the pattern several more times and wrapping the line across my fingers and drawing as tight as I could between each tuck. This causes the suture to ratchet down and the layers of tucks lock the first knot in place to form a ligature around the tissues. After carefully placing another ligature above the first, I slid a hemostat, or clamp, closer to the damaged liver lobe. I then laid the closest ligature over my left index finger and the hemostat over my middle finger with my thumb resting in the space in between. This is the space I would cut to remove the twisted liver lobe. I took a deep breath and tucked the scalpel blade into my right palm with the blade placed between my index and middle finger tips to cover the sharp edge to prevent stabbing important, healthy liver tissue. When I had the tips of my middle fingers touching, I used my right index finger to gently slide the blade across the vessels. As the vessels separated between the fingers of my left hand, I gently grasped the damaged tissue and lifted the lobe from Hero’s body. I carefully dropped the liver into a sterile dish and set the scalpel aside. Gently grasping the sides of Hero’s abdominal cavity, I angled his torso to shed more light on the source of the problem. To my relief, the ligatures were holding.

Next I carefully searched for other signs of bleeding around Hero’s liver, then traced his gastrointestinal system; stomach healthy and in its proper place, pancreas and spleen looking lively, intestines laying in their proper place, and kidneys still resting in the back of Hero’s body. I reviewed Hero’s response to anesthesia; his heart was doing well, blood oxygenated, and blood pressure improving. I carefully tacked Hero’s stomach to the left side of his abdomen, in a procedure called a gastropexy, to help prevent it from twisting like his liver had. I then started the long process of closing Hero’s abdomen up, slowly pinning the sides together by using single sutures starting in the middle. When the edges were held relatively close together, I threaded the suture through each side of the linea alba in an easy simple pattern. Once the linea alba was secured, I closed the subcutaneous and subcuticular tissues in a similar manner, then placed staples along the entire length of the incision.

We brought Hero up from anesthesia and he nuzzled our faces before we could even remove the tube that delivered oxygen from his throat. After a quick call to his parents, we examined the liver, then made long even slices to help the preservative seep into the tissue. The liver was placed in a jar of preservative and sent to a lab for a careful analysis. While I was pretty sure the liver lobe had twisted on itself, we didn’t know why, and we couldn’t absolutely rule out a cancer in that lobe. The Davises were thrilled to see a happy Hero that evening and reported that their friends and community had come together to support him. While they had asked friends to lend them money, many gave them smaller gifts and spread the word. As neighbors and other associates found out that the gorgeous Hero was in need of his own heroes, contributions flowed in. The Davises found support for their charming dog, and Hero’s bills were paid more quickly than expected. Two weeks later the tissue came back as not cancerous and Hero’s staples came out. His parents visit our hospital regularly, and Hero continues to amaze all of us.

Hair of the Dog? to Cure the Kitty

A cat needs blood. Feline blood products aren’t readily available. You don’t have any cats that can supply the amount you need but there’s a dog who can donate. What do you do? Hope for the best, harvest some blood, and transfuse it into the cat. We’ll have to wait and see if there are any negative consequences to this trans-species donation of blood cells, but for now, it’s a great story from the hospital where I complete a senior preceptorship. Sometimes the greatest medicine comes from the leaps of desperation; hope this leap lands the kitty with a healthy body. I am a little concern about how this cat’s immune system, kidneys, and liver will process the alien DNA, but perhaps the cells can serve their good before the cat’s body eliminates the foreign cells.

The Case of the Wide-Eyed Cat

Elwood, a 9 year old neutered and slightly overweight short haired cat, cowered in the back of his kennel, his lanky frame hunkered down and his head tucked beneath a blanket. “He is normally so outgoing! I’m really worried” Ms. Jackson’s voice wavered. Elwood was Ms. Jackson’s late mother’s cat and Ms. Jackson was afraid of losing this loved one as well. As I peered into Elwood’s kennel, Ms. Jackson continued “He hides all day now, and wants attention all night. I just don’t understand. He won’t even come out for his meals anymore.” I gently scratched around Elwood’s left ear and a rumbling purr arose from under the blanket and Elwood raised his head to look at me. I slid my hand beneath his chest and started to bring him out into the light, at which point Elwood desperately scrambled for the back of his kennel. “Ms. Jackson, when did Elwood start hiding?” “It started last week; I thought he just wasn’t feeling well, but that he would come back out in a day or so!” Elwood peered at me a again and gave a sad, plaintive ‘meow.’ I stared into his very wide eyes and wondered if he had really just turned into a night owl or if he was experiencing photophobia, a painful sensitivity to light. I reached out and flicked off the lights, then crooned to Elwood who emerged from his kennel and butted my chin with his head.

“I think Elwood’s eyes are hurting in the light.” I asked Ms. Jackson about any changes at home; no litter changes, no food changes, monthly Revolution to prevent fleas and heartworm disease, no access to the outdoors, no new pets or plants in the house, and Elwood didn’t have access to human medicines. Normally I start physical exams with the face by shining a light in the throat, eyes, and ears, but this time I worked my way from the rear end to the head. Elwood tolerated my fingers probing his abdomen and hands stretching his joints. He purred enthusiastically as my stethoscope delivered the notes of his heart and lungs. His temperature, pulse, and respiratory rate were all mildly elevated. I picked up my pen light and took a quick look in Elwood’s clean ears, then checked his teeth and throat. Finally, I shined my light in Elwood’s wide dilated eyes, a condition known as mydriasis. In a darkened room, I expect Elwood’s eyes to be wide, but when I shined a light into his eyes his pupils should contract. They did, slightly, before rebounding to their full widened gaze. Elwood tried to wrench his head away and I lowered the light for a moment. My nurse stepped in to cradle Elwood, gently gripping his jaw and skull. I reached into my pocket and withdrew a single lens, about the size of a small drink coaster, then rested my finger’s just below Elwood’s right eye, bracing the lens a few inches from his eye before raising the light to line up with my own eye and directing it through the lens.

This light shined through the lens in my hand, through the cornea and lens of Elwood’s eye, and onto the structures in the back of Elwood’s eye, letting me look at the vessels, nerve, and retina that enabled Elwood to see. Slightly off center was a creamy white egg shape known as the optic disc. Viewing the optic disc is similar to looking at a river flowing into the ocean; the disc is the visible end of the optic nerve that courses from the brain to spread into a thin sheet of nerve cells, called the retina, that collect visual information entering the eye. If the optic disc appears enlarged, much like a river overflowing after a storm, I worry about inflammation or high blood pressures. A small optic disc may indicate damage to the nerve or lack of use. The shape of the optic disc varies with some appearing almost triangular and others perfectly round. From the optic disc blood vessels project outwards like uneven spokes of a wagon wheel. I look to see if any of these vessels appear normal; larger vessels are at risk for putting pressure on surrounding tissues or even bleeding into the tissues while smaller vessels may not supply adequate blood to the tissues. Then I look at the retina stretched across the fundus, a fancy word for the back part of the inside of an organ, which can vary in color and texture. Some are stunningly beautiful like a bowl of sparkling blue, green, and yellow confetti while others are reddened and reminiscent of the eyes favored by horror film directors. Elwood’s fundus was a lovely glowing green that would match a firefly’s light on a dusky evening. I peered intensely, looking for cracks or bubbles, changes in color or texture that could represent damage to the retina. The inside of Elwood’s eye looked perfect and an examination of his left eye provided a perfect match.

Eyes really can be a window into the health of a creature by offering a platform to view nerves and vessels. Changes in other parts of the body, such as increased blood pressure from a straining heart, or an infection with certain viruses, are often visible in the eyes. Elwood’s wide-eyed gaze had alarmed Ms. Jackson and brought him to my examination table, but such an evident symptom wasn’t going to reveal a cause right away. We talked about what tests we could run to determine what was wrong with Elwood. We started out with blood work to check indicators of organ function, blood cell health, and response to infections. Elwood’s blood work was unremarkable; none of those values were outside of normal ranges. Next we took Elwood’s blood pressure using a smaller cuff, one that is used on newborn babies, but instead of wrapping it around a baby’s arm, we placed it around the base of Elwood’s tail. Elwood, being such a charming fellow, accepted this test with grace and his blood pressure was slightly above normal range. These could be signs of illness or stress from the visit to our hospital. Next we performed a test to see if Elwood’s irises had atrophied, or weakened and thinned, preventing Elwood from constricting his pupils. We test for iris atrophy by applying different concentrations of a drug called pilocarpine to one of his eyes. By responding to the pilocarpine, Elwood’s eyes showed us that the irises weren’t the issue; his issue was somewhere in his brain.

By this time, I noticed that Elwood was drooling a bit and seemed a bit twitchy. I was worried that Elwood had a disease that affected his brain or a cancerous tumor within his skull. We took a series of x-rays, which revealed nothing awry. With my mind whirling, I sat down with Ms. Jackson again. We discussed every visitor to her house, every cleaning product she had purchased, and every grocery item that came in the house. I asked Ms. Jackson to go through a detailed account of her day, and as I listened to her recount her morning coffee and afternoon walk I realized that she was giving Elwood treats every few hours, but that I had not noted treats on my previous history. My mind raced; could the treats be toxic? Was there a defect in the manufacturing process? A cruel hoaxer that found a way to add poison to the treats at the store in a manner reminiscent of the Tylenol tampering of 1982? I asked Ms. Jackson for the name of the treats, but she couldn’t remember, so I sent her home after the package. She returned with a package labeled ‘calming treats.’ Working with patients who have behavior problems, I recognized a key ingredient; L-tryptophan, which is a precursor to serotonin, a neurotransmitter. Ms. Jackson started using the treats because she was working longer hours and thought they would help keep Elwood calm while she was away. He was receiving 8-10x as many treats as the package indicated. I couldn’t be sure, but I feared Elwood was experiencing Serotonin Syndrome. I explained my concern to Ms. Jackson, noting that I didn’t have any way of testing my theory other than treating Elwood for Serotonin Syndrome and monitoring his response and that there were other diagnostics we could try to rule out other causes such as testing Elwood for toxoplasmosis and bartonella, performing a cerebral spinal fluid tap to look for infectious agents, or sending him to a veterinary university for a CT scan or MRI. Ms. Jackson explained that her savings were limited and she wanted to try treating for Serotonin Syndrome first.

We hospitalized Elwood, put him on fluids and monitored his vital signs, and gave him a drug called cyproheptadine, which competes with serotonin for spots on receptors in the brain, kind of like adding a whole bunch of extra people to a game a musical chairs. The chairs are the receptors, the original players are the molecules of serotonin, and new players are the molecule of cyproheptadine. We don’t know for certain, but we assume that fewer serotonin molecules can grab receptor seats if cyproheptadine is present. Meanwhile we monitored Elwood; if his condition worsened, the muscles supporting his lungs could stop functioning and we would need to provide him with respiratory support or he could have a series of seizures which we might need to treat with emergency drugs. I knew we should see improvements within 24 hours, but the total affects might last for 36 hours. Elwood continued to hide, the fluids helped bring his fever down, he never experienced trouble breathing or seizures. On his second day of treatment, his twitches stopped and his eyes returned to normal. Elwood returned home with Ms. Jackson, who promised not to use calming treats again! Now, I am not certain that Elwood had serotonin syndrome or that the treats caused it, but I am grateful Elwood returned to good health. Ms. Jackson is refraining from feeding calming treats to change behavior, instead she is sticking to Elwood’s flavorful favorites!

What’s your wide-eyed pet story?

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