This is my "trust and audit" case study of veterinary surgery performed at Toa Payoh Vets.

A vomiting female dog. Gastritis or closed pyometra?

Miniature Schnauzer, Female, 8 years, not spayed consulted my associate vet (Vet 1).  An old client of mine but I had not seen the dog for the past 7 years since the puppy vaccination. This is a common situation as the owner might have gone to other vets or just left the dog alone.

August 11, 2012
According to Vet 1's medical record, the dog was presented for vomiting several times, abdominal distension was noted and "suspect pyo" was recorded. Blood test was recorded but the total white cell count and neutrophils as "moderately" increased. Vet 1 advised spay.

The dog was warded for 3 days and treated. Vomiting disappeared on the 3rd day and the owner (Sister 1) wanted to take the dog home on August 14.

August 15, 2012
I was at work in the evening of August 15 and saw Sister 1 entered the Surgery with the dog. She said: "My dog is still vomiting." I checked Vet 1's medical records and examined the dog. I put her on the consultation table, palpated the swollen abdomen in the presence of Vet 1.

The dog gave a yelp as I palpated. "There is a swollen abdomen which is also painful," I said. "The total white cells of 22.4 (normal 6-17) is high. The neutrophils are 96.3% which indicated a bacterial infection as normally they are around 70%. Based on my findings, this dog is suffering from closed pyometra. An X-ray may confirm pus in the uterus, but it is not needed unless you want it done."

Vet 1 said; "It is better to get an X-ray done to rule out any foreign bodies inside the stomach or intestines as the one of the owners (Sister 2) had said that the dog ate some things." The owner gave permission for the X-rays.

August 16, 2012"How's the X-ray?" I asked Vet 1. "Does it show pyometra?"
"There is a lot of gas," Vet 1 did not think there was pyometra. "In any case, the owners agreed to the spay."

I saw Sister 1 in the evening at around 7.30 pm. She said: "Now the dog is eating and there is no vomiting, it will be better for the operation tomorrow since it is already late."
"We can still do surgery even at 8 pm," I said.

August 17, 2012The dog was operated. The dog's uterus was full of pus. So far, so good today August 17, 2012. The dog was on her chest and looking around. If vomiting returns, this will be bad news as the kidneys could have been severely damaged.

Conclusion
Time is of the essence in closed pyometra cases as toxins are being absorbed into the blood stream from the swollen uterus. The antibiotics given killed some bacteria and stopped the dog vomiting. So Sister 1 wanted the dog home.

But the toxins are not expelled as the cervix has closed. So the dog starts vomiting again. Toxins damage the kidneys and liver if the owners delay surgery further. Some older baby-boomer generation would prohibit surgery thinking that the dog would die or was just having some food infection. The  younger generation is much more sophisticated and educated and that was why this dog came in for diagnosis and treatment.

The dog owners need to be properly educated and given clear communications. "Vet 1 says 'suspect pyometra'", Sister 1 remarked to me when I reviewed her case on Day 3 when she returned with the dog that had started vomiting again.

Since the dog had stopped vomiting after 3 days of hospitalisation, she wanted the dog home.
Vet 1 should have advised X-rays or ultrasound during the 3 days of hospitalisation but this was not done as the mis-diagnosis was gastritis, in my review of this case.

The vet must be spot on in his or her diagnosis of closed pyometra based on history of heat around 6 months ago in around December 2011. In this case, Sister 3 said the heat was in Feb or March 2012 throwing Vet 1 off the closed pyometra diagnosis and thinking of gastroenteritis.

VOMITING
An older unspayed female dog.
A swollen painful abdomen
A high total white cell count with high neutrophils and low platelet count
are clues to a tentative diagnosis of CLOSED pyometra. It is an emergency.
 

Gastritis cannot be ruled out and that was why Vet 1 advised the X-ray and saw "lots of gas" in the intestines. Vet 1 said there were no signs of pyometra. Each vet has his or her own opinions but the confirmation is during the spay. The closed pyometra was large and in retrospective review of the X-ray, you could see the swollen uterus.

DIAGNOSIS OF CLOSED PYOMETRA
Vomiting is a common complaint in private practice in Singapore's older female dogs. However, based on abdominal distension and pain on palpation in the lower posterior 1/3 of the abdomen and the blood tests of increase in total white cell count, a history of recent estrus and the age of the female dog, the tentative diagnosis is closed pyometra even if no X-ray or ultrasound is done. The differential diagnosis is acute gastroenteritis but this condition is less likely in this dog.

The vet must not confuse the average owner with the wording "suspect pyo" as owners don't know the severity of this closed pyometra situation which could kill the dog if surgery is delayed. "Suspect pyo" to the owner means that the vet does not know it is pyometra or not.  

P.S. The dog was operated by Vet 1 and recovered. On Saturday, August 18, 2012, I was at the Surgery in the morning. The mother came to visit the dog. The 3 sisters also came. The dog was warded for 5 days because there was a very low platelet count and much bleeding during the surgery. "Your dog has a normal pink tongue colour and no longer vomits," I said to the sisters. "She has a high chance of survival."

This case required Vet 1 to use 3 packets of Monosyn sutures as there was "much bleeding" during removal of the infected uterus. As I had not seen the operation, I would not know how bad the bleeding was. Low platelet counts would be the cause of this profuse bleeding during surgery.  Usually I use one packet or two at the most for surgery of closed pyometra in a Miniature Schnauzer. 
 

COMPLICATIONS OF SURGERY
However, the intestines were seen dropping out of the opened surgical wound around the 7th day after surgery.  Infection is one known complication of any surgery for any veterinary surgeon. In this case, there was peritonitis. The stitches broke down and the intestines came out. The dog was re-stitched and the peritonitis cleared. The dog recovered and went home.

CONCLUSION
Spaying the dog when she is young would have eliminated the worries and risks of closed pyometra surgery. The pus produced toxins and the bacteria inside the uterus multiplied. Some pus and bacteria might have leaked out from the weakened walls of the uterus, causing peritonitis. This was one possibility as surgery was delayed for many days. The delay was due to Vet 1's "suspect pyo" differential diagnosis and the vet's favoured diagnosis of gastro-enteritis since the dog owner's could not give an accurate account of the onset of estrus. The dog recovered and went home. She could have died and the owners would not be happy.     

For dogs vomiting, gastro-enteritis is usually the first diagnosis and X-rays are seldom taken. This dog was hospitalised for 3 days and the owner took her home since the "vomiting had stopped."  Unfortunately, the vomiting recurred and so there was a delay in finally doing the closed pyometra surgery. Delays in surgery can be fatal to the dog. It is up to the owner and the vet to agree to an early surgery but in this case, there was no clear diagnosis of closed pyometra from Vet 1 due to conflicting histories of heat and causes of ingestion of inappropriate food from the 3 sisters.

September 9, 2012.  In this case, there was a happy ending as the dog is in good health now. I saw her on Sunday Sep 9 as Sister 1 brought her in for stitch removal by Vet 1. She told me she was not well as I noted that she was not her usual bright cheery self. There was a rise in flu cases in Singapore in August 2012 as reported by the newspapers interviewing general practitioners.

 "Where are the other two sisters?" I asked her. "Sleeping at home," she said. She was most happy that her dog had fully recovered as closed pyometra dogs do die during or after surgery if there was a delay or rupture of the swollen uterus.