Today’s case is a 12 year old Labrador Retriever with abdominal distension. Take a look at the radiographs and post your comments below. Residents and emergency practitioners: Would you send this dog to surgery? Answers available on Monday.
12 year old Labrador Retriever
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{ 6 comments… read them below or add one }
Okay, so I find it very intimidating when the people who normally post here write these extremely long posts detailing all of their findings while I look at the image and go “blu-bluh-bluhhhh….” But that’s silly; we all have to learn somehow. If anyone is bothered by the inaccuracy and ineptitude of my guessing… too bad. If I can make one student feel less stupid about their own interpretations, then I’ve accomplished my goal.
So anyway, here’s what I see…
The exposure and everything looks great, and the bony structures are fine. In the right lateral, the spleen looks funky to me– the cranial aspect seems to bulge from a narrow waist. I don’t have any idea what’s going on with the stomach, but I sure can’t find a gastric axis. Where are the kidneys? I don’t have a clue (that is true for all four images). All of the small bowel loops seem to be squished into a tiny area, which might indicate a mass? So that would be consistent with the splenic mass idea.
The left lateral is what convinced me that the bulge is spleen and not kidney, but on second look I’ve changed my mind… maybe that is a massive liver, and it runs together with the spleen. If so, it has a rounded border. Gahhh! Spleen? Liver? Something’s funky!
On Image 4, I’m finally starting to be convinced that the gastric axis is basically vertical… so I’m moving my guess officially back to enlarged liver.
I think I see a cecum on image 3! Also, some of the end-on bowel loops look like they have really thick walls to me, but I’m not confident about that finding.
That’s all I’ve got. Hepatomegaly.
Then again, I don’t know why hepatomegaly would cause abdominal distension. Is it possible for the liver to be so big that it causes the gut to bulge? That seems crazy.
I can always guess lymphoma, right? Lymphoma can do whatever it wants. Maybe it’s making the bowel diffusely thickened and enlarging the liver and it already ate the kidneys for breakfast.
When I see a dog with abdominal distention I start to think in some possibilities as ascites, visceromegaly or mass. In this case I don’t see decreased abdominal contrast with no identification of the serosa of intestinal loops, neither displaced viscera or organs that could be a sign of abdominal mass. The stomach is filled with gas and with its axis displaced to left, including the piloric region (image 4). On LL projection I see an image of a soft tissue density septation/plateau inside the stomach wich divides it in two portions, dorsal and ventral (image 2). I think that is a case of gastric distension with volvulus. I would indicate the animal to surgery. The spleenic shadow seems more dense than normal (image 2) wich could be related to a congestive process.
I thilnk there are a couple of important radiographic findings on this one. As Bagetti mentioned, the stomach is gas-filled and has an abnormal, compartmentalized appearance. The tricky thing about this case is that gas is present in the fundus on the right lateral and DV projections and gas is present in the pylorus on the left lateral and VD projections; i.e. the position of the stomach seems appropriate based on the position of gas on the different radiographs. The key to this case is the loop of gas-filled small intestine cranial to the stomach, which is best observed on the right lateral and VD projections. In a normal abdomen, there should never be small intestine between the stomach and diaphragm. The caudal esophagus is dilated with fluid, also, and I agree with H_student that the liver is enlarged and has a rounded caudal margin. The appearance of the stomach with the abnormally positioned loop of intestine is consistent with a 360-degree GDV. Although the stomach ends up in a relatively normal position (pylorus to the right of midline and fundus on the left), the innocent bystander duodenum gets dragged around and ends up between the fundus and diaphragm. Take this dog to surgery!
I hope that everyone reading this blog posts a comment about a case! Regardless of your level of confidence, you won’t learn unless you try it. So thanks to H_student for taking a stab at it. Important point 1: the abdomen is abnormal. Important point 2: taking a systematic approach to evaluating each organ in turn. Those two things are a great start on this case.
I think everyone agrees that the stomach looks abnormal, which might fit with some differentials for abdominal distension. If you didn’t see that subtle finding of the loop of bowel cranial to the stomach on the d/v and v/d projections, go back and take a look. This is not an easy case! So far the majority vote is for emergency surgery… good call! Full answers will be available on Monday.
Foreign bodies in bowel; quite extensive. Gas filled tubing? Beads? Needs surgery.
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