Case Studies – Sooty

Surgery is indicated in these cases to remove the stones from the common bile (CBD) and cystic ducts. To prevent rupture of the gall bladder it is removed also. Our surgeon performed the complex procedure. Inflammation indicative of infection was observed, and intravenous antibiosis (cefuroxime) was begun. After visual inspection of the organs, bile duct patency was checked and duodenotomy was performed to access the end of the CBD. The stones were removed, and duct was flushed. Duodenotomy was closed with simple continuous pattern. Cholecystectomy was performed (cystic duct was double ligated with non-absorbable suture material). The common bile duct was protected. A small cut biopsy was performed using a combination of electrosurgery and suture material. The abdomen was checked for active bleeding and closed routinely. Samples of liver, gall bladder and culture and sensitivity swab were sent for histology, culture & sensitivity. A nasogastric feeding tube was placed to ensure nutrition could be monitored and adequate supplementation could be administered when required.

Sooty recovered well, with opioid analgesia (methadone), anti-emetic (maropitant) and antibiotics (amoxicillin and clavulanic acid) on board as well as intravenous fluid therapy (IVFT). 24 hours after surgery she had eaten a small amount, and her pain score was low: 2/16. The vet recommended increasing the time interval between analgesia doses. Within the next 24 hours, Sooty seemed to regress and became inappetent causing the prescribed analgesia to return to the higher frequency and the adding of mirtazapine to stimulate her appetite. Full blood biochemistry was also repeated to provide an insight on organ function following the surgery. As the above demonstrates, liver enzyme values were much improved so NSAIDs (meloxicam) could safely be added into the analgesia protocol. A tube feeding plan was created; 181kcal per day to be met over 6 feeds with added water to reduce the need for IVFT. The following day saw Sooty eating of her own accord again, enjoying tuna and gastro-intestinal support wet food. Her pain score remained low, and methadone was swapped for less potent buprenorphine. Her nasogastric tube was removed, she remained stable and comfortable, and discharge was arranged.

Lab results concluded that the presence of E. coli and mixed anaerobic bacteria were the likely cause for irritation of the liver, and already initiated antibiosis was to be continued to address this. The gall bladder irritation leading to blockage was likely to be reactive to cholecystolithiasis; inflammatory bowel disease, pancreatitis and infection eventually result in immune-mediated inflammation.