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Management of intussusception mimicking rectal prolapse--a clinical study of six puppies.

Introduction

Intussusception is invagination of segment of gastrointestinal tract into lumen of an adjoining segment. The excessive peristaltic motility forces segment of bowel inside the segment just below it, as the smaller tube of telescope slides into slightly larger tube just ahead of it (Byrne et al., 2005). Enterocolic intussusception and particularly ileocolic intussusceptions is the most common type described (Allenspach, 2010) and dogs less than one year of age are mostly affected (Lewis and Ellison, 1987; Applewhite et al., 2002). It is believed that most intussusception in young animals are idiopathic, but a number of conditions such as intestinal parasitism, linear foreign bodies, viral enteritis, non-specific gastroenteritis and intraluminal masses have been suggested as predisposing factors for intestinal intussuspection (Schwandt 2008; Allenspach, 2010). According to Knowles et al. (1989), any lesion in bowel wall or irritant in lumen alters normal peristaltic pattern and may initiate invagination.

Partial or complete bowel obstruction, if left untreated interfere with venous drainage and arterial occlusion can lead to ischemia and necrosis of bowel and variety of life threatening electrolyte disturbance, endotoxic and septic shock (Burrows and Merritt, 1992). Laparotomy and various enteropexy techniques have been advocated to treat and prevent subsequent recurrence of intussusception. Most cases reported in literature of intussusception in dogs are of ileo-colic or jejuno-jejunal part of intestine where diagnosis from external examination without tools like ultrasonography and contrast radiography is difficult. It is clinical examination followed by laparotomy for confirming of intussusception.

The present communication reports intussusception in six puppies where the affected part of bowel of varying length were protruded from anus and a simple manual test confirmed of intussusception.

History and Clinical Examination

Six puppies (four males and two females) from six weeks to four months of age were reported with sausage shaped intestine of varying length protruding outside through anus (Fig. 1) since overnight or same day. All puppies were anorectic, dull, dehydrated (mild to moderate degree) and lethargic. Puppies were not taking feed since last one to four days. Initially there was history of vomition, diarrhoea and tenesmus in five cases, increased frequency of crying and vomiting in three cases and unable to pass faeces except blood mixed mucous drops. The mean temperature was within normal range while pulse (120/min) and respiration (35/min) were towards higher side. Palpation of mid caudal abdominal region revealed firm painful mass in all cases. Unobstructed passing of bulb of thermometer between outer wall of protruded mass and anal sphincter for a significant depth confirmed diagnosis. Haematological examination revealed an increased mean values of PCV (42mg/100 ml) and TLC 2900/ul with Neutrophilia (83%). All puppies were stabilized with fluid therapy (Ringer's lactate @50 ml/kg b. wt.). Pre-operatively, Ceftriaxone (Intacef (a)) and analgesic Meloxicam (Melonex (a)) were administered.

[FIGURE 1 OMITTED]

[FIGURE 3 OMITTED]

Surgical Treatment

Ventral abdomen of puppies were prepared for aseptic surgery. After 10 minutes of premedication with Atropine @ 0.04mg/kg IM, a cocktail of Xylazine Hcl @2 mg/kg and Ketamine Hcl @8 mg/kg IM was administered. After induction of anaesthesia, puppies were positioned in dorsal recumbency and ventral mid line incision in caudal abdomen was given in female puppies. However in male puppies, a paramedian incision was given on skin and subcutaneous tissue. Peritoneal cavities were entered by incision on linea alba after reflecting prepuce and penis laterally. The intussuscepted part (Fig. 2) was reduced manually by holding proximal healthy part of intestine inserted between thumb and index finger of one hand and pulling it forward however holding intussuscepiens gently between thumb and index of other hand to facilitate retrieval of intussuscetum from distal part. Once the affected intestine was unilayered, its viability was checked by change of adhered layer colour from whitish to pinkish. Special attention was paid to avoid any rupture in wall of intestine. The walls of intestine proximal and distal to starting point of intussusceptions were plicated with abdominal wall muscles with absorbable suture material (vicryl #2-0) to avoid recurrence. The abdominal incisions were closed routinely (Fig. 3). Post-operatively, puppies were administered with antibiotic and analgesics for three days and wound was dressed with Povidone iodine till complete healing. Puppies were initially kept on liquid diet for two days. Skin sutures were removed on 10th day. The healing was uneventful in all cases.

[FIGURE 2 OMITTED]

Discussion

Retrospective studies have indicated that puppies and kittens have a much higher incidence of intussusception than adult animals (Lewis and Ellison, 1987). Wilson and Burt (1974) reported 37 out of 45 animals were of less than one year of age whereas Weaver (1977) reported 19 of 26 dogs in were less than six months old. In our study, all dogs were below four month of age. There is no sex and breed predilection as two were Labrador retriever, one was German shepherd and three were mongrels. Intussusceptions have been reported as sequelae to a number of conditions, including intestinal parasitism (Tangner, 1982), linear foreign bodies (Larsen and Bellenger, 1974), viral induced enteritis (Ellison, 1986), intestinal masses (Runyon et al., 1984) and prior abdominal surgery (Dutoit et al., 1981). The faecal samples of all puppies were sent for stool examination but only one puppy was positive for ancylostoma eggs. One puppy passed pieces of cotton thread (a linear foreign body), plastic and rubber sheets in faeces. Three puppies had no history of vaccination against viral diseases like Parvo, Canine distemper and were suffering with bacterial / viral gastro enteritis. However, there was no obvious reason for intussusception in sixth puppy. The most common clinical signs in present study included vomition, diarrhoea, depression, anorexia (Lewis and Ellison, 1987) and sausage shaped mass prolapsed through anus. Ultrasonography is used to confirm intussusception but was not required in our study as intussuscepted mass was visible from outside and differential diagnosis from rectal prolapse was easy to make by inserting a blunt probe between mass and anal sphincter in all cases. Abdominal pain was not a consistent finding. The segment of intestine involved in all cases was ileocolic. Previous reports have indicated that majority of intussusceptions in small animals are enterocolic (Krahwinkel et al, 1983).

The surgical management of intestinal intussusceptions involves either manual reduction or resection and anastomosis or both (Ellison,1986). The decision to resect is based on surgeon's gross evaluation of viability of intestinal components of intussusception. As all puppies reported very early, manual reduction followed by enteropexy worked well in preventing recurrence as recurrence of intussusception is common without placation of affected segment (Crowe, 1990). The present study revealed that intussusceptions visible from outside the anus in early stages are easy to diagnose and treat even at field level with good prognosis.

References

Allenspach, K. (2010). Diseases of the large intestine.

In: Ettinger, S.J. and Feldman, E.C. (eds.). Textbook of Veterinary Internal Medicine. 7th edn. Saunders Elsevier. St. Louis, Missouri. pp 1573-1608.

Applewhite, A.A., Cornell, K.K. and Selcer, B.A. (2002). Diagnosis and treatment of intussusceptions in dogs. Compend. Contin. Educ. 24: 110-26.

Burrows, C.F. and Merritt, A.M. (1992). Assessment of gastrointestinal function. In: Anderson: Veterinary Gastroenterology, 2nd edn. Philadelphia, Lea and Febiger. p 16-42.

Byrne, A.T., Geoghegan, T., Govender, P., Lyburn, I.D., Colhoun, E. and Torreggiani, W.C. (2005). The imaging of intussception. Clin. Radiol. 60: 39-46.

Crowe, D.T. (1990). Enteroplication to prevent recurrent intestinal intussusception. In: Bojrab, M.J. ed. Current Techniques in Small Animal Surgery. 3rd edn. Philadelphia: Lea & Febiger. p 255-257.

Dutoit, D.F., Homan, W.P. and Reece-Smith, H. (1981). Canine intestinal intussusception following renal and pancreatic transplantation. Vet. Rec. 108: 34-35.

Ellison, G.W. (1986). Nontraumatic surgical emergencies of the abdomen. In: Bright, R., ed. Contemporary Issues in Small Animal Practice. Vol. 2. New York: Churchill Livingstone. pp 127-173.

Knowles, M.C., Fishman, E.K., Kuhlman, J.E. and Bayless, T.M. (1989). Transient intussusceptions in Crohn disease: CT evaluation. Radiol. 170: 814.

Krahwinkel, D.J. and Richardson, D.C. (1983). Intestines. In: Bojrab, M.J., ed. Current Techniques in Small Animal Surgery. 2nd edn. Philadelphia: Lea & Febiger. pp 162-73.

Lewis, D.D. and Ellison, G.W. (1987). Intussusception in dogs and cats. Compend. Contin. Educ. Pract. Vet. 9: 523-34.

Schwandt, C.S. (2008). Low-grade or benign intestinal tumours contribute to intussuspection: a report on one feline and two canine cases. J. Small Anim. Pract. 49: 651-54.

Tangner, C.H. (1982). A review of canine intestinal intussusception. Southwest Vet. 34: 203-07.

Weaver, A.D. (1977). Canine intestinal intussusception. Vet. Rec. 100: 524-27.

Wilson, G.P. and Burt, J.K. (1974). Intussusception in the dog and cat: A review of 45 cases. J. Am. Vet. Med. Assoc. 164: 515-18.

(a)--Brand of Intas Animal Health, Ahmedabad

R.N. Chaudhary, Satbir Sharma, Deepak Kumar Tiwari (1), Anand Kumar Pandey and Ram Mehar

Department of Veterinary Surgery and Radiology College of Veterinary Sciences Lala Lajpat Rai University of Veterinary and Animal Sciences (LUVAS) Hisar--125004 (Haryana)

(1.) Assistant Professor and Corresponding author.

E-mail: dr.deepaktiwari@rediffmail.com
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Title Annotation:Clinical Article
Author:Chaudhary, R.N.; Sharma, Satbir; Tiwari, Deepak Kumar; Pandey, Anand Kumar; Mehar, Ram
Publication:Intas Polivet
Geographic Code:9INDI
Date:Jan 1, 2016
Words:1498
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