scott@vtx-cpd.com
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This is really interesting!
Do you have any images? Definitely not associated with gastric ulcers? Ulceration of the gastric wall can sometimes cause some gas appearance?
I can only find the same case series that you have mentioned. I have contacted a surgical and imaging specialist to get some more input. I will let you know what they say!
I would be interested to hear the input of others!
Scott 🙂
How interesting!!!!! I did not know that.
Look forward to hearing more!
Scott x
Hello.
Sorry for the delay!
Further investigations included analysis of the patient’s electrocardiogram (ECG), thoracic radiography, and echocardiography. The radiographs were as follows:
Any thoughts?
Scott x
Thanks for sharing this.
This is really interesting but so sad.
I hate seeing things like this.
Scott 🙂
Hello again!
I have popped on a couple of posts about the different prokinetic options. Treatment of dysmotility is multimodal and should be implemented by taking individual patient factors into account. Early enteral nutrition appears to stimulate the return of normal bowel function and exerts a prokinetic effect. Adequate hydration and electrolyte balance should be maintained, but gut edema should be avoided at all times when implementing a fluid resuscitation plan. Alternative modes of analgesia, including local anesthesia, should be utilized, especially when attempting to decrease opioid use in postoperative patients. Prokinetic therapy in patients with dysmotility of critical illness is recommended; however, due to the lack of evidence for a single prokinetic, a multimodal approach should be utilized. Human and animal studies have suggested that early judicious nutritional support in addition to a combination of prokinetic drugs based on GI localization of clinical signs is superior to delayed EN and monotherapy with prokinetic agents.
It is likely that the cisapride/erythromycin combination is the best choice.
The following is a really good review:
Hope this helps.
Scott 🙂
Great question!
And quite a long answer! I will pop on a couple of posts about the different drugs!
Scott x
Hey.
I think they are definitely referring to the level of consciousness. I am not able to find anything in the literature that talks about this being specifically validated.
I think there is obviously a sliding scale between totally conscious and totally unconscious under the influence of drugs… I think this is what they must be referring to.
I agree with Sara, I would definitely be checking for a gag reflex in any patient where emesis is a consideration.
Scott 🙂
This is an interesting question that much better developed in human medicine:
The most common functional disorder of the biliary tract and pancreas relates to the activity of the Sphincter of Oddi. The Sphincter of Oddi is a small smooth muscle sphincter strategically placed at the junction of the bile duct, pancreatic duct, and duodenum. The sphincter controls flow of bile and pancreatic juices into the duodenum and prevents reflux of duodenal content into the ducts. Disorder in its motility is called Sphincter of Oddi dysfunction. Clinically this presents either with recurrent abdominal biliary type pain or episodes of recurrent pancreatitis. Most of these patients present with abdominal pain. Symptomatic treatment comprises treatment of abdominal pain. In patients with a severe episode of either biliary or pancreatic Sphincter of Oddi dysfunction the most appropriate pain medication is parenteral opiates. This is despite the known observation that opiates produce sphincter of Oddi contraction. The rational for their use is that the contraction has already occurred and the opiate is unlikely to aggravate matters further. However, on the other hand opiates are the most effective therapy for pain relief. In order to prevent future episodes in patients who have identified opiates such as codeine to provoke pain avoidance of these medications is recommended. There is no effective pharmaceutical therapy for these patients.
Reflecting on that, I would not withhold methadone/full opioids in cases of abdominal pain. If the rationale is that we are preventing Sphincter of Oddi contraction, it has probably already happened in these cases. In cases of known pancreatitis we would still use opioids, as further contraction will not worsen signs.
The only thing that we may have to be cautious of is long term opioid use, which is not really a thing for our patients:
https://www.gastrojournal.org/article/S0016-5085(13)00507-6/pdf
Hope that helps!
Scott x
I think you are right, this is obviously a bad complication, but quite rare in the grand scheme of things. I had a look through the other literature and overall it is reassuring. This recent JVECCS paper is helpful:
Retrospective evaluation of factors associated with degree of oesophagitis, treatment, and outcomes in dogs presenting with esophageal foreign bodies (2004-2014): 114 cases
Abstract
Objective: To characterize a population of dogs presenting for oesophageal foreign body removal and evaluate factors associated with degree of oesophagitis and minor and major complications.
Design: Retrospective evaluation of dogs who presented for oesophageal foreign body removal between January 2004 and December 2014.
Setting: University veterinary teaching hospital.
Animals: Data collected from 114 dogs included signalment, history, clinical signs, physical examination findings, duration and location of foreign body, degree of oesophagitis, foreign body removal success, feeding tube placement, and clinical outcomes. Owners were contacted for outcome data not available in the medical record. Data were analyzed for breed predispositions, whether duration or type of foreign body was associated with degree of esophagitis or complications, and factors associated with feeding tube placement.
Measurements and main results: The overall success rate for foreign body removal via oesophagoscopy was 95% with a complication rate of 22%. Small breed dogs were overrepresented. Dogs with a foreign body present for >24 h were significantly more likely to have severe esophagitis (P < 0.001) and major complications (P = 0.0044). Foreign body type did not predict degree of oesophagitis or complications, though fishhooks were more likely to require surgical removal (P = 0.033). Feeding tubes (15 gastrostomy, 1 nasoesophageal) were placed in 14% of dogs and were more likely to be placed if the foreign body had been present for >24 h (P < 0.001). Conclusions: Consistent with previous studies, oesophageal foreign bodies, appropriately identified and endoscopically removed, carry a good prognosis, particularly if they have been present for ≤24 h. The majority of dogs recovered without any minor or major complications (56/72, 78%). Overall, 16 patients had a complication reported, including those who did not survive to discharge. Four dogs recovered with minor complications (6%); 5 dogs suffered major complications (7%); 1 dog had a gastrostomy tube-associated complication (1%); 2 dogs underwent cardiopulmonary arrest under anesthesia (3%); 3 were euthanized prior to discharge (4%), and 1 decompensated within 24 h of discharge and was represented for euthanasia (1%). Minor complications included vomiting/diarrhea (3) and cough/tracheitis (1). No dogs were reported to have inappetence following foreign body removal. Major complications included oesophageal stricture (4) and aspiration pneumonia (2); 1 of the 5 dogs with major complications suffered from both aspiration pneumonia and an oesophageal stricture. Of the 4 dogs with a documented stricture, 2 were ultimately euthanized due to this complication, and 2 were managed with a gastrostomy tube. The gastrostomy tube-associated complication was described as pain associated with the feeding tube stoma. The overall complication rate for our patient population was 22% (16/72). Take home message... don't be scared! Scott 🙂
Thanks.
Intermittent seizuring like that is quite uncommon with liver disease. I think it is more likely that the epilepsy is worsening? Neurological signs with liver disease normally happen at very advanced stages of diseases, so would be unusual for the dog to be normal in between.
Just a thought.
Scott x
Good old rutin!
I have never been sure about how effective it is… but definitely worth a go!
Would be interesting to hear how this case does.
Scott 🙂
Hey Inga.
I thing the possibilities are endless with this drug!
“Tranexamic acid (TXA) is an antifibrinolytic agent that exerts its effects by reversibly binding to the lysine sites on plasminogen molecules and inhibiting plasmin. TXA is widely used in human medicine and decreases mortality, reduces blood loss after trauma or surgery, and lowers transfusion requirements in trauma patients with bleeding. TXA has been shown to decrease mortality over placebo in trauma patients, It is also noted to have good safety parameters upon administration and is recommended for use in human trauma patients with bleeding.
In veterinary medicine, TXA has been used to reduce blood loss by slowing fibrinolysis in various diseases causing clinical bleeding such as hemoperitoneum, haemothorax, thrombocytopenia, anticoagulant rodenticide intoxication, peri-operative bleeding, epistaxis, and feline interstitial cystitis-associated bleeding. It has a wide safety margin and is rarely associated with hypersensitivity reactions. In humans, common side effects of TXA are mild symptoms including nausea, flushing, vomiting, allergic skin reactions and headache, although anaphylactic shock is rarely reported. In dogs, the main reported side effect is vomiting”.
I think there is a lot more to come!
Scott 🙂
Hello!
Hope you are well. Great question. I do find these cases really frustrating to manage medically! I would go for as low fat a diet as possible. Hills ID low fat would probably be a good starting point. Would the owners consider surgical managemnt/pleural port?
Scott 🙂
Thanks for this.
Following on from what Sara has said… was the thinking that this dog was having seizures due to the liver disease? What other meds was this dog on? You are right, there is very little evidence to support exactly what drugs to use in cases that have seizures due to severe liver disase/hepatic encephalopathy. I think it would be fine in these cases to escualte yo the 60mg/kg dose for short term control. The following drugs can be cnsidered:
1. Avoid benzodiazepines
2. Phenobarbital (4 mg/kg IV q 3-6 h for 4 doses)
3. Potassium Bromide: Loading: 400-600 mg/kg/day divided over 1-5 days PO with food; can be given per rectum if needed. Maintenance: 20-30 mg/kg PO q 24 h. Sodium bromide can be used if an IV form is necessary.
4. Propofol 1-3.5 mg/kg IV bolus, followed by CRI of 0.01-0.25 mg/kg/min.
5. Keppra 20 mg/kg (up to 60 mg/kg) PO or IV q 8 h (there is no evidence-based medicine to support this).Hope that helps.
Scott x
Hey everyone.
I love the M&M suggestion, but understand the challenges of doing these when you are a locum.
I was having a really interesting conversation with Lou Northway the other day (Lou the vet nurse for thouse of you on Instagram). She was saying that one of the biggest barriers to peple doing M&M’s is that is seems like a very formal process with a presentation etc. M&M rounds could actually be a 10 minute informal chat over a cup of tea. We should feel comfortable to chat about what we can do better.
I passionately belive that every member of the team is equal! We can all learn from each other.
Sara, do you find you are able to M&M’s at Vets Now?
Scott x
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