Mikey's Big Spleen

Mikey wasn't feeling well. (Isn't that usually why critters come for a visit to the vet?) His owner said he just wouldn't eat, he was restless, acting like he couldn't get comfortable, and he was kind of crab-walking-hunched up and walking almost sideways. More importantly, he was hurting somewhere-he was crying when he was touched, even just lightly petted. Being part German Shepherd, he isn't known for being an overly brave dog (oops, I'm perpetuating a stereotype here, but it is silly how those fierce-looking, big, sturdy dogs can also be the biggest wimps!) When I saw Mikey, I quickly discovered this wasn't him just being wimpy. He didn't cry when I palpated his neck or spinal muscles or examined his legs, but he cried loudly when I barely touched his ribcage and belly.

Mikey's owner was pretty sure he wasn't the kind of dog to eat something he shouldn't have like a stick or rock or something, but an intestinal or gastric (stomach) obstruction and maybe perforation certainly could cause these symptoms. Pancreatitis or inflammation of the enzyme-secreting pancreas can often be very painful and very serious. Mikey was getting to be an older dog, so neoplasia or cancer had to be considered, too. He was just too painful for me to palpate or put pressure on both sides of the abdomen and feel for abnormalities, so we decided to run some blood work and do some abdominal radiographs. I didn't see any obvious obstructions or a large volume of free fluid on the x-rays, but he was a big dog and I felt he could be hiding things pretty easily-we sent the films to the radiologist for review. Since he hadn't been drinking well, Mikey was a little dehydrated. We gave him some fluids with electrolytes under the skin to tide him over until we could get some test results back and sent him home for the night. Fluids alone often make many ill pets feel better right away. This wasn't the case for Mikey.

The next morning we had the blood results back-there was a very minor anemia and that was all. The rest of his blood work was essentially normal. This is good news, but frustrating since, when we called to check up on our patient, Mikey was even worse, and we had no real answer. I did not feel that the degree of anemia was enough to be causing his extreme symptoms, but it was leading us in the right direction. We called the radiologist and put a "STAT" on his report; we ordinarily close early on Wednesdays and didn't believe he could wait for answers. Mikey's owners were very worried, so we had them bring him back in to the hospital while we waited for test results. We wanted to start him on IV fluids and pain relief medications at the least.

Dr. Root, our radiologist, called right away. He thought there might be some loss of detail in the abdomen which can be a result of free fluid or motion from breathing efforts. He thought the spleen looked enlarged, and when he learned of Mikey's symptoms, especially the extreme pain, he thought peritonitis or infection in the abdomen was possible. Dr. Root believed Mikey was a good candidate for an exploratory laparotomy-a surgery to open up the belly and go search for the cause of the problems. I really like exploratories because along with discovering the cause, I am always hopeful that we will find a "cure" as well, something to fix or remove to alleviate the pain or the cause or source of the infection, tumor, or swallowed thread as happened to Bunny a few weeks ago. I decided to get another piece of information first-to find out if there really was fluid in the abdomen, and if so, what type. Mikey's belly felt fuller today and had a "wave" feel to it. Peritonitis can have purulent fluid, pus, bacteria and white blood cells. An enlarged spleen could be due to cancer and rupture of a tumor, therefore blood was a likely fluid. Organ dysfunction can cause clear white or straw colored fluid. We made a quick prep of Mikey's belly and a thin needle was inserted in the caudal abdomen so as to try and avoid hitting the enlarged spleen itself. There was pure blood-a lot of it. We took some quick x-rays of his chest to rule out obvious metastasis or spread of cancer to the heart or lungs, and these appeared fine. Mikey was going to surgery.

It was unlikely given his symptoms that Mikey's bleeding happened suddenly. Since his body has sort-of acclimated to it, he wasn't in immediate need of a blood transfusion from a donor dog. This could change, of course, given the type of surgery I was anticipating, a splenectomy. The spleen is a highly vascular organ, comprised of lots of winding blood vessels and packed full of blood cells. In fact, it acts as a reservoir of blood cells, there to be "squeezed" out in times of need, such as when blood is lost if a dog is hit by a car. The spleen also filters the blood, removing older red cells from circulation, ensuring only vital, healthy red cells that can carry oxygen are cycled through. The spleen also removes parasites that might be present in red cells or entire cells if they are diseased. It also acts as a lymphatic organ, draining material from local areas of the body to the regional "lymph node-like" spleen, stimulating it to react or swell along with the rest of the immune system and the antibody producing lymphocytes. Now, Mikey would also have plenty of red cells in his bone marrow-he could do just fine without his spleen if it was found to be diseased, cancerous and/or hemorrhaging. It would just be a big stress to his body to remove it, and thus the potential need for a transfusion.

When I first cut into Mikey's abdomen, I realized he had been bleeding much more over night than the x-rays taken just yesterday had shown. Blood literally flowed out of the first small incision. I attempted to hold the edges up and contain the blood and instructed my nurses to collect it in an aseptic (very clean) manner, thus allowing us to perform an autotransfusion-we were going to give the blood right back to Mikey, but we were going to put it back where it belonged-in his veins. It took numerous syringes and 2 large collection bags with anticoagulant in them, and my fingers were stressed to their limits holding his abdominal wall edges up and open to keep the blood from spilling out while we collected it. The entire time we also monitored his anesthesia levels, blood pressure and oxygen carrying capacity-he did great! The collected blood was then put through filters before it was given back to him, slowly at first to be sure there would be no reaction. His hematocrit or packed cell volume, the percentage of blood cells in relation to the fluid portion of blood, never wavered during the day-this autotransfusion seemed to be a success.

Mikey's spleen was, indeed, really big. More importantly, it was covered in purple to black, ulcerated and bleeding various sized masses all over the spleen as well as through out the omentum supporting the organ. This is a common finding when the nodules have ruptured and blood clots or cells have spread, possibly metastasized. You can't know just by looking which this is, clots or metastatic disease, but I did my best to remove all affected tissue, knowing microscopically this wasn't likely. I knew that to have a chance, Mikey had to stop actively bleeding, so removing the source was necessary. We were set up to biopsy the tissues and then consult with oncologists for further plans to combat the cancer if that was the final diagnosis. The spleen was taking up a lot of space so it was difficult to visualize the rest of the abdomen clearly; I did find a large mass on a liver lobe-not good. It was the same color and texture as the splenic nodules-and it peeled away from the liver tissue, leaving an oozing crater. I used some hemostatic "styrofoam" to plug up the hole, but advised the owner by phone of the problem and the seriousness of the likely spread of the disease. She understood the situation and elected to be as aggressive as we could be right now-it was likely the only chance to save his life.

I mentioned how vascular the spleen is inside-well, it is just as vascular on the outside. Many large, tortuous vessels supply and drain the organ and the affected omentum, so I did quite a lot of ligating. When it was removed, the abdomen looked so much happier! Apart from the single liver mass, there was no other obviously affected organs. I took samples for microscopic examination to confirm this, but with no more bleeding and no distorted, tumorous masses, Mikey's belly almost looked-normal. I sutured his abdomen closed in 3 layers and we woke him up.

Because of his good pre-operative analgesia or pain relief medications, Mikey woke up very smoothly-quiet and comfortable in his warmed blankets. He had received all of his own blood and some additional IV fluids for support, as well as some prophylactic antibiotics. We helped his owner transfer him to her car so she could take him to the 24 hour care facility; after going through such a major procedure I didn't want him spending the night by himself, even if I could look in on him frequently. I knew he would be in far better hands having a critical care doctor on hand through out the night. My staff wrapped up everything after staying late for Mikey today. They knew how important this was to Mikey and his very scared owner, and to me to be able to provide this service for them. I couldn't have done it without their dedication and kindness in giving up their only free afternoon this week. Way to go Amber, Kayla and Terra. You are awesome nurses.

We aren't out of the woods yet. Mikey needs to get eating and drinking again and we have to be sure all the bleeding has stopped. Then, of course, we have to wait on the pathology report to identify the source of the masses. It is very likely they are a hemangiosarcoma, the malignant neoplasm of blood vessels. We could get lucky and the diagnosis could be hemangioma, the benign form. We will consult with the veterinary oncologists once we have the diagnosis and work together on the next step of his treatment plan. I have said more than a few prayers for Mikey and his owners, asking that he recovers quickly and that his owner can rest well knowing she has done everything possible for her friend in a really crummy situation. He is so well loved-that, and a belly free from a big bleeding spleen, is all that he needs tonight.

Peace,
DrReneigh