Having a bad day? It's all relative

So you've been having a bad Wednesday.

When your alarm went off at 6:15 am, the window had been open all night and it was in the 30s, so the bedroom was freezing.

As you entered the equally frozen bathroom, you found about 20 feet of shredded toilet paper unraveled on the floor. (Thank you, cats.)

You had cinnamon raisin toast for breakfast instead of your regular wheat toast with peanut butter; it was tasty but you worried it wouldn't be enough to get you through the morning, and sure enough, it's 10 am and you're starving.

The intern you've been working with all week seems constantly cranky; today is no exception.

It's seemed like a really long, demanding week already, and you're only a couple days into it.

You've got 2 exams due by Friday, for which you haven't studied at all yet.

You're sick of paperwork and writing up medical records and not knowing if you're doing things right.

You've been staying late over the lunch hour and after class is over in the afternoon to complete various tasks for your morning appointments.

All in all, it's not been a fantastic day so far.

.......

.......

.......

Let's take a step back for a moment, and get some perspective:

At least it's your 10 am appointment, and not you, that has a prolapsed rectum.

My sole appointment yesterday morning on Community Practice - Medicine (this week's rotation) was a 1.5 year old female Shiba Inu who we'll call Kahlua (name changed to protect the cute).

Kahlua presented with her fantastic owner to the VTH's emergency service for a rectal prolapse.

Let's take a minute to talk about rectal prolapse. What that basically means is that a variable amount of the dog's rectum is protruding through the anus. (Just to get things straight: the "rectum" is the last part of the intestine and the "anus" is the sphincter on the outside.)



(The above picture is from Google images, and obviously is not actually Kahlua, since she is not a Boston Terrier!)

Rectal prolapse is usually caused by straining -- and whatever is causing the straining is what you need to diagnose and fix. It can be caused by diarrhea, constipation, GI parasites, intussusception, GI foreign body, partial or complete obstruction, or just about anything causing blockage and/or inflammation of the intestinal tract. It can also be caused by dystocia (difficulty giving birth) or straining to urinate (e.g. with a stone in the urethra).

So you can treat a rectal prolapse (basically sedate the dog, push all the rectal tissue back in through the anus, and sew the anus shut for a few days so nothing pops out again). But unless you've found the underlying reason why the prolapse occurred in the first place, your patient may be back with a recurrence in the future.

Which, unfortunately, was the case with poor little Kahlua.

Kahlua actually came to the VTH in August with her first rectal prolapse. She'd been straining a little bit and having some diarrhea, for unknown reasons. Since she was young, one of the primary recommendations was a thorough fecal exam to check for any GI parasites that could be causing irritation. Even though Kahlua's fecal exam showed no parasite eggs, she was dewormed extensively anyway, just in case (fecal exams are not foolproof and can sometimes miss worm eggs).

In August, Kahlua also had abdominal xrays, which showed a normal abdomen.

Kahlua got some happy-making drugs, and had her rectum replaced and sewn shut for a few days.

And all was well.

Then, about a week after presenting with her prolapse, Kahlua's owner called the VTH and said that Kahlua had started vomiting up some pieces of carpet.

Mystery solved.

(Or was it???)

The theory in August was that Kahlua's first and only rectal prolapse had probably been due to a partial GI obstruction caused by foreign body ingestion which could not be seen on xrays.

That was all well and good, until Tuesday evening, when Kahlua went outside to defecate and came back in with a prolapsed rectum.

Kahlua's dad brought her in to the VTH as soon as possible, but even so, her prolapse had spontaneously reduced (i.e. the prolapse had fixed itself by the time Kahlua saw the vet). Nonetheless, Kahlua was put on a stool softener and wet food, and sent home at midnight with an appointment to see community practice the following day (Wednesday).

Unfortunately, when Kahlua went out to potty on Wednesday morning, her poor little rectum prolapsed again, and was hanging in the breeze when I went up to check her in for her 10:30 am appointment.

Now, I should tell you that Kahlua actually had a very mild rectal prolapse, both in August and this week. She only prolapsed 1-2 cm in August, and probably less than 1 cm yesterday. Compared with some pictures I've seen online, this is pretty darn good.

However, even a minor prolapse is an issue. For one thing, it's irritating and painful. Kahlua was adamant that we not touch her bottom area at all (and I can understand why). Obviously the longer the rectal tissue is out in the environment, the greater chance for contamination and trauma to a delicate structure. Additionally, some dogs will actually chew off the part that's hanging out if you don't keep a close eye on them (or an e-collar on them), and/or blood flow to the prolapsed portion can be cut off for so long that the prolapsed part becomes necrotic and dies (big mess).

So the plan today was an even more thorough work-up of Kahlua's potential underlying disease. She got some heavy-duty drugs on board for a rectal exam (feel if there is any foreign material or colonic intussusception, which there wasn't). She got abdominal radiographs to check for foreign bodies or obstruction (rads were 100% normal). She got an abdominal ultrasound to check for intestinal health and possible intussusception (100% normal). The only abnormal thing we found at all was some overgrowth of abnormal bacteria on her fecal cytology, which is usually a secondary change to some sort of GI upset, and was probably not the cause of her straining and prolapse.

So, no good answers for Kahlua. While sedated, her prolapse was reduced (replaced inside her body), and it stayed in for the rest of the afternoon even while she was having diarrhea all over the place. She went home with some tranquilizer pills that her owner could give if she prolapsed again, to keep her calm and ideally decrease her straining.

It's hard to say what her underlying disease is. Apparently in some cases, no obvious cause is ever found -- but it's still hugely important to investigate the possibilities, because some very serious diseases can cause the kind of straining that induces prolapse. Maybe in a few days Kahlua will start vomiting more carpet pieces. Who knows.

All in all, this was a very cool case (and, I might add, I worked it up as the only student on the case -- all but 1 senior student was in surgery, so with 5 of us juniors on to help with a full morning of appointments, we were all busy and taking cases on our own). And Kahlua is the nicest little Shiba Inu I've ever met.

I got to do a lot of neat things -- practice my physical exam, of course; take an axillary temperature; lots of owner interaction; learn how to create estimates for treatment costs; submit radiology requests for rads and ultrasound; decide on a sedation protocol, dosages, fill out a prescription request, and submit it to the pharmacy; and take a look at Kahlua's radiographs.

I gave Kahlua's dad a quick call this morning to see how she'd been doing, but I had to leave a message. Fingers crossed that little Kahlua's rectum stays put, or she's potentially looking at some not-so-fun surgery in the near future.