Noodle – Something to get off my chest!

Noodle, a 5 year old Labrador Retriever was referred to Northwest Veterinary Specialists (NWVS) from his primary vet due to a persistent cough, that did not resolve even following a course of antibiotic treatment. Although Noodle was still a typically happy Labrador who always wanted to play, the cough began to take its toll and Noodle was beginning to feel its tiring effects. Noodle came to NWS for a consultation with one of our internal medicine clinicians, Karen Crawford. On physical exam there was noticeable effort in how Noodle was breathing and when Karen listened to his lungs, there were notable abnormal sounds. Noodles cough was described as harsh sounding, deep within his lungs, which worsened with exercise.

Following consultation, it was unquestionable that Noodle required a Computerised Tomography (CT) scan. A cannula was placed for easy drug administration and blood samples were taken to check his liver and kidney function. A CT scanner works in a similar way to an X-ray machine, but coupled with a computer, it rotates around the patient to create cross sectional images of the selected part of the body, in this case, Noodle’s chest. The computer then reconstructs the images to create a 3D image, which we hoped would help diagnose why Noodle had a cough. In order to perform the scan, Noodle had to have a general anaesthetic (GA). In his case the risks were higher than any elective procedure due to his impaired breathing ability. Every pet that undergoes GA at NWS is monitored closely by one of our Registered Veterinary Nurses (RVN) from the start, right through to the recovery period and supervised by our specialist anaesthetists. During GAs our RVNs remain in direct contact with the anaesthetist overseeing the case to ensure that the best possible care is provided. The standard monitoring used during GA is capnography, pulse oximetry, blood pressure monitoring, ECG and temperature. In Noodle’s case particular focus was given to the first two monitoring aids as they show how the lungs are ventilating and getting oxygen into the blood stream, both of which were within the normal ranges.

The CT images were analysed by one of our Radiologists Annette Kerins and after close examination she discovered a large foreign body (FB) in one of the right lung lobes, with a surrounding area of pneumonia. We were positive that this was the cause of Noodles cough, so further investigation and treatment was essential. A common way of retrieving FB’s within the airway is with a bronchoscope (a camera into the lungs via the mouth) but in Noodle’s case this did not seem feasible because the FB was too deep and seemed to be wedged within the bronchus. Therefore we concluded that it could not be reached, and even if we could, we would most likely damage the bronchial wall during our attempts.



In such cases the medical and soft tissue teams join together to work out the best approach for the patient. Following much debate and due to the location of the FB, it was agreed that the most likely way of retrieving the FB was with surgery. Further discussions outlining the positives and negatives took place and both teams decided the best approach would be to perform a lung lobectomy (removal of the entire lung lobe which housed the FB).

Noodle was transported to the surgical preparation room, an area connecting to the surgical suites where patients are clipped and scrubbed before surgery. A lung lobectomy can be a rather painful surgery, so pain relief was a priority for Noodle at this stage. To begin with, Noodle received a schedule 2 opioid, the strongest class of pain relief available for our patients. Once his fur was clipped and skin scrubbed, Noodle then received two types of local anaesthetic techniques from our specialist anaesthetist, Elizabeth Leece. This reduces and potentially blocks pain sensation, not only during surgery but also during the first couple of hours following surgery.

Noodle went to surgery with soft tissue specialist Rachel Burrow. During the surgery, Rachel opened the chest cavity (thoracotomy), and Noodle was place on mechanical ventilation to breathe for him as the surrounding pressure that helps him breathe was lost. After 2 hours of intense surgery the lung lobe was removed successfully. A chest drain was placed to avoid any air or fluid accumulating in the chest which may have impaired Noodle’s ability to breathe following surgery. The chest was sutured and once surgery was complete Noodle was transported to the recovery area to wake up in a warm, quiet environment. Once Noodle was recovered, our attention turned to the lung lobe. Careful dissection reveal a large ear of wheat, measuring 5.6CM, which Noodle must have inhaled when running through a field. This would have gradually tracked deeper in the lung, pretty amazing.



Whilst hospitalised overnight, hourly observations took place focusing on Noodle’s respiratory rate and effort. Noodle remained hospitalised for 5 days under the care of our Inpatient Care Team who frequently monitored his respiratory function. Following plenty of TLC and medication, Noodle was discharged, happy (as always) and cough free.

Following his check-up appointments, Noodle has continued to improve and is now back to full health.

This case report was written by Ana Mota an Intern at NWS.

Smokey the survivor!

Smokey, a much loved 9 year old cat, was taken to see her local vets in January after her owner noticed that she had lost weight despite having a very good appetite. When Smokey was examined, her local vets found a large mass in her abdomen and promptly arranged referral to Northwest Surgeons to see Internal Medicine Clinician Karen Crawford.Smokey Potts 1

During Smokey’s initial consultation with Karen her owner reported that over the two days since the mass was diagnosed, Smokey had been quieter than usual and had lost interest in food. Nonetheless when Smokey was examined here, she was still fairly bright and showed no sign of discomfort – as we later found out, she was a very brave cat!

Experience tells us that possible explanations for Smokey’s weight loss and the abdominal mass included neoplasia (cancer), an abscess, or granuloma (a collection of inflammatory tissue which can result from infectious or non-infectious causes). After some blood tests to assess Smokey’s general health and to test she was free from typical cat viruses (FIV and FeLV), she was quickly prepared for an ultrasound scan.

Ultrasound showed a mass in Smokey’s intestine. Smokey had arrived at Northwest Surgeons just in time – there was free fluid and free gas in the surrounding abdomen showing that the mass had ruptured! This perforation in Smokey’s intestine was allowing gut contents and bacteria to leak out into the abdomen resulting in a life-threatening septic peritonitis. A sample of the fluid confirmed this and showed large numbers of bacteria. If Smokey was to survive she needed surgery straight away!

The prognosis for pets with septic peritonitis is always guarded and the mortality rate can be high, but despite the risks Smokey’s owner was keen to give her every chance. As soon as we had the go ahead, Smokey was clipped, scrubbed and taken to theatre by our soft tissue surgery specialist, Prof. John Williams. Her anaesthesia was supervised by specialist Georgie Herbert.

There was gross contamination of the entire abdomen with intestinal contents and a large, ruptured tumour was found at the junction between the small and large intestine. Thankfully the tumour was removable. The ileum (the lower part of the small intestine) and part of the large intestine had to be resected (removed) and the healthy ends of intestine sutured together (anastomosed).

Intestinal surgery always carries a risk that, if the surgical site does not heal well and dehiscence (wound breakdown) occurs, gut contents and bacteria can once again leak out into the abdomen causing septic peritonitis all over again. In Smokey’s case so much intestine, including the junction between small and large intestine, had to be removed that if she survived she was also likely to have diarrhoea on an ongoing basis. Smokey returned to the cat ward to recuperate in the hands of our team of round the clock nurses.

As it turned out, Smokey was a bit of a tough cookie and the day after surgery she was much brighter, seemed comfortable and had started to eat well. She even passed normal stools, with no evidence of diarrhoea! Within 4 or 5 days she was back to her normal self, demanding lots of fuss and attention from everyone who visited her in cat ward. She had made such good progress that she was ready to go back home.

Removing all of the ileum at surgery meant that Smokey would no longer be able to absorb vitamin B12. This vitamin is needed for many processes in the body and is important for nervous system function, bone marrow function and gut health. We arranged for Smokey to have regular injections of this vitamin at her local vets to make sure no signs of deficiency could develop.

The removed section of intestine was submitted to the laboratory for analysis. The results gave a diagnosis of intestinal lymphoma, one of the most common cancers in cats. After speaking with our oncology consultant we recommended a course of follow-up chemotherapy for Smokey. Smokey’s local vets were happy to carry out this treatment and so far she is responding very well – a great outcome for this lovely little cat!

Lilly – the Foxhound with a very unusual lameness

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Lilly, a 4 year old Foxhound first became unwell in December, shortly after the other dog in the household had sadly died. At first her owners thought Lilly might be missing her old friend but they soon noticed that poor Lilly was lame and that all four of her legs were swollen.

Lilly was treated for suspected immune-mediated polyarthritis (IMPA – a condition where the pet’s own immune system attacks the tissues in the joints and causes lots of inflammation) but despite using multiple medications she remained lame and was very lethargic. When she didn’t improve and the swelling got worse she was soon referred to the internal medicine service at Northwest Surgeons.

When she arrived Lilly was very quiet and subdued. Her owners felt her appetite hadn’t been good since she became unwell and Lilly had lost a significant amount of weight. Most importantly though, when I examined Lilly there were a couple of clues that gave me some idea of what might be going on – the swelling in her legs actually seemed to be affecting the bones rather than the joints, and she had also developed quite a nasty cough! Together, these signs were suspicious of a condition called hypertrophic osteopathy or Marie’s disease, a debilitating disease where bony swellings develop secondary to disease elsewhere in the body, often in the lungs.

Lilly was admitted for further investigations. Sure enough the chest x-rays showed a large mass, suspected to be a cancer, in her left lung. The x-rays of her limbs showed lots of new bone formation with a very irregular surface – this was the cause of the swelling her owners had noticed!

The reason for the strange bony reaction associated with some cancers in the chest is not well understood. Thankfully, though, treating the underlying disease usually helps a great deal and we discussed with Lilly’s owners that the best thing we could do would be to operate to remove the lung mass. They decided to go ahead and the next day Lilly was operated on by our soft tissue surgery specialist, Prof. John Williams. He was able to successfully remove the mass and, although Lilly had a few difficult  days while recovering (and gave those of us looking after her a few scares!) she was back at home and doing well a week later.

Follow-up tests revealed good news and bad news. The bad news is that the lung mass was, as we suspected, a cancer. The good news is that dogs with these types of cancer can do very well for several months or years following surgery and hopefully this will be the case with Lilly – a few months down the line her legs are no longer swollen and she is back to her normal bouncy self – long may it continue!

Sally – urinary incontinence

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Sally, a much loved family pet, developed the condition of urinary incontinence at 4 years of age in 2006. The incontinent episodes would occur mainly at night after Sally had been lying down but could also occur intermittently during the day time.

A thorough diagnostic investigation was performed incorporating urine analysis, ultrasonography and radiography with the use of contrast dye to highlight the anatomy of her bladder and associated structures. The tests revealed that Sally had an elongated bladder outline and the bladder neck was located within the pelvis rather than the more normal position of being in the abdomen. This is a common cause of incontinence in bitches referred to as acquired urethral sphincter mechanism incompetence  (AUSMI). This condition means that the bladder neck / urethral tone is no longer capable of restraining the urine collecting in the bladder and subsequently, urine leaks out in an uncontrolled manner, often whilst the dog is lying down.

Initial medical treatment with Propalin ( phenylpropanolamine) was successful, but soon there was evidence of incontinent episodes again. Another oestrogen medication called Incurin was trialled but again Sally experienced episodes of urine leakage. The combination of these two medications was given but still, there was minimal improvement.

In 2008, the next sensible step was to consider surgery and a urethropexy procedure was performed. This aim of this surgery is to fix the urethra in a more forward / abdominal position and hence increase the muscular tone of the urethra and bladder neck, hopefully giving urinary continence or at least reducing the level of incontinence. Sally was completely free of urinary accidents for 7 days, but sadly the incontinence returned after a sudden, unexpected episode of exertion. Disruption of the fixation sutures was suspected, so a second urethropexy was performed. There was some initial improvement but again despite a restricted exercise regime post operatively, the urinary accidents returned to the same frequency as prior to the surgeries.
Sally’s veterinarian at Village Vets worked tirelessly to research other medical options for Sally, but a year later in 2009, further referral was sought. At this time, one of the only other options was to consider a different surgical procedure called a Colposuspension, which aims to achieve similar goals to the urethropexy surgery but utilising the redundant vaginal tissue. Sally did very well for 7 days, no urinary accidents then day by day the wet beds started to occur again – the incontinence had returned.
More medication was trialled – this time imipramine followed by Enurace (ephedrine) – there was some improvement. But was there anything else that could be done……..
From  January 2010, Northwest surgeons were able to offer the treatment of urethral collagen injections by a specialised endoscope. The collagen blebs are injected directly into the urethra without the need for a surgical approach. The aim of the collagen is to act as a bulking agent around the urethra and cause some resistance to urine outflow, hence resolving or at least improving the episodes of urinary incontinence. The patients have a short anaesthesia, a pain free recovery and once they have demonstrated a good urinary flow after the procedure, they are ready for home. Sally is the first patient at Northwest Surgeons to receive urethral collagen injections for urinary incontinence. It is early days for Sally, but nearing 3 months after the collagen delivery with no additional medication, the urinary accidents are infrequent giving a more manageable situation for her caring , devoted owners.

Our thanks to veterinary surgeon Alan Humphreys of Village Vets, Woolton, Liverpool for referring Sally to Northwest Surgeons.

Riley – the Curious Case of a Vomiting Labrador

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At four years of age, Riley developed intermittent vomiting and diarrhoea which got progressively worse over a six month period. As a typical Labrador, he would often scavenge waste bins, but his owners struggled to find food that suited him and he continued to be poorly with weight falling off him. Despite blood tests and X-rays at his local vets and treatment with antibiotics, nothing seemed to help. He was eventually referred to Northwest Surgeons – despite its name, we specialise in medicine too!

On examination Riley was bright and alert, although he was very unhappy about having his abdomen examined – he even showed signs of nausea by smacking his lips when this was done. I discussed the long programme of detective work ahead of us with his owners – which would include infections, food sensitivity, a range of diseases affecting his liver or pancreas, along with the possibility of Riley having swallowed a foreign body that had become stuck inside him. What we needed to do was establish exactly what was wrong so that informed decisions could be made about his care, so Riley was admitted for further tests.

The first panel of tests on Riley’s blood and faeces were normal, so we decided to carry out a non-invasive ultrasound scan. This showed thickening in some of the loops of his gut, together with enlarged lymph nodes near his bowel. This was our first important clue, as Labradors can often be affected by inflammatory bowel disease – usually characterised by repeated incidents of vomiting and diarrhoea.

To confirm our suspicions we needed to carry out biopsies of Riley’s bowel in order to effectively differentiate between this disease and lymphoma, which is a type of bowel cancer. Endoscopy allows us to take these small samples in a far less invasive manner, which is also much less risky for poorly dogs like Riley. Under a light anaesthetic we passed a fibre-optic tube through his mouth and stomach and all the way to his intestines where we would be able to take a small sample of his bowel to be sent to the laboratory for testing.

However we were all in for a bit of a surprise! We found two sports socks in his stomach, which were carefully removed using special retrieval forceps through the endoscope. Once these socks were removed, we were then able to pass the tube down to his intestine to get the necessary biopsies. Riley recovered well from his procedure, perhaps feeling a little emptier in his stomach!

A few days later the results were in – Riley did have inflammatory bowel disease, and was placed on a diet of turkey and potatoes, along with some antacid medication.

A month on, Riley’s vomiting and diarrhoea had stopped and he was gaining weight. His diet was altered to a low allergy regime where he wouldn’t need further medication and at six weeks he was a much happier dog. His owners also reported that they hadn’t lost any more items of clothing!

Riley was treated by Dr Rebecca M. Littler MA, VetMb, PhD, DSAM, MRCVS