ACT Division Case Report

Photo of the patient three days post-op.

A 13 year-old, female speyed, Poodle was presented to Dr. Elvany Luswanto at the Animal Referral Hospital Canberra, Emergency Department,  in mid-October for an acute onset of laboured breathing and dry retching. On physical examination, she was found to have a Grade II/VI systolic heart murmur, abdominal pain and diffused lipoma of various sizes. The heart murmur was previously detected and she has been on Catrophen injections for the management of ongoing arthritis.

Haematology and biochemistry revealed lymphopaenia, monocytopaenia, eosionpaenia, mild elevation in creatinine, moderate elevation in ALT and a marked elevation in ALKP. Her lactate was elevated and SNAP cPLi showed a weak positive result. aPTT was run and her coagulation time was within normal reference range.

Orthogonal projections of the abdomen were radiographed which revealed a marked hepatomegaly. There was some gas in the stomach but no indication of obstructive pattern. An AFAST (Abdominal Focused Assessment with Sonography for Trauma) was also performed which revealed a small amount of free abdominal fluid.

Pain relief was initiated with Fentanyl CRI at 5 mcg/kg/h. Hepatobiliary disease was the tentative diagnosis so a specialist surgeon's opinion was recommended to the client. With the client's consent, specialist surgeon Dr. Bruce Smith and surgical resident Dr. Ryan Leong were called in afterhours.

Prior to surgery, three-view thoracic radiography were ordered for metastasis check, given the patient's signalment. Thoracic radiography was unremarkable.

A median, exploratory celiotomy was performed. There was about 30 ml of serosanguinous free abdominal fluid. There was a small area of omental adhesion most likely associated with previous ovariohysterectomy site. The liver appeared largely normal but there was a focal area of purulent discharge from the left lateral lobe. This was highly suggestive of hepatic abscess. A left lateral liver lobectomy was performed using a TA-60 stapler. There was minor haemorrhage which was controlled with bi-polar electrocautery. The abdomen was lavaged with sterile sodium chloride and the lobectomy site omentalized prior to closure.  

Parenteral antibiotics (Metronidazole 15 mg/kg slow IV q12h, Cefazolin 22 mg/kg slow IV q8h and Enrofloxacin 5 mg/kg slow IV q24h) were commenced while waiting for histopathology and tissue culture results. Postoperative monitoring included PCV/TPP, blood smear, ALT, lactate, electrolytes, aPTT at least once every 24 hours. Maropitant 1 mg/kg SQ q24h and Esomeprazole 0.8 mg/kg slow IV q24h were also added to the list for the management of a largely recumbent patient who was also inappetent. The patient's recovery was slow but progressive. She developed diarrhoea two days after her surgery.  Her ALT and lactate levels normalized two days after surgery. However, her platelet count and aPTT were fluctuating on a 12-hourly basis. DIC (Disseminated Intravascular Coagulation) was a possibility so Enoxaparin 1 mg/kg SQ q8h was commenced. She also developed gut ileus, hence Metoclopramide CRI at 1-2 mg/kg/day was started.

The client was very committed. She visited twice daily to spend time with her and was always trying to encourage her to eat during visitation. Unfortunately, five days after surgery, the patient developed marked pyrexia and had multiple episodes of seizure activity. Given the slow to poor progress, the client decided to euthanized the patient.

The histopathology came back as a mild acute multifocal necrosuppurative hepatitis with intracellular bacterial rods, septic peritonitis and multifocal nodular hepatocellular hyperplasia. Tissue culture revealed a moderate growth of Clostridium perfringens.

Not every case ends with a happy ending. In spite of everything that was done for the patient i.e. early detection of clinical signs by the client, immediate diagnostic tests and surgical intervention, we are always on a constant race with biology and the progression of the disease process. With every patient loss, there are always lessons we can learn from.


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