Case 8

Given the suspicion of concurrent intestinal disease (the thickened intestinal walls identified on ultrasonographic examination), you talk to Misou's owners about obtaining intestinal biopsy samples and placing a stomach tube for longer-term nutritional support. Either laparotomy or endoscopy can be considered in this scenario, and, in either case, a gastrostomy tube can be placed.

In the event that stomach tube placement was not an option, an esophagostomy tube would be a great option for prolonged nutritional support. The procedure is quick and easy and is very well tolerated.

An exploratory laparotomy is planned, and before surgery Misou's packed cell volume is 28%. Misou does well during surgery, and intestinal and hepatic biopsy samples are obtained and submitted for histologic examination. You place a gastrostomy tube, and Misou recovers uneventfully. You can start using the tube as soon as she is awake enough for feedings, so you start her on a blenderized canned food diet that is high in protein and low in carbohydrates, calculate her RER with the new diet as before, and resume her previous feeding schedule.

You start weaning Misou off of her intravenous fluids the next day, and you start administering her intravenous medications (metoclopramide, famotidine) through the gastrostomy tube as well. The cobalamin will continue to be administered parenterally.

Misou is sent home two days after surgery (day 9) on continued tube feedings, antibiotics (amoxicillin trihydrate-clavulanate potassium 62.5 mg b.i.d. for seven days), famotidine, and the weekly subcutaneous cobalamin injections. Your technician teaches the owners how to use the feeding tube to feed and administer medications and how to flush the tube with water. They are instructed to return in one week for a recheck visit and blood tests. They are asked to check Misou's tube site once a day for any evidence of swelling, discharge, or redness, and you recommend they keep fresh food and water available to determine when her appetite returns.

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