What Is Your Diagnosis?

Margaux Marclay from the Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803.

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Izari Chau from the Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803.

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Mathew A. Stewart from the Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803.

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Kirk A. Ryan from the Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803.

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History

An 18-month-old 24.4-kg (53.7-lb) sexually intact male Golden Retriever with hemophilia A was evaluated for a 2-day history of frequently vomiting yellow fluid. The dog was bright, alert, and responsive. No abnormalities were detected on physical examination. At 4 months of age, the dog had had recurrent episodes of hemarthrosis, and hemophilia A had been diagnosed on the basis of results for coagulation tests, including coagulation factor VIII (FVIII) activity < 1% (reference range, > 20%). Results were within reference limits for coagulation factors VII, IX, X, XI, and XII. Each episode of hemarthrosis improved following transfusions with whole blood and fresh frozen plasma. No episodes of hemorrhage were observed during the 4 months preceding the examination of the present report. Foreign body ingestion was a primary differential diagnosis for the dog's vomiting, given the dog's age, personality, and known history of playing with and eating toys.

Results of a CBC and serum biochemical analyses were within reference limits, including Hct (51.9%; reference range, 37% to 55%), platelet count (498 × 103 platelets/μL; reference range, 175 × 103 to 500 × 103 platelets/μL), and WBC count (13.33 × 103 WBCs/μL; reference range, 5.5 × 103 to 16.9 × 103 WBCs/μL). Abdominal radiography was performed (Figure 1).

Figure 1
Figure 1

Left lateral abdominal (A) and ventrodorsal thoracic and cranial abdominal (B), caudal abdominal (C), and composite abdominal (D) radiographic images of an 18-month-old 24.4-kg (53.7-lb) sexually intact male Golden Retriever with hemophilia A that was evaluated for a 2-day history of frequently vomiting yellow fluid.

Citation: Journal of the American Veterinary Medical Association 258, 12; 10.2460/javma.258.12.1333

Radiographic Findings and Interpretation

Abdominal radiography revealed a rounded, soft tissue opaque structure (approx 11-cm diameter) that was partially outlined by gas in the fundic region of the stomach and that was border effacing with the pyloric antrum (Figure 2). On the left lateral projection, 2 thin, curvilinear gas opacities were near the caudoventral region of the stomach wall. The duodenum was not well identified. Differential diagnoses for the large gastric soft tissue opacity included a foreign body with solid soft tissue characteristics, pylorogastric intussusception, and mural gastric mass (eg, neoplasia, hematoma, or granuloma).

Figure 2
Figure 2

The same left lateral (A) and ventrodorsal composite (B) abdominal radiographic images as in Figure 1. A rounded, soft tissue opaque structure (approx 11-cm diameter; arrows) is partially outlined by gas in the fundic region of the stomach and is border effacing with the pyloric antrum.

Citation: Journal of the American Veterinary Medical Association 258, 12; 10.2460/javma.258.12.1333

Treatment and Outcome

The dog underwent general anesthesia for upper gastrointestinal endoscopy (not shown). No foreign material was found in the esophagus, stomach, or duodenum; however, a purple to black discoloration of mucosa and a space-occupying mass at the lesser curvature of the stomach were observed, consistent with submucosal hemorrhage related to the dog's previously diagnosed hemophilia A. Endoscopic biopsy samples were not obtained because of the risk of inducing hemorrhage.

The dog recovered uneventfully from anesthesia and was hospitalized for transfusion with canine fresh frozen plasma (30 mL/kg [13.6 mL/lb]), fluid therapy (lactated Ringer solution; 80 mL/h), and treatment with maropitant (1 mg/kg [0.45 mg/lb], IV, q 24 h), famotidine (0.5 mg/kg [0.2 mg/lb], IV, q 12 h), pantoprazole (1 mg/kg, IV, q 12 h), and sucralfate (1 g, PO, q 8 h). During hospitalization, the dog was alert and active, readily ate small meals offered every 6 hours, and had pink mucous membranes and no further episodes of vomiting. After 48 hours of hospitalization, the dog was discharged with prescriptions of omeprazole (0.8 mg/kg [0.4 mg/lb], PO, q 12 h for 10 days), sucralfate (0.04 mg/kg [0.02 mg/lb], PO, q 12 h for 10 days), and maropitant (2.4 mg/kg [1.1 mg/lb], PO, q 24 h for 5 days).

One week later, radiography was repeated. The previously observed gastric abnormalities had resolved (Figure 3). The owner declined reassessment of the dog's coagulation status.

Figure 3
Figure 3

Left lateral abdominal (A) and ventrodorsal cranial abdominal (B) radiographic images of the dog described in Figure 1 obtained 1 week after hospital discharge. There is no evidence of the abnormal soft tissue structure identified during the previous radiographic examination.

Citation: Journal of the American Veterinary Medical Association 258, 12; 10.2460/javma.258.12.1333

Comments

Radiographic findings for the dog of the present report included a large, soft tissue opaque structure in the fundic region of the stomach. The differential diagnosis list for this finding included foreign body with solid soft tissue characteristics, pylorogastric intussusception, and mural gastric mass. Hematoma as a mural gastric mass was a concern because of the previous diagnosis of hemophilia A. Dogs with hemophilia A have spontaneous bleeding that is inversely proportional to their FVIII activity and that may occur with minimal trauma.1,2,3,4 Hematomas and other signs of hemorrhage may occur at unusual anatomic sites, such as in the submucosal area of the gastric wall as identified during endoscopy for the dog of the present report.

Pylorogastric intussusception with ischemia and vascular congestion could create radiographic findings similar to those of the dog of the present report.5,6 Abdominal ultrasonography was not performed but may have been useful in evaluating the presumed gastric mural hematoma and ruling out concurrent pylorogastric intussusception.7 Intussusception and submucosal hemorrhage could occur concurrently in a patient with hemophilia. Further, pylorogastric intussusceptions may resolve spontaneously and do not necessarily require immediate surgical intervention.6 In the dog of the present report, radiography repeated 1 week after treatment confirmed resolution of the gastric abnormalities initially observed.

With the use of endoscopy, we ruled out the presence of a foreign body in the esophagus, stomach, and duodenum and could see purple to black discolored gastric mucosa along a space-occupying mass consistent with gastric hematoma formation. When these findings were considered with the dog's hemophilia A and present health status and our key differential diagnoses for the abnormalities identified on the initial radiographic examination, conservative medical management was selected, the success of which was evident by the resolution of clinical signs and results of repeated radiography.

References

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    Lee H, Yeon S, Lee H, et al. Ultrasonographic diagnosis—pylorogastric intussusception in a dog. Vet Radiol Ultrasound 2005;46:317318.

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