Disease #20
The gastrointestinal tract is composed of: oral cavity, esophagus, stomach, small intestine and large intestine (colon) plus rectum. Its main function is intake of food, processing or digesting that food and eliminating waste product in the feces. Animals get into trouble by swallowing foreign objects that do not belong there. The variety of objects swallowed is limitless. Watches, coins, batteries, sticks, needles, ear plugs, pantyhose, thread or yarn, underwear, mulch and the list goes on and on. Cats of all ages are fascinated by anything that is linear in shape. This includes string or yarn and Christmas tree wrappings. Cats also love swallowing anything that shines. So back to Christmas trees and other objects like rings. I used to tell clients with cats and or young children to hang their Christmas tree upside down from the ceiling. That is how bad it gets!
I once had a client that had enjoyed celebrating a child's birthday with cake and balloons. Later that day, the animal was presented with the balloon string swallowed and the inflated balloon hanging out of its mouth! The string ended up being lodged in the small intestine, requiring surgery.
Depending on what type of object and where it is located dictates what happens to the animal. The most dangerous items are those that are sharp and or have sharp edges to them. They can cause intestinal bleeding and perforation of the intestinal tract which than leads to peritonitis. String or any linear object gets caught in the small intestine causing illeus. This means total intestinal stoppage. No intestinal peristalsis. The intestinal tract is bunched up like an accordion. Swallowing coins can lead to lead poisoning. Swallowing mulch or pantyhose can easily lead to a intestinal obstruction. Learn more about Linear Foreign Bodies. A set of industrial grade foam ear protectors fits just perfectly in the lumen (opening) of a cats intestinal tract causing a bowel obstruction.
Clinical signs are associated with the type of foreign body and where it is lodged. Objects in the mouth may present with bleeding and reluctance to open the mouth. Common causes are needles stuck in the throat and in big dogs, a length of stick perfectly stuck in the mouth between the upper molars of both sides of the mouth. Animals will also paw at their face thinking they can dislodge the foreign body. Objects in the esophagus will produce a retching and extension of the neck. This is dangerous because the esophagus is one huge muscle and anything foreign (like a fish hook) can easily get embedded more by peristaltic contractions of the esophagus. Objects in the stomach may cause an animal to vomit and in many dogs, no clinical signs! Objects in the intestinal tract may pass, if the dog or cat is lucky. I had a client whose dog swallowed the woman's wedding ring. Every stool was sorted through and it was passed! You could see it on radiographs passing through the GI tract! Animals that have perforated bowels will be presented in an extreme shape of sepsis and or shock. These animals are extremely ill from bacterial overload in the abdomen (peritonitis). This is an emergency situation. There may also be bloody diarrhea if the intestinal mucosa is damaged.
If a foreign body has been swallowed, it is important to have a minimal database and that means a CBC and Chemistry profile. White cell counts are crucial to check for infections caused by the foreign body. Radiographs, contrast studies, ultrasounds and the like are important for imaging a potential foreign body.
Diagnosis is made much easier if the client just saw an animal ingest or swallow a foreign body. A phone call to the veterinarian may be all that is needed. Just by using hydrogen peroxide to induce vomiting may be all that is needed. Most times people do not see the animal ingest the foreign body. It is than diagnosed via imaging devices or a good physical exam such as looking in the mouth, roof of the mouth and so on. Many times a foreign body can not be diagnosed. Suspected but one can not prove it. In those cases a call is made to do an exploratory laparotomy to find the offending foreign body. Some are radiolucent and can not be picked up via standard radiography.
Treatment depends upon what type of foreign body and where it is lodged. Foreign bodies in the mouth are removed with forcepts. Items in the esophagus and stomach are usually reached with an endoscope. Items in the intestinal tract may be allowed to pass (usually while hospitalized). Those that are identified as sharp may be removed by an enterotomy (intestinal incision). Some objects that are sharp and small may be treated medically by getting the animal to swallow a wad of cotton soaked in beef broth. Usually, the cotton catches up to the foreign body, envelops it and it is passed in the feces. A rupture of the intestinal tract is repaired or the section is removed and put back together (intestinal anastomosis). Perititonitis is treated with antibiotics, peritoneal lavage and by a peritoneal drain put in for post surgical lavage. The abdominal contents go through a culture and sensitivity to provide the most effect antibiotic combination possible; as peritonitis can be fatal if not aggressively treated.
The prognosis for most foreign body removals is excellent if recognized and treated early. Animals that develop peritonitis are at a greater clinical risk and have a much more guarded prognosis until the peritonitis is treated with antibiotics and lavages. When the animal is feeling better and radiographs are rid of the typical abdominal ground glass appearance, the animal is on its way to recovery.
Kennel Cough is a severe respiratory disease in dogs. It is caused by numerous pathogens but the most commonly diagnosed is caused by Bordetella bronchiseptica. Parainfluenza is a viral cause of the disease and usually produces mild respiratory disease in dogs. Kennel cough also goes under the name of tracheobronchitis.
Bordetella bronchiseptica is a gram negative bacterial organism that infects mainly young dogs or those that are immune compromised. It is commonly seen in areas where animals are housed in close quarters or in direct contact with one another. Examples are pet stores or shelters. Both Bordetella bronchiseptica and parainfluenza are both transmitted to animals via nasal droplets or respiratory secretions. Viruses can be transmitted on dust particles. These are called fomites.
Clinical signs are always respiratory in nature. Animals are anorexic, febrile and present with a hacky cough that sounds like a goose! Many have eye secretions associated with conjunctivitis in both eyes. They have difficulty breathing and many are presented with open mouth breathing or their forelimbs abducted making it easier to get air into their chest. Some dogs have mild signs while others will be presented with bronchopneumonia with the entire bronchi and lung fields congested.
Chest films are always performed initially and every day (to assess treatment) to check the severity of signs in the respiratory tract. A CBC and Chemistry profile are drawn to assess white cell count and organ integrity. The organisms can be cultured and isolated, if desired.
Diagnosis is made most of the time in a young animal from crowded conditions with associated clinical signs and or absence of parainfluenza or Bordetella vaccination. Culturing the agent can also be diagnostic but most veterinarians base their diagnosis on the above. Radiographs help instruct on the extent of the disease.
Treatment is based on the severity of clinical signs. Many puppies start out with a mild cough or runny eyes. These animals are usually treated with Clavamox® and Hycodan® syrup for cough. Nebulization is recommended at home. Many of these animals resolve but others get worse and need to be hospitalized. This entails: intravenous fluids and feeding, nebulization 4-5 times per day, treatment of the conjunctivitis with topical ophthalmic antibiotics and radiographs every day for clinical assessment. Clavamox® and or Baytril® are usually the antibiotics of choice whether used separately or together for maximum bacteriocidal coverage. Severe cough is controlled via parenteral butorphanol. The latter also eases a lot of the chest pain associated with acute cough. Once animals are breathing better with a clear lung field plus eating and drinking on their own, they are sent home on antibiotics, nebulizing supplies plus high caloric diets such as Hill's® Prescription a/d.
The prognosis for the vast majority of clinical cases of kennel cough are quite good. Tiny breeds such as Pomeranians or Toy Poodles with pneumonia are at a much greater risk due to their tiny lung fields.
Kennel Cough really weakens an animal's immune system. Vaccination is important but the animal has to be built up first, otherwise the vaccine can do more harm than good. All healthy animals should be placed back on a puppy vaccination program. This program also includes vaccination for the common causes of kennel cough: parainfluenza and Bordetella bronchiseptica.
Keratoconjunctivitis sicca also goes by the name of "dry eye". Tears are extremely important for eye functioning. They clear the corneal surface of dust, debris and mucous plus also lubricates the eye and surrounding tissues to minimize friction when the eyelids blink or the third eyelid rises. A deficiency in tear production in older animals is the most common cause of kerititis sicca in the dog. Tear production decreases can be often congenital or immune mediated. Medical induced KCS can be caused by the excision of the nicatating gland (cherry eye). Other causes can be eye irritants.
When tear production decreases, lubrication of surrounding ocular tissues is affected; particularly the cornea. The cornea can dry out and blinking can cause excessive friction and irritation. Vessels in the white of the eye (sclera) are inflamed as well as the subconjunctival tissues. Breed predisposition is always at play. This condition is seen commonly in Pugs, Pekingese, English Bulldogs or any other breed with an exopthalmic (protruding) eye structure.
The most commonly seen signs are: squinting of the eye, inflamed conjunctiva and vessels of the sclera, elevated third eyelid, presence of yellow, greenish mucous over the cornea and often the animal will paw at its eye trying to relieve the irritation. Severe cases can lead to corneal ulcers with possible loss of vision in the affected eye.
The most important test to perform is the Schirmer Tear Test. This is a dye impregnated strip that is inserted in the lower conjunctival sac that will monitor tear production. Normal readings in the dog or cat are about 18-20. Severe KCS produces reading in the 3-5 range and intermediate cases in the 8-16 range.
It is extremely important that the animal be screened for glaucoma at the same time by the use of a tonometer. Many dogs will have both dry eye and glaucoma presented at the same time!
Diagnosis is made by historical findings plus a complete physical examen. A Schirmer Tear Strip confirms the diagnosis. Clinical signs also lead towards a tentative diagnosis.
KCS can be present in one eye or both eyes at the same time. This is why both eyes are checked even though only one eye may be showing clinical signs. The other may be normal or a bit behind the other eye in clinical signs. Most treatments start with tear supplementation done 2-3 times per day. The patient is than reevaluated via a Schirmer Tear Test strip. If tear production has not been bumped up into normal ranges, 1% or 2% Cyclosporine drops are prescribed. Cyclosporine is an immuno-suppressant drug used in transplants and skin conditions but when applied to the eye, will stimulate tear production. Once Schirmer strips are normal, medication is continued life long with periodic Schirmer Tear tests performed.
If a corneal ulcer is diagnosed via a fluoroscein stain, the ulcer must be treated with appropriate antibiotics and restained in two weeks to check for corneal healing. All corneal ulcers heal from the outside in.
As long as there is no vision loss from an untreated corneal ulcer, most cases of KCS respond extremely well to medical care. It can not be cured but controlled with medical care.
The kidneys are extremely important for mammalian life. Their main function is to secrete urine which contains waste products (mainly urea) dissolved in water. They also regulate sodium and water re-absorption (via ADH). Urine is than passed through the ureters to the urinary bladder for storage. When the micturition (urinating) urge arrives, the urine is voided to the outside. Anything that upsets the apple cart will cause signs of renal disease. Renal disease can be broken down into: pre-renal, renal and post-renal. Causes of renal failure are many. Congenital, amyloidosis, bacterial, viral, toxins (anti-freeze), secondary to heart or liver failure are just a few of the causes. Renal failure can be acute or chronic.
The kidneys depend upon a consistent and reliable blood flow to and through the organ. This flow goes by the name of the Glomerular Filtration Rate (GFR). When it is interrupted, problems arise:
1. Pre-Renal Failure: In this type there is a clinical disease before the kidneys. This often includes heart, liver or circulatory issues. Insufficient waste products are delivered to the kidney producing signs of kidney disease.
2. Renal Failure: This is when the anatomy and or physiology of the kidney is altered. This prevents the normal production of urine leading to signs of kidney failure.
3. Post-Renal Failure: This type of failure is always below the kidneys and is produced by some obstructive disease of the lower urinary tract; either in the ureters, bladder or urethra.
In acute renal failure, damage to the kidneys is often minimal and will improve rapidly with appropriate medical care. Dogs or cats with chronic renal failure are usually suffering from parenchymal damage to the kidney itself. It barely functions. Acute failure dogs will produce very little urine initially. This is a survival response. In chronic failure the animals drinks excessive amounts of water and since kidney function is basically non-existent, produces urine concentration just a step above straight water.
Animals with renal failure are sick and I mean sick. They all have elevated Blood Urea levels. Urea is a depressant of the Central Nervous System (brain). Animals are sluggish, vomiting a yellow bile and have a characteristic halotosis associated with their renal failure. They rarely have an appetite. Animals may drink more water and urinate more. There may be blood in the urine. In severe cases, animals will be presented completely recumbent with typical Kussmaul respiration; deep and labored. These animals are extremely ill.
The most important tests are the CBC and Chemistry profile. Renal patients may be anemic since the kidneys are unable to produce the hormone, erythropoietin. This hormone stimulates the bone marrow to start manufacturing red cell precursors. The chemistry will show electrolyte imbalances (sodium and potassium), elevated phosphate levels PLUS an elevation in the BUN and Creatinine. Those tests determine renal function but the creatinine is the most important. BUN can vary even in normal individuals. Animals fed a low protein diet will have a low BUN. Regardless, these tests will be elevated when there is about 75% of renal tissue that is failing so therapy must be aggressive to save lives. A urinalysis is important. It will usually show a more dilute urine (normal is 1.025-1.030). Urine strips will show high protein concentrate in the urine. An ultrasound may be performed to visualize the form and structure of the kidneys. A Urine Protein Creatinine Ratio (UPC) is important. It will show if the animal is showing signs of glomerulonephritis. The glomerulous is like a drain in a kitchen sink. If debris is clogging the drain, water will not pass and will back up in the sink. This is exactly what happens in glomerulonephritis which makes renal failure even worse. In immune-mediated cases, antigen/antibody complexes "clog the drain".
A diagnosis of renal failure is made by a complete physical exam, history of clinical signs and particularly from the CBC and Chemistry profile. Diagnostic imaging may also suggest renal failure.
Treatment of renal disease depends upon the type of renal failure and whether it is acute or chronic. Many of these therapies will overlap in many circumstances. The most important treatment is trying to get the renal tissue functioning again, making sure obstructions are relieved plus eliminating as much urea waste as fast as possible. This involves intravenous fluids that are run at a relatively high rate without fluids backing up in the lungs. Diuretics such as furosemide are given intravenously to produce more urine and out through a urinary catheter placed earlier. Input/Output can be calculated by measure fluids in and fluids (urine) out. Nutritional feeding can be performed by a esophageal or stomach tube. All of these animals are vomiting and can not keep food down. They need combinations of Cerenia® with famotidine to keep vomiting under control. Urea not only depresses the CNS but is an extreme irritant of the mucosal lining of the intestinal tract. If there is no vomiting, the animal can be given carafate liquid or tablets orally. Phosphate levels are quite high so phosphate binders such as Aluminum Hydroxide are administered via a tube or orally when the animal can keep basic foods down. In acute failure dogs, animals respond reasonably quick. When they are not vomiting, a bland diet is attempted such as chicken and rice or Hill's® Prescription Canine k/d. To make these diets more palatable; sprinkling them with some Nutrical® or tuna juice will make it more palatable.
Many dogs with chronic renal failure will need off and on fluid support as well as phosphate binders and periodic injections of erythropoietin for bone marrow red cell precursors. These dogs drink a lot and urinate a lot so a large bowl of fresh water should always be present.
Most pre-renal failures are treated the way mentioned above. If there is concurrent heart or liver issues, those must also be addressed. In cases of post-renal failure, the obstruction has to be relieved surgical or medically so that there is no impediment of the flow of urine to the outside. In renal failure, what to do with the injured kidney varies with the cause. With renal amyloid, the entire renal architecture is one big glob of muck. Surgical excision is recommended. In pyelonephritis the above therapy plus intravenous antibiotics may work. In renal abscesses, an exterior drain or surgical removal may be necessary. When one kidney is removed leaving a healthy one, this is a classical case of normal hypertrophy. The remaining kidney enlarges taking on the physiological function of two. That is why all mammals can live with just one functioning kidney. Many of these animals will also undergo dialysis or abdominal lavage and drainage to control levels of urea.
The prognosis for rapidly treated straight acute renal failure is very good be it pre-renal or post-renal. The prognosis for renal failure due to tissue damage varies with the cause and treatment selected. Chronic renal failure has a overall long term poor prognosis. The animal becomes more debilitated over time with worsening renal functioning. There comes a time when medical therapy does not work anymore.
A laceration is a tear in any tissue. It can be of any length but what differentiates a laceration from an incision is that the latter is a smooth, delineated cut produced in tissue by a scalpel or laser beam. Lacerations may be jagged, irregular and involve multiple layers of tissue. Some are superficial and some are deep. Lacerations can be caused by: car accidents, stepping on sharp objects like glass or metal, animal bites, getting hung up on chain link fence (yes, I did treat one), getting caught in a metal trap, cats getting caught in fanbelts and so on. The causes are limitless and each wound is different.
When a laceration occurs, immediate cellular and tissue damage is done. Tearing of tissue causes the beginning of cellular death and decay. The skin is the largest organ in the body and one of its prime functions is to keep nasty pathogens from entering the body surface. The skin protects everything inside of it! If that barrier is broken, bacteria are allowed to proliferate causing a wound infection. Nothing can heal properly while there is infection. If this infection continues it may penetrate into deeper tissues; causing organ involvement in one way but also in another, by entering the blood stream. Bacteria than are free to travel anywhere in the body setting up multiple infection sites. With associated toxin production, this is called sepsis. All lacerations should be taken seriously; even if they are only half an inch in length.
The clinical signs of laceration presentation are as varied as the causes. They can occur anywhere on the body surface. They may be as long as the animal itself or only an inch long. Some have a jagged edge or a "V" type appearance; which is caused by a tear and the animal running away at the same time. Underlying tissue may be damaged, mainly the subcutaneous and muscle layers. Some lacerations will actually penetrate the adominal or thoracic cavities. The latter will cause the lungs to collapse since the thorax is under negative pressure. At a minimum, penetration of the thorax will cause a pneumothorax (air in the chest cavity). Dogs and cats will be in severe pain and will be limping if the lesion is on a limb. If infection has set in, many will be off their normal diets and be lethargic.
All laceration patients should have a CBC and Chemistry profile performed. The white cell count may be elevated if the patient wound is infected. If there has been blood loss, the red cell count will be lower. The chemistry profile provides an overview of general body functions. Other tests may be required depending upon the location of the injury. Chest and abdominal injuries require radiographs or an ultrasound performed.
Diagnosis is made on physical exam. Knowing the cause of the laceration makes it easier to understand what happened. Many times clients just see the injured animal without noticing what caused the damage in the first place. I got asked that all the time and my answer was often just speculative. In those moments, I wish pets could talk! Further tissue damage is best discovered or figured out when the animal is anesthetized and the wound can fully be explored.
The treatment of the wound depends upon the length and the severity of the laceration. A small half inch clean lesion will probably just be dabbed with a bit of surgical glue, wrapped and the animal placed on antibiotics for 2 weeks. The majority of lacerations require surgical care. If the lesion is small and the patient is able to be quiet, a local anesthetic is infiltrated and the wound is cleaned and stitched up. Many lacerations require surgical care under a general anesthetic or sedative. Wounds are first debribed. This means, that as much dead tissue is cut away providing a base for granulation (wound healing). If the wound is just superficial, the lesion is just stitched up. If their is damage underneath the skin lesion, it is repaired with multiple layers of sutures and a drain is placed to prevent formation of seromas (serum pockets that occur after trauma and form in "dead" space). There are lacerations that can not be closed by primary retention (skin to skin). Some have to fill in with scar tissue (third degree healing) and others can be brought together bit by bit over time (second degree healing). There are other flap techniques done by surgeons to close wounds on extremities. The goal is to provide as good an environment for healing to begin.
Wounds are than wrapped and the animal is placed on antibiotics for two weeks and anti-inflammatory drugs for about a week to control swelling. Some animals require analgesics such as Tramadol®. Most sutures are removed in about two weeks. Scar tissue does not have any hair follicles on it. If there is a scar that is usually not a problem in animals. Hair around the wound often covers or overlaps the scar area so it is not as noticeable.
The prognosis for almost all laceration repairs is excellent if diagnosed and treated promptly. If there are underlying problems such trauma to the abdominal or thoracic cavities, prognosis depends upon the resolution of those issues.