Splenic Torsion

PicoSearch
Site Search by PicoSearch. Help

Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Animal Surgical Center of Michigan

5045 Miller Road

Flint, MI 48507

www.animalsurgicalcenter.com

Phone: 810-671-0088

Key Points

Acute splenic torsion can cause acute collapse with abdominal pain

Chronic splenic torsion can have nonspecific signs of gastrointestinal upset or even port-wine colored urine

initial stabilization of the patient with early surgical removal of the spleen offers the best prognosis


Anatomy

The spleen is a large blood filter that removes red blood cells that are old, damaged, or are afflicted with parasites and other infectious agents. The spleen is attached to the stomach by a set of ligaments. The spleen has a robust blood supply from its splenic artery and vein, thereby allowing it to be an efficient blood filter.

 

What is splenic torsion?

Splenic torsion is a condition in which the spleen becomes twisted around its blood vessels. The cause of splenic torsion is unknown, however, is believed to occur after stomach bloat or partial intermittent stomach twisting. Secondary to this, the ligaments of the spleen, which normally hold it in place become stretched. When the stomach partially twists out of position, it pulls the spleen with it. If the spleen remains in this abnormal position, the thin-walled splenic veins collapse and become occluded, yet the artery (which has higher blood pressure than the vein) will continue to pump blood into this organ. The result is a very large, painful spleen.

 

Signalment

Large, deep-chested breeds of dogs are primarily afflicted, with German Shepherds and Great Danes over represented. This condition occurs in female and male dogs of any age.

 

Signs

Acute and chronic splenic torsion are the two forms of this condition and have largely different clinical presentations. Warning signs of the acute splenic torsion include abdominal distention, pain, pale gums, rapid heart rate, and weak pulses. Chronic splenic torsion has vague clinical signs of abdominal pain, enlargement of the spleen, intermittent vomiting, diarrhea, weakness, depression , lethargy, anorexia, and in some cases portwine (dark red) urine due to break-down of red blood cells. Both acute and chronic conditions may mimic an illness of the gastrointestinal tract (anorexia, lethargy, vomiting, and diarrhea), thereby making the diagnosis sometimes a difficult one.

 

Diagnosis

Blood work commonly will show mild to moderate anemia with a decreased hemoglobin concentration. The white blood count is frequently elevated and sometimes the platelet count is below normal. The chemistry profile may show elevations of liver enzymes and increases in the bilirubin (if high enough could result in jaundice). Urine testing may reveal hemoglobin in the urine from the breakdown of red blood cells. A clotting profile may show a reduced ability of the blood to clot.

X-rays of the abdomen will show an enlarged spleen that is displaced out of its normal position. The spleen may be folded into a C-shaped structure. The stomach shape may also be distorted with the outflow of the stomach pulled closer to the inflow tract.luid may be seen around the displaced spleen. Uncommonly gas is seen within the spleen due to an infection of the spleen by anaerobic bacteria (Clostridium).

Abdominal ultrasound will show an enlarged spleen. The veins are distended in the peracute case, but more commonly they are smaller than normal due to the vessels being collapsed from the twisted pedicle and from compression of the distended spleen. A doppler color flow ultrasound study will show reduced flow of blood in the veins and with time the flow of blood in the arteries will also stop.

Although CT scan is usually not needed to diagnose a splenic torsion, this test will show a cork screw soft-tissue mass at the base of the spleen, which is the twisted vessels of the spleen. The spleen is displaced and enlarged and frequently will lack enhancement with contrast (dye that is injected into the patient).

Other conditions that can result in an enlarged spleen include cancer, trauma (hematoma), immune-mediated diseases (hemolytic anemia), abscess, tick-borne diseases such as Ehrlichiosis, Rocky Mountain Spotted Fever, and Babesiosis.

 

Treatment

Prior to surgery, initial stabilization of the patient is critical when signs of acute shock are present. This treatment includes the administration of intravenous fluids, blood transfusion, and administration of plasma or hetastarch (vascular volume expander). After the patient is stabilized, surgical removal of the spleen is performed under general anesthesia. At the time of surgery, a large congested spleen (fig below left) with a twisted pedicle (blood supply) is seen (arrow below right). The spleen should always be sent out for biospy to rule out cancer of the spleen. In some cases, a partial removal of the pancreas is essential if it is devitalized. Prophylactic gastropexy should be done at the time of surgery to reduce the risk of stomach bloat in the future.

In the postoperative period, temperature, heart rate, respiratory rate, blood pressure, and EKG are closely monitored to ensure that your companion is making an uneventful recovery. Blood tests are frequently done in the early recovery period. Intravenous fluid therapy is continued to maintain good hydration. Blood is transfused may be required if the patient is anemic. Some dogs will develop abnormal heart beats that require treatment with medications.

At home, pet owners should monitor their companion for signs of incisional infection, inflammation of the pancreas (anorexia, vomiting, diarrhea), and bloat (abdominal distention, lethargy, and unproductive retching). Exercise should be limited for 3 weeks after surgery. There are no specific dietary requirements following splenectomy; however, your companion's surgeon may recommend a bland, low fat diet.

 

Prognosis

Most patients that are promptly treated for splenic torsion have a very favorable prognosis. Literature cited prior to 1990 showed a 74% survival rate, whereas reports after 1990 show a 96% survival rate. The acute form of splenic torsion may have slightly lower survival rate versus those that are chronic.

 

References

  1. Fossum TW: Small Animal Surgery. St. Louis, Mosby, 2002, pp 542–544.
  2. Millis DL, Nemzek J, Riggs C, Walshaw R: Gastric dilatation- volvulus after splenic torsion in two dogs. JAVMA 207(3):314– 315, 1995.
  3. Montgomery RD, Henderson RA, Horne RD, et al: Primary splenic torsion in dogs: Literature review and report of five cases. Canine Pract 15:17–21, 1990.
  4. Neath PJ, Brockman DJ, Saunders HM: Retrospective analysis of 19 cases of isolated torsion of the splenic pedicle in dogs. J Small Anim Pract 38:387–392, 1997.
  5. Slatter D: Textbook of Small Animal Surgery. Philadelphia, WB Saunders, 2003, pp 1054–1055.
  6. Stickle RL: Radiographic signs of isolated splenic torsion in dogs: Eight cases (1980–1987). JAVMA 194(1):103–106, 1989.

9/10/11

Frequently Asked Questions After Surgery

When should my dog have the first bowel movement after surgery?

  • Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a dog will not have regular bowel movements after surgery include:
    • The dog has been fasted prior to surgery
    • Dogs do not eat well during the hospital stay
    • They frequently do not eat well when they go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as morphine, fentanyl patches, and tramadol) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed
    • Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable

My pet had surgery and will not eat.  What can be done?

  • Dogs
    • Most pets will not eat their regular dog food after surgery, especially if it is kibble.
    • Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source.  The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked).   The carbohydrate can be pasta, potato or white rice.
    • Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
    • Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
    • Try Hill's A/D diet available at most veterinary hospitals
    • Hand feeding: place a small amount of food in the mouth so that your dog gets the flavor
    • Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
    • Remember that most pets will not eat the first day or two after they get home from surgery
  • Cats
    • Offer smelly foods that contain fish such as tuna or smelly cat foods
    • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
    • Hand feeding:  with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth
    • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature; it should be only luke-warm
    • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
    • Petting and stroking your cat frequently will help to stimulate appetite
    • Remember that most pets will not eat the first day or two after they get home from surgery
    • Appetite stimulants such as cyproheptadine may be helpful
    • If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My pet is vomiting.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled.  Usually the regurgited material will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics, narcotics or nonsteroidal anti-inflammatory medication commonly cause vomiting after surgery.  In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued. 
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • An uncommon cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days.  In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days.  Metoclopramide and Cerenia are good anti-vomiting medications for dogs and cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis.  This results in poor motility of the esophagus, therefore water and food will accumulate in this structure.  In most cases, esphagitis is self-eliminating and will resolve within two or three days. 
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week.  This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other).  Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my dog is in pain following surgery?

  • Signs of pain include
    • crying
    • biting if you get near the surgical site
    • grimacing (lips are pulled back and the the dog looks anxious)
    • tragic facial expression
    • panting
    • restlessness and unable to sleep; pacing
    • if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
    • the worst pain will be for the first 2 to 3 days after surgery

What can I do to control my dog's pain?

  • Narcotic medications that control pain: tramadol, butorphanol, Duragesic (fentanyl patch)
  • Anti-inflammatories used to control pain: Deramaxx, Rimadyl, Previcox, or Etogesic
  • If an orthopedic surgery has been done cold packing the surgical site may be helpful
    • A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack.  An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern.  Cooling the surgical site helps to numb the area.

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs

Is it okay for my pet to lick the incision?

  • If a dog licks the incision, the healing process may be delayed.
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.
    • A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons

What does it mean?

  • Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

  • Experience in the development of new surgical treatments

  • Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

  • Assurance that a veterinarian is a surgical specialist

All information on this web site is copyright © 2004 Vet Surgery Central Inc. VCS Inc. will not be held liable for any information on this site that may be used for or against medical litigation.