Monday, June 24, 2013

1474. Judgement Day - An unusual closed pyometra in a Jack Russell

Monday June 24, 2013  6pm

"It is up to the vet to decide when to operate," I had seen the X-rays of this small-built 7-year-old female Jack Russell X who could be a cross with a Chihuahua as this was a popular breed with local breeders. "I usually give the dog an IV drip plus antibiotics to stablise the dog and operate 24 hours later. Waiting another day may lead to the dog being toxic as there is a lot of pus and bacteria inside the swollen uterus of pyometra."

Dr Daniel had palpated the Jack Russell yesterday, Sunday. She had a painful abdomen and had been on heat 2-3 weeks ago. She could pee normally. Today, her rectal temperature was 37.6 deg C. "It is more important that she be operated to remove her swollen womb today," I advised. "If the womb ruptures overnight, she will be dead tomorrow. The X-rays showed the swollen uterine bodies. There is no need to wait for the complete blood test results."

I put the dog on the table and palpated a large swollen mass in the mid-abdomen. The dog did not cry in pain but was uncomfortable. "It felt like a big swollen bladder or stomach," I said. "But it could be the swollen uterus."

"The dog can pee with no problem," my assistant Nia said. "No blood in the urine."
So, it would likely be closed pyometra rather than a gastric dilatation (stomach swollen with gas). Dr Daniel decided to operate.

I could see a large distended uterus stretching from the lower chest to the pelvic area. This was unusually long and large in a small-bodied Jack Russell X. "Make a longer incision forward to the sternum," I could see that Dr Daniel could not fish it out.

"It is a swollen stomach," Dr Daniel said after fishing out the hemispheric swollen organ. Certainly it has the structure of a stomach full of gas or fluid with a greater curvature seen initially. As Dr Daniel extricated more of the organ, there were the continuation to the left uterine body which had 10 times smaller lumps. So this was closed pyometra confirmed.

This was an abnormal presentation as usually all uterine bodies would be filled with pus and be of similar sizes. Here, there was only one gigantic swelling of part of the left uterine body, as if both ends of the lobules were cut off, resulting in one portion grossly distended. I took a video and some images of the challenges diseases present to sharpen the diagnostic skills of the veterinary surgeon.

"Use the triple forceps method," I advised Dr Daniel. Each vet has his or her own method. "No need to ligate the omental fat separated from the uterine side but just clamp and cut. Surgery has to be quick in case the dog dies. For the uterus, ligate two parts so that if one ligature slips, there is another one."

The dog was recovering when the mother and her two adult children came to visit at 7 pm.  She looked dazed. "Why is her tongue sticking out? Will it be permanent?" the daughter asked me as Dr Daniel was busy clipping the long claws of a recumbent 18-year-old cat brought in by an adult son and his mother. It was his mother's cat.

"The tongue sticking out is due to anaesthesia," I said. "The tongue will be in when the dog is awake."
The dog's eyes were open wider as the owners stayed for another 20 minutes. But she could not stand. An Antisedan injection would reverse the Domitor given earlier and waken up the dog. But as each vet has his or her own ideas, I did not insist.   

The dog would likely recover after the operation on Judgement Day. If there was a delay, she might be dead. Evidence-based medicine is important in the diagnosis of closed pyometra as owners want to know for sure. In the old days, I would have got a history of the dog being on heat, passing out "blood with mucus", palpated a painful abdomen and advised spaying. This would save the dog's life and the owners some medical expenses. But nowadays, evidence-based medicine is important as owners are most sophisticated and likely to sue.

BLOOD TEST RESULTS Jun 24, 2013 on admission

Total white cell count and neutrophil - normal 
Total WCC 10.6 (6-17).  N 69.8  Absolute 7.4-R
Monocytes 18.6 --- high
Haemoglobin 11.8 (12-18).
Platelets 135  (200-500) --- toxaemia is present.

Urea 7.2 (4.2 - 6.3)
Creatinine 59 (89-177)

A swollen uterine body may be seen.

UPDATE Junw 25, 2013  9.30 am
Dog is OK, tongue colour much pinker. Not eating the A/D. Wound is OK.

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