Dog w/ bleeding into thoracic cavity, ideas for diagnostics please?

[Candle]

So, the love of my life, my 4 year old Boxer girl has spent the last 24 hours at the emergency clinic bleeding into her thoracic cavity for a completely unknown reason. We've shot multiple x-rays, clotting times are normal, hematocrit keeps dropping every six hours when we re-check. She was shocky when we brought her in last night, and has had a blood volume expander and fluids, and is breathing more comfortably. We seem to be in a holding pattern with re-checking crit levels and re-xraying, and it's frustrating, but I don't have any better ideas. The only thing I can think of is having the fluid drained out of her chest and try to ultrasound to rule out hemangiosarcoma. She looks like she has a funny shape to her right atrium on the x-ray, but the vet isn't reading anything into that at the moment, since there is enough blood in her chest that it may be pushing things out of whack. I just want her to come home :cry: Does anyone have any ideas, has anyone had success with some diagnostic that we're not thinking of? I want her out of the E-clinic!!! Thank you guys in advance!!!

[Bluey]

That is very puzzling.
Being in such a confined space, maybe whatever is leaking will self seal with the pressure?

Guess that exploratory surgery is not appropiated there?
Hoping all turns out well after all.:(

[SmokenMirrors]

Could she have been hit by a car and something has a small tear in it? How about any defects that may be known to the boxer breed that is now showing itself? Could she have eaten something that punctured through? No trauma to that area at all?

Good luck to you and your Boxer dog, that is very unsettling and I hope she pulls through.

[RedTahoe]

I am not a vet so I can't give any Dx advice; however, I did find this online (maybe it's something you have already read, but if not, maybe it can help):

http://www.petplace.com/dogs/hemothorax-bleeding-in-the-chest-in-dogs/page1.aspx

Hemothorax is defined as blood within the chest cavity. The most common cause of hemothorax is chest trauma, although tumors within the thorax (chest cavity) can also result in a hemothorax if they rupture, slowly bleed or invade into a blood vessel causing blood to accumulate in the thorax. Coagulopathies (clotting disorders) may also cause an animal to bleed within the chest cavity. A hemothorax is usually an emergency situation requiring rapid diagnosis.

[danceronice]

The vet hasn't suggested anything else? If rads are inconculsive they're going to have to try some other kind of imaging--if they say they can drain and do an u/s I would say authorize it. Especially with a "funny shape" on the right atrium--if x-rays aren't clear I'd want a better look at that pronto. (Not a vet, just an animal owner and zoo employee, so take that advice for what it's worth. Sadly the head librarian's not here--she's a vet tech and I could ask.)

[McVillesMom]

Have they run a coag panel?

[Candle]

She's clotting fine, thats within normal range. I got a call from the vet this morning that her crit stabilized at 24 overnight (from 44, been dropping since she went in), and if it's ok at noon, I can go pick her up. I'm terrified to bring her home however, I want to know what the heck is going on with her!!! No trauma that we can come up with, she was in our sight all day. Thank you all for the ideas, keep them coming?!?

[FreedomsPride]

did they do a full cbc/chem panel?

My mind goes to rat poison as it's a blood thinner and can kill if not treated promptly. (Vitamin K is treatment).

Could she have gotten into something like that or some other toxin?

[Horsegal984]

I know you said her crit was dropping, but what is it at? If they haven't, I would consider a transfusion, whole blood if it's under about 20%, and plasma if it's over that. I wouldn't tap the chest and pull off the blood unless it was to do an u/s, and I would have a transfusion ready to go if needed. If there's a large amount of blood drawn off it can cause hypovolemic shock, even though it's not in the bloodstream it can still have negative effects on the body to lose that much blood at one time.

I hate to be negative sounding, but it's a boxer and they make cancer like crazy. I would have the abdomen and the chest ultrasounded for two reasons. One to look for the obvious reason of looking for the cause of bleeding, and two to check for evidence of tumors on other organs.

The top three reasons for hemothorax are trauma, rodenticide poisioning and tumors. With still normal clotting times rodenticide is less likely, which leaves trauma of unknown origin or tumors. I hope for your sake it turns out to be a trauma cause, but since the crit is still dropping it doesn't look great. Please keep us posted, I've got my fingers crossed for you!

Katherine
Vet Tech

[Horsegal984]

If it was my dog I would be very hesitant to take her home this soon. If it has just recently clotted the stress of moving and a car ride could be enough to dislodge it and allow it to start bleeding again. Unless money is a problem and you need to take her home I would leave her for 24hours with a stable crit. If you do need to take her home keep her crated for 24-48 hours, out to potty on a leash and right back into the crate. Learn to count resp. rate and her CRT(capillary refill time) and if they're increasing back to the clinic.

Katherine
Vet Tech

Case study from a vet on a similar case.... all the more reason to leave her at the clinic.

This is a boxer, neon sign stamped on the breed says cancer, my patient was a 3 year old lovely female spayed boxer. Presented to the ER with spontaneous hemothorax of unknown origin, she lived on a farm, so we were all hoping for traumatic hemothorax, despite the underlying acknowledgement of the elephant in the room.

She was at the facility for 7-10 days, kept having recurrent hemothorax, it would stop, think about discharge, then start again. Lots and lots of repeat rads, saw every specialty group in the building, had ultrasounds of chest and abdomen by the internists and cardiologists, nothing, nothing, nothing, so we kept going, money not an issue, CT/MRI not available. Then rads showed nodules, lots of them, fairly big not on the rads taken 2 days prior, we all went back and looked with our imaginoscopes on high, there really was nothing there... -- hemangiosarc on post-mortem.

She was 3 years old, good body condition, no weight loss, no prior problems...<sigh>. It was a sad day...the owners tried so hard. So it does happen, even in the young and apparently healthy. But the owners have to understand you are playing the odds, you don't have a diagnosis until you have cells that say cancer on a slide, no matter how suggestive the imaging or gross exam.

[Candle]

Yes money is a problem, but my dog-dog is priceless to me. I'm hesitant to take her home also. What's the best and most aggressive diagnostic tools for finding out if it is a hemangiosarcoma? I am really terrified of dislodging whatever is causing this to clot off, but obviously as she is at the E-clinic, everything is about 4x as much $$. They are adopting the watch-and-wait method, but my wallet is hemorrhaging, hence the reason I want more aggressive diagnostics if they're available and reasonably accurate.

Her crit is at 24 right now, up from 22 at 2am today, and I don't have the results from the noon draw yet. She was 44 when she went in at 11pm on Monday, and all of her coag panel was normal. The rad last night showed less fluid in her chest. The vets keep saying that it is possible that there is a trauma, but it's *extremely* unlikely. I think so too, especially since she did NOTHING out of the ordinary the whole day prior to this.

I want to say thank you to everyone helping me reason through this, it was terrifying watching her get shocky like that, and thinking about her having aggressive cancer is obviously really upsetting. Thank you, COTH. Any more questions, please ask, I'll answer as best as I can.

[RedTahoe]

I just spoke with a friend of mine that has been breeding boxers for 20 years. She said that she would talk to the veterinarian about cancers, and whomever it was that said "boxers produce cancers like crazy" wasn't kidding.

[McVillesMom]

They really do produce cancer like crazy, unfortunately. It sucks, because they are such good dogs! And you probably already know that hemangiosarcoma likes the right atrium.

I too would be extremely hesitant to take her home at this point. Do you have a referral hospital in your area with an internist? That might be your best bet at this point in time. Best wishes for your dog - I spent some time in a small animal emergency/referral practice so I know how scary, and how touch-and-go, things like this can be. I hope they can figure out what's causing this, and hopefully it's nothing bad...

[Pancakes]

So cancer is probably #1 on the differential list. As for diagnostics, if you want to go really aggressive, I'd do a CT scan to see if there are any masses ANYWHERE that could be bleeding or on a vessel causing bleeding. There are a heck of a lot of vessels in the chest.
You're bound to get poor detail in a chest filled with fluid, so radiographs (x-rays) won't be as helpful for fine detail. Ultrasounding the chest cavity is difficult and not terribly diagnostic, either, unless there is abnormal lung tissue in there.

I would DEFINITELY keep her at the ER. She is not stable enough to go home, from what it sounds like.
Other diagnostics I'd run, and if the vet already hasn't run, are CBC/Chem/UA, chest fluid cytology (to see if there are cancer cells in it or what the total protein is), echocardiogram, abdominal ultrasound (since hemangio in the chest is rare without mets in the liver and spleen as well).
That is going to be very expensive, however.

The most definitive diagnostic for hemangio is biopsy...aka you'd have to take the dog to surgery to find the mass. Otherwise, abdominal ultrasound of the abdomen looking for masses in the spleen/liver could also help point towards that diagnosis, but that alone would not be definitive (again, biopsy is the only way).

It could be any other sort of tumor, including lymphosarcoma, that has gotten near enough to a blood vessel and eroded it, causing a bleed.

it could be a LOT of things. Honestly, the best thing to do is to keep her at the ER facility. A lot of the "wait and see" part of it is seeing how your dog responds to treatment, and that alone can tell a vet a lot about what disease it may or may not be. You want her there too, since if she crashes for any reason, they'll have the ability to do what's necessary.

I know it's scary and frustrating, but the best thing to do is let the vets try to figure this out. I hope they do soon.

[Candle]

I'm happy with their stabilizing care, but not necessarily with the diagnostics. They say that there's not much else they feel comfortable doing, they'd rather refer me to a radiologist and I really appreciate all the candor and honesty I've gotten from the clinic, they seem good about knowing where their limits are. I can see that they are mainly a trauma facility, and once she's (relatively) stabilized, it's not really their specialty anymore. :sigh: I'm looking pretty hard at the cancer differential too, I knew that about boxers, but she's SUCH a GOOD DOG (in her own boxer way :D) that I can't imagine not having had her around all this time, even if it does turn out that it's a tumor. This is all really informative, if anyone else has anything to add, please do, don't be afraid of freaking me out, I knew cancer was a possibility when I got her, I'm just hung up on the logistics of what's the best way to go from here.

They called and I suggested leaving her there, and they said they don't really want her there, she's too stable now to really 'qualify' to be there, I guess. I will get a copy of her labs when I pick her up, and see if a chest fluid cytology can be done. She's been there for about 48 hours now, and I don't know what else to do with her.

[TB or not TB?]

No more advice but many, many jingles. :(

[SMF11]

Candle, I had my dog in intensive care for two weeks a few months ago, I know what you are going through. You have my warm thoughts and support in this stressful time. I also know about the wallet hemorraging! Both vet practices I had my dog at worked with me on paying the bill, perhaps yours will too.

One thing I learned: if you move your dog to another practice, make sure it can do the tests you might need. I guess that means a vet hospital. I ended up pulling my dog out of one practice when he needed an ultrasound and the first practice didn't have the equipment and couldn't get it.

Good luck to you.

[McVillesMom]

I don't know anything about the area, and I don't know where she is at now, but I did a search on the ACVIM website for internists in Seattle, and I found Animal Critical Care and Emergency Services, which seems to have criticalists and internists on staff, so if where she's at currently isn't working out, maybe consider consulting with them? If she were my dog, ideally I would want her somewhere with emergency capabilities as well as a specialist. Their website is www.criticalcarevets.com if that helps. Apparently they also share a facility with Animal Cancer Specialists. Again - I know nothing about this clinic, but it sounds like it might be another option.

[Candle]

Question for the vets/techs: What does lactate measure? At one point it was up to 3.0 mmol/l with (0.0 - 2.0) as reference range. She's home, I'm looking for a vet in the morning, and hoping like crazy that nothing crazy happens overnight. I think that's the best I can do as of right now. Oh, and my bill looked something like $:eek::eek::eek::eek::eek::eek::eek::eek::eek:
:eek::eek::eek::eek::eek::eek::eek::eek::eek::eek: :eek::eek::eek:
:eek::eek::eek::eek::eek::eek:

[Amwrider]

If you anticipate more vet bills, you may want to check out Care Credit. I have used it before for large vet bills. If you pay it off within a couple of months there is no interest.

Jingles for your doggie.

[Candle]

Oh no, that was with Care Credit. So...... the consensus is MRI is the best diagnostic? Is there anything to be gained from confirming that this is hemangiosarc? I read in a couple of places that surgery and radiation did NOT improve outcomes for that.

[Pancakes]

Oh no, that was with Care Credit. So...... the consensus is MRI is the best diagnostic? Is there anything to be gained from confirming that this is hemangiosarc? I read in a couple of places that surgery and radiation did NOT improve outcomes for that.

Hemangio is not really responsive to radiation, as it is usually disseminated within vital organs. You'd have to go with chemo, and even then, survival times aren't good if it's metastasized. With mets and bleeding into cavities, you're looking at avg 2 month survival times. If it was encapsulated in, say, the spleen, you might have 6 months. That's IF it for sure is hemangio.

MRI is not the best diagnostic. CT scan is. MRI has good detail for brain structures but CT will better identify soft tissue structures from one another.

Honestly, at this point, you should focus on determining the cause, not focusing on hemangio. For all we know it could be lymphoma, mast cell tumor, or something else. There are so many other causes. You'd best spend money doing diagnostics at specialists (I second finding a good quality specialist referral hospital, or a university) to determine exactly what is causing the bleeding. It may not even be a tumor. You can't jump to conclusions without having the evidence.

[IFG]

I am so sorry for you and your dog. I would find a teaching vet hospital. Last September, my Standard Poodle started going down hill. He was not right for 2 weeks. Finally, he could not breathe. We had him to the vet multiple times. The regular vet could not diagnosis him despite keeping him for 3 days. We finally pulled him out and brought him to Tufts. They diagnosed him with a carcinoma within 24 hours by tapping his chest and doing cytology on the cells. With a diagnosis of carcinoma, the prognosis was dismal, but at least we were able to minimize his suffering. When we walked in to Tufts, we told them that we were there to get a diagnosis because the poor dog was suffering horribly, yet we did not feel that we could euthanize him without knowing what was going on.

I really hope that you get a better diagnosis, but I would get to a teaching hospital ASAP so you can at least figure out what is going on. We are still paying for it with Care Credit, but I am so mad at myself for not getting him straight to Tufts.

Good luck!

[IFG]

This seems like a good site with info on hemangiosarcoma:

http://www.vetinfo.com/dencyclopedia/dehemsarcoma.html

[cloudyandcallie]

I think you should head to the nearest vet school with a specialist in this field.
Good luck.

My aunt and uncle in Charleston had boxers many years ago and all of the boxers developed cancer. No vet ever told them why.

[Candle]

MRI is not the best diagnostic. CT scan is. MRI has good detail for brain structures but CT will better identify soft tissue structures from one another.

Honestly, at this point, you should focus on determining the cause, not focusing on hemangio. For all we know it could be lymphoma, mast cell tumor, or something else. There are so many other causes. You'd best spend money doing diagnostics at specialists (I second finding a good quality specialist referral hospital, or a university) to determine exactly what is causing the bleeding. It may not even be a tumor. You can't jump to conclusions without having the evidence.

Thank you for the advice, I am quickly running out of $$ to go shooting in the dark with, and the vet at the clinic wasn't optimistic that we'd ever find out what it was, so I didn't want to go throwing more money at diagnostics and not be able to do supportive care if she needed it if it was unlikely that I would be able to figure out what the heck is wrong with her. This is already more than my horse's 24 hour stay post-colic at a world-renowned vet hospital, and I have NO idea what's wrong with her. :sigh: I'll keep looking into the teaching hospital idea.

[Mara]

Jingling like crazy for the pupster. Poor baby. :cry:

[Horsegal984]

sometimes you have to make a diagnosis by ruling out all others. Since it sounds like you're like most of the rest of us and the wallet is running on E I highly support your decision to save for supportive care. Further diagnostics are expensive, and if you can get her stable you can buy yourself time to save towards more workups as needed.

I will just say that if she gets better, and doesn't relapse, then I'd bet my ass on trauma, even though it seems so unlikely. Any type of cancer or more severe problems are going to wind up causing relapses, so keep an eye out. I hope like hell that she is doing well still, and if you can save up I think that a further workup would give you a little more peace of mind. If you can afford it, doing the CT scan would be the best, and at least if it's negative you still know two things..... 1) you'll never know what caused her bleed, and 2) the chances of it happening again are way less than if you found a bunch of tumors.

Katherine
Vet Tech

[Pancakes]

Thank you for the advice, I am quickly running out of $$ to go shooting in the dark with, and the vet at the clinic wasn't optimistic that we'd ever find out what it was, so I didn't want to go throwing more money at diagnostics and not be able to do supportive care if she needed it if it was unlikely that I would be able to figure out what the heck is wrong with her. This is already more than my horse's 24 hour stay post-colic at a world-renowned vet hospital, and I have NO idea what's wrong with her. :sigh: I'll keep looking into the teaching hospital idea.

Oh, I understand that $$ is a problem -- it's hard to decide how far to go before you find the cause. I was just giving all the options, should you decide how far to go.

If you are interested in finding out the cause, you may certainly pursue that route, and you may find an answer. However, I really feel like your money is NOT wasted on just supportive care -- that is a viable option! In fact, by doing supportive care, which is basically keeping her comfortable and stable and alive, you are also doing the "wait and see" thing which can help vets determine maybe what it is, so in the future, they may have a lot more information to go one than now.

The teaching hospitals are great because they have so many sharp minds working together...but they may not be a great option if you are running out of money. However, they will help get to the solution to the current problem most directly.

[EponaRoan]

No helpful information, here, but I am sending jingles for your pup.

[Candle]

So...... we ended up back in the E clinic last night after she was working hard to breathe, and saw the most awesome vet there (we went to the other e-clinic to see if we could get a second opinion of sorts, they have better diagnostics and a cancer team also). She told me that a CT scan was probably the only way to go as far as figuring out what she did, and also that unless it was trauma (unlikely), it was most likely a tumor that would require surgical intervention of some kind, in her opinion. I am not doing surgery for many personal and ethical reasons, so I didn't think there was a very good reason to do a CT scan. I'm taking the money and instead am taking her to a vet who also does acupuncture and seeing if I can do some supportive care that way. The awesome vet also gave us a painkiller and a sedative, and we'll see if we can keep her quiet for the next two weeks or so.

THANK YOU THANK YOU to everyone posting on this thread, it's been a huge help.

[JSwan]

Candle -

Sorry your dog isn't doing well. Sounds like whatever it is might be pretty serious and I don't blame you for just trying to keep her comfortable - and not being more aggressive.

I hope she improves with the path you take and if not - that you have some good days left with her.

[Mara]

Honestly, I would do the same thing if I were in your position. Your dog's system is probably pretty stressed already, and anesthesia - if she were to require surgery - wouldn't be a great bet.
I really hope it isn't what everyone is dreading, but if it turns for the worst, at least your baby will be with the person she loves and trusts most.

[IFG]

Candle,

I am so sorry for you. I understand not wanting to put her through surgery. That was our choice as well.

Have they tapped her chest and examined the fluid? That would give her relief and might be diagnostic. When our poodle had this problem, tapping the fluid gave him relief. It was when Tufts examined the fluid that they found carcinoma cells.

Best of luck. You have all of my sympathy. It is agonizing to watch an animal that you love go through this.

[SMF11]

Candle, I'm just writing to say I'm still thinking of you and your dog. She is so lucky to have you, and I know you are lucky to have her. If you can, please keep us posted. I check the thread a couple of times a day. Hugs to you.

[Candle]

Candle, I'm just writing to say I'm still thinking of you and your dog. She is so lucky to have you, and I know you are lucky to have her. If you can, please keep us posted. I check the thread a couple of times a day. Hugs to you.

Awww thank you so much. It means a lot to have a community that I can go to for support, ideas and knowledge. She's perked up since she came home last night, and the second place gave us pain meds for her, and that seems to be really helping her. Now the challenge is keeping her quiet. Yeah right! She must. lick. everything. that. moves. and everything that doesn't move. She also wants a kitten beyond all reason, so I'm seriously thinking about getting her a kitty for her very own (she wants to play with kitties and lick them, bizarre I know, she can only pull this off with sick, old, and decrepid kitties, so I figured a kitten might work better). I however do NOT want anything else that may warrant a trip to the e-clinic, so I'll keep thinking about that one. :sigh: I'll see if I can post a picture of the Thing That Licks later on.

[BarefootFuzzyBunny]

You mentioned a high lactate.

Has anyone mentioned a concern for dilated cardiomyopathy?

Like Cancer, it's something these dogs are very prone to.

Best of luck. I hope she gets comfortable.

[Equino]

My parents lost a Boxer two weeks ago to hemangiosarcoma-she was 12 years old and had been dealing with Degenerative Myelopathy since the fall when she suddenly seemed weak and fainted. Thinking it was her heart, my parents rushed her to the vet and she was diganosed with hemangiosarcoma-the tumor was on her spleen (which was HUGE) and spread to her heart. Very fast growing and not a lot you can do. Best wishes, I hope this is not what is going on.