Case Study: Suspect foreign body in dog
by Jennifer Jellison, DVM
Max, a 5-year-old German Shorthaired Pointer, presented for acute vomiting of two days duration. The client had been out of town and when she returned, she let Max out into the yard unattended for a few hours. She knows he was eating mulch and yard materials while he was out there. He has no history of eating toys, bones or rawhides, and has had no acute diet change. He normally has a tremendous appetite but currently did not want to eat. The client described a bowing behavior with his front legs extending and stretching downward, with his back legs straight. He has not had a bowel movement for two days and vomits currently every four to five hours. The vomit consists primarily of bile. He is current on all vaccines, including heartworm test and prevention. He is urinating normally.
Max was very active during his exam. He was robust and playful. He did not show any signs of nausea, and there was no drooling. His temperature was normal. Soft feces were palpated on rectal examination. Heart and lungs auscultated normally. Abdominal palpation was non-significant with a slight tenseness noted. CRT< 2sec and mm were pink. Hydration appeared normal. Overall, Max did not appear to be in distress.
Differential diagnoses include gastric foreign body with obstruction; gastritis (viral); gastritis (ingestion); metabolic disease; pancreatitis.
Internal organ screen (wnl)
Abdominal radiographs (abnormal)
Radiographs of the abdomen showed significant gas throughout the small intestines and colon. The colon contained a significant amount of fecal material. The stomach appeared to be empty. The small intestine contained two radio opaque objects. They were identical, circular and matched to the approximate size of a nickel.
Discussion points to consider
What is your next step and why?
After reviewing the films with the client she tells you her mother has been missing a pair of circular earrings for two months. She also reported she was missing some change, some pill bottle lids, nail clippers, and two rings from last year, and wanted surgery performed immediately on her dog. What is your perception of the client's state of mind at this moment and what is your recommendation?
Max was very rambunctious during his radiographs and light sedation was needed to take the scout films. He was given Torbugesic and valium. Would this have any effect on his radiographs?
What would be an appropriate fluid rate for Max?
Max was started on an intravenous drip of 2.5 % dextrose at two times maintenance. He received 850 mg of cefazolin IV. He was NPO and monitored for vomiting, diarrhea, with TPR performed hourly. The client was advised based on Max's current condition. Immediate exploratory surgery was a possibility but not necessarily indicated at this time. The recommendation was to monitor Max closely and perform serial abdominal radiographs to assess the suspect foreign bodies. Serial films were taken every hour to assess the abdomen.
Throughout the day, Max showed no vomiting and no change in clinical signs. The small intestines continue to show large gas patterns cranial and caudal to the foreign bodies, which were steadily moving through the intestinal tract. The materials reached the colon, and Max was taken for a long walk. He had a large bowel movement and it was examined for suspect foreign bodies.
Examination revealed two completely intact Pepto-Bismol tablets. The stool also contained large amounts of mulch and pieces of sticks. This most likely accounted for the gastritis Max was experiencing. The client stated that she had given them to him the evening before and had not told the doctor because she did not think it was important. Max was given famotidine, continued on fluids for 24 hours and placed on a bland diet. He recovered completely.
Foreign bodies resulting in obstruction occur commonly in the dog and can cause vomiting without anorexia, depression or anorexia1. Finding a foreign object on a radiograph and clinical signs of obstruction is sufficient for a diagnosis. In this case the question involves whether the suspect foreign body is causing disease or if the ingestion or mulch and other irritants is causing disease without an obstruction. An exploratory laporotomy would be indicated in any patient with this history and radiology results.
The veterinarian needs to be prepared for negative results in exploratory procedures as does the client. In this case based on the friability of the Pepto Bismol tablets it is questionable whether the suspect tablets would be found on a routine run through of the intestinal loops. An accurate history is important to help rule out what may be significant on a radiograph and what may not. Pepto Bismol contains minerals which do appear radiopaque and can be easily confused with other metallic objects.
Nelson RW, Couto GC. Small Animal Internal Medicine. 2003; 452