Since I’m home today, I thought it would be a good idea to catch up on writing. I had a few ideas flowing, so this post is directed at veterinary students and new graduates.
So what does it mean to have an Acute Abdomen? Have you read any of those referral discharges or notes from emergency clinics? It’s not a cute abdomen, that is an hourglass shape, that’s for sure! I just had to make a joke in there. I’m laughing, if you’re not. Acute abdomen is an over-branching term or observation by a veterinarian that includes a painful abdomen. These patients may or may not have a distended abdomen. The abdominal distension however, is often called 'bloat' by owners. Bloat itself is a term we use to describe gas distension of the true stomach, not of the abdomen. Bloat is an acute abdomen, but not all acute abdomens are bloat.
My first case of shock as a fourth year veterinary student was an acute abdomen - that case will stick with me forever. Yesterday, when I was telling the associate, and new medical director at my hospital, about the case I am about to describe below, I was feeling really awful about the situation. She asked me why? As she felt I did everything that I could for the patient. I think the reason I feel badly is due to my first case and missing the diagnosis and observation that the patient was in shock at the time. This is why these cases of acute abdomen haunt me so much. I need the diagnosis to appropriately treat the patient, and when the diagnosis is open, which way do you go for treatment? Pain control of course, but if you cannot find the diagnosis, then all you are doing is controlling a symptom. The list of differentials (causes) of acute abdomen are lengthy. They also require a lot of additional diagnostics to rule out some of these causes. Some of which you don’t get to do, due to costs, or lack of facilities.
My most recent case is a 7-year-old female spayed mixed breed medium sized, though overweight, dog. She presented to me as my last appointment on Saturday early afternoon. It was my first time meeting her and I briefly reviewed her file that had blood work, stifle rads with some visible abdomen, and the report suggested hepatomegaly (enlarged liver). She was on Gabapentin and Metacam for osteoarthritis. On presentation, she was quiet, alert and responsive, her owner had carried her in, and reported she was not herself and hadn’t eaten, but was 'bloated'. The bloat was worse last night, but seemed to improve overnight. The owner hadn’t given her any of the medications this morning, and just came in for her appointment because she was still bloated. She had gained weight over the past two weeks, despite being put on a diet since her last visit. On physical, she had a distended abdomen with no gas ping or appreciable fluid wave, though tense and subjectively painful. Her heart rate was high normal for her size and the dorsal-pedal pulse was present, with the occasional bound. Her CRT and temperature were normal. Given that she was my last appointment on a day where I had no RVT and short staffed, I let the owner know that while my skills with the ultrasound are not perfect, I’d do a quick assessment to see if there is anything obvious and whether this is a wait and see case with pain meds, or if she should be referred for further diagnostics. I did not do a full A-FAST and did a standing quick assessment using our crappy old ultrasound much like I would do for a horse or a cow. Remember that thing called gravity? Fluid in a balloon is always on the bottom, the dependent side. Same with the abdomen, the fluid will be on the bottom in a standing patient (four legged standing to be specific, some vet assistants need to be told that). So with this ultrasound I saw a small amount of free fluid near the liver, but the gallbladder was also subjectively large. I froze the image so I could take a snapshot of it, but didn’t tell my assistant to leave the machine on. So by the time I discussed my recommendations to the owner and came back my assistant had shut the machine off. Otherwise I would have a photo to share! If you want to see some images of gallbladders you can check out this page. Her gallbladder did not have a mucocele, or any gallbladder sludge.
The patient was stable, though painful, but definitely needed further diagnostics. I told the owner that I would like her to go to an emergency clinic for care. I gave her two options of referral/emergency clinics that were close by, and had the receptionist call ahead. One of the clinics told us they wouldn’t see her, because they were short-staffed. When we called the other emergency clinic, I had to get a doctor-to-doctor consult, after they said they couldn’t see a bloat case and hung up. Communication from the general practice to the emergency clinic can be critical when your reception is calling, like I said, bloat means something different to veterinarians. I finally got a doctor on the line and she said she could take her but that her ultrasound skills weren’t the greatest and it sounded like mine may be better than hers. She thought referral to another hospital would be better, then she could get an appointment for a full abdominal ultrasound on Monday. I asked her if I was just being paranoid, or if this sounded bad, and she said it could be either way. Since I never wanted another acute abdominal case to slip through my fingers like my first, now I always ere on the side of caution. Call it a gut feeling when I know that something is wrong, but I just can’t get all the answers right away. Especially after hours. I then had to get an emergency doctor on the line at the referral centre, and discussed the case with her. I had a similar conversation about whether or not I was being paranoid, and received a similar answer, though, it may be a 5 to 6 hour wait to be seen. Either way, at least the patient would get the care that she needed.
On Tuesday, I arrive back at work, and I am curious about the case, I read the referral report: acute abdomen - open diagnosis. They opted to treat as an outpatient as she was stable, and opted to treat with pain medication and for NSAID (non-steroidal anti-inflammatory drug) reaction, or gastric ulcer. The patient was discharged and we called to get an update with no answer on Monday. By Wednesday, due to COVID-19, our clinic had adjusted our hours, and at the time we were still seeing patients for wellness visits and elective surgeries. We were operating 9 until 5 and we were swamped. Wednesday late morning, the client calls in saying now her dog is vomiting. I still hadn't received the blood work that the referral centre had run, so again, recommended referral as we could not hospitalize or have an ultrasound performed. We still do not have a diagnosis. Can you see how these cases can be troublesome? I will try to keep you posted so that you can learn from the case. What's your top differential?