Marley is a sweet Shiba Inu who presented to us with a history of 3 weeks of intermittent diarrhea and vomiting. His owner reported that he had gotten out of the house a few weeks ago for about 24 hours and when he returned he was vomiting and had diarrhea.
Marley was seen by another veterinarian 2 times over 3 weeks prior to our seeing him. Blood tests were performed each time he was seen and all were normal.
Radiographs (x-rays) were taken twice and were reported as normal to the owner. Marley was lethargic during this time, but could get excited to go on a walk. He was eating very little and the owner was concerned and brought him to us for a second opinion.
On presentation, Marley was alert but somewhat subdued. On physical exam the only abnormality that was noted was watery diarrhea in the colon.
Based on the history of vomiting, diarrhea, inappetence and lethargy with recently normal blood tests, our suspicions were raised for the possibility of a foreign body partial or full obstruction of the intestines.
We reviewed the radiographs taken at the other veterinary hospital and there was an area in the colon that looked suspicious. Therefore we opted to use ultrasound imaging to investigate the intestines in more depth. X-rays are good to see the overall shape of organs in the abdomen, and they are great for seeing certain types of foreign bodies such as metal, bone and stone. Ultrasound allows us to look inside the organs and measure the thickness of the walls of the intestines which can tell us if the intestines are swollen or inflamed. In addition, we can frequently find foreign material that is not opaque to x-rays.
The ultrasound revealed and interesting anomaly called an intussuception. This anomaly occurs when one loop of intestine slips into another loop of intestine, much in the way that you can make a tube sock invert on itself.
Cross section of intussusception on ultrasound
Notice the multiple layers representing each layer of each intestinal loop.
Longitudinal section of intussusception on ultrasound
Notice the similarity it has of a tube sock pushed in on itself.
Here is a schematic picture to help you visualize:
Intussusceptions occur when the normal peristaltic motion of the intestine goes awry. Usually all the intestines are slowly contracting in sequence to move food from the stomach towards the rectum. When a pet starts to vomit, the peristalsis is reversed, bringing food up towards the mouth. When a part of the intestine moving towards the mouth meets another section moving away from the mouth, the intussusception can occur.
When the first loop of bowel enters the second, the blood supply to the first section gets choked off and that section of intestine starts to die. This can be very painful to the dog. The body tries to clear the blockage by moving the intestines faster, which leads to diarrhea.
This problem has to be addressed by surgery. After discussing the problem with the owner, we took Marly to surgery. The intussusception was found at the junction of the ileum and the colon. The ileum was stuck inside the colon and it was very difficult to bring it out into the normal position. When we finally got it out, the tissue was already partially necrotic (dying). As such, we had no alternative but to cut out the damaged part of intestine and reconnect (anastamose) the intestine to the colon.
After the resection/anasatamosis was completed, we preformed a procedure called plication where we attach the intestines to each other in an accordion pattern which helps to prevent future insussusceptions.
Intussusception before reduction
Resected intestine from intussusception
Marley felt much better by the morning after surgery and began eating. We discharged him a few days later on bland food, antibiotics and pain medication. At suture removal, he was doing great. With the missing bowel, he may have intermittent issues with diarrhea as he grows up, but in general, his prognosis is very good.
We were lucky to have done surgery on Marley before the intestine opened up and contaminated the belly. If a pet is having chronic diarrhea and/or vomiting, it is always useful to use all of the imaging modalities available to us to try to identify the underlying cause as early as possible.