Emphysematous pyometra and emphysematous hepatitis caused by Klebsiella pneumoniae infection in a diabetic dog.

A 14-year-old intact female diabetic dog presented with seizures and hyperglycemic hyperosmolar syndrome. Radiographs revealed gas-filled tubular structures in the right and left caudal abdomen, raising concerns of emphysematous pyometra or small intestinal ileus. Ultrasonography played a pivotal role in confirming emphysematous pyometra, a technique previously documented only once in veterinary practice. This report also presents the first documented case of emphysematous pyometra in a diabetic dog attributed to Klebsiella pneumoniae and complicated by emphysematous hepatitis.

Sonographic features of the uncomplicated postoperative abdomen in dogs treated for pyometra by ovariohysterectomy.

Pyometra is a prevalent disease in intact bitches and the standard treatment is ovariohysterectomy (OHE). Published descriptions of normal sonographic findings after OHE are currently lacking. The aims of this prospective observational study were to describe and compare postoperative abdominal sonographic features for three timepoints following OHE in a group of dogs with pyometra and an uneventful recovery. A total of 22 dogs had sequential focused abdominal ultrasound examinations on days 1, 4-6, and 10-15 postsurgery. Recorded sonographic features for each examination time point and characteristics of the cervical stump and the mesovarium, size, and echogenicity of medial iliac lymph nodes (MILNs), presence of free peritoneal fluid, and pneumoperitoneum. The cervical stump appeared as a heterogenous area with a hypoechoic center surrounded by hyperechogenic tissue in all dogs. The cervical stump transverse-sectional area was larger on day 4-6 compared with day 1 and day 10-15 (P = .0009). Mesovarium ligature reactions were identified as heterogeneous and hyperechoic areas with central and/or edge shadowing in all dogs. The size and echogenicity of MILNs and the mesovarium reactions did not significantly differ among time points. Free peritoneal fluid was detected in 45%, 41%, and 9% and pneumoperitoneum in 95%, 82%, and 14% of dogs at sequential time points. Findings from this sample of dogs with an uneventful recovery following OHE due to pyometra can be used to assist veterinarians in interpreting postoperative abdominal ultrasonographic characteristics in future dogs treated surgically for pyometra.

Idiopathic pyometra in a postmenopausal patient.

Pyometra is a rare gynecological condition most commonly seen in elderly, postmenopausal women. Malignancy should always be considered as the primary etiology until proven otherwise in the investigation of an intrauterine infection. Clinical signs and symptoms can be vague or nonexistent, and thorough investigation with ultrasound and cross-sectional imaging may be necessary to understand the extent of the disease and best course of treatment. We describe a case of idiopathic pyometra in a postmenopausal woman, as well as review the pathophysiology, investigation, and management of pyometra.

A descriptive angiographic study of the uterine arteries during pregnancy, the postpartum period and CEH/pyometra in bitches.

The aim of this descriptive study was to monitor the changes in uterine arteries during pregnancy, postpartum period and pyometra in bitches using angiography. Fifteen uteri of mixed breed bitches on days 24, 30, 33, 40, 43, 47, 50 and 56 of pregnancy and weeks 1, 2, 3, 4 and 7-8 of postpartum and two CEH/pyometra bitches were examined after ovariohysterectomy. The results showed that with the onset of normal pregnancy and in about 30 ± 1 days of gestation, anastomoses begin to form between the left and right middle uterine arteries, developing during the next days and continuing until 4 weeks postpartum. On 4th week after parturition, when physiologic changes occur and the uterus returns to non-pregnant conditions, these anastomoses begin to degenerate, and they completely disappear approximately on the 7th-8th week after parturition. Similarly, in CEH/pyometra bitches, anastomoses were formed between left and right median uterine arteries. These findings can be considered as a part of the physiological changes of the uterus and its vessels during pregnancy and postpartum periods and could affect the results and interpretation of relevant findings.

Clinics in diagnostic imaging (199). Pyometra.

A 92-year-old woman presented to the emergency department with urinary symptoms, fever and suprapubic tenderness. Her inflammatory markers were raised. Urine and blood cultures were negative. Computed tomography performed to look for a source of sepsis showed distension of the uterine cavity with high-attenuation fluid, an air-fluid level and gas locules along the uterine wall. The causes, clinical presentation and imaging features of pyometra are discussed.

A case of obstructed hemivagina and ipsilateral renal anomaly syndrome complicated with pyometra: tips and tricks for laparoscopic hemihysterectomy.

OBJECTIVE: To present a case of obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome complicated with pyometra and explain tips and tricks for laparoscopic hemihysterectomy. DESIGN: A step-by-step explanation of the technique with the use of video (Canadian Task Force Classification III). Patient consent and Institutional Review Board approval were obtained. SETTING: OHVIRA syndrome is characterized by the triad of uterovaginal duplication, obstructed hemivagina, and ipsilateral renal agenesis (1). Patients with OHVIRA syndrome usually present with dysmenorrhea and a vaginal or a pelvic mass. Renal, uterine, and vaginal pathologies can be diagnosed with the use of ultrasonography and magnetic resonance imaging (MRI) (2). In cases in which the diagnosis is not delayed, treatment consists of vaginal septostomy (3). Delayed diagnosis may lead to pelvic infections in patients with microperforations in the septum, which may lead to abscess formation, pelvic inflammatory disease, pyometra, and subsequent need for hemihysterectomy and adnexectomy (4). PATIENT(S): A 21-year-old G2 P2 patient who had a history of hospitalization with the diagnosis of tubo-ovarian abscess three times previously presented to the emergency department with pelvic pain, nausea, high fever, and malodorous vaginal discharge. On physical examination, a pelvic abscess draining to the left vaginal wall and a 10-12-cm left adnexal mass were noticed. A diagnosis of OHVIRA syndrome and pyometra was made after evaluation of ultrasonographic and MRI findings. Longitudinal vaginal septum excision and drainage of the abscess was performed. Ten cubic centimeters of purulent abscess material was drained by incising the left vaginal wall. However, the mass extending from the left vaginal wall to the left adnexal area could not be drained. On hysteroscopy, no cervix was visualized belonging to the obstructed hemivagina and the left uterine cavity could not be entered. On reexamination of the MR images, the presence of a transverse vaginal septum overlying the left hemivagina was detected, preventing access to the left hemiuterine cavity. The transverse vaginal septum could have been excised and the pyometra drained; however, owing to the presence of chronic pelvic pain and dyspareunia, and a history of three failed previous attempts at treatment, the decision to perform hemihysterectomy was made. INTERVENTION(S): A laparoscopic hemihysterectomy was performed in the patient, who was diagnosed as having OHVIRA syndrome complicated with pyometra. Patient consent and Institutional Review Board approval were obtained for this report. MAIN OUTCOME MEASURE(S): On laparoscopy, the left hemiuterus on the same side as the obstructed hemivagina appeared three to four times larger than the normal hemiuterus, in which two pregnancies had occurred, and dense adhesions were present between this hemiuterus and the bowel. The left hemiuterus was densely adherent to the pelvic side wall. Laparoscopic hemihysterectomy was performed. A monofilament barbed suture were used for the repair of the paracervical area and left hemivagina. A transverse septum and cervical atresia was noticed at the distal end of the left hemiuterus. The surgical challenges encountered during treatment of this case were the difficulty in recognizing anatomic structures owing to chronic inflammatory changes, dissecting dense adhesions without injuring neighboring pelvic organs, providing adequate hemostasis during dissection of fragile and hemorrhagic tissues, gaining optimal visualization of the surgical field owing to hampered hemostasis, obtaining adequate exposure of the surgical site owing to the inability to use a uterine manipulator, and the difficulty in dissecting the left hemiuterus without damaging the right hemiuterus for fertility preservation. The ultrasonic scalpel is an energy modality that is known to cause the least amount of collateral thermal tissue damage. In the present case, an ultrasonic scalpel was used to dissect dense adhesions between the left hemiuterus and the urinary bladder to minimize the risk of thermal injury to the urinary bladder. The ultrasonic scalpel was also used when dissecting the unhealthy hemiuterus from the healthy hemiuterus owing to its ergonomic tip and to avoid thermal damage to the cervix of the healthy hemiuterus. In areas of dense adhesions and distorted anatomy, the broad tips of bipolar forceps are also helpful for blunt dissection and the creation of tissue planes, and it is also used for effective concomitant hemostasis. A vessel sealer is the most appropriate energy modality for providing effective hemostasis during dissection of the uterine artery while causing minimal collateral tissue damage (5, 6). When deciding the kind of energy modality to be used during operative laparoscopy, the source that minimized thermal injury while providing optimal hemostasis was preferred. Furthermore, additional features such as rotation, dissection, grasping, and the ergonomics of the tip of the device were also considered when choosing the energy source to be used. RESULT(S): The patient was discharged 48 hours postoperatively with no complications. No symptoms of pelvic pain, dysmenorrhea, and dyspareunia were present at the end of the third month after surgery. CONCLUSION(S): Understanding the exact nature of the uterine anomaly before hemihysterectomy is of paramount importance for a successful surgery. Laparoscopy is a safe and effective treatment modality even in the presence of dense pelvic adhesions and distorted pelvic anatomy.

Uterine two-dimensional and Doppler ultrasonographic evaluation of feline pyometra.

The aim of this study was to compare uterine two-dimensional and Doppler ultrasonographic parameters in queens suffering from pyometra from those in early pregnancy. Secondly, the effect of the presence of clinical signs of systemic illness on these parameters was also described. Fourteen post-oestrous queens, with uterine luminal content in the absence of embryos were included. According to their outcome (pyometra surgery or parturition), the queens were retrospectively assigned to one of the following groups: Pyometra (PYO; n = 7) or pregnant (PRG; n = 7). In all the queens, two-dimensional and Doppler ultrasound examinations of the uterus were performed. The presence or absence of clinical signs of systemic illness was recorded. The widest cross-sectional diameter (UD), uterine wall thickness (WT), uterine lumen contents (LC) and uterine artery resistance index (RI) were measured. Uterine horn diameter was higher in PYO group than in PRG group (p < 0.05), while WT (p > 0.1) and LC (p = 0.09) did not differ between groups. Values of RI for PYO and PRG groups were 0.61 ± 0.03 vs 0.53 ± 0.09 (p < 0.05), respectively. PYO cats suffering from clinical signs of systemic illness showed larger UD than those without signs (p < 0.01). It is concluded that two-dimensional and Doppler ultrasound might be useful to distinguish queens suffering from pyometra from those in early pregnancy. Secondly, the clinical signs of systemic illness were associated with a larger UD.

Radiographic and ultrasonographic findings in a dog with emphysematous pyometra.

BACKGROUND: Emphysematous pyometra is a rare canine disease characterized by gas-forming bacteria infecting the uterus and causing an accumulation of both gas and infectious exudate in the uterine lumen. While radiological features of emphysematous pyometra have been previously described in dogs, the ultrasonographic appearance has not been reported. CASE PRESENTATION: A 7-year-old intact female Labrador Retriever was presented because of a 1 day history of vomiting, anorexia, mild polyuria/polydipsia and signs of fatigue. On physical examination the dog had a swollen vulva with a sparse amount of yellow discharge. Lateral and ventrodorsal radiographs showed a dilated predominantly gas-filled tubular structure located in the mid and cranial abdomen traversing from left to right and ending dorsally at the level of the 12th thoracic vertebra. A small intestinal ileus was initially suspected. Following the radiographic examination, abdominal ultrasound was performed. In the left mid and caudal abdomen there were two thin-walled gas-containing tubular structures. One had the typical layered appearance of an intestinal wall and represented the descending colon. The second structure had a similar thickness but homogenously hypoechoic wall and contained gas and echogenic fluid in the lumen. By use of several positional changes of the dog aiming to alter the location of the intraluminal gas, the second structure was traced to the right ovary cranially and the uterine body caudally, confirming that the structure was the right uterine horn. A final diagnosis of emphysematous pyometra was made. CONCLUSION: Ultrasound can be used as a non-invasive diagnostic method to differentiate between small intestinal ileus and emphysematous pyometra.

Singleton pregnancy with concurrent pyometra in the contralateral horn in a bitch with a live puppy outcome.

A 20-month-old, 48-day pregnant female American Bulldog was presented for intermittent bloody vaginal discharge of 4-day duration. The bitch was clinically healthy with a mild neutrophilia. Transabdominal ultrasound revealed a viable foetus in the left uterine horn and fluid in the right uterine horn. She was treated with amoxicillin/clavulanic acid and re-examined at regular intervals to monitor for deterioration of the bitch or foetus. The uterine fluid progressively decreased in volume, and the puppy remained viable. A Caesarean section was performed on the bitch's expected due date, resulting in a healthy puppy. This is only the second published report of a pregnancy and concurrent pyometra with a live puppy outcome. This case is unique in that the bitch's pyometra resolved grossly during pregnancy.

IMAGING DIAGNOSIS-ENDOMETRIAL MINERALIZATION IN A DOG.

A 9-year-old intact female mixed breed dog was presented for mammary gland tumor surgery, and preoperative radiographs showed a tubular soft tissue opacity mass with multifocal mineralization in the caudoventral abdominal cavity. Subsequent ultrasonography demonstrated uterine dilation with echogenic fluid and endometrial acoustic shadowing consistent with mineralization. Resection of mammary gland tumors and ovariohysterectomy were performed. Pyometra was diagnosed on cytologic examination of uterine fluid. Histopathology of the uterine tissue confirmed a diagnosis of cystic endometrial hyperplasia with uterine mineralization.