In late June of this year Charlie, a 13 year old Shih-tzu presented to us as a referral from Nicola Valley vet clinic in Merrit. Charlie had been diagnosed with a disease called Cushings disease and was visiting us to have an abdominal ultrasound to help further understand the nature of his disease. Cushings disease is a common disease of usually older dogs which can present with symptoms of drinking a lot, peeing a lot, a voracious appetite and sometimes a pot belly and a poor looking hair coat. Poor little Charlie had all of these symptoms as well as his owner was concerned that he was just not feeling well. Dr. Ladyman at Nicola Valley had done a complete work up and had some concerns that Charlie might have a tumor of the adrenal gland. Cushings disease can be caused in two ways, the milder form arises from a tumor of the pituitary gland and the more aggressive form is due to a tumor of the adrenal gland. Both forms can be treated with medication but the adrenal tumor form of Cushings disease is much more difficult to control. We first saw Charlie in order to help decide if he could be well controlled with medication or if he needed a different and more involved treatment plan.
Charlie presented to us a little bit dull and demonstrating most of those symptoms we associate with Cushings disease. On ultrasound we found a very large right adrenal gland which appeared to be either invading the caudal vena cava, (the large vein which brings blood back to the heart,) or the tumor may have been pressing into this large vessel and collapsing it. This obstruction was probably contributing to poor circulation and a big reason why Charlie was not feeling very well. With large tumors of the adrenal gland there is some risk that these may be malignant and there is also risk that they may cause a large blood clot in the vena cava. After a long discussion with Charlie’s very concerned owner we elected to take Charlie to surgery to try and remove this life threatening tumor.
Surgically removing a right adrenal gland is a daunting task. The right adrenal gland sits just in front of right kidney and is nestled under an artery and is immediately adjacent to the vena cava and aorta. Exposure is critical to manage this type of surgery so we had to do a large incision that went both along Charlie’s midline and down behind his ribs to create a large window. With the help of an extra set of hands and a radiosurgery unit which helped control hemorrhage we were able to expose the right adrenal gland. The gland was huge but fortunately was not invading the vena cava and there was no blood clot in the vena cava. Careful dissection and ligation of blood vessels allowed us to eventually remove this unhappy piece of tissue. The body is of remarkably well designed with built in backup systems, and we were counting on the shrunken but otherwise normal left adrenal gland to step up and take charge once the overactive right side was removed. Charlie did well through surgery and woke up in a warm bed and with a lot of pain medication. Over the next few days Charlie showed his true colors as he recovered without so much as a whimper while offering very brave tail wags. The recovery from a major procedure such as an adrenalectomy at Charlies age has its challenges but after a few weeks Charlie was back to normal.
Charlie is a good example of the challenge many of us have in deciding whether to undertake major procedures in our elderly four legged friends. These decisions often are related to major dental issues, orthopedic conditions such as arthritis or ligament tears, and cancerous masses that our geriatric pets may be prone to developing. The decision of whether to operate are based on many criteria including long and short term prognosis, general quality of life, length of recovery, financial considerations and general health and well-being at the time of surgery assessed through history, physical exam and thorough diagnostic testing. We try to work very closely with the patient and their owners to explain the alternatives and help support them through these difficult decisions. As illustrated by Charlie sometimes even a rough and involved road can have a smooth and satisfying finish.