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Obstructive Small Intestinal Obstructive Small Intestinal

Obstructive Small Intestinal - PowerPoint Presentation

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Obstructive Small Intestinal - PPT Presentation

Epitheliotropic Tcell Lymphosarcoma in a Horse Author Ashley French 1714 Mizzou Pl Apt 6A Columbia MO 65201 AshleyFrenchmizzouedu 8163094848 Mentors Alison LaCarrubba DVM ABVP Martha ID: 912995

small intestinal neoplasia disease intestinal small disease neoplasia abdominal obstruction fluid cell reflux mass pain dvm necropsy colic dental

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Slide1

Obstructive Small Intestinal Epitheliotropic T-cell Lymphosarcoma in a Horse

Author: Ashley French1714 Mizzou Pl Apt 6AColumbia MO 65201AshleyFrench@mizzou.edu816-309-4848Mentors: Alison LaCarrubba DVM ABVP, Martha Rasch DVM, Philip Johnson BVSc MS ACVIM ECEIM MRCVS University of Missouri College of Veterinary Medicine

Slide2

Signalment“Hopi”393 kg (866 lbs)

25-year-old QH gelding

Slide3

History

Retired dressage horse living on pasture at a retirement horse farm in MissouriIn 2006, treated for an obstructive small intestinal colic consistent with proximal enteritis. Vaccinated 3/11 for EEE, WEE, West Nile, influenza, tetanus, rabies, and EHV-1,4.Dental prophylaxis 3/11Dewormed regularly, last deworming: 3/11 (pyrantel)

Slide4

History Continued…

5 lbs of Purina Equine Senior™ feed BID with free choice hayWeight loss of two months durationAnorectic on the morning of presentationKicking at abdomenPassed a small amount of loose manure Presented to MU-VMTH ambulatory service on 4-7-11 with acute colic

Slide5

Initial ObservationsActively colickyKicking at abdomen

Flank watchingInappropriate recumbencyBCS: 3/9 (1 = very thin; 9 = obese)MM: pink and moistCRT 2 seconds (rr: <2s)

Slide6

Vital SignsHeart Rate: 60 bpm (rr: 28-40 bpm)

Respiratory Rate: 20 bpm (rr: 12-20 bpm)Temperature: 98.9⁰F (rr: 99-102⁰F)

Slide7

Clinical Findings Continued…

Normal borborygmi (right); decreased (left)Hirsutism HalitosisRectal examination revealed prominent small intestine, not significantly distendedNasogastric tube yielded net 4 L yellow-green reflux + moderate amounts of ingesta

Slide8

Diagnostic considerations

Implicative for small intestinal obstruction colicRefluxPalpation findingsPrior historySuspect PPIDPhysical appearance and ageSignificance of halitosis?Dental diseaseGastric squamous cell carcinoma?

Slide9

On Farm Treatment

Analgesic medication (IV)Flunixin meglumine -400 mg (1 mg/kg)Xylazine HCL- 100 mg (0.25 mg/kg)Butorphanol tartrate- 1.5 mg (0.004 mg/kg)Administered 12 L lactated Ringer’s solution (IV)

Slide10

Problem List

Abdominal painGastric refluxTachycardiaAnorexiaChronic weight lossHalitosisHirsutism

Slide11

Differential Diagnosis

Tachycardia: pain, circulatory compromise, fear, cardiac diseasePain was most likely attributable to colic (pain); normal CRT and pink MM mitigated against hypovolemia, etc.Abdominal pain: Usually GIT obstruction; non-obstructive (“false”) colic could be considered. Palpation findings were implicative for small intestinal obstruction. Considerations included intraluminal obstruction (food impaction), infiltrative disease of the intestinal wall (neoplasia, granulomatous enteritis, etc), proximal enteritis (ileus), strangulation (mesenteric lipoma, mesenteric rent, volvulus, etc)Gastric reflux was implicative for small intestinal obstructionAnorexia

: Many considerations: pain, systemic illness, dental disease, dysphagia, neurological disease, esophageal obstruction, etc

Hopi had an acute loss of appetite, consistent with abdominal painChronic weight loss: Many considerations (common component of disease of most organ systems): malnutrition, endoparasitism, dental disease (geriatric attrition), EIA, chronic intestinal disease (

malassimilative

and/or protein-losing

enteropathies

), neoplasia,

etc

C

hronic intestinal disease was considered likely in light of the chronic and recurrent colic problem (also noting the regular deworming, dental care, and appropriate plane of nutrition).

Slide12

Differentials Continued…

Halitosis: Dental disease, gastric disease, oral, esophageal, or gastric cancer, oral wounds or ulcerationsDental disease ruled down based on results of oral cavity examination: age increased the risk of neoplasia and GI diseaseHirsutism: Time of year, pituitary pars intermedia dysfunction (PPID), severe parasitism, malnutrition Age was supportive for PPID; severe parasitism and malnutrition were less likely (management practice)Gastric reflux: obstruction due to either ileus or mechanical obstruction (usually small intestinal; sometimes gastric); ileus, proximal enteritis, strangulation, luminal occlusion (food impaction, etc), mass lesion (neoplasia, granuloma, etc), pyloric outflow obstruction (eg persimmon, neoplasia, etc)

All of these differentials were valid possibilities. Small intestinal condition was more likely based on palpation findings at this point

Slide13

Diagnostic Plan

CBC/Chemistry: evaluate systemic inflammatory response and organ functionAbdominal Ultrasonography: evaluate appearance & function of viscera, esp. abnormalities of GITAbdominocentesis: evaluate peritoneal fluid for evidence of intestinal devitalization, peritonitis or neoplasiaGastroscopy: evaluate esophagus and stomach for obstructive lesions, neoplasia, and/or ulcerations

Slide14

Referral

Pain and reflux persisted in spite of field treatmentReferral to VMTH for hospitalized treatmentRestricted budget (fluids/observation/reflux retrieval only)On admission at VMTHquiet & alertHR 88 bpm RR 16 bpm Temp 100.6°F MM pink and moist, CRT <2s

Slide15

Treatment at the VMTH

Held NPO & monitored for painIV fluid therapy LRS: 2 L per hour overnightEvaluate for NG reflux every 2 hInitially, reflux quantities were 3-5 L, gradually reducedReflux was not evident the next morning (tube removed)Further signs of colic not observed

Slide16

Diagnostic ResultsPCV

: 39 (rr 30-45)TS: 7.2 g/dL (rr 5.8-8.7)CBC: mature neutrophilia - likely from stressChemistry:Hypoalbuminemia (1.9 g/dl; rr, 3.2-4.5 g/dl): GIT protein losing disease, negative acute phase protein, iatrogenic (fluid therapy) Hyperfibrinogenemia (0.7; rr, 0.2-0.4 mg/dl): inflammation of >48 h durationHyperglycemia (124; rr, 83-115

mg/dl): likely due to stress ± PPIDHyperglobulinemia (5.5 g/dl; rr,

3.3-4.2 g/dl): likely from chronic inflammation (neoplasia, infection, GIT ulceration)F

ecal culture (biosecurity)

:

negative for Salmonella (reported later)

Slide17

Ultrasonography

Abdominal ultrasonography revealed increased peritoneal fluid and an abdominal mass closely associated with the small intestine.The mass appeared to be in the wall of the small intestine and was located in the ventral abdomen, cranial to the prepuce. Images were highly suggestive of neoplasia or less likely abscessation.

Slide18

US image obtained at IC space 16 (left), depicting spleen and increased quantity of peritoneal fluid

spleen

peritoneal fluid

Slide19

US image obtained at IC space 17 (left, ventral), depicting spleen and mass (showing infiltrated wall of intestine)

spleen peritoneal fluid

Intestinal wall infiltration

Slide20

Gastroscopy

Gastroscopy revealed mild ulcerations on the squamous epithelium

Slide21

Endoscopic image of stomach depicting mild squamous epithelial ulceration

Margo plicatusulcers

Slide22

Abdominocentesis

Cloudy straw-colored fluidTotal protein: 4.0 mg/dL (rr<2.0 ) TNCC: 12,436 cells/uL (rr

<5,000) Negative bacterial culture

Exudative suppurative peritonitis

Primary differentials: neoplasia, abdominal abscess, perforating ulcer

Slide23

Macrophage exhibiting

leukophagocytosisCytospin revealed primarily non-degenerate neutrophils; no neoplastic cells observed

Abdominocentesis Cytology

Slide24

Treatment Continued…

Treatment for infectious peritonitis was startedantibiotic therapy: potassium penicillin G, gentamicin, metronidazoleFlunixin meglumine 1.1 mg/kg SID, IV ProbioticSaccharomyces cervisiae (Yea-Sacc™)Lactated Ringer’s solution 1L/hr, IVSlowly reintroduced to Purina Equine Senior® food (as mash)

Slide25

Outcome

1Throughout the first 72 h of hospitalization…Horse improved remarkably – no pain, no refluxLow dose flunixin meglumine treatmentsBright, alert, and responsivePassed manureBorborygmi returnedExcellent appetiteDuring gradual progressive re-feedingFluids discontinued and treatment continued

Slide26

Outcome

2Signs of abdominal pain recurred at +72 hReflux was recoveredDue to age and unfavorable prognosis the owner elected humane euthanasiaExploratory coeliotomy was not allowedCosmetic necropsy performed burial at the owner’s request

Slide27

Necropsy Results

Two multi-nodular mural masses ranging 14-17 cm were present in the wall of the jejunum. Partially digested plant material was present in the lumen. The wall of the jejunum had multifocal thickenings of up to 1.5 cm. The affected areas were white on cross section, severely ulcerated with sloughing mucosa and had areas of necrosis and abscessation that oozed purulent material when cut.

Slide28

Cosmetic necropsy: appearance of intra-abdominal mass at ventral mid-line location just cranial to the prepuce

Slide29

Cosmetic

necropsy: appearance of resected intestines + mass submitted to the VMDL

Slide30

Cosmetic necropsy:

suppurative material identified in area of abscess development within the tumor

Slide31

Necropsy Results

Neoplastic infiltration

Jejunum

Abscessation

Mass

Slide32

Histopathology

Neoplastic infiltrationSmall intestinal lumen

Villlous mucosa

Magnification 2x

Slide33

Positive for CD3 = T cell Lymphoma

Nuclear molding

Anisocytosis

Anisokaryosis

Abnormal mitotic figures

Criteria of Malignancy

Negative for CD79a (B cell)

Monoclonal round cell population

In an abnormal location

Slide34

Final Diagnoses

Jejunal epitheliotropic T-cell lymphosarcomaPeritonitis resulting from cancer-mediated jejunal epithelial ulceration and infection

Slide35

Equine Alimentary

LymphosarcomaCommon tumor of the GI tractPoor prognosis: most horses do not live greater than 6 months after diagnosis regardless of treatment methodMost common clinical signs: weight loss and colicCommonly associated with malabsorption syndrome Segmental thickening of the small intestineAssociated with hypoproteinemia, and hypoalbuminemiaPossible TreatmentsSurgery to remove affected intestine

Chemotherapy: cytosine arabinoside, cyclophosphamide, vincristine, and prednisolone

Slide36

Further Reading

Joseph Bertone in Tumors and Tumor Like Lesions of the Abdomen. in: Equine Geriatric Medicine and Surgery. Saunders Elsevier, St. Louis. 2006. Pp. 158-160.Yvonne Elce in Neoplastic Disease of the Gastrointestinal Tract. In : Current Therapy in Equine Medicine. Ed 6. Robinson, Sprayberry. Saunders Elsevier, St. Louis. 2009. Pp 448-449.Head, Else, Dubielzig in Tumors of the Alimentary Tract. In: Tumors in Domestic Animals. D. Meuten. Iowa State Press, Blackwell Publishing Company. 2002. Pp 158, 401-483.Jour, Mair, Hillyer, Taylor, Pearson. Primary

Epitheliotropic Intestinal T-cell Lymphoma in a Horse Journal of Veterinary Diagnostic Investigation March 1, 2002 14: 150-152

Taylor, S., Pusterla, N., Vaughan, B., Whitcomb, M. and Wilson, W. (2006), Intestinal Neoplasia in Horses. Journal of Veterinary Internal Medicine, 20: 1429–1436.

doi

: 10.1111/j.1939-1676.2006.tb00762.x

Slide37

Thank you to…

Pictures provided by: Melanie Spoor DVM Sean Spagnoli DVM Alison LaCarrubba DVM ABVP Philip Johnson BVSc MS ACVIM ECEIM MRCVS Mentors: Alison LaCarrubba DVM ABVP Martha Rasch DVM

Philip Johnson BVSc MS ACVIM ECEIM MRCVS University of Missouri College of Veterinary Medicine