Case Report Rapport de cas Jejunal perforation due to porcupine quill ingestion in a horse Stacy L. Anderson, Luca Panizzi, Jose Bracamonte Abstract — An 8-month-old Andalusian filly was treated for jejunal perforations due to ingestion of a porcupine quill. During exploratory laparotomy, 2 separate stapled side-to-side jejunojejunal resection and anastomoses were performed. Post-operative complications after 2 years follow-up included mild incisional herniation following incisional infection and chronic intermittent colic. Résumé — Perforation jéjunale causée par l’ingestion d’une aiguille de porc-épic chez un cheval. Une pouliche d’Andalousie âgée de 8 mois a été traitée pour des perforations jéjunales causées par l’ingestion d’une aiguille de porc-épic. Durant une laparatomie exploratoire, deux résections et anastomoses jéjuno-jéjunales séparées et agrafées côte-à-côte ont été réalisées. Après un suivi de 2 ans, les complications postopératoires incluaient une légère hernie cicatricielle suite à une infection de l’incision et des coliques intermittentes chroniques. (Traduit par Isabelle Vallières) Can Vet J 2014;55:152–155
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oreign body perforation of the intestine is relatively uncommon in horses and generally results in some degree of septic peritonitis (1–3). Horses are often presented with signs of colic, with or without signs of endotoxemia (1,2). Cases in which intestinal perforation is suspected may be managed medically with fluids, antimicrobial therapy, peritoneal lavage and drainage, anti-inflammatories, and anti-endotoxic therapies (4). When horses are refractory to medical treatment or demonstrate signs of colic unresponsive to analgesia, exploratory laparotomy is indicated (5). The following case report documents the progression of an 8-month-old Andalusian filly that sustained 2 separate jejunal perforations from ingestion of porcupine quills.
Case description History and clinical findings An 8-month-old Andalusian filly was referred to the Western College of Veterinary Medicine at the University of Saskatchewan due to colic of 6 h duration that was unresponsive to on-farm medical therapy. The filly had a history of slow Department of Veterinary Biomedical Sciences (Anderson) and Department of Large Animal Clinical Sciences (Bracamonte), University of Saskatchewan, Western College of Veterinary Medicine, 52 Campus Drive, Saskatoon, Saskatchewan S7N 5B4; Massey Equine, Institute of Veterinary, Animal, and Biomedical Sciences, Tennet Drive, Palmerston North, 4442, New Zealand (Panizzi). Address all correspondence to Dr. Stacy Anderson; e-mail:
[email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office (
[email protected]) for additional copies or permission to use this material elsewhere. 152
growth as reported by her owner, but had not experienced any previous episodes of colic. On presentation, the filly was mildly painful and agitated. She was tachycardic (60 beats/min) and tachypenic (38 breaths/ min), but was normothermic (38.5°C). A complete blood (cell) count (CBC) revealed a mild microcytic, normochromic anemia [hematocrit 24.4%; reference interval (RI): 28 to 44%] and hyperfibrinogenemia (7 g/L; RI: 1.2 to 2.3 g/L). Significant findings on venous blood gas included hyperlactidemia (7.3 mmol/L; RI: 0.5 to 1.2 mmol/L) and hyperglycemia (9.3 mmol/L; RI: 3.7 to 6.7 mmol/L). Results of a serum chemistry panel were unremarkable other than mild hypokalemia (3.2 mmol/L; RI: 3.5 to 5.0). On abdominal palpation per rectum, no significant abnormalities were noted. Transcutaneous abdominal ultrasonography revealed locally distended loops of small intestine (5 cm diameter) in the right inguinal area. No reflux was obtained via nasogastric intubation. Upon abdominocentesis, cloudy, yellow fluid was obtained with a measured total solids of 42 g/L, lactate of 7.6 mmol/L, and glucose of 9.0 mmol/L. Cytology was not performed. Culture of the fluid resulted in no bacterial growth.
Treatment Due to unrelenting pain, small intestinal distention, and suspected peritonitis, the filly was taken to surgery within 2 h of presentation. Before surgery, she was administered gentamicin (Gentocin; Merck Animal Health, Kirkland, Quebec), 6.6 mg/kg body weight (BW), IV, and sodium penicillin (Penicillin G sodium; Pharmaceutical Partners of Canada, Richmond Hill, Ontario), 22 000 IU/kg BW, IV. The filly was pre-medicated with xylazine (Xylamax; Bimeda, Cambridge, Ontario), 1 mg/kg BW, IV, and anesthesia was induced with ketamine IV (Vetalar; Bioniche, Belleville, Ontario), 2 mg/kg BW, IV, and diazepam (Diazepam; Sandoz, Boucherville, Quebec), 0.1 mg/kg BW, IV. CVJ / VOL 55 / FEBRUARY 2014
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Post-operative treatments included: balanced polyionic intravenous fluid therapy (Lactated ringer’s solution; Baxter, Mississauga, Ontario), 1 to 2 L/h IV, supplemented with potassium chloride (20 mEq/L) and 23% calcium borogluconate (10 mL/L) for 2 d, sodium penicillin (22 000 IU/kg BW, IV, q6h) and gentamicin (6.6 mg/kg BW, IV, q24h) for 5 d, continuous rate infusion of lidocaine (Lurocaine; Vétoquinol, Lavaltrie, Quebec), loading dose of 1.3 mg/kg BW, IV, followed by 0.05 mg/kg BW/min for 2 d, flunixin meglumine (Banamine; Merck Animal Health, Kirkland, Quebec), 1.1 mg/kg BW, q12h for 5 d, then 0.5 mg/kg BW, q12h for 5 d, ranitidine (Apo-ranitidine; Apotex, Toronto, Ontario), 6.6 mg/kg BW, q8h for 5 d, abdominal lavage with 10 L of balanced polyionic solution q12h for 3 d. After these treatments the abdominal drain was removed and submitted for culture (a positive culture for Klebsiella sp. was obtained), and the filly was hand-walked frequently. The filly was allowed access to water beginning 12 h after surgery. She was fed a small amount of alfalfa leaves q3h starting 2 days after surgery. The quantity and particle size of feed was gradually increased daily until she was allowed free choice hay 7 days after surgery. Ten days after surgery, the filly began to show signs of colic. On abdominal ultrasound, multiple loops of distended small intestine (. 5 cm diameter) were noted. Electrolyte abnormalities included elevated bicarbonate and hypochloremia, suggesting proximal gastrointestinal obstruction. The filly was taken back to surgery due to pain that was unresponsive to analgesia and suspicion of obstructing intra-abdominal adhesions. Repeat laparotomy was performed through a right ventral paramedian celiotomy placed 2-cm lateral to the previous abdominal drain site. On exploration, adhesion of the proximal jejunum to the proximal anastomosis was found to be obstructing jejunal outflow. Because the initial anastomosis was at the most proximal aspect of jejunum that could be safely resected without risking gross contamination of the abdomen, the decision was made to sharply transect the adhesions from the anastomosis instead of resecting the adhesed anastomosis and creating a new one. Most of the adhesions were transected with Metzenbaum scissors. A 60-mm linear stapling device (GIA-60, Covidien) was used to transect adhesions and close the defects when there was a high probability of entering the intestine. After the adhesions were transected, unobstructed flow of ingesta through the jejunum was confirmed. The right ventral paramedian celiotomy was closed in 3 layers as previously described for the ventral midline celiotomy. Post-operative treatments were the same as before. Eight days after the second laparotomy, the right ventral paramedian incision began to drain purulent material and experienced incisional dehiscence extending to the abdominal fascia. Culture of the incision was positive for Escherichia coli, which was susceptible to common antibiotics. Some of the skin staples were removed to facilitate drainage. The filly was started on a 10-day course of trimethoprim sulfadiazine (Apo-Sulfatrim; Apotex, Toronto, Ontario), 30 mg/kg BW, PO, q12h. The incision was cleaned daily with chlorhexidine solution and honey was applied as a wound dressing under an abdominal bandage. Hand-walking was discontinued. Five days later, the abdominal bandage was 153
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The abdomen was explored via a ventral midline celiotomy. Upon exploration, 2 focal full-thickness perforating lesions of the jejunum were found with associated omental adhesions. One of the perforating lesions was located 6-m aboral to the duodenocolic ligament and a porcupine quill was seen to be partially exiting the perforation. Another perforating lesion was located in the proximal jejunum approximately 30-cm aboral to the duodenocolic ligament. A porcupine quill was not identified in this lesion, but because of the similarity to the first lesion, it was presumed to have also been the result of a porcupine quill perforation. The omental adhesion associated with the most aboral perforation was causing a focal non-strangulating jejunal obstruction that explained the small intestinal distension noted on transcutaneous abdominal ultrasonography. The omental adhesion obstructing the jejunum was ligated with 2-0 polydioxanone sulfate (PDS, PDS II; Ethicon, Somerville, New Jersey, USA) then transected to facilitate correction of the obstruction. The quill in the mid-jejunal lesion was removed via the perforation and the lesion was temporarily over-sewn with a single layer using a Cushing pattern and 2-0 PDS (Ethicon). Because the 2 focal lesions were over 5-m apart and separated by healthy jejunum, 2 stapled side-to-side jejunojejunal anastomoses were performed. Carboxymethylcellulose was applied liberally to the intestines during handling. Briefly, each lesion, including 8-cm of jejunum on either side of the lesion, was resected using an 80-mm linear stapling device (GIA-80; Covidien, Norwalk, Connecticut, USA) fired on either side of the lesion creating blind ends in the oral and aboral jejunum. The stapled ends of the intestine were over-sewn with 2-0 PDS in a Cushing pattern. The blind ends were then positioned in an isoperistaltic fashion at the antimesenteric borders, overlapped approximately 10-cm, and secured with cruciate stay sutures using 2-0 PDS. The side-to-side anastomoses were created using a 100-mm linear stapling device (ILA-100; Covidien) loaded with a 4.8-mm staple cartridge. Two adjacent 1-cm stab incisions were created on the antimesenteric border at one end of the overlapping segments of jejunum. The arms of the 100-mm, linear stapling device were inserted into each stab incision and fired once to create the stoma. Stab incisions were closed and the entire staple line was over-sewn with 2-0 PDS in a singlelayer using a continuous Cushing suture pattern. The mesenteric defect was closed with 2-0 PDS in a simple continuous pattern. The anastomoses were copiously lavaged with sterile physiologic saline solution prior to replacement into the abdomen. A 32 French abdominal drain with a one-way valve (Bard-Parker Heimlich valve; BD, Franklin Lakes, New Jersey, USA) was placed approximately 5-cm to the right of the linea alba and sutured in place with a Chinese finger trap using 1 polypropylene (Prolene, Ethicon). The linea alba was closed with USP 7 braided PDS (PDS II, Ethicon) in a simple continuous pattern, followed by closure of the subcutaneous layer using 2-0 PDS in a simple continuous pattern. The skin was closed with staples. A stent was sutured over the incision and covered with an iodine-impregnated adhesive bandage (Ioban; 3M, St. Paul, Minnesota, USA) for recovery from anesthesia. The stent was removed 24 h after recovery from anesthesia.
replaced with an equine hernia belt (CM Equine Hernia Belt; Norco, California, USA) that remained in place for 60 d.
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Outcome The filly was discharged 30 days after the initial surgery. She was presented to the hospital every 30 d for evaluation of incision healing for the first 3 mo after discharge. Despite the use of the hernia belt, the filly developed a mild incisional hernia of the right ventral paramedian incision, extending 10 cm in length, located in the caudal portion of the incision. She was presented at 2, 3, and 8 mo after discharge for colic that was successfully treated medically. On abdominal ultrasound, performed 8 mo after the initial surgery, there was an area near the right ventral paramedian incision that was suspicious for adhesion of intestine to the body wall as a section of bowel with decreased motility was located near and apparently attached to the incision by an isoechoic tissue. On follow-up, the filly was still alive 3 y after surgery, although she is reportedly smaller than expected by the owner and experiences rare episodes of mild colic (, 1 episode per year) that are managed with medical treatment.
Discussion The present case illustrates the use of a double jejunal resection and anastomosis to treat 2 focal intestinal perforations caused by porcupine quills. To the authors’ knowledge, this is the first report of 2 simultaneous jejunojejunostomies and identifying porcupine quills as the cause of small intestinal perforation in a horse. Adhesion formation in horses is a well-recognized, though often poorly quantified, post-operative complication following exploratory laparotomy (6–8) and septic peritonitis is a wellestablished risk factor for adhesion development (3,5). Adhesion formation is more prevalent in immature horses (, 25 months of age) (8). Therefore, the filly in this report was at particular risk for the development of intra-abdominal adhesions. Adhesion formation is often clinically “silent” until such time as it interferes with intestinal function, resulting in overt signs of colic. Because horses may be managed medically or euthanized without performing a necropsy, the prevalence of intra-abdominal adhesions in horses is likely underestimated. The inability to fully image the equine abdomen non-invasively limits the diagnosis of intra-abdominal adhesions without exploratory laparotomy or laparoscopy. Adhesions located within the depth imaged by an ultrasound probe (up to 12 cm) may be visualized, but their extent and exact location cannot be determined accurately (9,10). In this report, we suspected that an adhesion had formed after repeat laparotomy between a section of bowel and the right ventral paramedian incision, although this finding was not confirmed using laparotomy or laparoscopy. Adhesion formation was confirmed in this filly during repeat laparotomy 10 days after the first surgery. Even though adhesiolysis was performed, it is likely that more adhesions formed following surgery as repeat laparotomy has been identified as a risk factor for adhesion formation (7). The chronic intermittent colic that the filly experienced after discharge supports this finding. In humans, adhesions commonly re-form at sites where adhesiolysis was performed on de novo adhesions (11). Laparoscopic adhesiolysis, performed 10 days post laparotomy, 154
has been reported to be an effective technique in breaking down experimentally induced adhesions in pony foals because adhesions are in the early maturation stage of formation and are easily broken down (8). Exploratory laparoscopy and adhesiolysis, to be performed 10 days following first exploratory laparotomy, was considered in this case. However, this option was not pursued as the filly was initially clinically stable and the owner was concerned with placing the filly under general anesthesia for a diagnostic procedure. In this filly, 2 separate stapled side-to-side jejuno-jejunostomies rather than a single jejunojejunostomy were performed in order to avoid removal of a large portion of normal jejunum. The distance between the 2 focal lesions was approximately 25% of total jejunal length in this filly. Removal of 25% of the jejunum is well within the acceptable limits to prevent development of short bowel syndrome (12). By creating 2 separate anastomoses, it was likely that the chance for adhesion formation in association with the anastomoses would increase, especially in a horse less than 2 years of age (6,13). A recent study by Gorvy et al (7) found that adhesion formation was unrelated to the site of a primary lesion or area of resection, although the effect of horse’s age on adhesion formation was not evaluated. In humans, multiple anastomoses are not associated with adhesions per se, but increased operation complexity and placement of foreign material into the abdomen are risk factors for adhesion formation (11); and so it follows, that multiple anastomoses likely contribute to adhesion formation. In areas of the world where porcupines (Erethizon dorsatum) are prevalent, such as western Canada, quill injury in horses and other mammals is common. Quills are hollow modified hairs coated with keratin that have a backward-pointing barb at the tip. If they become embedded in tissue, they migrate deeper into the animal rather than fall out (14). Usually, in horses, they are associated with superficial lesions involving the muzzle and legs, although they can migrate into important inner structures and cause significant damage (15). It is presumed that this filly ingested the quills in hay that was contaminated with a porcupine carcass because there was no history of quill injury from an encounter with a porcupine. Interestingly, none of the other horses on the farm had signs of septic peritonitis or colic. Perhaps the filly was less selective in her ingestion of feed or, because of her young age, was lower in the herd hierarchy forcing her to eat less desirable feed left over from the other horses. The case described here demonstrates the importance in considering porcupine quill injury in cases of intestinal foreign body perforation in areas of the world where these animals are endemic. Double jejunal resection and anastomosis may be a potential surgical procedure to remove focal lesions separated by normal intestine in horses; however, the number of postoperative complications experienced by the filly in the case reported here suggests that case selection may be important in determining the final outcome. CVJ
References 1. Elce YA, Kraus BM, Habecker PL, Arnold C. Jejunal perforation in three young horses. Equine Vet J 2003;35:720–722. 2. Saulez MN, Burton A, Steyl JCA, Williams JH, Clift SJ. Perforation of the gastrointestinal tracts of four horses by metallic wires. Vet Rec 2009;64:86–89.
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10. Bouré LP, Pearce SG, Kerr CL, et al. Evaluation of laparoscopic adhesiolysis for the treatment of experimentally induced adhesions in pony foals. Am J Vet Res 2002;63:289–294. 11. Bruggmann D, Tchartchian G, Wallwiener M, et al. Intra-abdominal adhesions: Definitions, origin, significance in surgical practice, and treatment options. Dtsch Arztebl Int 2010;107:769–775. 12. Freeman DE. Small intestine. In: Auer JA, Stick JA, eds. Equine Surgery. 4th ed. St. Louis, Missouri: Elsevier, 2012:446. 13. Singer ER, Livesey MA. Evaluation of exploratory laparotomy in young horses: 102 cases (1987–1992). J Am Vet Med Assoc 1997;211: 1158–1162. 14. Johnson MD, Magnusson KD, Shmon CL, Waldner C. Porcupine quill injuries in dogs: A retrospective of 296 cases (1998–2002). Can Vet J 2008;47:677–682. 15. Magee RA, Ragle CA, Howlett MR. Use of tenoscopy for management of septic tenosynovitis caused by a penetrating porcupine quill in the synovial sheath surrounding the digital flexor tendons of a horse. J Am Vet Med Assoc 1997;210:1768–1770.
Book Review Compte rendu de livre Canine & Feline Gastroenterology Washabau RJ, Day MJ. Elsevier Saunders, St. Louis, Missouri, USA, 2013. 996 pp. ISBN 978-1-4160-3661-6. $170.00.
“C
anine & Feline Gastroenterology” is a multi-author hardcover reference book on the gastrointestinal, hepatic, and pancreatic systems. This is an impressive book that aims to assist us in managing such frustrating problems as chronic diarrhea, persistent vomiting, unfathomable liver disorders, and undiagnosable pancreatitis. The latest research, information, and evidence is included by the 85 international contributors. Each chapter is extensively referenced. There are six sections: biology; approaches to clinical signs; diagnostic tests including ultrasound, surgery, and pathology; nutritional approach; pharmacology; and diseases. This format, along with the clear Contents and succinct Index, makes the comprehensive information readily accessible. This reference book is state-of-the-art and practice for gastroenterology. Each topic is thoroughly covered, clearly, and succinctly. Each section starts with a short description of the pathogenesis which, of course, underlies our understanding of etiologies, diagnosis, and therapy. In the first section on biology, the complex physiology is well-explained and complemented by chapters on microbiota, immunology, inflammation, and neoplasia. The second section discusses approaches to clinical signs. Each clinical sign is briefly discussed including general principles and differential diagnoses. Many tables, lists, and algorithms make this section extremely useful for the busy practitioner. Diagnosis is the basis of successful outcomes and this section is comprehensive. The chapter on laboratory tests contains much useful information including detection of parasites in feces and CVJ / VOL 55 / FEBRUARY 2014
a table of the sensitivities and specificities of tests for pancreatitis in both dogs and cats. The diagnostic imaging chapter includes numerous photos of radiographs and ultrasonographs. The chapters on endoscopy and laparoscopy are similarly wellillustrated in addition to detailed descriptions of techniques. The histopathology descriptions are also well-illustrated. The section on nutrition includes malnutrition, obesity, adverse food reactions, nutritional therapy (including soluble fiber and probiotics), and enteral feeding. The advice about the nutritional requirements of patients with chronic liver disease is refreshingly rational, as is the discussion about pancreatic disorders. The section on pharmacology is especially practical with lists of drug mechanisms and of individual drugs along with their actions and doses. The largest section is that on diseases. Each part starts with a description of the structure and function, followed by diagnostic options. The diseases follow. There are many useful tables of differential diagnoses and therapeutic agents, diagrams, photographs, and algorithms. This is a definitive reference on the gastrointestinal system of dogs and cats (mostly dogs due to our understanding and research). This book is useful, even essential, for every small animal veterinarian, teacher, and researcher. It will be frequently used as the information is easy to find, complete but succinct, and practical. This evidence-based, well-written book will improve the care of our patients. I highly recommend this reference book.
Reviewed by Lea Stogdale, DVM, Diplomate ACVIM Small Animals, Aesops Veterinary Care, 260 St. Anne’s Road, Winnipeg, Manitoba R2M 3A4. 155
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3. Henderson ISF, Mair TS, Keen JA, Shaw DJ, McGorum BC. Study of the short- and long-term outcomes of 65 horses with peritonitis. Vet Rec 2008;163:293–297. 4. Davis JL. Treatment of peritonitis. Vet Clin North Am Equine Pract 2003;19:765–778. 5. Elce YA. Infections in the equine abdomen and pelvis: Perirectal abscesses, umbilical infections, and peritonitis. Vet Clin North Am Equine Pract 2006;22:419–436. 6. Mair TS, Smith LJ. Survival and complication rates in 300 horses undergoing surgical treatment of colic. Part 3: Long-term complications and survival. Equine Vet J 2005;37:310–314. 7. Gorvy DA, Barrie Edwards G, Proudman CJ. Intra-abdominal adhesions in horses: A retrospective evaluation of repeat laparotomy in 99 horses with acute gastrointestinal disease. Vet J 2008;175:194–201. 8. Eggleston RB, Mueller POE. Prevention and treatment of gastrointestinal adhesions. Vet Clin North Am Equine Pract 2003;19:741–763. 9. Reef VB. The use of diagnostic ultrasound in the horse. Ultrasound Quart 1001;9:1–34.