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A SUSPICIOUS CASE OF PERITONITIS

Xander Norval

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A SUSPICIOUS CASE OF PERITONITIS

ORDER OF EVENTS• INTRODUCTION TO XANDER

• HISTORY AND PRESENTATION

• CLINICAL EXAMINATION AND INVESTIGATION

• SURGERY AT GUVS

• DIAGNOSIS AND FURTHER ACTION

• THE FUN PART BEFORE THE END

• THE END

XANDER3 YEAR OLD MALE ENTIRE ROTTWEILER

HISTORY FROM THE BEGINNING...• JAN 2012 - INITIAL HL LAMENESS REPORTED - CAGE REST

AND MELOXIDYL

• MAR 2012 - RADIOGRAPHS SHOWING HIP DYSPLASIA AND REMODELLING OF RH - LOXICOM

• APRIL 2013 - CARPREIVE 50MG

• MAY 2013 - CARPREIVE 50MG AND SYNOQUIN LARGE BREED

• OWNER FEELS BY END OF MAY 2013 THAT XANDER IS NOT DOING WELL ON CARPREIVE OR LOXICOM. GIVEN PLT 28 DAY COURSE

• JUNE 2013 - TROXOCIL (95MG) - 1ST DOSE, 2 WEEKS LATER - 2ND DOSE

• DOSE END OF MONTH UNTIL NOV 2013

• RESTARTED TROCOXIL MAR 2014

HISTORY AND PRESENTATION• PRESENTED 6TH MAY 2014

• COLLAPSE

• 3 DAY HISTORY OF VOMITING, LETHARGY, ANOREXIA.

• VERY QUIET AND DULL

• PREVIOUS HISTORY OF HIP DYSPLASIA AND CHRONIC OSTEOARTHRITIS

• RECEIVING MONTHY TROCOXIL (95MG)

• SUPRELORIN IMPLANT (OCT 2012 AND DEC 2013)

• SHOW DOG AND SHOWING AGRESSION TOWARDS OTHER DOGS IN SHOW RING

CLINICAL EXAMINATION

• TACHYCARDIA – 160BPM

• POOR PERIPHERAL PULSES

• MM INJECTED AND SLOW CRT

• TEMPERATURE - 99OF

• DISTENDED ABDOMEN - FLUID THRILL AND TYMPANIC PERCUSSION

• HYPOVOLAEMIC SHOCK

FUTHER INVESTIGATIONS

• HAEMATOLOGY

• RBC 8.54 X10TO 12/L HIGH

• HCT 56.7% HIGH

• HGB 19.4 G/DL HIGH

• PLT 682 K/UL HIGH

• BIOCHEMISTRY

• GLU 8.32MMOL/L HIGH*

• UREA 36.6MMOL/L HIGH**

• PHOS 3.56MMOL/L HIGH**

• ALKP 329 U/L HIGH

• NA 128 MMOL/L LOW

• CL 95 MMOL/L LOW

IMAGING

• ABDOMINAL RADIOGRAPHY

• LOSS OF SEROSAL DETAIL

• GAS IN DORSAL QUADRANTS

• ABDOMINAL ULTRASOUND

• AREAS OF FLUID

• SUGGESTIVE OF ABDOMINAL EFFUSION

ABDOMINOCENTESIS

• GROSS APPEARANCE

• TURBID, HAEMORRHAGIC EXUDATE

• ABDOMINAL FLUID ANALYSIS

• GLUCOSE 1.3MMOL/L (8MMOL/L IN BLOOD)

• DEGENERATE NEUTROPHILS

• SEPTIC PROCESS

DIFFERENTIAL DIAGNOSES

• PRIMARY PERITONITIS (INFECTION/IDIOPATHIC)

• SECONDARY PERITONITIS MORE COMMON

• PERFORATION OF GI ORGANS

• BLADDER RUPTURE SECONDARY TO TRAUMA

• HEPATITIS

• PANCREATITIS

• PENETRATING INJURY TO BODY WALL

• DEHISCENCE OF WOUND CLOSURE

• ABDOMINAL NEOPLASIA...ETC

REFER TO GUVS!

SURGERYEXPLORATORY LAPARATOMY

• 4L OF FREE ABDOMINAL FLUID

• PERFORATING ULCER PRESENT OF PROXIMAL DUODENUM

• DUE TO CLOSE PROXIMITY TO COMMON BILE DUCT AND PANCREAS

• MINOR TISSUE RESECTION AND TRANSVERSE INCISION CLOSED LONGDITUDINALLY

• CLOSED SUCTION DRAIN PLACED AND CLOSED.

HISTOPATHOLOGY REPORT• GRANULATION TISSUE, SCATTERED WITH NEUTROPHILS AND OCCASIONAL FOCI OF MINERALISATION.

• EDGES OF THE SECTION ARE CHARACTERISED BY HYPEREOSINOPHILIC, AMORPHOUS NECROTIC MATERIAL INFILTRATE WITH KARYORRHETIC INFLAMMATORY CELLS (MAINLY NEUTROPHILS)

• NO EVIDENCE OF NEOPLASTIC PROCESS

DIAGNOSISSEPTIC PERITONITIS

SECONDARY TO PERFORATED DUODENAL ULCER

(SUSPECTED REACTION TO LONG TERM TROCOXIL

ADMINSTRATION)

POST OP INSTRUCTIONSMEDICATION

• OMEPRAZOLE 20MG

• CEPOREX 500MG.

• BAYTRIL 150MG.

• METRONIDAZOLE 400MG

• MISOPROSTOL 200UG

• CERENIA TABLETS

• TRAMADOL 50 MG

• Fed bland diet• Restricted exercise• Staples removed in 2 weeks• Stop using Troxocil• Avoid NSAIDs for 4 weeks

FURTHER ACTION

ADVERSE REACTION FORM TO VMD RE TROXOCIL

“UNDER INVESTIGATION”

COX2 INHIBITORS• COX-2 IS

• ACTIVATED IN DAMAGED AND INFLAMED TISSUES

• CATALYZES THE FORMATION OF INDUCIBLE PROSTAGLANDIN ASSOCIATED WITH INTENSIFYING THE INFLAMMATORY RESPONSE.

• ALSO INVOLVED IN THERMOREGULATION AND THE PAIN RESPONSE TO INJURY.

THEREFORE, COX-2 INHIBITION BY NSAIDS IS THOUGHT TO BE RESPONSIBLE FOR THE ANTIPYRETIC, ANALGESIC, AND ANTI-INFLAMMATORY ACTIONS OF NSAIDS.

TROCOXIL (MAVACOXIB)• SELECTIVE COX2 INHIBITOR

• TREATMENT OF PAIN AND INFLAMMATION ASSOCIATED WITH DEGENERATIVE JOINT DISEASE.

• PROLONGED DURATION OF ACTION (~1MONTH)

• SHOULD NOT BE USED FOR MORE THAN 6.5 MONTHS CONTINUOUS TREATMENT, WITH A ONE MONTH BREAK BETWEEN TREATMENTS.

• NOT TO BE USED IN:

• <12 MONTHS OF AGE

• <5KG BODYWEIGHT

• GI DISORDERS (INCLUDING ULCERATION OR BLEEDING)

• HAEMORRHAGIC DISORDER

• RENAL OR HEPATIC INSUFFIENCY

• PREGNANT, LACTATING OR BREEDING ANIMALS

• ANIMALS RECEIVING ANY CONCURRENT NSAID OR GLUCOCORTICOID THERAPY

TROCOXIL (MAVACOXIB)

A HAPPY ENDING• 2 WEEKS LATER…

• XANDER PRESENTED BACK TO REFERRING VET PRACTICE TO GET HIS STAPLES REMOVED… ANY LEFT FROM THE 36 THAT HE HADN’T REMOVED HIMSELF!

• HE HAS RECOVERED WELL AT HOMEAND IS CURRENTLY RECEIVING TRAMADOL FOR PAIN MANAGEMENT OF HIS OSTEOARTHRITIS