Monday, July 1, 2013

1495. Adhesive peritonitis and closed pyometra - a rare case in a 13-year-old Pom

TOA PAYOH VETS
toapayohvets.com

Date:   05 July, 2013  
 
Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits
The old Pomeranian has adhesive peritonitis & closed pyometra    
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date:   05 July, 2013  
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129

1495. Adhesive peritonitis and closed pyometra - a rare case in a 13-year-old Pomeranian


In my over 4 decades of practice in dogs and cats, I had never seen such a case of a "spider's web" of strands sticking intestines to the swollen uterus and the bladder to the uterine body. This shows that diseases of pyometra can present in various unexpected structures, adding to the challenges of veterinary surgery.
In normal pyometra cases, no matter how swollen the uterus, it is always easy to pull them out.

In this 13-year-old recumbent lifeless Pomeranian, I operated with Dr Daniel yesterday watching the isoflurane gas + O2 anaesthesia. Normally Dr Daniel can handle such an operation as this is a common problem in unspayed old female dogs. But I took over this emergency spay as I would be speedier and the shorter the anaesthestic, the higher chances of survival.

The dog was put just on isoflurane gas mask and intubated. "No sedation must be given in such ill cases," I said to Dr Daniel. "The dog is practically lifeless and a small dose of isoflurane gas would be sufficient." The owner had consented to the surgery despite the odds as his wife and young adult son were for the gamble.

"What are the chances of survival?" the father had asked me.
"Very slim," I said. "It is either euthanasia, let the dog die on her own or take the surgery."
I was not too keen on this type of high risk surgery and I would rather not let Dr Daniel stain his reputation on doing it. SAC - Speed, Accuracy and Completeness in this surgery will require experience and fortunately he did not need to do this surgery.

This was an unusual rare case of closed pyometra. The whole abdomen was dry, as if there was a drought. In other dogs with pyometra, there is peritoneal fluid inside the abdomen and the organs are wet. In this dog, besides dryness, there are fibrin strands bundling up the swollen uterine horns such that a portion of the horns can be seen at any one time.

On first incision, I saw a swollen portion of the right uterine horn . Normally I could hook it out with my forefinger and the rest of the uterine horn would follow. In this case, only this portion was exposed and I had to snip off the web of red fibrinous strands to loosen it. I had to extend my skin incision cranially by 2 cm and still had difficulty hooking it out.

A younger vet would really be stressed out as this was out of the world experience. The parts of the left horn was stuck to the dry pinkish small intestines and I had to carefully separate the intestinal adhesions. The omental fat was practically non existent.

After taking out the left uterine horn with its several lobes of reddish brown pus and thin walls likely to rupture anytime, I went for the right uterine horn. The cranial parts of the horns were buried deep inside as I could only see the caudal parts of smaller lobulated pieces. As I dissected away the intestinal and other adhesions, I saw a large swelling. "This is the right swollen kidney," I said to Dr Daniel. On further dissection, it was just another swollen lobule of the right uterine horn. I dissected away the adhesions. There was not an ounce of blood throughout this surgery.

"What's the maintenance dose?" I asked Dr Daniel.. "Maintain at the lowest dose." 
"0.25%," he said. "The dog is breathing normally. Any lower and the dog's breathing would increase."

Overall, the whole uterus weighed 750 gram, packed with reddish brown fluid.

The dog was still breathing slowly half an hour after the surgery and had an IV drip running. The dog was sleeping as before the surgery. I phoned the owner to inform him that the surgery was completed and the dog was still alive but barely. It was 8.33 pm when I went home with a worried heart. Chances of survival post op were not good. As at 9 am the next day, the dog passed away. The owner understood the challenges and was not angry.

This was such an unusual case in that all organs had dried up entirely, as if the car engine oil has leaked out, leaving no oil inside to lubricate the engine parts. No glistening peritoneal fluid lubricating the organs and preventing them from sticking to each other.

The thinning of the uterine walls indicated a long-standing infection and swelling of the uterine horns. Some lobules had shrunk, indicating leakage of toxins to the abdomen. The dog was said to have stopped heat for the past one year. She had heat last year.


P.S
Isoflurane + Oxygen were given for 26 minutes
The first incision to last stitch was 28 minutes. Speed, Accuracy and Completeness still needed time.  A normal dog would wake up on completion of the last stitch and would need around 2% maintenance dose instead of 0.25%.

The dog did not die on the operating table and was maintained on a IV drip post-operation.. No blood test was done as the owner was not in favour of it. I could diagnose closed pyometra in this thin dog as the gigantic uterine lobules could be felt easily with my hands as soft lumps.

The chronic peritonitis could be due to the rupture of the toxins into the abdomen and the self-repair of the body to stick the omental fat into the holes over a period of time. This resulted in a "spider web" of fibrinous strands constricting the uterine horns and burying parts of the horns. So there were large and small uterine lobules 

HISTORY

July 1, 2013. The boarding kennel operator brought in the dog saying she was vomiting for the last 2 days. She was weak and unable to stand. However she was eating and during the past 7 days of boarding while the owners were overseas. The owners would return today. They took the gamble to operate although the chances of survival were slim.

May 18, 2013
A right Mammary Gland 5 breast tumour was advised to be removed.

Sep 15, 2012
Urine dribbling and breast tumour. Owner was advised about possible pyometra by my associate vet but did not want blood test done.

Many owners in Singapore feel that the female dog should retain her reproductive system as in normal people. This dog was well loved and had her annual vaccination and dental work was done.

Breast tumours and pyometra develop in older age. Treatment has to be done early when the dog is still alert, eating and drinking normally, to give a better chances of survival.

TIPS

It may be wise to get the female dog spayed when she is young so that she can live to a ripe old age without this closed pyometra problem. So much financial expenditure, sadness and worries can then be avoided. Even at an older age of 8 years, the healthy female dog can still be spayed safely but most Singapore owners are inert and don't see the need to spay her since she has no problems.
 
Updates will be on this webpage:
http://www.sinpets.com/F6/20130705
closed_pyometra_peritonitis.htm




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