Case of the Week: Sequoia

     Sequoia is a 12 year old Bichon Frise that came to our clinic with a recent history of bloody diarrhea.  Routine blood and fecal testing failed to reveal a definite cause for her problem.  Since Sequoia was otherwise feeling great with an excellent appetite and no weight loss,  she was treated symptomatically for inflammatory bowel disease of the colon.  Her treatment included a special diet with Probiotics, anti-inflammatory and intestinal antibiotic medications.   Unfortunately, these therapies had little beneficial effect and Sequoia's problem progressively worsened.   When it became apparent that standard medical therapy was ineffective, we scheduled Sequoia for a comprehensive battery of advanced diagnostic tests on October 19.  
     Following an overnight fast, an abdominal ultrasound exam was performed.  This exam revealed an unusual tissue change localized in Sequoia's descending colon.  This type of change was suggestive of a possible tumor.  The arrows in the following ultrasound image point to the suspected tumor.

                                          

       The ultrasound exam was then followed by a colonoscopy under general anesthesia to allow for visualization and biopsy of the diseased tissues.   The colonoscopy revealed a mass of severely inflamed hemorrhagic tissue suspicious for colonic cancer.

     Following the colonoscopy, Sequoia was taken to radiology for a specialized x-ray series known as a "barium enema".   These x-ray images allow us to even better define the degree of disease change affecting the colon.   The arrows in the following x-rays point to the mass in the colon that is seen as a "filling defect".

     The most likely diagnosis based on these images was cancer of the colon known as "adenocarcinoma".  This type of cancer is highly malignant and rapidly spreads throughout the body.   Sequoia's owner was informed of the likely diagnosis and agreed to have surgery scheduled as soon as possible to remove the mass, even knowing that it may be too late to save Sequoia.

     Our surgical specialist, Dr. Bruce Berger, was immediately scheduled to perform this difficult and delicate complicated surgery.  The surgery required removing a 12 cm length of Sequoia's colon and took almost 3 hours to complete (even with a second surgeon's assistance for much of the procedure).

     Sequoia recovered from her lengthy anesthesia and surgery without complication.  Following 2 days of ICU post-op hospital care she was discharged to her owner's loving care. 

     The following video shows Sequoia demonstrating her desire to go home less than 48 hours after her surgery.

 

     Sequoia continued to recover beautifully at home and was back to normal with "lovely normal bowel movements" within 10 days of her surgery.

      To make Sequoia's story even better, the biopsies returned a diagnosis of polyploid adenomatous colitis, a pre-cancerous disease that is cured by surgical removal.

     Here's our girl at the time of her suture removal, 13 days following her surgery.

     Sequoia's case is noteworthy for several reasons.   

     First, her disease would not have been diagnosed without the use of our hospital's advanced diagnostic testing services: ultrasonography, endoscopy and digital radiology.

     Second, early diagnosis and aggressive treatment was critical to resolving Sequoia's disease before it progressed to colonic cancer.  Sequoia's disease is very similar to the colorectal disease in people that leads to colonic cancer and is the reason for routine human colonoscopic exams.

     And perhaps most importantly, her case demonstrates that our older pets are perfectly capable of undergoing lengthy anesthetic and surgical procedures.   All too often we see pets that have been forced unnecessarily to live with painful and debilitating medical problems due to the owner's misguided assumption that their pet is "too old for anesthesia".   With proper pre-anesthetic screening tests and our more advanced anesthetic delivery and monitoring systems, we are capable of successfully anesthetizing geriatric patients with a variety of disease problems and returning them to better health.

Sequoia is a shining example.

Blog changes to "Case of the Week"

     I've been finding it increasingly difficult to come up with fresh, entertaining and informative blogs of late.  It's not due to a lack of ideas or important veterinary topics.  It's finding a way to make the blogs entertaining and educational at the same time that's proving difficult.
   
     What I do find to be both easy and entertaining is discussing interesting medical cases that we see in our hospital.  Discussing these cases helps to put a more human face on the veterinary medical problems faced by my clients with their own pets.
   
     So, instead of writing a topical blog, I plan to present an interesting "Case of the Week" to highlight some of the more fascinating veterinary cases that challenge us each and every week.   Beware, some of these cases are sure to break your heart while others will brighten your day.
   
     One of my very first blogs was such a case presentation about "Murphy the Wonderdog".  To finish the Murphy story, I'm happy to report that Murphy enjoyed a full year of good health following her surgery.  This was a year that Murphy and her owner would have been denied without the combined efforts of everyone that contributed to her care.   Murphy served as an inspiration to us all.  It is to Murphy's memory that I wish to dedicate our new "Case of the Week" series.
   
     Check back next week to see our first installment.

Cancer - early recognition and diagnosis

     Just as with people, cancer is one of the leading causes of pet deaths. Also, as with people, early diagnosis of cancer gives us the best chance of curing or managing your pet's cancer. Early diagnosis requires recognition and close monitoring of many factors.   Some cancers show themselves as "lumps" that can be seen or detected by touch.  Other cancers are strictly internal and will require advanced diagnostic testing to detect.
     Pet owners should examine their pets for lumps at least once each month.  This will require a thorough visual and touching exam.  Run your hands over your pet's entire body surface.  Be sure to feel under the arm pits and groin areas.  Feel along the pet's underside for breast lumps.  Examine between the toes and the bottoms of the feet.  Look in and around the pet's ears.  Lift up the lips and examine around the gums.   Feel the glands under the pet's neck.   If you find any lumps, record the date, the location, the approximate size and any other characteristics you notice.   If the lump is painful or ulcerated, have your pet examined by the veterinarian an soon as possible.  Otherwise, schedule a veterinary appointment at your earliest convenience.  If you are unable to have your pet examined right away, recheck the lump(s) every few days and record any changes.  Be sure to bring this record to your pet's appointment.
     Some lumps are difficult to detect while others are very obvious.  This lump is of the obvious variety but demonstrates how massive they may become if left untreated.

     Fortunately, most of the lumps that pets develop are benign growths.   However, many lumps are cancerous growths.  This can usually be determined at the time of your pet's examination by aspiration and microscopic examination of cellular fluid removed from each and every lump.  No lump can be accurately diagnosed by "feel" alone.  Insist that each lump be properly examined.  Lumps that are suspected to be cancerous should be removed and biopsied as soon as possible.  The earlier this is done, the better chance your pet's cancer can be "cured".
     This is a photomicrograph taken of an aspiration sample from a innocent appearing smooth lump under the pet's skin.  The owner had been told previously by another veterinarian that the mass was just a "fatty lump" and not to worry.  The aspiration sample taken as part of our comprehensive exam confirms the lump to be a Grade 2 malignant Mast Cell Tumor.  Surgical removal of the mass was curative.

     This ugly "mass of lumps" around the pet's anus was caused by a type of cancer, perianal adenocarcinoma, that we were able to cure by surgery to remove the cancerous tissues and reconstruct the anus.

     Unfortunately, some of the cancerous growths cannot be cured by surgery alone.  These may require follow-up chemo-therapy, radiation therapy or one of the new cancer vaccines to offer your pet a better chance for long term good health.
     This lump in the pet's groin was found by the owner during a routine home exam.  The patient was seen as a Sunday emergency and the lump was diagnosed as Lymphosarcoma at the time of the exam.  This is a treatable cancer that usually responds well to chemo-therapy and the patient was referred to an oncology specialist to begin therapy.

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     Internal cancers, by their very nature of being "inside" the pet, are nearly impossible for the pet owner to find at an early stage of the disease.  Pet owners usually notice that the pet is "sick" with signs of weight loss, decreased appetite, vomiting, etc.  This usually means that the cancer is quite advanced and our chances of curing the pet are greatly reduced.  However, even these internal cancers can be caught in the early stages with proper diagnostic testing.   
     This x-ray shows a tumor in the lungs and on the spleen.  Neither of these cancerous tumors were evident on routine physical exam or indicated by blood testing.   X-rays were required to show the presence of the masses.  Both of these masses are potentially surgically removable.

     Cancerous tumors of the spleen are are very common in older dogs.  Early diagnosis is best done by ultrasound examination.   Ultrasound allows us to determine the size and shape of the mass and to better assess the possibility of surgical removal.   Ultrasound also allows us to biopsy an internal mass without the need for full exploratory surgery.   This ultrasound image is from the spleen of the dog in the previous x-ray.

     This x-ray shows the presence of a large cancerous mass in the abdomen of a captive Bobcat.  This mass was detected far beyond the point of being curable.

     At risk pets should be thoroughly examined and properly tested every 6 months.  These tests include a complete blood count (CBC), chemistry profile, urinalysis, chest x-rays, abdominal x-rays and abdominal ultrasound exams.   At risk patients include large breed dogs over 7 years of age, small breed dogs and cats over 10 years of age and certain breeds that are prone to cancer.
     If your pet falls into one of these categories, consider having a proper cancer screening scheduled for your pet at your earliest convenience.
     We at the Verandah Pet Hospital are committed to providing the very best medical care to help insure a long and healthy life for your pet.  To that end, we have developed discounted diagnostic cancer screening packages to help make proper medical testing for your pet more affordable.   Please call us to find out what we recommend for your pet.

Pyometra - another reason to spay your pet!

We all know the benefit of spaying our female pets to prevent unwanted heat cycles and litters. But did you know that spaying also prevents a life-threatening disease known as pyometra? The term pyometra is derived from Latin pyo meaning pus and metra meaning uterus. The disease occurs when the uterus becomes infected resulting in an abscessed pus filled uterus. The infection causes bacteria and toxins to leak into the bloodstream. Without treatment death is inevitable from the resulting septicemia and toxemia.

The typical patient is a middle-aged to older female dog that has undergone a heat cycle within the past 2 months. The heat cycle results in fluid accumulating inside the uterus; bacteria then ascend from the vagina and the uterus becomes infected and ultimately pus filled. The patient usually loses her appetite while drinking an excessive amount of water. As the disease progresses, she becomes weakened and lethargic and usually begins vomiting. The patient may have a discharge from her vagina if her cervix is open and allows some of the fluid to drain. However, many patients have a closed cervix and no discharge is seen. These patients tend to be sicker since the toxins and pus have no outlet.

The diagnosis is best made by ultrasound examination which quickly confirms the presence of a fluid filled uterus. Without ultrasound the diagnosis can be quite challenging and may require exploratory surgery.

Treatment requires immediate surgery to remove the uterus and ovaries. The surgery can be very challenging, especially if the patient is toxic. Aggressive antibiotic and IV fluid therapy are also essential to resolve the infection and reverse the toxic damages to the body.

Due to the complexity of the surgery and additional supportive therapy, the pyometra surgery typically costs 4-5 times as much as a routine spay surgery.















This is a picture of a normal uterus of a 55 pound dog following a routine spay surgery. Note the size of the uterus in relation to the ruler & surgical instruments.














This is a picture of a uterus filled with fluid which has not yet become infected. This patient would have developed a pyometra in the near future if the owner had delayed spaying much longer.
















This is an ultrasound image showing a section of the uterus filled with fluid. The patient was taken to surgery and the uterus was removed.

This is the pyometra uterus that was surgically removed. Note the size of the uterus in relation to the surgical instruments. This patient was also 55 pounds. As expected, the fluid filling the uterus was pus.

Spaying represents complete prevention of this disease and cannot be over-emphasized. Often owners plan to breed their pet or are undecided, time passes, and they fear she is too old to be spayed. A female dog or cat can benefit from spaying at any age. The best approach is to figure that pyometra will eventually occur if a female pet is left unspayed; any perceived risks of surgery are greatly out-weighed by the risk of pyometra.

Murphy the "Wonderdog"

Murphy is a sweet 12 year Boston Terrier. She is the constant companion to a wheelchair bound paraplegic client. Ten days before this past Thanksgiving, Murphy came into the hospital with labored breathing and coughing.

Murphy's exam revealed a heart murmur and diminished lung sounds suggestive of fluid in her chest. Digital x-ray imaging of Murphy's chest confirmed the presence of a moderate amount of free fluid in Murphy's chest cavity. Murphy's heart also appeared somewhat enlarged which is suggestive of additional fluid accumulation within the pericardial sac which surrounds the heart. Some of the fluid was aspirated from Murphy's chest and submitted to our pathology service for diagnostic interpretation. The pathology results suggested the presence of a tumor as the source of the fluid accumulation.

Digital x-rays of Murphy's Chest:

The digital x-rays were forwarded through the utilization of our hospital's telemedicine capabilities to both a veterinary radiologist, Dr. Ron Burk, and veterinary cardiologist, Dr. Wendy Arsenault, for additional interpretation. Both of these specialists believed a tumor was likely and an ultrasound exam of Murphy's chest was recommended. Our ultrasound exam confirmed the presence of fluid within the pericardial sac which is even stronger evidence for the presence of a tumor at the base of the heart.

Ultrasound images showing fluid in pericardial sac:

Arrangements were then made to have one of our clinic family members transport Murphy to Dr. Arsenault's clinic in Bonita Springs for a definitive cardiac ultrasound evaluation. That exam revealed the presence of a "chemodectoma" tumor arising from the base of her aorta. The tumor was causing a progressive buildup of fluid within the pericardial sac and would soon end Murphy's life. A life saving open-heart surgery known as a "pericardectomy" would be needed if Murphy was to survive.

Arrangements were made to have a veterinary surgical specialist, Dr. Bruce Berger, perform the surgery in our hospital on the Tuesday before Thanksgiving. On that same day, Murphy's owner was having surgery to remove her gall bladder.

Murphy's surgery required Dr. Berger to open up Murphy's chest to completely expose her heart. Dr. Berger then made an incision into the pericardium and meticulously dissected the pericardium for around her entire heart. Throughout this procedure, Murphy was unable to breathe for herself and required our nurse-anesthetist to breathe for her using manual intermittent positive pressure ventilation. Each breath had to be carefully coordinated with the surgeon to insure proper safety during the surgical dissection and proper inflation of Murphy's lungs. The surgery lasted almost 2 hours and Murphy resumed normal breathing on her own at the completion of the surgery.

Murphy spent the next 3 days recovering in our hospital and at the Piper family home. She was the star guest at the Piper Thanksgiving celebration. Murphy was discharged back to her owner's loving care 3 days after her surgery where she can once again be found in her favorite place - mom's lap.

Murphy at the time of her discharge:

I wanted to share Murphy's story with you for several reasons. First of all, this was a great Thanksgiving blessing to all of us at the hospital that worked so hard to save Murphy's life and to Murphy's lovingly devoted owners that entrusted us with her care. It was truly one of the most uplifting and satisfying things we have ever done in our 29 years of service. Secondly, Murphy's case demonstrates the advanced diagnostic and therapeutic services we are able to provide our patients in their time of need.

Urinary Calculi: Bladder and Kidney Stones

Just about all of us have heard stories of people "passing kidney stones". However, most of my clients are surprised when their pet is diagnosed with either kidney or bladder stones. Dogs, in fact, are quite commonly affected by the formation of stones in both their kidneys and bladder. The stones are composed of varying mixtures of minerals that accumulate within the urinary tract. The particular type of stone that forms is determined by several factors including diet, water consumption, breed predispositions, urinary tract infection and medical conditions that affect the pet's metabolism.

The most common symptom observed in patients is an increased frequency of urination. This may also be accompanied by straining to urinate, dribbling of urine or the passing of blood in the urine. These are symptoms that should be checked out by veterinary examination ASAP.

Male pets (canine and feline) frequently become partially or completely blocked when trying to pass the stones. A urinary blockage is a life-threatening emergency and requires immediate veterinary attention. The first x-ray image is a cat that was completely blocked with small bladder stones that had become wedged into the urethra. This cat required emergency catheterization to relieve the obstruction and surgery to remove the stones. The second x-ray is a dog with numerous bladder stones in the bladder and a large accumulation of stones in the urethra at the base of the penis. This dog also required emergency catheterization and surgery to relieve the urinary obstruction.

The most common type of bladder stones are known as "Struvite". These typically form in response to a bladder infection and are most commonly found in female patients. This type of stones can be dissolved with special prescription diets fed over a period of several weeks coupled with long term antibiotics to resolve the underlying infection. Unfortunately, not all patients are candidates for dietary dissolution and surgery is required to resolve the problem. Following surgery or dietary dissolution, modifications in the pet's diet can usually prevent the formation of new stones.

The seond most common type of stones are composed of calcium oxalate. These cannot be dissolved and must be surgically removed in all cases if the problem is to be resolved. There are no diets available to reliably prevent the formation of new calcium oxalate stones. However, with proper dietary management and the use of appropriate medications we can decrease the chances of new stone formation.

The photos are from 4 different cases that required surgical removal of the stones. The top and bottom pictures are two variations of calcium oxalate stones. The middle two pictures are struvite stones.

Other types of bladder stones may be formed due to liver disease and metabolic disorders. Occasionally we seen bladder stones being formed due to a pet being fed an inappropriate diet.

Certain breeds of dogs are notorious for forming bladder stones. Most notably these include the Schnauzer, Bichon Frise and Dalmation breeds. However, all dogs and cats are at risk.

If your pet shows any signs of urinary problems (urinary accidents, increased frequency of urination, straining to urinate, passing blood in the urine or change in urinary odor), have your pet examined as soon as possible. Insist on a urinary ultrasound exam or x-ray to rule-out this potentially life-threatening problem.

Hip Dysplasia: Diagnosis

One of the most common causes of lameness and degenerative arthritis we see in dogs is a genetic disorder known as Canine Hip Dysplasia (CHD). The disorder most commonly affects the larger breeds of dogs, but has been diagnosed in all breeds. The frequency of CHD runs between 15-50% in different breeds.

The hip joint is what's known as a "ball and socket" joint. The "ball" is the head of the femur (thigh bone) and is normally seated firmly within the "socket" (acetabulum) of the pelvis. This allows for the smooth rotation of the hip through a wide range of motions. The top left x-ray shows a patient with normal hip joints.

CHD causes an abnormal development and formation of the hip joint which compromises the mobility and stability of the hip. Frequently the socket is abnormally shallow and the ball is misshapened. The end result is progressive degenerative joint disease and osteoarthritis as the dog ages. Mildly affected dogs may show little problems until later in life. More severely affected dogs may be severely crippled at a very early age. The top right x-ray shows a dog with a severely deformed left hip joint.

The disorder can be positively diagnosed as early as 6 months of age. The diagnosis is made by radiographic (x-ray) and manipulative examination of the hips. These examinations require that the patient be sedated for proper positioning and joint relaxation. All larger breed dogs (adult weight greater that 50 pounds) should have these examinations performed between 6-8 months of age.

There are several medical and surgical options available to help pets afflicted with CHD. If diagnosed at an early age before degenerative changes occur, a repositioning surgery known as Triple Pelvic Osteotomy (TPO) can be performed to allow for deep firm seating of the ball within the socket. Once degenerative changes have occurred, the best surgical option is a Total Hip Replacement (THR). The x-ray on the bottom shows a dog that had a TPO procedure done on the left hip and a THR on the right hip (the "R" marker denotes the right side). Both of these procedures require the expertise of a "board certified" veterinary surgeon.

A less desirable, but much less expensive, procedure known as a Femoral Head Ostectomy (FHO) can be performed to remove the deformed ball and reduce the pet's discomfort. This procedure works marvelously well in the smaller dogs but has variable results in the larger dogs. The x-ray on the top right shows the appearance of the right hip following this procedure.

Pets unable to have surgery can frequently be kept comfortable by the administration of dietary supplements to support better joint function and anti-inflammatory pain relieving medications. Weight management is also critical to help prevent unnecessary stress to the hip joints.

Since this is a genetically determined disorder, all affected pets should be surgically neutered. Those pets intended for breeding should have their hips thoroughly examined for any signs of CHD and certified for breeding if normal. Never buy a large breed pet without documented proof that both parents were certified free of CHD by the Orthopedic Foundation for Animals (OFA).