A 5-year-old male neutered Labrador retriever was referred for abdominal exploration following a three-day history of gastrointestinal signs. He was known to have consumed corn cobs three days earlier followed by vomiting, abdominal distension and failure to defecate over the following 24 hours. Initial radiographs at the primary care facility showed a segment of distended intestine containing a large amount of radio-dense material. He was initially treated with IV fluids, pain medications and maropitant with cessation of vomiting and improvement in his abdominal comfort. Repeat radiographs (Figures 1 and 2) showed reduced serosal detail and severe intestinal distension persisted. Warm water with lube enemas were unsuccessful. He was referred to DoveLewis Veterinary Emergency & Specialty Hospital after starting IV antibiotics (ampicillin/sulbactam) due to concern for peritoneal effusion secondary to intestinal necrosis.
Upon arrival, he was normothermic, eupnic and mildly tachycardic at 120 bpm, was normotensive and described as quiet, alert and responsive. He was able to walk without assistance and was tense on abdominal palpation. No fluid wave was palpable and his rectum was absent of feces or blood. Initial blood work was unremarkable including a lactate of 1.2 mmol/L, PCV 39% and total solids of 5.8 g/dl. A second IV catheter was placed in anticipation of surgery, fentanyl and normosol were continued. Ampicillin sulbactam (30 mg/kg IV), metronidazole (11.5 mg/kg IV) and enrofloxacin (10 mg/kg IV) were begun prior to surgery. Cecocolonic volvulus was the prime differential given the history and radiographic evidence, although colonic necrosis (without volvulus) due to chronic obstruction was also considered.
At surgery, a 270-degree colonic volvulus and associated septic abdomen from loss of viability of the involved intestine were found. Multiple serosal and muscularis tears (parallel to mesentery) were found along the length of the colon without evidence of gross contamination. Abdominal fluid was dark red to purple, malodorous serosanguinous and highly proteinaceous. Greater than one liter was suctioned initially to improve visibility. The colon was tightly packed with firm material (gravel and corn cob fragments) from just aboral to the cecum to several centimeters cranial to the pelvic brim. Nonviable colon (purple to black to gray) extended to the proximal transverse colon but the cecum itself appeared viable as did the root of the mesentery and cranial mesenteric artery. The volvulus was reduced to improve visualization and the cecum , colon and distal ileum resected (total colectomy with resection of the ileocolic valve). Remaining gravel was removed from the distal colon (at pelvic brim) and rectum. An ileocolic anastomosis was performed preserving 2 cm of colon cranial to the pelvic brim. Lumen disparity was addressed by partial closure of the antimesenteric aspect of the colon. Omentopexy was performed following final lavage to augment angiogenesis at the anastomosis. An orogastric tube was used to gavage the stomach to remove gravel from the lumen. Following abdominal lavage (200 ml/kg), suction and culture, two Jackson Pratt (JP) drains were placed and the abdomen closed routinely.
The dog recovered smoothly in ICU and remained in hospital for four days. Abdominal fluid collected at surgery grew Escherichia coli with a predictable sensitivity pattern. His JP drain production (Figure 3) began to decline approximately two days post-surgery and both drains were removed 82 hours following surgery.
Cytology was evaluated at 25, 42 and 66 hours post-surgery. The second cytology showed an increase in WBCs from 2-4/HPF up to 10-20/HPF and a trend to degenerate neutrophils. Rare intracellular and extracellular cocci were seen. No change in antibiotic coverage was made as he was already well protected with the combination begun prior to surgery. Fluid production dropped and cytology improved between day two and day three with WBCs down to 5-10/HPF (non-degenerate) and no bacteria seen either intra- or extracellularly. Other supportive care included IV fluids, fentanyl CRI, and maropitant. He did not require blood products during his stay. Once he began to eat, pain medication was transitioned to gabapentin and tramadol and his antibiotic coverage transitioned to oral versions of those listed above. He was discharged four days after presentation. Based on the culture and sensitivity results, the dog completed a two week course of amoxicillin/clavulanate following discharge (metronidazole and enrofloxacin were discontinued six days following surgery). Six months following surgical correction of the colon impaction and volvulus, the dog is reported by the owner as back to full activity and he maintains soft, formed stool (no fecal incontinence observed). His owners were encouraged at the time of staple removal to meet with an internal medicine specialist to address the dog’s lifelong dietary needs.
Colonic volvulus (aka colon torsion) is an infrequent life threatening disease primarily seen in young to middle-aged large breed dogs. Cecocolic volvulus is reported more often than colonic volvulus and involves the cranial mesenteric artery, thus compromising the small intestine as well as the large intestine. Impaction with corn cob fragments and gravel in this patient may have predisposed him to colonic volvulus due to impaired motility, weight of intestinal contents and stretch of the mesocolon. The appearance of his colon and mesocolon at surgery would fit with initial chronic (days) impaction and subsequent volvulus. Although the cecum in this dog was viable, anastomosis between the proximal 1-2 cm of transverse colon to the colon at the pelvic brim would have resulted in significant tension and increased risk of dehiscence. Thus, the cecum and distal ileum were also resected to allow mobilization of the proximal ileum to the pelvic brim.
When not associated with impaction, colonic or cecocolonic volvulus usually presents as a severely painful abdomen in an unstable patient with marked gas distention of colon and small intestine radiographically. Survival is associated with aggressive stabilization and prompt surgery to decompress and either resect or reposition affected bowel. Colopexy to the left lateral abdominal wall is performed if the colon is viable after decompression and derotation. Prognosis with colonic and cecocolonic volvulus is guarded and relates strongly to degree and duration of volvulus. Prognosis was considered grave to guarded in this patient due to the compounding effects of septic abdomen.
DoveLewis would like to thank this Labrador’s owners for allowing discussion of his case for teaching purposes. We also thank the referring veterinarian community for continuing to send us interesting and challenging cases.
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