During an exuberant play session, Sebastian failed to complete an acrobatic jump onto a carpeted climbing tree and instead pulled the tree over. The vertical portion of the tree landed across his abdomen; pinning Sebastian to the floor. He was able to scramble away without human assistance and appeared normally ambulatory without any respiratory distress. Initially, the owners believed that the young cat was ok, but within a few hours noticed he was very quiet and seemed painful when they touched his left flank region, inciting a visit to DoveLewis. The 5 month old, seven pound domestic shorthair neutered male cat had an otherwise unremarkable medical history and was current on his vaccines.
Upon presentation approximately 2 hours after trauma, Sebastian was slightly hypothermic (97.3 F) with normal respiratory and heart rates. His mucous membranes were pale with a normal blood pressure (112 mm HgMAP) and he exhibited marked abdominal pain on gentle palpation. Auscultation of heart and lungs were unremarkable and the young cat was fully ambulatory with no orthopedic or neurologic abnormalities observed.
Initial abdominal radiographs (VD and lateral) did not show evidence of abdominal effusion, however wispy appearance to the retroperitoneal space suggested fluid leakage that would be consistent with either hemorrhage or urine. The right kidney silhouette was not entirely visualized due to superimposed gastrointestinal tract. The urinary bladder appeared normal and Sebastian was observed urinating in a litter box following trauma. A brief ultrasound exam at the time of initial evaluation showed a small amount of free fluid near the caudal pole of the right kidney but no peritoneal effusion.
Treatment consisted of intravenous pain medication (oxymorphone) and crystalloid fluids at a bolus rate followed by maintenance and a fentanyl CRI (3 μg/kg/hr) was begun to manage abdominal pain. Baseline blood work included PCV of 34% and total solids of 5.5 g/dl (see Table 1), normal electrolytes, mildly elevated lactate (2.8 mmol/L) and normal BUN and creatinine. Options discussed with the owner included stabilization and monitoring in ICU to assess ongoing fluid (hemorrhage or urine) loss into the retroperitoneal space, full abdominal ultrasound, possible need for blood transfusion and exploratory surgery.
Repeat blood work at 8 hours post-admission showed a drop in PCV to 20% and total solids to 4.4 g/dl. Sebastian was blood typed (A) and cross-matched prior to administering one unit of packed red blood cells. Clinically, the cat was bright and comfortable except when palpated in the dorsocaudal right quadrant of his abdomen. A full abdominal ultrasound performed approximately 18 hours following presentation showed a very small quantity of peritoneal effusion and moderately enlarged right kidney (left kidney measured 3.7 cm in long axis, right kidney 5.3cm). Blood flow, as evaluated by color Doppler, was almost completely absent in the cranial pole of the right kidney. Active hemorrhage was not observed in the retroperitoneal space. The rest of the abdominal organs appeared within normal limits.
Clinically, Sebastian appeared quiet but interactive and willing to eat when offered wet food. The fentanyl CRI was discontinued and oxymorphone introduced (0.2 mg IV q 4hours) to minimize the sedative effects of pain medication. Thirty-six hours after presentation a repeat PCV and total protein of 15% and 5.2 g/dl respectively suggested continuing losses and/or consumption of earlier transfusion. Based on the likelihood of hemorrhage from the damaged right kidney, surgery was recommended and accepted by the owners.
Immediately following an additional transfusion to make Sebastian a more stable anesthetic patient, exploratory celiotomy was performed. At surgery, the retroperitoneal space was distended bilaterally with dark blood and clots, obscuring both kidneys. Free peritoneal fluid was minimal (serosanguinous). The right kidney was grossly misshapen with the cranial pole ruptured and irregular in silhouette. The proximal ureter was observed to be intact. Approximately 75% of the kidney was dark purple and exhibited a pulpous consistency. No active hemorrhage was observed, however due to the large amount of retroperitoneal clots, continued blood loss may have been present. An ureteronephrectomy was performed in routine fashion (fig. 1) after confirming normal appearance and location of the left kidney and ureter. Sebastian maintained adequate blood pressure during the procedure (systolic 70-90 mm Hg) and recovered quickly from anesthesia.
Following surgery, Sebastian was immediately more interactive, affectionate and demonstrated a good appetite (fig. 2). He received a final blood transfusion seven hours post surgery after which his PCV and TP stabilized. Other than an oscillating PCV and TP, Sebastian’s chemistry and CBC remained normal throughout his hospitalization and he never demonstrated hematuria. He was discharged 18 hours after surgery and had normal renal values one month post-nephrectomy.
In small animals and humans, the most commonly injured abdominal organ following blunt trauma is the spleen. In Sebastian’s case, all abdominal viscera except his right kidney were completely normal in appearance (no hepatic or splenic lacerations, ruptures or hematomas). Many cases of blunt abdominal trauma resulting in hemoperitoneum or hemoretroperitoneum or both are managed conservatively. Indications for surgical intervention include, but are not restricted to, evidence of continued hemorrhage, avulsion or significant tear to a ureter, evidence of ongoing urine leakage from either a kidney or ureter, and evidence of biliary tract or gastrointestinal tract rupture. Serial ultrasound can help with determining the presence of active hemorrhage and potentially identify the source. An excretory urogram was considered contraindicated due to his hemodynamic instability resulting in the risk of further renal damage due to the dye study. Computed tomography is the diagnostic modality of choice in human medicine, however the need for full anesthesia in our small animal patients makes it less desirable during a hemodynamic crisis. In Sebastian’s case, a CT scan would have been quite useful in identifying the level of damage to the right kidney as well as the function of the left kidney. However, by the time that Sebastian was stable enough for anesthesia the indications for exploratory celiotomy had been met.
We would like to thank Sebastian’s owners for consenting to the use of his case as an educational opportunity for the veterinary community.
- Slatter D, editor. Textbook of small animal surgery. 3rd edition. Philadelphia: WB Saunders;2003.
- Weisse et al. Traumatic rupture of the ureter: 10 cases. J Am Anim Hosp Assoc 2002;38:188-192
- Milward I. Avulsion of the left renal artery following blunt abdominal trauma in a dog. J Sm Animal Practice 2009, 50:38-43.