Nala’s Story: Nala, a three years old, female, spayed mixed breed dog was referred to the Veterinary Emergency and Specialty Center of New England with a 12 hours history of vomiting throughout the day. She had previously been a healthy dog. There was neither known toxin exposure nor dietary indiscretion.

Nala had been taken earlier that evening to her regular veterinarian. Abdominal radiographs were taken and showed an increased amount of gas in the stomach and small intestine. As this was suggestive of a possible gastrointestinal obstruction, she was referred to VESCONE for further supportive care and diagnostics.

On physical examination, Nala was depressed. Her vitals were normal but she was dehydrated (her gums were dry). She was also painful when her abdomen was palpated.

Nala was admitted for supportive care and additional diagnostic testing to determine the cause of her vomiting.

Full bloodwork was run to evaluate Nala’s overall health and to look for any organ dysfunction. A complete blood count, which examines the white blood cells, red blood cells, and platelets, showed that her white blood cell count was mildly elevated. An elevated white blood cell count does not necessarily indicate infection.It can also indicate an inflammatory process. A chemistry screen, which examines liver enzymes, kidney enzymes, and electrolytes, was non-remarkable. A coagulation profile, to check blood clotting times, was performed and was normal. An animal’s ability to appropriately clot blood can sometimes be altered with serious disease. The coagulation profile was normal.

Nala was started on intravenous fluids to help with rehydration.An intravenous antacid, famotidine, was started. This is the active ingredient in over the counter Pepcidâ. As she demonstrated abdominal pain, Nala was started on pain medication as well. She was started on antibiotics due to the concern for a gastrointestinal obstruction.

Once she was better hydrated, repeat abdominal radiographs were taken to re-examine the intestinal gas pattern and to see if there were any changes from the prior radiographs. The new radiographs showed a gas pattern similar to the referring radiographs. There was not any progression of the gastrointestinal gas. Although she was still depressed, Nala was stable. She was no longer vomiting and her vitals were still normal. She was scheduled for an abdominal ultrasound later that morning prior to a likely planned abdominal exploratory surgery.

Abdominal ultrasound further supported a gastrointestinal obstruction, a structure thought to be a foreign body was seen. The presence of abdominal fluid emphasized the need for emergency surgery as there was the possibility that the intestine could have perforated. Thus, Nala was taken for immediate abdominal exploratory surgery.

While a foreign body was thought to be the cause of Nala’s gastrointestinal obstruction, surgery revealed something quite different. Nala actually had an intestinal torsion. There were loops of small intestine that had become twisted. The twisted intestine was surgically removed. The remaining small intestine was attached to the large intestine (colon). Due to the intestinal torsion found at surgery and the questionable vitality of the remaining small intestine, the dog was given a very guarded prognosis.

Intestinal torsion is rare in small animals.While it can happen in any dog, young adult, male, medium to large breed sporting or working dogs are more commonly affected. Specific breeds that may be predisposed include German shepherds and English pointers. There is no one true cause for the torsion.Possible associations include vigorous activity, dietary indiscretion, trauma, intestinal inflammation, intestinal parasites, foreign bodies, cancer, and concurrent gastric dilatation volvulus (GDV, bloat). These disorders are only possible associations; there is no known definitive cause for intestinal torsion.

Immediate post-operative care was aimed at maximizing blood flow to the intestine and all of the abdominal organs, controlling pain, and minimizing the chances of developing post-operative complications.

A special intravenous catheter, inserted in Nala’s neck, was placed post-operatively to allow sampling of Nala’s blood easily and painlessly. This jugular catheter also enabled accurate monitoring of the blood volume in her vessels (called central venous pressure). Thus, the rates of Nala’s intravenous fluids could be matched to her body’s needs. A continuous electrocardiogram (heart rhythm monitor) was started to carefully monitor for any heart arrhythmias. Nala’s blood pressure, heart rate, and respiratory rate were also monitored around the clock.

Due to the increased risk for body wide infection or sepsis, Nala was started on two additional antibiotics. Poor motility of the gastrointestinal tract, called ileus, can occur post-operatively.This can lead to excess gas, pain, nausea, and vomiting. In order to combat post-operative ileus, a medication called metoclopramide was started.

Nala was started on heparin, a blood thinner, to decrease the chance that she develop blood clots. Appropriate pain management was essential to Nala’s comfort and healing. A pain patch that releases fentanyl, a narcotic, across the skin was placed.

Nala was relatively stable during the first 12 hours after surgery. She was starting to walk outside and urinating. Her vitals were good.Her electrocardiogram demonstrated a normal heart rhythm. Nala was given a plasma transfusion.Plasma is the liquid portion of blood that has been separated from the red blood cells.Plasma contains blood clotting factors that Nala needed to heal.

Nala continued to do relatively well considering the major abdominal surgery she had and her guarded prognosis. However, her appetite was poor. Nala would not eat despite temping her with tasty foods. Nutrition is very important for post-operative healing. Thus, a nasoesophageal feeding tube was placed. A nasoesophageal feeding tube, NE tube, enters the animal’s nose and goes down the throat ending in the lower esophagus. A continuous drip of liquid nutrition was administered.

Two days after surgery, Nala started to eat some on her own. As she was eating on her own, the feeding tube was pulled. Nala was transitioned to from intravenous to oral medications. She was discharged four days after her abdominal surgery.

After going home, Nala’s attitude went back to normal and she continued to eat well. When animals have large portions of their intestine removed, there is decreased absorption of food, water and electrolytes leading to diarrhea and weight loss. This can be temporary. As Nala had persistent diarrhea and was thin despite a good appetite, she was referred to a nutritionist. Upon consultation, continued and permanent feeding with a low fat, high fiber diet was recommended. Today, Nala is doing great. Her energy level is normal, she is gaining weight.

Throughout it all, Nala was a brave trooper and an excellent patient. We at VESCONE could not be happier for her. We wish her many happy years of running and chasing her ball!