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The diagnosis and treatment of double intestinal intussusception in 3 pups with persistent vomiting, diarrhea, dehydration, anemia, leucocytosis, and electrolyte imbalance are described. Ultrasonography confirmed intussusception and laparotomy revealed double intussusceptions. Intussusceptions were corrected by manual reduction in 1 pup and intestinal resection and anastomosis in 2 pups. Two pups survived and 1 pup died on the 4th day after surgery.
Diagnostic échographique et gestion chirurgicale de l’intussusception intestinale double chez 3 chiens. Le diagnostic et le traitement d’une intussusception intestinale double chez 3 chiots avec des vomissements persistants, de la diarrhée, de la déshydratation, de l’anémie, de la leucocytose et un déséquilibre électrolytique sont décrits. L’échographie a confirmé l’intussusception et une laparatomie a révélé des intussusceptions doubles. Les intussusceptions ont été corrigées par une réduction manuelle chez 1 chiot et une résection intestinale et une anastomose chez 2 chiots. Deux chiots ont survécu et 1 chiot est mort le quatrième jour après la chirurgie.
(Traduit par Isabelle Vallières)
Surgery for intestinal obstruction in dogs has revealed intussusception (1,2), foreign bodies (3), torsion (4), incarceration (5), volvulus (6), and neoplasia (7) as possible causes of the obstruction. Intussusception can occur as a sequela to intestinal parasitism, linear foreign bodies, viral enteritis, intestinal masses, and prior abdominal surgery (2). Double intussusception in dogs is rare and causes symptoms typical for intussusception. The etiology of double intussusception is often unknown (8) but pieces of bone were reported as the inciting cause in an earlier study (9). The present report records the diagnosis and management of 3 dogs that had double intussusception and were treated at University Teaching Veterinary Hospital, GADVASU, Ludhiana, India.
Case 1 involved a 3-month-old, 2.7 kg, male American Eskimo puppy; case 2 involved a 2-month-old, 5-kg, male Saint Bernard puppy, and case 3 involved a 3.5-month-old, 10-kg, male German shepherd puppy. Diagnosis was made on the basis of clinical presentation, abdominal palpation, radiography, and ultrasonography. The dogs were presented with the primary symptoms of anorexia, vomiting, and bloody diarrhea. Duration of illness varied between 2 to 7 d (Table 1). Varying degrees of dehydration and pale mucous membranes were detected by physical examination in all 3 dogs. Abdominal palpation revealed an intra-abdominal lump in cases 2 and 3. In dog 1, no mass was palpable. Respiration rate, heart rate, and rectal temperature were within normal ranges. A mass was seen protruding from the anus in dogs 1 and 2.
Hematological examination showed anemia, neutrophilic leukocytosis, and normal platelet counts in all 3 cases (Table 2). Blood biochemical profile revealed low plasma sodium in all 3 cases, low chloride concentration in cases 2 and 3, and normal levels in case 1; plasma potassium concentration that was reduced in case 2 and normal in cases 1 and 3; lactate dehydrogenase (LDH) and alkaline phosphatase (AKP) levels that were elevated in all 3 cases; lactate levels that were increased in cases 1 and 2 and normal in case 3; total protein level that was normal in case 1, slightly elevated in case 2, and low in case 3; and albumin levels that were normal in case 1 and decreased in cases 2 and 3 (Table 2).
Survey lateral radiographs of the abdomen showed a ground glass appearance along with a radiopaque tissue mass at the base of the tail in dog 1 and uniform gas-filled distended intestinal loops occupying the entire abdominal cavity in dogs 2 and 3 (Figure 1). Ultrasonographic examination of the abdomen was performed using real-time ultrasound equipment (LOGIQ 3; Wipro GE Healthcare Private, Mountain View, California, USA) with curved array (2.0 to 5.0 MHz) and linear array (7.0 to 12.0 MHz) adjustable transducers. Ultrasonographic examination of the intestines showed a series of multiple hyperechoic and hypoechoic concentric rings with a hyperechoic center in the transverse plane, consistent with intussusception. The transverse plane ultrasonographic image of dog 1 showed a typical “triple circle sign” which is different from the target sign of classical single intussusceptions (Figure 2a) and consisted of the proximal prolapsed segment, the distal prolapsed part, and the distal intestinal segment (Figure 2a). Multiple hyperechoic and hypoechoic parallel lines were seen in the longitudinal plane (Figure 2b). Following diagnosis of the intussusception, immediate surgical intervention was planned.
The dogs were premedicated with atropine sulphate (Atropine Sulphate; BAIFLabs, Wagholi, Maharashtra, India), 0.04 mg/kg body weight (BW) subcutaneously and diazepam (Diazepam; Ranbaxy Laboratories, Solan, Himachal Pradesh, India), 0.5 mg/kg BW, intravenously. General anesthesia was induced with 2% thiopental sodium (Thiosol; Neon Laboratories, Mumbai, India). The dogs were maintained on 1% to 2% halothane in oxygen, and were administered normal saline (0.9%) sodium chloride solution (Claris NS; Claris Life Sciences, Ahmedabad, India) throughout the operative period until they recovered from anesthesia.
Exploratory laparotomy through a ventral midline incision was performed in all cases. Exteriorization of the intestine revealed a double jejunoileal intussusception in all cases. In dog 1, the intussusception occurred through the ileocolic orifice and in dogs 2 and 3 the caeco-colic orifice was involved. Mild adhesions were formed between intussusceptum and intussuscipiens in case 1. Initially, the intestinal segment involving the jejunoileal intussusception was reduced manually from the ileocolic orifice by applying gentle traction on the neck of the intussusceptum while milking its apex out of the intussuscipiens. The jejunoileal intussusception was then reduced by applying gentle traction; all the segments involved appeared viable (Figure 3a,b,c). In case 2, the involved intestinal segments at the site of intussusception were devitalized, with severe adhesions between the intussusceptum and intussuscipiens. A part of the jejunum and ileum were therefore resected (Figure 4a,b). In case 3, there were severe adhesions between the intussusceptum and intussuscipiens and parts of the jejunum, ileum, and cecum were resected. End-to-end anastomoses in cases 2 and 3 were performed using 3-0 Vicryl (Polyglactin-910; Ethicon, Johnson and Johnson, Aurangabad, India) in a single layer, simple continuous suture pattern. The defect in the mesentery was repaired using 3-0 Vicryl in a simple interrupted suture pattern. Abdominal muscles were closed with number 1 Vicryl, in a single layer simple interrupted suture pattern. Subcuticular suturing was done using 1-0 Vicryl and the skin incision was closed with Nylon in a simple interrupted suture pattern.
After surgery, the dogs were given amoxicillin and cloxacillin combination (Megaclox; Anrose Pharmaceuticals, Solan, Himachal Pradesh), 10 mg/kg BW, IM, q12h for 7 d, gentamicin sulfate (Gentamicin Sulphate; Ranbaxy Laboratories, New Delhi, India), 4 mg/kg BW, IM q12h for 3 d, metronidazole (Metronidazole, Claris Life Sciences, Ahmadabad, India), 10 mg/kg BW, slow IV, q12h for 3 d; atropine sulfate (Tropine, Neon laboratories, Mumbai, India), 0.02 mg/kg BW, subcutaneous q24h for 3 d, and meloxicam (Melonex; Intas Pharmaceuticals, Ahmadabad, India), 0.2 mg/kg BW and ranitidine (Aciloc; Cadila Pharmaceuticals, Ahmadabad, India), 0.5 mg/kg BW, IM q24h for 3 d. An oral liquid diet was started 24 h after surgery and a solid diet was started after 3 d. Isotonic balanced electrolyte solution was administered intravenously for 48 h following surgery. In case 1, 150 mL of normal saline and 150 mL of Ringer’s lactate solution (Claris Life Sciences) were administered in a 24-hour period (110 mL/kg/day); in case 2, 325 mL of normal saline and 325 mL of Ringer’s lactate solution were administered in a 24-hour period (130 mL/kg/day); and in case 3, 550 mL of normal saline and 550 mL of Ringer’s lactate solution were administered in a 24-hour period (110 mL/kg/day).
Vomiting and diarrhea were observed in case 1 on the 3rd day post-surgery. Prochlorperazine (Stemetil; Piramal Healthcare, Madhya Pradesh, India), 0.05 mg/kg BW, IM, q12h was administered for 2 d. Dogs 1 and 3 survived and started normal solid and liquid food intake after 3 days. The incision lines healed normally and the sutures were removed 12 d post-surgery. Telephone follow-up of case 2, however, revealed that the dog had died on the 4th day after surgery.
On the 12th day after surgery, hematology and blood biochemical profiles were recorded for cases 1 and 3. In case 1, post-operative values for hemoglobin (7.6 mmol/L) and PCV (42%) values showed improvement towards the normal range; in case 3 anemia was more severe (hemoglobin: 3.6 mmol/L and PCV: 18.5%). Total leukocyte count (19.85 × 103/μL and 6 × 103/μL) and platelet count (7.45 × 105/μL and 6 × 105/μL) were within normal limits in both cases. The biochemical profile showed improvement in plasma sodium (141 mEq/L and 138 mEq/L) and chloride (112 mEq/L and 110 mEq/L). Plasma potassium concentrations were within the normal range (4.4 mEq/L and 4 mEq/L). Alkaline phosphatase levels remained elevated post-surgery (380 U/L and 758 U/L). Lactate dehydrogenase values were reduced (320 U/L and 633 U/L) compared to preoperative values. Lactate levels did not show any significant change (5 mmol/L and 2.7 mmol/L).
Double intussusception involving the ascending colon (8), and jejunoileal intussusception through the ileocolic orifice (1) and into the colon (11) have been reported in dogs. All dogs in the present study were young (3 to 4 months old) as also reported by Applewhite et al (12). Anorexia, vomiting, and diarrhea were the main clinical signs in all 3 cases. Vomiting and diarrhea have been reported as the main clinical signs in dogs with intussusception (2). Neutrophilic leukocytosis has also been reported by Wilson and Burt (10) in dogs with intussusception. Low plasma sodium levels were likely due to third-space loss into the preobstruction intestinal segment as well as due to vomiting and diarrhea. Findings similar to those in the present study were reported by Weaver (13) in dogs with intestinal intussusception. The elevated level of lactate in all the cases was due to tissue hypoxemia because of hypoperfusion at the site of intestinal obstruction causing a shift from aerobic to anaerobic cellular metabolism.
Although plain radiography may not always lead to a specific diagnosis of intussusception (8), the use of ultrasonography in all the 3 cases along with radiography helped to establish a definitive diagnosis. The typical triple circle sign in the transverse plane of the ultrasonogram confirmed the diagnosis of double intussusception (14). The feasibility of manual reduction of intussusception may decrease with time, as adhesions become less reducible, the longer the intussusception is present, as seen in cases 2 and 3. However, Weaver (13) reported no relationship between duration of signs and the length of the intussusception with regards to the feasibility of manual reduction. Dog 2 with severe preoperative anemia died on the 4th day after surgery. Low preoperative serum values of Hb and PCV, high total leukocyte count and devitalization of the affected intestinal loops might have been responsible for the death of this dog. Certain preoperative factors such as anemia have been associated with significantly higher risk of postoperative mortality in dogs with obstruction in the small intestine (15) and in cases of double intussusception (1). Intensive antibiotic therapy was used in all 3 dogs as they were presented with prolonged signs of illness, shock, and variable degrees of intestinal compromise. Due to technical reasons blood transfusions were not performed; however, blood transfusions might improve the outcome and speed the recovery in cases of intussusception. Dogs with serum albumin concentrations ≤ 25 g/L are at increased risk of developing leakage following intestinal anastomosis (16). Appropriate fluid therapy administered postoperatively was instrumental in bringing the electrolyte values of sodium, potassium, and chloride towards normal ranges.
Double intestinal intussusception is a rare occurrence in dogs. Timely diagnosis with typical clinical signs and ultrasonographic findings, effective management of hemato-biochemical abnormalities, and immediate surgical intervention can improve the prognosis for these cases. CVJ
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