Foreign body obstruction

Q: Dear Dr. Mike,

First, I want to thank you for putting together such a great website; while my dog was sick this past summer, I consulted it a lot, and found the information really clear and helpful.

Unfortunately, my dog (a 2 ½ year old female black lab) had to be put to sleep a couple of weeks ago, which is why I'm writing you. We are really upset by her death, not only because she was a wonderful dog but also because she was so young and the reason for her death is not entirely clear. We like our vets a lot, and they worked incredibly hard to save her, but they too are not really sure what lead to her death. It may be that we never find out, but I wanted to run her history by you to see if you have any insights into what happened. I would feel better if we at least knew how to prevent something like this from happening in the future. (I apologise in advance for the length of the e-mail, but I don't want to leave anything out which might be relevant to what happened.)

1. The first indication that anything was wrong was in late July. Our dog suddenly developed a bad cough on 7/25. We took her to the vet, who diagnosed kennel cough, even though she had been vaccinated a little under a year previously (I learned from your site that these vaccines don't last quite a year). Our dog hadn't been in a kennel, though we took her every day to swim in a lake where there are a lot of other dogs (we live in Chicago near Lake MI). The vet put her on Amoxitabs and Guaifenesin/Dextromethorphan. She seemed to get worse, so we brought her back in on 7/30. The vet took x-rays and a CBC. The x-rays and CBC didn't turn up anything, though the vet did notice that her trachea was on the narrow side, and recommended that the dog lose a little weight. She put her on Cephalexin 500 mg, 6/day for 2 weeks plus cough tabs. Within about a week, the cough was a lot better, and seemed to have cleared up by the end of the 2 weeks (8/13). She did develop a small sore on her stomach, but that healed in about a week.

2. Since our dog was just about due for her vaccines, and we were taking her on a trip out east and were worried because she'd caught the kennel cough, we took her in at the end of her antibiotics on 8/13 for her vaccinations. The vet didn't vaccinate for bordetella because she'd had it so recently, but she was vaccinated for Canine Distemper/Parvo DHPP, and for Canine Corona.

3. We went on the trip, and all was fine until the last day. We had been in VT for about 2 weeks on a lake, and our dog swam every day. While there, she did manage to get a few table scraps from some of the kids (we never usually feed her scraps, only Science Diet maintenance). The last day of the trip we stopped near New Haven, CT to visit family, and took our dog on a walk along a bikepath. There was a small stream running along side it, and she did drink from it. The only other unusal thing that happened was that she ate some of the cat's food. Before going to bed, she had a normal stool. Late that night, she started to vomit. Initially she vomited 3-4 times. I stayed up with her, and she couldn't seem to get comfortable, and in the early morning vomited again, 3-4 times. I took her to the emergency vet clinic there (8/25). They took x-rays, but didn't see anything unusual. They recommended withholding food and water until that evening, then trying to give her a very little amount of each.

4. We drove back to Chicago with the dog, and that night tried to give her a little food and water. She seemed very thirsty, but threw up even the small amount we had given her. We tried again in the middle of the night, and the same thing happened, so we took her to our regular vet first thing the next morning (8/26). He put her on an IV and took x-rays, did a canine comprehensive/CBC, plus gave her an injection of tagamet and a carafate. Her blood work appeared normal, though the white blood cell count was just a little low, and the x-rays didn't turn up anything unusual. He recommended that we give her science diet I/D for a few days, then gradually reintroduce her regular food.

5. She seemed fine on the I/D, and after a few days we started mixing in her regular food. The night of 9/1, she vomited once. The next morning (9/2) when I took her on her walk, she had bloody diarrhea; the blood was bright red, not dark. We took her right back to the vet. He did a fecal exam, which didn't turn up anything. He also gave her an injection of centrine. He put her on flagyl 500 mg tablets, 2/day (14 total), and told us to return to the I/D for a few days, then to try to return to her regular food.

6. While on the flagyl, she seemed better. The bloody diarrhea disappeared; her stools were solid but smaller than normal, and much less frequent (down to one/day). She seemed ok, but ever since the first bout of vomiting, she wasn't quite herself, but was a little depressed and less active. Also she seemed to have a harder time getting comfortable, and sometimes would give a small groan. On 9/7 we started to reintroduce the regular food. This was also the last day of her flagyl. On 9/8 we gave her mainly her regular food with some I/D mixed in. Late that night she vomited quite a bit of food, as if it hadn't been able to leave her stomach. When we got up early the next a.m., it was clear that she'd vomited many times and had diarrhea, which was very unusual because she's never gone to the bathroom in the house. I took her out and she had streams of bloody diarrhea, almost pure liquid; of course I was really scared, and ran her up to the vet's.

7. Our vet immediately took x-rays, and this time they thought that they saw an obstruction in the small intestine. They recommended surgery to remove it, and also mentioned that we could go somewhere else for endoscopy. (This is my one big regret, that we didn't pursue endoscopy; at the moment it seemed like a straightforward case of an obstruction, and the vet seemed to think surgery wouldn't be a problem. Suddenly it seemed as though this was what had been causing the problem for the past weeks). We o.k.'d the surgery, and they did it at noon. In her small intestine they found a "squeaker," from one of her dog toys. It was pretty small, but the vet assumed that that's what had been causing all the problems. We were very relieved, and they said the surgery had gone really well. When she came to, though, she continued to have vomiting and bloody diarrhea. (This was Friday, 9/9). She was on an IV and they gave her injections of antibiotic and torbutrol/torbugesic. By the next morning, 9/10, she wasn't doing better, but was continuing to have vomit/bloody diarrhea, so the vet opened her back up. He was worried that her intestine might have twisted and also wanted to make sure they hadn't missed anything during the first operation. He also wanted to take an intestinal biopsy, because he was concerned that the squeaker hadn't been the problem after all. The initial surgery site was a bit red, but otherwise looked fine. She was on an IV and was given reglan and torbutrol injections again.

8. By Saturday 9/11 she seemed worse. We'd visited her each day since the first operation, and it was clear to me that she was in a lot of pain. the vomiting/bloody diarrhea continued. That afternoon her temperature soared, up to 106, and the vet gave her a steroid injection (I think soludelta cortef), plus they were continuing the antibiotic injections, tagamet, and IV. They did another CBC that day, and it appeared normal, though again the white count was very slightly lower than normal. By the end of the day her temperature had come down to about 102. On Sunday her temperature stayed around 102, and they continued the antibiotic injections, tagamet,reglan, carafate. At this point the vet suspected peritonitis had developed.

9. On Monday morning her temperature was again very high, 105. She looked terrible; I sat with her and she would barely open her eyes. Our vet was positive she'd developed peritonitis, and was pretty sure that she wasn't going to make it. he wanted to open her up to put drains into her stomach, and we gave him the o.k. When he did this, he saw that the enterotomy site from Thurs & Fri hadn't healed at all! he said that usually healing begins within a few hours, but that there was no evidence at all of this healing, which was how she developed peritonitis. Stuff was just leaking out of the area they'd stitched up. He was extremely puzzled as to why she hadn't healed at all, and said it had to be related to an immune system problem. He did another biopsy, and recommended that we put her to sleep.

10. When it came to making this decision, I had a really hard time. I called a specialist, and asked whether anything could be done at this point. She said they'd immeidately remove any sections of the intestine that were too infected, and that they'd treat it as an open wound, leaving it open and draining it with a pump. She said a 2nd operation might be necessary. Even with these measures, the chances were very low. I called back our vet, and asked him what he thought her chances were going to a specialist; he didn't think she'd make it. It just sounded like too much to put our poor dog through for such a slim chance of success, and we agreed to have her put to sleep. It was clear our vets were really upset about losing her too, and had tried everything within their power to save her.

11. Our vet had sent off the first intestinal biopsy on Friday, and heard back a couple days after our dog had been put to sleep. The lab had found lymphocytes and plasma cells, and thought she may have had chronic enterocolitis. At this point, our vet was convinced that the squeaker/obstruction had been secondary, and hadn't caused the initial vomiting/bloody diarrhea problems, but that this was caused by the IBD. This still didn't explain the immune system problem, though. The results of the second biopsy didn't shed much light on the problem; the pathologist suggested that she may have had viral enteritis, even a parvovirus. But our vets pointed out that her symptoms weren't consistent with parvovirus, because they waxed and waned. Also, they said that viral enteritis will usually show up in blood work, and it didn't. The only strange thing was a slight drop in the WBC. The pathologist said a perforation of the intestine could've caused the initial problems, but our vets had seen no evidence of this during the first operation - the stomach and intestines looked healthy.

So, here are my questions:

1] What could have caused the immune system suppression? What seems to have directly caused her death is the non-healing of the surgical site, which led to peritonitis. So what prevented her from healing? Could she already have had peritonitis before they did the operation? Or could her immune system have been suppressed from the infection she'd had earlier in the summer, or from her recent vaccines? Or from some other mysterious disease? Might she have caught something from the lake or stream on our trip? 2] The only thing I've read which indicates a slightly depressed WBC is erlichiosis; could she have had this? 3] Could the squeaker have caused everything? Could it have caused the waxing/waning symptoms of vomiting and bloody diarrhea? could it have caused the suppressed immune system? 4] Would endoscopy have saved her life; i.e. if the non-healing of the surgery/peritonitis was what killed her, I can't help but wonder whether she'd be alive today if we'd pursued endoscopy instead.

I would truly appreciate any and all insights on what happened, even if they are only speculative! I know it can't bring back our beloved dog, but it would help us psychologically to have a better sense of what lead to her death.

Thanks so much, S. R. .

A: S.R.

We had a situation similar to what you have experienced in a patient of ours. We did surgery to remove a foreign body (I think it was a small ceramic figure) and then our patient deteriorated quickly and when we repeated the exploratory laparotomy there was almost no healing of the incision site in the intestine. I think that this happens when the conditions in the intestine around the site of the obstruction were worse than they appeared to be during surgery. We have seen a couple of patients that seemed to be having toxic reactions around plastic foreign bodies and sometimes foreign bodies that are small enough to move a little at a time but large enough to cause damage as they move through the intestine lead to problems like this. By the time they lodge somewhere there has been enough disruption of the intestinal blood supply or inflammation around the obstruction site to make healing difficult. We feel lucky that the second surgery, in which we removed a section of the intestine around the original obstruction site, worked well enough to allow our patient to heal. I was not actually very hopeful for that outcome, even though his signs were not as severe as those experienced by your dog.

I did not think that we should have had to do surgery in our patient, in the first place. The foreign body made it through a large portion of the small intestine before it caused the obstruction. It was a material that I don't think of as being toxic, but that may not be true. Sometimes, it is just really hard to figure out why something like this causes problems in one dog and not another -- or why a dog can eat a squeaker two or three times and then have problems the next time it eats one.

I do not know where the foreign body was in the intestinal tract but there are limits to how far into the tract it is possible to "go" with an endoscope and simple removal of the object may still have left an area of severely damaged intestinal tract that would have ruptured, anyway. On the other hand, it may have helped. It is not possible to be sure --- but there are enough doubts that it seems to me that you should not be trying to second guess your decision at this point. You can't know for sure and you made a good decision even though it had a bad outcome.

There is a small chance that an infectious process could have been an influencing factor since there is some opportunity to have picked up an infectious agent (from the water in New Haven, for instance). This could also have adversely affected in the healing process in the intestine, as you noted in your letter to me.

Vaccinations cause immune suppression for a short period of time in many dogs. Generally this effect occurs about one week after the vaccination and lasts for a few days. Usually this is no problem as the immune suppression is not usually severe and most dogs do not experience an immune system challenge during this time period. However, in a situation in which a severe stress to the immune system does occur shortly after vaccination it is possible that the response will not be as good as it would have been without the vaccination. Many viral illnesses are also capable of causing some immune suppression. Traveling is stressful enough that it could have been a factor and when pets travel they sometimes get exposed to strains of bacteria or viruses that they are not exposed to at home and consequently develop problems from that might not have occurred at home.

Many illnesses cause decreased in white blood cell counts. This is not unusual with viral illnesses and is a prominent feature of parvovirus infection --- although it would be very unusual for a vaccinated dog that was older than a year of age to have much problem with parvovirus. It would be surprising if ehrlichiosis was the problem. There are dogs that do not have white blood cell counts in the normal range, ever, during their lifetimes. Many of these dogs never experience problems as a result of their low WBC levels but it does seem logical that they might be more likely to have problems when a strong need for white blood cell responses to disease occurred.

I think that the squeaker could have caused most or all of the problems. The most vexing foreign bodies are ones that stop in the intestine, cause illness, then move so that the illness seems to improve, then stop again --- and so on, until they either pass or finally stop moving entirely and cause an obstruction. The ones that have a toxic element (cause local inflammation or are actually poisonous) are a problem. Plastics can sometimes cause intense local irritation to mucosal tissue and that, combined with slow passage through the digestive tract, could have lead to a waxing/waning pattern in the symptoms.

I think there is a very good chance that endoscopy would not have been very helpful but there is just no way to be sure of this. You should give yourself the benefit of the doubt on this one, though.

I wish I could tell you exactly what happened but there are a lot of possibilities. It sounds like this may have been a situation in which the sequence of events occurred in just the right order to produce disastrous effects that ordinarily would not have occurred. There are times when bad luck is the best explanation or at least a big part of it. I wish that weren't the case.