Jake is a 6-month-old male Labrador retriever.
By day, he idles at rambunctious with only brief intervals of spontaneous napping. Even at rest, his dreams indicate that his brain continues to play, as evidenced by his muffled barks and spasmodic leg twitches. So, when he recently appeared listless and indifferent to his toys, a big red flag went up. His owners’ concern was elevated to worry when he turned away from a meal and began to vomit.
After they arrived at our emergency clinic, a clinician examined Jake and noted that his abdomen was tender and he appeared slightly nauseous. X-rays were not definitive, but given the circumstances, a gastrointestinal obstruction was suspected.
The clinician considered an upper GI study, which involves oral administration of barium and a series of X-rays to follow its course through the digestive tract. It can mark the spot of an obstruction. Jake, however, couldn’t hold anything down, so this test was out. An ultrasound was considered, but due to the low reliability of this test with gastric foreign bodies and its cost, it was declined.
So, now we have to choose. Do we administer anti-nausea medications and rehydration fluids while we wait a little more time, or do we explore the abdomen?
When it’s early in the course of the problem and X-rays are not definitive, waiting overnight as well as giving IV fluids and medications is a common path. If the patient fails to improve, further diagnostics or surgical exploratory would be the next steps to consider.
Jake became increasingly uncomfortable and continued to vomit. By the following day, his X-rays had changed. His stomach appeared full of fluid, which is unusual for a dog that is vomiting and refusing food. His intestines still appeared relatively normal.
The X-rays were reviewed by a board certified radiologist, and even he could only say that an obstruction was a possibility. He then went on to list a few nonsurgical conditions.
Our clinician explained to them that our No. 1 suspicion was of an obstructive foreign body. She explained that as long as it is there, it could be causing intestinal damage and may progress to an intestinal perforation, and life-threatening infection, or peritonitis.
She outlined further diagnostic options, including a CT scan or ultrasound, which are noninvasive means to evaluate the abdomen. The other option was to simply surgically explore the abdomen, which is a highly accurate diagnostic procedure, but is also the most invasive and expensive approach.
Why would we choose surgery over these noninvasive alternatives, or vice versa? For both the clinician and the client, this point in the case management is pivotal and communications must be handled with the utmost in sensitivity, frankness and clarity. Three elements dominate the recommendations and decisions made at this point.
Financial concerns weigh in, and rightfully so. Diagnostic procedures such as CT and ultrasound can be expensive, and they only tell you what’s wrong. Once they are complete, the problem still requires treatment, and that is often surgical. If funds are tight, clients have to be careful not to spend all of their money on diagnostics with nothing left over for treatment. Furthermore, these are not 100 percent accurate, so a client may spend money on a test and be in the same position as before it was run.
The clinician’s suspicions are key to recommendations. Simply put, if the clinician strongly suspects a nonsurgical cause, he or she may favor non-invasive diagnostics first. But if a foreign body is probable, surgery will likely be encouraged.
Finally, we must consider the risks of delaying a diagnosis and treatment. The consequences of leaving a foreign body in place can be severe intestinal damage and even death.
In Jake’s case, the owners were on board with exploratory surgery. What we found was toy stuffing in the stomach with dental floss trailing down the intestine and cutting into the wall. This likely would have been missed by both ultrasound and CT, and the delay may have risked or cost Jake his life.
As mere mortal clinicians, we cannot always know definitively what is wrong. Our diagnostic and treatment choices as well as recommendations must balance what we think best for the patient and with what a client is willing and able to do. To reach this result, effective communication between the client and clinician is imperative. We can’t always make perfect choices, but we must always strive to make the right ones.
Dr. Henri Bianucci and Dr. Perry Jameson are with Veterinary Specialty Care LLC. Send questions to firstname.lastname@example.org.