Daisy, a 9-year-old diabetic miniature Schnauzer was diagnosed with a mucocele. Four months prior, Daisy had been seen for a splenic mass. We performed a c. Sadly, the biopsy revealed malignant histiocytosis. She recovered well from this procedure, but never 100 percent, according to the owner. She returned for an abdominal ultrasound after the referring veterinarian noticed an enlarged liver on palpation. In addition, the owner complained of Daisy's abdominal discomfort, decreased appetite and abnormal demeanor. Ultrasound confirmed hepatomegaly. The gallbladder was mildly distended and a small amount of free fluid was noticed around the liver. Blood work was supportive of liver disease with gallbladder involvement. Among others, she had an elevated bilirubin and high liver enzymes: alkaline phosphatase (alk. phos.), gamma-glutamyltransferase (GGT), alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Exploratory surgery was recommended for what was considered by the ultrasonographer to be an early mucocele. A standard laparotomy and cholecystectomy were performed. Patency of the common bile duct was reestablished through a duodenotomy. All other abdominal organs appeared within normal limits. After lavage of the abdomen, closure was standard. Daisy recovered uneventfully and went home the next day. It was that simple. Overall this was a very straight forward surgery. Or so we thought... However, three days later, Daisy came back to the emergency clinic vomiting, anorexic and icteric. "Even her tongue is yellow," lamented the owner. Hmmm … so we have a sick, icteric patient three days after gallbladder surgery… Call me paranoid, but my first thought was that there was bile leakage in the abdominal cavity. However, a FAST ultrasound (Focused Assessment with Sonography in Trauma) showed no free fluid in the abdomen. Blood work mainly showed the following abnormalities: a PCV of 22 percent and total protein of 11.6. Urinalysis revealed the presence of glucose and ketones in the urine (recall she is diabetic). Clotting times were normal as well as the WBC count for a postoperative patient. To my relief and dismay Daisy was diagnosed with immune-mediated hemolytic anemia (IMHA). To my relief, because it had nothing to do directly with my surgery. To my dismay, because the treatment is steroids. Giving steroids to a dog with diabetes AND with a three-day-old enterotomy obviously made me nervous. But the steroids worked like a charm and within two days, daisy was eating, her natural color returned, and her blood work was markedly improved. IMHA can be secondary to a number of drugs (sulfonamides, cephalosporins, heparin, methimazole), type 3 hypersensitivity reactions, infections, heartworms, tumors and other conditions. Some cases are idiopathic, which may be Daisy’s etiology. Surely, at least in this writer’s experience, IMHA is a rare complication of laparotomy and cholecystectomy. It is an important reminder however not to panic and allow a client to give up. Had we not performed the proper tests, it would have been easy to assume that there was bile leakage, which explained the icterus, and possibly euthanize a patient for the wrong reasons. But it clearly was not the only rule out. An astute emergency colleague deciphered the possibilities, properly advised an emotional client, chose the correct treatment, and saved the day—and a patient’s life. Dr. Phil Zeltzman is a mobile, board-certified surgeon in Allentown, Pa. His website is www.DrPhilZeltzman.com. He is the co-author of "Walk a Hound, Lose a Pound” (www.WalkaHound.com). Katie Kegerise, a Certified Veterinary Technician in Reading, Pa., contributed to this article.
