Sam, a 5-year-old 54.3-lb (24.7-kg) male golden retriever, was presented for evaluation of a four-week history of intermittent
vomiting and anorexia, mild lethargy, and dark stools.
This hunting dog was adopted as a puppy. His initial growth was slower than his littermates' growth. When Sam was 1 year old,
a jejunal resection and anastomosis was performed to correct a congenital stricture.
Physical examination and initial diagnostic tests
At presentation, Sam's temperature was 101.9 F (38.8 C), pulse was 100 beats/min, and respiratory rate was 24 breaths/min.
His mucous membranes were pale pink and moist with a capillary refill time of < 2 sec. The rectal examination revealed soft
stool that was slightly dark in color. Abnormal initial laboratory findings are listed in Table 1.
Table 1: Abnormal initial diagnostic test results
Additional diagnostic tests
No eggs, larvae, or trophozoites were found by using fecal sedimentation. The abdominal ultrasonographic examination revealed
mild thickening of the gastric mucosal layer but no other significant findings. Sam's serum iron and ferritin concentrations
were low, and total iron-binding capacity was increased (Table 2).
Table 2: Iron profile
A 250-ml packed RBC transfusion was administered, which raised the patient's packed cell volume to 33%. Gastroduodenoscopy
was performed. No gross abnormalities were detected. Biopsy samples were collected from Sam's stomach and duodenum.
On exploratory laparotomy, Sam's organs appeared grossly normal. The site of the previous jejunal resection was identified.
No lesions were noted on the serosal surface (Figure 1). This area was excised, and a new anastomosis was created. When opened, an area of ulcerated mucosa was evident (Figure 2).
1. Intraoperative serosal surface of the previous jejunal anastomosis. (Image courtesy of Dr. Kelley Thieman of Texas A&M’s
College of Veterinary Medicine and Biomedical Sciences.)
Histologic examination results of the gastric and duodenal specimens were unremarkable. Jejunum at the site of the previous
anastomosis contained a focal mucosal ulceration and partial-thickness defect lined by inflamed granulation tissue and small
2. Mucosal surface of previous jejunal anastomosis. (Image courtesy of Dr. Kelley Thieman of Texas A&M’s College of Veterinary
Medicine and Biomedical Sciences.)
Sam was treated with a single intramuscular injection of iron dextran (13 mg/kg) followed by two months of ferrous sulfate
(250 mg orally once a day). Follow-up diagnostic test results showed a normal packed cell volume (43%), a normal mean corpuscular
volume (68 fl), and an improved mean corpuscular hemoglobin concentration (36.6 g/dl).
This case is an example of IDA secondary to chronic GI blood loss. Although the initial laboratory findings were highly suggestive
of chronic hemorrhage and confirmed iron deficiency, the cause of the blood loss was not easily identified.
Minimally invasive diagnostic tests, including abdominal ultrasonography and gastroduodenoscopy, failed to identify the source
of hemorrhage. This case highlights the role of an exploratory laparotomy in the work-up of chronic intestinal bleeding and
the limitations inherent in examining only the serosal surface of the bowel.
The decision to resect the previous surgical site was appropriate and was made because no other abnormalities were evident.
Although the underlying cause of the defect at the previous anastomosis is unknown, Sam did well after this surgical resection
and iron supplementation.