feline gastrointestinal foreign bodies(autosaved)

8/12/2019 Feline Gastrointestinal Foreign Bodies(Autosaved)

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Feline gastrointestinal foreign bodies

Trevor N. Bebchuk, DVMDepartment of Small Animal Clinical Sciences, Western College of Veterinary Medicine,

University of Saskatchewan, 52 Campus Drive, Saskatoon, Saskatchewan, S7N 5B4 Canada

Gastrointestinal foreign bodies are responsible for a wide range of clinical

presentations in veterinary practice. Cats may demonstrate vague mild signs

of a chronic nature, they may have acute or severe vomiting and diarrhea, or

they may be in hypovolemic or septic shock. The clinical signs vary depend-

ing on the location of the obstruction, the degree of obstruction, the foreign

body causing the obstruction, and the chronicity of obstruction. The

required treatment depends on numerous clinical and laboratory variables,

which must be evaluated before developing a treatment plan. The goal of

treatment is always relief of the obstruction with minimum morbidity. Thisarticle focuses on some of the different types of obstructions reported in cats,

how they affect the animal at different levels of the gastrointestinal tract,

diagnostic techniques, and the recommended treatments.

The vast range of clinical presentations possible with gastrointestinal for-

eign bodies precludes any specific generalizations regarding the appearance

of a cat with this problem. Clinical signs that may be present include vomiting,

diarrhea, regurgitation, ptyalism, inappetence, anorexia, depression, dehy-

dration, abdominal pain, abdominal distention, palpable firm segments of the

intestines, palpable intestinal dilation, and many more. It is imperative that acomplete physical examination, including an oral examination, be performed.

It is recommended that laboratory assessment, including routine hematology

tests, a serum biochemical profile, and urinalysis, be performed. Radiographs

are essential for the diagnosis of most gastrointestinal foreign bodies, and a

contrast study is necessary in some cases. Obtaining both left and right lateral

recumbent radiographs of the abdomen may prove beneficial in some animals.

Fluid and gas contents are extremely mobile and tend to move to the depen-

dent portion of the stomach during postural changes. The redistribution of

gas can act as a negative contrast medium to highlight foreign objects or dis-orders only visible on one lateral projection [1]. The same principle applies to

Vet Clin Small Anim 32 (2002) 861880

E-mail address: [email protected] (T.N. Bebchuk).

0195-5616/02/$ - see front matter 2002, Elsevier Science (USA). All rights reserved.

PII: S 0 1 9 5 - 5 6 1 6 ( 0 2 ) 0 0 0 3 0 - X


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the intestinal tract. Ultrasonography is useful for the diagnosis of certain for-

eign body obstructions. Ultimately, either endoscopy or surgery is required

for definitive diagnosis and treatment of foreign body obstruction.The most common hematologic abnormalities in cats with foreign body

obstruction range from a leukocytosis with or without a mild left shift to

a degenerative left shift in cases with peritonitis from intestinal perforation.

Dehydration and electrolyte imbalance are expected in animals that are

vomiting. These animals may have a normal pH or primary metabolic

acidosis. A normal pH results from equal loss of gastric acid secretions and

base secretions from the proximal duodenal, bile, and pancreatic juices. Pri-

mary metabolic acidosis is caused by a relatively greater loss of base secre-

tions from the upper intestinal tract, and lactic acidosis results fromdehydration and inadequate perfusion of splanchnic viscera, skin, and

muscle [2]. Cats with pyloric obstruction may demonstrate a hypokalemic,

hypochloremic, metabolic alkalosis. The dehydration and laboratory abnor-

malities should be corrected by appropriate intravenous fluid therapy, which

should be initiated before surgical intervention. Definitive correction

requires removal of the inciting cause of the vomiting and inflammation.

Foreign body locationEsophagus

The esophagus is responsible for the transport of food, water, and saliva

from the pharynx to the stomach. It is frequently under tension during the act

of swallowing and bolus formation. Unlike the intestines, the esophagus does

not have a serosal surface, and this may delay early fibrin sealing of entero-

tomy sites compared with the rest of the intestines. Vascular supply to the

esophagus is segmental, with the cervical portion supplied by branches of the

thyroid and subclavian arteries and the thoracic portion supplied by the bron-choesophageal arteries and segmental branches of the aorta [3].

Esophageal obstruction is less common than other gastrointestinal

obstructions. When it occurs, it can be complete or partial, each of which

demonstrates different clinical signs and sequelae. The most common clini-

cal signs are dysphagia and regurgitation depending on the level of obstruc-

tion. When the obstruction is incomplete, signs of chronic wasting, such as

emaciation, may be observed. If aspiration has occurred as a result of the ob-

struction, abnormal pulmonary sounds, such as crackles, may be auscultable,

and clinical signs, including coughing, mucopurulent nasal discharge, andfever, may be observed. If a foreign body has perforated the esophagus, a

secondary mediastinitis or pyothorax may develop [4]. Esophagobronchial

fistula formation secondary to a perforating foreign body can occur, leading

to secondary pulmonary pathologic findings [5].

There are three narrowed anatomic regions in the esophagus where a for-

eign body is likely to become lodged. These include the cricopharyngeal

862 T.N. Bebchuk / Vet Clin Small Anim 32 (2002) 861880


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thoracotomy at the appropriate intercostal space for the level of the obstruc-

tion. At the level of the heart base, where the aorta pushes it to the right, the

esophagus can be approached via a right lateral intercostal thoracotomy

at the fourth or fifth intercostal space. The esophagus is then packed off from

the rest of the neck or thorax using moistened laparotomy sponges. Ideally,

Fig. 1. Right lateral (A) and ventrodorsal (B) projections of the neck and thorax of a 1-year-old

female domestic shorthair cat. A 5-cm needle was ingested, punctured the pharynx, and is now

lying ventral to the larynx and trachea extending to the level of the fifth cervical vertebral body.



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Fig. 2. Right lateral (A) and ventrodorsal (B) projections of an esophagram in a 3-year-old

castrated male domestic longhair cat. There is a large filling defect in the thoracic esophagus

extending from the fourth thoracic vertebral body to the diaphragm. This is best viewed on the

lateral projection. This foreign body was not visible on survey radiographs. It was determined

to be clumps of hair and vegetation and was removed endoscopically.

865T.N. Bebchuk / Vet Clin Small Anim 32 (2002) 861880


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the cranial esophagus can be suctioned of contents before the esophagotomy

incision, but if this is not possible, an assistant can hold the esophagus

closed cranial and caudal to the proposed esophagotomy site to prevent con-tamination from leakage. If the esophageal wall over the foreign body looks

healthy, the incision can be made over the object and should be made large

enough to remove the foreign body with no additional damage to the esoph-

ageal wall. If the esophagus seems compromised, the incision should be

made aboral to the foreign body, beginning at the foreign body but large

enough to remove the object with minimal manipulation. Once the foreign

object has been removed, the esophageal mucosa is examined for any evi-

dence of perforation. The esophagotomy incision can be closed in one or

two layers. The first layer is an appositional pattern in the mucosa and sub-mucosa, and the second layer is an appositional pattern in the muscularis.

The holding layer is the submucosa. If the esophageal wall does not look

healthy, a resection and anastomosis should be performed on the damaged

region. Anastomosis of the esophagus can be performed with a one- or two-

layer closure. Suture material for esophageal surgery in cats should be a syn-

thetic, monofilament, absorbable suture, such as polydioxanone, in a 4-0

size and with a swaged on reverse cutting needle. If there is still concern rel-

ative to leakage of the esophagus at the site of the anastomosis or esopha-

gotomy, an omental patch can be brought through the diaphragm andwrapped over the anastomosis, a pericardial reinforcement can be applied,

or a pedicle intercostal graft can be used [9,10]. Anastomosis of the esoph-

agus should not be under tension, because the esophagus is constantly in

motion as a result of swallowing and respiration. The anastomosis may

dehisce if the tension is excessive. The major complication of surgery for

esophageal perforation is infection, and this occurred in 57% of cases in one

study with and without dehiscence [5]. In the postoperative period, a phar-

yngostomy tube can be used to provide caloric and fluid requirements; how-

ever, this is controversial, because the presence of the intraluminal tube mayimpair esophageal healing [5].

Stomach

Foreign bodies of the stomach are common and may be an incidental

finding in some cases (Fig. 3). Clinical signs of gastric foreign bodies range

from asymptomatic to intermittent or persistent vomiting as a result of out-

flow obstruction, gastric distention, and mucosal irritation. Vomiting is

more common with foreign bodies in the pyloric antrum, because distentionor noxious stimulation of the duodenum and/or pyloric antrum stimulates

vomiting, whereas similar distention of the fundus does not [3]. Cats com-

monly ingest string, yarn, and other string-like material when they play.

This can result in a linear foreign body, which is frequently anchored under-

neath the tongue or at the pylorus, causing intestinal plication. A gastric for-

eign body is generally not an emergency unless it is a linear foreign body or



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Fig. 3. Right lateral (A) and ventrodorsal (B) projections of a gastric foreign body (vintage

Canadian nickel) discovered as an incidental finding when obtaining radiographs of a 10-year-

old cat after trauma.



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the foreign object is lodged in the pylorus and causing obstruction and

severe vomiting.

Young animals are presented with gastric foreign bodies more frequentlythan older animals, and this should be a differential diagnosis for any kitten

that has clinical signs of vomiting. The cats are presented with a history of

intermittent or persistent vomiting or a more chronic history of inappetence/

anorexia and depression. Physical examination of these cats may be unre-

markable; however, many have some level of dehydration or abdominal

pain, and a gastric foreign body is palpable in some cats. The stomach is cra-

nially located in the abdomen and is shielded by the caudal costal arches,

making routine palpation of gastric foreign bodies difficult. If a linear for-

eign body is present, plicated intestines may be palpable.Laboratory abnormalities most commonly include evidence of dehydra-

tion. For example, an elevated hematocrit as well as elevated blood urea

nitrogen, creatinine, and total protein levels can be expected. In cases of

severe vomiting as a result of pyloric obstruction, a hypochloremic and

hypokalemic metabolic alkalosis may be present. In cases of vomiting with-

out pyloric obstruction, a metabolic acidosis would be expected as a result

of losses of base-rich duodenal and pancreatic secretions as would dehydra-

tion and lactic acidosis.

Radiopaque foreign bodies may be diagnosed radiographically; however,this is not always the case. Radiolucent foreign bodies may require a con-

trast gastrogram for diagnosis. This can be performed using barium; how-

ever, if an esophageal, gastric, or intestinal rupture is suspected, aqueous

iodine or iohexol should be used [6]. As in the case of the esophagus, many

gastric foreign bodies can be diagnosed and removed endoscopically. Con-

trast radiographs and endoscopy allow the clinician to discern between for-

eign bodies and other causes of vomiting, such as gastric neoplasia and

gastric ulceration. An additional tool for the diagnosis of a gastrointestinal

foreign body is ultrasonography. Using ultrasound, foreign bodies of thestomach and intestines may be identified, and many foreign bodies have a

characteristic ultrasonographic appearance depending on the tendency to

transmit or attenuate the ultrasound beam [11]. If the foreign body is

smooth and rounded, vomiting can be induced with xylazine (Rompun) at

a dose of 1 mg/kg of body weight [12]. This should only be attempted with

objects that can be expulsed with no harm to the esophagus and no risk of

lodging in the esophagus.

Foreign bodies that have sharp edges or are large should not be removed

by endoscopy because of the risks of esophageal laceration and lodging theforeign body in the esophagus. These foreign bodies are best removed by

gastrotomy [12]. Radiographs should be taken just before surgery to ensure

that the object has not moved from the stomach. The surgical approach to

the stomach for gastrotomy is via a cranial ventral midline laparotomy.

Because the intestines and stomach can contain foreign bodies concurrently,

a thorough exploratory laparotomy should be performed. The stomach is



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packed off from the rest of the abdomen with moistened laparotomy

sponges, and stay sutures are placed between the greater and lesser curva-

tures, near the cardia, and in the pyloric antrum. The gastrotomy incisionis created between these stay sutures in the hypovascular region between the

greater and lesser curvatures on the ventral surface of the stomach. The inci-

sion should not be made too close to the pylorus to prevent excessive nar-

rowing of the gastric lumen. Closure of the gastrotomy can be performed

in one or two layers. If a two-layer closure is used, the first layer is an appo-

sitional pattern that must incorporate the submucosa, and the second layer

is an inverting pattern in the serosa and muscularis [12]. Suture material

should be synthetic, monofilament, absorbable, and size 3-0 or 4-0.

In the postoperative period, hydration status and electrolyte levels shouldbe monitored. Intravenous fluid therapy should be continued and adjusted to

address any abnormalities. If the animal has been anorexic and vomiting for a

sustained period, hypokalemia is expected. This can be treated with intrave-

nous fluids containing 20 to 40 mEq/L of potassium chloride. The animal

should not receive more than 0.5 mEq/kg/h of potassium chloride. If vomiting

continues, treatment with an antiemetic may be necessary. If vomiting has

ceased, the cat should be started on a bland diet 12 to 24 hours after surgery.

The prognosis for removal of gastric foreign bodies via gastrotomy is

good. Recovery can be complicated by local or generalized peritonitis ifthere is gastric perforation present or if spillage of gastric contents occurs

during gastrotomy. The latter is uncommon if moist laparotomy sponges are

used effectively to isolate the stomach from the rest of the abdomen before

making the gastrotomy incision.

Small intestine

Small intestinal obstruction by a foreign body is a common condition in

cats. This obstruction can be complete or partial. The clinical signs vary inseverity as a result of the level and degree of obstruction. The location of the

obstruction also contributes to variability in the presenting clinical signs.

Common clinical abnormalities include vomiting, anorexia, depression, and

abdominal tenderness. Many intestinal foreign bodies can be detected with

careful abdominal palpation. Results of abdominal palpation include intes-

tinal distention, a palpable object, and abdominal pain.

The diagnosis of foreign body obstruction is usually made radiographi-

cally. The classic radiographic sign of mechanical obstruction is the presence

of multiple loops of gas-filled small intestine of various diameters. A smallintestinal diameter greater than 1.6 times the depth of the midcentrum of the

fifth vertebra has been used as a predictor of intestinal obstruction in dogs

[13]. A similar ratio may be useful in cats. The dilation may not be present to

the same degree in cases of partial intestinal obstruction. If the object is

radiopaque, it can be identified on plain radiographs (Fig. 4); however,

many foreign objects are radiolucent and require contrast radiography for



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identification (Fig. 5) [14]. Some foreign objects, such as various fruit seeds

and corn cobs, although nonopaque, can be identified on survey radio-

graphs because of their characteristic shape and contained gas lucencies[14]. Liquid barium or barium paste in food can be used if there is no sus-

picion of gastrointestinal perforation. If perforation is suspected, aqueous

iodine or iohexol should be used [6]. Most proximal small intestinal obstruc-

tions are visible within 6 hours, whereas a 24-hour study may be required for

more distal obstructions [15,16]. The presence of a nonopaque foreign body

is seen as a filling defect in the intestinal lumen or as a complete obstruction

to the flow of barium in some cases. Another imaging modality that can be

used to diagnose and characterize intestinal foreign bodies is ultrasono-

graphy [11,17]. Using ultrasonography, gastrointestinal motility can beassessed; when increased, it often signals the location of a mechanical

obstruction. The presence of fluid/gas distention also indicates the location

of the foreign object, and some objects may have characteristic acoustic sig-

nals. Ultrasonography may not accurately predict the presence of intestinal

perforation even when wall thickness is measured [11].

The treatment of intestinal foreign body obstruction is surgical. The sur-

gical approach is via a ventral midline laparotomy extending from the

xiphoid to the pubis. The entire intestinal tract should be explored to deter-

mine if there are multiple foreign bodies and to assess if the object causedany intestinal trauma in transit. If the bowel segment containing the foreign

body is healthy, the foreign object can be removed through an antimesen-

teric enterotomy incision just aboral to the obstruction. This placement

ensures that the intestine excised is healthy. There is potential for the intes-

tine immediately overlying the foreign body to be compromised as a result

of pressure necrosis of the intestinal wall contacting the object. Enterotomy

proximal to the obstruction is not recommended, because distention with

gas and fluid and the passage of the foreign body may have caused some

degree of vascular compromise [2,18]. The enterotomy incision is made largeenough to manipulate the foreign material out of the intestinal lumen with-

out causing further intestinal trauma. This usually requires an incision the

length of the diameter of the obstructing object [18]. The enterotomy inci-

sion is then closed with size 4-0, synthetic, monofilament, absorbable suture

material, such as polydioxanone, in a simple continuous or simple interrup-

ted appositional pattern [19,20]. If the bowel segment demonstrates evidence

of necrosis, such as a thin intestinal wall and dark discoloration, a resection

and anastomosis should be performed. End-to-end anastomosis can be

accomplished using a simple interrupted appositional pattern or a modifiedsimple continuous appositional pattern with the same type of suture material

used for enterotomy closure [20,21]. The modified simple continuous pattern

is performed by first placing two separate sutures at the mesenteric and anti-

mesenteric borders. They are tied, leaving a 3- to 4-cm end for a stay suture,

to which mosquito forceps are attached. The needle end of the suture is then

used to complete the anastomosis. One strand advances the perimeter of the



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Fig. 4. Right lateral (A) and ventrodorsal (B) radiographic projections of the abdomen of a 2-

year-old male domestic shorthair cat after ingestion of fishing tackle. Three radiopaque foreign

bodies are visible, including two hooks (one with leader attached) and a lead fishing weight.



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Fig. 5. Right lateral (A) and ventrodorsal (B) survey radiograph projections of a 3-year-old cat

with a 4-day history of vomiting and depression. The stomach is distended with gas, and there is

a large and primarily fluid-filled bowel loop in the caudal right abdomen. (C,D) A barium

contrast gastrointestinal study in the same cat. This contrast study confirms the presence of

foreign body obstruction of the proximal jejunum, and the distended bowel seen on the survey

radiographs is proximal to the obstruction. Complete obstruction is confirmed by the fact that

the barium does not flow past the lesion. There is mild gastroesophageal reflux.



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intestine with bites 2 to 3 mm apart from mesenteric to antimesenteric knots

and a square knot tied to the tagged end of the knot at the antimesenteric

border. The other strand is advanced on the other side in the opposite di-

rection and tied in the same fashion [20]. After the anastomosis has been

Fig. 5 (continued).



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completed, an omental or serosal patch can be used to aid in sealing the

anastomosis [10,19,22].

A unique form of intestinal obstruction that is seen commonly in cats islinear foreign body obstruction. This is caused by foreign bodies, such as

string, thread, a nylon stocking, or carpet fibers. One of the most common

causes is sewing thread alone or in combination with sewing needles [23].

The linear object becomes fixed around the base of the tongue or in the pylo-

rus. The intestinal peristaltic waves attempt to move the object aborally, and

the intestine gradually gathers up in a pleated fashion like an accordion on

the foreign object. The linear object becomes imbedded in the mesenteric

border of the small intestine and can erode through the intestinal wall, lead-

ing to leakage of intestinal contents and a local or generalized peritonitis[24]. Clinical signs with these foreign bodies are generally not severe, because

the obstruction is not complete. Vomiting tends to be less frequent and

severe than with other foreign bodies. If peritonitis develops, a rapid deteri-

oration in the cats status may be observed. The linear object is generally not

palpable even with careful abdominal palpation; however, plication and

clumping of the intestine often are observed.

The radiographic signs of a linear foreign body include small intestinal

accordion-like pleating, shortening or gathering of the intestine, increased

luminal gas bubbles, and peritonitis secondary to bowel lacerations [23].When clumping and plication of the intestine are visible on survey radio-

graphs, this is strong circumstantial evidence for the presence of a linear for-

eign body (Fig. 6). Another common radiographic sign of a linear foreign

body is a pattern of small, eccentrically located, luminal gas bubbles that are

tapered at one or both ends [23]. In a review of 64 cats with linear foreign

bodies, if three or more of these bubbles were seen, a definitive diagnosis

of a linear foreign body could be made [23]. Both ventrodorsal and lateral

projections should be obtained. The lateral view is preferred to determine

whether intestinal clumping is present, because the intestines are often onthe right side in a ventrodorsal view of a normal cat. The purpose of the ven-

trodorsal projection is to confirm that suspicious gas bubbles are located in

the small bowel. If a barium contrast study is used to confirm the diagnosis,

the abnormal plication of the intestines should be more evident, and the for-

eign object may appear as a linear filling defect. Once the contrast material

has passed through to the colon, a small amount may remain in the foreign

body, making it look like a linear opaque structure in the intestinal lumen.

On ultrasonographic examination, the bowel may have a ribbon candy

appearance. Ultrasonography of linear foreign bodies reveals plication orcorrugation of the intestinal tract that can be similar to the ultrasonographic

appearance of intussusception. The two disorders can be differentiated by

the presence of a hyperechoic structure within the lumen and lack of the wall

layers to form a complete concentric ring [11].

Linear foreign bodies may cause only mild chronic intermittent signs

because of the partial nature of the intestinal obstruction [25]. Continued



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Fig. 6. Right lateral (A) and ventrodorsal (B) survey radiographic projections of a 2-year-old

spayed female domestic shorthair cat with a linear foreign body (sewing thread). There is

clumping of the intestines on the lateral projection, and several eccentric tapered gas bubbles

can be seen in the small intestine. There is generalized decreased detail suggesting some free

peritoneal fluid.



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peristaltic activity may lead to erosion of the mesenteric border intestinal

wall with subsequent local or generalized peritonitis and vascular compro-

mise of the intestinal wall. For this reason, linear foreign body ingestionshould be treated as an emergency condition. Surgical management is the

traditional approach to this disorder. It has been reported that cats with

mild clinical signs, no pyrexia or severe abdominal pain, a linear foreign

body located around the base of the tongue, and evidence of only a mild left

shift on a complete blood cell count can be managed conservatively by cut-

ting free the sublingual attachment of the foreign body and maintaining the

cat in the hospital for observation and intravenous fluid therapy. Contrain-

dications to this conservative management approach include obvious pyloric

anchoring of the linear foreign body, the presence of severe abdominal painand pyrexia, radiographic evidence of peritonitis, and a degenerative left

shift on routine hematology testing [24].

Unlike most other intestinal foreign bodies, linear foreign bodies are not

easily removed from a single enterotomy incision. Pulling the object out

through a single proximal enterotomy can cause friction of the object against

the intestinal mesenteric border, and occult perforations may develop. It is

preferable to remove the object in short segments via multiple enterotomies

on the antimesenteric border. To begin, the anchor point, which is usually sub-

lingual or pyloric, must be released. Incising the string under the tongue orperforming a gastrotomy to release a pyloric anchor point accomplishes this.

The linear object can then be removed by one or more intestinal enterotomies.

A technique has been described for removal of linear foreign bodies from a

single enterotomy incision. The procedure is performed by creating a single

enterotomy in the antimesenteric border of the proximal duodenum. The lin-

ear foreign body is tied or sewn to a red rubber catheter, which is advanced

into the duodenum aborally, and the enterotomy is closed. The red rubber

catheter is then milked aborally along the intestine, relieving the plication

as it is advanced, until it is advanced the length of the colon; an assistant canthen retrieve it and the linear foreign body from the anus [26]. This technique

may not be effective for certain linear objects that have caused more severe pli-

cation or are knotted or matted and cannot be advanced aborally [27]. It is dif-

ficult to detect perforations on the mesenteric border should they occur,

because they are shielded by the attachment of the mesentery and mesenteric

vasculature. Where laceration has occurred, inflammation and infection at the

site are occasionally walled off, making removal of the string difficult. In these

cases, the intestine may not resume normal functioning after surgery [12].

At our teaching hospital, we see a combination of local clients and refer-ral cases. Over the past 10 years, we have treated 113 cats for gastrointesti-

nal foreign bodies, with 2 of these cats presented on two different occasions.

Linear foreign bodies caused almost 50% of these cases. Over half of these

cases were caused by needles and thread or thread alone. Other foreign

objects identified were coins, earplugs, small toys, trichobezoars, an almond,

fishing tackle, and a cork. Cats are susceptible to intestinal obstruction by



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many different types of foreign bodies, but linear foreign body obstruction is

clearly the most common type.

Although most feline intestinal foreign bodies can be removed with agood prognosis, intestinal surgery is not without morbidity. Intestinal dehis-

cence is the most significant complication and has been associated with an

80% mortality rate in cats and dogs after intestinal surgery. This compares

with a mortality rate of only 7.2% in animals without dehiscence [28]. In a

series of 121 dogs undergoing small intestinal anastomosis or enterotomy,

dehiscence was identified in 15.7% of the animals, with a mortality rate of

73.7% [29]. It has also been shown that the survival rate is negatively corre-

lated with multiple intestinal procedures [28]. For these reasons, it is impor-

tant to ensure that only a single enterotomy or resection and anastomosis isperformed whenever possible, only healthy intestine is sutured, and intesti-

nal closure is meticulous.

When extensive intestinal injury results from the passage of a foreign

body or the presence of a linear foreign body, there may be a large or multi-

ple areas of intestinal necrosis. This would require the resection of a large or

multiple segments of the small intestine. This can result in various clinical

signs known as short bowel syndrome. The pathophysiology of this syn-

drome is a result of decreased secretin and cholecystokinin in the proximal

duodenum, thereby decreasing pancreatic and biliary secretions. The loss ofintestinal brush border enzymes also contributes to the syndrome, with the

changes resulting in maldigestion. Decreased intestinal transit time and

decreased mucosal surface area may also contribute to malabsorption. The

decreased transit time, increased lumenal osmotic pressure, bacterial over-

growth, and gastric hypersecretion ultimately result in diarrhea, dehydra-

tion, electrolyte imbalances, and malnutrition. The precise percentage of

small intestinal length that can be removed in cats without causing short

bowel syndrome is not known. In people, 40% to 50% can be removed

safely, but when greater then 75% is removed, nutritional status cannot bemaintained on enteral nutrition alone [30]. In four of five experimental dogs,

resection of 85% of the small intestine did not affect their ability to live for

11 to 24 months with no special therapy [31]. If massive resection of the

small intestine is required, it must be anticipated that the cat is going to need

nutritional support until adaptive changes in the intestine can occur. These

adaptive changes include increased bowel diameter, crypt and villus mucosal

cell hyperplasia, an increase in villus height and crypt depth, and an increase

in the number of epithelial cells per unit length of the villus. In the interim,

antidiarrheal therapy may be necessary as well as antibacterial therapy tolimit bacterial overgrowth [30].

Large intestinal foreign bodies

Large intestinal foreign body obstruction is exceedingly rare in cats.

Once passed into the colon, most objects are passed in the feces without



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complication. In the rare case where colonic obstruction is identified, it can

be treated in a similar fashion as small intestinal obstruction. It should be

recognized that the large intestine heals similar to the stomach and smallintestine but that healing is delayed. Wound tensile strength lags behind that

of the small intestine, and suture line failure is more likely. The blood supply

is segmental, there is a large population of bacteria, and solid feces place

more tension on the suture line than the liquid ingesta in the small intestine.

All these factors theoretically lead to greater morbidity and mortality with

colonic surgery [19]. One study, however, did not detect a difference in dehis-

cence between animals undergoing large or small intestinal surgery [28].

Conclusion

Cats can be affected by foreign body obstruction at all levels of their gas-

trointestinal tract. Foreign bodies can be diagnosed and identified by a com-

bination of physical examination and palpation techniques, medical

imaging, and endoscopy. Medical imaging can consist of survey radio-

graphs, contrast radiographs, or any combination of the three. Endoscopy

is useful for the identification and removal of both esophageal and gastric

foreign bodies. If possible, esophageal surgery should be avoided. Small

intestinal foreign bodies are most commonly linear foreign bodies in cats,and these constitute an emergency presentation. Traditionally, these have

been addressed as a surgical emergency, but in selected cases, conservative

management is appropriate. When surgery is performed for intestinal for-

eign bodies, the object should be removed using the fewest number of enter-

otomies necessary for removal with minimal intestinal trauma. If there is

evidence of intestinal necrosis, a resection and anastomosis is performed.

To prevent leakage and to aid in intestinal healing, an omental or serosal

patch can be placed over the enterotomy and anastomotic sites after suture

closure. If large intestinal segments must be removed, the cat may need to bemanaged for short bowel syndrome with nutritional and pharmacologic

support.

The successful management of cats with gastrointestinal obstruction is

based on a knowledge of the relevant anatomy, proper use of diagnostic and

therapeutic techniques, an understanding of the physiologic effects of

obstruction, and an appreciation for intestinal tract healing at the affected

location. If all these factors are considered, most cats with gastrointestinal

foreign bodies can be managed with a good prognosis.

References

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