Rocco is a 7 month old Shit-Tzu who presented to us last month with a history of vomiting and runny stools for a few days. According to the owners, Rocco was feeling a bit depressed, not as playful as usual. He was still interested in food, but would vomit each time he ate. The owners are very observant of Rocco and were pretty sure that he did not have access to any poisons. His diet diet was puppy food and he did not get any treats from the table. On physical exam, Rocco was quiet but responsive. His temperature was normal and there were no gross abnormalities found on palpation. His stools were soft but no blood was present in the stool.
Given Rocco’s young age, our main considerations at this point were, a possible intestinal foreign body, dietary indescretion (garbage eating), or toxin ingestion, viral infection or parasites. We recommended taking blood tests, radiographs (x-rays) and a stool test for intestinal parasites. The owners authorized our intitial diagnostic plan and the tests were performed. The blood tests and fecal tests were normal. The radiographs, however showed a suspicious mass in the center of the abdomen.
Radiograph of the lateral abdomen. Note the grossly thickend mass of intestines.
Looking at the radiographs, our suspicious were raised as to the presence of an intestinal foreign body such as a piece of cloth, or an intestinal intusuception. An intusuception occurs when an intestine gets caught within another part of an intestine similar to when you push the end of a tube sock into another part of the sock. This occurs when the intestines are inflammed and the normal patterns of muscular contraction gets out of sync. Normally, intestines all contract away from the mouth and towards the rectum, which keeps the ingesta moving in the right direction. When a pet is vomiting, the muscular contractions reverse and sometimes, one part of the intestine is going away from the mouth while the other end is moving towards the mouth which causes one end to slip in to the other.
At this point, we recommended an ultrasound examination of the abdomen to help us narrow down the diagnosis. The owners consented and we found the following:
This is a cross section of the mass. You can imagine the multiple layers formed by the different layers of the intestines.
Here you can see the detail comparing a normal intestine to the intusuception.
The mass was clearly an intusuception which can only be fixed surgically. We talked over the options and the owners agreed to have the surgery performed.
We placed an IV catheter and placed him on intravenous fluids. We administered mild sedation and then induced anesthesia. We performed a midline exploratory surgery. When we opened the belly, we looked at all of the organs and found the intusuception located at the junction of the ileum (end of the small intestine) and the colon. Six inches of intestine had slipped into the large colon through the ileoceco valve which is supposed to keep the two parts of the intestine separated. We were reluctant to resect the colon, because the incidence of infection and wound complications is higher in the colon than in the small intestines due to the large amount of bacteria present in the colon. Fortunately, we were able to gently push the small intestine back out of the colon. That portion of the intestine was dying from lack of blood caused by the pressure of being in the colon. Therefore, we had to resect about 8 inches of the ileum. After we removed the damaged portion of the intestine, we reconnected (anastamosed) healthy intestine to the ileocecal valve. When a pet has had one intusuception, it is possible that they will have it again as the neuromuscular coordination may still be out of sync. Therefore, we performed a procedure known as “plication” where we attached the intestines running up to the intuscuception point to each other in an “accordian” fashion. This prevents the intestine from slipping too far into the adjacent intestine.
Here are photos of the surgery:
View of intusuception notice unhealthy color of intestines.
Intusuception reduced. The intestine that was in the colon is unhealthy.
The diseased intestine about to be resected.
Healthy intestines anastamosed.
The plicated intestines, note how they appear like an accordion.
We closed the belly in the usual fashion. Rocco stayed in the hospital for 3 days after the surgery. We managed his post operative pain and kept him on iv antibiotics and fluids until he was able to eat and hold down his food. He was sent home and had an uneventful recovery. His long term prognosis is excellent.
This case is a good example why we need to take radiographs of all vomiting dogs. It also shows how abdominal ultrasound helps us clarify the diagnosis. If we had not seen the intusuception, the intestines involved would have died and Rocco would have gotten extremely ill from peritonitis. Attempting to save him at that point would have had a very guarded prognosis.