History and Signalment
Lucky is a 9-year-old male neutered Labrador who presented to his primary care practitioner for lethargy and vomiting, 5 days following a dental procedure. The patient had recovered well from the procedure and finished his 3-day course of post-operative Meloxicam with no obvious adverse effects.
However, Lucky started vomiting in the past 2 days and was just “not himself”. The primary care practitioner initially administered anti-emetics and kept Lucky in the clinic for further observation.
As the day passed, it quickly became clear that Lucky’s condition was deteriorating fast with his blood pressure dropping. After initial stabilisation at the primary care vet, Lucky was referred over to the ECC department at VES for critical care and further work-up.
At The ECC Department
That same night, Lucky was presented to the VES ECC department with a dull mentation and a systolic BP of 70mmHg, and was quickly stabilised with 50ml/kg LRS boluses. The following workup was carried out:
- Mild neutrophilia and monocytosis
- Mild hypoproteinaemia and hypoalbuminaemia
- AFAST ultrasound
- Free fluid was found in all 4 quadrants of the abdomen.
- Full abdominal ultrasound
- No glaring abnormalities beyond the free fluid
- Peritoneal fluid analysis, which found the following:
- PCV 2%
- TP 4.9g/dL
- Lactate “High”
- BG “Low”
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With the results above, our ECC team was highly suspicious of a septic process. The top differentials included a septic process that was gastrointestinal in origin, abscessation (hepatic, prostatic, etc), GI rupture or bacterial translocation, with no definitive answer to the cause on ultrasound.
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Our differentials for causes of GI rupture and bacterial translocation included:
- Foreign body
- Adverse drug reaction from meloxicam
Given the strong suspicion of septic peritonitis and the critical condition that Lucky was in, the owners elected for an exploratory laparotomy the same night to find the underlying cause of the septic peritonitis, and our specialist surgeon Dr Jayson was called in to perform the surgery.
Surgery For Lucky
The lucky thing about “Lucky” was that the issue was discovered very quickly: after gaining access to the abdominal cavity and suctioning out large amounts of brown abdominal fluid, Dr Jayson was immediately able to find a gaping gastroduodenal perforation with an obvious leakage.
However, no obvious foreign body was found, and so the edges of the perforation were debrided and submitted for histopathology, before being closed in single layer with 4-0 PDS.
A Jackson-Pratt active suction drain was placed, and Lucky was transferred back to our ECC department for ongoing care post-surgery.
Learning Point #1: Tips for an exploratory laparotomy from Dr Jayson
- Never be too distracted by the obvious problem (unless it is bleeding badly!). An obvious problem may not be the only problem. A systemic approach that you adopt consistently will help prevent you from falling into that trap.
- Never let the size of your abdominal incision hold you back. You need to see as clearly as possible. Use retractors where possible to get the best view of your surgical field.
- Flushing more is always better than less. It needs to be warm and a suction is very useful, if not essential.
- Always remember to consider taking tissue biopsies. This is especially important if the exploratory laparotomy did not reveal an obvious problem.
In the care of our hospital’s ECC team, Lucky recovered remarkably well in the next 5 days, and was able to make a full recovery to discharge.
But wait, we’re forgetting the most important thing!
What actually caused Lucky’s gastroduodenal perforation? The histopathology report came back with the following results:
- There is no evidence of neoplasia. Possible causes include foreign body or a severe response to chronic NSAID administration
But remember – Lucky only had a 3 day course of Meloxicam at the correct frequency and dosage! How did he end up with an NSAID related complication?
Learning Point #2: NSAID Toxicity should always be in the back of your mind!
As it turns out, some patients are so sensitive to NSAIDs that they can still develop gastric ulcers on appropriate dosages of NSAIDs, which can then lead to gastrointestinal perforations.
In a recent paper by Pfeifer et al., 2022, 60% of a population of dogs diagnosed with gastroduodenal perforations received only a single NSAID at the labelled dose. In addition, the majority of these dogs received a COX-2 selective NSAID.
Therefore, administration of an appropriate NSAID dosage does not rule out the possibility of a perforation.
Needless to say, Lucky is strictly forbidden from taking any NSAIDs from now on! Thanks to the observant owners and quick stabilisation of the primary care practitioner, our ECC and surgery team at VES were able to respond in quick fashion to produce a favourable outcome for our shared patient.
At VES, we work closely between departments, as well as with our referring clinicians, to develop the best plans for our patients and clients. We hope this case offered a glimpse into the way our specialists and hospital works.