Linear foreign bodies can cause life-threatening illness in cats, with ingestion resulting in plication of the intestine and potentially perforation and peritonitis. In this case a young cat ingested a cotton thread which became anchored at the base of the tongue and caused bunching of the intestines, resulting in clinical signs of vomiting, lethargy and ptyalism. The thread was removed via coeliotomy and three incisions into the duodenum and jejunum. The cat recovered uneventfully with the risks of complications such as peritonitis reduced by prompt presentation by the owners, good aseptic surgical preparation and technique and close perioperative monitoring. Cotton, wool, string and other linear fabrics or rubber bands should be kept away from cats to reduce the risk of linear foreign body.
Linear foreign bodies are a serious, potentially life-threatening condition causing partial or complete intestinal obstruction following ingestion of thread, wool or string. This case study discusses the care of a cat requiring surgical removal of an ingested piece of thread.
Signalment
Leo is a 7-month-old male neutered domestic shorthaired cat. He is the only cat of the household, an indoor–outdoor cat, is up to date with worming, flea treatment and vaccinations and is fed a standard complete wet and dry diet.
History
Leo was brought into the clinic due to acute onset lethargy and inappetence, less than 24h after he was seen playing and subsequently ingesting a piece of cotton sewing thread. His owners initially were not concerned about the ingestion as they believed it wasn’t a significant length of thread and hoped that it would pass through his intestines without a problem. Leo started vomiting a few hours after thread ingestion, and, although he ate his breakfast the next morning and held this down, the fact that he was becoming increasingly subdued and salivating excessively prompted the owners to contact the clinic.
Physical examination
On examination in the clinic Leo was quite stressed, bright and alert but had a tender abdomen. No intestinal bunching was felt and, unfortunately, I was unable to examine his mouth (particularly the base of his tongue where linear foreign bodies can lodge) due to his anxiety.
With the recent history of ingestion of a piece of thread, linear foreign bodies were discussed at length in the consult room. I discussed with the owner the need for me to visualise the base of his tongue as this is an anchor point for thread. Abdominal radiographs were also recommended to detect any obvious signs of obstruction, plication of his intestines or even peritonitis.
Lateral radiographs of Leo’s abdomen showed no evidence of peritonitis or severe plication of his intestines but there was a suspicious ‘bunching’ and some gas present in his intestines.
Leo was prepared for surgery and a ventral midline coeliotomy was performed. The thread was cut at the base of the tongue to enable its removal from the enterotomy. The full intestinal tract was examined and no gross abnormalities were visualised, the duodenum and part of the jejunum were exteriorised from the abdomen and the abdomen was packed off with laparotomy sponges which had been moistened with warmed sterile saline.
A moist laparotomy sponge was also placed over the exteriorised intestines to prevent desiccation from the hot operating lights. A small longitudinal incision was made in the anti-mesenteric border of the duodenum and the string was visualised and grabbed using forceps (Figure 3). There was tension on the string which prevented complete removal from this incision. To avoid further trauma to the intestinal wall by excessive force, the string was cut at this point and the rostral portion removed. The incision was closed using simple interrupted pattern and monofilament absorbable 4–0 suture material. A further two incisions needed to be carried out on the anti-mesenteric border of the jejunum to remove the remainder of the thread (Figure 4). The area was flushed with warmed sterile saline and omentum was laid over the incision sites.
No spillage of any intestinal contents occurred during the laparotomy so, after removal of the laparotomy sponges, and a change of surgical gloves, the abdomen was closed routinely using three layers. Leo was monitored closely on recovery for any signs of vomiting, hypothermia and pain. His fluid rates were reduced to 2.5 ml/kg/h and he was given buprenorphine (0.02 mg/kg IM q4–6h).
In the post-operative period the patient regularly re-assessed for:
- adequate fluid therapy by monitoring vital parameters and thoracic auscultation to avoid over-perfusion;
- electrolyte abnormalities such as hypokalaemia from previous inappetance and vomiting;
- pain using a pain scoring system such as the Glasgow Composite Measure Pain Scale.1
Additionally the cat’s calorie requirement was calculated and food introduced little and often once fully recovered from anaesthesia (figure 5)
Outcome
Leo made an excellent recovery and the day after surgery had improved significantly and was eating small amounts of food easily. He was discharged that afternoon with buprenorphine 0.02 mg/kg sublingually q4–6h and a special gastrointestinal diet for a few days postoperatively.
An informative discharge advice handout was given to Leo’s owners advising monitoring Leo for signs of inappetence, lethargy or vomiting and to contact the clinic if they were at all concerned. A soft Elizabethan collar was provided. Leo was brought back 3 days after his surgery for a recheck and 10 days later for suture removal and the owners reported he was doing very well and back to his normal lively self the day after surgery.
In future the family are going to be very careful about not leaving any thread or string around the house.
Discussion
The most common sites for a linear foreign body (FB) to anchor in the cat are the base of the tongue or the pylorus of the stomach. A thorough oral examination, paying particular attention to the base of the tongue should be undertaken in any cat presenting with acute vomiting. As Leo was quite stressed due to the car journey thorough oral examination was impossible, emphasising the need for communication with our clients about ways to reduce the stress of the visit. This will not only reduce their cat’s stress levels but also make it easier for the vet to perform a thorough clinical examination and reach a quicker diagnosis.
When a linear FB becomes anchored at the base of the tongue or at the pylorus of the stomach, normal peristalsis of the intestines propels the FB along the intestine until it becomes taut. As this peristalsis continues, the intestines become plicated and the linear FB acts as a saw which can lead to full thickness laceration of the intestine potentially causing life-threatening peritonitis.3 The earlier the diagnosis of a linear FB is made, the less trauma caused to the intestines and the better the prognosis.
Conservative management may be carried out in some circumstances by cutting the anchor point below the base of the tongue and allowing the FB to pass while being closely monitored in a hospital environment.
This may avoid the need for surgery and can have a good prognosis if the cat is presented less than 2 days after known ingestion, but owners must be made aware of the risk of complications and the potential need for emergency surgery.5
Good perioperative care of the patient is essential when dealing with the gastrointestinal tract, as for any surgery.5 Linear FB removal often requires multiple incisions in the intestinal tract, leading to increased surgery times and increased risk of complications like stricture and sepsis.6 Multiple incisions in the gastrointestinal tract were one risk factor for higher mortality in a large study of dogs and cats with intestinal FBs.7
Flushing the abdomen with copious amounts of sterile warmed fluids is important in helping reduce the risk of bacterial contamination.
Buprenorphine was administered as analgesia for Leo and perhaps should have been given IV to provide a greater magnitude of antinociception, faster speed of onset and longer duration of action compared to other routes. Certainly regular reassessment of the hospitalised patient is very important as the duration of action of buprenorphine has been found to be shorter than what is commonly published.8
Significant advances in pain assessment have occurred over the last few years with the production of new clinical tools that can be used on the feline patient in a clinical setting. Combining a facial scale,8 that shows changes in feline facial expression during differing degrees of pain with the Glasgow CMPSfeline,1 will help us gain a more accurate assessment of each individual patient.
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