NOVEMBER/DECEMBER

JULY/AUGUST 2015
2016 Volume
Volume6,5,
Number
Number
43

14 PET HEALTH BY
THE NUMBERS
Feline Urinary
Diseases

34 FEVER OF
UNKNOWN ORIGIN
Diagnosis in Dogs

40 FELINE URETHRAL
OBSTRUCTION
Emergency
Management

53 PRACTICAL
TECHNIQUES FROM
THE NAVC INSTITUTE
Regenerative
Medicine

61 ENDOSCOPY
ESSENTIALS
Lower GI Evaluation

69 APCC PRACTICAL

EXCISING LYMPH TOXICOLOGY

Firework Ingestion

NODES 77 PRACTICE
BUILDING
Effective Surgical Expanding into
Exotics
Strategies 83 IMAGING
ESSENTIALS
Hepatic & Biliary
Abnormalities

92 THE BACK PAGE

Future Veterinarians

tvpjournal.com
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 July/AugusT 2016 Volume 6, number 4

Interim Editor in Chief

Subscriptions (only)
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390, Glen Mills, PA 19342-0390
Email subscription form to
TVP_subscriptions@NAVC.com
or fax to 610.558.1437
Chief Executive Offcer Free subscriptions only to
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*Qualifying Subscribers:
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Staff Writer: Megan Cox College of Veterinary Medicine
the veterinary health care
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Staff Editors: Maureen McKinney; Suzanne B. Meyers; faculty, veterinary students,
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Graphic Designers: Courtney Ballauer; Michelle Taylor to the feld. Eastern States
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VMD, Diplomate ACVS (NAVC) reserves the right to
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Todays Veterinary Practice Wilmington, Delaware subscription.
is proudly published by
the NAVC

Sheila Grosdidier,
NAVC Board of Directors rVT, PHr
Veterinary Management Consultation
President
Evergreen, Colorado
Melinda D. Merck, DVM WArrANTIES, LIMITATIONS. Except
as expressly set forth herein, Eastern
Immediate Past President States Veterinary Association,
Christine Navarre, DVM, MS, Diplomate ACVIM Inc (NAVC) makes no warranties
whatsoever, express, implied,
(Large Animal Internal Medicine) or statutory. NAVC specifcally
Garret Pachtinger,
disclaims any implied warranty
President-Elect VMD, Diplomate ACVECC of merchantability or ftness for a
Gail Gibson, VMD Veterinary Specialty & Emergency Center particular purpose. In no event will
Levittown, Pennsylvania NAVC be liable to you or any third
Vice President party for any indirect, punitive,
K. Leann Kuebelbeck, DVM, Diplomate ACVS special, incidental, or consequential
damages (including loss of profts,
Treasurer use, data, or other economic
advantage), however it arises, even
Laurel Kaddatz, DVM if NAVC has previously been advised
Michael Schaer, of the possibility of such damage.
Directors DVM, Diplomate ACVIM & ACVECC All rights reserved. No part of this
Paige Allen, MS, rVT University of Florida publication may be reproduced in any
Harold Davis, Jr, BA, rVT, VTS form without written permission from
College of Veterinary Medicine the publisher. Entire contents 2016
(Emergency & Critical Care) (Anesthesia & Analgesia) Eastern States Veterinary Association,
Cheryl Good, DVM Inc (NAVC).

tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice 1

Volume 6, number 4 July/augusT 2016

Table of Contents : FEATURES

RACE-AppRoVEd CE CREdIT ARTIClE
SURGICAL SKILLS .....................................................................24
lymphadenectomy: overview of surgical anatomy &
removal of Peripheral lymph nodes
Tanya Wright, DVM, and Michelle L. Oblak, DVM, DVSc, Diplomate ACVS (Small Animal),
ACVS Fellow of Surgical Oncology
lymphadenectomy and subsequent histopathology play an important role in determining metastasis of
neoplasia to regional lymph nodes. This article describes the anatomic location of commonly removed peripheral
lymph nodes as well as procedures for surgical excision of those nodes.

CE TEST.....................................................................................33
Lymphadenectomy: Overview of Surgical Anatomy & Removal of
Peripheral Lymph Nodes

UNCOVERING THE CAUSE OF FEVER IN DOGS ....................34

Kenneth R. Harkin, DVM, Diplomate ACVIM (Small Animal Internal Medicine)
Finding the cause of persistent fever in dogs that present with no other overt clinical signs often requires
advanced diagnostics that owners may not choose to pursue. understanding the disease processes that typically
cause fever and undertaking an extensive patient workup are the keys to solving cryptic fever.

RACE-AppRoVEd CE CREdIT ARTIClE

FELINE URETHRAL OBSTRUCTION .........................................40
diagnosis & Management
Christopher M. George, DVM, and Gregory F. Grauer, DVM, MS, Diplomate ACVIM (Small Animal Internal Medicine)
Feline urethral obstruction has the potential to be extremely serious and potentially life threatening, and
recurrence is common. With proper emergency treatment and follow-up, however, the prognosis for survival is
quite good.

CE TEST.....................................................................................50
Feline Urethral Obstruction: Diagnosis & Management

Cover image by Dean Palmer Photography. Dr. Oblak prepares to make a ventral midline incision for bilateral mandibular
and retropharyngeal lymph node excision via a ventral midline approach. Learn about this surgical technique by reading
Lymphadenectomy: Overview of Surgical Anatomy & Removal of Peripheral Lymph Nodes on page 24 of this issue.

Todays Veterinary Practice does not, by publication of ads, express endorsement or verify the accuracy and effectiveness of the products and claims contained
therein. The publisher, Eastern States Veterinary Association, Inc (NAVC), disclaims any liability for any damages resulting from the use of any product advertised
herein and suggests that readers fully investigate the products and claims prior to purchasing. The opinions stated in this publication are those of the respective
authors and do not necessarily represent the opinions of the NAVC nor its Editorial Advisory Board. NAVC does not guarantee nor make any other represen-
tation that the material contained in articles herein is valid, reliable, or accurate; nor does the NAVC assume any responsibility for injury or death arising from
any use, or misuse, of same. There is no implication that the material published herein represents the best or only procedure for a particular condition. It is the
responsibility of the reader to verify the accuracy and applicability of any information presented and to adapt as new data becomes publicly available.
Todays Veterinary Practice (ISSN 2162-3872 print and ISSN 2162-3929 online) is published bi-monthly (Jan/Feb, Mar/Apr, May/June, Jul/Aug,
Sept/Oct, Nov/Dec; 6x per year) by North American Veterinary Conference, 37 Paul Lane, Glen Mills, PA 19342. Periodicals postage paid at
Glen Mills, PA 19342 and additional mailing offces. POSTMASTER: Send all UAA to CFS (See DMM 507.1.5.2); NON-POSTAL AND MILITARY
FACILITIES: send address corrections to Todays Veterinary Practice, PO Box 390, Glen Mills, PA 19342.

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2 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com

 There is a New Option
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inappropriate urination, alopecia, decreased appetite/anorexia, panting, vomiting, diarrhea, shaking/trembling, polyphagia, urinary tract infection,
urinary tract incontinence and restlessness. ZYCORTAL Suspension should be used with caution in dogs with congestive heart disease, edema, severe
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 Volume 6, number 4 July/augusT 2016Volume 6, number 4 July/augusT 2016

ZYCORTAL Suspension
(desoxycorticosterone pivalate
injectable suspension)
Mineralocorticoid for subcutaneous use in
dogs only.
Brief Summary (For Full Prescribing
Information, see package insert)
CAUTION: Federal (USA) law restricts this
drug to use by or on the order of a licensed
veterinarian.
DESCRIPTION: Desoxycorticosterone
pivalate is a mineralocorticoid hormone.
Zycortal Suspension contains 25mg/ml of
desoxycorticosterone pivalate.
INDICATION: For use as replacement therapy
for mineralocorticoid defciency in dogs with
primary hypoadrenocorticism (Addisons
disease).
CONTRAINDICATIONS: Do not use
ZYCORTAL Suspension in dogs that have
previously had a hypersensitivity reaction to
desoxycorticosterone pivalate.
WARNINGS: Use ZYCORTAL Suspension
with caution in dogs with congestive heart
disease, edema, severe renal disease or
primary hepatic failure. Desoxycorticosterone
pivalate may cause polyuria, polydipsia,
increased blood volume, edema and cardiac
enlargement. Excessive weight gain may
indicate fuid retention secondary to sodium
retention.
HUMAN WARNINGS: Not for human use.
Keep this and all drugs out of the reach of
children. Consult a physician in case of
accidental human exposure.
PRECAUTIONS: Any dog presenting with
severe hypovolemia, dehydration, pre-renal
azotemia and inadequate tissue perfusion
(Addisonian crisis) must be rehydrated with
intravenous fuid (saline) therapy before
starting treatment with ZYCORTAL Suspension.
The efectiveness of ZYCORTAL Suspension
may be reduced if potassium-sparing
diuretics, such as spironolactone, are
administered concurrently.
ADVERSE REACTIONS: The feld safety
analysis included evaluation of 152 dogs.
The most common adverse reactions reported
are polyuria, polydipsia, depression/lethargy,
inappropriate urination, alopecia, decreased
appetite/anorexia, panting, vomiting, diarrhea,
shaking/trembling, polyphagia, urinary tract
infection, urinary tract incontinence and
restlessness. Reports of anaphylaxis and
anemia have been associated with a diferent
desoxycorticosterone pivalate injectable
suspension product.
Z Y C O R T A L
SUSPENSION (desoxycorticosterone
pivalate injectable suspension)
Distributed by:
Dechra Veterinary Products
7015 College Boulevard, Suite 525
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ZYCORTAL is a trademark of
Dechra Ltd 2015,
All rights reserved
NADA 141-444, Approved by FDA
Table of Contents : COLUMNS
EDITORS NOTE ...................... 6
NAVC PERSPECTIVES............ 10
ADVERTISER INDEx .............. 11
GUEST EDITORIAL ................ 12
BANfIELD PET HEALTH
BY THE NUMBERS ................. 14
Feline Urinary Diseases
TODAYS VETERINARY
NEWS ..................................... 16
PRACTICAL TECHNIQUES
fROM THE NAVC INSTITUTE 53
Regenerative Medicine for Soft
Tissue Injury & Osteoarthritis
Brittany Jean Carr, DVM, CCRT, and
Sherman O. Canapp, DVM, MS, CCRT,
Diplomate ACVS & ACVSMR
The goal of regenerative medicine is to
help the body restore injured tissues to
their original or near-original condition.
This article discusses types of regenerative
therapies, the applications for such therapies,
and follow-up rehabilitative therapy.
ENDOSCOPY ESSENTIALS ... 61
Lower Gastrointestinal
Endoscopy Series
Liver & Gallbladder: Part 2
Part 1: Overview of Lower
Gastrointestinal Endoscopy
Patrick S. Moyle, DVM, and Alex Gallagher,
DVM, MS, Diplomate, ACVIM
lower gi endoscopy is a minimally
invasive technique to evaluate the rectum,
colon, cecum, and ileum and obtain biopsy
samples in animals with chronic small and
large bowel disease. This article describes
diagnostic evaluation and therapy that
should be performed before endoscopy.
Have you seen the NAVCs newest journal? Share Todays
Veterinary Technician with your practice team. Sign up for
free print subscriptions at todaysveterinarytechnician.com.
tvpjournal.com
facebook.com/todaysveterinarypractice
twitter.com/tvpjournal
APCC PRACTICAL
TOxICOLOGY ........................ 69
Illuminating the Toxicity of Fireworks
Charlotte Means, DVM, MLIS, Diplomate
ABVT & ABT
When freworks are mentioned, noise
phobias are what frst come to mind.
However, dr. charlotte Means introduces
frework toxicity, including types and
ingredients of freworks, clinical signs and
diagnosis of ingestion, and management of
patients that have ingested them.
PRACTICE BUILDING ............ 77
Are Exotics a Fit for Me? Part 1:
Development of the Exotics Practice
Angela M. Lennox, DVM, Diplomate ABVP
(Avian & Exotic Companion Mammal) &
ECZM (Small Mammal)
This article discusses the many factors that
should be considered before adding care
for exotic pets to a practices offerings,
including what questions practice owners
should ask themselves and what supplies
and staff training should be considered.
IMAGING ESSENTIALS.......... 83
Small Animal Abdominal
Ultrasonography
Danielle Mauragis, AS, CVT, and Clifford R.
Berry, DVM, Diplomate ACVR
Pinpointing a diagnosis in dogs and cats
with hepatobiliary disease is diffcult and
often frustrating. a thorough ultrasound
examinationincluding systematic
evaluation of parenchymal echogenicity and
uniformity, vascular and biliary structures,
and liver sizecan be an excellent aid in
differentiating the many possible fndings in
these patients.
THE BACK PAGE: VETERINARY
VIEWPOINTS.......................... 92
Making Dreams a Reality for
Todays Aspiring Veterinarians
an interview with dr. chris carpenter

4 Todays VeTerinary
Todays
PracTice
VeTerinary
| July/august
PracTice
2016 ||tvpjournal.com
July/august 2016 | tvpjournal.com
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 ediTors noTe

What Would Lesley do?

Kelly Soldavin

Writing this is hard. How our team, Lesley was

do you fnd the words to humble at heart, and
fully describe an amazing evaluated her experience
person like Lesley? How do objectively. Turns out that,
Lesley G. King, MVB, you capture what she did despite her concerns,
Diplomate ACVECC & for all her readers as the she was a natural. One
ACVIM (SAIM), died
editor in chief for Todays that always found time to
May 14, 2016. Dr.
King was Professor Veterinary Practice? carefully assess and help
of Critical Care at In memory of Lesley, create articles, columns,
the University of Dr. Garret Pachtinger, one and ideas that made TVP
Pennsylvania School of her former students what it is today.
of Veterinary Medicine at University of Pennsylvania, now a boarded
and the Editor in Chief
emergency and critical care veterinarian himself, strEngtH & ConfidEnCE
of Todays Veterinary
Practice. She was posted a photo of a bracelet inscribed WWLD However, humility doesnt lead to insecurity.
instrumental in the on Facebook. The caption reads: WWLD (What Lesley had an inner strength and confdence that
development of the Would Lesley Do?) bracelets Dana Clarke and allowed her to do everything well. She taught
veterinary intensive I created during our residency. Such amazing me that it was never good enough to settle. That
care specialty and memories! the only way to do a job was to push myself, and
trained numerous
This acronym is perfect. Lesley did veterinary those around me, just a bit harder. To ask for the
emergency and critical
care residents, interns, medicine. No patient was too small, too hopeless, best from each of us.
and technicians. Dr. too diffcult, too old, or too anything. Each This drive came from the fact that those
King received her one received her full attention, intelligence, and receiving the benefts of our journal were
veterinary degree concern. And Lesley did veterinary education, ultimately veterinary patients. Patients that didnt
from University through working with students, lecturing, writing, have a voice. Through TVP and its readers, a
College Dublin
and editing. Every concept and every article voice was given to them, one that insisted on
School of Veterinary
Medicine, and then included in the pages of TVP received her caring, compassion and the provision of best medicine.
spent her entire career intellectual assessment. Her goal was to make
at PennVet. She was the information as clear, concise, practical, and Passion & CommitmEnt
surrounded by her readable as possible. Lesley not only touched my life through work,
closest family and And she succeeded. but also through another passionwe shared a
friends during her last
mutual love for horses. Lesley pursued dressage,
days. Contributions
can be made in Dr. Humility & EntHusiasm and the same precision and empathy that made
Kings memory for a Lesley and I became colleagues in 2011 when her such a skilled veterinarian also led her to
student scholarship TVP was a fedgling journal. I met Lesley to success with her beloved horses, Hank and Romy.
at University of interview her for the editor in chief position, and For as much as we discussed work, we
Pennsylvania School of my fear was that she would not have time to discussed our other lives, the lives that we
Veterinary Medicine;
work on a new journal. I was surprised when she, shared with our equine friends. Lesley always had
for further information,
visit www.vet.upenn instead, voiced her qualms about whether she encouraging words for me, wisdom only gained
.edu/about/press-room had the talent for the job. through a lifetime of experience with these
/press-releases. As enthusiastic as she was about joining creatures that allowed us to dance with them.

6 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com

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 ediTors noTe
Kelly and rally, left, with lesley and romy.
Just as with the journal, she gave them her all and
inspires me every day to do the same.
sElflEss & strong
Lesley told me about her cancer last fall, and
her reason for not telling me sooner, despite
both of us facing our own health challenges, was
completely unselfsh. She did not want to burden
those around her with her news. Lesley preferred
that we treat her no different than if she was
perfectly healthy.
I was shocked at the news. Lesley approached
life with such zeal that I didnt know how she
could do all she did, and fght such a horrible
disease, with a smile on her face at all times. She
never complained, never felt sorry for herself.
Lesley made sure to make her life full, and told
me this spring, when she knew the end was near,
to remember her at her best.
And now, I fnd that I remember Lesley best
when I ask myself, What would Lesley do? With
that mantra, Lesley is always with me, when I edit,
when I ride, when I live.
While Lesleys life was one that was cut short
much too soon, the last lines from the book Me
Before You (JoJo Mayes) are words that bring
me some peace; they are words I believe Lesley
would say:
Live well. Just live.
Kelly Soldavin
Editorial Director
We encourage you to share your own stories
about how lesley has touched your life. in what
ways do you ask yourself, What would lesley do?
you can email them to ksoldavin@navc.com.
8 Todays VeTerinary
July/august 2016 | tvpjournal.com
PracTice | July/august 2016 | tvpjournal.com
Caution
Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian.
Indications
SENTINEL SPECTRUM (milbemycin oxime/lufenuron/praziquantel) is indicated for the
prevention of heartworm disease caused by Diroflaria immitis; for the prevention and
control of fea populations (Ctenocephalides felis); and for the treatment and control of
adult roundworm (Toxocara canis, Toxascaris leonina), adult hookworm (Ancylostoma
caninum), adult whipworm (Trichuris vulpis), and adult tapeworm (Taenia pisiformis,
Echinococcus multilocularis and Echinococcus granulosus) infections in dogs and
puppies two pounds of body weight or greater and six weeks of age and older.
Dosage and Administration
SENTINEL SPECTRUM should be administered orally, once every month, at the
minimum dosage of 0.23mg/lb (0.5mg/kg) milbemycin oxime, 4.55mg/lb (10mg/kg)
lufenuron, and 2.28mg/lb (5mg/kg) praziquantel. For heartworm prevention, give once
monthly for at least 6 months after exposure to mosquitoes.
Dosage Schedule
Milbemycin Lufenuron Praziquantel
Body Oxime per per per Number of
Weight chewable chewable chewable chewables
2 to
2.3 mg 46 mg 22.8 mg One
8 lbs.
8.1 to
5.75 mg 115 mg 57 mg One
25 lbs.
25.1 to
11.5 mg 230 mg 114 mg One
50 lbs.
50.1 to
23.0 mg 460 mg 228 mg One
100 lbs.
Over
Administer the appropriate combination of chewables
100 lbs.
To ensure adequate absorption, always administer SENTINEL SPECTRUM to dogs
immediately after or in conjunction with a normal meal.
SENTINEL SPECTRUM may be offered to the dog by hand or added to a small amount
of dog food. The chewables should be administered in a manner that encourages the
dog to chew, rather than to swallow without chewing. Chewables may be broken into
pieces and fed to dogs that normally swallow treats whole. Care should be taken that
the dog consumes the complete dose, and treated animals should be observed a few
minutes after administration to ensure that no part of the dose is lost or rejected. If it
is suspected that any of the dose has been lost, redosing is recommended.
Contraindications
There are no known contraindications to the use of SENTINELSPECTRUM.
Warnings
Not for use in humans. Keep this and all drugs out of the reach of children.
Precautions
Treatment with fewer than 6 monthly doses after the last exposure to mosquitoes may
not provide complete heartworm prevention.
Prior to administration of SENTINEL SPECTRUM, dogs should be tested for existing
heartworm infections. At the discretion of the veterinarian, infected dogs should be
treated to remove adult heartworms. SENTINEL SPECTRUM is not effective against
adult D.immitis.
Mild, transient hypersensitivity reactions, such as labored breathing, vomiting,
hypersalivation, and lethargy, have been noted in some dogs treated with milbemycin
oxime carrying a high number of circulating microflariae. These reactions are
presumably caused by release of protein from dead or dying microflariae.
Do not use in puppies less than six weeks of age.
Do not use in dogs or puppies less than two pounds of body weight.
The safety of SENTINEL SPECTRUM has not been evaluated in dogs used for breeding
or in lactating females. Studies have been performed with milbemycin oxime and
lufenuron alone.
Adverse Reactions
The following adverse reactions have been reported in dogs after administration of
milbemycin oxime, lufenuron, or praziquantel: vomiting, depression/lethargy, pruritus,
urticaria, diarrhea, anorexia, skin congestion, ataxia, convulsions, salivation, and weakness.
To report suspected adverse drug events, contact Virbac at 1-800-338-3659 or the FDA
at 1-888-FDA-VETS.
Information for Owner or Person Treating Animal
Echinococcus multilocularis and Echinococcus granulosus are tapeworms found in
wild canids and domestic dogs. E.multilocularis and E.granulosus can infect humans
and cause serious disease (alveolar hydatid disease and hydatid disease, respectively).
Owners of dogs living in areas where E.multilocularis or E.granulosus are endemic
should be instructed on how to minimize their risk of exposure to these parasites,
as well as their dogs risk of exposure. Although SENTINEL SPECTRUM was 100%
effective in laboratory studies in dogs against E. multilocularis and E. granulosus,
no studies have been conducted to show that the use of this product will decrease
the incidence of alveolar hydatid disease or hydatid disease in humans. Because the
prepatent period for E. multilocularis may be as short as 26 days, dogs treated at the
labeled monthly intervals may become reinfected and shed eggs between treatments.
Manufactured for: Virbac AH, Inc.
P.O. Box 162059, Ft. Worth, TX 76161
NADA #141-333, Approved by FDA
2015 Virbac Corporation. All Rights Reserved.
SENTINEL and SPECTRUM are registered trademarks of Virbac Corporation.
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 naVc PersPecTiVes
Life is Good: Lessons
Learned from a T-shirt
Laurel Kaddatz, DVM
Pound Ridge Veterinary Center, Pound Ridge, New York
As I write this column, Im remembering the 2016 NAVC
Conferencethe valuable education sessions and the
fun we had during those fve days in January. One of
the highlights for me and, perhaps for you, too, was the
opening session with Life is Good cofounder Bert Jacobs.
In addition to telling the story of founding Life is Good
with his brother John, Bert shared inspirational anecdotes
that resonated with many of us. Our profession and our
businesses, like theirs, form an emotional bond with
clients that builds and maintains a sense of community.
Do what you like, like what you do is one of the Life
is Good maxims that has appealed to many of us over
the 20 years that Bert and Johns company has been
in existence. These truisms can serve as motivational
life lessons for all of us hardworking and stressed
veterinarians.
I was born into the Baby Boomer generation. The
understanding was, if you didnt work more than 60 hours
a week, your work ethic left something to be desired.
Thankfully, many of us are fortunate in that we dont
consider what we do actual work. Even with liking what
we do, down time is important for our mental health.
What do you do to chill out, remove your mind from
the offce, and rejuvenate your body? For me, golf is part
of the answer. Being outside in fresh air and engaging
in enjoyable physical activity gives me a lift, while at the
same time keeping me humble, knowing Ill never play
the tour! Golf allows me to think of something other than
the patient from yesterday that isnt progressing as I had
hoped.
Golf is an activity that many veterinarians are attracted
to, as most of us are driven to do the best we can with
whatever we do. The well-struck shot to the green and
the satisfying sound that indicates perfect contact of the
ball off the clubface gives the perfectionist in me a boost
that keeps me coming back for more.
As Arnold Palmer said, Golf is deceptively simple
and endlessly complicated; it satisfes the soul and
frustrates the intellect. It is at the same time rewarding
and maddeningand it is, without a doubt, the greatest
game mankind has ever invented. I agree. Despite its
challenges, and perhaps because of them, golf is good.
Work to live, dont live to work. This maxim
correlates well with the frst one. Work should provide
the means to enjoy your life. I take that to heart by
Top: Dr. Kaddatzs dog, enjoying photography and travel. Im grateful that Ive
Halley; center: along had the opportunity to travel to many parts of the world
the canals of Bangkok, and bring home amazing memories in photographs
Thailand; bottom: from Cambodia to New Zealand to South Africa to the
trekking the Great Wall of Galapagos Islands.
China. The primary lesson Ive gained from photography is
10 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com
that, when observing the world and your surroundings
through a camera lens, your perspective changes when
looking at what has been familiar. Looking at the detail of
what you see opens your mind to a different understand-
ing and meaning of the world around you.
Veterinarians are, by nature and training, detail
oriented. Photography works by bringing those details
we connect withsubject matter, composition, lighting,
exposure, and editingto an audience, allowing them to
see the subject matter through our eyes and emotionally
connect with it in a similar manner. Photographs are also
a tangible reminder, once we are home again, that our
world is so much larger than our work.
My interest in photography has also become an
important part of my work, and utilizing this new skill
in my practice became rewarding in a number of ways.
In addition to posting on Facebook for our practice,
we use photos of various skin tumors and lesions that
are imported into the medical chart as a means of
following the progression of a case. Another example
is using a photo taken of a fne needle aspirate through
the microscope lens as an educational resource when
comparing it to the histopathology report.
Life is good, together was printed on the t-shirt given
to everyone who attended Bert Jacobs presentation.
(Thanks, Merial, for your sponsorship! The shirts were
incredibly popular.)
Throughout my career in organized veterinary
medicine, Ive understood that it doesnt matter if you
are a small animal or food production veterinarian, a
small business owner or someone who works in the
industry, from New York or the Midwest, from the
United States or Thailandour common denominator
is that we are all veterinarians who share a passion for
our profession. We are a community of individuals who
feel the need to give back to the profession in our own
unique way.
The NAVC Board of Directors and the entire NAVC
team personify that passion by providing the best
educational opportunities for each person on the
health care team, whether its at the Conference,
Spring Institute, online with Vet Folio, or through our
leading journals, Todays Veterinary Practice and Todays
Veterinary Technician. With the veterinary industry
professionals we serve, we are, all together, better.
Ill sign off with my favorite Life is Good maxim: Be the
person your dog thinks you are. With or without the
t-shirt, you just cant improve on that advice!
Laurel A. Kaddatz, DVM
Treasurer, NAVC Board of Directors
 adVerTiser
naVc index
PersPecTiVes

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companionregenerative
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Advanced Veterinary
NAVC Conference Continuing Education
Ultrasound, 81 Dechra, 3, 4 navc.com vetfolio.com
Veterinary Ultrasound Zycortal
advancedveterinary dechra-us.com NAVC, 23
ultrasound.com VetStem Biopharma, 60
NAVC Institute Stem Cell Therapy
Endoscopy Support navc.com
Services, 67 vetstem.com
Antech Diagnostics, 11
Pre-Op Diagnostics Veterinary Video Endoscopy Nutramax Laboratories, inside
endoscopy.com Virbac, inside front cover, 8
antechdiagnostics.com back cover
Sentinel Spectrum
Proviable-Forte
IDEXX, 7 virbacvet.com
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SNAP Test
Animal Poison Control Center idexx.com/idexxsnap2 VPL, 51
Petplan, 68
aspca.org Duralactin
2017 Petplan Awards
Impromed, 76 duralactin.com
gopetplan.com/vet-awards
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AVMA Convention 2016 impromed.com WSAVA One Health, 13
PRN Pharmacal, 49
avmaconvention.org Proin 2-Day Symposium
InGeneron, 59
prnpharmacal.com/urinaryhealth wsava-obesity.com
Regenerative Therapy
Big Heart Pet Brands, 5 ingeneron.com
Milk Bone Advanced Care Protg Biomedical, 32 Zoetis, 21, 22
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tvpjournal.com | July/august 2016 | Todays VeTerinary PracTice 11

 GuesT ediTorial
Managing Obesity in People & Their Pets:
a one Health solution
Michael J. Day, BSc, BVMS(Hons), PhD, DSc, FASM, FRCPath,
FRCVS, Diplomate ECVP
University of Bristol
A recent analysis of global human obesity evaluated
data from 19.2 million people in 200 countries over
a 40-year period. In 1975, an estimated 3.2% of men
and 6.4% of women were obese; however, by 2014,
these statistics had risen to 10.8% of men and 14.9%
of women. If these trends continue, it is suggested
that by 2025 more women in the human population
will be obese than underweight.1
Similar data exist for our canine and feline
populations. A 1995 study of 21,754 U.S. dogs
revealed that 34% were overweight or obese2 and,
in the year 2000, 33.5% of 2661 Australian dogs
surveyed were overweight, with a further 7.6% of
these animals considered obese.3 In Great Britain, a
study published in 2012 reported that 11.5% of 3227
cats were overweight or obese.4
As for people, obesity is linked to a range of dis-
ease states in pets, including orthopedic problems,
diabetes mellitus, cardiorespiratory disease, urinary
and reproductive disorders, neoplasia, and dermato-
logic disease.5
ONE HEALTH TACKLES OBESITY
These are worrying trends and the rising rates of
obesity in people and their pets is a problem that
falls frmly within the area of One Health. The
One Health concept proposes that veterinarians,
physicians, and other health care providers work
together with scientists and social scientists to tackle
shared human and animal disease problems in the
context of the common environment in which we live.
It is recognized that, underlying human obesity,
there are complex medical, psychological, and
socioeconomic factors, and that these factors may
impact the relationships that people with obesity
have with their companion animals.6 Solutions to the
global problem of obesity must lie in a One Health
approach and in developing healthier lifestyles
for the human and animal members of the family.6
Addressing obesity in pets and their owners may be
considered a signifcant public health role for the
small animal practitioner.7
THE ONE HEALTH COMMITTEE
In 2010, the World Small Animal Veterinary Associa-
tion (WSAVA) established a One Health Committee
(OHC) and its mission statement is: To ensure the
12 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com
prominence of the small companion animalhuman
interface in the global One Health agenda.
The committee works to promote three areas of
One Health related to small companion animals: (1)
the humancompanion animal bond and the health
benefts to people interacting with companion
animals, (2) comparative and translational clinical
research in companion animals for the beneft
of both animal and human health, and (3) the
importance of surveillance and control for zoonotic
infectious diseases shared between people and
companion animals.
The committee is made up of a group of veterinary
and human medical experts in these felds, with rep-
resentation from the World Organisation for Animal
Health (OIE) and the One Health Offce of the U.S.
Centers for Disease Control and Prevention (CDC).
ATTEND THE SYMPOSIUM
The OHC is currently working to present a two-day
symposium that will showcase the comparative
scientifc and interlinked social aspects of human and
pet animal obesity, and seek to identify One Health
solutions to human and animal obesity problems. The
symposium, titled Preventing Obesity in People and
Their Pets: A One Health Approach, will take place
this year in Atlanta, Georgia, November 10 to 11, and
is being organized in association with the CDC and
other educational partners.
The conference will promote the vision of a world
where regular activity, a balanced diet, and healthy
weight are part of every familys life. Over the two
days of this continuing education accredited event,
human medical and veterinary experts will address
the impact of obesity on clinical diseases, such as car-
diovascular disease, type II diabetes, and cancer; the
societal costs, behavior, and psychology of obesity;
and practical One Health Solutions to obesity.
Further information and registration for the
meeting can be found on our designated website,
wsava-obesity.com. We strongly encourage any
veterinarian with an interest in this important subject
to register for the meeting.
Michael J. Day
Chairman, WSAVA One Health Committee
References may be found at tvpjournal.com.
New ways to communicate successfully about
shared human and animal health issues

Preventing Obesity in People and Pets: A One Health Approach

2-Day Symposium EARLY BIRD

REGISTRATION
for Veterinarians Before August 1: $455

and Physicians SAVE $40

November 10-11, 2016
Atlanta, Georgia, USA
Adopt concrete approaches to
preventing obesity in both pet owners
and their pets. Global experts in the
human and veterinary felds will
jointly present the best tactics for
promoting ftness in the entire human
and animal familycentering their
recommendations in regular activity,
a balanced diet, and healthy weight.

For more information

and to register, visit
wsava-obesity.com
RACE/CME accreditation for 12 CE hours pending

The World Small Animal Veterinary Association (WSAVA) is an umbrella organization representing 96 member associations. Its One Health
Committee promotes unifcation of the medical and veterinary professions through the establishment of collaborative ventures.
 PeT HeaLTH By THe nUMBers

Feline Urinary diseases

Brought to you in
partnership with: The following table outlines the prevalence of cats with urinary diseases presented to Banfeld Pet
Hospitals in 2015. Feline urethral obstructions are discussed in Feline Urethral Obstruction: Diagnosis &
Management (page 40).

Prevalence of Select Urinary Diseases per 10,000 Cats Seen,

Grouped by Age & Reproductive Statusa (2015)
In each issue of Population in Urinary Tract Feline Urologic
Age & Reproductive Status Cystitisb
Todays Veterinary Category Obstruction Syndrome
Practice, Pet Health All cats combined 498,061 48.1 239.5 24.7
by the Numbers Juvenile (< 1 year) 115,849 5.5 41.9 3.2
correlates an article Young adult (1 to < 3 years) 115,174 56.8 199.9 3.6
topic with statistics Mature adult (3 to < 10 years) 192,779 74.5 309 7.4
provided by Banfeld Geriatric (> 10 years) 103,059 24.5 318.8 13
Pet Hospital (banfeld. Castrated male 223,967 97.9 256.5 39.6
com). These statistics
Spayed female 223,235 1.9 258.9 14
are extracted from
Intact male 22,512 68.9 70.6 10.2
data collected
Intact female 27,345 1.5 88.1 3.7
from the medical
NOTEs
records of nearly 2.5 a. Age group and reproductive status totals will not match overall totals. Age groups are derived from visit age in 2015; some
pets may have been counted in multiple age categories (eg, a pet that visited as a juvenile and then as a young adult in 2015).
million dogs and Reproductive status totals will not match due to animals of unknown sex or reproductive status.
nearly 500,000 cats b. The lower prevalence of cystitis in the intact group compared to the neutered group may be due to the age differences of
these cohorts in which intact animals tend to be younger than castrated and spayed animals.
presented to more
than 920 Banfeld Pet Path to Pet Wellness: This dataset is an interesting look at the diagnosis of cats presented to their primary
care veterinarians with lower urinary tract signs (LUTS). The main causes of both obstructive and nonobstruc-
Hospitals in 2015.
tive LUTS in cats include feline interstitial cystitis, urolithiasis, urethral plugs, bacterial infection, anatomic
abnormalities, and neoplasia.
From this data, only a small number of cats were identifed as having feline urologic syndrome (FUS)a
term that historically had been used to describe cats with idiopathic LUTS with or without urethral
obstruction (UO)when all other causes have been excluded.1 This term has been largely replaced by feline
idiopathic or interstitial cystitis (FIC), which may explain the low number of cats with the diagnosis of FUS.
The most common diagnosis in this dataset is cystitis, which likely includes cats with FIC as well as cats with
bacterial cystitis. FIC is cited as the most common cause of LUTS in cats, which is similar to the data present-
ed here.2-4 The literature on a gender predisposition to FIC has been conficting with studies from the United
States citing male and female cats affected equally,2,5,6 as noted in this dataset; however, recent studies from
Europe and a large epidemiologic study from the U.S. have demonstrated a male predisposition.3,7,8
Bacterial cystitis is a less common cause of LUTS and is cited to occur in 2% to 13% of cats.4,8,9 Consistent
with the literature, UO was found to occur most commonly in young and mature adult male cats due to the
narrow penile urethra, and rarely occurring in female cats. UO is diagnosed in approximately 22% to 55% of
male cats presenting with LUTS.3,4,6,7
As both recurrence of UO and idiopathic cystitis is common, it is possible that cats are represented more
than once in this dataset. This data does not specifcally identify cats diagnosed with urolithiasis, which may
cause both obstructive and nonobstructive LUTS. In the most recent studies, urolithasis was found in 29% to
47% of cats with UO.10,11
Erica L. Reineke, VMD, Diplomate ACVECC, University of Pennsylvania

References
1. Buffngton CA, Chew DJ, DiBartola SP. Interstitial cystitis in cats. Vet Clin North Am Small Anim Pract 1996; 26:317-326.
2. Buffngton CA, Chew DJ, Kendall MS, et al. Clinical evaluation of cats with nonobstructive urinary tract diseases. JAVMA 1997; 210:46-50.
3. Dorsch R, Remer C, Sauter-Louis C, et al. Feline lower urinary tract disease in a German cat population. A retrospective analysis of demographic data, causes,
and clinical signs. Tierarztl Prax Ausg K Kleintiere Heimtiere 2014; 42:231-239.
4. Gerber B, Boretti FS, Kley S, et al. Evaluation of clinical signs and causes of lower urinary tract disease in European cats. J Small Anim Pract 2005; 46:571-577.
5. Jones BR, Sanson RL, Morris RS. Elucidating the risk factors of feline lower urinary tract disease. N Z Vet J 1997; 45:100-108.
6. Kruger JM, Osborne CA, Goyal SM, et al. Clinical evaluation of cats with lower urinary tract disease. JAVMA 1991; 199:211-216.
7. Saevik BK, Trangerud C, Ottesen N, et al. Causes of lower urinary tract disease in Norwegian cats. J Fel Med Surg 2011; 13:410-417.
8. Lekcharoensuk C, Osborne C, Lulich JP. Epidemiologic study of risk factors for lower urinary tract disease in cats. JAVMA 2001; 218:1429-1435.
9. Lund HS, Krontveit RI, Halvorsen I, Eggertsdttir AV. Evaluation of urinalyses from untreated adult cats with lower urinary tract disease and healthy control
cats: Predictive abilities and clinical relevance. J Feline Med Surg 2013; 15:1086-1097.
10. Gerber B, Eichenberger S, Reusch CE. Guarded long-term prognosis in male cats with urethral obstruction. J Fel Med Surg 2008; 10:16-23.
11. Nevins JR, Mai W, Thomas E. Associations between ultrasound and clinical fndings in 87 cats with urethral obstruction. Vet Radiol Ultrasound 2015; 56:439-447.

14 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com

 Loud noises
can be scary.
At least one-third of all dogs in the United States experience noise aversion,1 a condition
that can lead to distress and sufering2,3 during noise events. If lef untreated, the
condition may worsen over time. Now theres SILEO (dexmedetomidine oromucosal
gel), the first and only FDA-approved treatment for canine noise aversion. SILEO provides
fast and efective at-home treatment that calms without sedating.
Visit sileosoundsolution.com or ask
your Zoetis Representative about SILEO.
(dexmedetomidine
oromucosal gel)

IMPORTANT SAFETY INFORMATION: Do not use SILEO in dogs with severe cardiovascular disease, respiratory, liver
or kidney diseases, or in conditions of shock, severe debilitation, or stress due to extreme heat, cold or fatigue or
in dogs hypersensitive to dexmedetomidine or to any of the excipients. SILEO should not be administered in the
presence of preexisting hypotension, hypoxia or bradycardia. Do not use in dogs sedated from previous dosing.
SILEO has not been evaluated in dogs younger than 16 weeks of age or in dogs with dental or gingival disease
that could have an efect on the absorption of SILEO. SILEO has not been evaluated for use in breeding, pregnant
or lactating dogs. Transient pale mucous membranes at the site of application may occur with SILEO use. Other
uncommon adverse reactions included emesis, drowsiness or sedation. Handle gel-dosing syringes with caution to
avoid direct exposure to skin, eyes or mouth. See Brief Summary of full Prescribing Information on page 18
XX.
1
Based on online survey conducted by Harris Poll on behalf of Zoetis in November 2013 among 784 dog owners.
2
Sherman BL, Mills DS. Canine anxieties and phobias: An update on separation anxiety and NoiseAversions. Vet Clin Nor Amer: Small Anim Pract,2008; 38: 1081-1106.
3
Shull-Selcer EA,Stagg W. Advances in the understanding and treatment of noise phobias. Vet Clin Nor Amer: Small AnimPract, 1991; 21: 353-367.
SILEO is trademark owned by Orion Corporation Orion Pharma Animal Health. It is manufactured by Orion Corporation and distributed by
Zoetis under license from Orion Corporation Orion Pharma Animal Health. 2016 Zoetis Services LLC. All rights reserved. SIL-00110A
 Todays VeTerinary news

The Latest news in

Veterinary Medicine
DECHRA RECEIVES SEAL OF QUALITY, NEW INSULIN SYRINGES NOW
UNITES WITH PUTNEY, INC AVAILABLE
Dechra Veterinary Products has been BD (Becton, Dickinson, and
awarded the National Animal Supplement Company) announced it has
Councils (NASCs) Seal of Quality for launched BD Pet Syringes. To
its Phycox joint health supplements for address the insulin requirements
canine and equine patients. The NASC of pets with diabetes, BDs Pet
seal is only awarded after an independent Syringe is designed with U-40,
audit to ensure conformance with quality system requirements a smaller concentration insulin,
has been performed and deemed consistent with Current compared with the standard
Good Manufacturing Practices (cGMP) and quality standards U-100 insulin available for human
established by NASC. Dechra Pharmaceuticals PLC recently medicine. BD Pet Syringes are
announced the acquisition of Putney, Inc, a leading developer of available in both 0.5 mL and 0.3
generic companion animal pharmaceuticals in the U.S., which will mL sizes to accommodate various
provide Dechra access to Putneys existing product portfolio and levels of insulin dosing. For more
development pipeline. For more information, please visit information, visit bd.com/us/
dechra-us.com or call (866) 933-2472. petdiabetes.

NEW METRIC-ONLY LAUNCH OF NEW DIGESTIVE

DOSAGE CUPS MEET ISMP HEALTH SUPPLEMENT
RECOMMENDATIONS Nutramax Laboratories Veterinary
Medi-Dose EPS has released new Sciences, Inc, has introduced
metric-only dosage cups, meeting Proviable-Forte Digestive Health
the latest Institute for Safe Medi- Supplement. Proviable-Forte
cation Practices (ISMP) recommen- capsules contain 2 times as many
dations for metric graduations. bacterial colony-forming units
For more Available in 3 sizes20, 30, and 60
mLthese new dosage cups com-
(CFUs) as Proviable (10 billion
CFUs versus 5 billion CFUs for
veterinary plement EPS growing line of other metric-only and dual graduation Proviable). Proviable-Forte is
news, go to dispensing products for both hospitals and the community. All EPS available in four 45-count blister
Metric-Only Dosage Cups are manufactured from FDA-acceptable cartons in a convenient dispenser
Facebook.com/ polypropylene and printed with compliant food grade inks. All (180-count total) for long-term
TodaysVeterinary
graduations are on the exterior of the cup so theres no contact be- use. Veterinarians can dispense
Practice
tween the ink and the cups contents. For more information on EPS capsules as needed to meet
Metric-Only Dosage Cups and complementary products, contact each pets needs. Learn more at
Robert Braverman at (800) 523-8966 or visit medidose.com. proviable-forte.com.

WSAVA ANNOUNCEMENTS (September 2730, 2016), with volunteers providing

New Online Modules: Two online training modules
designed to provide veterinarians with a solid
grounding in contemporary animal welfare issues
have been launched by the World Small Animal
Veterinary Associations (WSAVAs) Animal Wellness
and Welfare Committee. Both
modules are now available for free
download at tinyurl.com/hfs6s3s.
Call for Veterinary Volunteers:
WSAVA is seeking volunteers for
its latest Global Outreach project
in Colombia for the week prior to
WSAVA World Congress in Cartagena
clinical care to pets whose owners cannot afford to
pay for treatment. Further details can be found at
wsava2016.com.
Campaign to Support Ketamine: Despite a
recent decision by the United Nations Commission
on Narcotic Drugs to reject the international
scheduling of ketamine, WSAVA remains concerned
that access to this essential medicine is threatened.
It is calling on veterinarians globally to support its
campaign to ensure continued access to the drug for
veterinary and human medicine. More information
about WSAVAs ketamine campaign is available at
wsava.org/educational/global-pain-council.

16 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com

When noise hurts,
SILEO can help
SILEO, the first and only FDA-approved treatment for canine noise aversion,
calms without sedatingfreeing dogs from fear and anxiety triggered
by noise events, including construction, fireworks, thunder and trafic.
Visit sileosoundsolution.com or ask
(dexmedetomidine
your Zoetis Representative about SILEO.
oromucosal gel)

IMPORTANT SAFETY INFORMATION: Do not use SILEO in dogs with severe cardiovascular disease, respiratory, liver
or kidney diseases, or in conditions of shock, severe debilitation, or stress due to extreme heat, cold or fatigue or
in dogs hypersensitive to dexmedetomidine or to any of the excipients. SILEO should not be administered in the
presence of preexisting hypotension, hypoxia or bradycardia. Do not use in dogs sedated from previous dosing.
SILEO has not been evaluated in dogs younger than 16 weeks of age or in dogs with dental or gingival disease
that could have an efect on the absorption of SILEO. SILEO has not been evaluated for use in breeding, pregnant
or lactating dogs. Transient pale mucous membranes at the site of application may occur with SILEO use. Other
uncommon adverse reactions included emesis, drowsiness or sedation. Handle gel-dosing syringes with caution to
avoid direct exposure to skin, eyes or mouth. See Brief Summary of full Prescribing Information on page 18
XX.
SILEO is trademark owned by Orion Corporation Orion Pharma Animal Health. It is manufactured by Orion Corporation and distributed by
Zoetis under license from Orion Corporation Orion Pharma Animal Health. 2016 Zoetis Services LLC. All rights reserved. SIL-00110B
Brief Summary of Prescribing Information Pale mucous membranes were frequently seen in dogs treated with dexmedetomidine
oromucosal gel. In most cases, the effect was transient and no adverse reactions due to
NADA 141-456, Approved by FDA mucosal irritation were reported.
In a second well-controlled European field study which included a total of 36 dogs
ranging from 2 to 17 years of age and representing both mixed and pure breed
(dexmedetomidine oromucosal gel) dogs (12 treated with dexmedetomidine oromucosal gel at 125 mcg/m2, 12 treated
Each mL of SILEO contains 0.09 mg dexmedetomidine with dexmedetomidine oromucosal gel at 250 mcg/m2, and 12 treated with a
(equivalent to 0.1 mg dexmedetomidine hydrochloride). vehicle control), no serious adverse reactions were attributed to administration of
For oromucosal use in dogs only. Not intended for ingestion. dexmedetomidine oromucosal gel. Table 3 shows the number of dogs displaying
CAUTION: adverse reactions (some dogs experienced more than one adverse reaction).
Federal law (USA) restricts this drug to use by or on the order of a licensed veterinarian. Table 3. Adverse Reactions - Number (%) of dogs
INDICATIONS: SILEO is indicated for the treatment of noise aversion in dogs. Dexmedetomidine Dexmedetomidine
Adverse Control
CONTRAINDICATIONS: 125 mcg/m2 250 mcg/m2
Reaction N = 12
Do not use SILEO in dogs with severe cardiovascular, respiratory, liver or kidney N = 12 N = 12
disease, or in conditions of shock, severe debilitation, or stress due to extreme heat, Sedation 0 2 (16.7) 4 (33.3)
cold or fatigue. Do not use in dogs with hypersensitivity to dexmedetomidine or to Lack of
4 (33.3) 0 1 (8.3)
any of the excipients. effectiveness
Urinary
WARNINGS: 0 1 (8.3) 1 (8.3)
incontinence
Human Safety: Not for human use. Keep out of reach of children. Emesis 0 2 (16.7) 0
Avoid administering the product if pregnant, as exposure may induce uterine Head tremor 0 0 1 (8.3)
contractions and/or decrease fetal blood pressure. Inappropriate
0 1 (8.3) 0
Appropriate precautions should be taken while handling and using filled syringes. urination
Impermeable disposable gloves should be worn when handling the syringe, Ataxia 0 0 1 (8.3)
administering SILEO, or when coming in contact with the dogs mouth after Mydriasis 0 0 1 (8.3)
application. Anxiety
0 0 1 (8.3)
If skin is damaged, dexmedetomidine can be absorbed into the body. In case of skin disorder
contact, wash with soap and water. Remove contaminated clothing. Tachypnea 1 (8.3) 0 0
Lethargy 1 (8.3) 0 0
SILEO can be absorbed following direct exposure to skin, eyes, or mouth. In case of
accidental eye exposure, flush with water for 15 minutes. If wearing contact lenses, Tachycardia 1 (8.3) 0 0
eyes should be rinsed first, then remove contact lenses and continue rinsing, then To report suspected adverse events, for technical assistance or to obtain a copy of the
seek medical advice immediately. SDS call 1-888-963-8471.
Accidental exposure may cause sedation and changes in blood pressure. In case of For additional information about adverse drug experience reporting for animal drugs,
accidental exposure, seek medical attention immediately. Exposure to the product contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/AnimalVeterinary/
may induce a local or systemic allergic reaction in sensitized individuals. SafetyHealth
Note to physician: This product contains an alpha-2 adrenoceptor agonist. HOW SUPPLIED:
The safety data sheet (SDS) contains more detailed occupational safety information. SILEO is packaged in HDPE dosing syringe enabling doses from 0.25 to 3 ml. The
To report adverse reactions in users or to obtain a copy of the SDS for this product call syringe is fitted with plunger, dosing ring and end cap. Each syringe is further packed
1-888-963-8471. into a carton with a label and a leaflet.

Animal Safety: SILEO should not be administered in the presence of pre-existing Package sizes: (1 syringe per carton) 1 x 3 ml, 3 x 3 ml, 5 x 3 ml, 10 x 3 ml, 20 x 3 ml.
hypotension, hypoxia, or bradycardia. Sensitive dogs may experience a drop in body Not all package sizes may be marketed.
temperature and heart rate, and may appear sedated. These dogs should be kept STORAGE INFORMATION:
warm and not offered food or water until SILEOs effects have worn off (usually within Store unopened and opened syringes in the original package at controlled room
a few hours). Do not use in dogs sedated from previous dosing. temperature 20-25C (68-77F) with excursions permitted to 15-30C (59-86F). Use
PRECAUTIONS: syringe contents within 2 weeks after opening the syringe.
SILEO is not meant to be swallowed. Instead, it must be placed onto the mucosa between SILEO is a trademark of Orion Corporation.
the dogs cheek and gum. If SILEO is swallowed, the product may not be effective. If
SILEO is swallowed, do not repeat the dose for at least two hours. Feeding and giving
treats within 15 minutes after administration should be avoided. Mfd by:
The use of other central nervous system depressants may potentiate the effects of Orion Corporation
SILEO. Turku, Finland
As with all alpha-2 adrenoceptor agonists, the potential for isolated cases of hypersen- Dist by:
sitivity, including paradoxical response (excitation), exists. Zoetis Inc.
SILEO has not been evaluated in dogs younger than 16 weeks of age or in dogs with Kalamazoo, MI 49007
dental or gingival diseases that could have an effect on SILEOs absorption. SILEO has Made in Finland
not been evaluated for aversion behaviors to thunderstorms. Revised: April, 2016
The safety and effectiveness of SILEO in breeding, pregnant, and lactating dogs has
not been evaluated. Administration to pregnant dogs may induce uterine contractions
and/or decrease fetal blood pressure.
ADVERSE REACTIONS:
In a well-controlled European field study, which included a total of 182 dogs ranging
from 2 to 17 years of age and representing both mixed and pure breed dogs (89
treated with dexmedetomidine oromucosal gel and 93 treated with control), no
serious adverse reactions were attributed to administration of dexmedetomidine
oromucosal gel.
Table 2 shows the number of dogs displaying adverse reactions (some dogs
experienced more than one adverse reaction).
Table 2. Adverse Reactions - Number (%) of dogs
Dexmedetomidine
Control
Adverse Reaction 125 mcg/m2
N = 93
N = 89
Emesis 1 ( 1.1) 4 ( 4.5)
Gastroenteritis 0 1 ( 1.1)
Periorbital edema 0 1 ( 1.1)
Drowsiness 0 1 ( 1.1)
Sedation 0 1 ( 1.1) 148211-3A&P
 Todays VeTerinary news

NEW MULTI-
FUNCTION
DIETS FOR
DOGS & CATS
For over 45 years
Royal Canin has
partnered with
veterinarians to
bring out the
best in cats and
dogs. Having
discovered
that 1 in 3 pets
suffer from
multiple health
conditions, Royal Canin has developed
an innovative multifunction formula
COMPANION ANIMAL PARASITE COUNCIL thats highly palatable and digestible
RELEASES 2016 FORCAST MAPS and addresses different combinations
Each year, the Companion Animal Parasite Council (CAPC) of nutritional needs. By pairing specifc
creates parasite prevalence maps that forecast the future formulas, two conditions can be treated
of tick-borne, heartworm, and intestinal parasite diseases in in a single diet. From urinary and anxiety
U.S. pets. These maps are based on a broad collection of data, issues to improvements in weight
including tick-borne and heartworm disease test results, climate management, a pet can improve its
statistics, vector censuses, economic fgures, and population overall wellness. To learn more, visit
densities. Heres what can be expected in 2016: multifunction.royalcanin.com.
Lyme disease is expected to have a higher than normal
national prevalence, even in recently invaded states, such as
Illinois, Iowa, Indiana, and Kentucky. Eastern states, including
New York, Pennsylvania, and West Virginia, and the west,
including northern California, will see increased Lyme-
positive animals, while New England is expected to have
below normal activity, most likely due to increased testing,
treatment, and prevention.
While this year is expected to be average for
anaplasmosis, it will be prevalent in New York, western
Pennsylvania, West Virginia, and northern California, but
the upper Midwest, including Minnesota and Wisconsin, is
expected to see a lower than average number of animals
testing positive.
Ehrlichiosis will also present as average this year.
However, above normal activity is forecast for western Texas,
Oklahoma, and Missouri, where Ehrlichia remains prevalent,
as well as for southeastern states and southern California.
Arkansas, where Ehrlichia is traditionally rampant, will see
fewer cases.
Positive heartworm diagnoses will increase nationwide, with
increased activity seen particularly in the lower Mississippi
River region, eastern Missouri, southern Illinois and Indiana,
New Mexico (due to the wet winter that has left more
standing water than normal), northern California, and
southern Florida (where incidence has been down for many
years).
In addition to the forecast maps, CAPC also offers prevalence
data that localizes reported parasitic disease down to the
county level. Visit capcvet.org to download the maps and
prevalence data for free; a free CAPC app for iPads is available
for download through iTunes.

tvpjournal.com | July/august 2016 19

 Todays VeTerinary news

WELLNESS MONITORING
PROGRAM FOR
MANAGEMENT OF
CANINE CONDITIONS
i4C Innovations, Inccreator of the Voyce Health and Wellness
Management Systemis pleased to announce that the
implementation of the Voyce Pro Wellness Monitoring Program
by veterinarians has helped save or improve the lives of dogs
in several case studies. Voyce Pro enables remote observation
VETERINARIAN BECOMES
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CERTIFIED CRIMINAL
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INVESTIGATOR
burned. This data is collected from a dogs home environment
Dr. Ernest Rogers of Maplewood,
and is used to drive better patient outcomes and practice health.
New Jersey, has achieved the
Product information and support for Voyce Pro is available at
prestigious designation of Certifed
voycepro.com.
Criminal Investigator (CCI) by the
American College of Forensics
Examiners Institute, the worlds
PET-FRIENDLY WORKPLACE WINS IN NEW SURVEY
largest association for professionals
Banfeld Pet Hospitals released its frst Pet-Friendly Workplace
in the feld of forensic science. A CCI
PAWrometer (pets at work barometer) survey, revealing the
is a professional investigator who
positive impact pet-friendly workplaces have on employees and
uses forensic skills to investigate
human resources decision makers. The vast majority of responses
all types of cases. The designation
indicate that pet-friendly workplaces have a positive impact,
CCI identifes a professionals high
boost morale, and contribute to talent retention and loyalty. More
level of excellence, achievement,
information and a full executive summary on the Banfeld Pet-
and competence, and it confrms
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that the professional has made a
about-us/news-room/press-releases-announcements/banfeld-
commitment to providing reliable
shares-data-on-the-positive-impact-of-pet.
service and maintaining the highest
of ethical standards. Learn more at
acfei.com.
REGISTRATION OPEN FOR
THE 2016 VETERINARY
TECHNOLOGY SUMMIT
For more Registration is now open for
Henry Schein Animal Healths 2016 Veterinary Technology Summit,
veterinary an event that will focus on helping veterinary practices increase
news, go to their practice management software usage and improve practice DIABETES SCREENING
effciency and proftability. The summit will take place October PROGRAM DIAGNOSES
Facebook.com/
19-21 at the Gaylord Opryland Resort & Convention Center in HUNDREDS OF PETS
TodaysVeterinary
Practice Nashville, Tennessee. Attending veterinarians and their staff will Thousands of pets were screened
receive hands-on software training classes for the companys in 2015 at participating veterinary
AVImark, ImproMed Infnity, and ImproMed Triple Crown clinics, and 353 were diagnosed
software programs. To register or receive more information, visit with diabetes, thanks to the
vetsummit.com. collaboration of Merck Animal
Health, Nestl Purina PetCare,
and Zoetis through the Diabetes
NEW URINARY DIET FORMULA Pet Care Alliance. As part of the
FOR DOGS program, owners whose pets were
Purina Pro Plan Veterinary Diets is introducing diagnosed with the disease received
dry UR Urinary Ox/St Canine Formula as an a Diabetes Pet Care Alliance disease
additional dietary option for managing struvite management kit that contained a
or calcium oxalate bladder stones in dogs. free glucose monitoring system, free
The new UR Canine diet was formulated therapeutic food, and free insulin.
with controlled mineral levels to promote a Merck, Nestl Purina PetCare, and
urinary environment that is unfavorable to Zoetis have plans to collaborate
the development of both sterile struvite and once again during National
calcium oxalate crystals. Information about Diabetes Month in November 2016.
Purina Pro Plan Veterinary Diets can be found For more information, please visit
at purinaproplanvets.com. usa.petdiabetesmonth.com.

20 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com

END THE ITCH CYCLE.
BEGIN FAST AND SAFE
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A targeted therapy that quickly and safely controls the itch associated with allergies in dogs
so you can feel condent that youre improving the quality of life for the dog and its owner.
NOVELUniquely targets the cytokines involved in itch and inammation with minimal negative impact on
immune function1
FASTProvides onset of relief within 4 hours. Efectively controls itch within 24 hours2,3
SAFEWithout many of the side efects associated with steroids3,4

APOQUEL is not a steroid or cyclosporine

To learn more, please visit www.APOQUEL.com

Indications
Control of pruritus associated with allergic dermatitis and control of atopic dermatitis in dogs at least 12 months of age.
Important Safety Information
Do not use APOQUEL in dogs less than 12 months of age or those with serious infections. APOQUEL may increase the
chances of developing serious infections, and may cause existing parasitic skin infestations or pre-existing cancers to
get worse. APOQUEL has not been tested in dogs receiving some medications including some commonly used to treat
skin conditions such as corticosteroids and cyclosporines. Do not use in breeding, pregnant, or lactating dogs. Most
common side efects are vomiting and diarrhea. APOQUEL has been used safely with many common medications
including parasiticides, antibiotics and vaccines.
For more information, please see Brief Summary of full Prescribing Information on next page.
References: 1. Gonzales A, Bowman J, Fici G, Zhang M, Mann D, Mitton-Fry M. Oclacitinib (Apoquel) is a novel Janus kinase inhibitor with activity against cytokines involved in
allergy. J Vet Pharmacol Ther. In press. 2. Data on le. Study report A161R-AU-12-096. 2013. Zoetis Inc. 3. Cosgrove SB, Wren JA, Cleaver DM, et al. Efcacy and safety of oclacitinib
for the control of pruritus and associated skin lesions in dogs with canine allergic dermatitis. Vet Dermatol. 2013;24(5):479-e114. 4. Cosgrove SB, Wren JA, Cleaver DM, et
al. A blinded, randomized, placebo-controlled trial of the efcacy and safety of the Janus kinase inhibitor oclacitinib (Apoquel) in client-owned dogs with atopic dermatitis.
Vet Dermatol. 2013;24(6):587-e142. doi:10.1111/vde.12088.

All trademarks are the property of Zoetis Services LLC or a related company or a licensor unless otherwise noted.
2016 Zoetis Services LLC. All rights reserved. APQ-00376
Brief Summary of Prescribing Information
For oral use in dogs only In the 283 dogs that received APOQUEL, the following additional clinical signs were reported
Caution: Federal (USA) Law restricts this drug to use by or on the order of a licensed veterinarian. after beginning APOQUEL (percentage of dogs with at least one report of the clinical sign as a
non-pre-existing fnding): pyoderma (12.0%), non-specifed dermal lumps (12.0%), otitis (9.9%),
Indications: Control of pruritus associated with allergic dermatitis and control of atopic dermatitis vomiting (9.2%), diarrhea (6.0%), histiocytoma (3.9%), cystitis (3.5%), anorexia (3.2%), lethargy
in dogs at least 12 months of age. (2.8%), yeast skin infections (2.5%), pododermatitis (2.5%), lipoma (2.1%), polydipsia (1.4%),
Dosage and Administration: The dose of APOQUEL (oclacitinib maleate) tablets is 0.18 to lymphadenopathy (1.1%), nausea (1.1%), increased appetite (1.1%), aggression (1.1%), and
0.27 mg oclacitinib/lb (0.4 to 0.6 mg oclacitinib/kg) body weight, administered orally, twice daily weight loss (0.7).
for up to 14 days, and then administered once daily for maintenance therapy. APOQUEL may be Control of Pruritus Associated with Allergic Dermatitis
administered with or without food. In a masked feld study to assess the effectiveness and safety of oclacitinib for the control of
Dosing Chart pruritus associated with allergic dermatitis in dogs, 216 dogs treated with APOQUEL and 220 dogs
treated with placebo (vehicle control) were evaluated for safety. During the 30-day study, there
Weight Range Weight Range
Number of Tablets to be Administered were no fatalities and no adverse reactions requiring hospital care. Adverse reactions reported (and
(in lb) (in Kg)
percent of dogs affected) during Days 0-7 included diarrhea (2.3% APOQUEL, 0.9% placebo),
Low High Low High 3.6 mg 5.4 mg 16 mg Tablets vomiting (2.3% APOQUEL, 1.8% placebo), lethargy (1.8% APOQUEL, 1.4% placebo), anorexia
Tablets Tablets (1.4% APOQUEL, 0% placebo), and polydipsia (1.4% APOQUEL, 0% placebo). In most of these
6.6 9.9 3.0 4.4 0.5 - - cases, signs spontaneously resolved with continued dosing. Five APOQUEL group dogs were
10.0 14.9 4.5 5.9 - 0.5 - withdrawn from study because of: darkening areas of skin and fur (1 dog); diarrhea (1 dog); fever,
15.0 19.9 6.0 8.9 1 - - lethargy and cystitis (1 dog); an infamed footpad and vomiting (1 dog); and diarrhea, vomiting,
20.0 29.9 9.0 13.4 - 1 - and lethargy (1 dog). Dogs in the APOQUEL group had a slight decrease in mean white blood cell
30.0 44.9 13.5 19.9 - - 0.5 counts (neutrophil, eosinophil, and monocyte counts) that remained within the normal reference
45.0 59.9 20.0 26.9 - 2 - range. Mean lymphocyte count for dogs in the APOQUEL group increased at Day 7, but returned to
60.0 89.9 27.0 39.9 - - 1 pretreatment levels by study end without a break in APOQUEL administration. Serum cholesterol
90.0 129.9 40.0 54.9 - - 1.5 increased in 25% of APOQUEL group dogs, but mean cholesterol remained within the reference
130.0 175.9 55.0 80.0 - - 2 range.
Warnings: Continuation Field Study
APOQUEL is not for use in dogs less than 12 months of age (see Animal Safety). After completing APOQUEL feld studies, 239 dogs enrolled in an unmasked (no placebo control),
APOQUEL is not for use in dogs with serious infections. continuation therapy study receiving APOQUEL for an unrestricted period of time. Mean time
APOQUEL may increase susceptibility to infection, including demodicosis, and exacerbate on this study was 372 days (range 1 to 610 days). Of these 239 dogs, one dog developed
neoplastic conditions (see Adverse Reactions and Animal Safety). demodicosis following 273 days of APOQUEL administration. One dog developed dermal
Human Warnings: pigmented viral plaques following 266 days of APOQUEL administration. One dog developed a
This product is not for human use. Keep this and all drugs out of reach of children. For use in dogs moderately severe bronchopneumonia after 272 days of APOQUEL administration; this infection
only. Wash hands immediately after handling the tablets. In case of accidental eye contact, fush resolved with antimicrobial treatment and temporary discontinuation of APOQUEL. One dog was
immediately with water or saline for at least 15 minutes and then seek medical attention. In case of euthanized after developing abdominal ascites and pleural effusion of unknown etiology after
accidental ingestion, seek medical attention immediately. 450 days of APOQUEL administration. Six dogs were euthanized because of suspected malignant
neoplasms: including thoracic metastatic, abdominal metastatic, splenic, frontal sinus, and
Precautions: intracranial neoplasms, and transitional cell carcinoma after 17, 120, 175, 49, 141, and 286 days
APOQUEL is not for use in breeding dogs, or pregnant or lactating bitches. of APOQUEL administration, respectively. Two dogs each developed a Grade II mast cell tumor after
The use of APOQUEL has not been evaluated in combination with glucocorticoids, cyclosporine, or 52 and 91 days of APOQUEL administration, respectively. One dog developed low grade B-cell
other systemic immunosuppressive agents. lymphoma after 392 days of APOQUEL administration. Two dogs each developed an apocrine gland
Dogs receiving APOQUEL should be monitored for the development of infections, including adenocarcinoma (one dermal, one anal sac) after approximately 210 and 320 days of APOQUEL
demodicosis, and neoplasia. administration, respectively. One dog developed a low grade oral spindle cell sarcoma after
Adverse Reactions: 320 days of APOQUEL administration.
Control of Atopic Dermatitis To report suspected adverse events, for technical assistance or to obtain a copy of the MSDS,
In a masked feld study to assess the effectiveness and safety of oclacitinib for the control of atopic contact Zoetis Inc. at 1-888-963-8471 or www.zoetis.com.
dermatitis in dogs, 152 dogs treated with APOQUEL and 147 dogs treated with placebo (vehicle
control) were evaluated for safety. The majority of dogs in the placebo group withdrew from the For additional information about adverse drug experience reporting for animal drugs, contact FDA
112-day study by Day 16. Adverse reactions reported (and percent of dogs affected) during Days at 1-888-FDA-VETS or online at http://www.fda.gov/AnimalVeterinary/SafetyHealth.
0-16 included diarrhea (4.6% APOQUEL, 3.4% placebo), vomiting (3.9% APOQUEL, 4.1% Storage Conditions:
placebo), anorexia (2.6% APOQUEL, 0% placebo), new cutaneous or subcutaneous lump APOQUEL should be stored at controlled room temperature between 20 to 25C (68 to 77F) with
(2.6% APOQUEL, 2.7% placebo), and lethargy (2.0% APOQUEL, 1.4% placebo). In most cases, excursions between 15 to 40C (59 to 104F).
diarrhea, vomiting, anorexia, and lethargy spontaneously resolved with continued dosing. How Supplied:
Dogs on APOQUEL had decreased leukocytes (neutrophil, eosinophil, and monocyte counts) and APOQUEL tablets contain 3.6 mg, 5.4 mg, or 16 mg of oclacitinib as oclacitinib maleate per tablet.
serum globulin, and increased cholesterol and lipase compared to the placebo group but group Each strength tablets are packaged in 20 and 100 count bottles. Each tablet is scored and marked
means remained within the normal range. Mean lymphocyte counts were transiently increased at with AQ and either an S, M, or L that correspond to the different tablet strengths on both sides.
Day 14 in the APOQUEL group.
NADA #141-345, Approved by FDA
Dogs that withdrew from the masked feld study could enter an unmasked study where all dogs
received APOQUEL. Between the masked and unmasked study, 283 dogs received at least one Made in Italy
dose of APOQUEL. Of these 283 dogs, two dogs were withdrawn from study due to suspected
treatment-related adverse reactions: one dog that had an intense fare-up of dermatitis and se-
vere secondary pyoderma after 19 days of APOQUEL administration, and one dog that developed
generalized demodicosis after 28 days of APOQUEL administration. Two other dogs on APOQUEL
were withdrawn from study due to suspected or confrmed malignant neoplasia and subsequently
euthanized, including one dog that developed signs associated with a heart base mass after 21 days Distributed by:
of APOQUEL administration, and one dog that developed a Grade III mast cell tumor after 60 days Zoetis Inc.
of APOQUEL administration. One of the 147 dogs in the placebo group developed a Grade I mast Kalamazoo, MI 49007
cell tumor and was withdrawn from the masked study. Additional dogs receiving APOQUEL were February 2013 428007800A&P
hospitalized for diagnosis and treatment of pneumonia (one dog), transient bloody vomiting and
stool (one dog), and cystitis with urolithiasis (one dog).
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 Peer reviewed sUrGicaL sKiLLs: LymPhadenecTomy
Lymphadenectomy: Overview of
Surgical Anatomy & Removal of
Peripheral Lymph Nodes
Tanya Wright, DVM, and Michelle L. Oblak, DVM, DVSc, Diplomate ACVS (Small Animal),
ACVS Fellow of Surgical Oncology
Ontario Veterinary College, University of Guelph
In the feld of veterinary oncology, lymphadenectomy
can play an important role in our veterinary
patients with regard to clinical staging, determining
prognosis, developing treatment plans, and
decreasing tumor burden.
For a given oncologic disease, peripheral regional
lymph nodes should be carefully palpated for
enlargement, asymmetry, and degree of fxation.
While identifcation of palpably enlarged lymph
nodes is typically straightforward, identifcation and
extirpation of peripheral lymph nodes when they are
of normal size can be challenging.
Techniques for surgical excision of peripheral
lymph nodes are infrequently described in the
literature. The goal of this article is to describe
the location and anatomy of commonly removed
peripheral lymph nodes and illustrate effective
strategies for surgical excision of these nodes.
GENERAL LYMPH NODE FUNCTION &
ANATOMY
The lymph node is the structural and functional unit
of the lymphatic system. Lymph nodes act as a flter of
lymph, as well as a germinal center for lymphocytes.
Lymph nodes are typically frm, smooth, and
ovoid or bean-shaped. They contain a poorly
defned cortex and medulla, and have a concave
hilus region, which contains efferent lymphatics and
blood vessels.
Lymph fows from lymph capillaries via the
afferent lymph vessels to the regional lymph node,
and efferent lymph vessels leave the lymph node,
carrying lymph that is fltered and enriched with
lymphocytes.
Groups of neighboring lymph nodes that occur
CE
ARTICLE
in the same region of the body and receive afferent
vessels from approximately the same region, in
most species, are known as lymphocentrums or
lymphocenters.
24 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com
INDICATIONS FOR LYMPH NODE
BIOPSY
Research suggests that lymph node biopsy should
be performed to determine regional lymph node
status in patients in which malignant disease is a
possibility.1-6 Lymph node biopsy methods include:
Fine-needle aspiration and cytology
Needle core biopsy
Incisional biopsy
Excisional biopsy.
Palpation
Abnormal lymph node palpation may be helpful for
raising suspicion for metastatic disease; however,
clinical judgment regarding metastasis to local
lymph nodes should not be based on palpation
alone, as lymph node size is not an accurate
predictor of metastasis.1-3
Aspiration & Cytology
Lymph node fne-needle aspiration and cytology
is easy, quick, noninvasive, and has been shown to
be highly sensitive and specifc for detecting solid
tumor metastasis to regional lymph nodes.2,3
Within a lymph node, metastatic lesions may
be focal and missed by cytology. If metastasis is
suspected clinically, but cytology is negative for
neoplastic cells, histopathology is warranted to
ensure the cytology sample is representative of the
entire lymph node.
In addition, for head and neck lesions, the
sensitivity of cytology is only reported for mandibular
lymph nodes. Access to the retropharyngeal lymph
nodes for aspiration can be challenging and typically
requires ultrasound guidance, which may be a
limitation of this technique.
Mixed cell responses are often hard to interpret,
as some cells do not readily exfoliate and, in some
cases, reactive hyperplasia can mimic neoplasia.
 sUrGicAL sKiLLs: LymPhAdenecTomy Peer reviewed

Needle Core & Incisional Biopsy

We rarely perform needle core or incisional biopsies
unless the lymph node is signifcantly enlarged, due
to the relative ease of excisional biopsy. If a needle
core or incisional biopsy is performed, prolonged
direct pressure to the lymph node or closure of the
capsule may be required to address any hemorrhage
that occurs.

Excisional Biopsy
When possible, excisional lymph node biopsy is
considered the preferred method to determine if
metastatic disease is present. Excisional lymph node
biopsy is also warranted in patients with metastatic
neoplasia in which lymph node biopsy is not only
useful for diagnosis, but also to decrease tumor
burden prior to adjunctive therapy.

SELECTION OF LYMPH NODES

Common peripheral lymph node biopsy sites
(Figure 1) include:
Mandibular lymph nodes
Medial retropharyngeal lymph nodes
Superficial cervical (prescapular) lymph nodes
Popliteal lymph nodes.
The mandibular lymph nodes are the easiest to
palpate and, subsequently, the easiest to surgically
remove.
Figure 1. illustration of the pertinent regional anatomy of the neck
In dogs and cats, the medial retropharyngeal
lymph node group serves as the collecting center
for the head, receiving drainage from the lateral
retropharyngeal, parotid, and mandibular nodes.
Based on lymphatic drain patterns, the medial
retropharyngeal lymph node may yield the most

Techniques for removal include sharp or blunt
dissection or careful electrocautery, aiming to
stay immediately outside the lymph node capsule
(Figure 2). Cotton tip applicators (ie, cotton
swabs) can be used to perform blunt dissection
of small or more delicate lymph nodes.
Maintaining a grip on the lymph node to
be removed is recommended to avoid losing its
location. To maintain a tight hold on the desired
lymph node and aid in dissection, the perinodal
tissue can be carefully grasped with thumb Lymphadenectomy:
forceps, Allis tissue forceps, or a stay suture
placed through the node, depending on the size Approach &
and fragility of the node. Care must be taken to
avoid crush artifact of the lymph node. Supplies
Ligation of the lymph nodes blood supply,
provided via the vascular hilus, can be achieved
using absorbable monoflament suture (ie,
4-0 or 3-0 PDS, depending on size) or with
electrocautery.

A B C
Figure 2. extirpation of the lymph node is accomplished with a combination of blunt and sharp dissection (A). The lymph
node is grasped with fngers or the perinodal tissue to prevent damage, as it can be very friable (B). Electrocautery, if avail-
able, can be useful for dissection and coagulation of small vessels and the vascular bundle (C).

tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice 25

 Peer reviewed sUrGicaL sKiLLs: LymPhadenecTomy

information regarding regional metastasis of oral
neoplasms.7 However, these lymph nodes cannot be
palpated when normal in size and are one of the most
challenging types of lymph nodes to identify surgically.
In the neck, commonly, only the superfcial
cervical lymph nodes are excised, as the deep
cervical lymph nodes are deeply located, variable in
number and position, small in size, and require a
much more extensive dissection for removal.
The popliteal lymph node is easily located caudal
and distal to the stife. This lymph center is typically
present as a single node and it is the easiest lymph
node to sample when peripheral lymphadenopathy is
present.

MANDIBULAR LYMPH NODE CENTER typically long and ovoid, approximately

TECHNIQUE 10 mm wide by 20 mm long, and flattened
Anatomy transversely.
The mandibular lymph nodes (Figure 3 and Table)
are: Patient Positioning
Bilateral Position the patient in:
Comprised of groups of 2 or 3, and occasionally up Lateral recumbency, with the affected side up, for
to 5, nodes unilateral removal
Superficial in location. Dorsal recumbency for bilateral removal (see
The two most prominent and predictable lymph Patient Positioning, Medial Retropharyngeal
nodes in the group lie immediately dorsal and ventral Lymph Node Center, page 28).
to the facial vein: If bilateral lymphadenectomy of the mandibular
The dorsal mandibular lymph node is typically and retropharyngeal lymph nodes is desired, the
flattened, 3-sided, and approximately 10 mm long midline ventral cervical technique is recommended
in the dog. (see Surgical Technique, Medial Retropharyngeal
The ventral mandibular lymph node is Lymph Node Center, page 28).

Table.
Key Anatomical Landmarks for Lymph Nodes
TECHNIQUE LYMPH NODE LANDMARKS

Mandibular lymph Just ventral and caudal to angular process of

node center mandible
Caudoventral to masseter muscle
Located on either side of facial vein, craniomedial to
bifurcation of linguofacial vein bifurcation
Cranial to mandibular salivary gland
Craniolateral to the basihyoid
Medial Ventral to wing of the atlas
retropharyngeal Bound by digastricus muscle cranially, longus
lymph node colli muscle dorsally, and larynx and pharynx
center ventromedially
Medial, dorsal, and slightly caudal to the easily
palpable mandibular salivary gland
Medial and immediately caudal to linguofacial vein
bifurcation
Caudal to hyoid venous arch
Superfcial Located at cranial edge of supraspinatus muscle, just
cervical under the omotranversarius muscle
(prescapular) Superfcial cervical artery and vein are located medial
lymph node to caudal portion of lymph node Figure 3. Position of the mandibular (A) and
center medial retropharyngeal (B) lymph nodes relative
to the anatomy of the neck, mandibular salivary
Popliteal lymph Located, along with surrounding subcutaneous fat, in gland (C), caudal extent of the mandible (D),
node center the popliteal space caudal to stife joint
thyroid cartilage (E), cricoid cartilage (F), trachea
Lateral saphenous vein courses proximally to
(G), external jugular vein (H), hyoid venous arch
gastrocnemius muscle to the level of popliteal lymph
node caudal to stife joint (I), facial vein (J), and thyroid gland (K).

26 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com

 sUrGicAL sKiLLs: LymPhAdenecTomy Peer reviewed

Surgical Technique
1. Palpate the freely mobile mandibular lymph node
just caudal to the caudal angle of the mandible.
2. While digitally grasping the desired lymph node,
make an incision parallel with the angle of the
mandible, directly over the node (Figure 4).
3. Continue the incision through the subcutaneous
tissue until the superfcially located lymph node
is encountered. Be cautious with dissection as the
facial vein lies directly beneath this node and can
be inadvertently lacerated.
4. Grasp the node atraumatically with thumb forceps
or Allis tissue forceps, or use a stay suture; dissect
it free from surrounding tissue.
5. Repeat this procedure, if needed, on the
contralateral side.
6. Close the subcutaneous tissues in a single layer Figure 4. incision for single mandibular lymph
node removal. This approach can be performed
interrupted or continuous closure, with 3-0 or
bilaterally but only is recommended for access
4-0 monoflament absorbable suture. and excision of the mandibular lymph nodes.
7. Close the skin in interrupted cruciate pattern.

MEDIAL RETROPHARYNGEAL LYMPH yield with regard to staging and, in our institution,
NODE CENTER TECHNIQUES are not excised unless overtly abnormal.
Anatomy Regardless of the technique selected, identifcation
The medial retropharyngeal lymph nodes (Figure 3 of a normal-sized retropharyngeal lymph node can
and Table) are: be challenging and good anatomical knowledge is
Bilateral essential for effcient and safe removal.
Comprised of either 1 or 2 nodes
More deeply located than the mandibular lymph
nodes, but still within the deep subcutaneous tissue
and external pharyngeal fascia layer.
These lymph nodes are the largest nodes in
the head and neck. The most prominent node in
the group is elongated, transversely compressed,
and approximately 50 mm long by 20 mm wide
(Figure 5). Do not confuse them with the thyroid
gland, which is closer to midline, medial to the
carotid artery and caudal to the thyroid cartilage. The A
thyroid gland is also generally smaller with a more
distinct blood supply.
Normal medial retropharyngeal lymph nodes
cannot be palpated externally. In addition, important
structures located in the neck can be damaged with
extensive and unnecessary dissection, including the
recurrent laryngeal nerve, vagosympathetic trunk,
carotid artery, and jugular vein.
For unilateral removal of a medial retropharyngeal
lymph node, a lateralized or ventral midline incision
B
can be performed. Concurrent unilateral removal
Figure 5. Removal of retropharyngeal lymph
of the parotid, submandibular, and retropharyngeal
node (A); note the typical tubular or elongated
lymph nodes has also been described,3 although the
shape (B) of this normal lymph node.
parotid lymph nodes are generally considered low

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 Peer reviewed sUrGicaL sKiLLs: LymPhadenecTomy
Figure 6. Patient positioning for access to bilateral mandibular
retropharyngeal lymph nodes. A rolled towel can be placed under
the neck to aid in providing a fat working surface. The area for hair
removal in this image is based on a midline approach and would need
to be more lateral for the lateralized approach. The dotted line rep-
resents the location of the incision.
Patient Positioning
Position the patient in dorsal recumbency with a
rolled towel under the neck (Figure 6).
Surgical Technique: Lateralized Incision
This approach is not commonly performed but can
be used unilaterally or bilaterally for removal of the
medial retropharyngeal lymph nodes. The mandibular
lymph nodes can also be removed, as described
earlier, from this approach.
Approach
1. Palpate the mandibular salivary gland and
mandibular lymph nodes caudal to the angular
process of the mandible.
2. Make an approximately 3- to 5-cm incision,
starting just cranial to the mandibular salivary
gland, in a craniolateral to caudomedial direction.
This incision can be extended in either direction
as necessary.
3. Continue the skin incision through the
superfcial subcutaneous tissue layer. Small
vessels encountered can be cauterized with
electrocoagulation or grasped with mosquito
forceps to minimize bleeding.
4. Use Gelpi retractors for skin retraction and
to help improve visualization of the deeper
structures.
Retropharyngeal Lymph Nodes
5. Identify the mandibular salivary gland and retract
laterally.
6. Identify the medial retropharyngeal lymph node.
The cranial border of the lymph node is often
28 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com
medial and caudal to the caudal pole of the
salivary gland, and medial to the linguofacial vein
(not always seen) when approached using this
technique.
7. Carefully dissect the lymph node free with blunt
dissection, staying close to the capsule and taking
care to not extend the dissection too medially.
8. Ligate or cauterize the vessels located at the hilus
and remove the lymph node.
Closure
9. Close the subcutaneous tissues in a single or
double layer subcutaneous closure (depending
on dead space) with 3-0 or 4-0 monoflament
absorbable suture.
10. Close the skin in an interrupted cruciate or Ford
interlocking pattern.
Surgical Technique: Midline Ventral Cervical
Incision
This approach is recommended when bilateral
excision of the medial retropharyngeal bilateral
mandibular lymph nodes is desired.6
Approach
1. Identify the angular process of one side of the
mandible and palpate the ipsilateral mandibular
lymph nodes externally just ventral and caudal
to this location. Do not mistakenly identify the
mandibular salivary gland, which lies just caudal
and dorsal to the lymph nodes, as a lymph node.
2. Perform a ventral cervical midline incision that
extends from just cranial to the angular process of
the mandibles to the cranial aspect of the larynx
(thyroid cartilage). This skin incision location is
essentialdo not make the approach too caudal.
3. Continue the skin incision through the superfcial
subcutaneous tissue layer, taking care not to
dissect too deeply. Small vessels encountered can
be cauterized with electrocoagulation or grasped
with mosquito forceps to minimize bleeding.
4. Use Gelpi retractors to help improve visualization
of lymph nodes.
Mandibular Lymph Nodes
5. Approach the mandibular lymph nodes frst,
identifying the mandibular salivary gland and
linguofacial bifurcation.
6. Gently dissect the superfcial subcutaneous tissue
layer with blunt dissection until the ventral
mandibular lymph node is encountered, just
ventral to the facial vein.
 sUrGicAL sKiLLs: LymPhAdenecTomy Peer reviewed

7. Once identifed, dissect the ventral mandibular

lymph node free from surrounding tissue,
staying close to the lymph node capsule. Ligate
or cauterize the vessels located at the hilus and
remove the lymph node.
8. Repeat the procedure on the contralateral
side through the same incision to remove the
contralateral lymph node.

Retropharyngeal Lymph Nodes

9. Use the hyoid venous arch (Figure 3) as a landmark
for orientationthe retropharyngeal lymph node is
located caudal to this often-prominent vessel and at
the level of the cricoid cartilage.
10. Identify the lymph node medial, dorsal, and slightly
caudal to the easily palpable mandibular salivary
gland, parallel to the linguofacial vein, and just
caudal and medial to the linguofacial bifurcation.
11. Retract the salivary gland laterally and cranially
and retract the sternocephalicus muscle laterally.
Remove the medial retropharyngeal lymph nodes
as described above.
Closure
12. Once the mandibular and retropharyngeal lymph
nodes are removed, two small spaces where
previous lymph nodes existed can be observed
(Figure 7).
Figure 7. Appearance of the neck following
removal of the mandibular (thin arrow) and
retropharyngeal (wide arrow) lymph nodes
on one side. The skin incision has been pulled
laterally; note the linguofacial bifurcation
(arrowhead). The salivary gland is also located
dorsal to the bifurcation in this image but is
diffcult to visualize.
13. Close the subcutaneous tissues in a single or
double layer subcutaneous closure (depending
on dead space) with 3-0 or 4-0 monoflament
absorbable suture.
14. Close the skin in an interrupted cruciate or Ford
interlocking pattern.

SUPERFICIAL CERVICAL (PRESCAPULAR)

LYMPH NODE CENTER TECHNIQUE
Anatomy
The superfcial cervical (prescapular) lymph nodes
(Figure 8 and Table) are:
Bilateral
Comprised of 1, 2, or occasionally, greater than 3
nodes
Located just cranial to the shoulder joint in the
subcutaneous tissue, under the superficial muscles
of the neck.
The majority of these lymph nodes are oval in
shape, somewhat fattened, and approximately 30
mm long by less than 10 mm thick.

Patient Positioning
Position the patient in dorsal or dorsolateral
recumbency, with the forelimb of the affected side
pulled caudally (Figure 9, page 30).
Drape the affected shoulder region into the
surgical feld. The affected limb can also be draped
into the surgical feld to assist with manipulation and
positioning.
Figure 8. Position of the superfcial cervical
lymph node relative to relevant local anatomy.
The region is frst identifed by palpation of the
point of shoulder (A). The lymph node is medial
to the omotransversarius muscle (B), subscapu-
laris muscle (C), and cleidocephalicus muscle (D).
The lymph node is highlighted in green.

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Peer reviewed sUrGicaL sKiLLs: LymPhadenecTomy

Figure 10. View of the omotransversarius

muscle after the incision has been made in the
patient from Figure 9. In this patient, the incision
is quite large because the lymph node is very
enlarged (as can be seen in Figure 9B).

and rib cage. Make an approximately 3- to 5-cm

B of the omotransversarius muscle.
Figure 9. Patient positioned for extirpation of
the superfcial cervical lymph node (A) and sub-
sequent incision (B).
Surgical Technique
1. First, palpate the lymph node(s) externally, if
possible. This is one of the more diffcult lymph
nodes to identify if not enlarged.
2. Palpate the point of shoulder, medial to scapula
incision just cranial to the shoulder, starting at the
shoulder and extending cranially in the direction
3. Locate the lymph nodewhich is just medial to
the superfcial neck muscle and omotransversarius
(Figure 10) and supraspinatus muscles of the
scapulaand excise it.
4. Close the subcutaneous tissues in a single or
double layer subcutaneous closure (depending
on dead space) with 3-0 or 4-0 monoflament
absorbable suture. Close the skin in an interrupted
cruciate or Ford interlocking pattern.

POPLITEAL LYMPH NODE CENTER

TECHNIQUE
Anatomy
The popliteal lymph node center is composed of the
superfcial popliteal lymph nodes only. These lymph
nodes (Figure 11 and Table) are:
Most frequently single but, in rare cases, can be double
Consistent in positionlocated in the subcutaneous
fat deposit between the medial border of the biceps
femoris and medial border of the semitendinosus
muscle where the muscles diverge from each other.
This oval-shaped lymph node is considered
the largest lymph node of the pelvic limb and is
approximately 20 mm long.

Patient Positioning Figure 11. Position of the popliteal lymph node

Position the patient in dorsal or lateral recumbency,
with the pelvic limb draped into the surgical feld.
Surgical Technique
1. Locate the dead space (popliteal fossa) between the
relative to the relevant anatomy of the pelvic
limb, including the semimembranosus muscle
(A), semitendinosus muscle (B), gastrocnemius
muscle (C), and lateral saphenous vein (D). The
lymph node is highlighted in green.

30 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com


A B
Figure 12. Popliteal lymph node removal (A) and closed incision (B). In this case, the lymph node is a
normal size.
hamstring muscles and biceps femoris muscle by
palpating the stife joint and drawing a straight
line to the caudal aspect of the stife.
2. Palpate the lymph node and perform a
proximodistal incision in the popliteal space over
the lymph node (Figure 12). The lymph node
is in a relatively superfcial position and extensive
or deep dissection should not be necessary to
identify the node. The lymph node is often
COMPLICATIONS OF
LYMPHADENECTOMY
Potential complications of lymphadenectomy include:
Infection, incision dehiscence, and seroma of the
surgical site
If careful and close dissection technique is not
followed, potential risk of laceration of the major
vessels of the neck or nerve damage
Accidental removal of mandibular salivary glands
during mandibular or medial retropharyngeal
lymphadenectomy.
Lymph node dissection may result in disruption of
the normal drainage pattern of the lymph nodes that
can cause an abnormal collection of lymphatic fuid
TANYA WRIgHT
Tanya Wright, DVM, is a small animal surgical
resident at Ontario Veterinary College
(OVC), Canada. She is currently researching
surgical methods for staging canine cancers
and minimally invasive surgery options for
osteosarcoma and splenic tumors. Dr. Wright
received her DVM from Western College of
Veterinary Medicine, Saskatchewan, Canada.
She completed a rotating small animal
internship at Atlantic Veterinary College,
Prince Edward Island; a surgical internship at
the Veterinary Emergency Clinic, Toronto; and
a surgical oncology and soft tissue surgery
internship at OVC prior to her residency.
tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice
sUrGicAL sKiLLs: LymPhAdenecTomy Peer reviewed
surrounded by fat and can be diffcult to identify
but should be the only round superfcial structure
in this region. Once identifed, grasp the lymph
node gently, bluntly dissect the fat to expose the
underlying lymph node, and then excise routinely.
3. Close the subcutaneous tissues in a single layer
interrupted or continuous closure with 3-0 or 4-0
monoflament absorbable suture. Close the skin in
an interrupted cruciate pattern.
(lymphedema), especially when both mandibular
and medial retropharyngeal lymph nodes are
removed. This is a transient condition, however,
and not expected to be a chronic complication of
lymphadenectomy.
Minimizing Complications
Complications can be minimized by following these
strategies:
Ensure you have a thorough understanding of the
regional anatomy.
Remove only affected and necessary lymph nodes.
Carefully dissect and gently handle tissue to
minimize dead space and trauma to the tissue bed.
MICHELLE L. ObLAK
Michelle L. Oblak, DVM, DVSc, Diplomate
ACVS (Small Animal), is an assistant
professor of soft tissue and oncologic
surgery at Ontario Veterinary College
(OVC), Canada. Dr. Oblak has presented
at national and international meetings
and mentors veterinary students, interns,
and residents. She has published a
number of research articles and a book
chapter. Dr. Oblak received her veterinary
degree from OVC and then completed
an ACVS Surgical Oncology Fellowship
at the University of Florida College of
Veterinary Medicine.
31
Peer reviewed sUrGicaL sKiLLs: LymPhadenecTomy SURGICAL SKILLS: LyMPHADENECTOMy

Postoperatively, decrease any possible pressure to

the head and neck (ie, neck collars), which may
disrupt lymphatic flow.
Apply warm packs to, and massage, suspected
seromas to minimize swelling.
Never drain seromas; draining allows fluid
contamination and increases risk of infection.
During dissection, do not mistake the salivary
glands for lymph nodes.

Antibiotic Therapy
In our experience, in cases of dissection of large,
abnormal lymph nodes and/or concurrent surgeries
of the head and mouth, a short course of antibiotics

Introducing (eg, frst generation cephalosporins or amoxicillin/

clavulanic acid) is recommended to decrease the risk
of postoperative infection.
VET IN SUMMARY
Stops Bleeding Fast
Lymphadenectomy is an important technique
ClotIt VET is a sterile, single-dose for evaluating abnormal lymph nodes or staging
application of ClotIt blood clotting evaluation of patients with neoplasia. With
powder the latest addition to the a good understanding of local anatomy and
ClotIt family designed exclusively lymphatic drainage patterns, peripheral lymph
for veterinarians.
node extirpation can be straightforward and
Recommended and tested by rewarding, providing valuable information for
veterinarians for use with hematomas,
bleeding tumors, dental procedures, treatment recommendations and prognosis in
and soft palate surgery. these patients.
All-natural white powder
Non-staining References
Minor to severe wounds 1. Williams LE, Packer RA. Association between lymph node
Triple-action process results in size and metastasis in dogs with oral malignant melanoma:
100 cases (19872001). JAVMA 2003; 222:12341236.
complete clotting in seconds
2. Langenbach A, McManus PM, Hendrick MJ, et al. Sensitivity
Faster than the leading competitor* and specifcity of methods of assessing the regional lymph
nodes for evidence of metastasis in dogs and cats with solid
ClotIt.com tumors. JAVMA 2001; 218(9):1424-1428.
3. Herring ES, Smith MM, Robertson JL. Lymph node staging
of oral and maxillofacial neoplasms in 31 dogs and cats. J Vet
Dent 2002; 19:122126.
4. Smith MM. Surgical approach for lymph node staging of
oral and maxillofacial neoplasms in dogs. J Vet Dent 2002;
19(3):170-174.
SOFT PALATE 5. Tuohy JL, Milgram J, Worley DR, Dernell WS. A review
SURGICAL CASE EXAMPLE: of sentinel lymph node evaluation and the need for its
Conducted by: incorporation into veterinary oncology. Vet Comp Oncol
Dr. Carlos Campos 2009; 7:8191.
Voted Americas Favorite Veterinarian 2013 6. Green K, Boston SE. Bilateral removal of the mandibular and
medial retropharyngeal lymph nodes through a single ventral
ClotIt applied during a soft palate midline incision for staging of head and neck cancers in dogs:
laser surgery stopped bleeding within A description of surgical technique. Vet Comp Oncol 2015;
45 seconds and complete hemostasis Advance online publication. doi: 10.1111/vco.12154.
was achieved. 7. Beltz GT, Heath TJ. Lymph pathways of the medial
retropharyngeal lymph node in dogs. J Anatom 1995;
*Comparison data available upon request 186:517-526.

32 32 2016
Todays VeTerinary PracTice | July/august July/August 2016 | tvpjournal.com
| tvpjournal.com
 sUrGicAL sKiLLs: LymPhAdenecTomy Peer reviewed

CE TEST. Lymphadenectomy: Overview of Surgical

Anatomy & Removal of Peripheral Lymph Nodes
This article is RACE-approved for 1 hour of continuing education credit. To receive credit,
take the approved test online at VetMedTeam.com/tvp.aspx (CE fee of $5/article).

Learning Objective
After reading this article, practitioners should be able to list the commonly sampled peripheral lymph
nodes and identify many of these lymph nodes via palpation. Readers should also be able to explain the
general surgical approach for removal of each of these nodes and describe their anatomic locations.

1. What is the primary role of lymphadenectomy 7. Which of the following lymph nodes
in patients with tumors? CANNOT be palpated externally when
a. Grading normal?
b. Staging a. Popliteal
c. Removing of all disease burden b. Superfcial cervical
d. Determining tumor type c. Mandibular Note
d. Medial retropharyngeal Questions online
2. Which of the following is NOT a role of the may differ from
lymph node? 8. Which of the following is not a landmark those here; answers
a. Lymph fltration that can be palpated to determine where to are available once
b. Lymphocyte germinal center position your ventral cervical incision? CE test is taken at
c. Tumor barrier a. Angular process of the mandible vetmedteam.com/
d. Functional unit of the lymphatic system tvp.aspx. Tests are
b. Thyroid cartilage
valid for 2 years from
c. Thyroid gland
3. Lymph node size is an accurate predictor of date of approval.
d. Mandibular salivary gland
metastasis.
a. True
9. Which of the following is INCORRECT
b. False
regarding the popliteal lymph node?
a. The popliteal lymph node center is found
4. Which of the following is the most accurate
deep within the space between the biceps
test for determination of lymph node
femoris and semitendinosus muscles.
metastasis?
b. It is most frequently single but can
a. Histopathology
occasionally be double.
b. Cytology
c. Palpation c. The lateral saphenous vein is a useful
d. Diagnostic imaging landmark for identifcation.
d. It is located just caudal to the stife joint.
5. Which of the following peripheral lymph
nodes is NOT a common biopsy site? 10. Which of the following should NOT be
a. Mandibular performed to minimize complications?
b. Medial retropharyngeal a. Minimize dead space and trauma with
c. Parotid careful dissection and gentle tissue
d. Popliteal handling.
b. Drain any seromas that form to prevent
6. When removing unilateral mandibular lymph infection and accelerate healing.
nodes, a ventral midline incision is most c. Avoid neck collars to decrease any potential
commonly used. disruption of lymphatic fow to the head and
a. True neck.
b. False d. Administer perioperative antibiotics.

tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice 33

 Peer reviewed UncoVering The caUse of feVer in dogs
Uncovering the Cause of
Fever in Dogs
Kenneth R. Harkin, DVM, Diplomate ACVIM (Small Animal Internal Medicine)
Kansas State University
The term fever of unknown origin (FUO) is often
overused in veterinary medicine, as the number of
patients in which a true cause of fever cannot be
uncovered is relatively small.
In 1961, Petersdorf and Beeson frst defned FUO
in humans as a fever 101F (38.3C) that persists
for greater than 3 weeks, with the diagnosis uncertain
after one week of study in the hospital. This defnition
has remained mostly intact today except for the
requirement of in-hospital study.1,2 The duration of
greater than 3 weeks was intended to eliminate cases
of acute self-limited infectious disease (often viral)
from the retrospective analysis of FUO cases.1
When describing FUO in dogs, fever is usually
defned as greater than 103.5F to 104F (39.7
40C), with no duration of fever specifed.3,4 In
animals, the path to revealing the cause of persistent
fever can be lengthy and expensive but, in most
patients, an etiology can be eventually identifed (see
FUO in Animals: Often a Misnomer).
CLINICAL CHALLENGES
When a patient presents with an elevated
temperature, it is important to distinguish from
FUO in Veterinary patients are often described
incorrectly as having FUO when routine
Animals: Often diagnostic testingwhich can usually be
completed over the course of a dayyields
a Misnomer negative results. In these cases, the designation
of FUO is often applied prematurely. The term
should be reserved for patients in which no
etiology is revealed after an extensive workup.
Another commonly used, yet erroneous,
criterion for defning FUO is a fever that does
not respond to empiric antibiotics. A response
to antibiotics does not prove a bacterial cause
for fever because a transient response may be
associated with an anti-infammatory effect of
the antibiotic or the waxing and waning course
of disease. Thus, the cause of fever remains
unknown.
34 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com
the outset whether the increase is due to fever
or nonfebrile hyperthermia (see Is It Fever or
Hyperthermia?).
Most dogs that present with fever have some
abnormality on physical examination that helps
guide the diagnostic process. Abnormal fndings
that present with fever may include, among
others, lymphadenomegaly, joint effusion, spinal
or paraspinal pain or discomfort, low-grade
cough, abnormal fndings on thoracic auscultation,
enlarged and painful prostate or swollen testicles in
intact dogs, resistance to manipulation of the neck
and head, red and swollen gums, or abdominal
discomfort on palpation.
A dog that presents only with vague client
complaints of lethargy and hyporexia can be a
particularly diffcult diagnostic challenge when
the only signifcant fnding on routine physical
examination is fever. Cryptic fever becomes even
more challenging when:
Routine diagnostic laboratory work fails to
localize the disease process
The only abnormal finding on routine diagnostics
is inaccessible (eg, enlarged peribronchial lymph
nodes)
Evaluation of identified abnormalities (such as
an aspirate of an enlarged lymph node) fails to
suggest a definitive disease process (eg, reactive
lymph node).
The veterinarian is then faced with the dilemma
of determining which additional diagnostic tests to
pursue, and pursuit of more advanced diagnostics
can be curtailed by owner fnancial concerns that
arise with high-cost/low-yield tests and owner
compliance (or lack thereof).
DIFFERENTIAL DIAGNOSIS
Fever often results from an immune or infammatory
response, and most causes of fever can be classifed
as infectious, immune-mediated, or neoplastic
(Table).2,5
 UncoVering The cAUse of feVer in dogs Peer reviewed

Fever implies an internal resetting of the
hypothalamic set point, whereas the elevated
body temperature in hyperthermia results
from outside causes. Many veterinarians
have embarked on misguided diagnostic or
therapeutic pathways due to the presumption
that an elevated rectal temperature is associated
with infammatory disease.
In my experience, it is not uncommon to see
dogs with elevated rectal temperatures associated
with anxiety, environmental conditions, exercise,
drugs, and catheters/wraps. In fact, I have seen
dogs that have presented with rectal temperatures
in the 103F to 104F range (even as high as 105F)
as a consequence of anxiety.
Is It Fever or
The presence of fever can be confrmed either Hyperthermia?
by hospitalizing the dog for several hours or
instructing the owner to take the dogs tempera-
ture at home when the pet is relaxed. Likewise,
when a dog that is being treated in the hospital
for a noninfammatory disease suddenly develops
an elevated rectal temperature but no other signs
(eg, cough), the frst step should be removal of
tight bandages and removal/replacement of
intravenous catheters before investigation for a
nosocomial infection or other source of fever.

Infectious Causes commonly lymphoma, leukemia, multiple myeloma,

With infectious causes of cryptic fever, many animals
have evidence of some abnormality on physical
examination or routine laboratory screening.
However, even diskospondylitis, pyelonephritis,
leptospirosis, and the deep mycoses may present with
no specifc abnormalities.4,6-10
A recently detected cardiac murmur can indicate
bacterial endocarditis, although the murmur may
be missed early in the course of disease. However,
it is just as likely the murmur has been present and
undetected for some time and is not part of the
current febrile disease.
hepatic neoplasia, and necrotic tumor masses. One
would expect hematologic abnormalities on the
complete blood count (CBC), but these changes
can often be subtle and/or misleading. Unexplained
hematologic abnormalities should be viewed as an
invitation to perform a bone marrow examination
aspiration or biopsywhich often yields a diagnosis.
DIAGNOSTIC APPROACH
Initial Diagnostics
The initial diagnostic approach in a dog with
unexplained fever should begin with signalment,

Immune-Mediated Causes Table.

Sterile infammatory diseases are most commonly Causes of Persistent Fever in Dogs
immune-mediated, and include immune-mediated
Infectious Bronchopneumonia
polyarthritis (IMPA), steroid-responsive meningitis- Deep mycoses
arteritis (SRMA), and systemic lupus erythematosus. Diskospondylitis
In some dogs, IMPA and SRMA can be more diffcult Leptospirosis
Pyelonephritis
to diagnose because: Pyothorax
1. Laboratory changes are often restricted to an Soft tissue abscess
infammatory leukogram Tick-borne disease
2. Dogs with IMPA may have relatively subtle Toxoplasmosis or neosporosis
lameness and minimal joint effusion, presenting Immune- Granulomatous
with more generalized stiffness and discomfort Mediated meningoencephalitis
Panniculitis
(which can also be confused as SRMA).11
Polyarthritis
Lameness can sometimes be uncovered by Steroid-responsive fever
hyperfexing a limb; then having the dog walk Steroid-responsive meningitis-
immediately afterward. arteritis
Systemic lupus erythematosus
Some sterile infammatory processes are not
immune-mediated but can produce signifcant fever; Neoplastic Lymphoid leukemia
Lymphoma
these diseases include acute pancreatitis, pansteatitis,
Myeloma
nodular panniculitis, granulomatosis, juvenile Other leukemias
cellulitis, shar-pei fever, hypertrophic osteodystrophy,
Miscellaneous Hypertrophic osteodystrophy
and panosteitis.3,4,12,13 Intervertebral disk disease3
Pancreatitis, acute or chronic
Neoplastic Causes Panosteitis
Portosystemic shunt1
Fever may be seen with various cancers, most

tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice 35

 Peer reviewed UncoVering The caUse of feVer in dogs
patient history, physical examination, and laboratory
diagnostics (see Diagnosing Fever: A Stepwise
Approach, page 38). When the diagnosis is not
readily apparent following the initial diagnostic
approach, the clinician is faced with the option of a
therapeutic trial or continued diagnostics.
Ask Therapeutic Trial
Yourself The goal of the therapeutic trial should be diagnosis
The question that (or, at least, elimination of a disease category);
needs to be asked therefore, antibiotics should not be combined with
and answered at every antipyretics, such as nonsteroidal anti-infammatory
step of the way is: Do
drugs (NSAIDs) or corticosteroids. Artifcial
I have reasonable
information for resolution of fever due to antipyretic administration
a diagnosis and may improve the patients demeanor but is rarely
treatment plan? This required and tends to delay and confuse the
question should always
be re-evaluated just diagnosis.
before and after an Antibiotic selection is empiric and often based
antibiotic trial (either on prior experience or suspicions (eg, doxycycline
failure or success).
in a dog with high tick exposure). Depending on
the patients condition, most antibiotic trials are
administered for 48 to 72 hours before declaring
failure and considering either an alternate antibiotic
choice or the next step in diagnostics.
During this trial period, the patient can be
stabilized with IV fuids and other supportive care,
if required, or discharged to the client if relatively
stable.
Further Diagnostics
Presuming there is no response to the therapeutic
trial(s) and no distinctive localized fndings to
prompt more specifc diagnostic tests, the next level
of diagnostics should be pursued.
These tests, some of which may require referral to
specialty practitioners, include:
Cytology and blood cultures
Serology or polymerase chain reaction (PCR)
Antinuclear antibody testing
Imaging, such as radiography and ultrasound
Bone scan
Bronchoscopy.
Cytology & Other Testing
Random cytologic sampling is often not valuable,
but simple collections, such as peripheral lymph node
aspirates, can be obtained easily. There are a variety of
sites from which to sample, some more challenging
than others, and diagnostics can include aspirates
of apparently normal lymph nodes, joint taps, bone
marrow aspirate, and cerebrospinal fuid (CSF) tap.
Serology or PCR may be indicated for certain
36 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com
infectious diseases, and the specifc selection of tests is
often based on regional prevalence of such diseases.
Imaging
Abdominal radiographs and ultrasound (if available)
are commonly pursued because it is diffcult to
palpate the abdomen in many dogs, especially
those that are particularly deep chested. Abdominal
radiographs are also important in the diagnosis
of diskospondylitis. In the absence of identifable
abdominal pain or abnormalities on palpation,
thoracic radiographs often have more value than
abdominal radiographs.
Computed tomography or magnetic resonance
imaging of the brain rarely has value in the absence
of neurologic abnormalities; CSF analysis has
surprisingly greater beneft and is less expensive.
DEFAULT DIAGNOSIS
When the clinician has exhausted the diagnostics
or, at least, reached a reasonable confdence level
that infectious disease is not present and there is
no evidence of neoplasia, the default diagnosis is
immune-mediated fever.
Corticosteroid trials must be administered
appropriately; my protocol is to administer
prednisone at 2 mg/kg Q 24 H (or 60 mg/M2 for
larger dogs) for a minimum of 3 weeks (presuming
the patients response is good), with gradual
reduction by 25% every 3 to 4 weeks. If infectious
disease is present, most dogs will deteriorate within 3
to 5 days of initiating a corticosteroid regimen.
LITERATURE REVIEW
Three large retrospective studies of fever in dogs offer
a valuable perspective on the outcome of diagnostic
investigations into fever.3,4,14 Although the studies
were conducted in Europe, where prevalence and
type of infectious diseases may differ from those seen
in the United States, the general fndings are relevant
across canine populations.
Inclusion Criteria
Inclusion criteria for these studies were fairly
straightforward. Two studies included dogs that had
a recurrent or persistent fever (> 40C [104F] on
at least one occasion) documented for 1 week or
longer.3,14 In the other study, investigators searched
patient records for the term FUO or fever of unknown
origin in the letter from the referring veterinarian
as well as documentation of a fever (> 39.7C
[103.5F]).4

Diagnostic Results
The records of 217 dogs with fever were evaluated.
The most common fnal diagnostic category was
immune-mediated disease, which was present in 32%
(69/217) of the dogs. This category included IMPA
and SRMA, both of which commonly have localizing
signs.
Diagnostic Approach
When additional diagnostic tests were performed,
presumably based on an abnormal fnding on physical
examination or routine screening laboratory tests
(CBC, serum biochemistry profle, urinalysis),
Over the past 6 to 8 years, clinicians at Kansas
State University Veterinary Health Center have
identifed more than 50 dogs with fever and a
variety of clinical signs, including facial cellulitis,
lymphadenomegaly, polyarthritis, hematologic
abnormalities, hepatic enzyme elevation, and
general malaise.
Diagnostic Findings
The most common cytologic fnding from
aspirates of the affected organ or tissue in these
patients was pyogranulomatous (sometimes
just suppurative) infammation with no visible
organism.
These fndings led to a consideration of
several diagnosesfungal disease, systemic
lupus erythematosus, or IMPA. However, the
antinuclear antibody tests were negative and the
polyarthropathy did not respond as expected to
corticosteroids (although, often with very little
detrimental effect other than the disease did not
resolve completely).
The pursuit of this disease as infectious
began when a holiday delayed an exploratory
surgery on a febrile dog with pyogranulomatous
hepatitis (from a liver aspirate). The dog was
serendipitously administered enrofoxacin and
azithromycin and responded completely to this
combination, with no surgery needed.
Use of Two Antibiotics
Subsequently, it was discovered that other
dogs with pyogranulomatous infammation of
no apparent cause responded completely to a
combination of:
` A fluoroquinolone (enrofloxacin, 7.510 mg/
kg PO Q 24 H or 5 mg/kg PO Q 12 H) or
` Ciprofloxacin, 1520 mg/kg PO Q 24 H and
` Azithromycin, 5 mg/kg Q 24 H.
When dogs respond (eg, resolution or reduc-
tion of fever, cellulitis) to this antibiotic combina-
tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice
UncoVering The cAUse of feVer in dogs Peer reviewed
the diagnostic yield was fairly high. For instance,
cytology (which was poorly defned in these studies
but included aspirates of masses or enlarged lymph
nodes, CSF or synovial fuid analysis, and evaluation
of bronchoalveolar lavage samples) provided, or was
crucial to, the diagnosis in 56% to 62% of the dogs, and
bone marrow aspiration yielded a diagnosis in 64%.
However, diagnostics that are often performed
as screening tests and not always chosen based on
a specifc identifed abnormality had a much lower
yield. Radiographs revealed a diagnosis in 48% of
patients (22/46 dogs) in the study by Dunn and
Dunn3 but in only 9.5% and 3.3% of the patients in
tion, they show dramatic improvement within 48 Unpublished
hours and the typical protocol is to proceed with
a 6-week course; then carefully monitor the dog Observations
over the following 6 months for relapse. As with from Kansas
all antibiotic trials, if dogs do not respond within
72 hours, the trial should not be continued. State University:
Ongoing Investigation
Dual Therapy for
This treatment approach is based on the Antibiotic Trials
assumption that patients likely have bartonellosis
or are infected with an unidentifed unculturable
organism even though:
` Bartonellosis has not been confirmed with
PCR or serology testing in these dogs
` Use of this antibiotic combination varies
from other treatment recommendations for
bartonellosis.
Bartonellosis has been reported in dogs with
fever and pyogranulomatous infammation in
various organs,15-18 and the investigation into the
dogs at Kansas State University continues.
Note on Ciprofoxacin
Some veterinary professionals feel that
ciprofoxacin has unpredictable absorption
and pharmokinetics and, therefore, should not
be used in dogs due to the results of a 2012
study.19 That study was conducted on 6 beagles
that were fasted for 18 hours; 4 demonstrated
high levels of absorption when administered
ciprofoxacin, while 2 had poor absorption.
A study comparing oral ciprofoxacin and
norfoxacin in 4 beagles also noted inconsistent
absorption of ciprofoxacin.20 In contrast, a 1990
study on 4 mixed breed dogs (range, 16.427.3
kg) did not demonstrate large variations in
pharmacokinetic variables.21 Therefore, a study
involving a larger number of dogs receiving
ciprofoxacin in real-world conditions (ie, with
food) is needed to understand the prevalence of
variable absorption among dogs.
37
 Peer reviewed UncoVering The caUse of feVer in dogs
DiAgnOSing Fever: A STepwiSe ApprOAch
Consider signalment
Age
Neuter status
Breed
Obtain a thorough patient and environmental history, which may uncover:
+ Unexpected travel history or recent boarding or recreational activities (eg,
lake swimming)
+ Evidence of previous diseases
+ Prior treatments for the presenting complaint (especially with clients who may
be pursuing a second or third opinion)
+ Response to prior therapy, which often provides the greatest clues to a
potential diagnosis (or at least category of disease)
Perform a careful physical examination:
Orthopedic and neurologic assessments and evaluation
Fundic, oral, and otic examinations
Digital rectal, spinal, and paraspinal palpation
Direct diagnostics based on physical examination fndings
(eg, aspirates of enlarged lymph nodes, radiographs of abdomen or thorax)
Undertake laboratory diagnostics:
+ Complete blood count
+ Serum biochemical profle
+ Urinalysis and urine culture (often performed regardless of the urine sediment)
+ Screening for vector-borne disease (eg, SNAP 4Dx Plus [idexx.com]), depend-
ing on disease prevalence, time of year, and hematologic abnormalities
Conduct additional directed diagnostics
based on initial laboratory work
(eg, bone marrow with bi- or pancytopenia)
If no diagnosis, consider frst antibiotic trial or additional
nondirected diagnostics:
+ Abdominal and thoracic radiographs (including spine)
+ Abdominal ultrasound
+ Echocardiogram
+ Urine or blood culture
+ Aspirates of normal lymph nodes
+ PCR screening for infectious organisms
+ Antinuclear antibody testing
If no response, consider second antibiotic trial or
additional nondirected diagnostics (see list above)
Repeat antibiotic trial with different targeting of spectrum
If antibiotic trials have failed, and no additional diagnostics seem
reasonable, consider corticosteroid trial for immune-mediated disease
38 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com
the studies by Battersby et al4 and Chervier et al,14
respectively.
Although thoracic and abdominal radiographs
were reportedly obtained in almost all dogs in
the studies by Dunn and Dunn and Battersby
et al, diagnoses were most commonly acquired
from lesions identifed on bony structures (eg,
osteomyelitis, diskospondylitis, hypertrophic
osteodystrophy).3,4 Chervier et al did not specify what
type of radiographs were obtained.14
Likewise, abdominal ultrasonography, PCR
testing for vector-borne disease, and serology for
toxoplasmosis and neosporosis infrequently yielded a
diagnosis.4 These methods failed to yield a diagnosis
in 19/1013, 15/664, and 14/5014 dogs.
Effect of Therapy
In the study by Battersby et al, therapy administered
in the 24 hours before referral increased the time
necessary to obtain a diagnosis.4 Chervier et al also
looked at the effect of prior treatment, and although
the mean time to diagnosis was longer in the group
that had received prior treatment (12.75 versus 9.2
days in those that had not received prior treatment),
this fnding was not statistically signifcant.14
The fndings by Battersby et al emphasize the
need to resist the knee-jerk response to administer
anti-infammatories (NSAIDs or glucocorticoids)
in response to fever4a reaction often referred to
as fever phobia in human medicine.22 Although fever
may be a marker for a serious and life-threatening
disease process, no evidence demonstrates that fever
itself will result in organ damage or other serious
consequences.23
Although an antibiotic trial is often recommended
and frequently employed in the workup of fever,
antibiotics should be administered only after
target areas have been sampled (eg, blood, urine,
or abdominal fuid for culture or PCR). It is
important that no additional antimicrobials or anti-
infammatories that may confuse the interpretation of
the response be administered concurrently.
Outcomes
Outcomes for dogs with FUO were discussed in
only one of these studies, with nearly half the dogs
(7/15) demonstrating resolution of fever without
treatment, 3 responding to antibiotics, and 2
requiring glucocorticoids.4 Chervier et al highlighted
the importance of client compliance in obtaining
a diagnosis: of 14 dogs in which a diagnosis was
not obtained, failure of clients to pursue diagnostic
 UncoVering The cAUse of feVer in dogs Peer reviewed

investigation was the reason for lack of diagnosis in 13

patients.14 KeNNeTh R. hARKIN
Kenneth R. Harkin, DVM, Diplomate ACVIM (Small
Animal Internal Medicine), is a professor and head of
IN SUMMARY
the Section of Medicine in the College of Veterinary
Uncovering the cause of fever in dogs is usually a
Medicine at Kansas State University. His research
straightforward process. For those in which the etiology
interests include infectious diseases and immunology,
is not easily uncovered, however, an ordered and logical with a special interest in leptospirosis. He currently
diagnostic and treatment protocol helps categorize the lectures on gastroenterology, hematology, hepatology,
etiology (ie, infectious, immune-mediated, neoplastic)even and neurology.
if the ultimate diagnosis is vague (eg, immune-mediated
fever). Bartonella henselae bacteremia. Can Vet J 2014; 55:970-974.
19. Papich MG. Ciprofoxacin pharmacokinetics and oral
CBC = complete blood count; CSF = cerebrospinal fuid; absorption of generic ciprofoxacin tablets in dogs. Am J Vet
Res 2012; 73(7):1085-1091.
FUO = fever of unknown origin; IMPA = immune- 20. Albarellos GA, Montoya L, Waxman S, et al. Ciprofoxacin and
mediated polyarthritis; NSAID = nonsteroidal anti- norfoxacin pharmacokinetics and prostatic fuid penetration in
dogs after multiple oral dosing. Vet J 2006; 172:334-339.
infammatory drug; PCR = polymerase chain reaction; 21. Walker RD, Stein GE, Hauptmam JG, et al. Serum and
SRMA = steroid-responsive meningitis-arteritis tissue cage fuid concentrations of ciprofoxacin after oral
administration of the drug to healthy dogs. Am J Vet Res
1990; 51(6):896-900.
References 22. Purssell E, Collin J. Fever phobia: The impact of time and
1. Petersdorf RG, Beeson PB. Fever of unexplained origin: Report on 100 mortalityA systematic review and meta-analysis. Int J Nurs
cases. Medicine 1961; 40:1-30. Stud 2016; 56:81-89.
2. Cunha BA, Lortholary O, Cunha CB. Fever of unknown origin: A clinical 23. Neto AS, Pereira VGM, Colombo G, et al. Should we treat
approach. Amer J Med 2015; 128:1138e1-1138e15. fever in critically ill patients? A summary of the current
3. Dunn KJ, Dunn JK. Diagnostic investigations in 101 dogs with pyrexia of evidence from three randomized controlled trials. Einstein
unknown origin. J Small Anim Pract 1998; 39:574-580. 2014; 12(4):518-523.
4. Battersby IA, Murphy KF, Tasker S, et al. Retrospective study of fever in
dogs: Laboratory testing, diagnoses and infuence of prior treatment. J
Small Anim Pract 2006; 47:370-376.
5. Flier JS, Underhill LH. The neurological basis of fever. New Engl J Med
1994; 330(26):1880-1885.
6. Burkert BA, Kerwin SC, Hosgood GL, et al. Signalment and clinical
features of diskospondylitis in dogs: 513 cases (1980-2001). JAVMA 2005;
227(2):268-275.
7. Harkin KR, Roshto YM, Sullivan JT. Clinical application of a polymerase
chain reaction assay for diagnosis of leptospirosis in dogs. JAVMA 2003;
222:1224-1229.
8. Bromel C, Sykes JE. Histoplasmosis in dogs and cats. Clin Tech Small Anim
Pract 2005; 20:227-232.
9. Graupmann-Kuzma A, Valentine BA, Shubitz LF, et al. Coccidioidomycosis
in dogs and cats: A review. JAAHA 2008; 44:226-235.
10. Bromel C, Sykes JE. Epidemiology, diagnosis, and treatment of
blastomycosis in dogs and cats. Clin Tech Small Anim Pract 2005; 20:233-
239.
11. Rondeau MP, Walton RM, Bissett S, et al. Suppurative, nonseptic
polyarthropathy in dogs. J Vet Intern Med 2005; 19:654-662.
12. Safra N, Johnson EG, Lit L, et al. Clinical manifestations, response to
treatment, and clinical outcome for Weimaraners with hypertrophic
osteodystrophy: 53 cases (2009-2011). JAVMA 2013; 242(9):1260-1266.
13. Hess RS, Saunders HM, Van Winkle TJ, et al. Clinical, clinicopathologic,
radiographic, and ultrasonographic abnormalities in dogs with fatal acute
pancreatitis: 70 cases (1986-1995). JAVMA 1998; 213:665-670.
14. Chervier C, Chabanne L, Godde M, et al. Causes, diagnostic signs, and the
utility of investigations of fever in dogs: 50 cases. Can Vet J 2012; 53:525-
530.
15. Drut A, Bublot I, Breitschwerdt EB, et al. Comparative microbioligical
features of Bartonella henselae infection in a dog with fever of unknown
origin and granulomatous lymphadenitis. Med Microbiol Immunol 2014;
203:85-91.
16. Breitschwerdt E, Blann KR, Stebbins ME, et al. Clinicopathological
abnormalities and treatment response in 24 dogs seroreactive to Bartonella
vinsonii (berkhoffi) antigens. JAAHA 2004; 40:92-101.
17. Friedenberg SG, Balakrishnan N, Guillaumin J, et al. Splenic vasculitis,
thrombosis, and infarction in a febrile dog infected with Bartonella henselae.
J Vet Emerg Crit Care 2015; 25(6):789-794.
18. Tucker MD, Sellon RK, Tucker RL, et al. Bilateral mandibular
pyogranulomatous lymphadenitis and pulmonary nodules in a dog with

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| July/August |2016 39 2016 | TodAys VeTerinAry PrAcTice
July/August 39
 Peer reviewed FeLine UreTHraL oBsTrUcTion: diaGnosis & ManaGeMenT
FELINE URETHRAL
OBSTRUCTION: DIAGNOSIS
& MANAGEMENT
Christopher M. George, DVM, and Gregory F. Grauer, DVM, MS,
Diplomate ACVIM (Small Animal Internal Medicine),
Kansas State University
Feline urethral obstruction (UO) is a common
disorder encountered in small animal emergency
practice, with incidence estimates ranging from
1.5% to 9%.1,2
The etiology of UO was long thought to be a
physical obstruction, such as a urethral plug, calculi,
stricture, or neoplasia. In a recent study,3 however,
causes of UO in 45 cats were found to be idiopathic
(53%), uroliths (29%), and urethral plugs (18%),
indicating that functional obstructions may be more
common than previously thought.
Feline UO is a treatable emergency, with a survival
rate to discharge higher than 90%,1 despite the fact
that it is potentially life threatening due to severe
electrolyte and acidbase imbalances secondary
to acute postrenal azotemia/uremia.1,4 Treatment
commonly involves days of hospitalization,
with substantial owner investment, and rates of
recurrence following treatment are relatively high
(range, 11%43%).3,5
PREDISPOSING FACTORS
Given their relatively long and narrow urethra, male
cats are much more likely than female cats to develop
obstruction. Segev and colleagues determined that
the mean age of cats with UO (51.7 37.7 months)
was signifcantly lower than gender-matched and
time-matched (sequential hospital admissions)
controls without UO (75.5 61.3 months).4 In
addition, obstructed cats were more likely to live
indoors only, weigh more, and be fed a dry diet
exclusively.4
PRESENTATION
CE
ArTICLE
Clinical Signs
The most common early clinical signs of UO are
similar to those of idiopathic cystitis, including
stranguria, dysuria, and hematuria. Delayed systemic
40 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com
signsassociated with the onset of uremiainclude
anorexia, vomiting, and lethargy/collapse.
Clinical signs depend on the completeness and
duration of the obstruction. The median duration
of signs before veterinary presentation was 3 days in
one study of 223 cats.1
Physical Examination
The classic physical examination fnding in cats with
UO is an overdistended, turgid urinary bladder that
cannot be expressed. It is important to note, however,
that the inability to express urine can be a normal
fnding in male cats and not diagnostic for UO.
The penis may be reddened from self-trauma, and
a urethral plug may be observed protruding from
the tip of the penis. Dehydration may be present
as indicated by prolonged skin turgor and tacky
mucous membranes.
Moderate bradycardia (100140 beats/min)
and severe bradycardia (< 100 beats/min) were
observed in 6% and 5% of cases, respectively.1
Bradycardia and arrhythmias occur secondary to
the effects of hyperkalemia on cardiac conduction.1
Of cats with UO, 50% can be expected to have a
normal body temperature, 40% hypothermic, and
10% hyperthermic.1 In one study, the combination
of hypothermia (< 9596.6F) and bradycardia
(< 120 beats/min) was 98% specifc for severe
hyperkalemia (> 8 mEq/L).6
Systolic blood pressure on presentation is
typically normal7; in one study, 71% of cats were
normotensive and 29% were hypertensive.7
INITIAL DIAGNOSTICS
Diagnosis and management of UO are performed
simultaneously. Diagnostics should ideally include:
Minimum database, including packed cell
volume/total solids, blood urea nitrogen (BUN),
 FeLine UreTHrAL oBsTrUcTion: diAGnosis & MAnAGeMenT
creatinine, blood glucose, pH, sodium, potassium,
chloride, phosphorus, and ionized calcium
Electrocardiogram
Urinalysis with sediment examination
Abdominal/perineal radiographs.
Blood Analysis
In one study of cats with UO1:
Serum creatinine concentration was above the
reference range in 29% of cats
BUN was above the reference range in 33% of cats
Serum phosphorus was above the reference range
in 25% of cats.
Hyperkalemia is one of the most common
laboratory abnormalities observed in cats with
UO and can contribute to severe bradycardia and
arrhythmias. In one study of cats with UO, serum
potassium concentration was1:
Less than 6 mmol/L in 76% of cats
6 to 7.9 mmol/L in 12% of cats
8 to 10 mmol/L in 12% of cats
Above 10 mmol/L in only 0.5% of cats.
Hyperkalemia was also most often encountered
with acidosis and low serum ionized calcium
concentrations.1 In cats with UO and bradycardia
and/or arrhythmias, the magnitude of hyperkalemia
should be assessed and corrected prior to sedation or
anesthesia for urethral catheterization.
Urinalysis
If urine is available, the urine specifc gravity (USG)
may be greater than 1.040 early in UO, but more
dilute urine can be observed with prolonged UO
as a result of increasing renal tubular dysfunction.
Microscopic hematuria is almost always present,
and gross hematuria is common due to bladder
overdistension and/or the presence of underlying
cystitis. Hematuria is also frequently associated with
pyuria and proteinuria.
Nearly all cats presenting for UO have sterile urine;
however, urine contamination or misinterpretation
of particulate matter in the urine sediment may
be mistaken for a urinary tract infection (UTI).
Quantitative bacterial culture of urine obtained by
cystocentesis is recommended to confrm UTI in
patients with suspected infection. Struvite crystals
may be observed as well, especially in alkaline urine.
Struvite crystals are more likely to form secondary to
urine stasis and alkalinuria as opposed to being the
primary cause of UO.
Imaging
All cats with UO should be evaluated with abdominal
tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice
Peer reviewed
radiography to rule out urolithiasis as a cause. It
is important to make sure the radiographs include
the entire urinary system, which allows the kidneys,
ureters, bladder, and entire length of the urethra to be
assessed for urolithiasis.
Free abdominal fuid, as indicated by loss of serosal
detail in the caudal abdomen, may be observed but is
not always caused by rupture of the urinary bladder.8
Increased bladder permeability secondary to severe
distension and diffuse cystic mural disease may result
in transmural leakage of urine without overt bladder
rupture. Positive-contrast urethrography/cystography
is the most sensitive diagnostic test for bladder or
urethral rupture.
Ideally, survey radiographs are obtained prior to
passage of a urethral catheter because the presence
of the catheter can make urethral evaluation more
diffcult, and urolithiasis may be undetected. If
the patient is in critical condition, steps to address
metabolic derangements should have priority over
radiographs.
PATIENT STABILIZATION
The magnitude of azotemia, electrocardiographic
stability, and degree of bladder distension helps
dictate the order of treatment and how quickly it
must be performed. Cats in uremic crisis with very
large, turgid bladders require prompt intervention.
Stabilization of the patient and treatment of
adverse effects of UO are essential before anesthesia is
administered. Hypovolemia and hyperkalemia must
be the frst treatment priorities.
Fluid Administration
Intravenous access should be obtained soon after
presentation because IV fuid administration is critical
for severely ill cats with UO.
Crystalloid fuid therapy is indicated; 0.9% sodium
chloride is often recommended because it does not
contain potassium. However, in a randomized study
comparing treatment with 0.9% sodium chloride and
a balanced polyelectrolyte solution (Normosol-r,
hospira.com), no difference was observed in the rate
of decline of serum potassium; in addition, a more
rapid correction of acidosis was observed in the cats
treated with polyelectrolyte solution than in those
treated with 0.9% sodium chloride.9 This suggests
that balanced electrolyte solutions may actually be
preferred for correcting acidbase imbalances in cats
with UO.
IV fuid therapy is started at a rate of 10 to 20 mL/
kg/H, and the rate adjusted as the patient stabilizes
and urethral patency is established. Mild increases
41
 Peer reviewed FeLine UreTHraL oBsTrUcTion: diaGnosis & ManaGeMenT

Degrees of Various degrees of hyperkalemia occur in cats with UO (Table). Hyperkalemia adversely affects cardiac
conduction. As a result, tall and spiked T waves, widened QRS complexes, lengthened PR intervals,
Hyperkalemia fattened P waves, atrial standstill, ventricular fbrillation, and/or asystole may be observed on a lead II
ECG rhythm strip (Figure).

Table.
Cats with Urethral Obstruction: Degrees of Hyperkalemia
DEGREE OF SERUM TREATMENT OPTIONS
HYPERKALEMIA POTASSIUM
CONCENTRATION

Mild < 6 mEq/L Dilutional fuid therapy (1020 mL/

hyperkalemia kg/H), with rate adjusted as patient
stabilizes

Moderate 68 mEq/L IV administration of:

hyperkalemia Dextrose (50% solution [1 mL/kg]
diluted to fnal concentration of
10%20%)
Regular insulin (1 U)
Severe > 8 mEq/L Calcium gluconate (0.51 mL/kg
hyperkalemia IV), followed by regular insulin and
dextrose IV

in serum potassium concentrations will return to

reference intervals with dilutional fuid therapy
and relief of UO; however, targeted correction of
moderate to severe hyperkalemia is necessary prior
to sedation or anesthesia for relief of the UO (see
Degrees of Hyperkalemia).
Calcium Gluconate
Calcium gluconate is the treatment of choice for
cats with severe hyperkalemia, bradycardia, and
electrocardiographic instability.
Calcium gluconate (10%) is administered at 0.5
to 1 mL/kg IV slowly over 2 to 3 minutes while
continuously monitoring the electrocardiogram.
If bradycardia worsens or QT interval shortening
occurs, the infusion should be stopped.
While this treatment rapidly stabilizes cardiac
conduction, it does little to reduce hyperkalemia. In
addition, its benefcial effects are short lived (2030
min) and other strategies to lower serum potassium
are often needed (Table).
An IV infusion of calcium gluconate may also be
administered to treat muscle twitching or seizures
associated with hypocalcemia. Hypocalcemia usually
resolves rapidly after relief of obstruction as serum
phosphorus concentration decreases.
Dextrose
IV dextrose is helpful for longer term control of
hyperkalemia. A 50% dextrose solution (1 mL/
kg), diluted to a fnal concentration of 10% to
Figure. examples of how different degrees
of hyperkalemia can adversely affect cardiac
conduction. Picture the lead ii rhythm strip as a
string being pulled apart. Note the fattened P
waves, prolonged Pr interval, and widened QrS
complexes. The exception to this string analogy
is the tall, spiked T waves.
20%, is administered as an IV bolus. This treatment
stimulates endogenous insulin release, causing
intracellular translocation of plasma potassium.
Administration of 1 unit of regular insulin IV
hastens the intracellular translocation process.
However, insulin should never be given without a
concurrent dextrose bolus, followed by a constant
rate dextrose infusion to prevent hypoglycemia.
Sodium Bicarbonate
Sodium bicarbonate may be administered in cats with
severe hyperkalemia to help translocate potassium
from the plasma into the intracellular fuid in exchange
for hydrogen ions. Sodium bicarbonate (1 mEq/kg) is
administered IV, with a maximum dose of 4 mEq/kg.
If excessive amounts of bicarbonate are
administered, the major disadvantage of this
treatment is the development of ionized hypocalcemia
due to increased binding of calcium to albumin

42 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com

 FeLine UreTHrAL oBsTrUcTion: diAGnosis & MAnAGeMenT
and intracellular translocation of ionized calcium,
creating an alkalemia. Sodium bicarbonate may also
be less effective than dextrose or insulin in reducing
potassium concentrations.
Cystocentesis
Therapeutic cystocentesis should be performed as
soon as possible in cats with very large bladders and
prior to anesthesia for urethral catheter placement
to aid in stabilizing the patient. The benefts of
therapeutic cystocentesis almost always outweigh the
potential adverse effects; benefts include:
rapid reduction of bladder pressure
Improvement in glomerular filtration rate
Collection of an uncontaminated urine sample
reduction of cystic pressure, which may facilitate
urethral catheterization and back flushing.
Cystocentesis in cases of UO is considered
controversial by many clinicians, with the major
concern being bladder rupture or tear. However,
clinical experience and recent evidence have shown
that the overall risk for bladder rupture is low.8,10 In
a recent study of 47 cats with UO, decompressive
cystocentesis, followed by urethral catheterization,
had no signifcant adverse effects on the bladder.8 In
most cases, a needle hole in the bladder resulting in a
clinically signifcant uroabdomen is unlikely, especially
if the bladder is kept decompressed by placement of a
urinary catheter.10
To reduce potential complications of bladder
laceration and aortic puncture:
Perform the procedure with the cat in lateral
recumbency
Use a 22-gauge needle attached to an extension
set with a 3-way stopcock and 35-mL syringe; the
extension tubing and 3-way stopcock allow the
bladder to be emptied at least partially without
manipulation and movement of the needle
Advance the needle through the bladder wall at a
45-degree angle directed toward the trigone; the
45-degree angle helps the needle tract seal after
withdrawal
Stabilize the bladder with one hand while the other
hand guides the needle and an assistant operates
the syringe.
URETHRAL OBSTRUCTION RELIEF
Anesthesia
After the cat has been stabilized, suffcient anesthesia
is administered to provide immobilization and
urethral relaxation. Many effective anesthesia
protocols are available and can be chosen based on
clinician comfort and drug availability.
tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice
Peer reviewed
Ketamine (25 mg/kg IV), with either diazepam
(0.20.5 mg/kg IV) or acepromazine (0.0050.05
mg/kg IV), is generally a safe and effective
protocol; a second dose of ketamine and diazepam
can be administered if additional time is needed to
complete the procedure.
Diazepam may be a better choice for more
critical patients because it is less likely to cause
hypotension compared with acepromazine.
Inhalational anesthesia (isoflurane or sevoflurane)
via endotracheal tube may be necessary in some
cats that are not sufficiently relaxed with the above
protocols.
Propofol is also effective, but apnea and
hypotension are possible adverse effects. If
propofol is used, the cat should be intubated to
provide adequate ventilation.
Epidurals provide analgesia to the penis and
bladder and may reduce the depth of anesthesia
necessary, but these techniques require additional
training and expertise. A simplifed method of
coccygeal epidural with local anesthetic has been
described and provides safe and effective analgesia to
the penis and urethra.11
Urethral Catheter Placement
Aseptic technique and a gentle hand are fundamental
to urethral catheter placement.
1. Clip the hair in the perineal region carefully and
prepare the skin aseptically.
2. Extrude the penis and retract it caudally to
straighten the urethra. Failure to fully retract
the penis caudally impedes the catheter from
navigating the sigmoid fexure of the urethra.
3. Advance a urinary catheter (see What Types of
Catheters?, page 44) into the urethra to the site of
obstruction. Advance the catheter slowly to avoid
urethral trauma; it should never be forced past an
obstruction.
4. Urethral irrigation (hydropulsion) with sterile
physiologic saline via an extension tube is
recommended both to dilate the urethra and to fush
any obstructing material retrograde into the bladder.
5. A 50:50 mixture of water-soluble lubricant and
sterile physiologic saline may also be injected
through the catheter to provide lubrication along
the entire length of the urethra and aid in catheter
advancement.
6. Once the urethra is patent, fush it thoroughly to
ensure all debris is removed and then advance the
catheter into the bladder.
7. After catheterization, fush and drain the bladder
multiple times with sterile saline to remove
43
 Peer reviewed FeLine UreTHraL oBsTrUcTion: diaGnosis & ManaGeMenT
What Types of For urethral catheter placement, use a well-
lubricated, rigid, open-ended urinary catheter
Catheters? (eg, 3.5- or 5-Fr, 10-cm polypropylene). A 20- to
22-gauge over-the-needle catheter (without the
needle) or olive-tip catheter may also be used;
however, these are not usually long enough to
reach the trigone and drain the bladder.
For indwelling catheter placement, use
a longer, softer catheter; material options
include polyvinyl (red rubber catheter or
infant feeding tube), polytetrafuroethylene
(Slippery Sam Tomcat Urethral Catheters,
surgivet.com), or polyurethane. A 3.5-Fr
catheter is preferred over a 5-Fr catheter
because the smaller diameter catheter is
associated with a decreased incidence of
recurrent UO within 24 hours (in one study,
6.7% of cats with a 3.5-Fr catheter versus 19%
of cats with a 5-Fr catheter).5 Polypropylene
catheters should not be used as indwelling
catheters because they tend to be more
irritating to the urethra than other types of
urinary catheters.12
debris and help prevent rapid recurrent UO. We
use refrigerated sterile saline to help promote
vasoconstriction and reduce hemorrhage.
Role of Atracurium Besylate
One study evaluated the effect of intraurethral
atracurium besylatea neuromuscular blocking agent
that causes paralysis of striated musclein male cats
with urethral plugs in aiding the resolution of UO.13
A solution of 0.5 mg/mL atracurium besylate was
infused into the urethral lumen of treated cats for
5 minutes prior to retrograde flushing; the control
group was infused with saline.
The percentage of cats with urethral plug removal
at the first attempt was significantly higher in the
atracurium group (64%) compared with the saline
group (15%).
The mean time required for removal of the UO
was also significantly reduced in the atracurium
group.
Use of this protocol may result in shorter anes-
thetic events and easier urethral catheterization in
cats with UO.
Indwelling Catheters
Indwelling urethral catheters are not necessary in
all cases of UO because the presence of the catheter
causes urethral irritation. However, indwelling
urethral catheters are necessary in patients with:
Severe azotemia, which often results in
44 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com
postobstructive diuresis (requiring measurement of
urine production to guide fluid therapy; see After
Relief of Urethral Obstruction)
Severe bladder distension, which often results in
detrusor atony and inability to void
Grossly abnormal urine or cystic calculi, both of
which increase the risk for immediate recurrent UO.
To avoid trauma to the bladder mucosa and the
catheter tangling inside the bladder, indwelling
urethral catheters (see What Types of Catheters?)
should not be inserted fully into the bladder.
Catheters should be premeasured and inserted only
to the level of the trigone. The indwelling catheter is
then secured to the prepuce using a nonabsorbable
suture and fnger trap technique, tape butterfy and
suture, or other technique depending on clinician
preference.
A sterile collection system should always be
attached and secured to the cats tail. It is never
acceptable to leave an indwelling catheter exposed
to the environment due to the risk for bacterial
infection. An Elizabethan collar or hind leg hobbles
should be used to prevent the cat from chewing out
the catheter.
AFTER RELIEF OF URETHRAL
OBSTRUCTION
After obtaining urethral patency, intensive supportive
care is indicated until resolution of metabolic
derangements. This care includes:
Maintenance of urethral catheter
Monitoring for postobstructive diuresis and
secondary UTI
Administration of IV fluid therapy, analgesia, and
urethral relaxants/antispasmodics
Potential supplementation with potassium.
Postobstructive Diuresis
Postobstructive diuresis (POD) is a well-described
phenomenon in human medicine that may result
secondary to UO in cats as well. In one study, 46%
(13/28) of cats developed POD, defned as urine
production exceeding 2 mL/kg/H within 6 hours
after relief of UO.15 Several cats had diuresis up to 84
hours following relief of UO.15
The high incidence of POD calls for close
measurement of urine output and continued IV fuid
administration using an ins and outs fuid therapy
protocol after resolution of hypovolemia. This
protocol involves administering balanced electrolyte
fuids at a rate to replace the urine volume produced
hourly, plus 20 mL/kg/day for insensible losses to
prevent negative fuid balance.
 FeLine UreTHrAL oBsTrUcTion: diAGnosis & MAnAGeMenT
Conventional management of UO can involve
substantial owner expense. Financial constraints
may result in euthanasia of cats with UO,
especially those with recurrent UO. While
conventional management with urethral catheter
and intensive care should always be offered as
the frst treatment choice, a noncatheterization
protocol may be a viable alternative to
euthanasia.
In a 2010 study, Cooper and colleagues
described a protocol for managing UO in male
cats without urethral catheterization14:
1. Acepromazine (0.25 mg IM) and buprenorphine
(0.075 mg IM) are administered to provide
sedation and analgesia.
2. The penis is inspected and gently massaged in
an attempt to dislodge any obstruction in the
distal penis, followed by a single attempt to
express the bladder.
3. If no urine is expressed, therapeutic cystocen-
tesis is performed and the cat is housed in a
dark, quiet room to minimize stress.
Monitoring & IV Fluid Rate
Serum electrolytes should be monitored at minimum
every 24 hours, and potassium supplementation may
be required to prevent hypokalemia, especially in the
face of substantial POD. reduced urine production
typically occurs after resolution of azotemia.
If urine production does not decrease, the high
rates of IV fuids may be driving the diuresis. The IV
fuid rate in these patients should be tapered initially
by 25%. If urine production decreases, continued
reduction of IV fuids by 25% every 6 to 12 hours is
recommended. If urine production is not reduced, the
fuid rate should be increased to its previous level and
tapering attempted again 24 hours later.
Analgesics
Continued treatment with analgesics for 5 to 7 days
after relief of UO is indicated in all patients. Opioid
derivatives (eg, buprenorphine) are used most
commonly.
Use of the nonsteroidal anti-infammatory drug
(NSAID) meloxicam was evaluated recently in the
treatment of obstructive feline idiopathic cystitis.16
Cats were separated into 2 treatment groups: one
receiving buprenorphine and meloxicam and the other
receiving buprenorphine and a placebo. Meloxicam
did not infuence the recurrence rate of UO or rate
of recovery from clinical signs. Due to these fndings
and the risk associated with NSAIDs in the face of
hypovolemia and decreased renal function, NSAIDs
should be used with caution in cats with post-UO.
tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice
Peer reviewed
4. Acepromazine (2.5 mg PO Q 8 H) and Avoiding
buprenorphine (0.075 mg PO Q 8 H) are
administered, with cystocentesis repeated euthanasia:
every 8 hours. Medetomidine (0.1 mg IM Q 24
H) can be administered if no urination is noted Nonconventional
within 24 hours, and SC fuids can be given as Management
needed.
Treatment success, defned as spontaneous
urination within 72 hours, occurred in 11 of 15
(73%) cats; treatment failure occurred in 4 of
15 (27%) cats. Cats that experienced treatment
failure had signifcantly higher serum creatinine
concentrations, although the magnitude of
pretreatment azotemia was not an exclusionary
criterion. Necropsy of 3 of the cats with treatment
failure showed no evidence of bladder rupture.14
Cats with unresponsive mentation, severe
metabolic derangements (severe acidosis or
hyperkalemia), or radiographic evidence of
uroliths were excluded from the study and are
not good candidates for this protocol.14
Indwelling Catheter Removal
The duration of indwelling urethral catheterization is
controversial. removing the indwelling catheter too
soon may not allow for adequate clearing of bladder
debris, clots, or crystals. However, the presence of a
urinary catheter causes irritation and infammation of
the lower urinary tract.13
The duration of urethral catheterization should
be based on the patients clinical status rather
than a specifc amount of time. Guidelines for
catheter removal include resolution of metabolic
derangements (such as azotemia) and POD as well as
improvement in the gross character of the urine (clear
versus cloudy/hemorrhagic).10 The average duration
of indwelling catheterization is 48 hours.
Use of Antimicrobials
Antimicrobials are not recommended unless
quantitative bacterial culture demonstrates the
presence of a UTI. The majority of cats presenting for
their frst UO do not have a UTI, and antimicrobials
do not prevent the development of catheter-associated
UTI.
A prospective study of cats with UO found zero
positive cultures on presentation, but 6 of 18 (33%)
cats developed UTI while catheterized.17 Cats treated
with an indwelling urethral catheter should have a
quantitative bacterial culture performed on urine at
the time of catheter removal or 7 to 10 days later.
Antimicrobials should be prescribed based on culture
and sensitivity results.
45
Peer reviewed FeLine UreTHraL oBsTrUcTion: diaGnosis
FELINE
& ManaGeMenT
UrETHrAL OBSTrUCTION

Urethral Relaxants
Because urethral irritation and spasm can contribute
to UO, the use of urethral relaxants has become
standard. Medications most commonly used include
acepromazine, phenoxybenzamine, and prazosin, all
of which function as alpha-1 antagonists, which cause
smooth muscle relaxation. Since smooth muscle is
located in the proximal 1/3 of the penile urethra only,
whereas striated muscle comprises the remainder of
the urethra, urethral relaxants may not be effective
in improving outcome in cats with more distal
obstructions.
One retrospective study evaluating factors affecting
recurrent UO rates found that patients receiving
prazosin had signifcantly lower recurrent UO rates
than those receiving phenoxybenzamine at 24 hours
(7% versus 22%, respectively) and 30 days (18%
versus 39%, respectively).5 This may be due to the
more rapid onset of action of prazosin compared with
phenoxybenzamine as well as the effects of prazosin
Daily Nutrition on both the preprostatic and prostatic urethra.

Matters
Therefore, prazosin (0.251 mg/cat PO Q
812 hours) is recommended in cats for 5 to 10
days post-UO. However, phenoxybenzamine or
acepromazine may be substituted based on availability.
Clients are asking tough It is important to consider the sedative effects of
questions about nutrition. acepromazine, as these may be benefcial in reducing
Are you ready? Daily stress or contraindicated based on the individual
Nutrition Maters is a free, patient.
Further prospective studies are needed to evaluate
comprehensive education
the effects of other alpha-1 antagonists on recurrent
program brought to you by
UO.
nutrition experts.
AFTER DISCHARGE
Earn up to Home Environment
15.5 CE The home environment of cats with UO should be
HOURS changed as needed to help decrease stress and increase
water consumption. Alterations may include:
Increasing contact time between the cat and owner
Improving litter box hygiene and increasing
ONLINE,
interactive number of litter boxes
& self-paced Switching to a canned food diet and increasing
water availability
Environmental enrichment, such as vertical perches
and hiding places
Earn
Increasing hunter behavior and use of pheromones
PRIZES
(Feliway spray, feliway.com) to help reduce stress.18
In a prospective study evaluating risk factors
associated with recurrent UO, the combination of
Sign up today at
environmental modifcations signifcantly lowered
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continuingeducation/ the risk for recurrent UO, but increasing water
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associated with a decreased risk for recurrent UO.19

46 46 July/August
Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com
2016 | tvpjournal.com
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Peer reviewed FeLine UreTHraL oBsTrUcTion: diaGnosis & ManaGeMenT
Follow-Up
re-evaluation 7 to 10 days after discharge is
recommended. Factors to evaluate include:
Urinalysis to monitor USG (goal of < 1.030),
urine pH, and crystalluria
Quantitative bacterial culture (obtained by
cystocentesis) to rule out UTI that may
have occurred during indwelling urethral
catheterization.
IN SUMMARY
UO is a common but complex disorder encountered
in cats. A great deal remains to be learned about the
treatment of UO and the risk factors for recurrent
UO to help standardize care. Despite the severe
metabolic consequences associated with UO,
aggressive treatment results in high success rates.
When aggressive conventional treatment is not
an option, nonconventional management may be
successful.
BUN = blood urea nitrogen; NSAID = nonsteroidal
anti-infammatory drug; POD = postobstructive
diuresis; UO = urethral obstruction; USG = urine
specifc gravity; UTI = urinary tract infection
References
1. Lee JA, Drobatz KJ. Characterization of the clinical
characteristics, electrolytes, acid-base, and renal parameters
in male cats with urethral obstruction. J Vet Emerg Crit Care
2003; 13(4):227-233.
2. Lekcharoensuk C, Osborne CA, Lulich JP. Evaluation of
trends in frequency of urethrostomy for treatment of urethral
obstruction in cats. JAVMA 2002; 221(4):502-505.
3. Gerber B, Eichenberger S, reusch CE. Guarded long-term
prognosis in male cats with urethral obstruction. J Feline Med
Surg 2008; 10:16-23.
4. Segev G, Livne H, ranen E, Lavy E. Urethral obstruction
in cats: Predisposing factors, clinical, clinicopathological
characteristics and prognosis. J Feline Med Surg 2011;
13:101-108.
5. Hetrick PF, Davidow EB. Initial treatment factors associated
CHRISTOPHER M. GEORGE
Christopher M. George, DVM, is a
small animal internal medicine resident
at Kansas State University College
of Veterinary Medicine. Dr. George
received his DVM degree from Kansas
State University and completed a small
animal surgery and medicine internship
at VCA Mission Animal Referral and
Emergency Center before returning
to Kansas State University for his
residency training. His clinical interests
and Masters research include feline
chronic kidney disease and urology.
48 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com
with feline urethral obstruction recurrence rate: 192 cases
(2004-2010). JAVMA 2013; 243(4):512-519.
6. Lee JA, Drobatz KJ. Historical and physical parameters as
predictors of severe hyperkalemia in male cats with urethral
obstruction. J Vet Emerg Crit Care 2006; 16(2):104-111.
7. Malouin A, Milligan JA, Drobatz KJ. Assessment of blood
pressure in cats presented with urethral obstruction. J Vet
Emerg Crit Care 2007; 17(1):15-21.
8. Hall J, Hall K, Powell L, Lulich J. Outcome of male cats
managed for urethral obstruction with decompressive
cystocentesis and urinary catheterization: 47 cats (2009-
2012). J Vet Emerg Crit Care 2015; 25(2):256-262.
9. Drobatz KJ, Cole SG. The infuence of crystalloid type
on acid-base and electrolyte status of cats with urethral
obstruction. J Vet Emerg Crit Care 2008; 18(4):355-361.
10. Cooper ES. Controversies in the management of feline
urethral obstruction. J Vet Emerg Crit Care 2015; 25(1):130-
137.
11. OHearn AK, Wright BD. Coccygeal epidural with local
anesthetic for catheterization and pain management in the
treatment of feline urethral obstruction. J Vet Emerg Crit Care
2011; 21(1):50-52.
12. Lees GE, Osborne CA, Stevens JB, Ward GE. Adverse
effects caused by polypropylene and polyvinyl feline urinary
catheters. Am J Vet Res 1980; 41(11):1836-1840.
13. Galluzzi F, De rensis F, Menozzi A, Spattini G. Effect of
intraurethral administration of atracurium besylate in male
cats with urethral plugs. J Small Anim Pract 2012; 53:411-
415.
14. Cooper ES, Owens TJ, Chew DJ, Buffngton CA. A protocol
for managing urethral obstruction in male cats without
urethral catheterization. JAVMA 2010; 237(11):1261-1266.
15. Francis BJ, Wells rJ, rao S, Hackett TB. retrospective study
to characterize post-obstructive diuresis in cats with urethral
obstruction. J Feline Med Surg 2010; 12:606-608.
16. Dorsch r, Zellner F, Schulz B, et al. Evaluation of meloxicam
for the treatment of obstructive feline idiopathic cystitis. J
Feline Med Surg 2015; DOI: 10.1177/1098612X15621603.
17. Hugonnard M, Chalvet-Monfray K, Dernis J, et al.
Occurrence of bacteriuria in 18 catheterised cats with
obstructive lower urinary tract disease: A pilot study. J Feline
Med Surg 2013; 15(10):843-848.
18. Pereira JS, Fragoso S, Beck A, et al. Improving the feline
veterinary consultation: The usefulness of Feliway spray in
reducing cats stress. J Feline Med Surg August 2015 [Epub
ahead of print]; DOI: 10.1177/1098612X15599420.
19. Eisenberg BW, Waldrop JE, Allen SE, et al. Evaluation of
risk factors associated with recurrent obstruction in cats
treated medically for urethral obstruction. JAVMA 2013;
243(8):1140-1146.
GREGORY F. GRAUER
Gregory F. Grauer, DVM, MS, Diplomate ACVIM
(Small Animal Internal Medicine), is a professor
and Jarvis Chair of Medicine, Department of
Clinical Sciences, at Kansas State University
College of Veterinary Medicine. His clinical
and research interests involve the small animal
urinary system. He is on the board of directors
of the IRIS and American Society of Veterinary
Nephrology and Urology. Dr. Grauer received
his postgraduate training in internal medicine
at Colorado State University. He has been a
faculty member at University of Wisconsin
and Colorado State University Colleges of
Veterinary Medicine.
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 Peer reviewed FeLine UreTHraL oBsTrUcTion: diaGnosis & ManaGeMenT

CE TEST. FElInE URETHRAl ObSTRUCTIOn:

DIAgnOSIS & MAnAgEMEnT
This article is RACE-approved for 1 hour of continuing education credit. To receive credit,
take the approved test online at VetMedTeam.com/tvp.aspx (CE fee of $5/article).

Learning Objectives
Upon completion of this article, readers should be able to formulate a plan for appropriate diagnostics
that will facilitate patient stabilization prior to relief of a urethral obstruction (UO). Readers should also
have an increased understanding of traditional and nontraditional methods of relieving UO as well as
some of the factors that may contribute to recurrent obstruction.

1. Cats treated for UO have a survival rate to 6. True/False: Therapeutic cystocentesis is

discharge of: contraindicated in cats with UO.
Note a. < 70%
Questions online b. 7080% 7. What type of urinary catheter is not
may differ from c. 8090% recommended for use as an indwelling
those here; answers d. > 90% catheter?
are available once a. Polypropylene (Tomcat catheter)
CE test is taken at 2. Classic historical and physical examination b. Polyvinyl (red rubber catheter or infant
vetmedteam.com/ fndings in cats with UO include all of the feeding tube)
tvp.aspx. Tests are following except: c. Polytetrafuroethylene (Slippery Sam Tomcat
valid for 2 years from a. Stranguria, dysuria, and/or hematuria
date of approval. Urethral Catheter)
b. Anorexia and vomiting d. Polyurethane
c. Perineal and hindlimb edema
d. A large, turgid urinary bladder
8. True/False: Cats with UO must be treated
with urethral catheterization; other
3. What is the most signifcant laboratory
treatment protocols are ineffective.
abnormality requiring emergent treatment in
cats with UO?
9. When are antimicrobials indicated in the
a. Hyperkalemia
treatment of UO?
b. Hypercalcemia
a. When cats present for recurrent UO
c. Hyponatremia
b. When quantitative bacterial culture
d. Hypochloremia
suggests signifcant bacteriuria
4. What type of imaging is recommended for all c. To prevent UTI during urethral
cats presenting with UO? catheterization
a. Abdominal ultrasonography d. In all cats being discharged after urethral
b. Abdominal radiography catheterization
c. Thoracic radiography
d. Abdominal computed tomography 10. The use of _________ has become standard
in cats with UO to help prevent recurrent
5. What emergent IV therapy is most effective UO secondary to urethral irritation and
in rapidly reducing serum potassium levels? spasms.
a. Calcium gluconate a. Meloxicam
b. Sodium bicarbonate b. Diazepam
c. Dilutional fuid therapy c. Alpha-1 antagonists
d. Regular insulin and dextrose d. Calcium gluconate

50 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com

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 PrAcTicAL TecHniQUes FroM THe nAVc insTiTUTe Peer reviewed

RegeneRative Medicine
foR Soft tiSSue injuRy &
oSteoaRthRitiS
Brittany Jean Carr, DVM, CCRT, and Sherman O. Canapp, DVM, MS, CCRT,
Diplomate ACVS & ACVSMR
Veterinary Orthopedic & Sports Medicine Group, Annapolis Junction, Maryland

Each year, the navc institute gathers the top specialists in select areas of veterinary medicine to
provide hands-on, one-on-one continuing education to the Institute attendees.
Practical techniques from the navc institutebrought to you by the navc and Todays
Veterinary Practiceprovides the opportunity for you to experience the excellent education
provided at the Institute within the pages of this journal.
This article reviews information from the session, canine Sports Medicine & Rehabilitation,
presented at the NAVC Institute 2015. The NAVC Institute 2017 takes place in Orlando, Florida,
May 21 to 26; visit navc.com/institute for further information.

regenerative medicine therapy has become
increasingly popular in both human and veterinary
medicine for treatment of multiple disease
processes, and recent studies have demonstrated
its effcacy in managing numerous orthopedic
conditions in humans, dogs, and horses, including
osteoarthritis and soft tissue injuries.1-13
While some tissues can heal to their original
or near-original strength and stiffness, other
tissues, such as cartilage, heal poorly. regenerative
medicine has been used to stimulate healing in
areas that have not responded to more traditional
approaches, helping injured tissues heal to their
original or near-original condition.
regenerative medicine is often used as an
adjunct to surgical, medical, and/or rehabilitation
therapy in a multimodal approach to treat a
condition or injury. As with any other treatment
modality, it is important to obtain a defnitive
diagnosis and tailor an appropriate treatment plan
for the patient.
PLATELET-RICH PLASMA THERAPY
Platelet-rich plasma (PrP) is an autogenous fuid
concentrate composed primarily of platelets and
growth factors. recent studies indicate that PrP
mediates healing by supplying growth factors,
cytokines, chemokines, and other bioactive
compounds.14,15
PrP is used in both humans and animals to
aid healing in numerous tissues. recent studies
have shown PrP to be effcacious in managing
many different orthopedic conditions, including
osteoarthritis and soft tissue injuries.1,2,16-36 one
recent study in dogs with partially transected
cranial cruciate ligaments and meniscal release
demonstrated improved range of motion,
decreased pain, and improved limb function for up
to 6 monthsafter treatment with 5 intra-articular
injections of leukoreduced PrPcompared with
the control group.37
Role in Tissue Healing
Platelets play roles in both hemostasis and wound
healing, and PrP has been used as a regenerative
medicine therapy to aid in tissue healing.
Platelets contain alpha granules that release
growth factors to stimulate other cells of the body
to migrate to the area of trauma, facilitating tissue
healing. The growth factorsincluding platelet-
derived, vascular endothelial, basic fbroblastic, and
epidermal growth factors and transforming growth
factor beta1 and beta2contained within the
platelets are important for tissue healing.1,2,14-16
Many growth factors act individually or
synergistically to enhance cellular migration
and proliferation, angiogenesis, and matrix
deposition, which promotes tendon and wound

tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice 53

Peer reviewed PrAcTicAL TecHniQUes FroM THe nAVc insTiTUTe
Figure 1. Blood collected for platelet-rich
plasma (PrP) processing using an 18-gauge
butterfy needle and syringe. Most systems
require 10 to 60 mL of blood for PrP
processing.
healing, aids in cartilage health, and counteracts
the cartilage breakdown associated with
osteoarthritis.1-3,5,6,15-20,25-28,31,34,36 Platelets also
recruit, stimulate, and provide a scaffold for stem
cells.32,36,38-45
Components of PRP
Multiple formulations of PrP have been developed
and studied. Previous studies in humans suggest
that the ideal PrP product should lead to a 4- to
7-fold increase in platelets.1,2,14,15,17
However, platelet concentration is not the only
important component of a PrP product. inclusion
or exclusion of mononuclear cells, neutrophils,
and red blood cells not only defnes an autologous
platelet product but also affects the clinical effcacy
of the product and the infammatory responses
after PrP injection.15,16,19,25-28,46-50 in general, red
blood cells and neutrophils should be reduced
because they have an infammatory effect, while
the effect of mononuclear cells remains largely
unknown.42,46,47,51-54
recent studies compared key parameters of the
PrP product from the commonly used commercial
canine PrP systems in healthy, adult canines and
found variations in product composition.50,55,56
Performing PRP Therapy
PrP therapy is a minimally invasive procedure
that typically can be performed on an outpatient
basis. it is often performed as a series of 1 to 3
injections, with 2 weeks between each injection. if
54 TodAys VeTerinAry PrAcTice | July/August 2016 | tvpjournal.com
Figure 2. Both centrifugation and fltration
systems are available for PRP processing. This
centrifugation PRP system used for processing
produces a leukocyte- and erythrocyte-poor
PrP sample.
PrP is being used to manage moderate to severe
osteoarthritis, in my experience, about 50% of
dogs require more than 1 injection for signifcant
improvement.
To perform PrP therapy:
Approximately 30 to 60 mL of blood is
obtained using an 18-gauge needle or butterfly
needle, processed, and prepared for injection
(Figures 1 and 2).
once the PrP is processed, the area to be
treated is clipped and aseptically prepared.
sedation or general anesthesia may be required
for injection, depending on the location of the
injection.
For osteoarthritis, PrP joint injections are
usually performed without sedation; however,
some joints, such as the hip, require sedation and
may also require advanced imaging (fuoroscopy)
for guidance. if one is not familiar with joint
injections, it is wise to sedate patients until
comfort with the procedure is obtained.
PrP has been used for tendon and ligament
injuries, and is most commonly used for low
grade strains or sprains. For soft tissue injuries,
ultrasonography guidance is used to ensure
accuracy of the injection because PrP is most
 PrAcTicAL TecHniQUes FroM THe nAVc insTiTUTe
effective when administered directly into the
lesion. if musculoskeletal ultrasound is not
available for obtaining a defnitive diagnosis or
guidance for treatment administration, referral
should be considered. Ultrasound-guided
injections also require sedation.
Pain Management & Rehabilitation
The most common side effect is discomfort
associated with the injection, which can be
managed with pain medications, if needed,
and typically resolves within 12 to 24 hours
of the injection. However, nonsteroidal anti-
infammatory medication and steroids need to
be avoided 2 weeks before and after PrP therapy
because they have been shown to alter platelet
function.57
A dedicated rehabilitation therapy program
is often recommended in conjunction with
PrP therapy to achieve and maintain the fullest
musculoskeletal potential and performance level.
since the effects of certain modalities on PrP have
not been well documented, therapeutic ultrasound,
electrostimulation, and hydrotherapy are not
recommended during the 4 weeks following PrP
therapy.
STEM CELL THERAPY
stem cells are the bodys progenitor cells, from
which all other cells are derived. recent studies
have shown that stems cells can regenerate and heal
injured tissue, decrease infammation, stimulate
new blood supply to support healing, activate
resident stem cells, create a scaffold for healing
tissue, protect cells from death, and break down
scar tissue.9,10,58-61
Mechanisms of Stem Cells
The mechanisms by which stem cells initiate
healing within the body are complex. Mesenchymal
stem cells (Mscs) become immunosuppressive
after activation by soluble factors; then secrete
factors that inhibit T-lymphocyte activation and
proliferation.9,10,58-61 They:
Use their diverse plasticity to help numerous
types of injured tissues regenerate and heal
decrease proinflammatory, while increasing anti-
inflammatory, mediators
secrete bioactive levels of cytokines and growth
factors that support angiogenesis, tissue
remodeling, differentiation, antiapoptotic events,
and neovascularization.9,10,58-61
tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice
Peer reviewed
Orthopedic Treatment Indications
recent studies have demonstrated the effcacy
of stem cell therapy for canine osteoarthritis.62-64
While many factors play a role in the decision
to choose stem cell therapy for a patient, in
our experience, patients with severe to end-
stage osteoarthritis typically respond better to a
combination of stem cell and PrP therapy rather
than PrP therapy alone.
A recent study in dogs with elbow osteoarthritis
caused by spontaneous fragmented coronoid
process demonstrated that those that underwent
arthroscopic fragment removal and a proximal ulnar
ostectomy and received stromal vascular fraction
(sVF; see Adipose-Derived Stem Cells, page
56) or allogeneic stem cells had a more favorable
outcome than those treated with surgery alone.62
in another recent study, dogs with hip
osteoarthritis that received a single intra-articular
injection of adipose-derived cultured stem cells had a
better outcome than control patients and those that
received plasma rich in growth factors (PrGF).12
similarly, other recent studies also demonstrated
superiority in osteoarthritic dogs treated with
adipose-derived cultured stem cells over control
patients and those treated with PrGF on
controlled blinded force platform analysis.13,63 A
recent study in a dog with a gastrocnemius strain
concluded that stem cell therapy with a custom,
progressive, dynamic orthosis may be a viable,
minimally invasive treatment option.64
Sources of Stem Cells
stem cells that can be obtained from the patients
own body are called autologous adult-derived MSCs.
The most common places from which to harvest
adult-derived Mscs are the patients bone marrow
or adipose tissue (Figures 3 and 4, page 56).
Both bone marrow-derived and adipose-derived
stem cells can differentiate into cartilage, bone,
tendons, and ligaments. To date, no evidence
supports superiority of one over the other in terms
of viability or effcacy of the derived stem cells.
However, adipose tissue may be a preferred source
in dogs (see Adipose-Derived Stem Cells).
Stem Cell Procedure
once the sample is obtained, it is processed and
prepared for injection. Both bone marrow-derived
stem cells and adipose-derived stem cells can be
processed onsite or shipped to a university or
private company for processing, culturing, and
banking for future use.65
55
Peer reviewed PrAcTicAL TecHniQUes FroM THe nAVc insTiTUTe
A B
Figure 3. Bone marrow collection (A) from the proximal femur with fuoroscopic guidance (B) for
processing of bone marrow aspirate concentrate (BMAC).
As with other forms of regenerative medicine,
stem cell therapy is a minimally invasive procedure
that typically can be performed on an outpatient
basis with or without sedation, depending on
the location of the injection. in addition, because
recent studies have shown that PrP recruits and
stimulates stem cells, PrP is often combined with
stem cells before injection to both activate and act
as a scaffold for the stem cells.43,66-71
Adipose-Derived Stem Cells
Almost all veterinary research has focused on adult
stem cells, specifcally Mscs, derived from bone
marrow (BM-Mscs) or adipose tissue. Adipose
tissue may be a preferred source in dogs for several
reasons, including ease of access, low morbidity and
pain associated with collection, and high-yielding
Msc count (especially falciform) (Figure 4).
Figure 4. Collection of adipose tissue from
the falciform ligament for processing of stromal
vascular fraction (SVF).
56 TodAys VeTerinAry PrAcTice | July/August 2016 | tvpjournal.com
The cells isolated from the adipose tissue include
not only the Mscs but also endothelial progenitor
cells, pericytes, immune cells, fbroblasts, and
other growth factor-secreting bioactive cells. The
use of this combination of stem cells and other
regenerative cells is known as sVF therapy, and
this mixture can be injected directly into the
injured tissue or joint or can be administered by
iV route. However, recent studies have shown
that stem cells given by iV do not actually reach
joints or injured tissues72; thus, for orthopedic
applications, we currently do not recommend
administering stem cells iV.
Alternatively, stem cells can be isolated from
adipose tissue, cultured, and expanded. This
technique, which yields a more homogenous
population with a larger quantity of cells for
injection, is known as adipose-derived cultured
progenitor cell, or ADPC, therapy. To date, no
studies show superiority of adipose-derived
sVF versus culture-expanded adipose-derived
Mscs for treatment of canine orthopedic
conditions.
Bone Marrow-Derived Stem Cells
BM-Mscs are most commonly used in equine
regenerative medicine but can also be used in dogs.
There are 2 primary techniques for canine BM-
Msc therapy: bone marrow aspirate concentrate
(BMAc) and cultured-expanded.
only 2% to 4% of the mononuclear cell
population of bone marrow is considered an
Msc. The BMAc technique evolved such that
the nucleated cellular portion of tissue aspirates
obtained from bone marrow was concentrated and
then applied to the injured tissue. This therapy is
appealing for several reasons:
 PrAcTicAL TecHniQUes FroM THe nAVc insTiTUTe
Figure 5. Ultrasonography-guided injection of BMAC and PRP into the supraspinatus tendon. The
green arrow points to the needle being inserted into the supraspinatus tendon.
The cells can be processed quickly for faster
therapeutic application. Processing takes only
1 to 2 hours if it can be performed in-house by
using a commercially available kit, which allows
the practitioner to initiate therapy 3 to 4 weeks
earlier than can be done with culture-expanded
cells.
These cells are not manipulated in culture to the
extent that culture-expanded cells are, meaning
that they do not undergo adherence, expansion,
or trypsinization through multiple passages,
which can alter cellular phenotype.
This cellular therapy also delivers portions of
the bone marrow cell pool that could potentially
participate in tissue regeneration.
Alternatively, BM-Mscs can be isolated,
cultured, and expanded. This yields a more
homogenous population with a larger quantity
of cells for injection. To date, no studies show
superiority of BMAc over culture-expanded
BM-Mscs in the treatment of canine orthopedic
conditions. in addition, no studies have
documented the superiority of BM-Mscs over
adipose-derived stem cells or identifed the number
of stem cells needed for treating soft tissue injuries
or osteoarthritis.
REHABILITATION AFTER THERAPY
A dedicated rehabilitation therapy program guided
by trained and certifed individuals in canine
rehabilitation is often recommended for 12 weeks
after regenerative medicine therapy, depending on
the diagnosed condition. rehabilitation therapy
should be performed weekly in conjunction with
an at-home exercise program.
During PRP/Stem Cell Therapy
rehabilitation therapy helps speed healing by
decreasing infammation and swelling, building
muscle mass, increasing range of motion, and
tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice
Peer reviewed
Procedural Pearls
Injection of PRP or stem cells is a minimally invasive procedure that
typically can be performed on an outpatient basis.
Sedation or general anesthesia may be required, depending on the
location of the injection; sedation is required for injections administered
under ultrasound guidance.
Joint injections are usually performed without sedation; however, some
joints, such as the hip, require sedation and may also require advanced
imaging (fluoroscopy) for guidance. If one is not familiar with joint
injections, it is wise to sedate patients until comfort with the procedure
is obtained.
For soft tissue injuries, ultrasonography guidance ensures accuracy of
the injection because both PRP and stem cells are most effective when
administered directly into the site of injury (figure 5).
The most common side effect is mild discomfort associated with the
injection, which typically resolves within 12 to 24 hours.
improving overall comfort. Therapy sessions
often include manual therapies, standard isometric
exercises, and class iiib low-level laser therapy,
which is recommended because recent studies have
shown that this laser therapy can stimulate stem
cell differentiation, proliferation, and viability.73
certain therapies are contraindicated within
the frst 8 weeks of regenerative medicine therapy
because their effects on stem cells and PrP have
not been fully studied; these therapies include
class iV low-level laser therapy, therapeutic
ultrasound, shockwave therapy, neuromuscular
electrical stimulation/transcutaneous electrical
neurostimulation, and nonsteroidal anti-
infammatory drugs.
After PRP/Stem Cell Therapy
Underwater treadmill therapy can usually be
initiated 8 weeks after the start of rehabilitation
therapy.
once the tissue has healed, as confrmed
via orthopedic examination, gait analysis, and
diagnostic ultrasonography or needle arthroscopy,
57
Peer reviewed PrAcTicAL TecHniQUes FroM THe nAVc insTiTUTe
the rehabilitation program focuses on
strengthening and conditioning.
After appropriate muscle mass has been attained,
dogs are cleared for retraining and return to sport.
on average, patients treated with regenerative
medicine therapy typically return to competition or
normal activity within 4 to 6 months of treatment.
IN SUMMARY
regenerative medicine has been used to stimulate
healing and help restore injured tissues to their
original or near-original condition. canine
regenerative medicine therapy can be used to
help treat medial shoulder syndrome, shoulder
tendinopathies (eg, supraspinatus tendinopathy or
biceps tendinopathy), iliopsoas strain, Achilles tendon
injury, early partial cranial cruciate ligament tear,
carpal and tarsal ligament injuries, and osteoarthritis.
it is important to obtain a defnitive diagnosis
and ensure that the patient is an appropriate
candidate for regenerative medicine. it is equally
important to incorporate a dedicated rehabilitation
therapy plan into the recovery process to optimize
results from regenerative medicine therapy.
AdPc = adipose-derived cultured progenitor cell;
BMAc = bone marrow aspirate concentrate; BM-
Msc = bone marrowderived mesenchymal stem
cell; Msc = mesenchymal stem cell; PrGF =
plasma rich in growth factors; PrP = platelet-rich
plasma; sVF = stromal vascular fraction
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ligament fbroblasts in vitro. Vet
Comp Orthop Traumatol 2006;
19:43-47.
33. souza TFB, Andrade AL, R
Ferrreira GTnM, et al. Healing
and expression of growth factors
(TGF-B and PdGF) in canine
radial osteotomy gap containing
platelet-rich plasma. Vet Comp
Orthop Traumatol 2012; 25:445-
34.
452.
Van Buul GM, Koevoet WLM, Processing System
Kops n, et al. Platelet-rich
plasma releasate inhibits
infammatory processes in
osteoarthritic chondrocytes. Am
J Sports Med 2011; 39(11):2362-
2370.
35. Xie X, Hua W, Zhao s, et al. The
effect of platelet-rich plasma on
patterns of gene expression in a
dog model of anterior cruciate
ligament reconstruction. J Surg
3UHSDUHVWHPFHOOVLQ\RXUFOLQLF
36.
Res 2013; 180:80-88.
Xie X, Wang y, Zhao c, et al. 1RQHHGWRVHQGRIIVDPSOHV
1RQHHGWRFXOWXUHFHOOV
comparative evaluation of
Mscs from bone marrow and
adipose tissue seeded in PrP-
derived scaffold for cartilage 2QO\JDGLSRVHWLVVXHQHHGHG
regeneration. Biomaterials 2012;
37.
33:7008-7018.
cook JL, smith PA, Bozynski
&HOOVUHDG\LQPLQXWHV
cc, et al. Multiple injections of
leukoreduced platelet rich plasma
8VHGLQRUWKRSHGLFVXUJHU\DQG
reduce pain and functional
impairment in a canine model of RVWHRDUWKULWLV
AcL and meniscal defciency. J
Orthop Res 2015; 1-9.
38. Broeckx s, Zimmerman M,
crocetti s, et al. regenerative
therapies for equine degenerative
joint disease: A preliminary
study. PloS One 2014; Menton this ad and get
$200 o your rst order!
9(1):e85917.
39. cho Hs, song iH, Park sy, et
al. individual variation in growth
factor concentrations in platelet-
rich plasma and its infuence on
human mesenchymal stem cells.
Korean J Lab Med 2011; 31:212-
218.
40. del Bue M, ricc s, ramoni US Sales: European Sales:
r, et al. equine adipose-tissue
derived mesenchymal stem
www.ingeneron.com www.ingeneron.de
cells and platelet concentrates: Tel: 713.440.9900 Tel: +49 (0)89 149 903 1927
Their association in vitro and sales@ingeneron.com sales@ingeneron.de
in vivo. Vet Res Commun 2008;
32(s1):s51- s55.
July/August 2016 59
 Peer reviewed PrAcTicAL TecHniQUes FroM THe nAVc insTiTUTe

41. drengk A, Zapf A, strmer eK, et al. infuence of platelet-rich
plasma on chondrogenic differentiation and proliferation of
chondrocytes and mesenchymal stem cells. Cells Tissues Organs
2009; 189:317-326.
42. dohan ehrenfest dM, rasmusson L, Albrektsson T.
classifcation of platelet concentrates: From pure platelet-rich
plasma (P-PrP) to leukocyte- and platelet-rich fbrin (L-PrF).
Trends Biotech 2008; 27(3):158-167.
43. Mishra A, Tummala P, King A, et al. Buffered platelet-rich
plasma enhances mesenchymal stem cell proliferation and
chondrogenic differentiation. Tissue Eng Part C Methods 2009;
15:431-435.
44. schnabel LV, Lynch Me, Van der Meulen Mc, et al.
Mesenchymal stem cells and insulin-like growth factor-i gene-
enhanced mesenchymal stem cells improve structural aspects of
healing in equine fexor digitorum superfcialis tendons. J Orthop
Res 2009; 27(10):1392-1398.
45. Torricelli P, Fini M, Filardo G, et al. regenerative medicine for
the treatment of musculoskeletal overuse injuries in competition
horses. Internat Orthop 2011; 35:1569-1576.
46. Braun HJ, Kim HJ, chu cr, dragoo JL. The effect of
platelet-rich plasma formulations and blood products on human
synoviocytes. Am J Sports Med 2014; 42(5):1204-1210.
47. sundman eA, cole BJ, Fortier LA. Growth factor and
catabolic cytokine concentrations are infuenced by the cellular
composition of platelet-rich plasma. Am J Sports Med 2013;
39(10):2135-2140.
48. sundman eA, Boswell sG, schnabel LV, et al. increasing platelet
concentrations in leukocyte-reduced platelet-rich plasma decrease
collagen gene synthesis in tendons. Am J Sports Med 2013;
42(1):35-41.
49. castillo Tn, Pouliot MA, Kim HJ, dragoo JL. comparison
of growth factor and platelet concentrations from commercial
platelet-rich plasma separation systems. Am J Sports Med 2011;
39(2):266-271.
50. stief M, Gottschalk J, ionita Jc, et al. concentration of platelets
and growth factors in canine autologous conditioned plasma. Vet
Comp Orthop Traumatol 2011; 24:285-290.
51. Boswell sG, schnabel LV, Mohammed Ho, et al. increasing
platelet concentrations in leukocyte-reduced platelet-rich plasma
decrease collagen gene synthesis in tendons. Am J Sports Med
2013; 42(1):42-49.
52. cavallo c, Filardo G, Mariani e, et al. comparison of platelet-
rich plasma formulations for cartilage healing. J Bone Joint Surg
Am 2014; 96:423-429.
53. naldini A, Morena e, Fimiani M, et al. The effects of autologous
platelet gel on infammatory cytokine response in human periph-
eral blood mononuclear cells. Platelets 2008; 19(4):268-274.
54. yoshida r, Murray MM. Peripheral blood mononuclear cells
enhance the anabolic effects of platelet-rich plasma on anterior
cruciate ligament fbroblasts. J Orthop Res 2013; 31(1):29-34.
55. Franklin sP, Garner Bc, cook JL. characteristics of canine
platelet-rich plasma prepared with fve commercially available
systems. Am J Vet Res 2015; 76(9):822-827.
56. carr BJ, canapp so, Mason dM, et al. canine platelet rich
plasma systems: A multicenter, prospective analysis. Front Vet Sci
2015; 2:73.
57. schippinger G, Pruller F, divjak M, et al. Autologous platelet-
rich plasma preparations: infuence of nonsteroidal anti-
infammatory drugs on platelet function. Orthop J of Sports Med
2015; 3(6):1-6.
58. Grassel s, Lorenz J. Tissue engineering strategies to repair
chondral and osteochondral tissue in osteoarthritis: Use of
mesenchymal stem cells. Curr Rheumatol Rep 2014; 16:452.
59. Ham o, Lee cy, Kim r, et al. Therapeutic potential of
differentiated mesenchymal stem cells for treatment of
osteoarthritis. Int J Mol Sci 2015; 16:14961-14978.
60. Wang W, cao W. Treatment of osteoarthritis with mesenchymal
stem cells. Sci China Life Sci 2014; 57(6):586-595.
61. Wolfstadt Ji, cole BJ, ogilvie-Harris dJ, et al. current concepts:
The role of mesenchymal stem cells in the management of knee
osteoarthritis. Sports Health 2015; 7(1):38-44.
62. Kiefer K, Wucherer KL, Pluhar Ge, conzemius MG.
Autologous and allogeneic stem cells as adjuvant therapy for
osteoarthritis caused by spontaneous fragmented coronoid
process in dogs. VOS Symposium Proc, 2013.
Continued on page 67

Stem Cell Therapy V-PET Veterinary Platelet Enhancement

The Principle: To deliver a number of active and adaptive
mix of cells to promote regeneration of tissues at the site
of injury. Mitigating on-going tissue degeneration, scarring
and pain.
The Methodology: Adipose tissue cell extraction,
concentration and processing for autologous
(patient is donor) treatment.
48 hours turn-around time from fresh tissue
collection
Cell banking services included the first year
Peer reviewed publications (canine arthritis, equine
tendons, ligaments and joints)
Therapy system
The Principle: To deliver a platelet concentrate to promote
and stimulate healing by amplifying the biological signals at
the site of injury.
The Methodology: Peripheral blood collection,
concentration and processing for autologous (patient is the
donor) treatment.
All-inclusive kit (30 minute procedure)
Closed sterile system
No centrifuge needed ( gravity filtration)
Peer reviewed publications (equine soft tissue, canine
arthritis)

1-88-VETSTEM1
60
www.vetstem.com
TodAys VeTerinAry PrAcTice | July/August 2016 | tvpjournal.com
 endoscoPy essenTiALs Peer reviewed

Lower Gastrointestinal endoscopy series

Part 1: Overview Of
LOwer GastrOintestinaL
endOscOPy
Patrick S. Moyle, DVM, and Alex Gallagher, DVM, MS, Diplomate ACVIM
University of Florida

Welcome to endoscopy essentials, a column that discusses endoscopic evaluation of specifc

body systems, reviewing indications, disease abnormalities, and proper endoscopic techniques.
Visit tvpjournal.com to read the frst three Endoscopy Essentials articles:
Overview of Upper Gastrointestinal Endoscopy (November/December 2014)
Upper Gastrointestinal Endoscopy Techniques (March/April 2015)
Endoscopic Foreign Body Retrieval (November/December 2015).

Lower gastrointestinal (Gi) endoscopy is a minimal-
ly invasive diagnostic technique that allows the clini-
cian to evaluate the mucosal surfaces of the rectum,
colon, ileocolic sphincter, cecum, and distal small
intestine (ileum) (Figure 1). Lower Gi endoscopy
can be used:
diagnostically, to collect biopsy samples in animals
with chronic large bowel disease (colonoscopy)
and/or chronic small bowel disease (ileoscopy)
Therapeutically, for treatment of strictures,
foreign bodies, polyps, and tumors.
COLONOSCOPY & PROCTOSCOPY
Indications
colonoscopy and proctoscopy have similar
indicationsboth are important diagnostic
modalities for evaluating animals with clinical
signs referable to the large bowel. These signs may
include diarrhea with increased frequency, tenesmus,
dyschezia, hematochezia, increased fecal mucus, and
occasionally, constipation/obstipation (Table 1).
Many animals with large bowel disease can be
diagnosed and/or treated by less invasive options and
do not require colonoscopy. Hence, a rational, stepwise
diagnostic and therapeutic plan should be pursued
before colonoscopy or proctoscopy is performed.
differences in proctoscopy and colonoscopy tech-
nique will be addressed in Part 2 of this article series.

TAble 1.
clinical signs that indicate investigation with
Lower Gi endoscopy
colonoscopy Diarrhea with increased frequency
& Proctoscopy Tenesmus
Dyschezia
Hematochezia
Increased fecal mucus
Figure 1. Anatomy of the lower gastrointestinal Constipation/obstipation (occasionally)
tract, including the rectum, colon, ileocolic sphinc- ileoscopy Vomiting
ter, cecum, and distal small intestine (ileum). Weight loss
Courtesty Savannah Mauragis Small bowel diarrhea

tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice 61

 Peer reviewed endoscoPy essenTiALs

Evaluation Prior to Endoscopy aforementioned diagnostics and empiric therapies

digital rectal examination should be performed to
evaluate for rectal masses, strictures, and mucosal
abnormalities. recommended diagnostics for
animals undergoing lower Gi endoscopy are listed
in Table 2.
Therapeutics Prior to Endoscopy
recommended therapeutics for animals undergoing
lower Gi endoscopy are listed in Table 3. if the
fail to improve the patient, biopsy is recommended
before immunosuppressive therapy is initiated.
During Endoscopy: Normal Appearance
Colon
The normal appearance of the colonic mucosa
is smooth, pale pink, and glistening (Figure 3).
submucosal blood vessels should be readily
apparent throughout the length of the colon.

Table 2.
diagnostics Prior to Lower Gi endoscopy
diaGnOstic test PUrPOse Of diaGnOstics
intestinal dysbiosis
relates to alterations Laboratory diagnostics Prior to colonoscopy, Proctoscopy, & ileoscopy
in the microbiota
complete blood count Assesses overall health prior to anesthesia
throughout the small Identifes concurrent diseases
and large intestines, Serum biochemical profle May uncover diseases causing secondary GI signs, such as renal or hepatic
while Gi dysbiosis Urinalysis disease, Addisons disease, or hyperthyroidism
refers to microbiota Detects hypoalbuminemia, which can occur with predominantly small bowel
abnormalities disease; may indicate need for more aggressive diagnostic approach (rather
anywhere along the than therapeutic trials)
GI tract. additional Laboratory diagnostics Prior to ileoscopy

thyroid function testing Identifes hyperthyroidism in cats, which can cause secondary GI signs

resting cortisol or actH Identifes atypical Addisons disease, which can cause GI signs without
stimulation test biochemical changes

folate Low serum folate concentrations are consistent with proximal intestinal disease
Increased folate concentrations suggest intestinal dysbiosis
Note that normal serum folate levels do not exclude presence of small intesti-
nal disease

cobalamin/B12 Low cobalamin concentrations indicate distal small intestinal disease

Note that normal serum cobalamin levels do not exclude presence of small
intestinal disease

trypsin-like Decreased serum trypsin-like immunoreactivity is diagnostic for exocrine

immunoreactivity pancreatic insuffciency

Pancreatic lipase Increased pancreatic lipase immunoreactivity is supportive of pancreatitis

immunoreactivity

fecal testing Prior to colonoscopy, Proctoscopy, & ileoscopy

Fecal fotation Determines presence of GI parasites, particularly Trichuris vulpis (figure 2)

direct saline fecal smears Aid in diagnosis of infectious diseases (eg, Giardia intestinalis, Tritrichomonas
species, Clostridium species)
fecal Pcr Because these tests can be insensitive and nonspecifc, results should always
Specifc immunoassays be interpreted within context of the case

cytology from rectal May aid in diagnosis of infection with Histoplasma capsulatum, Prototheca
mucosal scrape species, and Pythium insidiosum, and colonic lymphoma

fecal culture Detects presence of pathogenic bacteria, but typically has low diagnostic yield,
especially if a specifc pathogen is not already suspected

imaging Prior to colonoscopy, Proctoscopy, & ileoscopy

radiography or Determines presence of:

ultrasound Masses or chronic foreign bodies/radio-opaque foreign material
Infltrative diseases, such as infammatory bowel disease, neoplasia, or infec-
tious diseases (cytology or histopathology required for defnitive diagnosis)
ACTH = adrenocorticotropic hormone; PCR = polymerase chain reaction

62 TodAys VeTerinAry PrAcTice | July/August 2016 | tvpjournal.com

 endoscoPy essenTiALs Peer reviewed

Figure 2. Whipworms in the ascending Figure 3. Normal appearance of the

colon of a dog. Appropriate deworming is
recommended prior to endoscopy.
Lack of visualization of the submucosal vessels
suggests mucosal thickening secondary to edema or
infltrative diseases.
occasional lymphoid follicles can be observed
in the normal colon of dogs and cats. A variable
amount of adhered fecal material may be visualized
depending on the quality of the patient preparation.
Mucosal hyperemia should be interpreted
cautiously. Hyperemia can be a normal physiologic
response to warm water enemas or mild trauma
from the endoscope but can also be due to
infammatory disease.
Ileocolic & Cecocolic Junctions
At the most orad portion of the ascending colon,
both the ileocolic and cecocolic junctions are
visualized. The cecocolic sphincter is often open or
partially open and usually can be entered.
descending colon in a dog. The mucosal surface
is smooth, light pink, and glistening. The
submucosal blood vessels are easily visible.
dog, the cecum is a spiral structure that can be up
to 30 cm in length and terminates in a blind end.
in the cat, the cecum is extremely short, and the
entirety of the structure can usually be examined
from the ascending colon.
During Endoscopy: Colonic Abnormalities
Infammatory Bowel Disease
The appearance of infammatory colitis ranges from
normal to severe mucosal changes. Frequently, the
mucosa will appear focally to diffusely hyperemic,
irregular, or granular. in more severe cases,
ulceration or erosions may be present. Areas of
mucosal hemorrhage may be present as well. The
mucosa may be friable as the scope is advanced.
Frequently, submucosal blood vessels are not visible
(Figures 4 and 5, page 64).

Cecum Histiocytic Ulcerative Colitis

The mucosa of the cecum is smooth and pale pink, in dogs with histiocytic ulcerative colitis, the colonic
with submucosal blood vessels readily visible. in the mucosa may contain multifocal areas of ulceration

Table 3.
therapeutics Prior to Lower Gi endoscopy
tHeraPeUtic PUrPOse Of tHeraPy
aPPrOacH

deworming With a broad-spectrum parasiticide, such as fenbendazole

Even if fecal examination fndings are negative, GI parasites can shed ova intermittently

trials with probiotics May be attempted for intestinal dysbiosis

or antibiotics Trial therapy with enrofoxacin could be considered in young dogs at risk for
histiocytic ulcerative colitis (eg, boxer dogs, French bulldogs, English bulldogs);
biopsy for culture recommended for defnitive diagnosis and to ensure appropriate
antibiotic selection due to emerging resistance

trials with soluble Can be attempted before initiation of a diet trial

fber or sulfasalazine Results are typically known within 4 to 6 days of initiation of trial

strict hypoallergenic With novel protein diet or hydrolyzed diet

food trials Strongly encouraged because histopathology cannot distinguish infammation sec-
ondary to food hypersensitivity from idiopathic infammatory bowel disease
May take 2 to 3 weeks to determine if a diet trial was effective

tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice 63

Peer reviewed endoscoPy essenTiALs
and erosion, often with mild to marked intraluminal
hemorrhage, depending on the chronicity of the
disease. in areas that lack ulceration, the submucosal
blood vessels are frequently not seen.
Infltrative Infectious Organisms
The endoscopic appearance of infltrative
infectious diseases (pythiosis, protothecosis, and
histoplasmosis) cannot be distinguished from that
of infammatory bowel disease. The colonic mucosa
may appear normal, discolored, or granular with
multifocal areas of ulceration. occasionally, the
lesions may appear more nodular or mass-like. The
mucosa can be friable, and submucosal blood vessels
are rarely seen.
Adenomatous Polyps
When present, benign polyps are mucosal lesions
seen in the colon or rectum of dogs (Figure 6).
Figure 4. Ascending colon in a dog with mild
lymphoplasmacytic infammatory bowel disease.
The mucosal surface is mildly hyperemic, and
submucosal blood vessels are not readily
visible. The ileocolic sphincter is closed and
the cecocolic sphincter is open, enabling
visualization of the proximal cecum.
Figure 5. Descending colon in a dog with lymph-
oplasmacytic and eosinophilic colitis. The mucosal
surface has a cobblestone appearance and
contains multifocal areas of mucosal hemorrhage.
Submucosal blood vessels are not visualized.
64 TodAys VeTerinAry PrAcTice | July/August 2016 | tvpjournal.com
often, only a solitary mass is encountered, but
multiple lesions can be seen. The masses are broad-
based or pedunculated and can have a smooth or
irregular surface. The remainder of the colonic
mucosa usually appears normal.
Neoplasia
colonic neoplasia has a wide variety of appearances.
it can occur as generalized infltrative disease or a
solitary mass.
Adenocarcinoma, the most common neoplasia
in the colon of dogs and cats, often occurs in the
rectum or descending colon but may be anywhere
in the large bowel (Figure 7). if a discrete mass is
present, it can appear nodular, pedunculated, broad-
based, or polypoid. Alternatively, adenocarcinoma
can appear as a circumferential narrowing of the
lumen. The surface of the lesion often contains
ulcers or erosions, is easily friable, and can have a
variable amount of associated hemorrhage.
Lymphoma can also have a wide variety of
appearances. Lymphoma can be indistinguishable
from infammatory bowel disease or may appear as
Figure 6. Descending colon of a dog showing
an adenomatous polyp. The polyp was removed
endoscopically.
Figure 7. Descending colon in a dog with
an annular adenocarcinoma. The surface of
the mass is irregular and contains multifocal
pinpoint areas of hemorrhage.
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Peer reviewed endoscoPy essenTiALs

Therapeutics Prior to Endoscopy

After a thorough diagnostic evaluation, empiric
therapies are typically recommended (Table 3),
unless the clinical condition of the animal (eg, com-
plete anorexia, severe weight loss, or hypoalbumin-
emia) dictates further evaluation immediately.

During Endoscopy: Normal Appearance

Figure 8. ileum of a dog with moderate
lymphoplasmacytic infammatory bowel disease.
The ileal mucosa is pale in appearance and has
a markedly irregular and granular appearance.
diffuse nodular thickening, a broad-based mass, or
segmental circumferential narrowing of the colonic
lumen. The mucosa can contain ulcerations or
erosions and may be friable.
ILEOSCOPY
Indications
ileoscopy should be considered in any animal
with chronic or recurrent clinical signs referable to
the small intestines. clinical signs associated with
small intestinal disease include vomiting, weight
loss, and small bowel diarrhea (Table 1). recent
studies suggest that biopsy of the ileum increases
the diagnostic yield of endoscopic sampling
(Figure 8).
in addition, in some patients, ileoscopy is
performed as an extension of colonoscopy because
severe distal small intestinal disease can present with
large intestinal signs.
As is the case with colonoscopy, many animals
with small bowel disease do not require endoscopy,
and animals should undergo a full diagnostic
workup and empiric therapy before endoscopy.
Evaluation Prior to Endoscopy
recommended diagnostics (Table 2) for animals
prior to ileoscopy are identical to those for animals
undergoing upper Gi endoscopy.
Ileocolic & Cecocolic Sphincters
in dogs, the ileocolic sphincter normally appears as
a smooth mucosal cuff of tissue. in cats, the ileocolic
sphincter can appear as a smaller mucosal cuff or
a mucosal fold. in either species, the cecocolic
junction is generally visualized immediately adjacent
to the ileocolic sphincter.
Ileum
The opening to the ileum is located in the center
of the ileocolic junction. The normal ileal mucosa
is similar to that of the duodenum and is light pink
with a velvet-like texture. in contrast to the proximal
small intestines, Peyers patches are present in high
concentrations in the terminal ileum.
During Endoscopy: Colonic Abnormalities
Because ileoscopy is an extension of upper Gi
endoscopy, small intestinal lesions visualized
by endoscopy are described in the Upper
Gastrointestinal endoscopy series; see Part 1:
Overview of Upper Gastrointestinal Endoscopy
(november/december 2014) and Part 2: Upper
Gastrointestinal Endoscopy Techniques (March/
April 2015), available at tvpjournal.com.
IN SUMMARY
Lower Gi endoscopy is a minimally invasive
diagnostic technique to evaluate the rectum, colon,
cecum, and ileum and obtain biopsy samples in
animals with chronic small and large bowel disease.
All animals with chronic Gi signs should undergo
an appropriate diagnostic evaluation and therapeutic
trials before endoscopy because many patients do
not require this procedure.
Part 2 of this article series will outline preparation
and techniques for performing lower Gi endoscopy.
Gi = gastrointestinal

Patrick s. MOyLe
Pa
P
Patrick S. Moyle, DVM, is a
second-year resident in small
animal internal medicine at
University of Florida College
of Veterinary Medicine. He
received his DVM from Auburn
University and completed an
internship at Wheat Ridge
Animal Hospital in Wheat
Ridge, Colorado.
aLex GaLLaGHer
Alex Gallagher, DVM, MS, Diplomate ACVIM, is a
clinical assistant professor of small animal medicine
at University of Florida College of Veterinary
Medicine, where he also received his DVM. He
completed a rotating internship at Virginia
Maryland College of Veterinary Medicine; an
internal medicine internship at Affliated Veterinary
Specialists in Maitland, Florida; and a residency in
internal medicine at VirginiaMaryland College of
Veterinary Medicine.

66 TodAys VeTerinAry PrAcTice | July/August 2016 | tvpjournal.com

 PrAcTicAL TecHniQUes FroM THe nAVc insTiTUTe

Continued from page 60

63. Vilar JM, Morales M, santana A, et al. controlled, blinded force platform analysis
of the effect of intraarticular injection of autologous adipose-derived mesenchymal
stem cells associated to PrGF-endoret in osteoarthritic dogs. BMC Vet Res 2013;
9:131.
64. case JB, Palmer r, Valdes-Martinez A, et al. Gastrocnemius tendon strain in a dog
treated with autologous mesenchymal stem cells and a custom orthosis. Vet Surg
2013; 42:355-360.
65. Martinello T, Bronzini i, Maccatrozzo L, et al. canine adipose-derived-mesenchymal
stem cells do not lose stem features after a long-term cryopreservation. Res Vet Sci
2011; 91:18-24.
66. carvalho AM, Badial Pr, Alvarez Le, et al. equine tendonitis therapy using
mesenchymal stem cells and platelet concentrations: A randomized controlled trial.
Stem Cell Res Ther 2013; 22(4):85.
67. chen L, dong sW, Liu JP, et al. synergy of tendon stem cells and platelet-rich-
plasma in tendon healing. J Orthop Res 2012; 30(6):991-997.
68. Uysal cA, Tobita M, Hyakusoku H, Mizuno H. Adipose-derived stem cells enhance
primary tendon repair: Biomechanical and immunohistochemical evaluation. J Plast
Reconstr Aesthet Surg 2012; 65(12):1712-1719.
69. Manning cn, schwartz AG, Liu W, et al. controlled delivery of mesenchymal stem
cells and growth factors using a nanofber scaffold for tendon repair. Acta Biomater
2013; 9(6):6905-6914.
70. yun JH, Han sH, choi sH, et al. effects of bone marrow-derived mesenchymal
stem cells and platelet-rich plasma on bone regeneration for osseointegration of
dental implants: Preliminary study in canine three-wall intrabony defects. J Biomed
Mater Res B Appl Biomater 2014; 102(5):1021-1030.
71. Tobita M, Uysal cA, Guo X, et al. Periodontal tissue regeneration by combined
implantation of adipose tissue-derived stem cells and platelet-rich plasma in a canine
model. Cryotherapy 2013; 15(12):1517-1526.
72. Harting MT, Jimenez F, Xue H, et al. intravenous mesenchymal stem cell therapy for
traumatic brain injury. J Neurosurg 2009; 110(6):1189-1197.
73. Ginani F, soares dM, Barreto MP, Barboza cA. effect of low-level laser therapy
on mesenchymal stem cell proliferation: A systemic review. Lasers Med Sci 2015;
30(8):2189-2194.

ea.
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 APcc PrAcTicAL ToXicoLoGy Peer reviewed

IllumInatIng the toxIcIty

of fIreworks
Charlotte Means, DVM, MLIS, Diplomate ABVT & ABT
ASPCA Animal Poison Control Center, University of Illinois

Welcome to Practical Toxicology, brought to you in partnership between Todays Veterinary

Practice and the ASPCA Animal Poison Control Center (APCC) (aspcapro.org/about-animal-
poison-control-center). This column provides practical clinical information about diagnosing and
treating pets that have been exposed to potentially harmful substances.
The APCC:
Provides 24-hour diagnostic and treatment recommendations by specially trained veterinary
toxicologists
Protects and improves animal lives through toxicology education, consulting services, and case
data review
Developed and maintains AnTox, an animal toxicology database system that identifies and
characterizes toxic effects of substances in animals
Works closely with human poison control centers to provide animal poisoning information
Offers extensive veterinary toxicology consulting to organizations in industry, government, and
agriculture.
If treating a patient that requires emergency care for poisoning, call the APCC at 888-426-4435.

it is Fourth of July weekend, and you are prepared
for the many unscheduled appointments, from
patients with gastroenteritis due to downing
hot dogs to those suffering from noise phobia.
However, the patients you end up seeing are neither
fearful nor full of food.
in the exam room, Mrs. smith explains that her
dog ate frecrackers. A technician takes a phone
call and reports that Mr. Jones is coming inhis
dog ingested sparklers. Then the whole doe family
arrives with their dog: while walking by the river
this morning, Fido chewed on remains of the
municipal freworks.
should you worry about these patients?
Hospitalize? refer? How do you treat?
FIREWORK INGREDIENTS
Fireworks are a class of low explosive pyrotechnic
devices that contain many different ingredients
(Table 1, page 70). To produce combustion,
freworks require a:
Binder: Typically dextrin and rarely contributes
to toxicity
Fuel: Typically black powder (gunpowder), a
mixture of sulfur, carbon (charcoal), and potas-
sium nitrate (saltpeter); aluminum powder (flash
powder) may be used for brighter explosions
Oxidizing agent: Produces oxygen to support
fuel combustion; includes nitrates, chlorates, or
perchlorates
Reducing agent: Burns the oxygen provided by
oxidizing agent; frequently includes both sulfur
and charcoal
Regulator: controls the speed of the reaction,
with various metals used
Coloring agent: Provides color but does not
contribute to combustion.1
chemical reactions during the combustion
process affect kinetics, bioavailability, and toxicity of
various ingredients2-4; therefore, spent freworks can
have different compositions than unused freworks.
TYPES OF FIREWORKS
common freworks include frecrackers, smoke
bombs, sparklers, snakes, and bottle rockets (Table
2), and these are the types of freworks your patients
will most likely ingest.4,5
Charcoals: Not All the Same
Charcoal (carbon) in black powder is composed of partially pyrolyzed
(partially decomposed) cellulose from soft wood. Activated
charcoal (activated carbon) is made specifcally for medical use (ie,
decontamination of the gastrointestinal [GI] system) by heating common
charcoal in the presence of a gasa process that creates many internal
pores, which help trap chemicals within the activated charcoal.

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Peer reviewed APcc PrAcTicAL ToXicoLoGy

LEGALITY OF FIREWORKS most display freworks, which require a Bureau

Most states and cities have stringent regulations
regarding the purchase and use of freworks, and dif-
ferentiate between freworks available for purchase
by consumers versus licensed pyrotechnicians.
The United states government uses the United
nations explosives shipping classifcation system
to categorize freworks: Class 1.3G includes
of Alcohol, Tobacco, Firearms and explosives
(ATF) permit to purchase. Class 1.4G consists of
consumer freworks, which can contain a maximum
of 50 mg of explosive material.
illegal consumer freworks, such as M-80
and M-100 frecrackers and cherry bombs, are
sometimes sold as legal consumer freworks. To

TABLe 1.
Ingredients Commonly Found in Fireworks
INGREDIENT USE EFFECTS AFTER INGESTION

Aluminum Silver and white fames and Poor oral absorption; little risk of toxicity
sparks (common in sparklers)
Antimony (antimony Glitter effects Poor oral absorption; poisoning is very rare
sulfde)
Barium (barium chlorate, Green color; can help stabilize See Table 3, page 72
barium nitrate) other volatile elements
Beryllium White sparks Poor oral absorption; inhalation can cause lung
cancer
Calcium (calcium Orange color; used to Poor GI tract absorption; however, calcium
chlorate) deepen other colors chloride is corrosive and can cause oral/
esophageal ulceration and GI hemorrhage. See
Table 3 (Chlorates)
Cesium (cesium nitrate) Indigo color Toxicity is of minor importance
Chlorine Component of many oxidizers Toxicity is of minor importance
in freworks
Copper (copper Blue color Copper salts are locally corrosive
chloride, copper halides)
Iron Gold sparks The amount of iron in freworks is generally
minimal; toxicity is of minor importance
Lithium (lithium Red color While toxicity is of minor importance, vomiting is
carbonate) common
Magnesium White sparks and improves Toxicity is of minor importance
brilliance
Phosphorus Glow-in-the-dark effects; may Red phosphorus (safety matches) is an insoluble
be a component of the fuel substance and nontoxic in oral ingestions,
whereas white phosphorus (freworks) can cause
severe gastroenteritis and cardiotoxic effects
Potassium (potassium Violet color; black powder Animals with normal renal function have minimal
nitrate, potassium explosive used to oxidize toxicity consisting of GI signs
perchlorate) frework mixtures
Rubidium (rubidium Violet color Toxicity is of minor importance
nitrate)
Sodium (sodium nitrate) Gold or yellow color See Table 3 (Nitrates)
Strontium (strontium Red color; used to stabilize Toxicity is of minor importance; mild vomiting and
carbonate) frework mixtures diarrhea may be seen
Sulfur (sulfur dioxide) Component of black powder Vomiting and diarrhea are common after ingestion
Titanium Silver sparks Poor oral absorption; heavy dust exposures can
cause coughing and dyspnea
Zinc Smoke effects Zinc salts can cause vomiting, diarrhea, and GI
ulcers; however, frework ingestions rarely cause
zinc toxicosis

70 TodAys VeTerinAry PrAcTice | July/August 2016 | tvpjournal.com

 APcc PrAcTicAL ToXicoLoGy Peer reviewed

TABLe 2.
Common Types of Fireworks
TYPE INGREDIENTS CONCERNS

Bottle rockets Gunpowder Ingestion can result in GI irritation and intestinal foreign bodies.
Nitrates are of minor concern in monogastrics, such as dogs,
but are of greater concern in ruminants (see Table 3).
While ingredients other than gunpowder may be used, clinical
signs and treatment are generally the same.
Sparklers Barium dinitrate Ingestion causes GI signs in most patients and can also result in
Strontium carbonate intestinal foreign body obstruction.
Potassium perchlorate Barium causes severe hypokalemia, which leads to muscle
weakness, cramping, and cardiac muscle dysfunction.
Amounts of barium and perchlorates are not likely to cause
signifcant clinical signs unless many sparklers are ingested.
Snakes Potassium nitrate In most cases, clinical signs are limited to gastroenteritis.
(also called black Carbon If more serious signs are present, potential for signifcant
snakes or glow Sulfur toxicity, such as barium toxicity, exists.6
worms) Perchlorates
Aluminum
Strontium nitrate
Barium

add to the confusion, illegal and legal freworks
may share similar names. Legal freworks can be
identifed by the:
Manufacturer name on the item or box
Provision of instructions for proper use and list of
cautions.
illegal freworks should be reported to the ATF.5
CLINICAL SIGNS
in small animal practice, chlorate and barium result
in the most problems associated with frework
ingestion. As mentioned earlier, composition of
spent versus unused freworks can affect toxicity.
Unused (unexploded) consumer freworks
can cause gastroenteritis in dogs. Unused display
freworks can cause methemoglobinemia, along
with vomiting, diarrhea, lethargy, abdominal pain,
and salivation. chlorates are not only local irritants,
causing Gi effects, but potent oxidizing agents that
can oxidize red blood cells, causing hemolysis and
methemoglobin formation.
Spent display freworks from municipal displays
cause more severe clinical signs. often there is a
signifcant amount of spent ash present, and the
ash contains large amounts of more toxic frework
components, such as barium (Table 3).
Illegal freworks may be more likely to cause
methemoglobinemia because they frequently contain
high levels of chlorates (Table 3).
DIAGNOSIS
in most patients, history provides enough
information to diagnose frework ingestion.
However, if a symptomatic dog is presented with an
unknown history, the potential differential diagnosis
for methemoglobinemia includes ingestion of
acetaminophen, onions or garlic, aniline dyes,
naphthalene, and phenazopyridine. Hemorrhagic
gastroenteritis can be caused by parvoviral enteritis,
arsenic, and dietary indiscretion.
MANAGEMENT
if a client reports that the pet has ingested freworks,
try to determine:
The brand of firework and amount (eg, one
firecracker or a box)
Whether firework was legal type of firework
Where the firework was purchased: illegal
fireworks may be purchased from unauthorized
firework stands, in other states or countries (ie,
Mexico), from movie/TV production companies/
suppliers, or through the internet.
Frequently, the answers to these questions are
unknown and treatment is based on clinical signs.
Emesis Induction
if the pet is asymptomatic and ingestion occurred
less than 1 hour previously, emesis may be induced:
if the fireworks contain barium, magnesium
sulfate precipitates barium in the Gi tract and
prevents further absorption.
if the fireworks contain chlorates, administration
of mineral oil may prevent absorption as well as
speed transit time through the Gi tract. However,
administer mineral oil with caution; if the oil is
aspirated, lipid pneumonitis may occur.
However, if the ingredients are known to be
corrosive, do not induce emesis. note that activated

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Peer reviewed APcc PrAcTicAL ToXicoLoGy

TABLe 3.
Ingestion of Fireworks: Clinical Signs
INGREDIENT CLINICAL SIGNS

Barium Barium salts are soluble, leading to rapid absorption.

(barium chloride or Barium blocks the exit channel for potassium in skeletal muscle cells, sequestering
barium nitrate) the potassium in the cells; it also stimulates skeletal, smooth, and cardiac muscle.
The net result is severe hypokalemia, with:
Vomiting, diarrhea, hypersalivation, cyanosis, bradycardia, and dyspnea within 10
to 60 minutes after exposure
Tremors, seizures, paralysis, hypertension, and severe hypokalemia that may occur
at 2 to 3 hours after ingestion
Progression to arrhythmias, respiratory failure, cardiac shock and, possibly, death in
severe cases.
If no signs develop within 8 hours, toxicity should not be expected.2,6
Chlorates Chlorates, especially sodium chlorate, can cause vomiting, tachycardia,
hemolysis, hyperkalemia (secondary to methemoglobinemia and hemolysis),
methemoglobinemia, and nephropathy (secondary to hemolysis).
Methemoglobinemia may develop within an hour or, in rare cases, be delayed for 10
hours.2
Nitrates Monogastrics, such as dogs, generally only develop mild GI upset.
In ruminants, rumen micro-oganisms reduce nitrates to nitrites, which oxidize
hemoglobin to methemoglobin, and severity of clinical signs correlates with the
severity of methemoglobinemia.
Corrosive salts These salts may result in oral and/or esophageal ulcers.

charcoal does not bind to chlorates or heavy metals
and, thus, is not recommended.
Critical Care
iV fuids can be used to maintain normal blood
pressure and urine production, and saline diuresis
increases excretion of barium. if the animal
is cyanotic, oxygen is recommended. oxygen
saturation and electrolytes, especially potassium,
should be monitored. in addition, obtain a complete
blood count, measure liver and renal function
(baseline and at 24, 48, and 72 hours), and assess
urine output.
Chlorate Toxicity
chlorates are slowly excreted unchanged from the
kidneys and may damage the renal proximal tubules,
causing renal vasoconstriction; renal enzymes may
be elevated. chlorates can also cause hyperkalemia.4
if chlorate toxicity is present, several options
are available to assist in the conversion of
methemoglobin to hemoglobin.
Methylene blue (10 mg/kg iV as a 2%4%
solution); do not substitute new methylene blue
for methylene blue.
if methylene blue is unavailable, N-acetylcysteine
(140 mg/kg iV or Po; then 70 mg/kg iV or Po
Q 6 H for 57 treatments) can be tried.
Ascorbic acid (vitamin c; 1020 mg/kg
iV, sc, or Po Q 4 H) aids in conversion of
methemoglobin to hemoglobin and can be used
as an adjunct treatment to methylene blue or
N-acetylcysteine. However, if aluminum is an
ingredient in the firework, do not use ascorbic
acid because it enhances aluminum absorption.
Additional therapies include:
Adding sodium thiosulfate (25 g in 200 mL of
5% sodium bicarbonate Po or iV) to mineral oil
to inactive chlorate ions.
Administering sodium bicarbonate (12 meq/
kg iV; titrate up as needed) to shift potassium
extracellularly; then monitor acidbase status
carefully.
Using blood transfusions to treat hemolytic
anemia.
Barium Toxicity
The primary treatment for barium toxicity is to
correct profound hypokalemia.
Potassium chloride (not to exceed 0.5
meq/kg/H iV) can be used to treat cardiac
arrhythmias, hypokalemia, and diarrhea caused by
barium.
if severe cardiac arrhythmias are present,
measurement of troponin I levels is
recommended, with subsequent echocardiography
and cage rest, if needed.2,6
Corrosive Salts
if the ingested freworks contained corrosive salts,

72 TodAys VeTerinAry PrAcTice | July/August 2016 | tvpjournal.com

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monitor for oral and/or esophageal ulcers, which
may not be noted for 12 or more hours. However,
oral and esophageal burns are rare in cases of
frework ingestions.
Sucralfate slurries (0.251 g Po Q 68 H) and
famotidine (0.51 mg/kg Po, sc, iM, or iV)
can be used to treat gastric irritation.
Proton pump inhibitors, such as omeprazole
(0.51 mg/kg Po Q 24 H), can also be used,
especially for esophagitis.
Opioids should be administered to address the
pain of oral and esophageal ulcers, as needed.
Soft or liquid diets should be fed. in patients
with severe ulcers, an esophagostomy or
gastrotomy tube may be required.
A broad-spectrum antibiotic should be
administered due to the risk for bacterial
translocation.
ChARLOTTE MEANS
Charlotte Means, DVM, MLIS, Diplomate ABVT & ABT, is Director
of Toxicology at the ASPCA Animal Poison Control Center (APCC).
She received her DVM and undergraduate degree from Oklahoma
State University and a masters degree in library and information
science from University of Oklahoma. Dr. Means worked in small
animal practice and as a clinical medical librarian before joining the
ASPCA APCC.
74 TodAys VeTerinAry PrAcTice | July/August 2016 | tvpjournal.com
PROGNOSIS & RECOVERY
Most patients that have ingested freworks respond
well to symptomatic and supportive care. recovery
usually takes 24 to 72 hours (1014 days for oral or
esophageal burns). ingestion of freworks is just one
more reason to leave dogs safely confned indoors
during celebrations that end with a bang.
APcc = Animal Poison control center; ATF
= Bureau of Alcohol, Tobacco, Firearms and
explosives; Gi = gastrointestinal
References
1. Gondhia r. The chemistry of freworks. imperial college
London; available at ch.ic.ac.uk/local/projects/gondhia/
composition.html.
2. Wismer TA. Matches and freworks. in osweiler Gd, Hovda Lr,
Brutlad AG, et al (eds): Blackwells Five-Minute Veterinary Consult
Clinical Companion Small Animal Toxicology. Ames, iA: Wiley
Blackwell, 2001, pp 568-573.
3. Martin-Alberca c, de la ossa MA, saiz J, et al. Anions in pre-
and post-blast consumer freworks by capillary electrophoresis.
Electrophoresis 2014; 35(21-22):3272-3280.
4. Gahagan P, Wismer T. Toxicology of explosives and freworks
in small animals. Vet Clin North Am Small Anim Pract 2012;
42(2):361-373.
5. American Pyrotechnics Association; available at americanpyro.
com.
6. rhyee sH, Heard K. Acute barium toxicity from ingestion of
snake freworks. J Med Toxicol 2009; 5(4):209-213.
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Are exotics a Fit for Me?

Part 1: DeveloPment of
the exotics Practice
Angela M. Lennox, DVM, Diplomate ABVP (Avian & Exotic Companion Mammal)
& ECZM (Small Mammal)
Avian and Exotic Animal Clinic, Indianapolis, Indiana

To see (exotics) or not to seethat is a very good
question.
The quality of exotic pet medicine has increased
dramatically over the last decade, which is
illustrated by the appearance of board-certifed
specialists for exotic animals and increasing
numbers of high quality articles in the peer-
reviewed veterinary literature. However, the
decision whether to incorporate exotic pets into a
practice should be made carefully.
ADDING EXOTICS:
READY OR NOT?
The term exotic pets traditionally refers to any pet
that is not a dog, cat, or large farm animal, and
includes pet goats and chickens, parrots, reptiles,
rabbits, and rodents. some practices elect to add
exotic companion mammals frst, as mammal
medicine is generally more familiar than avian and
reptile medicine.
However, no one should add exotics reluctantly
or to make a few extra bucks because no other
veterinarians in the area are providing that service.
exotics should be added only when the practice staff
is enthused aboutor at least open tothe prospect.
The team must be committed to adding an entirely
new skill set and participating in regular continuing
education to continue the learning process.
Practices must make a full commitment to
clinical competency to avoid doing harm, and
they must be willing and prepared to seek help
from colleagues or decline to see exotic pets
altogether. client expectations have increased as
well, and many demand a level of care equal to
what they receive for their dogs and cats.
The initial path to clinical competency includes:
1. Acquisition of a basic knowledge base, including
husbandry information, and technical skills
through initial staff training, followed by regular
continuing education
2. Acquisition of additional resources and equipment
necessary for exotics practice (Figure 1, page 78)
3. development of mentors/experts for
consultation and referral.

TABLE 1.
Selected Resources for Veterinarians Interested in Increasing Profciency in
exotic Pet medicine
Professional Association of Avian Veterinarians (aav.org)
organizations Association of Exotic Mammal Veterinarians (aemv.org)
Association of Reptilian and Amphibian Veterinarians (arav.org)

continuing ExoticsCon (exoticscon.org), which often combines the AAV, AEMV, and ARAV conferences
education NAVC Conference (navc.com)
with exotic Wisconsin Exotic Animal Veterinary Conference (apps.vetmed.wisc.edu)
Pet emphasis Wildlife and Exotic Animal Medicine Symposium, University of CaliforniaDavis (vetmed.
ucdavis.edu/CE, under Wildlife tab)
Oxbow Animal Health Exotic Mammal Symposia (oxbowanimalhealth.com/vets/exot-
ic_symposium)
Many other conferences, including state meetings, are now incorporating exotic pet topics
into their programs.

Periodicals Journal of Avian Medicine and Surgery (aav.org/?page=jamshome)

Journal of Exotic Pet Medicine (exoticpetmedicine.com)
Journal of Herpetological Medicine and Surgery (jherpmedsurg.com/loi/hpms)
Veterinary Clinics of North America: Exotic Animal Practice (vetexotic.theclinics.com)

tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice 77

 Peer reviewed PrAcTice BUiLdinG

further training for the Practitioner: aBvP exotics specialties

furthe
If you fnd that you have a passion and competency for exotics, further train-
ing is readily available at conference wet labs, and you can pursue specialist
designationin Avian Practice, Exotic Companion Mammal Practice, and/or
Reptile and Amphibian Practicethrough the American Board of Veterinary
Practitioners (ABVP, abvp.com). The ABVP is an American Veterinary Med-
ical Association recognized specialty organization and their credentialing
routes are designed specifcally for the private practitioner who excels in
clinical practice in a species group or associated area.

TRAINING EXISTING STAFF

nothing destroys the confdence of exotic pet
owners more than reception and technical staff
with little working knowledge of these pets. in
some cases, staff members are unable to identify
exotic pets or even provide basic information
to owners over the phone. in other cases, staff
members are obviously uncomfortable with
handling and restraining these animals. For these
reasons, the entire team should participate in the
development of an exotics practice.
Many conferences (Table 1, page 77) offer
training opportunities for staff members. However,
fnding the right combination suitable for every
skill level is challenging, especially when funds
must go to cover continuing education for
traditional pet species as well.
Multi-day exotics only conferences offering
hands-on laboratories are excellent options.
exotic animal topics are increasing in number and
popularity within conferences previously dedicat-
ed to traditional pet species, including the nAVc
conference and others; this approach allows busy
practitioners and team members to spend time in
both traditional pet species and exotics sessions.
FIGURE 1. The well-equipped exotics practice
features products suitable for exotic pets,
including foods, bedding, treats, and toys.
some well-established private exotics practices
may consider hosting veterinary visitors
(veterinarians or technicians) for short-term
visits as well. This is an exceptional opportunity
to observe an existing exotics practice in action.
Alternatively, one might consider contacting an
exotics expert to inquire about custom in-house
training, because travel costs and a stipend for
a private in-house conference may be similar
to sending multiple staff members to outside
conferences.
ACQUISITION OF RESOURCES &
EQUIPMENT
Journals
several veterinary clinical medicine journals focus
specifcally on exotics, including:

TABLE 2.
textbooks recommended for Developing exotic animal Practices
avian Doneley B. Avian Medicine and Surgery in Practice: Companion and Aviary Birds. Boca Raton,
FL: CRC Press, 2010.
Speer BL. Current Therapy in Avian Medicine and Surgery. St. Louis: Elsevier, 2016.

exotic Capello V, Lennox AM. Clinical Radiology of Exotic Companion Mammals. Ames, IA: Wiley
companion Blackwell, 2008.
mammal Oglesbee B. Blackwells Five-Minute Veterinary Consult: Small Mammal, 2nd ed. Ames, IA:
Wiley Blackwell, 2011.
Quesenberry K, Carpenter JW. Ferrets, Rabbits, and Rodents: Clinical Medicine and Surgery,
3rd ed. St. Louis: Elsevier, 2012.

reptile Mader D. Reptile Medicine and Surgery, 2nd ed. St. Louis: Elsevier, 2006.
Mader D, Divers S. Current Therapy in Reptile Medicine and Surgery. St. Louis: Elsevier, 2013.

all species Carpenter J. Exotic Animal Formulary, 4th ed. St. Louis: Elsevier, 2013.
Mayer J. Clinical Veterinary Advisor: Birds and Exotic Pets. St. Louis: Elsevier, 2013.
BSAVA Exotic Pet Series, various editions and authors, BSAVA.
This list is by no means comprehensive; there are many other excellent textbooks available.

78 TodAys VeTerinAry PrAcTice | July/August 2016 | tvpjournal.com

 PrAcTice BUiLdinG Peer reviewed

Journal of Avian Medicine and Surgery (JAMS) Textbooks

Journal of Exotic Pet Medicine (JEPM)
Journal of Herpetological Medicine and Surgery
(JHMS).
each of these journals is included with
membership in its sponsoring organization
Association of Avian Veterinarians, Association
of exotic Mammal Veterinarians, and Association
of reptilian and Amphibian Veterinarians,
respectively (Table 1) (see Development of
Mentors & Experts, page 80).
Veterinary Clinics of North America Exotic Animal
Practice provides comprehensive reviews of specifc
topics, such as dentistry, surgery, and behavior. A
number of small animal veterinary journals include
articles on exotic animal medicine as well.
exotic pet medicine textbooks are numerous,
and more are published every year, which
contrasts with the scant resources available a
decade ago. some of these textbooks focus on
specific species, and some on specific topics,
such as exotic mammal radiology and behavior.
Table 2 contains a list of textbooks that the
veterinary team at my clinic find particularly
helpful.
Online Resources
online resources, such as the Veterinary
information network (Vin, vin.com), have an
active and extensive section dedicated to exotic

TABLE 3.
Basic Equipment Required for Exotic Animal Practice That May Not
Be Readily Available in a Traditional Canine/Feline Pet Practice
handling Escape-proof containers in case pets are not brought in an
appropriate enclosure
Small- to medium-sized squeeze cages
Various sized towels for restraint
Physical Gram scale (weighing in 1 g increments) (figure 2)
examination Secure containers or perches to set on the gram scale for patients to
rest in/on comfortably FIGURE 2. Simple plastic container placed on
Mouth speculums designed for birds a digital scale to weigh small exotic pets.
Discarded credit card for gently opening the mouth of reptiles
Pediatric stethoscope
Small diameter thermometers or temperature probes
Various sized nail trimmers, and hand-held rotary tool (eg, Dremel)
for bird nail trims
Magnifcation, ideally with a light source (also for surgery)
Diagnostic Smaller needles/syringes for blood sample collection
Micro blood sample tubes
Surgical/ Incubators with temperature control and oxygen inlets (figure 3)
critical care Safe high-tech warming blankets with temperature control settings
Smaller gauge IV catheters
Pediatric infusion or syringe pump (figure 4) FIGURE 3. A small animal incubator with digital
Smaller anesthetic masks temperature control, modifed to allow oxygen
Smaller endotracheal tubes (ie, 14 mm, uncuffed) supplementation. This incubator can house
Smaller or micro surgical instruments small exotic mammals, reptiles, and birds.
Small to medium hemostasis clips
Atraumatic towel clamps
Transparent surgical drapes
Smaller sized suture
Ultrasonic Doppler (minimum monitoring equipment); other
equipment may be suitable for smaller exotics as well
Specialty Dental: Rabbit/rodent dental equipment (eg, mouth gags, cheek
spreaders, luxators)
Nutrition: Species-specifc foods for self feeding and assist feeding;
metal gavage feeding tubes for birds/reptiles
Pharmacy: Supplies for in-house compounding
Vaccination: Species-specifc vaccines (ie, ferret, exotic carnivore, FIGURE 4. A pediatric syringe pump can be
miniature pig, avian) used to deliver small volumes of intravenous
Note that some equipment is more applicable for specific species. or intraosseous fuids.

tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice 79

 Peer reviewed PrAcTice BUiLdinG

TABLE 4.
Selected Manufacturers and Distributors of Exotic Animal Specialty Supplies & Equipment
comPanY ProDUcts

abaxis VetScan in-house biochemistry analyzer (capable of analyzing very small

abaxis.com samples)
harrisons Bird foods Avian diets, treats, pet poultry food, and other products
harrisonsbirdfoods.com
Hot Dog Warming System Patient warming system for all veterinary patients
vetwarming.com
lafeber Avian diets and nutritional support products
lafeber.com
mazuri Specialty and unusual exotic animal diets
mazuri.com
mDs-vet General endoscopy, lighting, and illumination equipment, plus rabbit/
mdsvet.com rodent intubation scope
merial Only approved rabies and distemper vaccines for ferrets
merial.us
oxbow animal health Rabbit and rodent diets, nutritional support products, and foraging items
oxbowanimalhealth.com
rica surgical Products Very fne surgical equipment ideal for small exotic animal surgery
ricasurgical.com
Universal surgical instruments General surgical instruments, plus rabbit and rodent dental equipment
universalsurgical.com
Veterinary Specialty Products Special use exotic animal equipment: Transparent drapes, Lonestar
vetspecialtyproducts.com retractor, metal gavage feeding tubes, etc
virbac animal health Deslorelin GnRH agonist implants for treatment of adrenocortical disease
virbacferretsusa.com in ferrets
ZuPreem Avian and some exotic mammal diets
zupreem.com

animal medicine. one beneft of Vin membership Equipment

is access to a variety of conference proceedings
that can be reviewed for basic, intermediate, and
advanced information.
exoticdVM (groups.yahoo.com/neo/groups/
exoticdvm/info) is a free online forum that hosts
more than 1000 veterinary professionals who
regularly share cases and advice. several exotics-
oriented companiesincluding Lafeber company
(lafeber.com/vet) and oxbow Animal Health
(oxbowanimalhealth.com/vets)host veterinary
portals containing a wealth of information.
Most equipment required for exotics practice is
already stocked in the veterinary clinic, especially
equipment and supplies appropriate for exotic
companion mammals. More specialty equipment
may be required for avian and reptile practice.
some veterinary manufacturers offer equipment
specifcally for exotic pet practice:
Table 3, page 79, features specialized equipment
that is extremely useful for exotics medicine.
Table 4 features products routinely used in my
practice and their sources.

DEVELOPMENT OF MENTORS &

angela m. lennox
Angela M. Lennox, DVM, Diplomate ABVP (Avian & Exotic Companion EXPERTS
Mammal) & ECZM (Small Mammal), owns Avian and Exotic Animal Associations
Clinic, in Indianapolis, Indiana, and is an adjunct professor at Purdue
University College of Veterinary Medicine. She has exclusively
The following associations promote exotic animal
practiced exotic animal medicine since 1991 and is a past president of medicine and provide resources for exotic animal
the Association of Exotic Mammal Veterinarians. Dr. Lennox lectures practitioners (Table 1, page 77):
extensively throughout the U.S. and internationally, and has authored
and edited many books, book chapters, and scientifc articles. She
Association of Avian Veterinarians (aav.org)
received her DVM from Purdue University. Association of exotic Mammal Veterinarians
(aemv.org)

80 TodAys VeTerinAry PrAcTice | July/August 2016 | tvpjournal.com

 FINALLY!
I A LY
PrAcTice BUiLdinG PrAcTice BUiLdinG Peer reviewed

Association of reptilian and Amphibian

Veterinarians (arav.org).
These associations include lists of members by
location, and some provide veterinary forums
and other benefts for members. each offer a
yearly continuing education conference, often
held together, and sometimes with other exotics-
related groups.
Veterinarians,
Professional Networking
All practices seeing exotic pets should develop you now have a
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consultation and referral. if there is no expert
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exotics specialists will consult with colleagues, Advanced Veterinary Ultrasound
sometimes for a consultation fee, depending on is your one-stop source for:
the complexity of the case.
The ABVP website (abvp.com) provides Systems Parts and Probes
lists of board-certifed specialists by specialty Service Repairs
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on the association websites provided under Why choose AVU as your #1 SOURCE
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Vast Inventory and Unparalleled
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training must commence, equipment needs to Ultrasound Electronics, a leader in the industry.

be purchased, and a mentor should be secured. www.AUEtulsa.com

once your practice has completed the above
steps, the earnest work of developing the exotics
practice begins. The next article in this series
will cover further development of the exotics
practice, including scheduling, price setting, and
marketing of exotics services. AdvancedVeterinaryUltrasound.com
ABVP = American Board of Veterinary 1-866-620-2831
Practitioners; Vin = Veterinary information
network Ultrasound is our only business.
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tvpjournal.com |81July/August 2016 | TodAys VeTerinAry PrAcTice 81
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 imAging essenTiALs Peer reviewed

small Animal Abdominal Ultrasonography

Liver & GaLLBLadder: Part 2

Danielle Mauragis, AS, CVT, and Clifford R. Berry, DVM, Diplomate ACVR
University of Florida

Welcome to our series of articles on small animal abdominal ultrasonography. The initial articles
provided an overview of basic ultrasonography principles and a discussion about how to perform a
sonographic tour of the abdomen. This articleand the rest of the serieswill discuss ultrasound
evaluation of specifc abdominal organs/systems, including scanning principles, normal sonographic
appearance, and identifcation of common abnormalities seen during ultrasound examination.
Read the Small Animal Abdominal Ultrasonography articles published in Todays Veterinary
Practice at tvpjournal.com:
Basics of Ultrasound Transducers & Image Formation (January/February 2015)
Physical Principles of Artifacts & False Assumptions (May/June 2015)
Basics of Imaging OptimizationHow to Obtain High-Quality Scans (November/December 2015)
A Tour of the Abdomen: Part 1 (January/February 2016) and Part 2 (March/April 2016).

When using the systematic approach described
in previous articles, the sonographic tour of the
abdomen begins in the cranial abdomen, evaluating
the liver and gallbladder. Proper ultrasound
evaluation of the liver includes:
Volume or size (enlarged or small)
margins/borders (smooth versus irregular)
overall echogenicity of the hepatic parenchyma
Appearance of the portal and hepatic veins
distribution of any abnormalities (focal,
multifocal, or generalized).
Part 1 of this seriespublished in the may/June
2016 issue of Todays Veterinary Practicereviewed
the normal ultrasound appearance of the liver and
gallbladder as well as the sonographic appearance
of nodules. This article reviews abnormalities of the
hepatobiliary system found via ultrasonography.
HEPATIC ABNORMALITIES
The normal echotexture of the liver is a subjective
evaluation. The clinician or technician must know
how to improve and manipulate the image in order
to present a normal liver with the appropriate
echogenicity. Too much gain results in increased
echogenicity and misinterpretation that the liver is
abnormal, whereas too little gain results in decreased
echogenicity and misinterpretation that the liver is
abnormally hypoechoic (Figure 1).

C
Figure 1. Long-axis images of the left liver lobe
in a dog in which the gain is set properly (A),
B increased overall (B), and decreased overall (C).

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Peer reviewed imAging essenTiALs

TABle 1.
Differential Diagnostic Considerations for Generalized Hepatic Changes
HYPOECHOIC HYPERECHOIC MIXED ECHOGENICITY (HETEROECHOIC)
Acute cholangiohepatitis Chronic hepatitis Amyloidosis
Acute hepatitis Cirrhosis Hepatitis
Amyloidosis Fibrosis Hepatocellular carcinoma
Histiocytic neoplasia Lipidosis Lymphoma
Leukemia Lymphoma Metastasis
Lymphoma Mast cell tumor Necrosis
Passive congestion Steroid hepatopathy Steroid hepatopathy with hyperplasia

Diffuse Liver Disease
diffuse liver disease can be marked by an increase,
decrease, or no changes in overall echogenicity
(Table 1, Figure 2). in dogs with increased
echogenicity secondary to vacuolar hepatopathy,
the ultrasound waves can appear hyperattenuating.
This occurs when the ultrasound beam no longer
penetrates to the depth that would be expected
for a given frequency. Typically, the microconvex
transducer (c8-5 at 8 mHz) can penetrate to
the level of 8 cm. in diseases that cause vacuolar
hepatopathies, however, the ultrasound beam is
often attenuated to a depth of only 4 to 5 cm.

Other Liver Diseases

other diseases affect the hepatic parenchyma
diffusely but cause no changes in the overall
echogenicity of the liver (eg, lymphoma,
disseminated mastocytosis, acute hepatitis or
cholangiohepatitis). This is why cytology or
histology is required for defnitive diagnosis.

A
B

B
Figure 3. evaluation of the long axis of the left
C liver lobe. in this dog, the liver margins come
Figure 2. Normal echogenicity in a dog (A). to a point (arrow) and are seen ventral (near
increased echogenicity and decreased portal feld) relative to the stomach (A); this fnding
vascular markings in a dog with diabetes is normal. in another dog, the margins of the
mellitus (B). Decreased overall echogenicity and liver lobe are rounded and seen caudal to the
increased portal vascular markings in a dog with stomach (B); this is an indication of increased
lymphoma (C). hepatic volume/size.

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TABle 2.
Differential Diagnostic Considerations for Changes in Hepatic Size & Volume
INCREASED SIZE DECREASED SIZE ASYMMETRIC ENLARGEMENT
Amyloidosis Cirrhosis Abscess
Diffuse primary or secondary neoplasia Congenital portosystemic shunt Cyst
Lipidosis Fibrosis Granuloma
Round cell neoplasia Microvascular dysplasia Liver lobe torsion
Vacuolar hepatopathy Portal vein hypoplasia Primary neoplasia
Vascular congestion Secondary neoplasia

changes in hepatic size can be symmetric or An overall decrease in echogenicity with an

asymmetric (Table 2); increased size often results in
rounding of the hepatic margins (Figure 3).
ill-defined nodular areas of decreased echogenicity
and hyperplasia often indicate vacuolar
hepatopathy (Figure 4).
diffuse heterogeneous enlargement of the liver
can be seen as a specific pattern in dogs with
hepatocutaneous syndrome (superficial necrolytic
dermatitis; Figure 5).
increase in size can be caused by cholangitis or
cholangiohepatitis. in these cases, the portal
markings appear brighter than usual (Figure 6).
A hyperechoic liver that can be normal or
decreased in size with portal hypertension
and ascites indicates hepatic cirrhosis (Figure
7). These dogs often have multiple acquired
portosystemic shunts in the region of the normal
renal vasculature at the level of the aorta and
caudal vena cava (Figure 8, page 86).

Figure 4. Long-axis image of the left side

of the liver in a dog with pituitary-dependent
hyperadrenocorticism. The liver is hyperechoic,
and hypoechoic nodules (arrows) are present;
these are areas of nodular regeneration. in
addition, the liver is hyperattenuating, and the
image drops out in the far feld.
Figure 6. Long-axis image of the right side of
the liver with the gallbladder visible (anechoic
circle) in a cat with acute cholangiohepatitis.
Overall, the liver is hypoechoic, with bright areas
representing the normal portal vascular markings.

Figure 5. Short-axis image of the left side of the
liver. The liver is enlarged and has a honeycomb
appearance, which is characteristic of hepatocu-
taneous syndrome and fbrotic end-stage liver
disease without hepatocutaneous syndrome.
Figure 7. Hyperechoic liver lacking normal
portal vascular markings. The liver margins are
contracted, and an anechoic effusion is present.
These fndings are consistent with hepatic
cirrhosis and fbrosis.

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 Peer reviewed imAging essenTiALs

A
A

B
B Figure 9. Long-axis right-sided image of
the liver and gallbladder in a normal dog (A).
Figure 8. Multiple acquired extrahepatic Oblique ultrasound image near the right cranial
portosystemic shunts in a dog with chronic quadrant in a cat (B). The bile duct (< 2 mm) can
hepatic cirrhosis. Color Doppler evaluation of be visualized in this cat (arrow); this is a normal
the major abdominal vessels adjacent to the fnding. The cystic and bile ducts will not be
left kidney (A); note the multiple low-fow small dilated in the normal dog.
vessels adjacent to the aorta and caudal vena
cava. Color Doppler evaluation of the major
abdominal vessels near the level of the spleen
(B); the low-fow small vessels adjacent to the
aorta and caudal vena cava can be seen. Other
notable areas include the rectal and mesenteric
vasculature. These shunts open with chronic
portal hypertension.

A Prim
Primer on Attenuation & Echogenicity A
Attenuation is the loss of acoustic energy or number of ultrasound
waves traveling at depth. Hyperattenuation results in fewer ultrasound
waves interacting with tissue at depth; therefore, the overall
image becomes darker as the clinician looks deeper into a tissue.
Hypoattenuation describes areas that do not attenuate the ultrasound
waves, resulting in artifact and distal acoustic enhancement, and the area
deeper to the cystic structure appears whiter on the image.
Echogenicity is the characteristic internal architecture of a given organ
that is based on refectivity of organ parenchyma. Tissues with increased
echogenicity are called hyperechoic and are usually represented by B
increased grayscale or white, while tissues with decreased echogenicity
are called hypoechoic and are usually represented by darker, decreased Figure 10. Various ultrasound fndings of
grayscale values. Areas that lack echogenicitysuch as fuid-flled gallbladder debris (echogenic) in 2 different
structures, including blood vessels or cystsare called anechoic dogs without other ultrasound signs of
hepatobiliary disease. gravity-dependent
and typically appear completely black (again, with distal acoustic
echogenic material within the gallbladder (A)
enhancement due to lack of attenuation of the ultrasound waves through
and echogenic material with irregular margins
the fuid-flled structure).
within the gallbladder (B).

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 imAging essenTiALs Peer reviewed

BILIARY ABNORMALITIES
The gallbladder is normally found to the right of mid-
line surrounded by the hepatic parenchyma. The cystic
and bile ducts are not normally visualized in dogs but
can be seen in cats (up to 23 mm, Figure 9).

Luminal Abnormalities
some echogenic material may be seen within the
canine gallbladder (Figure 10). in addition to wall
A thickening, echogenic material in the gallbladder
is not normal in cats and indicates infammatory
biliary disease, such as cholecystitis (Figure 11).
other luminal abnormalities include nonmineralized
and mineralized choleliths (Figure 12).

Gallbladder Mucocele
mucoceles are an important cause of hepatobiliary
disease in dogs. A mucocele is an abnormal
collection of bile salts and mucus within the
B gallbladder that may potentially cause hepatobiliary
obstruction, gallbladder wall necrosis, and rupture
(Figure 13, page 88).
The pathogenesis of mucoceles is unknown,
although multiple factors have been suggested to
result in abnormal bile salt retention, decreased

C
Figure 11. Cholecystitis in 3 different animals.
Long-axis image of the right side of the liver
in a dog with clinical signs of vomiting, weight
loss, and icterus (A); the gallbladder wall is
markedly thickened with irregular margins. A
Hypoechoic areas are noted along the wall
of the gallbladder consistent with abnormal
mucus collections. Hyperechoic material
is noted in the middle of the gallbladder,
and there is a slight effusion cranial to the
gallbladder (small anechoic crescent). Dilated
bile and cystic ducts in a cat with cholecystitis
and cholangiohepatitis (B); the ductal walls
are thickened, dilated, and tortuous (arrow).
Transverse section of the right side of the liver
in a dog with cholecystitis (C); the gallbladder B
wall is thickened and hyperechoic and has
irregular margins. There is a focal anechoic Figure 12. Mineralized echogenic material
effusion lateral to the gallbladder (arrow) with distal shadowing noted in the neck of
consistent with infammation adjacent to the the gallbladder in a dog without clinical or
gallbladder wall. This appearance can be seen chemical evidence of biliary disease (A). Two
in dogs with mucoceles and is consistent with small mineralized choleliths in the neck of the
leakage of bile through a necrotic wall, gallbladder in a dog with no clinical or chemical
resulting in a biliary peritonitis. evidence of cholestasis (B).

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A C

B D
Figure 13. Multiple examples of mucoceles
in dogs with hepatobiliary disease. Long-
axis image of the gallbladder with a stellate-
appearing mucocele (kiwi fruit sign; A). Long-axis
image showing echogenic material within the
cranial aspect of the gallbladder with stellate
radiating lines of increased echogenicity (B); the
gallbladder wall is thickened, hypoechoic, and
edematous. Transverse image from the same
dog as in B (C); note the hypoechoic, thickened
edematous wall of the gallbladder. Long-axis e
image showing a central hyperechoic line and
radiating stellate echogenic lines extending toward the gallbladder wall (D). Transverse image of
the same dog as in D demonstrating curvilinear echogenic lines (E); there is a focal effusion noted
(just below effusion label).
biliary motility (gallbladder contractility), and cystic and bile ducts, resulting in extrahepatic biliary
excessive mucus secretion by the biliary epithelium. obstruction. mucoceles have been reported in dogs
dogs with hyperadrenocorticism have a 29-fold with no clinical signs; however, mucoceles progress,
higher risk for developing a mucocele than those with the possibility of future wall necrosis and
without hyperadrenocorticism.1 perforation, which should be considered a reason
The ultrasound features of a mucocele include to monitor the lesion or pre-emptively surgically
variations of mucus collections and ultimate linear remove the mucocele.
striations (stellate or kiwi-like appearance), with
the gallbladder completely flled with echogenic Extrahepatic Biliary Obstruction
material. These striations are secondary to fracture extrahepatic biliary obstruction in dogs usually
lines between the mucus collections. The gallbladder results from pancreatitis. infammation and edema
wall is typically thick and the gallbladder abnormally surround the bile duct, causing obstruction at the
distended. level of the pancreas. in experimental bile duct
gallbladder wall necrosis leads to leakage of obstructions, the bile and cystic ducts dilate within
bile contents into the peritoneal cavity, with an 24 hours. The gallbladder distends within 48
increase in echogenicity to the mesentery, which is hours, although it might take a week before the
in contact with the gallbladder wall (Figure 14). intrahepatic ducts become dilated.
The abnormal mucus collection can extend into the The distended extrahepatic ducts are usually

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 imAging essenTiALs Peer reviewed

A A

B B
Figure 14. Transverse (A) and long-axis (B)
images in a dog with a mucocele in which the
gallbladder wall has undergone necrosis and
biliary leakage is present. The mesentery (MeS)
surrounds part of the gallbladder, and increased
echogenicity is associated with the infamed
mesentery. Additionally, a focal effusion is
noted in A (arrow).
tortuous and can be distinguished easily from
the portal vein using color doppler ultrasound.
The dilated intrahepatic ducts can be seen around
the portal veins within the hepatic parenchyma
(Figure 15). intrahepatic bile ducts have abrupt
changes in luminal diameter, irregular walls, and
branching patterns when compared with the
Figure 15. Long-axis, right-sided liver image in
a cat in which a distal biliary mass has obstruct-
ed the bile duct (A). The bile and cystic ducts
are dilated (> 3 mm) and tortuous. intrahepatic
biliary ductal dilation is identifed within the left
side of the liver in this transverse image (B). The
color Doppler image documents normal fow
within the hepatic and portal veins. The biliary
ductal dilation is seen without fow in the liver.
portal vasculature (tapering luminal diameter,
smooth walls, and branches in the midzone to the
periphery of the hepatic parenchyma).
other causes of extrahepatic biliary obstructions
include choleliths, duodenal strictures at the major
duodenal papilla, and biliary tumors (Figure 16).

A B
Figure 16. Transverse image in a cat with a biliary adenocarcinoma inside the bile duct near the
level of the duodenum and pancreas (A). The mass is distal to the dilated bile duct and outlined by
measuring markers (x and +). The label distal is located on top of the dilated bile duct. Long-
axis image of the liver in a cat with an abnormally dilated cystic duct (arrow) at the neck of the
gallbladder with a cholelith in the distal bile duct, resulting in extrahapatic and intrahepatic biliary
dilation (B). The hypoechoic circle adjacent to the dilated cystic duct is the portal vein.

tvpjournal.com | July/August 2016 | TodAys VeTerinAry PrAcTice 89

 Peer reviewed imaging essenTiaLs imAging essenTiALs

71% of clients cats can develop a condition known as triaditis, which

research cost and involves concurrent cholecystitis/cholangiohepatitis,
pancreatitis, and infammatory bowel disease.
nancing before IN SUMMARY
they make a decision. When performing ultrasonography of the liver and
gallbladder, it is important to realize that a negative
scan does not rule out disease. in particular, hepatic
scans can appear normal in dogs and cats with certain
round cell tumors, such as lymphoma and systemic
mastocytosis. cytology or histology is required
for defnitive diagnosis in patients in which these
tumors are suspected. Biliary disease is common
in dogs and less so in cats. it is incumbent on the
novice sonographer to review current textbooks and
other sources for further descriptions detailing the
ultrasound appearance of hepatic and biliary disorders.

Reference
1. mesich mL, mayhew Pd, Pack m, et al. gallbladder
mucoceles and their association with endocrinopathies in
dogs: A retrospective case-control study. J Small Anim Pract
2009; 50:630-635.

Suggested Reading
Kremkau FW. Sonography Principles and Instruments, 8th ed.
Philadelphia: saunders elsevier, 2010.
mattoon J, nyland T. Small Animal Diagnostic Ultrasound, 3rd
ed. Philadelphia: elsevier, 2015.
Penninck d, dAnjou m (eds). Atlas of Small Animal
Abdominal Ultrasonography, 2nd ed. Ames, iA: Wiley
Blackwell Publishing, 2015.

DANIELLE MAuRAGIS
Be ready. Danielle Mauragis, AS, CVT, is a
radiology technician at University
When clients know you accept the CareCredit of Florida College of Veterinary
Medicine, where she teaches
healthcare credit card, it helps them move diagnostic imaging. She coauthored
forward with care for their pets. Sooner rather the Handbook of Radiographic
Positioning for Veterinary Technicians
than later. and received the Florida Veterinary
Medical Associations 2011 Certifed
Veterinary Technician of the Year
ENROLL NOW award.

by calling 844-812-8109
CLIffORD R. BERRY
Ask for the special oer: FREE Eric Garcia Clifford R. Berry, DVM, Diplomate
ACVR, is a professor of diagnostic
Digital Strategy Tips Sheets.
imaging at University of Florida
College of Veterinary Medicine. His
research interests include cross-
sectional imaging of the thorax,
nuclear medicine, and biomedical
applications of imaging. He
received his DVM from University of
Florida and completed a radiology
www.carecredit.com residency at University of California
Davis.

* Path to Purchase Research-Veterinary

category conducted for CareCredit
90
by Rothstein Tauber Inc., 2014.
Todays VeTerinary PracTice 90 July/August
| July/august 2016 |2016 | tvpjournal.com
tvpjournal.com
Mention oer code TVP2016VA
 The BAck PAge: VeTeRINARY VIeWPOINTS
Continued from page 92
generation explored their world via YouTube and
other Internet video properties. She used an iPad
at school and became extremely profcient early
on at web navigation. This gave me an idea.
I remembered how badly I wanted to see
what veterinarians did when I was a tweenand
aspiring veterinarianand decided that I would
go out and video veterinarians as they practiced.
At frst I went out and videoed my colleagues.
Basically, these videos allowed veterinarians,
who could only have 1 or 2 people shadow them
a week, to reach literally tens of thousands of
aspiring veterinarians.
Veterinarians loved this idea! As did the
audience of tweens who viewed the subsequent
videos. As I continued making videos over
the years, I learned about additional ways to
expose tweens to veterinary medicine, including
veterinary and zoo camps. Ultimately, the effort
to share these opportunities with tweens led to
the launch of vetsetgo.com in January 2016.
In addition to Vet Set Go, how can veterinarians
and their teams stimulate interest in veterinary
medicine and good pet care from an early age?
Every veterinarian needs to recognize what a
gift they have been given when tween aspiring
veterinarians come into the
hospital and tell you about
their aspirations to become
veterinarians. Dont dismiss
them by saying, Go study
science and get animal
experience. Instead,
recognize this opportunity
for what it isfor both the
health of your practice and
the profession as a whole.
If you have the time, set up a veterinary camp
or open house specifcally for this audience. If
you feel you are too busy to do something large-
scale, just have a resource available to offer, such
as the Vet Set Go! book. If you provide future
veterinarians with a free book when they share
their dreams of pursuing this profession, you will
gain their parents goodwill for life.
tvpjournal.com | July/August 2016
CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian.
Description:
NexGard (afoxolaner) is available in four sizes of beef-favored, soft chewables for oral administration to dogs and puppies
according to their weight. Each chewable is formulated to provide a minimum afoxolaner dosage of 1.14 mg/lb (2.5 mg/
kg). Afoxolaner has the chemical composition 1-Naphthalenecarboxamide, 4-[5- [3-chloro-5-(trifuoromethyl)-phenyl]-4,
5-dihydro-5-(trifuoromethyl)-3-isoxazolyl]-N-[2-oxo-2-[(2,2,2-trifuoroethyl)amino]ethyl.
Indications:
NexGard kills adult feas and is indicated for the treatment and prevention of fea infestations (Ctenocephalides felis), and
the treatment and control of Black-legged tick (Ixodes scapularis), American Dog tick (Dermacentor variabilis), Lone Star tick
(Amblyomma americanum), and Brown dog tick (Rhipicephalus sanguineus) infestations in dogs and puppies 8 weeks of age
and older, weighing 4 pounds of body weight or greater, for one month.
Dosage and Administration:
NexGard is given orally once a month, at the minimum dosage of 1.14 mg/lb (2.5 mg/kg).
Dosing Schedule:
Body
Weight
Afoxolaner Per
Chewable (mg)
Chewables
Administered
4.0 to 10.0 lbs. 11.3 One
10.1 to 24.0 lbs. 28.3 One
24.1 to 60.0 lbs. 68 One
60.1 to 121.0 lbs. 136 One
Over 121.0 lbs. Administer the appropriate combination of chewables
NexGard can be administered with or without food. Care should be taken that the dog consumes the complete dose, and
treated animals should be observed for a few minutes to ensure that part of the dose is not lost or refused. If it is suspected
that any of the dose has been lost or if vomiting occurs within two hours of administration, redose with another full dose. If
a dose is missed, administer NexGard and resume a monthly dosing schedule.
Flea Treatment and Prevention:
Treatment with NexGard may begin at any time of the year. In areas where feas are common year-round, monthly
treatment with NexGard should continue the entire year without interruption.
To minimize the likelihood of fea reinfestation, it is important to treat all animals within a household with an approved fea
control product.
Tick Treatment and Control:
Treatment with NexGard may begin at any time of the year (see Effectiveness).
Contraindications:
There are no known contraindications for the use of NexGard.
Warnings:
Not for use in humans. Keep this and all drugs out of the reach of children. In case of accidental ingestion, contact a
physician immediately.
Precautions:
The safe use of NexGard in breeding, pregnant or lactating dogs has not been evaluated. Use with caution in dogs with a
history of seizures (see Adverse Reactions).
Adverse Reactions:
In a well-controlled US feld study, which included a total of 333 households and 615 treated dogs (415 administered
afoxolaner; 200 administered active control), no serious adverse reactions were observed with NexGard.
Over the 90-day study period, all observations of potential adverse reactions were recorded. The most frequent reactions
reported at an incidence of > 1% within any of the three months of observations are presented in the following table. The
most frequently reported adverse reaction was vomiting. The occurrence of vomiting was generally self-limiting and of short
duration and tended to decrease with subsequent doses in both groups. Five treated dogs experienced anorexia during the
study, and two of those dogs experienced anorexia with the frst dose but not subsequent doses.
Table 1: Dogs With Adverse Reactions. Treatment Group
Afoxolaner Oral active control
Vomiting (with and without blood)
N1
17
% (n=415)
4.1
N2
25
% (n=200)
12.5
Dry/Flaky Skin 13 3.1 2 1.0
Diarrhea (with and without blood) 13 3.1 7 3.5
Lethargy
Anorexia
7
5
1.7
1.2
4
9
2.0
4.5
1
2
Number of dogs in the afoxolaner treatment group with the identifed abnormality.
Number of dogs in the control group with the identifed abnormality.
In the US feld study, one dog with a history of seizures experienced a seizure on the same day after receiving the frst
dose and on the same day after receiving the second dose of NexGard. This dog experienced a third seizure one week after
receiving the third dose. The dog remained enrolled and completed the study. Another dog with a history of seizures had
a seizure 19 days after the third dose of NexGard. The dog remained enrolled and completed the study. A third dog with a
history of seizures received NexGard and experienced no seizures throughout the study.
To report suspected adverse events, for technical assistance or to obtain a copy of the MSDS, contact Merial at 1-888-637-
4251 or www.merial.com/NexGard. For additional information about adverse drug experience reporting for animal drugs,
contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/AnimalVeterinary/SafetyHealth.
Mode of Action:
Afoxolaner is a member of the isoxazoline family, shown to bind at a binding site to inhibit insect and acarine ligand-gated
chloride channels, in particular those gated by the neurotransmitter gamma-aminobutyric acid (GABA), thereby blocking pre-
and post-synaptic transfer of chloride ions across cell membranes. Prolonged afoxolaner-induced hyperexcitation results in
uncontrolled activity of the central nervous system and death of insects and acarines. The selective toxicity of afoxolaner
between insects and acarines and mammals may be inferred by the differential sensitivity of the insects and acarines
GABA receptors versus mammalian GABA receptors.
Effectiveness:
In a well-controlled laboratory study, NexGard began to kill feas four hours after initial administration and demonstrated >99%
effectiveness at eight hours. In a separate well-controlled laboratory study, NexGard demonstrated 100% effectiveness against
adult feas 24 hours post-infestation for 35 days, and was 93% effective at 12 hours post-infestation through Day 21, and on
Day 35. On Day 28, NexGard was 81.1% effective 12 hours post-infestation. Dogs in both the treated and control groups that
were infested with feas on Day -1 generated fea eggs at 12- and 24-hours post-treatment (0-11 eggs and 1-17 eggs in the
NexGard treated dogs, and 4-90 eggs and 0-118 eggs in the control dogs, at 12- and 24-hours, respectively). At subsequent
evaluations post-infestation, feas from dogs in the treated group were essentially unable to produce any eggs (0-1 eggs) while
feas from dogs in the control group continued to produce eggs (1-141 eggs).
In a 90-day US feld study conducted in households with existing fea infestations of varying severity, the effectiveness of
NexGard against feas on the Day 30, 60 and 90 visits compared with baseline was 98.0%, 99.7%, and 99.9%, respectively.
Collectively, the data from the three studies (two laboratory and one feld) demonstrate that NexGard kills feas before they
can lay eggs, thus preventing subsequent fea infestations after the start of treatment of existing fea infestations.
In well-controlled laboratory studies, NexGard demonstrated >97% effectiveness against Dermacentor variabilis, >94%
effectiveness against Ixodes scapularis, and >93% effectiveness against Rhipicephalus sanguineus, 48 hours post-infestation for
30 days. At 72 hours post-infestation, NexGard demonstrated >97% effectiveness against Amblyomma americanum for 30 days.
Animal Safety:
In a margin of safety study, NexGard was administered orally to 8 to 9-week-old Beagle puppies at 1, 3, and 5 times the
maximum exposure dose (6.3 mg/kg) for three treatments every 28 days, followed by three treatments every 14 days, for
a total of six treatments. Dogs in the control group were sham-dosed. There were no clinically-relevant effects related to
treatment on physical examination, body weight, food consumption, clinical pathology (hematology, clinical chemistries, or
coagulation tests), gross pathology, histopathology or organ weights. Vomiting occurred throughout the study, with a similar
incidence in the treated and control groups, including one dog in the 5x group that vomited four hours after treatment.
In a well-controlled feld study, NexGard was used concomitantly with other medications, such as vaccines, anthelmintics,
antibiotics (including topicals), steroids, NSAIDS, anesthetics, and antihistamines. No adverse reactions were observed
from the concomitant use of NexGard with other medications.
Storage Information:
Store at or below 30C (86F) with excursions permitted up to 40C (104F).
How Supplied:
NexGard is available in four sizes of beef-favored soft chewables: 11.3, 28.3, 68 or 136 mg afoxolaner. Each chewable size
is available in color-coded packages of 1, 3 or 6 beef-favored chewables.
NADA 141-406, Approved by FDA
Marketed by: Frontline Vet Labs, a Division of Merial, Inc.
Duluth, GA 30096-4640 USA
Made in Brazil.
NexGard is a registered trademark, and TMFRONTLINE VET LABS is a trademark, of Merial.
2015 Merial. All rights reserved.
1050-4493-03
Rev. 1/2015
91
 The Back Page: VeTerinary VieWPoinTs

Making Dreams a Reality for Todays Aspiring Veterinarians

an interview with dr. chris carpenter
Chris Carpenter, DVM, MBA, has worked for years to
help young people explore their dreams of becoming
veterinarians. This passion for education led Dr. Carpenter
to found Vet Set Go (vetsetgo.com)the frst, and only,
web community dedicated to aspiring veterinariansand
write Vet Set Go!, a book that provides ideas on how
tweens can pursue careers in veterinary medicine.
Dr. Carpenter is the Executive Director of the
Companion Animal Parasite Council and a member of the
AVMA and the National Science Teachers Association.
He received his veterinary degree from Auburn University
College of Veterinary Medicine, his bachelor of science
degree in microbiology from University of Florida, and an
MBA from New Hampshire College.

Can you tell us the main concept behind Vet
Set Go?
Id like to point out 2 facts: First, almost 1
in 5 tweens (ages 914) wants to become a
veterinarian. Second, the majority of practicing
veterinarians today made the decision to become
veterinarians before they were 13 years of age.
What this data shows us is that veterinary
medicine is a calling, and one that starts early in
life. We know these tweens are passionate about
their love of animals and their desire to become
veterinarians. They just dont know how to
explore their dreams.
You see, tweens who are aspiring veterinarians
face a quandary: they want to get experience
with animals, interact with veterinarians, and
learn the science of animals, but they dont know
HOW. For example, most humane societies
want volunteers to be 16 years of age or older.
Similarly, most veterinarians will only let older
teens shadow them. So how do younger, aspiring
veterinarians explore their dreams?
That is where Vet Set Go comes in. We
encourage tweens to explore their dreams today
and show them how to do it. We have specifc
ideas on how they can get animal experience and
connect with veterinarians. We also believe the
veterinary profession as a whole needs to reach
out and connect with this important consumer
group. Research shows, if we do, we will improve
pet care and increase veterinary hospital visits
today and into the future.
What is the major beneft of embracing young
people this age and helping them learn about
veterinary medicine?
These aspiring veterinarians want to talk to
todays practitioners and learn all they can about
animals and veterinary careers. We need to
interact with these tweens as much as possible
and teach them about our profession and the
importance of good animal care.
The most important thing to remember is,
while some of these aspiring veterinarians will
become animal doctors, most will not. However,
almost all of them will become something else
pet owners! If we reach out to them today and
educate them about animal health, we will have
well educated future clients that have a close
connection to our profession.
More important, research shows us that this
group of tweens has a strong infuence on the
care of their current family pets.
How did the idea of Vet Set Go grow and
germinate for you?
This whole journey started 6 years ago when
I noticed how much my daughter and her
Continued on page 91

92 Todays VeTerinary PracTice | July/august 2016 | tvpjournal.com

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7 Probiotic Strains & 2 Prebiotics

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FLEA AND TICK control
dogs run to, not from
NexGard (afoxolaner) for dogs is:
POWERFUL so it keeps killing feas
and ticks all month long

EASY to give because its soft

and beef-favored

Dogs
love
1
it!

1
Data on fle at Merial.
NexGard is a registered
trademark, and FRONTLINE
VET LABS is a trademark of
Merial. 2015 Merial, Inc.,
Duluth, GA. All rights reserved.
NEX16TRADEAD (01/16).
IMPORTANT SAFETY INFORMATION: NexGard is for use in dogs only. The most
frequently reported adverse reactions included vomiting, dry/faky skin, diarrhea,
lethargy, and lack of appetite. The safe use of NexGard in pregnant, breeding, or lactating
dogs has not been evaluated. Use with caution in dogs with a history of seizures. For
more information, see full prescribing information or visit www.NexGardForDogs.com.