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Presentation: Upon arrival at The COVE, Biscuit was BAR.
- Weight: 14.3 lbs/6.5 kgs (BCS 4-5/9)
- Temp: 101.6; mm - pink
- CRT: <2sec
- Heart rate: 150 BPM
- Respiratory rate: Panting; normal bronchovesicular sounds, but decreased sounds on left side were noted on auscultation.
- Distended abdomen. Tensing on abdominal palpation and could not palpate deep.
- Pain Score 2-3/4
Diagnostics and lab work: Radiographs (lateral abdomen, lateral and VD thorax): Large, fluid-filled stomach that took up most of the abdomen with part of it into the left side of thorax. All the small intestine (gas distended) was in the left side of the thorax. Loss of serosal detail of the liver/spleen/kidneys. Gas-distended colon. The heart was displaced to the right.
- Abdominal FAST scan: Large, fluid-filled stomach in abdomen. Normal lungs on right side.
- CBC/CHEM: Leukocytosis 33,650; Neutrophilia 29,270; Monocytosis 1,570. Hyperalbuminemia 4.3. All else WNL. PCV: 54% TS: 8.0 g/dL.
Diagnosis: Radiographs were indicative of a chronic diaphragmatic hernia. Concern was expressed that his stomach was obstructed due to the size and location. Methadone was given IV(0.2mg/kg), and the patient was held vertically and agitated to allow organs to settle back in their respective places. Biscuit's RR/RE improved and ultrasound confirmed a smaller stomach. He was hospitalized overnight for pain management until a surgery consult could be performed. Maropitant 1mg/kg IV SID was administered in addition to Unasyn 30mg/kg IV TID.
Biscuit did well while hospitalized, aside from several episodes of diarrhea. He had intermittent episodes of increased respiratory rate, but no vomiting or retching was noted. After reviewing the case and the radiographs, our surgeon, Dr. Jeff Stallings, recommended an exploratory laparotomy to assess the severity/chronicity of Biscuit's injury, and if able, diaphragm repair via diaphragmatic flap +/- liver lobectomy. Pet parent was made aware of the risks and complications associated with surgical intervention and elected to proceed with surgery the following day.
Surgery: A lumbosacral epidural was performed following anesthetic induction. Biscuit was maintained on total intravenous anesthesia using alfaxalone 5-7mg/kg/hr with 100% O2 via a circle anesthesia circuit. The cranial abdomen was approached via a standard midline celiotomy. The abdominal contents (intestines, spleen, liver) were removed carefully from the thoracic cavity. Although the small intestines became dusky for a short period of time, they soon normalized. The diaphragm was reconstructed under moderate tension. An omental pedicle graft was formed and placed over the repair. After thorough irrigation, closure was accomplished routinely under moderate tension in multiple layers. A thoracostomy tube was placed, and the thoracic cavity evacuated of air and a small amount of serosanguinous fluid. Closure: diaphragm - 0 PDS, 3-0 Monocryl; abdomen - 2-0 PDS, 2-0 Monocryl, 3-0 Monocryl, skin staples.
Outcome: Biscuit had a smooth recovery overnight. His thoracostomy tube produced a slightly above physiological rate of fluid, but no air. ALT was elevated, secondary to manipulation during surgery. He was discharged the following day. The owners were very compliant during the healing phase, and Biscuit healed rapidly as would be expected under ideal conditions with a dog of his age. He presented for a two-week recheck for staple removal and critical care recheck. At that point, his blood work was rechecked, and ALT had normalized. His owners reported he was doing very well at home. No further rechecks were warranted at that time, but they were advised to monitor for change in respiration or vomiting.
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