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Wednesday, August 31, 2016

When You Get It......

Here's some veterinary humor that I came across on Facebook.  It may take you a second, but I'm sure many of my readers will laugh.

Monday, August 22, 2016

Undernourished Or Sick? Getting A Pet To Gain Weight

Recently a reader sent me an email with a question about their dog.  I think the situation is applicable to any pet, and is a good topic of discussion.
Last month, my dog, a 1 and a half year old female Belgian Malinois suddenly lost her appetite, shed a lot and resulting in her losing about 2++ kg from her previously 23 kg body frame. 
My vet gave her some antibiotics tablets for 2 weeks because he suspected it was tick fever, which he told me was common all year long in our location. 
She started to show interest in food again on third day after starting antibiotics, which is a great relief. Apart from her vomitting on the second last day on antibiotics, i think she is all cured now.
When she had recovered, she was still very thin, her hip bones are very visible, she has a very obvious abdominal tuck and waist, her lumbar vertebra is very pronounced, her ribs are showing at a certain angle. I would say she easily score a 2.5 in the body score chart. She stands at 24inches at withers, her weight was only around 20kg then. 
Even though she was still very very energetic, basically there was no obvious change in her energy level throughout the whole time, I was very concern on her weight lost, so on top of her usual diet of Royal Canin Medium Adult, I bought a high protein adult Orijen dry food to boost her weight.
I mix it half and half, but she did like the Orijen better. Her waist is not so obvious now, but her hips are still showing. 
She is also having soft runny stool, likely from the switch in diet and also the high protein?
I would like to know whether what I did was ok, was i too anxious about her weight and wanting her to put on weight fast, so I introduced a high protein food in her diet a bad thing? How to ensure my dog gain weight safely and properly post an illness? My dog is not food motivated but is highly energetic , which was why I always ensure she eats properly, but is my concern for her weight valid, as I have seen rescue dogs gaining weight beautifully anyway.
Please let me know your thoughts, i would love to know how to care for my dog properly post an illness.
The question here is why is the pet underweight?  Is it due to the recent illness, or is there something else going on?  Based on this email I'm not sure if any diagnostic tests were performed on the first visit, and I'll make a perhaps incorrect assumption that they were not.
Weight loss can happen for a number of reasons.  Maybe it's because the pet simply isn't getting enough food and calories, and would need to be fed more.  Maybe they aren't eating well for some reason, and we need to figure out why their appetite has decreased.  Some disorders prevent the intestines from properly absorbing nutrients, leading to weight loss.  Certain illnesses such as cancer can draw resources out of the body, resulting in other tissues being malnourished and a resulting decrease in weight and muscle mass.  At just a glance and doing only an exam there really isn't a way to tell which of these things is causing weight loss.
In a case like the one above I would first recommend starting with a simple, fast, inexpensive exam of the feces for parasites.  If there is a high number of parasite eggs we may be able to fix the problem with inexpensive dewormers.  If the fecal exam was negative I would want to run a full blood chemistry profile and complete blood cell count.  Kidney disease, liver disease, diabetes, and other disorders can be detected with these tests and could give an answer.  It may also be worthwhile to give a broad-spectrum dewormer such as fenbendazole (Panacur) even if the fecal sample tests negative, as no fecal test is 100% accurate.  If all of these tests were normal and the stools were soft or loose, I would probably recommend testing for a condition called exocrine pancreatic insufficiency (EPI).  This disorder happens because the pancreas stops producing certain digestive enzymes, and can be resolved with a simple dietary supplement. 
Assuming that all of these tests are normal I would try feeding more, and perhaps even giving a higher protein diet.  I wouldn't increase the protein level without first checking the kidney values on the chemistry profile.  While high protein levels aren't the only source of "stress" to the kidneys, we need to be careful with it if there is kidney damage.  I would also consider switching to a different brand of food based on the vet's recommendations, and at least temporarily using a puppy formula to promote weight gain.

As you can see there is more here than simply feeding more or using a high protein food.  The problem may not be a deficit of calories and may actually suggest a more serious health problem.  If there are underlying diseases or health problems simply increasing the food intake isn't going to help.

Friday, August 19, 2016

Doing Surgery Immediately Is Sometimes The Best Option

In my last post I talked about when waiting to do surgery is sometimes in the best interest of the patient.  However, that's certainly not always the case.  As a contrast, I want to talk about another real-world case where the opposite situation occurred. 
The patient was a five month old mixed breed dog.  She came in for vomiting, not eating, and seeing some cloth in the feces.  The clients were limited on funds and couldn't do much on the first visit, so one of my associates gave her some symptomatic treatment for an irritated digestive tract but told them that they needed to watch her closely.  Two days later she wasn't any better and came back.  This time the client allowed us to do x-rays.  There was certainly something unusual in the abdomen, though we couldn't identify exactly what it was.  In the cranial (front part) abdomen there was  an unusual pattern on the x-ray, which made us suspicious.  We really thought that we needed to do an exploratory surgery, but the owner didn't think they could do that.  We ended up having to send her home again to let the owners discuss the situation.
Thankfully they came up with the funds and the next day I did surgery on her.  Once I got into her abdomen I quickly saw three parts of the small intestine that were folded in on themselves, (called an "intussusception".
[Sorry that I don't have any photos for this case, but my phone was messing up and wouldn't save any pictures.  I ended up having to replace the phone.]
This is a very, very bad condition.  If it goes on long enough intussuscepted part of the bowel can lose blood supply and start to die.  The back-up of intestinal contents quickly becomes worse and stretches the bowel.  So when I saw three of these areas my heart skipped a few beats.
As I explored more I saw that these areas of intestine were inflamed, but still had a good blood supply.  Our first big break!  As I inspected the intestine I felt something firm and long inside, what we call a linear foreign body.  These are dangerous kinds of foreign objects, and are typically something long and thin such as string, rope, etc.  The object itself doesn't pass through easily, and as the normal contractions of the intestine (peristalsis) moves along it the intestine starts to bunch up.  Imagine a thread through the pleats in a curtain.  When you pull on the string to open the curtain, the curtain bunches up and folds.  This also happens to the intestine.
I found a picture from another site that shows a different vet with a similar case.  Notice the smooth, flat part of the intestine on the lower left of the picture.  That's the normal section.  The top and right of the image are bunched up, which is due to the linear foreign body.  In my own case this resulted in a full inversion of the intestine.
As I continued to explore I saw that there was a very long section of intestine that was affected and which contained the foreign object.  I finally found a larger ball of material at the far end, which indicated the extent of the problem.  From that point I was able to make a small incision in the intestine and slowly removed the object.  Our second big break was that I was able to slowly work this very long material out of a single incision.  Sometimes we have to cut the object into small pieces and make several small incisions in the intestine, but in this case I was able to work with only one area, which significantly lowers the risk of complications.
The rest of the surgery went well and was uneventful.  Once the object was removed the intestines quickly started returning to a normal appearance and the swelling started to decrease slightly.  After closing her up and ensuring she was recovering well I examined what I had removed.  This is where I wish I still had those photos!  The foreign object was a strip of women's underwear about 18 inches (45cm) long!  As it was chewed it unraveled and turned into a long strip, which then caused the obstruction.
The clients and the patient were very, very lucky.  This was a case where we did NOT want to wait on surgery to see if the object would pass.  We were already in a risky situation because the surgery was delayed by several days.  I don't really fault the client, as they weren't financially prepared to handle that kind of crisis, and thankfully were able to come up with the money.  If they had waited a few more days we may have had permanent damage to the intestines resulting in a perforation of the bowel, or the need to remove a large section of intestine (a much more expensive and risky procedure).  Doing the surgery right away was necessary to save the dog's life.
These two cases show some of the challenges of being a vet.  When do we decide to postpone a surgery?  When do we jump in immediately?  What is best for the pet?  Sometimes it's not always clear-cut, and I've had situations where we did an exploratory but found nothing, as well as situations where a dog died because the owners postponed surgery.  Sometimes we can get a better idea with ultrasound as well as x-rays, but most vets don't have an ultrasound machine.  In the end it comes down to a risk assessment based on the clinical presentation, lab tests, and to some degree the vet's experience and instincts.

Tuesday, August 16, 2016

Waiting On Surgery Is Sometimes The Best Option

I love soft tissue surgery and do some fairly advanced procedures.  I have no hesitation to jump in and open up a stomach or intestines to remove something that a dog has swallowed.  But despite my interest in this part of veterinary medicine I never want to do a surgery without it being absolutely necessary.  Every surgery carries at least some risks, and GI surgeries are riskier than most.

Recently a client came in because her dog had chewed up a toy tire and had vomited up some of the pieces.  One of our associate doctors took x-rays and saw a large number of pieces of the toy in the stomach.

On the above image you can see small white pieces on the lower left side of the radiograph, which is the stomach.  If you look closely you can see that these pieces actually fill up most of the stomach.  And this was the day after the client noticed the pieces that were vomited up.  There was a high likelihood that the toy pieces weren't going to pass through and surgery was going to be necessary.

The other doctor saw this dog later in the afternoon, too late to jump right into surgery.  Since the dog was stable it was decided to wait until the next day when I would be there since I was more experienced with these kinds of procedures.

I saw the dog that morning and he was wagging his tail and acting normal.  I told the client that I wanted to repeat the x-rays to see if there was any movement of the pieces.  They were hesitant to do so because of the additional cost and the fact that 24 hours after chewing it up the toy was still in the stomach, suggesting that it wouldn't pass.  But I explained that if the x-rays showed it was out of the stomach we may not need to do surgery; and even if it had started to pass I'd have a better idea of where to look during surgery.  Finally, though somewhat reluctantly, they agreed.  Here are the x-rays on that day (the day after the one above).

Compare this image to the one above.  The white pieces are no longer in the stomach!  You can actually see them in the intestine on the far right.  So I took some additional views to better see exactly where it was.

If you look closely you will see that pretty much all of the pieces of the toy are in the lower digestive tract.  Specifically they are in the colon.  This is most easily identified on the lower image with the pieces fully in a tubular shape on the left side of the abdomen (right side of the image).  The colon is the widest part of the intestinal tract, so if something has made it that far it has already gone through much narrower and more winding areas.  So if an object has made it to the colon, it is virtually assured that it will pass the rest of the way in an upcoming bowel movement.

The repeated radiographs showed that no pieces remained in the stomach and everything had passed into the colon.  I said that the next time the dog defecated he would pass most of the toy pieces.  We decided to postpone surgery and watch the dog.  He did fine and was acting normal and eating well the next day.

By spending less than $200 on x-rays we avoided a $1500 surgery and the associated risks.  If I had just gone straight into surgery without repeating the images I would have discovered the pieces in the colon after having found an empty stomach and intestinal tract.  That's not the time that you want to learn that surgery wasn't necessary!  If it had turned out that the pieces were still in the stomach w would have headed to surgery and I would have had a much better idea of exactly what to expect.  Either way the x-rays were necessary and important.

This was a great case of why not immediately jumping into surgery is sometimes the best option.  But that's not always the case.  In my next post I'll talk about a similar situation with a different recommendation and outcome.

Saturday, August 13, 2016

He's Neutered, So Why Is My Dog's Penis Swollen?

Many times over my career I've had clients come in with their neutered dog, worried because they thought he still had testicles.  Or they may have thought that there was a tumor growing.  Thankfully most of the time this is a simple issue because people don't know canine anatomy.

Dogs have a structure at the base of the penis called the bulbus glandis.  This is a knot of tissue that surrounds the penis and becomes enlarged during erection.  In intact (un-neutered) males this is the "knot" that locks them into a female during intercourse.  

So why does this structure enlarge in a neutered dog?

Growth of the bulbus glandis does not happen in a neutered male due to sexual activity.  With a lack of significant testosterone levels they don't feel sexual attraction or excitement.  However, "excitement" can be due to non-sexual reasons.  When a male dog gets happy and excited due to play, the bulbus glandis can become swollen.  Typically when I see this it's in a very energetic, happy-go-lucky young dog that loves attention and play.  Having this happen is normal and nothing to worry about.

The key to recognizing the bulbus glandis is that it comes and goes.  When your dog is resting or asleep it shouldn't be enlarged.  If the swelling is persistent under any circumstances, or if you're simply not sure what it is, have your vet take a look.

Wednesday, August 10, 2016

Severe Anxiety....Euthanize Or Not?

This question comes from Nicole, and I'm sure many dog owners can relate to her situation.

I have a question about euthanasia. Not for health reasons but for quality of life reasons.

We have a 12.5 year old German Shepherd / Husky / Boxer mix. (We know she is definitely 50% husky as her mother was a purebred Boxer - they speculate her father had to be a GSD/Husky mix bc of Bella's appearance)

Bella has had destructive separation anxiety and noise anxiety her whole life. She outgrew the separation anxiety, for the most part, by the time she was 3 or so. She used to rip through solid wood doors (at 4 months old), try to dig through floors, rip of rugs, etc.

We have not found a crate to hold her. She shredded one year breaking out of one of those black metal crates on more than one occasion. We switched to the plastic airline style crate and she ripped off claws and teeth trying to break out one night when the neighbors were lighting fireworks.  She put a hole in her skull when she broke through the sliding patio door during a thunder storm - she, for some reason, wanted to get under the deck outside. At some point she tried to stand up under the 8" tall deck and got a nail through the top of her head. She hides under our bed during most storms and, at least one time, has tried to stand up under the bed and lifted us up (I weigh 300 lbs, my husband 200 lbs, plus the weight of box spring and mattress) so high that she's been able to jump out between the box spring and bed frame.

Her reaction to storms, fireworks, and now loud bass from passing cars is getting worse and worse. Her heart beats so hard and so fast it feels like it's going to explode. She was given 1mg Xanax 2 years ago by a vet after being treated for the nail through the head. I take 1mg Xanax myself and it knocks me out within minutes. It gets her to at least lay down instead of pacing and harming herself, but she's still looking panicked & bug-eyed and panting. After 1-3 hours she'll eventually drift off to sleep.

Add to this, she slowing down a lot. She was always the kind of dog to chase a ball and run around the yard. The last two summers we noticed her slowing down, but this year it's so much worse. She used to love being outside. Now we go outside and the other two dogs want to play and she drags us towards the house and wants to be let into the basement where she just lays on a dog bed. When I can convince her to stay outside, she will lay near me and growl at the other dogs if they come near her or she'll just walk circles around my chair 'til I eventually bring everyone in the house.

And she seems to be less able to see and hear us. We will call the other dogs "lets go potty" and she won't even perk up her ears or acknowledge that were speaking to her. We've been right in front of her saying "Bella, let's go potty" and clicking the leash "hook" and she doesn't show any recognition that were speaking to her. Her house have been kind of cloudy since she was 7 or 8, but the past 6-8 months they're sometimes so clouded over I wonder if she can see at all. (Amazingly, sometimes they're clear so I don't even know what's going on)

But our main question is, with her FREAKING OUT during storms and noise in general, should we consider euthanasia?  We know it's a tough choice bc we had to euthanize one of our Beagles in 2009 when her kidneys were failing and it was the most painful thing to watch Daisy go. We just don't want Bella to be miserable and anxious every day. I have severe anxiety myself and I know what it feels like, I don't want her to feel that way, too.

Thanks for any input you can offer.

Nicole, it doesn't sound like you've exhausted all possibilities with her, and I think that there are still some things that help.  As someone who has dealt with various degrees of anxiety and clinical depression myself, I understand what it can feel like for these pets, and I completely sympathize. 

I am in complete disagreement with vets who only prescribe sedatives for anxiety, even noise-related problems.  Acepromazine is a common tranquilizer that even I used to prescribe until I learned better.  Sedatives don't actually fix anxiety.  They make the animal too sedated to do much, but the anxiety is usually still present.  So really they are still feeling anxious but can't work up the energy to do much about it.  I don't think that's the right way to treat this kind of problem.

Alprazolam (Xanax) and trazadone are two common medications used for short-term anxiety.  They are nice because they absorb quickly into the system and start to work immediately without the need to build up in the body.  The down side is that they are short acting, usually being effective for only a few hours, typically no more than six or so.  So these drugs are good for patients who are usually free of anxiety but experience some during a limited, relatively predictable circumstance such as fireworks or thunderstorms.  Because of their short efficacy time they aren't really good options for long-term control of anxiety.

Better choices are drugs like fluoxetine and clomipramine. These are good for long-term problems and are designed to be used on a daily basis.  They take three to six weeks for full efficacy, so it's not a short-term solution, but they are good for long-term use.  In fact, they can be used along with the shorter acting medications above.  I've had patients that are pretty well managed on fluoxetine daily, but still get anxious during storms.  In these cases we'll use alprazolam for that day.

It doesn't sound like you've exhausted the possibilities in controlling your dog's anxiety.  There are actually many options left, including various medications, behavioral therapy, and desensitization techniques.  I would strongly recommend finding a vet who is skilled in treating behavioral disorders.  This may take a bit of calling around, as many vets don't take the time to get the training to handle behavioral problems in the appropriate way.  If you don't have a vet who you feel is qualified in this area, ask your vet about a referral to a board-certified behavioral specialist (a member of the American College of Veterinary Behavior, or similar organizations in other countries).  You do not want a pet trainer!  You need a veterinarian who can prescribe medications as well as discuss non-medical ways to help her behavior.

I definitely do not recommend euthanasia until you have investigated these other options and have seen no improvement whatsoever.  But because you still have many options, please look into those before deciding on such a final option.

Wednesday, August 3, 2016

Does Euthanasia Burn?

Lisa sends in the following scenario.

My 8 yr. old male Shih Tzu suffered from seizures.  In the last 3 years, we tried many drugs, including the standard protocol of phenobarbital and K bro. He ended up having a toxic type of reaction to the K Bro.  We tried Keppra  but the seizures kept on coming, and then finally moved to phenobarbital once again, along with Zonisamide.  We thought we found the perfect dosage, and we had mild seizures usually about 1 a month.  Nothing like the full blown grand mal seizures we had experienced before.

Unfortunately, he began having break through seizures, with his last session of 10 seizures in 2 days.  He also began pressing his head against the wall which was a new symptom.  We believed that perhaps he had a brain tumor.   

We decided to put him down since the seizures seemingly were becoming uncontrollable and would not respond to diazepam shots when he had the last 2 seizures. 

I asked the vet before the procedure if he needed a sedative as they did with our lab, as her euthanasia was a 2 shot process.

With our little Buddy, he put a catheter in him and told me he didn’t need the extra sedative and that it would take effect in 20 to 30 seconds.  I was holding him underneath his ribcage with his head on my shoulder, face was away from me.  My husband had the bottom half of his torso.  While he was passing, he began to breathe hard and deep, and took 4.5 deep, deep breaths.  He was also very hot to touch under his rib cage. 

My question is: Did this burn as it was going through his system?  Did it paralyze him?  Because I just have this strong feeling that a sedative type of solution wouldn’t cause the burning or hot sensation that I felt.  His heart also SPED UP before it stopped.  I feel haunted that maybe it burned but he was in pain for about 40 seconds but that he couldn’t move.  Any insight you could give would be helpful.   
Euthanasia solution is essentially anesthesia.  Other drugs within that same category used to be used (at a much lower dose) to induce anesthesia.  Nowadays we have much safer induction agents so we don't use these drugs anymore.  But what happens during anesthesia and euthanasia has many similarities.

When used appropriately, euthanasia solution first induced unconsciousness similar to inducing anesthesia.  The brain activity decreases before anything else happens, and I've been in situations where the pet needed a higher than expected dose, but they weren't conscious while we were giving more.  As the drug works through the system the brain activity continues to decrease and eventually completely stops.  Once that happens the heart no longer receives signals to contact and will also stop but the animal isn't aware of this.  Essentially the patient falls asleep, and then continues to get deeper and deeper until all body functions cease.  Since the first thing that happens is unconsciousness they are not aware of the rest.  At no point should an animal be paralyzed but conscious during euthanasia.

Deep, hard breathing is normal in the last moments of life, and represents a change in the function of the respiratory and cardiovascular systems.  Sometimes you can even see a deep "gasp" or "breath" after death, due to the diaphragm and other muscles continuing to have involuntary contractions.

The heart wouldn't speed up in the last moments of life, at least not in my experience.  However, the heart may temporarily "flutter" and have arrhythmias.  This could be potentially interpreted as "fast", even though it really isn't.  What is more likely to have happened is a condition called atrial fibrillation, where the atria (the top chambers of the heart) are spasming and contracting in a rapid, abnormal pattern.  The heart has two sets of pace makers that can stimulate contraction and beating when the brain isn't sending the right signals.  During death and with these drugs you can get a temporary arrhythmia due to the abnormal electrical signals in the body.

Again, the animal is aware of none of these things happening.  They are unconscious while the body is shutting down.

I have never experienced or heard of a sudden heat or warming during euthanasia, and I have performed this service on many, many dogs, cats, and other animals over my career (19 years as of this writing).  I have no explanation for that phenomenon, but it's not typical and I would think that it wasn't a true burning sensation.

Many vets will use sedation prior to euthanasia, truly inducing unconsciousness before giving the euthanasia drug.  If the pet is relatively easy to handle I've never seen a need for sedation.  The vast majority of animals I've euthanized have quietly passed away in less than 30 seconds.  I don't think there is anything wrong with giving a sedative, but I also don't think it's usually necessary and would never criticize a vet for choosing not to use it.

Lisa, I'm sorry that this seemed to be difficult for you and that you lost your friend.  Try and take comfort that I don't think he felt anything during this process, and it sounds like it was actually a peaceful passing.