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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
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
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
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
REFERENCES
• HTTP://WWW.NCBI.NLM.NIH.GOV/PMC/ARTICLES/PMC339922/
• HTTP://WWW.EMA.EUROPA.EU/DOCS/EN_GB/DOCUMENT_LIBRARY/EPAR_-_PRODUCT_INFORMATION/VETERINARY/000132/WC500069279.PDF
• HTTP://WWW.NOAHCOMPENDIUM.CO.UK/PFIZER_LIMITED/TROCOXIL_CHEWABLE_TABLETS_FOR_DOGS/-50802.HTML
• HTTP://ONLINELIBRARY.WILEY.COM/DOI/10.1111/J.1939-1676.1989.TB00863.X/PDF
• HTTP://ONLINELIBRARY.WILEY.COM/DOI/10.1111/JSAP.12151/PDF