Abdominal enlargement, decreased appetite, and lethargy in a 3-year-old female intact Toy Poodle

Hsin-Yeh Cheng Veterinary Medical Teaching Hospital, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan

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Wei-Yau Shia Veterinary Medical Teaching Hospital, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan
Department of Veterinary Medicine, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan

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Hsien-Chi Wang Veterinary Medical Teaching Hospital, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan
Department of Veterinary Medicine, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan

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Kuan-Sheng Chen Veterinary Medical Teaching Hospital, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan
Department of Veterinary Medicine, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan

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History

A 3-year-old 4.05-kg sexually intact female Toy Poodle was brought to the veterinary medical teaching hospital at the National Chung Hsing University for evaluation of abdominal enlargement as well as decreased appetite and activity for a month. The owner reported that the dog had been vomiting 2 to 3 times over a month, especially after feeding. Increased urination and brown urine were also observed by the owner for a week. The owner also believed that the dog was pregnant.

Physical examination findings included lethargy, 5% dehydration, emaciation (body condition score, 3/9), severe muscle loss, tachycardia (168 beats/min; reference range, 70 to 120 beats/min), 5/6 continuous heart murmur at the left heart base, and a strong and synchronous femoral pulse. The self-respiratory rate (42 breaths/min; reference range, 18 to 35 breaths/min) and lung sounds were normal upon thoracic auscultation. The dog’s rectal temperature was within reference range (38.2 °C; reference range, 37.2 to 39.2 °C). The oral mucous membrane was pale and moist with a capillary refill time of < 2 seconds.

Hematological and serum biochemical analyses and urinalyses were performed. Based on CBC, there was marked leukocytosis (62.4 X 103 WBCs/μL; reference range, 5.05 X 103 to 16.7 X 103 WBCs/μL) characterized by lymphocytosis (14.3 X 103 lymphocytes/μL; reference range, 1.05 X 103 to 5.1 X 103 lymphocytes/μL), monocytosis (4.3 X 103 monocytes/μL; reference range, 0.16 X 103 to 1.12 X 103 monocytes/μL), and severe neutrophilia (43.4 X 103 cells/µL; reference range, 2.95 X 103 to 11.64 X 103 cells/µL) with 21.2 X 103 cells/µL of band neutrophils. 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 radiographic (C) projections of the abdomen of a 3-year-old 4.05-kg sexually intact female Toy Poodle undergoing examination for enlargement of the abdomen and decreased appetite and activity for 1 week.

Citation: Journal of the American Veterinary Medical Association 261, 7; 10.2460/javma.23.04.0191

Diagnostic Imaging Findings and Interpretation

Abdominal radiography (Figure 2) revealed a large gas-filled, thin-walled, oval structure measuring approximately 11 cm in diameter and 17.4 cm in length that occupied approximately two-thirds of the abdomen and displaced the small intestine craniodorsally and the descending colon dorsally without distention. A soft tissue band was found in this structure, resulting in compartmentalization. The stomach could not be visualized. On the ventrodorsal view, another dilated, gas-filled tubular structure (approx 5.8 cm in thickness) was observed in the left abdomen. On the ventrodorsal and left lateral views, other smaller gas-filled tubular structures were noted on the left side of the peritoneal cavity and ventral to the displaced descending colon. However, this gas-filled structure was not visible in the right lateral view, most likely because of the filling of the intraluminal fluid due to its positioning. There was decreased visualization of the intra-abdominal serosa, suggesting a mass effect, effusion, peritonitis, or emaciation. Other organs could not be evaluated because of the mass effect and decreased serosal detail. The included osseous structures were unremarkable.

Figure 2
Figure 2
Figure 2
Figure 2

Radiographic images as shown in Figure 1. There is a huge distended, gas-filled structure (arrowheads) with a soft tissue band (thick arrows in B) noted in the midabdomen and another dilated, gas-filled tubular structure (thin arrows in C) in the left abdomen seen on the ventrodorsal view causing the small intestine craniodorsal displacement (asterisks). The descending colon (daggers) is displaced dorsally by the gas-filled tubular structure seen on the right lateral view. A smaller gas-filled tubular structure (chevrons) is noted in the left side of the peritoneal cavity in the ventrodorsal view and ventral to the descending colon in the left lateral view but not in the right lateral view.

Citation: Journal of the American Veterinary Medical Association 261, 7; 10.2460/javma.23.04.0191

The differential diagnoses of the large distended, gas-filled structures were emphysematous pyometra, gastric distension-volvulus (GDV), or severe mechanical ileus. The smaller gas-filled structure was most likely a part of the emphysematous pyometra or mechanical ileus. However, GDV or mechanical ileus was considered less likely due to lack of acute gastrointestinal symptoms. Abdominal ultrasonography was performed for further evaluation.

Ultrasonography revealed an echoic fluid-filled tubular structure with thin walls and an irregular mucosal surface in the midabdomen and caudal abdomen. Reverberation artifacts were also observed in the tubular structure, indicating the presence of gases (Figure 3). The gas- and fluid-filled tubular structures were ultrasonographically confirmed as the left uterine horns. The uterine body, right uterine horn, and both ovaries were unremarkable. No mechanical ileus was observed. The left and right medial iliac lymph nodes were mildly enlarged with a thickness of 9.4 and 8.9 mm, respectively, suggestive of reactive or neoplastic lymphadenopathy. No free fluids or gases were detected in the abdomen. The remaining abdominal organs were unremarkable.

Figure 3
Figure 3

Abdominal ultrasonographic images of the same dog. The left uterine horn is distended with a large amount of echogenic fluid (F) and gas (pound sign).

Citation: Journal of the American Veterinary Medical Association 261, 7; 10.2460/javma.23.04.0191

Treatment and Outcome

An ovariohysterectomy was performed. The left uterine horn showed markedly segmental dilatation and was filled with gas and brown-colored pus-like fluid, whereas the right uterine horn appeared to be normal. The gastrointestinal tract and remaining abdominal structures were grossly unremarkable during surgery. The exudate was collected from the lumen of the left excised uterine horn, and Clostridium perfringens was isolated. The patient recovered uneventfully and was discharged from hospital.

Comment

Based on the review of literatures, emphysematous pyometra with such a large gas-filled oval to tubular structure in the midabdomen has not been described previously. In this case, because the stomach was not visualized, the massive gas-filled structure with compartmentalization may mimic GDV. However, the craniodorsal displacement of the small intestines in this case was not consistent with GDV. The compartmentalization was likely caused by the folding of the massively enlarged gas-filled tubular structures. Furthermore, the absence of nonproductive retching symptoms made the diagnosis of GDV less likely.

In abdominal radiography, a soft tissue tubular structure observed between the descending colon and the urinary bladder and/or distorted tubular soft tissue structures in the caudal abdomen with symmetrical distribution on ventrodorsal radiography are typical radiographic features of an enlarged uterus.13 However, when gas is present in the dilated uterus, it can be challenging to differentiate emphysematous pyometra from mechanical ileus due to the similar appearance of gas-filled tubular structures.2,4 A bifurcated gas-filled tubular structure observed radiographically could be a feature of a gas-filled uterus,4 but emphysematous pyometra could not be confirmed if this feature was not visualized. In this case, a bifurcated gas-filled tubular structure was not observed, and the gas-filled tubular structures were difficult to differentiate between mechanical ileus and emphysematous pyometra radiographically. Therefore, ultrasound was utilized to distinguish between the 2 conditions.

Although a large amount of gas could interfere with ultrasound transmission, distinguishing between the structures of the uterus and small intestine can also be accomplished through the examination of wall layering. The uterus lacks identifiable wall layering, and the small intestine has 5 layers.2 Furthermore, tracing the gas-filled structure cranially or caudally may reveal the ovaries or uterine body located between the colon and the urinary bladder. This could aid in distinguishing emphysematous pyometra from mechanical ileus. In this case, ultrasonography was performed, and the gas-filled tubular structures did not have layered walls as the small intestine does, indicating that they were not intestine. In addition, the tubular structure could be traced to the uterine body, and the diagnosis was confirmed as emphysematous pyometra.

The reason for the unilateral distribution of uterine gas, like unilateral pyometra, remains unclear.5 In this case, no obstruction was found at the base of the affected uterine horn as previously described in unilateral pyometra.5 However, a cause of segmental infection cannot be excluded.5

In conclusion, distinguishing emphysematous pyometra from other large gas-filled gastrointestinal structures may not be possible through radiographic examination alone. If the origin of a large gas-filled structure cannot be determined radiographically, ultrasonography can assist in making a definitive diagnosis.

Acknowledgments

The authors have nothing to declare.

The authors thank Dr. Chia-Hung Huang for providing surgical assistance in this case.

References

  • 1.

    Hagman R. Pyometra in small animals 2.0. Vet Clin North Am Small Anim Pract. 2022;52(3):631-657.

  • 2.

    Mattei C, Fabbi M, Hansson K. Radiographic and ultrasonographic findings in a dog with emphysematous pyometra. Acta Vet Scand. 2018;60(1):67. doi:10.1186/s13028-018-0419-z

    • Search Google Scholar
    • Export Citation
  • 3.

    Hernandez JL, Besso JG, Rault DN, et al. Emphysematous pyometra in a dog. Vet Radiol Ultrasound. 2003;44:196-198.

  • 4.

    Chang AC, Cheng CC, Wang HC, et al. Emphysematous pyometra secondary toEnterococcus avium infection in a dog. Tierarztl Prax Ausg K Kleintiere Heimtiere. 2016;44(3):195-199.

    • Search Google Scholar
    • Export Citation
  • 5.

    Van Israël N, Kirby BM, Munro EAC. Septic peritonitis secondary to unilateral pyometra and ovarian bursal abscessation in a dog. J Small Anim Pract. 2002;43(10):452-455.

    • Search Google Scholar
    • Export Citation
  • Figure 1

    Left lateral (A), right lateral (B), and ventrodorsal radiographic (C) projections of the abdomen of a 3-year-old 4.05-kg sexually intact female Toy Poodle undergoing examination for enlargement of the abdomen and decreased appetite and activity for 1 week.

  • Figure 2

    Radiographic images as shown in Figure 1. There is a huge distended, gas-filled structure (arrowheads) with a soft tissue band (thick arrows in B) noted in the midabdomen and another dilated, gas-filled tubular structure (thin arrows in C) in the left abdomen seen on the ventrodorsal view causing the small intestine craniodorsal displacement (asterisks). The descending colon (daggers) is displaced dorsally by the gas-filled tubular structure seen on the right lateral view. A smaller gas-filled tubular structure (chevrons) is noted in the left side of the peritoneal cavity in the ventrodorsal view and ventral to the descending colon in the left lateral view but not in the right lateral view.

  • Figure 3

    Abdominal ultrasonographic images of the same dog. The left uterine horn is distended with a large amount of echogenic fluid (F) and gas (pound sign).

  • 1.

    Hagman R. Pyometra in small animals 2.0. Vet Clin North Am Small Anim Pract. 2022;52(3):631-657.

  • 2.

    Mattei C, Fabbi M, Hansson K. Radiographic and ultrasonographic findings in a dog with emphysematous pyometra. Acta Vet Scand. 2018;60(1):67. doi:10.1186/s13028-018-0419-z

    • Search Google Scholar
    • Export Citation
  • 3.

    Hernandez JL, Besso JG, Rault DN, et al. Emphysematous pyometra in a dog. Vet Radiol Ultrasound. 2003;44:196-198.

  • 4.

    Chang AC, Cheng CC, Wang HC, et al. Emphysematous pyometra secondary toEnterococcus avium infection in a dog. Tierarztl Prax Ausg K Kleintiere Heimtiere. 2016;44(3):195-199.

    • Search Google Scholar
    • Export Citation
  • 5.

    Van Israël N, Kirby BM, Munro EAC. Septic peritonitis secondary to unilateral pyometra and ovarian bursal abscessation in a dog. J Small Anim Pract. 2002;43(10):452-455.

    • Search Google Scholar
    • Export Citation

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