Repeat abdominal ultrasonography
After the exploratory laparotomy, the dog continued to vomit at least six times a day. Four days after surgery, the dog also
developed signs of acute abdominal pain. However, the dog's vital parameters remained normal (temperature = 101.3 F [38.5
C]; pulse rate = 120 beats/min with a strong pulse; respiratory rate = 36 breaths/min). A repeat abdominal ultrasonographic
examination revealed a fluid-filled hypomotile stomach, an enlarged and hypoechoic pancreas, and hyperechoic peripancreatic
fat (Figure 1). The enlarged hypoechoic pancreas and the hyperechoic peripancreatic fat were consistent with pancreatitis.1,2
Figure 1. An abdominal ultrasonogram of the dog's pancreas four days after the Billroth I procedure. The pancreas is enlarged
and hypoechoic, with surrounding hyperechoic fat.
Cytology and serum cPLI assay
Aspirates of the pancreatic region were obtained, and a cytologic examination revealed marked suppurative inflammation with
no etiologic agents identified. A blood sample for a serum canine pancreatic lipase immunoreactivity (cPLI) assay was collected.3 Serial serum chemistry profiles and complete blood counts revealed a rising serum alkaline phosphatase (ALP) activity and
marked mature neutrophilia but no other abnormalities. The serum cPLI concentration was 388 µg/L (reference range = 2 to
102 µg/L; concentrations greater than 200 µg/L are considered diagnostic for pancreatic inflammation).4
The day after the ultrasonographic examination, the dog was anesthetized again for a gastroduodenoscopy to assess gastric
emptying and a laparotomy to place a jejunostomy tube for nutritional support. Gastroscopy revealed fluid in the stomach but
a normal-appearing gastric mucosa. The pyloric antrum appeared swollen, but an 8.5-mm endoscope was easily passed into the
duodenum, indicating that the pyloric obstruction had been successfully relieved. The entire pancreas appeared swollen and
firm (Figure 2), and multiple adhesions were noted between the small intestine and the greater omentum. The previous Billroth I surgery
site appeared to be healing appropriately. An 8-F jejunostomy tube was placed in the proximal jejunum, and the site was sutured
to the body wall.
Figure 2. The pancreas during a laparotomy five days after the Billroth I procedure. Note that the body and right limb of
the pancreas appear red and swollen.
To calculate the resting energy requirement (RER), we used the formula: RER (kcal/day) = 70 (BWkg)0.75 . We initially fed the dog 25% of its RER and planned to increase the amount gradually over the next three or four days until
the RER was met. A constant-rate infusion of liquid elemental nutrition—a mixture of Vivonex T.E.N. (Novartis Medical Nutrition),
8.5% Aminosyn II (Abbott Laboratories) solution, B vitamins, and water—was administered. We administered crystalloid fluids
supplemented with potassium chloride to maintain venous access and to meet maintenance fluid requirements until enteral feeding
reached the RER.
CONTINUED CARE AND MONITORING
The dog continued to vomit several times a day, despite receiving ondansetron (0.5 mg/kg intravenously b.i.d.), and also developed
profound diarrhea. To allow the dog's gastrointestinal tract more time to adjust, we did not increase the enteral nutrition
amount to the RER. We instituted peripheral partial parenteral nutrition to help meet the dog's caloric requirements.