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What Is Your Diagnosis?

What Is Your Diagnosis?

Alyssa J. Carrillo Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL

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Kathleen M. Ham Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL

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 DVM, DACVS
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Ronald Gonçalves Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL

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 DVM, PhD
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Hayley Paradise Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL

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Federico R. Vilaplana Grosso Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL

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 LV, DECVDI, DACVR
DOI:
https://doi.org/10.2460/javma.22.09.0392
Volume/Issue:
Volume 261: Issue 2
Online Publication Date:
31 Oct 2022
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History

A 6-year-old 3.4-kg neutered male mixed-breed dog was presented to the University of Florida Small Animal Hospital for evaluation of a possible mechanical obstruction. The dog was presented to its referring veterinarian 1 month prior for hyporexia, vomiting, and an episode of diarrhea. At that time, abdominal radiographs were obtained and were concerning for a segmental small intestinal dilatation suggestive of mechanical obstruction. The dog underwent an exploratory laparotomy at the referring veterinarian that was reported as negative for mechanical obstruction. According to the owners, the dog never fully recovered and was reported to have hyporexia, intermittent vomiting, tenesmus, and diarrhea as well as decreased fecal production despite medical management, being subsequently referred. At the University of Florida Small Animal Hospital, on physical examination, palpable dilated loops of intestine with no overt foreign bodies or masses were appreciated. The remainder of the physical examination was unremarkable. A CBC revealed a moderate normocytic, normochromic, nonregenerative anemia (Hct, 29.9% [reference range, 37.3% to 61.7%]; MCV, 68.1 fL [reference range, 61.6 to 73.5 fL]; MCHC, 25.1 pg [reference range, 21.2 to 25.9 fL]; and reticulocyte count, 15.4 K/µL [reference range, 10 to 110 K/µL]), leukocytosis (34.27 × 103 WBCs/μL; reference range, 5.0 × 103 to 13.0 × 103 WBCs/μL) characterized by a mild to moderate neutrophilia (30.77 WBCs/μL; reference range, 2.7 × 103 to 8.9 × 103 WBCs/μL) and mild monocytosis (1.32 × 103 WBCs/μL; reference range, 0.1 × 103 to 0.8 × 103 WBCs/μL), and a mild thrombocytosis (647 × 103 platelets/μL; reference range, 148 × 103 to 484 × 103 platelets/μL). A limited chemistry panel revealed a mildly elevated AST (88 U/L; reference range, 0 to 50 U/L) and ALT (231 U/L; reference range, 10 to 125 U/L). Three-view abdominal radiographic images were obtained (Figure 1).

Figure 1
Figure 1
Figure 1
Figure 1

Left lateral (A), right lateral (B), and ventrodorsal (C) abdominal radiographic images of a 6-year-old 3.4-kg neutered male mixed-breed dog presented for evaluation of a possible mechanical obstruction.

Citation: Journal of the American Veterinary Medical Association 261, 2; 10.2460/javma.22.09.0392

Diagnostic Imaging Findings and Interpretation

Abdominal radiography revealed a severely distended small intestinal bowel segment containing fluid, a small volume of gas, and granular mineral debris. The remaining small intestinal segments were normal in size. A small amount of formed fecal material was noted within the descending colon. In addition, the stomach was moderately to markedly distended with fluid and gas. A small amount of mineral opaque debris was present in the pyloric region of the stomach in all radiographic projections. Additionally, moderate dorsal thoracic subcutaneous emphysema was present due to prior subcutaneous administration of fluids (Figure 2). The severe, segmental small intestinal dilation with mineral debris and the moderate to severe, gastric distension with gastric mineral debris were concerning for small intestinal mechanical obstruction with gravel sign, suggestive of a chronic, partial to almost complete obstruction. Based on these findings and the chronicity, differential diagnosis for causes of the suspected small intestinal mechanical obstruction included adhesions, stricture, chronic intermittent intussusception, neoplasia, mesenteric or omental incarceration, and, less likely, foreign body.

Figure 2
Figure 2
Figure 2
Figure 2

Same radiographic images as Figure 1. Occupying most of the midventral, caudoventral, and right side of the abdomen is a severely distended small intestinal loop (arrowheads) containing fluid, gas, and granular mineral material (asterisk). Several normal-sized small intestinal loops are also noted (arrows). The stomach is moderately to severely distended with homogeneous fluid opaque material, a small amount of gas, and a mild amount of granular mineral opaque material (dotted white line). In addition, a moderate amount of subcutaneous gas is noted along the caudodorsal thorax.

Citation: Journal of the American Veterinary Medical Association 261, 2; 10.2460/javma.22.09.0392

For further assessment, an abdominal ultrasound was performed. Few contiguous jejunal segments were severely dilated with echogenic fluid and a small amount of suspended, hyperechoic shadowing debris and hyperechoic sediment, compatible with a gravel sign (Figure 3). At the orad and aborad aspects of the contiguous dilated segments, the small intestine tapered to normal diameter. There was no evidence of intraluminal foreign body, intussusception, or intestinal mass. The stomach contained a small to moderate amount of heterogeneous fluid and small amount of gas. The pyloroduodenal junction was patent and normal. With the inclusion of ultrasonographic findings, the updated primary differential diagnoses included small intestinal stricture, adhesions, mesenteric incarceration, or other undetected type of incarceration.

Figure 3
Figure 3

Ultrasonographic images of the abdomen of the dog described in Figure 1. A severely distended jejunal loop containing hyperechoic fluid is visible in the center of the image (arrowheads). Along the dependent aspect of this loop is a moderate amount of hyperechoic material (asterisk) with associated clean distal acoustic shadowing (wide arrow). An empty jejunal loop is also seen (arrow).

Citation: Journal of the American Veterinary Medical Association 261, 2; 10.2460/javma.22.09.0392

An abdominal CT was then performed the next day. The CT confirmed the ultrasonographic findings of a markedly dilated segment of jejunum containing fluid and mineral debris. Within the right caudal abdomen, the severe jejunal distension was followed by moderate to severe focal relative narrowing of the jejunum in comparison with the abnormally dilated segment. At this level, the jejunum protruded dorsolaterally into the abdominal wall, then returning to normal size aborad (Figure 4). Additionally, there remained a mild to moderate gastric distension. The CT findings were compatible with a small, subtle, right caudal abdominal wall herniation with presumed incarceration and adhesion of the jejunum leading to chronic, partial to almost complete mechanical obstruction.

Figure 4
Figure 4
Figure 4
Figure 4

Postcontrast transverse (A) and dorsal plane (B) images and postcontrast sagittal plane maximum-intensity-projection (C) abdominal CT images of the dog described in Figure 1. There is presumed incarceration and adhesion of a jejunal loop through a small right caudal and dorsal abdominal wall defect (arrowheads). The jejunal segment cranial to the presumed incarceration is severely distended with fluid attenuation and mineral-attenuating material (asterisk), while the segment caudal is normal in size. There are multiple normal-sized small intestinal loops (arrows). The images are displayed in a soft tissue window (window width, 400 HU; window level, 40 HU) with a 3-mm slice thickness. The dog was scanned in dorsal recumbency. The dog’s right side is located on the left side of all images.

Citation: Journal of the American Veterinary Medical Association 261, 2; 10.2460/javma.22.09.0392

Treatment and Outcome

A regular exploratory laparotomy was performed under general anesthesia without complication and confirmed the presence of a right dorsolateral abdominal wall hernia with entrapment of an approximately 5-cm-long segment of jejunum. Serosal adhesions in the hernia were bluntly and sharply dissected until the small intestinal segment was freed, and subsequently, multiple small serosal defects visualized on the antimesenteric segment of the previously entrapped jejunum were closed with a simple interrupted pattern. The bowel was healthy in color with normal mesenteric pulses and no leaks or defects detected on inspection, leading to an abdominal wall herniorrhaphy and lavage of the abdomen followed by the celiotomy closure. The patient was managed postoperatively in the intensive care unit with IV lactated Ringer’s solution (90 mL/kg/d), metoclopramide constant rate infusion (2 mg/kg/d), methadone (0.19 mg/kg, IV, q 6 h), cisapride (0.3 mg/kg, PO, q 8 h), trazodone (3.7 mg/kg, PO, q 8 to 12 h as needed), and gabapentin (11 mg/kg, PO, q 8 to 12 h as needed) and was then discharged 24 hours postoperatively with metoclopramide (0.4 mg/kg, PO, q 8 h for 7 days) and previously described gabapentin (14 days prescribed), trazodone (14 days prescribed), and cisapride (33 days prescribed). Approximately 2 months following surgery, the patient had progressively gained weight with no gastrointestinal signs and had been doing well at home overall.

Comments

An abdominal wall hernia is a defect or weakness within the abdominal wall that allows for protrusion of abdominal contents and may occur secondary to trauma or as a congenital lesion.1 Furthermore, abdominal wall herniation may lead to incarceration of organs causing luminal obstruction.1,2 The patient in the present case report had a previous history of trauma. Although the exact cause of prior trauma is unknown, it is likely that the patient experienced abdominal wall herniation during the traumatic event. On intake abdominal radiographs, a gravel sign with concurrent focal small intestinal dilation was noticed. A gravel sign is characterized by accumulation of granular mineral-opaque material within the gastrointestinal tract. Furthermore, a gravel sign is indicative of poor gastrointestinal motility and suggestive of chronic, partial obstruction.3 Based on the chronicity of signs and radiographic evidence of chronic mechanical obstruction, an abdominal ultrasound was elected. The abdominal ultrasound served to rule out differentials (such as a foreign body, intussusception, mural mass, or intestinal thickening) that may have prompted obstruction. However, the abdominal ultrasound failed to rule out differentials including strictures, adhesions, or mesenteric incarcerations. Computed tomography was ultimately required to determine the cause of obstruction before surgery. Abdominal exploration confirmed the presence of a small abdominal wall herniation and jejunal incarceration. Abdominal wall herniation and jejunal incarceration were initially missed assumptively by the referring veterinarian’s abdominal exploration. The abdominal wall hernia was located in the caudodorsal abdomen, which may have presented visibility challenges. The described case report is noteworthy, as advanced imaging was essential to localize the source of obstruction and assisted in surgical planning prior to abdominal exploration. If a patient presents with a history of trauma, persistent gastrointestinal signs, and radiographic evidence of intestinal obstruction, an abdominal wall hernia with incarceration of intestinal loops should be considered as a differential diagnosis and explored.

Acknowledgments

No external funding was used in this study. The authors declare that there were no conflicts of interest.

References

  • 1.↑

    Fossum T. Umbilical and abdominal hernias. In: Small Animal Surgery. 4th ed. Elsevier; 2012:364–365.

  • 2.↑

    Iodence AE, Perlini M, Grimes JA. Jejunal strangulation and incarceration associated with bilateral perineal hernias in a neutered male dog. J Am Vet Med Assoc. 2021;260(1):110–114.

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    • Export Citation
  • 3.↑

    Dennis R, Kirberger R, Barr F, Wrigley R. Gastrointestinal tract. In: Handbook of Small Animal Radiology and Ultrasound Techniques and Differential Diagnoses. 2nd ed. Saunders; 2010:267–285.

    • Search Google Scholar
    • Export Citation

Contributor Notes

Corresponding author: Dr. Vilaplana Grosso (fvilaplanagrosso@ufl.edu)
Cover Journal of the American Veterinary Medical Association
Journal of the American Veterinary Medical Association
Publication Date:
01 Feb 2023
  • Figure 1 Figure 1 Figure 1
    View in gallery
    Figure 1

    Left lateral (A), right lateral (B), and ventrodorsal (C) abdominal radiographic images of a 6-year-old 3.4-kg neutered male mixed-breed dog presented for evaluation of a possible mechanical obstruction.

  • Figure 2 Figure 2 Figure 2
    View in gallery
    Figure 2

    Same radiographic images as Figure 1. Occupying most of the midventral, caudoventral, and right side of the abdomen is a severely distended small intestinal loop (arrowheads) containing fluid, gas, and granular mineral material (asterisk). Several normal-sized small intestinal loops are also noted (arrows). The stomach is moderately to severely distended with homogeneous fluid opaque material, a small amount of gas, and a mild amount of granular mineral opaque material (dotted white line). In addition, a moderate amount of subcutaneous gas is noted along the caudodorsal thorax.

  • Figure 3
    View in gallery
    Figure 3

    Ultrasonographic images of the abdomen of the dog described in Figure 1. A severely distended jejunal loop containing hyperechoic fluid is visible in the center of the image (arrowheads). Along the dependent aspect of this loop is a moderate amount of hyperechoic material (asterisk) with associated clean distal acoustic shadowing (wide arrow). An empty jejunal loop is also seen (arrow).

  • Figure 4 Figure 4 Figure 4
    View in gallery
    Figure 4

    Postcontrast transverse (A) and dorsal plane (B) images and postcontrast sagittal plane maximum-intensity-projection (C) abdominal CT images of the dog described in Figure 1. There is presumed incarceration and adhesion of a jejunal loop through a small right caudal and dorsal abdominal wall defect (arrowheads). The jejunal segment cranial to the presumed incarceration is severely distended with fluid attenuation and mineral-attenuating material (asterisk), while the segment caudal is normal in size. There are multiple normal-sized small intestinal loops (arrows). The images are displayed in a soft tissue window (window width, 400 HU; window level, 40 HU) with a 3-mm slice thickness. The dog was scanned in dorsal recumbency. The dog’s right side is located on the left side of all images.

Figure 1

Left lateral (A), right lateral (B), and ventrodorsal (C) abdominal radiographic images of a 6-year-old 3.4-kg neutered male mixed-breed dog presented for evaluation of a possible mechanical obstruction.
Figure 1

Left lateral (A), right lateral (B), and ventrodorsal (C) abdominal radiographic images of a 6-year-old 3.4-kg neutered male mixed-breed dog presented for evaluation of a possible mechanical obstruction.
Figure 1

Left lateral (A), right lateral (B), and ventrodorsal (C) abdominal radiographic images of a 6-year-old 3.4-kg neutered male mixed-breed dog presented for evaluation of a possible mechanical obstruction.
Figure 2

Same radiographic images as Figure 1. Occupying most of the midventral, caudoventral, and right side of the abdomen is a severely distended small intestinal loop (arrowheads) containing fluid, gas, and granular mineral material (asterisk). Several normal-sized small intestinal loops are also noted (arrows). The stomach is moderately to severely distended with homogeneous fluid opaque material, a small amount of gas, and a mild amount of granular mineral opaque material (dotted white line). In addition, a moderate amount of subcutaneous gas is noted along the caudodorsal thorax.
Figure 2

Same radiographic images as Figure 1. Occupying most of the midventral, caudoventral, and right side of the abdomen is a severely distended small intestinal loop (arrowheads) containing fluid, gas, and granular mineral material (asterisk). Several normal-sized small intestinal loops are also noted (arrows). The stomach is moderately to severely distended with homogeneous fluid opaque material, a small amount of gas, and a mild amount of granular mineral opaque material (dotted white line). In addition, a moderate amount of subcutaneous gas is noted along the caudodorsal thorax.
Figure 2

Same radiographic images as Figure 1. Occupying most of the midventral, caudoventral, and right side of the abdomen is a severely distended small intestinal loop (arrowheads) containing fluid, gas, and granular mineral material (asterisk). Several normal-sized small intestinal loops are also noted (arrows). The stomach is moderately to severely distended with homogeneous fluid opaque material, a small amount of gas, and a mild amount of granular mineral opaque material (dotted white line). In addition, a moderate amount of subcutaneous gas is noted along the caudodorsal thorax.
Figure 3

Ultrasonographic images of the abdomen of the dog described in Figure 1. A severely distended jejunal loop containing hyperechoic fluid is visible in the center of the image (arrowheads). Along the dependent aspect of this loop is a moderate amount of hyperechoic material (asterisk) with associated clean distal acoustic shadowing (wide arrow). An empty jejunal loop is also seen (arrow).
Figure 4

Postcontrast transverse (A) and dorsal plane (B) images and postcontrast sagittal plane maximum-intensity-projection (C) abdominal CT images of the dog described in Figure 1. There is presumed incarceration and adhesion of a jejunal loop through a small right caudal and dorsal abdominal wall defect (arrowheads). The jejunal segment cranial to the presumed incarceration is severely distended with fluid attenuation and mineral-attenuating material (asterisk), while the segment caudal is normal in size. There are multiple normal-sized small intestinal loops (arrows). The images are displayed in a soft tissue window (window width, 400 HU; window level, 40 HU) with a 3-mm slice thickness. The dog was scanned in dorsal recumbency. The dog’s right side is located on the left side of all images.
Figure 4

Postcontrast transverse (A) and dorsal plane (B) images and postcontrast sagittal plane maximum-intensity-projection (C) abdominal CT images of the dog described in Figure 1. There is presumed incarceration and adhesion of a jejunal loop through a small right caudal and dorsal abdominal wall defect (arrowheads). The jejunal segment cranial to the presumed incarceration is severely distended with fluid attenuation and mineral-attenuating material (asterisk), while the segment caudal is normal in size. There are multiple normal-sized small intestinal loops (arrows). The images are displayed in a soft tissue window (window width, 400 HU; window level, 40 HU) with a 3-mm slice thickness. The dog was scanned in dorsal recumbency. The dog’s right side is located on the left side of all images.
Figure 4

Postcontrast transverse (A) and dorsal plane (B) images and postcontrast sagittal plane maximum-intensity-projection (C) abdominal CT images of the dog described in Figure 1. There is presumed incarceration and adhesion of a jejunal loop through a small right caudal and dorsal abdominal wall defect (arrowheads). The jejunal segment cranial to the presumed incarceration is severely distended with fluid attenuation and mineral-attenuating material (asterisk), while the segment caudal is normal in size. There are multiple normal-sized small intestinal loops (arrows). The images are displayed in a soft tissue window (window width, 400 HU; window level, 40 HU) with a 3-mm slice thickness. The dog was scanned in dorsal recumbency. The dog’s right side is located on the left side of all images.
  • 1.

    Fossum T. Umbilical and abdominal hernias. In: Small Animal Surgery. 4th ed. Elsevier; 2012:364–365.

  • 2.

    Iodence AE, Perlini M, Grimes JA. Jejunal strangulation and incarceration associated with bilateral perineal hernias in a neutered male dog. J Am Vet Med Assoc. 2021;260(1):110–114.

    • Search Google Scholar
    • Export Citation
  • 3.

    Dennis R, Kirberger R, Barr F, Wrigley R. Gastrointestinal tract. In: Handbook of Small Animal Radiology and Ultrasound Techniques and Differential Diagnoses. 2nd ed. Saunders; 2010:267–285.

    • Search Google Scholar
    • Export Citation

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