1157. KPI - Uroliths surgery. Audit of one calcium oxalate case

Date of Audit: Oct 25, 2012
Urolithiasis - bladder stones calcium oxalate removed by an associate vet, Dr Vanessa

Owner has financial constraints
Oct 2.2012
Maltese, Male, 9 years, 3.1 kg, 38.5C
Straining to urinate. Blood in the urine

Anaesthesia & Surgery Record No. 207
Declined urine analysis
X-rays done
Cystotomy -  several uroliths
Stone analysis - Calcium oxalate
Sutures - monosyn 3/0 x 2 packets

C-B:  Isoflurane + O2 on to switched off  - 46 minutes
E-D: Skin stitched up from lst skin incision - 43 minutes
E-A:  Sedation injected to skin stitched - 66 minutes


COMPARISON TO ONE CASE OF EXPLORATORY LAPAROTOMY & CYSTOSTOMY DONE ON A MINIATURE SCHNAUZER BY ME (DR SING KONG YUEN) IN OCT 2012

ANAESTHESIA
A: Inject sedation drug 10.20am
B: Isofl first given 10.27 am. Mask, then intubate. Dog vomited again.
C: Isofl stopped 11.37 am
D: First skin incision 10.39 am
E: Completion of skin stitching 11.37 am

E-A = 57 min
E-D = 58 min (time taken to check out stomach, kidneys visually and remove >10 bladder stones)
C-B = 64 min



No post-op complaints as at Oct 25, 2012. Phoned owner at 11.30 am today. No response from phone. Phoned home number. Spoke to a lady. Dog is OK. No urination problems. Had stitched removed. This urination problem existed for some months. Advised to see associate vet who operated on this dog, regarding the feeding of U/D diet and stop feeding dry food presently given.

Health check on a big-sized 13-year-old male Jack Russell

The lady owner was studying medicine in the US. When she came back for a holiday, her Jack Russell was scratching his eyes till the eyelids bled, his chest so that it was red and his penile skin till it was bald, the four paws with deep red blood in between the toes and on the toes. What was the cause? Yet the ears were spared but I saw crusty lumps on the edges of the left ear. Scabies? Allergy? Demodecosis?  Skin scrapings were negative.

Blood test - monocytes higher than normal at 11.2%.  Other values are normal.
Calcium and uric acid within normal range. Liver, kidney, joints normal.
Dental scaling done.

X-rays showed no radio-dense urinary stones but there is possibly one in the bladder area. It is hard to tell on the lateral view of the X-ray.
Urine showed calcium oxalate crystals
pH 6.5,  SG 1.022,  Protein 2+, Blood trace, Crystals calcium oxalate occasional, bacteria occasional.

The "occasional" presence of calcium oxalate does not mean there are no urinary stones. Absence of crystals does not mean there are no urinary stones. Much depends on the clinical signs of blood in the urine. The dog was furiouslylicking its penile length till the area was red and hairless. This was unusual. There could be difficulty in urination but nobody knows as the caregiver owner was studying in the US.

FEEDING OF U/D CANINE NON-STRUVITE URINARY TRACT HEALTH

Indications: Urolithiasis due to calcium oxalate, urate and cystine stones; end-stage kidney disease
Decreases purine intake and uric acid excrerion, which lowers the risk of forming urate crystals and uroliths

Monitoring Urine SG, urinarypH and BUN will let the vet know the food's effectiveness and owner compliance. Dogs fed on this diet commonly show unusual lab values like USG <1 .020=".020" bun="bun" dl="dl" mg="mg" p="p">
Long term use: Check for protein depletion as U/D is a low protein diet to decrease urea production,  but the protein level is suitable for maintenance of the adult dog. Advise a fasting serum chemistry profile and ECG every 6 months.









  

1155. A hamster from Italy

On Sun, Oct 14, 2012 at 7:21 PM, Valentina C...@gmail.com> wrote:

Dear Sir/Madam,

I am Valentina and I am writing from Italy. I have a one-year-old dwarf male hamster and he has got a problem; I only realized it yesterday. I follow from here all your surgery cases and your successes, the photos and the articles on the web site, so I thought it was better to write down a line to have an advice from you, because you are experts and I admire your job.

This is my first hamster and I do not what to do, really, I am desperate, because so far we had any kind of problems. The problem is related to its lower area of the body, and it's like an abscess or a tumor or something like that because it is a hard distended underskin lump near the penus.

Here in Italy the vets are closed on saturday and sunday so I medicated it as I could on my own, doing some chamomile hot packs.

Do you think he probably will go through a surgery? What am I supposed to do? Please help me, I'm sending you some photos. Talking about the hamster, he is acting as normal, it is not weak, he plays, eats, sleeps.... Thanks a lot, you really do not know how important is to me if you answer back. Sorry to bother you.

Your sincerely,

Valentina C.

 

EMAIL REPLY FROM DR SING DATED OCT 23, 2012

Thank you for your email. It is hard to see from your 2 images what is the affected area you mentioned. It is best to consult your vet.
 

1154. The urinary stone Schnauzer barks and eats at 6.47 pm

Tuesday Oct 23, 2012  6.47 pm
I asked Dr Daniel to bring JJ out for a walk at 6 pm. Evening sunset, tranquility. This dog had not wanted to eat since my surgery on last Saturday and I am most worried. The owners visited her every afternoon.

Dr Daniel said: "The owners say that this dog does not eat after surgery and it is common."
JJ walked out with a spring in her step. She peed outside and the urine was yellow and has no signs of blood unlike this morning.

Suddenly she barked at a jogger.  This was excellent news. A dog that barks suddenly at joggers is on the road to recovery. Dr Daniel took off her e-collar and gave her canned food. She ate and my worries of the post-op decline in health vanished. She walked up and down the back room looking for Dr Daniel. She sat on her back. "Put her back into the cage," I said.

1153. Retrospective study of the vomiting Schnauzer with urinary stones in kidney and bladder

Oct 23, 2012  8.56 am

The Schnauzer, F, 4 years is still not eating. But I had given her the IV drips including glucose and some hand feeding of the L/D diet. She would just lick a bit and not swallow, according to Dr Daniel who was assisting me in this case. She could sit up and look at me with sad eyes. The only good news is that she does not vomit anymore, unlike the 5 days and on the day of surgery.
I am now reading the voluminous records of previous vets and summarise the findings below:



1.  Nov 14, 2009
Health check and vaccination

2. Sep 28, 2011
Ear infections treated.

3. Feb 18, 2010
Intermittent cough when sleeping. Vomits mostly fluids. Spay and dental scaling done.
4. Nov 8, 2011
Urinating blood. Bladder stones palpated. X-ray. Cystotomy to remove stones
Stones removed digitally and by retropropulsion
Post-op X-ray - no stones in the bladder

5.  Nov 11, 2011
Cystostomy to remove bladder stones. Bladder entry swab c/s to lab.  Heavy growth of Coagulase-negative staphylococcus
Stone analysis to Minnesota. Stone and shell 100% magnesium ammonium phophate (struvite)

5. Nov 13, 2011
Discuss options
1. See if recurrence, then start food trial
2. start food trial

6. Nov 14, 2011
Follow up. Owner said dog vomited few times at night on the 3rd day afer surgery.
W/D canine dry

Nov 19, 2011
Review.  Owner says some vomiting on 3rd day of surgery might be due to eating something downstairs. No more vomiting. Advised owner to monitor for uroliths. Pet is female and there is the option of urohydropropulsion. To change from S/D to W/D as the breed is prone to pancreatitis or RC urinary s/o

Dec 2011, Feb, April & Jun 2012
W/D canine 8.5 lbs dry


Jul 22, 2012
Straining to urinate and leaking urine for 2-3 days
Bladder stones palpated and seen on X-ray
Unable to get urine for analysis
Treat UTI first, try to dissolve stones with 1 S/D can/day and review in 3 weeks.
Blood test. low RBC, HCT, HGB.
High total WCC 22.4 (5-17), N 18 (3-12), M 1.4 (0.16 - 1.1)


Aug 12, 2012
Multiple large bladder stones on X-rays. Vet 1 advised surgery. Owner did not accept advice. Went to Vet 2 who treated with antibiotics, acidifying tablets and then S/D

Oct 19, 2012
A few days ago, the owner asked me whether he could buy medication from Toa Payoh Vets as the Jurong vet was too far for him to collect medication and S/D.
I advised another X-ray and blood test as Vet 2's 2nd x-ray already showed multiple stones in August 2012 and the owner said that the urine was very smelly.

The dog started vomiting for 5 days before Oct 19, 2012. Test showed bacteraemia and toxiaemia with low platelets. Dog was operated on Oct 19, 2012. Around 13 stones removed from bladder.  Normally I don't do exploratory laparotomy in cases of bladder stones as this was the case. However, I checked the stomach and intestines for foreign bodies as there were radio-dense objects inside the
intestines on X-ray taken by me.


Oct 23, 2012.
Dog on drips and medication daily. Not eating. Alert.
At 10 am I asked Dr Daniel to take her out to have some sunshine. She peed red blood and pooped soft brown stools. No vomiting. The blood could be from the chronic cystitis of the bladder wall as stones were left too long. Also, possibly from the bladder bleeding.
So far, the dog is walking and alert. No fever. Just would not eat.

Oct 23, 2012  10.09 am
That was when I found a 3x enlarged purplish red left kidney with prominent blood vessels in its capsules and as big as a golf ball compared to the normal right kidney. Some bleeding spots near this kidney and brownish stained spot in the omentum. This was serious as the left kidney could be bleeding. There was anterior abdominal pain on palpation earlier.

She would walk about, drank water and sit on her backside. Some panting.

CONCLUSION
Each vet has his or her own advices on the management of struvite stones to prevent recurrence after surgery. Vet 1 advised S/D and W/D dry which is also indicated for struvites. For this dog, I have advised:

1. 2-3-weekly urine analysis
2. X-ray 2 monthly for 3 times
3. S/D canned food for 4 weeks followed by C/D canned food for 3 months with the usual urine tests and X-rays.
4. No dog treats or other food and no DRY dog food of any kind.
PROBLEM: What about the enlarged right kidney with the stone?
If the stones are small and packed in the renal pelvis, I hope they will pass down the ureter to the bladder and gets peed out. Wait and see as the dog is now active and starts to eat.

Due to economics, contrast radiography is not advised for the time being. Prevention is better than cure and for struvite stones in Miniature Schnauzers and other dogs, 2-monthly urine analysis and at least one X-ray of the abdomen for urinary stones are best done. Seldom do owners do it as monitoring requires discipline and planning.  
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1152. A pet rat in Singapore fractures his tooth

Unusual case as I seldom see pet rats as Singaporeans don't keep pet rats.

October 18, 2012

This handsome black and white rat fractured the lower gum end of his low right incisor teeth as he chewed on the bars of his cage. Hamsters and rabbits commonly do that too. The tooth did not fracture completely and so he would be feeling the pain every time he tried to eat. His owner quickly took him to the vet and I was surprised to see my first pet rat patient in over 30 years of practice.


What is the solution? Clipping off both lower incisor teeth and levelling them.  Now, this young rat strenuously object to any human opening his mouth even to examine the teeth. So, I needed to put him under anaesthetic isolflurane + O2 gas and clip off both lower incisors to the same gum level. His fracture was at the gum level.

 

 

 

 

FEEDBACK FROM THE OWNER ON OCT 23, 2012

Dear Dr.Sing,

Thank you for the photos. S... is recovering well. Today - for the first time since the procedure - he was able to chatter his teeth (which he normally does when he's happy). He's also been able to start eating his regular Lab Blocks food again, albeit very slowly and with some difficulty as the teeth have just grown back a little bit. We're supplementing his diet with softer, easier to eat foods like vegetables and he doesn't appear to be losing an unhealthy amount of weight.

1151. Kidney & stone Schnauzer not eating

Today is Monday, 48 hours after operation to remove the 13 stones and an exploratory laparotomy to find that the left kidney was 3X larger than normal, as big as a golf ball, congested and red, hepatititis and congested spleen with bleeding spots around the omentum of the right kidney and one dark brown patch on the omentum, an abnormal finding. Was the right kidney breaking down due to the long delay in getting the bladder stones removed since X-ray by Vet 1 had shown their presence in August 2012?

Some bleeding from the posterior end of the wound. Bleeding and infections are complications of surgery. No fever. Could it be infection? I needed to take out two stitches to drain.  A protein and glcouse drip will be given. Other than that, the dog looks alert.

Never delay bladder stone surgery. Best is to have routine urine analysis to detect presence of stones esp. in breeds prone to bladder stone, e.g. Miniature Schnauzer. The couple with their two young children visited yesterday Sunday and the dog wagged her tail and was wanting to go home yesterday. There was already redness in the cranial part of the stitch which I presumed was due to licking as the e-collar was smaller. "My dog is great at licking," the husband said. Today, fluid came out from this part and I review again with Dr Daniel. This is a teaching case for him as this dog could have right kidney stones as shown in the X-ray.

Vets usually take the bladder to check for stones and in nearly all cases, there will be no need to check for kidney stones. But this case shows that exceptions do occur. Now what to do with the right kidney stones?

The only good news is that this dog does not vomit for the past 2 days. She was vomiting daily before surgery for at least 6 days including the day of surgery.   

"It is due to infection," my assistant Min said. "Pus comes out."
"Since the area is so clean with no blood clots unlike the cranial part of the wound, I would say it was due to licking." But the dog does not lick in the presence of Mr Min or owners and so many assume that licking could not exist with an e-collar being worn. I got Min to change to a bigger collar and got Dr Daniel to take out two stitches. "Nothing inside the wound," he said as I followed up. So it was inflammation and swelling due to traumatic licking. We gave a drip. The cephalic veins had been bust due to previous IV drips at Vet 1 where the dog had one bladder surgery to remove the stones and another surgery to spay 2 years ago.

Prevention of diseases is cheaper than treatment as Vet 1 had quoted $1,200 for the bladder stone surgery for the 2nd time and the owner said he had paid $1,800 for the first bladder stone removal surgery. That would total at least $3,000. Yearly or half-yearly urine analysis would be much cheaper but no Schnauzer owner would ever do it.