Tied Up in Knots

We saw Bunny yesterday-she had been vomiting and not eating very well for about 2 weeks. No, bunny isn't a rabbit-she is a darling little wisp of a kitty, about 10 months old and ordinarily rambunctious and in to EVERYTHING as all good kittens are. She was sleeping a lot and wouldn't play with her beloved toys. Ordinarily a tiny cat, she was losing weight (and doesn't have it to lose.) In getting her history, we found out she was particularly fond of the Christmas tree and all the pretty packages with the shiny ribbons and all. More than once her owner had to take chewed up ribbons and strings away from her, but was very concerned she didn't catch her at some time and that she might have a piece of string, or maybe a toy or who knows what stuck inside her. Looking at how sick this cute kitten was, it sure was possible.

We took radiographs of her abdomen and ran some blood work. While there wasn't an obvious toy or piece of "something" present on the x-ray film, there was a distinctive "bunching" of the small intestinal loops that often happens when animals eat strings or ribbons or fishing line. Some gas was building up on either side of these bunched up gut loops, but there was, thankfully, no evidence of free fluid in her abdomen as there would be if she had large perforations or tears in her gastrointestinal organs. We sent the films to our radiologist for review, just like they would if they took x-rays of us.

Bunny's blood work came back this morning and it showed that she was low in her total protein, no surprise since she hadn't eaten in so long. Most concerning, however, was the elevation of her white blood cell count. Normal values are about 6 to 14,000-Bunny's were over 43,000! WBCs come about in times of infection or inflammation-perforation of the gut walls was looking more likely. The radiologist called this morning (he usually just sends a faxed report in the afternoon but knew there was a need for a "STAT" report in Bunny's case) and he concurred that she had evidence of a linear foreign body. He suggested giving her some contrast medium, barium, and follow it with multiple x-rays through out the day to see if it was obstructed in the region where we saw the bunching of intestines. When I told him about the elevated WBCs, he said doing an exploratory enterotomy (doing abdominal surgery to find out what was going on in there) was a smart choice, especially since it was a Friday and we are closed for the weekend. Why do animals always who have been sick for WEEKS get ready to die hours before we close for a holiday or weekend?

Linear foreign bodies (strings, fishing line, ribbons, etc.) are very attractive to cats-anyone who has tried to knit or crochet with cats in the house knows how "helpful" they can be, batting at your yarn, chewing on the end and making your project all spitt-y. My Stella has been incredibly lucky so far because she is obsessed about these things and I really have to string-proof the house. I have had to pull ribbon away from her on numerous occasions. What a brat.

The reason they are so dangerous is they often snag or get hung up at one end, the other end continues to travel through the GI tract, and this is what literally causes the bunching up of the intestinal loops. It can cut through the mesenteric border or the top edge where the connective tissue is located, making small perforations difficult to see, but causing leakage of intestinal contents into the abdominal cavity. This sets the cat up for peritonitis, a potentially deadly infection. We treated Bunny with two broad spectrum antibiotics, pain medications and placed an IV catheter for fluid support. Then we took her to surgery.

The first thing we did when we got her in surgery was to look under her tongue. Yes, her tongue. What in the world was I thinking? Well, cats who swallow string foreign bodies often hook the string under their tongue-that is why it catches and won't pass through the intestines in the first place. It cuts into the delicate tissue there and becomes buried, very difficult to see in an awake cat. Bunny wouldn't let me see under her tongue during her exam, either because she didn't like being messed with or because it hurt-and sure enough, there was a necrotic ring around the base of her tongue! We had our diagnosis, darn it. We dissected into this tissue and pulled out the thinnest, see-through thread you have ever seen. I have used thread like this, I think they actually call it "invisible thread" on sewing projects in the past. If we hadn't seen what the string foreign body looked like there, I don't know how we would have found it buried in those intestines.

I made an incision into her stomach and after a lot of searching, found the micro-thin thread, and put gentle traction on it. The mouth ends of the string came right out, but the end leading into the small intestine had too much tension and I was afraid that by pulling on it, I could pull it through the fragile tissues and cause a perforation. I sewed up this incision and made another one a few inches along the small intestine. I was able to get the stomach end out, but again, there was more tension where there was obviously more string in the bunched up intestines. I made a third cut into the small intestine and was finally able to remove what I hope is all of the offending string. I followed all of the intestinal tract a final time, looking for tears and any remaining bunching and none remained. There were many areas of small hemorrhages or bleeds where the mesentary or connective tissues join with the intestinal walls, but no overt leaking. We went ahead and spayed Bunny since she hadn't yet had this done, flushed out her abdomen and closed her up.

Bunny's recovery was surprisingly quick and uneventful-that is a good thing. Her body temperature never fell very low as it certainly could have due to the length of the surgery and the fact that her abdomen was wide open to the elements for a while. She had good pain medication before and after her procedure, so she didn't thrash around or act painful or scared. We will send her to a 24 hour hospital for monitoring over night and they will discharge her if there are no complications and she is eating OK. She is a young, healthy kitten and should do well, but this was a major procedure and you can't be too careful.

Bunny's owner will have to Bunny-proof her home all over again. All her sewing things will have to go up or into cabinets. It was a good thing there was no needle attached to the thread this time-I have seen that happen in other cats. Not good. Her owner has a toddler in the home and thought baby-proofing equaled kitten-proofing. Bunny has proven this isn't necessarily the case. We hope she has learned her lesson about strings, and tieing her intestines up in knots.

Peace,
DrReneigh