TJVM Vol. 49 No. 3 September 2019

Case Report Severe parasitic gastroenteritis (PGE) in a goat: A veterinary case report and way forward Faez Firdaus Abdullah Jesse1,2* Asinamai Athliamai Bitrus3 Eric Lim Teik Chung2,4 Innocent Damudu Peter1,5 Mohd Azmi Mohd Lila6 Annas Salleh7 Abstract This veterinary case report highlights the failure of herd health programme and feeding management that led to severe parasitic gastroenteritis (PGE) infection in a goat. The discussion of this case report is on the possible causes that led to this negative condition and way forward towards related to this case. For avoiding similar cases in the future to uplift the welfare of small ruminants. In this case report, a goat was presented with the history of severe diarrhea and inappetence. Furthermore, that farm did not practice regular deworming and vaccination programmes. Physical and clinical examination of the goat in this case report revealed emaciation, dullness, lethargy, pale mucuos membrane, anaemia, hypoglobinemia, hypoglycaemia and high strongyle egg count. Therefore, the clinical diagnosis of severe PGE concurrent with moderate pneumonia infection was made in this case. The therapeutic plans for this case were administration of anthelminthic drugs, fluid therapy, glucose replacement but unfortunately the patient died on the second day of hospitalization due to grave prognosis. Port mortem findings indicated the cause of the death of the patient to be due to hypovolemic shock caused by circulatory failure due to anaemia and hypoalbuminemia due to severe PGE infection and malnutrition. In conclusion, holistic application of herd health programmes (HHP) in small ruminants’ farms are needed to avoid this type of cases. Keywords: case report, goat, malnutrition, PGE, veterinary, way forward 1Department of Veterinary Clinical Studies, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia. 2Institute of Tropical Agriculture and Food Security, Universiti Putra Malaysia, 43400 UPM Serdang,, Selangor, Malaysia 3Department of Veterinary Pathology and Microbiology, Faculty of Veterinary Medicine, University of Jos, P.M.B 2084 Jos, Plateau Nigeria 4Department of Animal Science, Faculty of Agriculture, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia. 5Department of Theriogenology, Faculty of Veterinary Medicine, University of Maiduguri, PMB 1069 Maiduguri, Borno Nigeria. 6Department of Veterinary Pathology and Microbiology, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia. 7Department of Veterinary Laboratory Diagnostics Services, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia. *Correspondence: [email protected] (F.F.A. Jesse) Thai J Vet Med. 2019. 49(3): 295-299.

296 Jesse F.F.A. et al. / Thai J Vet Med. 2019. 49(3): 295-299. Introduction Universiti Putra Malaysia with a complaint of inappetence and severe diarrhea. Farm records Parasitic gastroenteritis is one of the major and showed that the farm had 34 goats with a previous history of recurrent diarrhea. This farm did not practice underestimated factors limiting the successes of small any vaccination and deworming Programme. ruminant productivity worldwide. Parasites constitute a significant public health problem and can be transmitted directly or indirectly to humans through Clinical Examination: Physical examination of the goat showed that the patient was dull, lethargic, consumption of contaminated food or water (Sultan et dehydrated (5%) with pale mucous membrane. The al., 2016). Parasitic gastroenteritis causes a devastating goat had a rectal temperature, pulse and respiratory rate of 37.1 °C, 86 bpm and 24 bpm respectively. socio-economic downturn to livestock production, this Auscultation of the cranial left lung field revealed moderate crackling lung sounds sound. Further in-turn affects farm profitably for both commercial and examination showed soiled perineum and subsistence agriculture (Jesse et al., 2017). This is enlargement of the right pre-scapular lymph node measuring 4cm x 2cm. The clinical diagnosis made at because in small economies of the world, small that point of time was severe PGE concurrent with moderate pneumonia infection. ruminants make significant contributions to human livelihood (Zvinorova et al., 2016). Parasitic gastroenteritis is mainly caused by nematode parasite, particularly strongyles which included Trichostrongylus, Cooperia, Haemonchus, Strongyloides and Oesophagostomum (Abdullah et al., 2016; Jesse et al., 2017b). Nor-Azlina et al. (2011) reported that strongyles Sample collection and Diagnostic work up: Blood and are the major nematode parasitic infestation commonly fecal samples were collected for complete blood count found in goats. The condition is associated with severe (CBC), serum biochemistry and fecal egg count diarrhea, anemia, lethargy, weight loss, tachycardia, analysis. The result of the CBC revealed mild to tachypnea and death (Eysker and Hassan, 2005). moderate normocytic hypochromic regenerative Nematodes cause severe devastating economic losses anemia, leukocytosis, monocytosis and neutrophilia in small ruminant production because of high with regenerative left shift. Analysis of the serum mortality (Sani et al., 2004). Additionally, small biochemistry revealed hypoglycemia, ruminant endoparasitism due to haemonchosis have hypoalbuminemia and hyperglobulinemia (Table 1). been reported to be second most significant causes of Fecal egg count revealed strongyle (30,100 epg), mortality in sheep and goats (Nor-Azlina et al., 2011). Strongyloides (800 epg) and coccidia (750 opg). The Prevention and control of worms in sheep and strongyle count was highly significant or this clinical goats depend solidly on anthelminthic drugs and case. chemical dewormers. However, cases of anti- helminthic resistance in small ruminants have been Treatment plan: The therapeutic plan that was carried out for this case were the goat was administered reported due to ease of access and availability to Fercobsang® (4 ml) subcutaneously (SQ) BID, 2 ml Biodly (Crystallized trisodium salt of adenosine anthelmintic drugs which in part is aided by triphospate-0.1g, Vitamin B12 -0.05g, Sodium Selenite government subsidized ruminant health Programme -0.10g, Crystallized potassium aspartate 1.00g and Crystallized magnesium aspartate-1.50g) Grovet, (Nor-Azlina et al., 2011; Jesse et al., 2017a). This has led Netherlands, SQ, every other day (EOD) to improve the animal’s blood profile, Levamisole (2.5 ml/10 kg) to the emergence and widespread dissemination of of 1.9 ml per os (PO) on the second day was nematode parasite that are resistant to anthelminthic administered to treat PGE parasite infestation. Lactated ringers’ solution (140 ml) was also drugs. Effective control of parasitic gastroenteritis in administered to correct the 5% dehydration, Propylene glycol 10 ml, PO and Mollases 10 ml, PO were also ruminants is a multidisciplinary approach that administered twice daily to provide immediate sources includes the combination of chemotherapy, biological of energy. The goat however died on the second day after treatment was instituted due to grave prognosis control, grazing management, worm vaccination and and postmortem examination was performed. The farmer was then advised to improve the overall herd genetic resistance of the host. Additionally, having a health program in the farm particularly the more comprehensive understanding of the deworming program and regular screening for worm burden. Pasture management and correct nutrition epidemiology of the parasites and its interaction with supplementation to all the animals in the farm were advocated to avoid malnutrition. the host in a specific management, production and climatic environment provides a more rational and sustainable control of nematodes causing parasitic gastroenteritis. Furthermore, control measures also require understanding of the seasonal larval availability, factors that enhances hatchability of the parasites eggs, larva development and survivability as well as the origin of the larval stages (Bukhari and Sanyal, 2011; Nor-Azlina et al., 2011; Ardo and Bitrus, 2015). This case report will discuss the possible causes and way forward towards PGE cases clinical in small ruminants. Postmortem findings: Systematic postmortem examination of the carcass was carried out to ascertain Clinical Description the actual cause of death. The procedure involved visual examination, palpation and incision of vital A four-month-old semi-intensively raised, male Boer cross goat weighing 7.5 kg with a body condition visceral organs such as the liver, lungs, kidney, score of 1.5/5 was presented to the large animal ward intestinal, and mesenteric lymph nodes. The of the University Veterinary Hospital (UVH), postmortem examination of the thorax showed

Jesse F.F.A. et al. / Thai J Vet Med. 2019. 49(3): 295-299. 297 multifocal dark discoloration on the left cranial lobe of bladder and enlargement of the mesenteric lymph the lung and exudation of serosanguinous fluid upon nodes. The cause of death that can be concluded in this incision of the lung tissue. Slight yellowish case are the goat died due to hypovolemic shock due discoloration of the aorta and fibrin deposition was to circulatory failure due to anemia and observed on the pericardial sac. Examination of the hypoalbuminemia due to PGE infection and abdominal cavity revealed multifocal hyperemic malnutrition. segments in the small intestine, a distended gall Table 1 Complete blood count (CBC) and serum biochemistry profiles Parameters Units Results Reference value Packed cell volume (PCV) L/L 9% 22-38% 80-120 Hemoglobin g/L 28.7 8-18 16-25 Erythrocytes X 1012/L 6.34 300-360 4-13 MCV f/L 16 0.00 1.2-7.2 MCHC g/L 287 <0.55 0.05-0.65 Leucocytes X 109/L 14.6 60-75 2.7-4.7 Band neutrophils X 109/L 0.15 55-70 90-200 Segmented neutrophils X 109/L 9.49 25-35 35-45 Monocytes X 109/L 0.88 Eosinophils X 109/L 0 Plasma protein g/L 48 Glucose mmol/L 0.7 Total protein g/L 57.1 Alkaline phosphatase U/L 25 Albumin g/L 23 Globulin g/L 34.1 MCV=Mean corpuscular volume, MCHC=Mean Corpuscular Hemoglobin Concentration Figure 1 Gross photographs of the carcass showing serous atrophy of the omentum (A), hyperemic segments in the small intestine (B) areas of red hepatization (consolidation) on the left cranial and caudal lung lobes (C) hyperemic trachea, hepatomegaly with areas of pericardial ecchymotic hemorrhages and swollen kidneys (D). Discussion mortality. In this case report, the goat was less than 1- year-old and clearly manifested signs of PGE with Parasitic gastroenteritis (PGE) is one of the most bilateral serous nasal discharge and crackle lung important causes of economic losses in small ruminant and cattle production. These losses arise from the sound. According to Chung et al. (2015), stress factors severity of clinical signs such as anemia, diarrhea, such as concurrent diseases and worm burden could anorexia, edema and decreased weight gain (Eysker alter the normal homeostasis of commensals in the and Ploeger 2000). This is particularly important in upper respiratory tract leading to respiratory tract young animals because of lowered immunity that infection which was observed in this case. The results in predisposition to infection and subsequent diagnosis of nematode infection in small ruminants is

298 Jesse F.F.A. et al. / Thai J Vet Med. 2019. 49(3): 295-299. usually based on the fecal egg, larvae or total parasite practice of an effective herd health program that count using flotation method such as McMaster include parasite control program which is focused at chamber or Larval culture, serology and PCR detection prevention rather than treatment. It is important to (Roeber et al., 2013; Jesse et al., 2017b). In this clinical note that treating goats after heavy worm infestation case report, McMaster chamber was employed for produce little results on the overall welfare of the parasite fecal egg detection and high worm burden animals and the prospect of minimizing environmental was observed. Effective diagnosis of the various forms contamination is low. This could partly explain why of parasitic gastroenteritis in young small ruminants the goat in this clinical case report died even after encompasses the integration of clinical history of the instituting treatment regime. Therefore, to avoid such farms and animals as well as the clinical signs of poor losses by farmers, adult goats should be treated with body condition, reduced weight gain and anorexia. anthelminthic every two to three months while Other factors that are pertinent to arriving at good deworming of kids should be carried out immediately diagnosis of this condition include grazing history, after weaning and repeated 21 days after the initial season, age of the animal and the use of anthelminthic dose has been administered (Shahudin et al., 2018). agents. This is consistent with the approach utilized in the management of this clinical case report. The goat Conclusion reported in this clinical case report was young and farm records showed that its vaccination and This clinical case reported the management of a deworming statuses were not up-to-date. severe case of parasitic gastroenteritis in a goat. The Additionally, the goat manifested clinical signs of blood profile of the animal showed significant severe diarrhea and anemia, which are characteristics alteration in the hematology and serum biochemistry of PGE. due to the parasitic infection which was evident from the fecal egg count. The cause of death can be Importantly, administration of anthelminthic attributed to hypovolemic shock due to anemia should be given priority whenever a case of resultant from the severe PGE infection concurrent gastroenteritis is suspected. This is because, with malnutrition. In conclusion, strict and consistent eliminating the underlying cause of the condition is application of holistic herd health program (HHP) in important in achieving a good prognosis. In this case, livestock will avoid negative condition towards these levamisole and ivermectin were administered to the animals and will uplift the welfare of the livestock goat to take care of both internal and external parasites. animals. The goat was also administered blood tonics, antibiotics and other supplements to improve its Acknowledgements overall welfare. The authors wish to that the staff of the large Even though the goat died while treatment was on- animal ward of the University Veterinary Hospital going, the farmer was advised on the practice of good (UVH), Universiti Putra Malaysia for their technical management practice with emphasis on improving assistance during the time of handling this case. grazing pattern and nutrition of the other animals in the farms. This is consistent with the findings of Knox References et al. (2006) and Sykes & Coop, (2001) where the authors reported a correlation between resilience of Abdullah JFF, Chung ELT, Sabrina L, Abba Y, Sadiq animals to parasite infestation and improvement in MA, Mohammed K, Hambali IU, Bitrus AA, Haron their overall nutrition. Additionally, it was observed AW and Mohd Lila MA 2016. Clinical Case of that animals placed on nutritious diet can withstand Severe Anaemia in a Sheep Due to Parasitic the stress of worm burden in comparison to those on Gastroenteritis (PGE) Infection Concurrent with low plain ration. In this case, analysis of the blood Eperythrozoonosis. Livest. res. Int. 4(2): 75-78. profile of the goat showed that the animals had anemia in addition to hypoproteinemia and hypoglycemia. Ardo MB and Bitrus I. 2015. Prevalence of parasitic Based on postmortem examination of the carcass, the gastrointestinal nematodes of small ruminants at cause of death can be attributed to hypovolemic shock Jalingo abattoir, Taraba state, Nigeria. Bayero J. P. associated with the anemia that had arisen due to the Sci. 8(2): 29-33. PGE infection and lice infestation. In a study by Jesse et al.(2017b), whole blood transfusion proved to be Bukhari S and Sanyal PK 2011. Epidemiological effective in a sheep with complicated case of PGE. The intelligence for grazing management in strategic success of the transfusion in the study can be attributed control of parasitic gastroenteritis in small to the prompt presentation of the case to the clinic by ruminants in India-A Review. Vet World. 4(2): 92. the client. In this study, the PCV of the goat was 9%, which is critical and incompatible with life. In another Chung ELT, Abdullah FFJ, Abba Y, Tijjani A, Sadiq study by Abdullah et al. (2016), blood transfusion to MA, Mohammed K, Osman AY, Adamu L, Lila ewe with PGE proved to be abortive as the animal died MAM and Haron AW 2015. Clinical management on the 5th day of hospitalization. of pneumonic pasteurellosis in Boer kids: a case report. Int. J. Livest. Res. 5(4): 100-104. Prevention and control of gastrointestinal parasites can also be achieved through vaccination. These Eysker M and Ploeger HW 2000. Value of present vaccines work by identifying hidden protective diagnostic methods for gastrointestinal nematode antigens collected from the cells of the worm’s infections in ruminants. Parasitology. 120(7): 109- intestines (Zvinorova et al., 2016). Because PGE causes 119. severe economic losses, it is important to adopt the Eysker M, Bakker N, Kooyman FNJ and Ploeger HW 2005. The possibilities and limitations of evasive grazing as a control measure for parasitic

Jesse F.F.A. et al. / Thai J Vet Med. 2019. 49(3): 295-299. 299 gastroenteritis in small ruminants in temperate climates. Vet. Parasitol. 129(1-2): 95-104. Jesse FFA, Abba Y, Peter ID, Bitrus AA, Hambali IU, Jamaluddin NL and Haron AW 2017b. Clinical management of parasitic gastroenteritis (pge) concurrent with mycoplasmosis and orf in sheep. Adv. Ani. Vet. Sci. 5(9): 358-361. Jesse FFA, Hambali IU, Galli MFBT, Abba Y, Bitrus AA, Peter ID, Lila MAM, Haron AW and Muhamad AS 2017a. Clinical management of parasitic gastroenteritis (PGE) concurrent with moderate pneumonia in a goat: a clinical veterinary case report. J. Adv. Vet. Anim. Res. 4(3): 307-310. Knox MR, Torres-Acosta JFJ and Aguilar-Caballero AJ 2006. Exploiting the effect of dietary supplementation of small ruminants on resilience and resistance against gastrointestinal nematodes. Vet. Parasitol. 139(4): 385-393. Nor-Azlina AA, Sani RA and Ariff OM 2011. Management practices affecting helminthiasis in goats. Pertanika J. Trop. Agric. Sci. 34(2): 295-301. Roeber F, Jex AR and Gasser RB 2013. Impact of gastrointestinal parasitic nematodes of sheep, and the role of advanced molecular tools for exploring epidemiology and drug resistance-an Australian perspective. Parasit. Vectors. 6(1): 153. Shahudin MS, Ghani AAA, Zamri-Saad M, Zuki AB, Abdullah FFJ, Wahid H and Hassim H A 2018. The Necessity of a Herd Health Management Programme for Dairy Goat Farms in Malaysia. Pertanika J. Trop. Agric. Sci. 41(1):1-18. Sultan, K., Elmonir, W. and Hegazy, Y., 2016. Gastrointestinal parasites of sheep in Kafrelsheikh governorate, Egypt: Prevalence, control and public health implications. Beni-Suef University J. Basic Appl. Sci. 5(1): 79-84. Sykes AR and Coop RL 2001. Interactions between nutrition and gastrointestinal parasitism in sheep. New Zeal. Vet. J. 49(6): 222-226. Zvinorova PI, Halimani TE, Muchadeyi FC, Matika O, Riggio V and Dzama K 2016. Breeding for resistance to gastrointestinal nematodes–the potential in low-input/output small ruminant production systems. Vet. Parasitol. 225: 19-28.



Boonwittaya N. et al. / Thai J Vet Med. 2019. 49(3): 301-308. 303 Case Report Rare form of gastrointestinal intussusceptions: Report of two challenging canine cases Nithida Boonwittaya1* Piyathida Ardaum1 Sunee Kunakornsawat2 Kannika Siripattarapravat3 Veerada Wachirodom4 Abstract A 6-year-old crossbred dog and a 10-year-old Shih Tzu were presented with vomiting and were both diagnosed with intussusception in the gastroduodenal part via an ultrasonographic finding. In the first case, invagination of the pylorus, proximal duodenum and a segment of the right pancreatic limb into the gastric body were found following a laparotomy as a duodenogastric intussusception, whereas in the second case, the pyloric antrum was prolapsed into the proximal duodenum as a gastroduodenal intussusception. A manual reduction and a duodenopexy were performed in both cases. The tumor was excised from the proximal duodenum in the second case and the histopathological result was consistent with adenocarcinoma. Both cases made complete recoveries without the recurrence of intussusception within 24 months and 15 months, respectively, of the follow-up processes. While the first case continued well, recurrence and the metastasis of the intestinal tumor were addressed with a second round of surgery in the second case and the dog was euthanized. This report describes the unique case of canine duodenogastric intussusception with a pancreatic involvement and it is the first report of a canine gastroduodenal intussusception with an associated intestinal tumor in the veterinary literature, with surgical treatment being accomplished in both cases. Keywords: dog, duodenogastric intussusception, gastroduodenal intussusception, intestinal tumor, pancreas 1Surgery Unit, Kasetsart University Veterinary Teaching Hospital, Faculty of Veterinary Medicine, Kasetsart University, Phahon Yothin Road, Chatuchak, Bangkok 10900, Thailand 2Department of Companion Animals Clinical Sciences, Faculty of Veterinary Medicine, Kasetsart University, Phahon Yothin Road, Chatuchak, Bangkok 10900, Thailand 3Department of Pathology, Faculty of Veterinary Medicine, Kasetsart University, Phahon Yothin Road, Chatuchak, Bangkok 10900, Thailand 4Endocrine and Gastroenterology Center, Kasetsart University Veterinary Teaching Hospital, Faculty of Veterinary Medicine, Kasetsart University, Phahon Yothin Road, Chatuchak, Bangkok 10900, Thailand *Correspondence: [email protected] (N. Boonwittaya) Thai J Vet Med. 2019. 49(3): 301-308.

302 Boonwittaya N. et al. / Thai J Vet Med. 2019. 49(3): 301-308. Introduction surrounding mesentery into the dilated, fluid-filled gastric body (Figure 1). Multiple concentric Intussusception is uncommon in adult dogs hyperechoic and hypoechoic rings were presented. The clinically and upper gastrointestinal involvement is an extremely rare (Barreau, 2008; Ragni and Moore, 2012). gastric wall had severe thickening and a hypoechoic While there have been many medical reports region was detected with suspected severe edema. No indicating that the lead points of human upper ultrasonographic evidence of pancreatitis was noted. A intussusception are usually both benign and malignant diagnosis of duodenogastric intussusception was gastroduodenal tumors (Behrooz and Cleasby, 2018; made and abdominal exploration was elected to Chahla et al., 2014; Gyedu et al., 2011; Prakash et al., 2016; Rittenhouse et al., 2013; Sankaranunni et al., 2001; confirm the initial diagnosis and to provide treatment. Vinces et al., 2005; Yildiz et al., 2016), the predisposing A duoneogastric intussusception was presented factors have been variable in canine cases. Gastrointestinal outflow obstruction is the most with the pylorus, proximal duodenum and right limb common sequential event which exhibits as a clinical of the pancreas invaginated into the gastric body sign. Because of its rarity, the treatment for this (Figure 2). Other abnormalities were not found. problem cannot be guided by formal information in veterinary medicine. The outcomes are variable Manual traction was placed gently on the duodenal depending on the severity of vascular compromise, portion adjacent to the intussusception while the abdominal organ association and the underlying cause. gastric body was milked at the tip of the However, about one-half of the previous canine upper intussusceptum. Following reduction, the intussusception cases involved death postoperatively intussuscepted organs were examined, indicating that or euthanization (Bowersox et al., 1991; Lee et al., 2005; Lideo et al., 2010; Marks, 1983; Watson, 1997). To date, the pyloric wall had thickened and the intussuscepted only two cases of pancreatic involvement in pancreatic segment was congested. The stomach was duodenogastric intussusception (Allman and Pastori, examined externally using digital palpation on the 2013; Bowersox et al., 1991) and one case of non- serosa wall. A small, incisional, full-thickness pyloric tumorous gastroduodenal intussusception (Watson, biopsy was performed on the thickened region. A digit 1997) have been reported in the veterinary literature. With the rarity and poor prognosis of upper was inserted inside to examine the mucosa and to intussusception in dogs, the current study aimed to evaluate the gastroduodenal outflow tract. No polyp report the challenging case of duodenogastric was found within the stomach. The intussuscepted intussusception with a prolapsing pancreas and also to portion and the thickened wall did not compromise the discuss the first case report of gastroduodenal outflow. The incisional area was closed with 3-0 intussusception with a duodenal tumor, both being managed using surgical treatment. The outcomes are polydioxanone in a simple interrupted pattern. A discussed in terms of treatment and recurrent duodenopexy was performed with a 3 cm incision in prevention. the seromuscular layer of the antimesenteric border of the proximal duodenum at 3 cm caudal to the Clinical Description intussuscepted portion and a 3 cm incision was made Case 1 on the musculo-peritoneum of the right dorsolateral A 6-year-old intact female crossbred dog was abdominal wall. Both incisional lines were sutured to each other using a simple continuous pattern with 3-0 presented at the emergency unit of the Kasetsart polydioxanone. The abdominal cavity was aseptically University Veterinary Teaching Hospital (KUVTH), irrigated with warm isotonic saline solution and closed Bangkhen campus, Thailand with a 5-day history of severe vomiting and anorexia. Despite normal in a routine fashion. abdominal ultrasonography, serum biochemistries The dog recovered well and admission was were noted of remarkable elevations in blood urea nitrogen and creatinine in the referral information. continued with the treatment of the concurrent disease. IV fluid was applied. Postoperative analgesia was On physical examination, the dog was clinically provided using 0.3 mg/kg morphine (morphine lethargic with abdominal pain on palpation from the cranial-to-mid region. Diagnoses of acute pancreatitis sulfate, M & H Manufacturing Co., Ltd., Thailand) SQ and chronic kidney disease were made based on the every 4 hours for the first two days. This was followed laboratory results of complete blood count, serum by 5 mg/kg tramadol (Trosic, General Drugs House biochemistry, venous blood gas, urinalysis and canine Co., Ltd., Thailand) IV every 12 hours with 100 mg/kg pancreatic lipase immunoactivity testing (SNAP gabapentin (Vultin, Unison Laboratories, Co., Ltd., cPLTM test kit). Thailand) orally every 12 hours. The empiric Supportive therapy was provided. The dog was antimicrobial treatment was administered using a admitted to the critical care unit to receive continuing combination of metronidazole (Metrolex®, Siam treatment and stabilization on the day following Bheasach Co., Ltd., Thailand) IV 15 mg/kg every 12 presentation. During the 48 hours of monitoring, the hours and imipenem-cilastatin (Sianem, Siam vital signs were stable but severe vomiting still Pharmaceutical Co., Ltd., Thailand) IV 5mg/kg every occurred after meals. Repeated abdominal ultrasonography was performed identifying the 8 hours. The injectable metronidazole was invagination of the proximal duodenum and discontinued after 3 days and replaced with a metronidazole tablet 15 mg/kg orally every 12 hours. The dog was also given hyoscine (hyoscine-N- butylbromide, GPO, Thailand) IV 0.5 mg/kg every 12 hours, ondansetron (Onsia, Siam Pharmaceutical Co., Ltd., Thailand) IV 0.5 mg/kg every 12 hours, omeprazole (Solcer, Mylan Laboratories, Ltd., India) IV 1 mg/kg every 24 hours, meropitant (Cerenia, Zoetis, Belgium) SC 1 mg/kg every 24 hours and sucralfate (UlsanicTM, Siam Bheasach Co., Ltd., Thailand) PO 50

Boonwittaya N. et al. / Thai J Vet Med. 2019. 49(3): 301-308. 303 mg/kg every 8 hours. divided into four meals per day then gradually A small amount of water was offered 12 hours after increased in volume daily. The dog’s normal diet including cooked skinless chicken and boiled egg was surgery and followed by multiple small amounts of a slowly reintroduced combined with the prescription low-fat diet component food 12 hours later, which the diet at four days postoperative. No vomiting occurred volume was calculated based on the caloric density. At and soft stool defecation was noted during post- commencement, the food was introduced with one- operative hospitalization. third of the resting energy requirement (RER) and Figure 1 Transverse (A) and longitudinal (B) ultrasonographic images of gastroduodenal portion of a 6 year-old intact female crossbred dog with severe vomiting (case 1), demonstrating multiple concentric hyperechoic and hypoechoic rings in the gastroduodenal portion and the proximal duodenum and surrounding mesentery (X marker) prolapsed into the gastric body (asterisk). Figure 2 Intraoperative view of the duodenogastric intussusception in case 1. (A) Pylorus, proximal duodenum and right limb of pancreas invaginated into the stomach. (B) Manual reduction performed. (C) Duodenopexy at the right dorsolateral abdominal wall. The asterisk indicates the stomach and the D marker indicates the remaining duodenal portion external to the intussusception. Thai J Vet Med. 2019. 49(3): 301-308.

304 Boonwittaya N. et al. / Thai J Vet Med. 2019. 49(3): 301-308. Histopathological examination revealed hours of treatment. Abdominal ultrasonography was performed on the next day. A mass was found at the edematous of the pyloric submucosa. no evidence of a gastric antrum and showed multiple layers of the tumor was found. The dog was discharged in an gastrointestinal wall inside, which was possibly an intussusception (Figure 3). The gastric wall was improved state at nine days after surgery. The dog has prominent and the pancreas was swollen with heterogenous hyperechoic surrounding fat. been presented for regular follow-up treatment of the On abdominal exploration, a gastroduodenal concurrent disease and to monitor clinical signs. After intussusception was found with the pyloric antrum two years of follow-up, the dog has shown no displacing into the proximal duodenum (Figure 4). There was also distal common bile duct dilatation symptoms of a recurrence. secondary to the gastroduodenal outflow obstruction. The reduction was done manually. The survey Case 2 A 10-year-old intact male Shih Tzu was presented examination was performed and a ~3 cm intraluminal mass was found on the antimesenteric side of the to KUVTH for evaluation after A 1-month history of proximal duodenum. The dog underwent mass excision with resection of the affected intestinal wall. anorexia and intermittent vomiting. A small volume of The tissue was submitted for histopathological vomitus was presented about twice a day intermixed with episodic normal clinical signs. evaluation and the proximal duodenum was closed transversely with 4-0 polydioxanone in a simple On physical examination, the dog was moderately interrupted pattern. A duodenopexy was performed to dehydrated and was tense upon abdominal palpation. the right dorsolateral abdominal wall using a similar procedure to that in case 1 above. The pancreatic Based on laboratory studies of complete blood count, serum biochemistry and venous blood gas, blood parenchyma was firm and a biopsy was also taken. The glucose concentration, urinalysis and the coagulation rest of the exploratory examination was within normal profile, abnormalities were noted of leukocytosis with limits. The abdominal cavity was aseptically irrigated toxic neutrophils, increased alanine transaminase, using warm isotonic saline solution and closed in a routine fashion. increased alkaline phosphatase, and mild prolongation of PT and TT. Supportive treatment was provided using intravenous fluid therapy to correct the hydration and to maintain the fluid status. Antiemetic drugs were administered. The electrolyte and acid-base status were monitored. Vomiting did not occur during the 24 Figure 3 Transverse (A) and longitudinal (B) ultrasonographic images of gastroduodenal portion of a 10 year-old intact male Shih Tzu with intermittent vomiting (case 2), indicating a large soft tissue mass located in the pyloric region and multiple concentric hyperechoic and hypoechoic lines identified in both views of the gastroduodenal portion. The dog recovered uneventfully from the surgery. Pharmaceutical Co., Ltd., Thailand) IV 5 mg/kg every IV fluid was continued and postoperative analgesia 8 hours. The injectable metronidazole was was provided using 0.2 mg/kg morphine (morphine discontinued after 2 days and replaced with a sulfate, M & H Manufacturing Co., Ltd., Thailand) SQ metronidazole tablet 20 mg/kg orally every 12 hours. every 4 hours in the first day. This was followed by 5 The dog was also given hyoscine (hyoscine-N- mg/kg tramadol (Trosic, General Drugs House Co., butylbromide, GPO, Thailand) IV 0.5 mg/kg every 12 Ltd., Thailand) SC every 8 hours. The empiric hours during the 72 hours after surgery. antimicrobial treatment was administered using a combination of metronidazole (Metrolex®, Siam Twelve hours after surgery, a small amount of Bheasach Co., Ltd., Thailand) IV 20 mg/kg every 12 water was offered and followed by a brand diet with one-third of RER 12 hours after. The food was divided hours and imipenem-cilastatin (Sianem, Siam into four meals per day and was gradually increased in volume daily.

Boonwittaya N. et al. / Thai J Vet Med. 2019. 49(3): 305 However, during the postoperative period the dog mucosal layers (Figure 5). The pancreatic biopsy developed worsening anemia requiring a blood showed hemorrhagic foci at the periphery of the transfusion; vomiting was not observed during pancreas and moderate-to-locally-extensive chronic admission and the animal was discharged in improved necrotizing pyogranulomatous cellulitis of adipose condition on day 12. tissue. The histopathological findings revealed duodenal adenocarcinoma with the tumor cells only invading Figure 4 Intraoperative view of the gastroduodenal intussusception in case 2. (A) Pylorus invaginated into the proximal duodenum (D marker). The asterisk indicates the body of the stomach. (B) Intraluminal mass (arrowhead) on the antimesenteric side of the proximal duodenum (D marker). Figure 5 Photomicrograph of a section of the duodenal mass in case 2, revealing atypical hyperplastic epithelial cells arranged in tubules with papillary projection toward the luminal center. These mucosal layers are lined by single-to-multiple layers of atypical epithelial cells. Some normal epithelial cells were noted adjacent to cancerous cells. Tumor cells had a high n/c ratio, scant cytoplasm and a large vesicular nucleus with prominent nucleolus with moderate hyperchromasia, anisocytosis, and anisokaryosis. The mitotic figure was approximately 3/hpf. Tumor cells only invaded mucosal layers. Infiltration of lymphocytes and plasma cells was noted in lamina propria. Taken together, this tumor was characterized as a duodenal adenocarcinoma, tubulopapillary type with T1NxMx. H&E stain; bar = 50 m. Thai J Vet Med. 2019. 49(3): 301-308.

306 Boonwittaya N. et al. / Thai J Vet Med. 2019. 49(3): 301-308. Over the following period, the dog’s clinical study. However, in humans, computed tomography condition improved without any recurrent evidence of has been used for entire, comprehensive abdominal the gastroduodenal intussusception. Abdominal screening and has revealed the relationships among ultrasonography was provided routinely for monitoring. Fifteen months after surgery, the dog had the other organs in upper intussusception cases intermittent vomiting. Abdominal ultrasonography (Behrooz and Cleasby, 2018; Chahla et al., 2014; and a CT scan indicated an enhanced mass at the Prakash et al., 2016; Rittenhouse et al., 2013; Vinces et proximal duodenum where it had been previously al., 2005; Yildiz et al., 2016). Endoscopy was one of the removed and the recurrence of intestinal choices for diagnosis and treatment in previous reports adenocarcinoma was suspected. A second abdominal exploratory incision was performed revealing in both dogs and humans. This allows the evaluation metastases on the duodenal loop extending to the of intraluminal gross appearances, the collection of pyloric antrum with the common bile duct and hepatic specimens and noninvasive reduction from the inside duct dilatation due to severe biliary obstruction. The area (Allman and Pastori, 2013; Chahla et al., 2014; de pancreas was firm and congestion suggested tumor Brito Galvao et al., 2011; Prakash et al., 2016; Vinces et metastases. With the owner’s consent, the dog was eventually euthanized. al., 2005; White et al., 1991). If these procedures have been or are unlikely to be accomplished, surgical Discussion intervention should be considered for patients with severe outflow obstruction. In dogs, intussusceptions frequently occur in the young age group, being located in the jejunum, Canine GDI/DGI have only been noted in case proximal ilium and ileocecal junction (Barreau, 2008; Ragni and Moore, 2012). Adult canine intussusception reports in the veterinary literature. With the reported is uncommon and intussusception at a gastroduodenal variable outcomes, it is difficult to recommend suitable region is extremely rare. Duodenogastric treatment and prognosis. There have been two cases of intussusception (DGI) is a retrograde invagination of pancreatic involvement in DGI (Allman and Pastori, the duodenal segment into the gastric body while 2013; Bowersox et al., 1991) and one of them was gastroduodenal intussusception (GDI) is a normograde type. Unlike in humans, etiologies of euthanatized due to subsequent abdominal soft tissue adult canine upper gastrointestinal intussuceptions are trauma with severe necrosis (Bowersox et al., 1991). variable regarding non-tumor factors including dietary Furthermore, only one case of GDI has been published indiscretion and foreign bodies (Allman and Pastori, to date which was also euthanatized perioperatively 2013; Applewhite et al., 2001; Bowersox et al., 1991; because of a duodenal perforation under manipulation Marks, 1983). Some are due to unknown causes (Choi et al., 2012; de Brito Galvao et al., 2011; Lideo et al., and a critical fragile necrotic area (Watson, 1997). Other 2010). In addition, other concurrent diseases associated reports of upper intussusceptions have also shown a with severe gastroenteritis have been advocated as high rate of poor prognosis with 40% mortality predisposing factors (Huml et al., 1992; Lee et al., 2005; including severe conditions such as abdominal tissue Watson, 1997). The precise etiology has been unclear necrosis, electrolyte imbalances, uncontrolled due to the low number of reported cases. Our first case shared similarities with previous reports in the cardiovascular status and suffering from an predisposing factor. Chronic renal failure and underlying disease which contributed to death or pancreatitis cause severe vomiting due to gastritis and being euthanized (Lee et al., 2005; Lideo et al., 2010; the release of inflammatory mediators which are the Marks, 1983). Conversely, some cases reported lead points. However, there was an important spontaneous reduction within the treatment period difference with regard to the tumorous lesions in the second case for which there have been no previous (Choi et al., 2012; Lee et al., 2005). reports in the veterinary field. We suggest a A few treatment options have been applied for pathophysiological mechanism of the etiology that may lead to the upper intussusception, in which any treating DGI/GDI. In our cases, the choice of surgery conditions that alter the normal gastrointestinal was influenced by prior information from the imaging motility or outflow could be a contributing factor and and clinical findings that included expanding the aggravate the severity of this problem. investigation to any associated abdominal organs. Of The symptoms are not disease-specific but most of concern was that pancreatic prolapsing was found them, including those in the current report, presented perioperatively in case 1. It was presumed to have with similar obstructive signs such as severe vomiting, compromised the pancreatic duct outflow and led to abdominal pain and anorexia (Allman and Pastori, pancreatitis. Moreover, not undertaking any treatment 2013; Applewhite et al., 2001; Bowersox et al., 1991; Choi et al., 2012; de Brito Galvao et al., 2011; Huml et al., 1992; carries a high risk of severe inflammation and necrotic Lee et al., 2005; Lideo et al., 2010; Marks, 1983; Watson, progression in the surrounding abdominal organs, 1997). Abdominal ultrasound was valuable in resulting in life-threatening conditions. Manual identifying the location, reaching a diagnosis and reduction was successful in our cases due to early providing adequate details for an effective treatment detection and there being less vascular compromise. plan as was performed in the two cases in the current Some cases performed a gastrotomy to facilitate the reduction (Applewhite et al., 2001; Choi et al., 2012; Huml et al., 1992; Marks, 1983) and a partial gastrectomy was provided for the necrotic area in one case (Choi et al., 2012). For better outcomes, after initial stabilization, emergency surgery should be followed for every intussusception of the upper gastrointestinal tract that causes severe outflow obstruction. Although there are no reported cases of recurrent GDI/DGI without surgical treatment in veterinary literatures (Choi et al., 2012; de Brito Galvao et al., 2011; Lee et al., 2005) and complications of gastrointestinal

Boonwittaya N. et al. / Thai J Vet Med. 2019. 49(3): 307 tract plications should be of concern, duodenopexy than a year. Thus, in considering the appropriate was recommended in our two cases. This decision was surgical procedures regarding a proximal duodenal based on the concurrent problems of chronic renal tumor in each case, the surgeon should weigh up the disease with pancreatitis in case 1 and a future benefits against possible complications. gastrointestinal tumor in case 2, in which vomiting Hydration, electrolyte, and acid-base abnormalities occurred. Severe vomiting is the identifiable condition should be corrected and monitored in both and the predisposing factor in terms of both the preoperative and postoperative treatment. primary cause and the expectable cause of recurrent evidence of intussusception. In addition, with the The recurrence of clinical signs in case 2 occurred unknown duodenal mass at the time of the first 15 months after the first surgery, which was at the exploration in case 2, the recurrence of that tumor upper end of the survival time previously reported of could act as a lead point for future recurrent 3-15 months following surgical treatment. The median intussusception. With these unpredictable survival time of intestinal adenocarcinoma is 12 days postoperative outcomes, plication of the duodenum in untreated dogs. Most previously cases reported was expected as a prophylactic treatment. either a recurrence or metastasis, with 40% of cases reporting metastasis at the time of diagnostic Case 2 is the first report of an upper gastrointestinal exploration. The 1 year survival rate was 20% and intussusception associated with a gastrointestinal 66.7% with and without lymph node metastasis, tumor in the veterinary literature. Conversely, in respectively (Birchard et al., 1986; Crawshaw et al., humans, there have been many reports of upper 1998; Selting, 2012). Similarly, the prognosis of gastric intussusception (in which the majority of cases were adenocarcinoma was not good in the long-term results caused by gastric tumors) and many reports of with survival of only up to 8 months in surgically pancreatitis with GDI induced by gastrointestinal treated dogs and less than 3 months without treatment obstruction due to a pedunculated lesion of the lumen (Swann and Holt, 2002). In the second exploratory in (Behrooz and Cleasby, 2018; Chahla et al., 2014; Gyedu case 2, complete excisions were considered, including et al., 2011; Prakash et al., 2016; Rittenhouse et al., 2013; a partial gastrectomy with pylorectomy, resection of Sankaranunni et al., 2001; White et al., 1991; Vinces et the proximal duodenum and a total pancreatectomy, al., 2005; Yildiz et al., 2016). Evidence was obtained followed by gastrojejunostomy and from biopsy in our two cases from the questionable cholecystojejunostomy. The dog was euthanized area perioperatively. In case 2, the tumorous lesion was because of the high mortality and mobility rates of found arising from the mucosa of the proximal these risky surgical procedures with the assumed poor duodenum and expanding to the intraluminal area. prognosis based on the type of tumorous metastases. The histopathological result was adenocarcinoma. This could cause a mechanical outlet obstruction and In conclusion, we presented two cases of rare compromise normal peristalsis where the canine upper intussusception; one involving DGI with intussusception was induced. In addition, the pancreatic invagination and the other one being the intussusception might have been a result of severe first report of canine GDI occurring with intestinal vomiting from acute pancreatitis with the mass causing malignant neoplasm in the veterinary field. Both cases compression of the common bile duct and the were treated successfully using surgery. Thus, pancreatic ducts at the duodenal papillae. duodenogastric and gastroduodenal intussusception should be listed as differential diagnoses in any ages of Adenocarcinoma is one of the most common dogs with a clinical finding of upper gastrointestinal intestinal malignancies leading to intussusception in obstruction. Regardless, either pancreatic involvement middle-to-old-aged dogs and originates in both small or a gastrointestinal tumor should be included in the intestine and large intestine. Furthermore, a pyloric investigation. Rapid identification and treatment are antrum is a common occurrence with this type of necessary to achieve remarkable success. tumor. Gastrointestinal adenocarcinoma tends to invade locally with slow progression. The clinical signs Acknowledgements are not specific depending on the size of the mass, the location, the metastases and the associated organs. The authors express appreciation to Saroch Accordingly, most of the cases are asymptomatic in the Kaewmanee, DVM, PhD, for assistance in improving early stage and the tumors are only detected when an this manuscript. The ultrasonography and CT scan outflow obstruction occurs. Abdominal radiography, results were interpreted by Piyatip Choochalermporn, contrast radiography, ultrasonography, CT scanning, DVM, and Theethad Tangpakornsak, DVM, from the endoscopy and laparoscopy can provide details of the Kasetsart Veterinary Imaging and Radiotherapy tumor, the metastases and assist in sample collection Center, Kasetsart University Veterinary Teaching (Culp et al., 2012; Frgelecová et al., 2013; Head et al., Hospital, Bangkok, Thailand. 2002; Paoloni et al., 2002; Selting, 2012; Swann and Holt, 2002; Withrow, 2007). References In case 2, the local resection of the duodenal tumor Allman DA and Pastori MP 2013. Duodenogastric was attempted over a wide excision or via bypass intussusception with concurrent gastric foreign procedures due to the consideration of postoperative body in a dog: a case report and literature review. J complications, the current condition and the Am Anim Hosp Assoc. 49(1): 64-69. intussusception. With a questionable outcome, the likelihood high of morbidity was a concern in this case Applewhite AA, Cornell KK, Selcer BA 2001. peri-to-post operatively. Clinical improvement was Pylorogastric intussusception in the dog: a case noted in the postoperative follow-up period for more report and literature review. J Am Anim Hosp Assoc. 37(3): 238-243. Thai J Vet Med. 2019. 49(3): 301-308.

3068 Boonwittaya N. et al. / Thai J Vet Med. 2019. 49(3): 301-308. 5B92ar1rtreeaautmPent.20I0n8:. Intussusception: diagnosis and 12 dogs with intestinal adenocarcinoma. Vet Radiol Proceedings 33rd WSAVA & 14th Ultrasound. 43(6): 562-567. FECAVA 2008. WSAVA Congress. Dublin Ireland. Prakash M, Pavunesan SK, Sharma V, Mangat PS and 614. Khandelwal N 2016. Gastro-gastric and gastro- Behrooz A and Cleasby M 2018. “Gastrogastric duodenal intussusception with pancreatitis due to intussusception in adults: a case report with review GIST. Trop Gastroenterol. 37(4): 305-307. of the literature.” [Online]. Available: Radlinsky MG 2013. Surgery of the digestive system. https://doi.org/10.1259/bjrcr.20180006. Accessed In: Small Animal Surgery. 4th ed. TW Fossum (ed). November 23, 2018. St. Louis: Elsevier 521-528. Birchard SJ, Couto CG and Johnson S 1986. Ragni RA and Moore AH 2012. Intussusception. Nonlymphoid intestinal neoplasia in 32 dogs and Companion Anim. 17(1): 13-18. 14 cats. J Am Anim Hosp Assoc. 22: 533-537. Rammohan A, Sathyanesan J, Rajendran K, Bowersox TS, Caywood DD and Hayden DW 1991. Pitchaimuthu A, Perumal SK, Srinivasan UP, Idiopathic, duodenogastric intussusception in an Ramasamy R, Palaniappan R and Govindan M adult dog. J Am Vet Med Assoc. 199(11): 1608-1609. 2013. A gist of gastrointestinal stromal tumors: A Chahla E, Kim MA, Beal BT, Alkaade S, Garrett RW, review. World J Gastrointest Oncol. 5(6): 102-112. Omran L, Ogawa MT and Taylor JR 2014. Rittenhouse DW, Lim PW, Shirley LA and Chojnacki Gastroduodenal intussusception, intermittent KA 2013. Gastroduodenal intussusception of biliary obstruction and biochemical pancreatitis a gastrointestinal stromal tumor (GIST): case due to a gastric hyperplastic polyp. Case Rep report and review of the literature. Surg Laparosc Gastroenterol. 8(3): 371-376. Endosc Percutan Tech. 23(2): 70-73. Choi J, Keh S, Kim T, Jang J, Kim H and Yoon J 2012. Sankaranunni B, Ooi DS, Sircar T, Smith RC and Barry Ultrasonographic findings of pylorogastric J 2001. Gastric lipoma causing gastroduodenal intussusceptions in two dogs. J Vet Sci. 13(2): 215- intussusception. Int J Clin Pract. 55(10): 731-732. 217. Selting KA 2012. Intestinal tumors. In: Small Animal Crawshaw J, Berg J, Sardinas JC, Engler SJ, Rand WM, Clinical Oncology. 5th ed. SJ Withrow and EF Mac- Ogilvie GK, Spodnick GJ, O’Keefe DA, Vail DM Ewen (ed). Philadelphia: WB Saunders Co. 412–423. and Henderson RA 1998. Prognosis for dogs with Swann HM and Holt DE 2002. Canine gastric nonlymphomatous, small intestinal tumors treated adenocarcinoma and leiomyosarcoma: a by surgical excision. J Am Anim Hosp Assoc. 34(6): retrospective study of 21 cases (1986-1999) and 451-456. literature review. J Am Anim Hosp Assoc. Culp WT, Cavanaugh RP, Calfee III EF, Buracco P and 38(2):157-164. Banks TA 2012. Alimentary. In: Veterinary Surgical Vinces FY, Ciacci J, Sperling DC and Epstein S 2005. Oncology ST Kudnig and B Séguin (ed) New Jersey: Gastroduodenal intussusception secondary to a Wiley-Blackwell 179-271. gastric lipoma. Can J Gastroenterol. 19(2): 107-108. de Brito Galvao JF, Johnson SE, Sherding RG, Baan M, Watson PJ 1997. Gastroduodenal intussusception in a Ball RL and Ben-Amotz R 2011. Endoscopic young dog. J Small Anim Prac. 38(4):163-167. diagnosis of a pylorogastric intussusception with White PG, Adams H, Sue-Ling HM and Webster DJ spontaneous resolution. J Am Anim Hosp Assoc. 1991. Case report: gastroduodenal intussusception- 47(6): 156-161. -an unusual cause of pancreatitis. Clin Radiol. Frgelecová L, Škorič M, Fictum P and Husník R 2013. 44(5): 357-358. Canine gastrointestinal tract tumours: a Willard MD 2014. Disorders of the intestinal tract. In: restrospective study of 74 cases. Acta Vet Brno. 82: Small Animal Internal Medicine. 5th ed. RW Nelson 387-392. and CG Couto (ed). St. Louis: Elsevier. 477-483. Gyedu A, Reich SB and Hoyte-Williams PE 2011. Withrow SJ 2007. Gastric cancer. In: Small Animal Gastrointestinal stromal tumor presenting acutely Clinical Oncology. 4thed. SJ Withrow and DM Vail as gastroduodenal intussusception. Acta Chir Belg. (ed). St. Louis: Elsevier 480-483. 111(5): 327-328. Yildiz MS, Doğan A, Koparan IH and Adin ME 2016. Head KW, Else RW and Dubielzig RR 2002. Tumors of Acute pancreatitis and gastroduodenal intussusce the alimentary tract. In: Tumors in Domestic ption induced by an underlying Animals. DJ Meuten (ed). Iowa state: Iowa 451-477. gastric gastrointestinal stromal tumor: A case Huml RA, Konde LJ, Sellon RK and Forrest LJ 1992. report. J Gastric Cancer. 16(1): 54-57. Gastrogastric intussusception in a dog. Vet Radiol Zoran DL 2008. Diseases of the small intestine. In: & Ultras. 3(3):150-153. Handbook of Small Animal Practice. 5th ed. RV Lee H, Yeon S, Lee H, Chang D, Eom K, Yoon J, Choi Morgan (ed). St. Louis: Elsevier 378-381. H and Lee Y 2005. Ultrasonographic diagnosis- pylorogastric intussusceptions in a dog. Vet Radiol Ultrasoun. 46(4): 317-318. Lideo L, Mutinelli F and Milan R 2010. Pylorogastric intussusception in a chihuahua puppy. A case report. J Ultrasound. 13(4): 175-178. Marks DL 1983. Canine pylorogastric intussusception. Vet Med. 78: 677-680. Paoloni MC, Penninck DG and Moore AS 2002. Ultrasonographic and clinicopathologic findings in