1. Baylor 2 year old spayed female GSD Vomits bile daily, for 2 weeks Exam - NSAF 1. CBC, profile, electrolytes, urinalysis, fecal, HW – NSAF 2. Imaging – Abdominal radiographs, practice does not have abdominal ultrasound

2. Baylor

4. My recommendation was to take dog to surgery for gastropexy and to explore spleen, or refer for abdominal ultrasound. Radiologist rad report says no significant abnormal findings. Dog was treated empirically for vomiting. Baylor presented for acute GDV at a local clinic 2 weeks later, was euthanized. On necropsy, the spleen was engorged and large.

5. Lady Middle aged spayed female GSD, presented for chronic vomiting 1. CBC, profile, electrolytes, urinalysis, fecal, HW – NSAF 2.Abdominal radiographs showed an abdomen similar to Baylors, except: No splenic mass Gas filled esophagus 3. Lady was taken to surgery, the chronic GV reduced and tube gastropexy performed --she was treated for esophagitis, fed via tube for several weeks and recovered

6. Jovi 1-1/2 year old SF Great Dane1-1/2 year old SF Great Dane 120 lbs120 lbs CC – Referred for chronic cough andCC – Referred for chronic cough and vomiting vomiting Not eating for 2 daysNot eating for 2 days Exam – BCS 4/6, temp 104FExam – BCS 4/6, temp 104F

7. Jovi CBCCBC –PCV 30% –MCV, MCH, MCHC normal –Neutrophils 38,000/ul –Monocytes 2,700/ul panel – albumin 2.2 g/dlpanel – albumin 2.2 g/dl UA – no abnormalitiesUA – no abnormalities Electrolytes/blood gases –Electrolytes/blood gases – –normal Thoracic radiographsThoracic radiographs

8. Jovi

9. Jovi DDx MegaesophagusDDx Megaesophagus –Idiopathic –Obstruction Vascular ring anomalyVascular ring anomaly stricturestricture –Hypothyroidism –Hypoadrenocorticism –Myasthenia gravis –Esophagitis Chronic GDVChronic GDV Urine suckling in orphan kitten littersUrine suckling in orphan kitten litters

10. Jovi Thyroid PanelThyroid Panel –TSH - undetectable –T4 – 2.9 (low) –Free T4 - normal ACTH Stimulation TestACTH Stimulation Test –Pre ACTH cortisol – 0 ug/dl –Post ACTH cortisol – 0 ug/dl Anti Ach Receptor AntibodyAnti Ach Receptor Antibody –negative

11. Jovi DxDx –Megaesophagus due to hypoadrenocorticism hypoadrenocorticism –Secondary aspiration pneumonia pneumonia –Sick euthyroid

12. Jovi TxTx –Prednisone 10 mg PO SID –Amoxicillin 1500 mg PO BID x 4-8 weeks x 4-8 weeks –Ciprofloxacin 500 mg PO BID x 4-8 weeks BID x 4-8 weeks –Follow pneumonia with chest x-rays chest x-rays

13. Jovi TxTx –Jovi eventually needed treatment also with treatment also with mineralocorticoids mineralocorticoids –Megaesophagus due to Addison’s responds well to Addison’s responds well to treatment treatment –This is in contrast to megaesophagus due to hypothyroidism –ME due to MG can resolve after 6-18 months

14. What Does Addison’s Look Like? Hypoalbuminemia and Addison’sHypoalbuminemia and Addison’s –Albumin may have been contributed to also by lung infection in this case –Hypoalbuminemia can be the primary presenting symptom of Addison’s

15. Benji Boy 3 year old neutered male papillon Hx – never been sick before, except got stepped on by a cow 6 weeks ago Wheezes in the lungs Trauma to the right inguinal area Healed with time CC – anorexia and lethargy, vomits 1-2x a week Exam – NSAF

16. Benji Boy CBC – WBC 22,450/ul Neutrophil 16,390/ul Monocytes 2,360/ul Basophils 140/ul Electrolytes – normal Panel – SAP 262 U/L Fecal flotation – negative Abdominal x-rays – NSAF Tx Denosyl 90 mg PO SID Clavamox 62.5 mg PO BID x 7d

17. Benji Boy 5 days later – not eating or drinking, still does not feel good, in pain Exam – mild to moderate discomfort on abdominal palpation, grunts Temp 104.7 o F cPL - >400 GI series with gastrografin

18. Filling defect in stomach Dog has not eaten anything in 2 days Benji Boy

19. Surgery – removed piece of ribeye gristle lodged in the lower esophageal sphincter, also some in the stomach Pancreas inflamed, peritoneum angry Hospitalized to treat for pancreatitis IV fluids Continue Denosyl Buprenex for pain Ampicillin and enrofloxacin Eating in a few days, fever down, sent home on antibiotics and Denosyl

20. Benji Boy 2 weeks later CC - Did well for awhile, now there is straining to defecate and fresh blood and mucus on the stool, eating well. Wt - 6 months ago 14 pounds, 1 month ago 12 pounds, now 11.5 pounds Exam – no pain on abdominal palpation, rectal exam and rest NSAF Fecal – negative Rx – metronidazole 62.5 mg PO BID x 7 days

21. Benji Boy 3 weeks later CC – got better for awhile, but now worse - anorexia, vomiting, diarrhea Wt – 9 lbs Exam – NSAF Fecal – negative rectal scraping – no fungal organisms seen Tx – Cerenia and Tylan while awaiting GI lab results

22. Benji Boy 5 days later – appetite better GI panel – B12, PLI, TLI normal Folate low Proximal small intestinal disease Recommend intestinal biopsies Declines referral for flexible endoscope Diagnostic surgery for multiple biopsies liver, stomach, duodenum, jejunum, ileum Rigid scope colon biopsies

23. Benji Boy Histopath Moderate suppurative hepatitis Inflammatory bowel disease (EP inflammation in the duodenum and jejunum, villous blunting, crypt lesions) Tx – prednisone 5 mg PO BID x 2 weeks, then 5 mg PO SID 3 weeks later – Benji doing great 10.2 lbs Owner - “Dr. Blount is the smartest vet in the universe”

24. Benji Boy 1 week after that (8 weeks after 1st visit) CC - not feeling well GI signs have stopped, but Benji cries out when you pick him up Owner – “Dr. Blount, are you sure you know what you are doing?”

25. Benji Boy Exam Wt 11.5 lbs (way up) Mucopurulent discharge from the eyes Cranial drawer sign both stifles Pain on palpation of the muscles and long bonesPain on palpation of the muscles and long bones T – 104.7 o FT – 104.7 o F What’s the catch?

26. Benji Boy CBC – WBC 52K – segs, monos Panel – SAP 1132 U/L Lytes - normal Radiographs Pelvis Front limbs Rear limbs

27. Benji Boy

29. DDx Periosteal proliferation Pulmonary hypertrophic osteopathy Hepatozoon spp. Thoracic radiographs – normal Abdominal ultrasound – normal MiraVista Histoplasma Ag - negative Hepatozoon PCR – positive Clindamycin 25 mg/kg PO BID x 2 weeks Albon 25 mg/kg PO BID x 2 weeks decoquinate 50 mg/kg once daily

30. Benji Boy Benji does well as long as he takes decoquinate He needs an occasional round of Albon and clindamycin – 2-3x a year

31. DDx Eosinophilic IBD Food allergy Parasitic infection Mast Cell Tumor Fungal infection Idiopathic IBD Feline Hypereosinophilic Syndrome Hepatozoon??? Basophils on the first CBC were a clue

32. Lila 1.5 year old female Rottweiler Acute onset of abdominal pain and tachypnea Has not eaten for 2 days, no vomiting, mucus in the stool Abdominal splinting on palpation Fever – 103.8F CBC, panel – NSAF cPLI – abnormal (>400) Fecal float negative No response to treatment with IV fluids and antibiotics for 2 days (began vomiting)

33. Lila

34. Ileus and abdominal effusion

35. Lila Abd US declined due to financial limitations Elected diagnostic surgery Generalized peritonitis, serosanguinous abdominal fluid No obstruction or foreign body

36. Lila Lymph node cytology

37. Lila Abdominal fluid sediment

38. Lila Fluid analysis –Modified transudate –Neoplastic very large lymphoid cells Mesenteric lymph node biopsy –Large cell lymphoma No other enlarged lymph nodes found

39. Lila 80 lbs at the time of diagnosis in Nov12 –BCS 3/9 Responded to chemo within a few days –TAMU Large Cell Protocol (CHOP) Had mild GI signs for a few days twice Neutropenic once (asymptomatic) Thrombocytopenic once (asymptomatic) 107 lb at last chemo treatment –BCS 7-8/9 Relapsed about a month after chemo stopped Owner declined rescue therapy

40. Lila Owner failed to “pay as she went” as promised She would ask for the first exam room near the door so she could sneak out without paying She still owes us $1500 Ran into her at the WalMart the other day and she couldn’t stop telling me how wonderful our clinic is.

41. Waddles Sig: 3 year old male poodle CC: vomits once a week, otherwise seems to feel fine Exam: BCS 3.5/9, heart and lung sounds are muffled on the right side, cryptorchid MDB: CBC, panel, lytes, UA, HW Test, fecal NSAF

42. Waddles Thoracic Radiographs:

43. Waddles

44. Waddles Barium Study

45. Waddles Thoracic Ultrasound

46. Waddles Dx – diaphragmatic hernia with one lobe of the liver herniated into the thorax Tx - Owners chose not to repair surgically, due to financial limitations Waddles lived a long and productive life as a cryptorchid breeding animal

47. Mandy Sig: 14 year old SF dachshund CC: not eating well, vomits daily, getting worse gradually over 2 weeks has lost 2 pounds over 5 months Eating dirt for 2 months 3-4 episode of vomiting and diarrhea over the past year, one with fever, all responded to antibiotic therapy Exam: does not allow deep abdominal palpation, she’s a biter

48. Mandy MDB: CBC – neutrophilia 18,000/ul, PCV 25% Panel – albumin 2.1 g/dl lytes, UA, HW Test, fecal - NSAF 2 nd round of tests: Reticulocytes – 488,400/ul Highly regenerative Fecal cytology No gross melena Many RBC seen on cytology

49. Mandy Abdominal rads:

50. Mandy

51. Mandy Abdominal ultrasound:

52. Mandy

53. Mandy Histopathology: GIST – gastrointestinal stromal tumor aka leiomyoma Comments generally slow-growing, and do not metastasize. Neoplastic cells do not extend to the specimen borders, and recurrence will likely not be an issue for this dog.

54. Mandy Thoracic rads NSAF on 3 view met check R lateral, L lateral, VD Surgery – anastamosis and resection: Mass found at the duodenal flexure NSAF in the abdomen

55. Mandy One year later: recurrence of all symptoms, but sicker than before Abdominal ultrasound:

56. Mandy

57. Mandy

58. Elvis Sig: 5 year old Male English Bulldog Hx: Doc W gets a call from animal control at 5am that there is a rabid dog that needs to be dispatched and sent for testing Doc W arrives on the scene to find a dog that is indeed salivating profusely He aims his pistol and is ready to shoot when he recognizes Elvis as his patient. He captures the dog with a control stick and transports him to the clinic in a carrier The dog does not seem to have neurologic deficits, but is vomiting profusely Doc W calls the owner and learns that Elvis has been missing for 5 days, since the July 4 picnic

59. Elvis Exam – severe pain on abdominal palpation MDB: CBC – neutrophilia 22,320/ul Panel, lytes – NSAF HW Test – positive Fecal – negative Owner want Elvis saved – cost is no object

60. Elvis Abdominal Radiographs

61. Elvis

62. Elvis Doc W drops Elvis off at my clinic on his lunch hour We reach the owner and he indeed wants Elvis saved, at any cost He will pay when he can

63. Elvis Exploratory Surgery for obstruction:

64. Elvis

65. Elvis Elvis recovered and went home in 2 days One year later, Mr. Elvis Dad had still not made payment on his bill The debt was settled by trading for three guns and a bushel of apples