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 (). 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.
Case description for the 3 dogs with double intussusceptions
Hematological examination showed anemia, neutrophilic leukocytosis, and normal platelet counts in all 3 cases (). 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 ().
Preoperative hematological and blood biochemical parameters in the 3 dogs with double intussusceptions
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 (). 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 () and consisted of the proximal prolapsed segment, the distal prolapsed part, and the distal intestinal segment (). Multiple hyperechoic and hypoechoic parallel lines were seen in the longitudinal plane (). Following diagnosis of the intussusception, immediate surgical intervention was planned.
Lateral radiograph of the abdomen showing multiple gas-filled severely distended intestinal loops in the dog of Case 2.
Figure 2 a — Ultrasonogram showing a typical “triple circle sign” in the transervse plane of case 1. In the triple circle sign, 1 indicates proximal prolapsed segment, 2 the distal prolapsed part, and 3 the distal intestinal segment. b (more ...)
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 (). 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 (). 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.
Figure 3 a — Photograph showing double intussusception in case 1 with jejunoileal intussusception through the ileocolic orifice (a), after partial reposition of the jejunoileal part of the intussusception (b) and complete reposition of the ileocolic part (more ...)
a, b — Photograph showing double intussusception in case 2 before and after intestinal resection and anastomosis.
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).