A Christmas Eve dilemma

When Lion just wasn’t himself.

Australian Kelpie - By CryonicPlatypus

With everyone busy with holiday preparations, travel plans, or visiting friends and family, late December is usually a peaceful time around my office. Most of my staff was away, but Susan, my long-term secretary and assistant, and I were there on Dec. 24, seeing a few appointments, refilling prescriptions, selling last-minute pet supplies. Since my practice is attached to my home, I was in the kitchen baking gingerbread houses. My (Jewish) kids would decorate them the next day while their Christian friends were busy opening presents. Then Lion, the Australian kelpie, arrived.

No, that’s not a Down Under marsupial. It’s a midsize, intelligent, active herding dog, similar to the better-known Australian cattle dog. Kelpies need lots of exercise and a job to do to keep them busy, happy, and out of mischief. At 6 years old, Lion is in his prime, but had been vomiting intermittently for several days, and now wasn’t eating. We don’t panic every time a dog has a vomiting bout. After all, being dogs, they often eat things they shouldn’t. Simple symptomatic treatment is often sufficient intervention, but Lion’s owners had already tried the usual home remedy of multiple small bland meals and over-the-counter tummy medications. He had stopped vomiting, but also stopped eating, and was increasingly lethargic. A slow-moving Newfoundland might lie motionless on the floor even when feeling fine, but Lion was usually a bouncy boy. Watching him walk very, very slowly into my office instead of bounding in — well, he was definitely not himself. His temperature was normal. He was slightly dehydrated. On palpation, his belly seemed slightly tender, but I couldn’t feel anything obviously abnormal. Should I just give antinausea medication and see if he improved? Hmmm. It was Christmas Eve. My office would be closed the next three days. The owners planned to travel soon. Lion had been sick for several days already, and was pretty down.

Twenty-five years ago I saw another dog with similar signs. The owners were very concerned, but I was young and cavalier, and kept assuring them it was “just nonspecific gastroenteritis,” in other words, an upset tummy. I sent them home without running diagnostics. Although many vomiting dogs do not have serious illnesses, that dog was actually in kidney failure. I lost the clients, and they eventually lost their dog. Although earlier diagnosis would not have ultimately changed the outcome, that case has always stuck with me. “Considering everything, let’s do blood work,” I advised. “Radiographs, too.” I asked them to leave Lion with me for the morning. The client agreed and left to run errands. I ran blood tests, while Susan started on the radiographs. The only abnormalities on the lab work were slightly low sodium and chloride levels, a result of the repeated vomiting and anorexia.

Now, the radiographs. Radiographs give a two-dimensional view of internal organs, showing everything superimposed together in a single plane. In order to envision things in three dimensions, we usually take at least two views, oriented at 90° to each other. In other words, one with Lion flat on his side, a second rolled up on his back. The developed film shows everything in variations of black, gray, and white. Bone and metal appear white. Air, black. Everything else, various shades of gray. We call the grays “soft tissue density.” Gray can be fluid, like urine in the bladder. Gray can be solid, like liver or heart. Intestines? It depends what’s inside. Poop will be different shades of gray, depending on the density. Chewed-up bones will be white. Fluid diarrhea, gray. Gas, which is essentially air in the bowel, appears black.

Unlike organs that are fixed in one place, like the heart or liver, intestines are more mobile, shifting around and changing appearance depending on their contents. Lion’s films showed several excessively large gas-filled tubes of bowel. “Looks like an obstruction,” I sighed. The difficulty is that unless a blockage is caused by something bone or metal, many foreign objects won’t show up on x-rays: socks, rubber toys, corncobs. Such items can cause life-threatening obstructions yet not be visible on our films. Presumptive diagnosis is made based on how intestinal appearance changes in response to not being able to function normally. Our options now? In the old days, we would force-feed Lion barium. This “radio-opaque” fluid shows up distinctly on x-rays. By taking films every hour or so, we could confirm an obstruction if the barium stopped flowing through the bowel. But barium studies take many hours, and if an obstruction is found, having barium in the gut increases the risk of surgical complications. What about ultrasound? I don’t have the equipment, but called another veterinarian who does. “There’s a high risk of false negatives for foreign bodies,” he said. In other words, ultrasound could still miss making the definitive diagnosis.

Christmas Eve was approaching fast. I believed Lion needed surgery to relieve an intestinal obstruction, but couldn’t be positive. Nor could I tell whether the surgery would be a fairly simple foreign-body removal or a more complex procedure requiring excising damaged bowel. In either case, Lion would best go to a large hospital with round-the-clock intensive care. “I hope I’m wrong,” I told the owner as we made arrangements to send Lion off to the specialists. “I hope I’m sending you on a wild-goose chase.”

But there were no wild geese. Lion went straight to surgery that evening. On Christmas Day, while my daughters stuck gumdrops onto gingerbread houses with gooey icing, I called the specialist. Turns out a large acorn had been firmly lodged in Lion’s intestines. He was recovering well, but they were keeping him hospitalized until his electrolytes normalized and he began eating. “Really? An acorn? ” I blurted out. “A great big acorn,” the surgeon replied. “It was stuck in there good and tight.” I shook my head in amazement that this acorn had grown, not into a mighty oak, but into a mighty big problem.