A challenging case: Acute-on-chronic vomiting in a German shepherd - Veterinary Medicine
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A challenging case: Acute-on-chronic vomiting in a German shepherd
These clinicians discover that this dog's history of chronic vomiting was disguising a serious underlying problem.


The incision in the esophagus was closed in a two-layer, simple continuous pattern with 3-0 polydioxanone suture. An incisional gastropexy at the level of the pyloric antrum was performed to attach the stomach to the right body wall with 0 polydioxanone suture. The abdominal and thoracic cavities were copiously lavaged with 0.9% sterile saline solution. The diaphragm incision was closed with 0 polydioxanone suture in a simple continuous pattern. An enterostomy tube (8-F infant feeding tube) was placed aborally in the proximal jejunum. A 24-F thoracostomy tube was placed at the right eighth intercostal space. The abdomen was closed in a routine manner.


After surgery, the dog received nasal oxygen insufflation (5 L/min), cefazolin (22 mg/kg intravenously t.i.d.), enrofloxacin (10 mg/kg intravenously once daily), famotidine (0.5 mg/kg intravenously b.i.d.), and sucralfate (1 g orally t.i.d.). The fentanyl infusion was continued for 24 hours. The lidocaine infusion was also continued for 24 hours for its anesthetic and prokinetic effects. Continuous telemetric monitoring was performed, and no arrhythmias were noted. The chest tube was aspirated every four to six hours. The dog recovered well from surgery and was bright, alert, and normothermic the next day. The urinary catheter placed after surgery was removed the next morning.

Twenty-four hours after surgery, one-fourth of the patient's required caloric intake was calculated for CliniCare Canine/Feline Liquid Diet (Abbott Animal Health) and was fed through the jejunostomy tube as a continuous rate infusion. The fentanyl and lidocaine infusions were discontinued. Pain was controlled with morphine (0.5 mg/kg subcutaneously q.i.d.).

Forty-eight hours after surgery, the dog remained bright, alert, and normothermic, and we removed the chest tube because only a small amount of fluid had been removed. The liquid diet continuous rate infusion was increased to half the required daily caloric intake.

Three days after surgery, the dog was still bright and alert but had vomited blood (not regurgitated) several times and had a temperature of 103 F (39.4 C). Our differential diagnoses for the recurrence of vomiting and the pyrexia were gastrointestinal necrosis, infection, sepsis, and pneumonia. We instituted an intravenous continuous rate infusion of metoclopramide (0.05 mg/kg/hr).

Figure 5
Four days after surgery, the dog's vomiting frequency increased despite the metoclopramide, and the dog's temperature increased to 104.2 F (40.1 C). Our differential diagnoses were pneumonia, sepsis, gastrointestinal necrosis, and leakage. Thoracic radiography (Figure 5) revealed an alveolar pattern most consistent with bronchopneumonia in the left cranial, right middle, and right cranial lung lobes. The severe megaesophagus was still evident in the cranial thoracic esophagus. Results of a complete blood count (Table 1) showed a leukocytosis, neutrophilia with a regenerative left shift, mild lymphopenia, and a monocytosis. Abnormal results of a serum chemistry profile (Table 1) included hypoproteinemia, hypoalbuminemia, hypocholesterolemia, and decreased alanine transaminase and elevated alkaline phosphatase activities. We considered measuring serum acetylcholine receptor antibody concentrations because myasthenia gravis can cause megaesophagus, but we elected not to because of the dog's declining condition and the time needed to receive the results.

At this time, we thought the dog had aspiration pneumonia associated with megaesophagus. We recommended performing a transtracheal wash and bacterial culture, but the owner declined. Our treatment for the patient's aspiration pneumonia included nasal oxygen (5 L/min), nebulization of saline solution, coupage every four to six hours, and antibiotic therapy. We increased the frequency of enrofloxacin administration (10 mg/kg intravenously b.i.d.). Since the dog was not improving with the cefazolin therapy, we discontinued it and began ampicillin therapy (24 mg/kg intravenously t.i.d.).


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