Thursday, June 1, 2017

What Gets Swallowed Must Go Through,, Or Else... Foreign Body Obstructions.

This is a blog about foreign bodies.. This is a blog about saving lives at the precipice of death.

This is also a blog about Levi.. He has been a source of my writings before. He is one of those patients who teaches you, tortures you, and reinforces where medicine diverges from sentience.

Levi has not had the best of luck. He was given up by his first owner because "it was cheaper to get a new dog without a problem than to treat his epilepsy." We parted ways permanently and with sincere words of disappointment and I kept Levi.

Levi found his real parents a few weeks later. They have been inseparable and in love since... but,,, the seizures have required medications which produced polyphagic mania. Levi has become a voracious counter surfer, toy eater, and frequent flyer for pancreatitis and induction of emesis. He has been to the ER or us for eating two loaves of banana bread, 6 loaves of sandwich bread (in plastic bags), two sleeves of gauze, a ceramic butter dish, and numerous other less disastrous close calls.

He is an excellent example of the meat of this blog.

Levi
In my experience the foreign body dogs fall into one of three categories;

1. The "OCD needy" type. The dogs who are inside, with their people fully integrated into their family unit. Often a single female who bonds so closely to the dog that the dog can no longer deal with anything without her, see also separation disorder, OR, the embedded family dog with the busy active lives, the dog thinks of themselves as a human child (because that is the only reality they know) and can't deal with them being out of the house for any reason including school, work, social life. These pets eat their way out of the stress of being alone. Labs, Border Collies and German Shepherds are over represented in this category.

2. The "keep my mouth busy because my body isn't" pets. There is no exchanging exercise and tiredness with indoor activities. All dogs need the outside, their nose in the dirt/grass/leaves/sidewalk, brain chugging away on primal sight/smell/touch/sensory experiences. This is a core part of their being. If your current daily regimen isn't getting you the desired results change it. If your dog is chewing, biting, stressing, needing, whatever and they are inside the majority of them time get outside (with them (this is imperative)) and let them share their life with you.

3. The "demons inside of me make me do it" pets. Drugs, stress, fear, paranoia, imbalance, pain, gi discomfort, etc., are all reasons that dogs eat things other than their food. Do not ignore this group. We know that pain can be inside, hidden from view, and that many of these pets live with chronic pain and/or disease that manifests as chewing/eating/ foreign body ingestion (this can also include hair, wounds to the body, and pica).

Some of my gang in the sunshine
I have a long list of questions to ask owners when I get a pet in the clinic with a affinity for eating/ingesting items that are not provided to them in their food bowls.

There should be a long discussion with your veterinarian the first time (and even longer discussions with any subsequent infractions)  your dog eats something that is non-sensical.

Levi arrives for surgery
In past blogs and videos I have mentioned the previous pica items that I have seen pets eat (see my blog about tampons, underwear, rocks, toys, balls, nuts, and even endless yards of Berber carpet which is a beast to surgically remove from intestines (it sort of melts and snakes through yards of gut making it almost impossible to extract). I find this behavior most commonly in larger breed dogs who are primarily inside and often younger versus older. I think there is a very strong correlation to obsessive-compulsive disorder, boredom, and behavioral problems. I am not saying that every dog who eats a sock, or other random non-food item needs a psych evaluation but I do think that every person involved in the pets life should at least be thinking about what their pet is trying to tell them, and why they are eating things that are not food. (P.S. an older dog who starts eating random non-food items is trying to tell you something. listen. dig. figure it out.)

The other group of indiscriminate PAC-MANesque pets are those on anti-seizure meds and steroids. These guys are driven by the drug that makes them voracious eaters who will eat a blanket if it even smells like it had a crumb hiding within it. Ask Levi the epileptic who ate a whole ceramic butter dish, lid included. (When we induced vomiting in him he spit out a collection of ceramic rubble akin to an archaeological dig... had I known what it would have looked like on the floor I would have thought twice about all the jagged ceramic edges transiting his esophagus AGAIN on the way up).

Doesn't anyone but me ever wonder what possesses them to eat these things?
Levi's catheter conundrums.
When you have had i.v. catheters placed as many times as Levi has
you surrender to the process and your veins are impossible to access.
When you bring up the discussion with your vet please make sure to be discussing the following items;

1. Diet. I always want to know what specifically you are feeding. This includes the dry food, the wet food, and the snacks. I want to know every item that you are putting in your pets mouth. Treats count! If you have a pet with an oral fixation on food they may become compulsive about always eating. You have essentially trained them to be constantly rewarded with food. Breakfast and dinner and play, love and exercise in between is the ideal way to spend the day. If you are feeding a deficient, substandard diet your pet will seek food/nutrients elsewhere.

2. How much exercise your pet gets? How much of it is structured? By this I mean is it a regularly scheduled daily event? Does the breed of your dog have an activity level that meets their needs? I often find that many house dogs are being asked to live a lifestyle that is too sedate and placid for their mental stability and health. Having a fenced in yard does not guarantee that your pet is actually out AND exercising in it. Please try to take daily walks of a measured distance. It is a wonderful activity to bond with your pet, provide enrichment and help both of your cardiovascular systems.

3. Stress. When I say stress for a pet I am talking about anything that your pet might find disconcerting. Not what you and I think about as stressful, but rather what your pet might see as stressful. Is there a change in activity in the house? Are their new or different noises? Or anything that their highly sensitive noses might be detecting? What about their super perceptive bionic ears? Or is anyone in the household upset? New neighbors? New family members? I know it is hard to try to think like your pet, but often they are picking up on something that is very disturbing for them and we are completely oblivious to it.

4. I often have my clients keep a daily journal of every aspect of their pets day so we can go over it together and try to identify any sources of any possible reason that their pet is now chewing on the furniture , or swallowing the items they find in the trash bin.

5. The "pacifier" dogs . These are the pups who we provide treat-stuffed-toys, bully bones, antlers, chewies, (etc., etc.) to in the hope we can keep them 'busy, 'quiet' 'entertained' for a few hours. Dogs with a high chew drive, or, those who have been repeatedly "pacified" by being given a treat when they are demanding attention are taught to be acquiesced only by chewing.. When the chewing leads to ingesting these items they can become deadly.

Levi post-op, I know he feels better already.
Levi  was actually seen swallowing his toy. His parents knew it went down. They couldn't believe how huge the toy was, and that it could have even been swallowed. I can't tell you how many times I hear this! I have seen whole towels, beds, toys, golf balls, tennis balls, walnuts, and cutlery swallowed in one fell and fast GULP!. Since then he had a decrease in eating for a few days, persistent vomiting, lethargy, and general malaise. His belly seemed painful and his x-rays showed something in the stomach,, even though we were all fairly certain it wasn't food.


The size, material and amount of time since ingestion all matter.

If you know your pet has ingested something other than their food it is best to do the following;

1. Call your vet immediately. Ask for guidance on what to do. They may advise that you;

2. Call the Pet Poison Helpline. Although there is a cost associated with this in some cases of toxin ingestion the information they provide you and your vet is well worth it.

3. Induce vomiting. Only do this after confirming with one of the above.

4. Watch and wait. If the material is able to be broken down by the stomach or small enough and benign enough to pass through the gut you may never see it until it is defecated out.



Any sign of the following indicates an immediate trip to the vet or ER;

1. Vomiting that is persistent, intractable, or producing material that is stuck in the mouth. Vomiting of more than 4 times, or, lasts longer than 3-4 hours, or consistent over more than 12 hours. (These are my guidelines). OR, if your pet is acting quiet, lethargic, depressed, seems distended in the abdomen, or is trying to vomit but not producing anything.

2. Straining to defecate and not producing feces, producing scant amount of feces, or there is material protruding from the rectum.
Levi's stomach is full of...
well, that's the fun of exploratory surgeries in pets.
You never know what you are going to find in them.

DO NOT PULL ANYTHING OUT OF ANY END OF YOUR PET! If you pull and tear something it could kill your pet.

This came out of the back end of Levi on the same day that  we removed his toy from his stomach.

This is the toy we took out of Levi's stomach.


When I examine a pet for a suspected foreign body I start with the following;

1. History: Many of these pets are repeat offenders. Serial swallowers. The first time it happens I go over all of the above information so that it never happens again. You can either decide to stop wearing socks, underwear and using sanitary products, OR, cage your dog when you aren't supervising, OR, don't train your dog to be a chewer. Every client with a chew-swallow dog knows they have one.. don't create, perpetuate, or hope the problem away. Or, buy pet insurance.

2. Exam; I know no one wants to go to the vet every time you fear your dog swallowed something they shouldn't have,, but, your vet can tell a lot about your dog based on an exam. I was called out of bed at 1030 pm to check on a dog who vomited up a sock and undies. Based on the exam I felt pretty comfortable he wouldn't need surgery that night. Which saved her about $2500 at the ER. "Has your dog ever eaten socks before?" I asked. "Yes, all the time," IS NOT what I want to hear at 1030 pm. He threw some of them up at 1 pm, has been lethargic and vomiting all day and I get called panic stricken at 1030 pm? "It's time to stop wearing socks and panties, cage your dog when you aren't there to supervise or get pet insurance. I'm going back to bed." About $50-$100

Exam for a blocked dog usually has the following; history of ingestion, painful abdomen, distended intestines, elevated heart rate, elevated respiratory rate.

3. Radiographs are the cornerstone for confirming a suspected foreign body obstruction. Start with a radiograph. Based on history, exam and radiograph you can try to manage conservatively with fluid therapy. Start i.v. fluids as quickly as possible. In some cases the fluids will help relax and restore pliability to the intestines and allow the obstruction to move through. Additional radiographs should be taken to confirm this. This is the conservative, avoid surgery (and cost associated with it) plan. Expect to pay about $200 for radiographs per series. Usually a few series are needed a few hours/day apart.

4. Ultrasound can be used to help confirm a suspected foreign body. If you can afford ultrasound make sure you can also afford surgery. About $200-$500.

My preference is to understand and discuss the best and worst case scenarios and keep the end game in mind as you manage the financial resources. If my client can only afford surgery we start there. Worst case scenario is that the patient needs surgery to survive this. Spending thousands of dollars to confirm this and then running out of money when you realize this is.... unethical, unimaginable, and happens far too often.


After about the third or fourth time going into the abdomen to cut out an obstruction it becomes nearly impossible due to the scar tissue and fibrosis inside and around the intestines. Please do everything to have the first obstructive surgery be the last.

Here's to Levi.. The epileptic with the phenobarb telling him to eat it.. We are pulling a toy out of his stomach today. He is also the butter dish eater.

Levi heads home
And to Buster, the sock and panty guy. Who dodged the scalpel thanks to i.v. fluids and time.

And to the countless other labs who can't seem to either stop chewing or aren't caught fast enough before swallowing.

When it comes to the surgery to remove a foreign body I offer the following advice;

1. Never euthanize based on price alone. Call for help if you cannot afford the first estimate given. Drive to wherever you can afford it. BUT, keep the pet on fluids, antibiotics and analgesics until you get there. I have had numerous pets wait overnight at the ER to have surgery the next day with us. Often at a savings of about $2000. It is not ideal, but it can save a pets life.

2. An obstruction is an emergency. The faster it is removed the more favorable the prognosis.

For those of you concerned about the prices of Levi's care his care was provided over three days and amounted to about $1400 for everything. If you are unable to afford surgery ask us how you may be able to pare down the price by visiting Pawbly.com for help.

If you have any questions or comments please find me at @FreePetAdvice, or Pawbly.com. I am also at the clinic Jarrettsville Veterinary Center in Jarrettsville Maryland. I am also sharing these videos on YouTube.

On average an exploratory surgery at my clinic costs about $800 to $1200. Our clinic price list is available on our website.

I look forward to hearing from you...




Related stories;
Corncob obstruction. Video included on corncob surgery removal,, (it's a goodie!)

Toy removal in a dog video here;