Saturday, November 19, 2011

Ruger's Ominous Mystery Illness

Ruger’s story began in April 2010 when he came into JVC (Jarrettsville Veterinary Center) because he had a decreased appetite and was vomiting. Ruger, a 7 year old Golden Retriever, is owned by two of the nicest people and they adore him. He is a 70 pound gentle, docile, affectionate boy. He is charming and irresistible.
On his first visit we treated him like we do many acute gastro-intestinal disease dogs. We took a full history, gave him a thorough physical examination, offered to run some basic diagnostics, (but didn’t force because he was “acute”) and treated conservatively with anti-nausea drugs, subq fluids, and gastro-protectants. Three days later his owners called back to say he had begun to vomit again and now his stool was loose. This time his owners elected to run the recommended basic diagnostics. 
We ran bloodwork, took x-rays, and went over the history again to make sure nothing had changed or been overlooked. This time we learned that his food had recently been changed, and he wasn’t on heartworm preventative. So we ran a heartworm test, it was negative, thank-goodness, and put him on a bland commercial diet. We also learned that Ruger had had seizures in the past. His bloodwork came back inconclusive (a nice way to say, thanks for paying for this but saddly it didn’t really help us get an answer). But a day later Ruger was feeling better.
10 days later and Ruger was back. OK detectives here where the years of sleuthing pay off! So let’s go back over his history so far. Because we now have all of the clues we need to help steer us in the right direction.
·         7 year old Golden Retriever; unfortunately for Goldens this is the time we start looking for cancer. These guys are cancer factories. They all die of cancer!
·         Waxing and waning disease. Big red flag. There is something going on. The dog knows it, so you better start digging, it is there lurking somewhere.
·         Vomiting and loose stool/diarrhea means you have something going on in the gut. These cases frequently wax and wane so take serial weights. The scale doesn’t lie. He was 70 pounds his first visit, 68 the second, and 64 the last.
He now needs to be watched very closely. Any small note of concern is reason for discussion with the Vet.
He returned 4 days later, now it was 2nd of May, with the complaint “still not eating or drinking.” His stools were getting even looser. His owners were offering anything and everything to peak his interest in food, but very little of the offerings were being contemplated or taken. We recommended they repeat the blood work and radiographs but they declined. (I think that initially this was acceptable to decline but now it should have been repeated. Just because the blood doesn’t indicate something on the first try doesn’t mean that it won’t later. I say this a lot; “Your body knows there is something wrong before the lab does.” Trust the dogs word over the labs!) We also recommended an ultrasound.
Ultrasounds are a much more sensitive way of looking inside the abdomen. Radiographs (slang = x-ray) are great for bone, but an ultrasound allows you to see the internal soft tissue architecture that is the contents of your belly. That’s why we use ultrasound for fetuses, and x-ray for broken bones.
The May 2nd examination also revealed a depressed and dehydrated Ruger. I think most people significantly underestimate how important good hydration is. A day of not eating or drinking normally or a few episodes of vomiting can cause significant dehydration. Once the dehydration snowball starts every hour makes it exponentially and significantly worse. This is why we Vets tell owners to bring your pet in when you call and tell us your pet has been vomiting and/or having diarrhea. The Vet who saw Ruger on this visit had only two rule outs for his possible diagnosis; gastrointestinal disease and cancer.
By May 5th  Ruger still wasn't eating or drinking. At this point everyone at the clinic was worried enough to start talking about referring Ruger to a specialist. This and repeating the bloodwork was declined. We also scheduled them for an ultrasound in 2 days, (the soonest we could get it) and we added medications for diarrhea. We offered to run the diagnostics as soon as the owners wanted. We received a few phone calls updating us on Ruger. He was doing better, eating better, and his owners believed he was back to normal: disaster averted, and ultrasound cancelled.
On May 20th Reuger vomited bile. His parents scheduled an ultrasound for ASAP, which was 5/25. The ultrasound finally hit pay dirt! Thank goodness, after all of this it was time to start finding a villain to point the finger at. The ultrasound found “the mid to distal (away from) small intestine revealed a significant infiltrative pattern with loss of detail, (something is there that is mucking up the normal architecture).. strongly suggestive of lymphoma or carcinoma (bad and worse cancer). Intraoperative ultrasound would be warranted." Another word’s the Internal Medicine Specialist reading the ultrasound thinks that the abnormal tissue won’t be seen grossly during an exploratory surgery. He recommends the surgeon be ultrasounding their way through the abdomen so we don’t miss the abnormal spot. Problem with that is it is waay expensive! I discussed the ultrasound findings and suggestions with Ruger’s parents and they decided to have me just go in and do the old fashioned exploratory surgery. (Ok time for my personal admission, I LOVE EXPLORATORIES! I love the whole treasure hunting, never know what your-gonna-find mystery, so fun I can’t even stand it!)
One big deep breathe and all doubts of ability cast aside the ext day Ruger was in surgery. I made my midline ventral abdominal incision and entered Ruger’s belly. Lucky for all of us I found a big abnormal mass in the area of the stomach. It was easily removed and Ruger’s worrysome surgery ended quickly and without fanfare. His intestinal culprit was put in a bottle and sent off to be fixed in formaline, shaved into little slivers, and scrutinized under a microscope. 5 days later we had a diagnosis for Ruger. It was lymphoma. His biopsy report read “intestinal mass: malignant lymphoma..the long term prognosis is poor.” With these words Ruger was taken to an oncologist for a treatment plan and a miracle.
Getting the already not eating Ruger to eat after having been opened and explored was not happening. He protested for days, and refused every morsel offered. We were also struggling with keeping his total protein, (specifically albumin, the tiny very important vital to life protein so that your blood actually stays in your vessels) in the normal range. He became so weak and lifeless that we were forced to give him a plasma transfusion. As happy as I was to have a diagnosis I was concerned I might lose my patient before we got to the treatment part. Even with the transfusion he wouldn’t resume eating. So we turned to drugs, and within a day those drugs had him eating. Ruger took his second wind and ran. He did great for a month. During this time he started his chemotherapy and we all regained our hope for his recovery and conquest of cancer. Because he was doing so well and because there are detrimental adverse effects to long term drug use we started to taper his drugs. But unfortunately as we started to taper him off of these drugs he started to turn his nose up to his food. Within a few days we ended up right back at transfusions and those same steroids and appetite stimulant drugs.

Ruger spent his last three days at the emergency hospital. They were suggesting he continue with the transfusions. His parents called me in deep despair seeking advice for what they should do. I knew by their voices that they wanted Ruger to be cured, but understood he wasn’t going to be. They wanted someone to give them advice based on what was right for Ruger and not what was right for the cancer. I told them that Ruger had given up a long time ago, and that keeping him alive in a hospital wasn’t what he wanted. He was weak, and tired and ready. They were so grateful for the permission to let him go. They just couldn’t say it and they didn’t want to admit it.
There were many conversations exchanged between us after Ruger passed. There were words of sorrow, acceptance, and grief, and many, many tears. I was sad to say goodbye to Ruger, but I was more saddened by the thought of not seeing his parents, or worse yet, not seeing them and knowing that they didn’t want to love another dog, or love anything again, because it hurts too much to lose a pet.
A few weeks later Ruger’s dad came in with an eight week old Golden that they named Timber.
Oh, Timber, you are another story! Cutest puppy ever, but his story, that’s another tale of drama and…oh, its too good to leak..stay tuned!

1 comment:

  1. My condolences to Ruger's people. They obviously loved that dear dog.

    Glad to hear they have opened their hearts to a new joy in life, Timber.