Case Studies
 

A Linear Foreign Body Attached Under the Tongue of a Domestic Short Hair.

Linear Foreign Body-01
IMAGE 1: String under the tongue on examination with an accompanying ulcerated wound on the ventral aspect of the tongue cranial to the frenulum.


 

VETERINARIAN SPECIALTY CASE STUDY

Linear foreign bodies can include objects such as string, rope, floss, broken hair bands, pieces of toy or clothing, or other long objects. They account for 50-61% of feline foreign body cases and 36% of canine cases. If a linear foreign body is diagnosed, ideally surgery should be pursued.

By Kristin Renkei, BVMS
and Andreas Andreou, DVM
Emergency & Critical Care

1. Referral

Runner is a 1 year old MN DSH who was referred to Animal Specialty Group’s Emergency & Critical Care Service for a history of vomiting, reduced appetite and lethargy. He was seen playing with a needle and string prior to the onset of clinical signs. Runner was otherwise doing well, drinking, urinating and defecating normally. Prior to referral an in house CBC/Chem showed leukopenia and radiographs revealed gas pockets throughout the small intestine. Runner was treated with 3.5mg SC Cerenia and 200ml LRS SC before transferring.

2. Examination

On physical examination Runner was dehydrated and pyrexic. Oral examination revealed an ulcerated lesion at the frenulum and a white string under the tongue (See Image 1).

3. Diagnostics

Abdominal radiographs revealed plication with tear drop pattern consistent with linear FB (See Image 2) . The remainder of diagnostics including blood pressure, FAST scan, thoracic radiographs, and blood gas were unremarkable.

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Linear-Foreign-Body-02

IMAGE 2 & 3: Abdominal radiographs are consistent with a linear foreign body.


4. Diagnosis

Runner was diagnosed with a linear foreign body attached under the tongue extending to the distal jejunum causing severe plication of the intestines.

5. Treatment/Procedures

  1. Runner underwent an emergency exploratory laparotomy. A string was appreciated under the tongue causing plication from the descending duodenum to the distal jejunum. A large perforation was present on the mesenteric border of the distal jejunum with multiple small perforations around this area.
  2. The string was released from around the tongue and a total of 3 enterotomies were performed to remove the string. Enterotomy sites were closed with 4-0 PDS SC. A resection and anastomosis was performed in the area of intestines with perforations using a ligasure device and 4-0 PDS SI. Mesentery was then closed with 4-0 PDS SC. All closures were leak test negative.
  3. The abdomen was lavaged with copious amount of sterile saline. A routine 3 layer closure was performed.
  4. Intraoperative complications included episodes of hypotension responsive to crystalloid and colloid boluses.
  5. Post-operatively, Runner was maintained on plasmalyte 2x maintenance + Reglan, unasyn 110mg IV q8h, enrofloxacin 22.7mg IV q24h, cerenia 4mg IV q24h, pantoprazole 5mg IV q24h, and analgesic including a fentanyl CRI immediately post op and transitioned to buprenorphine 0.08mg q8h prn pain control. Runner vomited once while recovering from anesthesia, no other vomiting episodes in hospital after surgery.

6. Recovery

Runner was discharged 2 days after surgery. He remained rested at home with an E-collar and buprenorphine as needed for pain. At his 2 week recheck Runner was eating and drinking well, activity back to normal with no further vomiting. His ventral midline incision was healed and sutures removed.

7. Discussion

Linear foreign bodies can include objects such as string, rope, floss, broken hair bands, pieces of toy or clothing, or other long objects. They account for 50-61% of feline foreign body cases and 36% of canine cases (3, 4). These string-like material can wrap around the base of the tongue. Radiographs may not always highlight the classic plication pattern. Visualizing the base of the tongue during physical examination ercan aid in the diagnosis. In certain situations the three person technique is utilized.  The handler will often burrito the cat, an assistant will open the mouth and the examiner will typically use a tongue depressor, cotton tipped applicator or even a pen to actually lift the tongue and visualize the frenulum. Strings can be pale, saliva can cover or look like string, or the cat may be fractious.  In more fractious patients, a pen or tongue depressor to quickly open the mouth and lift the tongue can give you an adequate view. If sedation is required for any reason, a quick look under the tongue in a vomiting or inappetent cat can be wise.

Linear foreign objects have a lower survival rate than discrete foreign bodies due to the damage they can cause (1). After ingestion of a linear foreign object, the body attempts to move the foreign material down the gastrointestinal (GI) tract with normal involuntary contractions and relaxations called peristalsis. If the foreign body becomes anchored at a single portion of the GI tract, then the intestines further down climb up the foreign material causing plications and sometimes perforations. In some cases ultrasonography can be used to provide additional information on location of a foreign body and gastrointestinal function in that region (2).

If a linear foreign body is diagnosed, ideally surgery should be pursued. If a string is visible under the tongue, cutting the string is typically not recommended until they are in surgery and the bowel is exteriorized. Prematurely cutting the string can make the intestines less taught and any microperforations that are barely being held together can result in intestinal contents leaking into the abdominal cavity. It also makes the point of obstruction easier to locate and remove. The string is only cut if exploratory laparotomy cannot be performed. In one study they found 1/3 of felines with linear foreign bodies wrapped around the tongue could avoid surgery if the string was cut (3).

Surgery is the treatment of choice, especially if there are plications or perforations. Plications can result in tissue death where a portion of the GI tract must be removed. If perforations occur, then bacteria can enter the abdominal cavity resulting in septic peritonitis. Septic peritonitis can be life threatening and requires emergency surgery with a higher mortality rate. To prevent more severe complications prompt diagnosis and surgical intervention is critical (1).


REFERENCES: [1] Bebchuk TN. (2002) Feline gastrointestinal foreign bodies. Vet Clin North Am Small Anim Pract;32:861-880; [2] Tyrrell D, Beck C. (2006). Survey of the use of radiography vs. ultrasonography in the investigation of gastrointestinal foreign bodies in small animals. Vet Radiol Ultrasound;47:404-408; [3] Basher, A.W.P. and Fowler, J.D. (1987) Conservative versus surgical management of gastrointestinal linear foreign bodies in the cat. Veterinary Surgery 16, 135-138; [4]Boag, A.K., et. Al. (2005) Acid-base and electrolyte abnormalities in dogs with gastrointestinal foreign bodies. Journal of Veterinary Internal Medicine 19, 816-821

Animal Specialty Group

DVM, Emergency + Critical Care

Besides his professional interest in surgery and emergency medicine, Dr. Andreas Andreou also has a passion for avian and exotic medicine. In 2004, he was honored with the Pamela Slack Award, which is presented to the third-year veterinary student who has demonstrated the most outstanding competence and motivation in avian medicine.