Small Intestinal Foreign Body Guide
Key Points
  • Obstruction may be caused by a discrete foreign body (DFB) or a linear foreign body (LFB) and may be partial or complete
  • Common clinical signs include lethargy, anorexia, vomiting and abdominal pain
  • Diagnosis is via abdominal palpation, radiography or ultrasonography
  • Ultrasonography has the highest diagnostic value
  • The decision to proceed to surgery will depend upon many factors including the type of foreign body, the problems associated with the material of the foreign body and the degree of obstruction that it causes.
    Not all small intestinal foreign bodies require surgical intervention
  • Prognosis is good with early appropriate surgery
  • Without prompt appropriate treatment, there is a risk of decreased bowel perfusion and bowel wall necrosis, septic peritonitis and death
  • Increased mortality has been reported for: LFB vs DFB, if multiple enterotomies are performed and with a longer duration of clinical signs
Definition
  • Partial or complete obstruction of the small intestine caused by ingestion of foreign material
  • Partial or complete obstruction of the small intestine caused by ingestion of foreign material
Prevalence
  • Reported prevalence of gastrointestinal foreign bodies in USA hospitals of 26.4 per 10,000 cases (dogs) and 16.1 per 10,000 cases (cats)
  • Prevalence from UK first opinion practices indicate that overall gastrointestinal foreign bodies are significantly more common in dogs than in cats
    [1][53]
  • Prevalence of dogs with gastrointestinal foreign bodies presented to Banfield hospitals (USA) in 2014 was 26.4 per 10,000 cases53
  • Prevalence of cats with gastrointestinal foreign bodies presented to Banfield hospitals (USA) in 2014 was 16.1 per 10,000 cases53
  • Prevalence data from UK indicate that overall gastrointestinal foreign bodies are significantly more common in dogs than in cats. Out of 208 cases presented with gastrointestinal foreign body to first opinion practice over 48 months, 184 were dogs and 24 were cats1
Causes
  • Discrete foreign body entrapment (e.g. plastic toys, stones, balls, glue, trichobezoars, food items, fabric)
  • Linear foreign body (e.g. string, nylon stockings, sewing thread, fishing line)
  • The intestine proximal to the obstruction dilates with gas and secretions
  • Severe cases may result in ischaemic necrosis of the intestinal wall
    [1][2][3][4][5][6][7][72][79][94]
  • Discrete foreign body (DFB) entrapment (e.g. plastic toys, stones, balls, glue, trichobezoars)1,2,3,72,79
  • Linear foreign body (LFB) (e.g. string, nylon stockings, sewing thread, fishing line)1,4,5,79
  • The most common categories of gastrointestinal foreign bodies (not including those with metallic or mineral components) in a U.S. survey were balls, food items, fabric, soft plastic and hard plastic94
  • The most common site in the dog is jejunum1,2,6
  • Cats appear to have a more uniform distribution of locations1,5
  • The intestine proximal to the obstruction dilates with gas and secretions7
  • Severe cases may result in ischaemic necrosis of the intestinal wall7
Risk Factors
  • Young cats
  • Young, medium to large dogs
  • Over-represented dog breeds include Terriers and Labrador/Golden Retrievers
  • Increased risk of intestinal necrosis and perforation in dogs with increased duration of clinical signs, increased preoperative lactate, presence of a linear foreign body and delayed surgery
    [1][6][8][9][10][24][65][87]
  • Young cats and young, medium to large-breed dogs are over-represented1,9,10,24,87
  • Dog breeds that are over-represented vary depending on the study:
    Staffordshire Bull Terrier, English Bull Terrier, Jack Russell Terrier, Border Collie, Springer Spaniel1
    Labrador Retriever, Dachshund, and German Shepherd Dog8
    Labrador Retriever, Golden Retriever, American Pit Bull Terrier6
  • Labrador Retrievers, Mixed Breed dogs, English Bulldogs and Golden Retrievers were over-
    represented in a retrospective study of obstructive pyloric and duodenal foreign bodies87
  • Increased risk of intestinal necrosis and perforation in dogs with increased duration of clinical signs, increased preoperative lactate, presence of a linear foreign body and delayed surgery > 6hrs65
Clinical Features
  • Common clinical signs include lethargy, anorexia, vomiting and abdominal pain
  • Diarrhoea may be seen in partial obstructions
  • Coughing, hairballs, hiding away and altered urination may be seen in cats
  • Protracted vomiting or diarrhoea may lead to dehydration and hypovolaemic shock
  • If signs of pyrexia and abdominal distension are present, septic peritonitis should be suspected
  • The foreign body may be palpable with the patient conscious or under general anaesthesia but the absence of a palpable foreign body does not exclude the diagnosis
    [1][2][3][4][5][6][7][10][15][16][81]
  • The clinical signs seen in animals with small intestinal obstructions vary with the location, duration and severity of the obstruction4,5
  • Foreign bodies (or an intestinal abnormality) may be palpable in the conscious patient (detection may improve if anaesthetised or sedated);1,7  however, in one large study in dogs, only 13% of DFB and 15% of LFB were palpable6

Common clinical signs

  • Lethargy (61–92%)1,2,3,5,6,15,81
  • Anorexia 55–85%1,6,65,81
  • Vomiting 87–100%1,6,15,16,65,81
  • Abdominal pain2,5,6,7,81 (more likely with linear foreign bodies)6
  • Palpable mass in abdomen81
  • If signs of pyrexia and abdominal distension are present, septic peritonitis should be suspected4
  • Protracted or profuse vomiting or diarrhoea can result in dehydration and eventually hypovolaemia10

Less common clinical signs

  • Diarrhoea 5–23.8%1,81
    May be more common in cases with partial obstruction7
  • Haemorrhagic diarrhoea 2%1
  • Coughing, hairballs, hiding away and altered urination (cats)81
Investigations
First-line diagnostics
  • Haematology
  • Biochemistry
  • Electrolytes and acid–base balance
  • Abdominal imaging
Investigations to consider
  • Peritoneal fluid analysis if suspect peritonitis
Emerging tests
  • Intestinal fatty acid binding protein (I‐FABP)
Haematology
  • PCV/TP may be raised due to dehydration and haemoconcentration
  • Presence of  leucocytosis or leucopenia with a stress leucogram or degenerative left shift, particularly if septic peritonitis
    [5][6][7][10][81]
Biochemistry
  • Raised urea
  • Hypoproteinaemia, hypoalbuminaemia
  • Hyperlactataemia
    [6][7][10][78][81]
Electrolytes and acid–base balance
  • Fluid losses from vomiting/diarrhoea, decreased intake and intestinal secretion of fluid can lead to profound fluid, electrolyte and acid–base abnormalities
    [10][81][87]
Abdominal radiography
  • Definitive results reported in 52–88.9% of cases but less sensitive with radiolucent foreign bodies
  • May see the foreign body or segmental intestinal dilation
  • Decreased peritoneal detail on radiographs may be seen but it is not pathognomonic for obstruction and further imaging studies (e.g., ultrasonography) should be utilised
  • Bowel plication, presence of tapered enteric gas bubbles or bunching of small intestines are reported with linear foreign bodies
  • Can take measurements from the lateral view to indicate the likelihood of mechanical obstruction

Dog

  • Ratio of maximum small intestinal diameter to the height of L5 at its narrowest point on the lateral view
  • Ratio ≤ 1.4 very unlikely to be obstructed
  • Ratio ≥ 2.4 very likely to be obstructed
  • Ratio in between (requires further evaluation)

Cats

  • Ratio of small intestinal diameter to cranial endplate height of L2
  • Ratio < 2 non-obstructive disease was more likely
  • Ratio of 3 probability of mechanical obstruction was > 70%
  • Normal SI diameter should be < 12 mm
    [6][7][11][12][13][14][15][16][17][31][34][82]
Abdominal ultrasoography
  • May correctly identify foreign bodies not visible on radiographs but its sensitivity is likely to be operator-dependent. Ultrasonography is likely to be superior to radiography, where experienced clinicians are available to perform these investigations
  • Can provide additional information, e.g. presence of free fluid, perforation
  • Findings consistent with a foreign body include distal acoustic shadowing and surface reflection
  • CAUTION Although it has been shown to be possible to use tele-ultrasonography to help clinicians identify mechanical obstruction in dogs and cats it should be used with caution as a study demonstrated a low positive predictive value with this technique
    [15][16][65][79][82]
Computed tomography (CT)
  • A review of six small studies comparing imaging modalities for intestinal foreign body obstruction diagnosis demonstrated that CT was superior in both sensitivity and specificity to ultrasound and radiography
    [82]
Specific indicators for septic peritonitis
  • Peritoneal fluid analysis is indicated if suspicion of septic peritonitis
  • Intracellular bacteria or toxic or degenerative neutrophils with foreign debris would confirm the diagnosis
Intestinal fatty acid binding protein (I‐FABP)
  • Emerging test used in humans
    [32][33]
Haematology
  • PCV/TP may be raised due to dehydration and haemoconcentration6,7,10
  • Presence of  leucocytosis or leucopenia with a stress leucogram or degenerative left shift, particularly if septic peritonitis5,81
Biochemistry
  • Urea may be raised if pre-renal azotaemia or gastrointestinal haemorrhage6,7
  • Hypoproteinaemia and hypoalbuminaemia may occur in chronic obstructions or in patients with gastrointestinal perforation-induced septic peritonitis7,78
  • Hyperlactataemia is common (30%)81 and likely related to intestinal ischaemia or systemic hypoperfusion10
Electrolytes and acid–base balance
  • Fluid losses from vomiting/diarrhoea, decreased intake and intestinal secretion of fluid can lead to profound fluid, electrolyte and acid-base abnormalities10
  • Hypochloraemia (32–72.8%)10,81,87 and associated metabolic alkalosis (22–45.2%)10,87 are common
  • Hypokalaemia (25-64.4%)10,81,87 and hyponatraemia (20.5–77.4%)10,81,87 also occur frequently
  • No significant association was found between electrolyte or acid-base abnormality and the site of the foreign body10
  • In a retrospective study of pyloric and duodenal foreign body obstructions, 37% of dogs had a normal pre-op acid-base status, 22% had a metabolic alkalosis (only 10% had a simple metabolic alkalosis, 12% had a mixed acid-base status with a component of metabolic alkalosis), and the remaining dogs had a variety of other acid-base profiles.87 This study excluded dogs that were euthanased instead of proceeding to surgery, potentially biasing these results87
  • Following adequate intravenous fluid therapy and surgical or endoscopic resolution of gastrointestinal obstruction, electrolytes improve, and acid-base disturbances resolve in most dogs87
Abdominal radiography
  • Definitive results are reported in 52–88.9% of cases but less sensitive with radiolucent foreign bodies6,15,16,74,86
  • The foreign body may be visible7,15,6,82
  • Segmental small intestinal dilation (not always present)15,16,82
  • Decreased peritoneal detail on radiographs may be seen but it is not pathognomonic for obstruction and further imaging studies (e.g., ultrasonography) should be utilised. However, when an intestinal foreign body obstruction is confirmed and there is altered peritoneal detail, bowel compromise should be suspected74
  • Bowel plication, presence of tapered enteric gas bubbles or bunching of small intestines are reported in linear foreign bodies15,16,34
  • Can take measurements from the lateral view to indicate the likelihood of mechanical obstruction
  • Radiographing a potential foreign object in water and air to determine lucency in different environments may assist in interpreting radiographs94
  • Altering the patient position (and therefore the environment surrounding the foreign body) may help with radiographic identification94

Dogs
A 1998 study11 used ratio of small intestinal diameter (SID) to L5 body height at its narrowest point on lateral radiograph

SID:L5 ratio < 1.6:1 Very unlikely to be obstructed
SID:L5 ratio > 1.6:1 May indicate SI obstruction
SID:L5 > 1.95:1 80% (77% 31) probability of being obstructed
SID:L5 > 2.07:1 90% (86% 31) probability of being obstructed

A 2014 study12 used measurements of L5 body height at its narrowest point (L5), maximum small intestinal diameter (SImax), minimum small intestinal diameter (SImin) and average small intestinal diameter (SIave)

SImax:L5  ≤ 1.4
SImax:SImin ≤ 2
SImax:SIave ≤ 1.3		 Very unlikely to have mechanical obstruction and could be managed as medical outpatient or investigated for other conditions
SImax:L5  ≥ 2.4
SImax:SImin ≥3.4
SImax:SIave  ≥ 1.9
With or without segmental dilation		 Very likely to be obstructed and could be taken directly to surgery if ultrasonography is declined or not available
With ratios between these thresholds Should be investigated with other diagnostic tools
Reproduced with permission from © B. Eastwood

Reproduced with permission from © B. Eastwood

Cats

  • Ratio of small intestinal diameter (SID) to cranial endplate height of L213
    SID:L2 ratio < 2, nonobstructive disease was more likely13
    SID:L2 ratio 3, probability of mechanical obstruction was > 70%13
  • Normal SI diameter should be < 12 mm14
Reproduced with permission from the BSAVA Manual of Canine and Feline Gastroenterology ©BSAVA

Courtesy of Professor M Vignoli, VTH Teramo University. Reproduced with permission from the BSAVA Manual of Canine and Feline Gastroenterology ©BSAVA

Reproduced with permission from the BSAVA Manual of Canine and Feline Gastroenterology ©BSAVA

Reproduced with permission from the BSAVA Manual of Canine and Feline Radiography and Radiology ©BSAVA

Abdominal ultrasonography
  • Can provide additional information, e.g. presence of free fluid, perforation15
  • May correctly identify foreign bodies not visible on radiographs but its sensitivity is likely to be operator-dependent15,16,82
  • A 2023 paper reviewed studies comparing diagnostic techniques for the identification of intestinal foreign body obstruction. This study concluded that ultrasonography is likely to be superior to radiography, where experienced clinicians are available to perform these investigations82
  • Especially useful for non-radiopaque foreign bodies15,82
  • Findings consistent with a foreign body include distal acoustic shadowing and surface reflection15
  • In one study in dogs, only 37% of linear foreign bodies were diagnosed preoperatively, using abdominal imaging65
  • CAUTION Although it has been shown to be possible to use tele-ultrasonography to help clinicians identify mechanical obstruction in dogs and cats it should be used with caution as a study demonstrated a low positive predictive value with this technique (55.9% to 70.8%) which could result in a high false positive rate. Given the potential surgical decision at hand these results question the usefulness of this technique in this clinical context79
Computed tomography (CT)
  • A review of six small studies comparing imaging modalities for intestinal foreign body obstruction diagnosis demonstrated that CT was superior in both sensitivity and specificity to ultrasound and radiography82
Peritoneal fluid analysis

Peritoneal fluid cytology

  • Intracellular bacteria or toxic or degenerative neutrophils with foreign debris

Peritoneal fluid nucleated cell count

  • > 13,000 cells/µl

Peritoneal fluid biochemistry

  • Abdominal fluid glucose > 1.1 mmol/l lower than serum glucose
  • Abdominal fluid lactate > 2.5 mmol/l
  • Abdominal fluid lactate > 2 mmol/l higher than serum lactate
  • Septic peritonitis
Intestinal fatty acid binding protein (I‐FABP)
  • Concentrations of I‐FABP increase in people with ischaemic bowel obstruction32
  • In dogs, concentrations in excess of 8.52 ng/ml are strongly suggestive of foreign body obstruction (FBO), while concentrations < 0.35 ng/ml suggest that an FBO is unlikely33
Diagnosis
  • High degree of clinical suspicion based on signalment and presenting signs
  • Diagnosis with abdominal palpation, abdominal radiography or ultrasonography
  • High degree of clinical suspicion based on signalment and presenting signs
  • Diagnosis can be made by abdominal palpation or with abdominal radiography or ultrasonography
Differential Diagnosis
  • Gastric foreign body
  • Neoplasia
  • Intussusception
  • Drug side effects
  • Addison’s disease
  • Toxin ingestion
  • Viral infection
  • Gastroenteritis
  • Pancreatitis
    [55]

Differential diagnoses55

  • Gastric foreign body
  • Neoplasia
  • Intussusception
  • Drug side effects
  • Addison’s disease
  • Toxin ingestion
  • Viral infection
  • Gastroenteritis
  • Pancreatitis
Treatment
Treatment plan
  • CAUTION Surgical intervention is not always required
  • The decision to proceed to surgery will depend upon many factors including the type of foreign body, the problems associated with the material of the foreign body and the degree of obstruction that it causes
  • Close monitoring and repeated radiographic studies may be a valid treatment option for straight metallic sharp-pointed gastrointestinal foreign bodies in dogs and cats who are stable and when there is no evidence of gastrointestinal perforation or other complications
  • If clinical signs consistent with small intestinal foreign body obstruction have persisted for more than 5 days, strong recommendations should be made to rule this diagnosis out to prevent complications
    [83][84]
Fluid therapy
  • i/v isotonic crystalloids
  • Correct deficits
  • Provide ongoing maintenance
  • Address any electrolyte abnormalities prior to surgery
    [7][10][56][87]
Analgesia
  • Opioids are the first choice analgesics
  • Paracetamol (not in cats)
  • CAUTION Avoid NSAIDs
    [17][18][54]
Antibiotics
  • Antibiotic prophylaxis is not necessary for clean contaminated surgery, e g. simple enterectomy (no spillage < 90 minutes)
  • Otherwise broad-spectrum prophylactic antibiotics are indicated
  • However, due to difficulty in predicting spillage, prophylactic antibiotics may be justified in all bowel surgery
  • Administer 30–60 minutes pre-induction
  • Repeat every 90–180 minutes depending on chosen antibiotic
  • Additional prophylactic antibiotics should not be administered after the incision is closed unless spillage of intestinal contents occurred
    [7][18][26][41][42][43][44][47][48]
Use of antiemetics?
  • No safety studies available
  • Antiemetic therapy in patients with gastrointestinal foreign body obstructions has been shown to increase the time to definitive care and to increase the length of hospitalisation because their use can “mask” clinical signs
  • Not inherently contraindicated in patients for whom gastrointestinal foreign body obstruction is a differential, so long as appropriate diagnostic evaluations are employed and the progression of clinical signs is closely monitored and followed up accordingly
    [84]
General principles for enterotomy or enterectomy
  • CAUTION Evaluate the entire gastrointestinal tract
  • Manually express the contents away from the incision site and place atraumatic clamps (e.g. Doyen) oral and aboral
  • Single-layer closure
  • Appositional patterns
  • Simple interrupted, simple continuous full-thickness or modified Gambee suture pattern
  • Sutures placed no more than 3 mm apart and 5 mm from the wound edge
  • Inclusion of the submucosal layer is essential
  • Synthetic absorbable monofilament
  • Use 1.5 metric (4/0 USP) in cats and small dogs
  • Use 2 metric (3/0 USP) in larger dogs
  • Swaged-on taper-point needle
  • Place the first and last suture outside the enterotomy incision
  • Measures to assess suture line security include leak testing (using saline infusion or air insufflation) and probe testing using a mosquito haemostat to gently probe the space between sutures
  • Omental wrapping is advised but not evidence-based
  • Perform abdominal lavage and suction excess fluid
  • Mechanical staplers have been shown to be a viable, rapid, safe alternative to suturing for anastomoses
  • Handsewn and stapled enterectomies equally preserve perfusion
  • Reported dehiscence rates are 2-3.8% for enterotomy and 14-18.2% for enterectomy
  • Anastomotic dehiscence and mortality rates in cats following intestinal surgery seem to be lower than in dogs
    [4][7][19][20][21][22][23][35][36][37][38][40][48][49][57][58][60][61][62][63][64][67][68][70][71][73][75][76][80][81]
Alternative to enterotomy
  • A novel method of laparotomy-assisted transoral retrieval of gastrointestinal foreign bodies has been described and may provide an alternative to enterotomy or gastrotomy in carefully selected cases
  • The foreign object is first digitally manipulated into the stomach and then removed via an orogastric tube using a grasping instrument
  • It has been shown to be a technically straightforward procedure that may reduce operating and hospitalisation times
  • CAUTION Serosal tears can occur due to foreign body manipulation and case selection is therefore paramount. Foreign objects that are sharp or abrasive should not be removed in this way unless they can be retracted reliably into the orogastric tube or safely oriented prior to removal
    [66][77]
Assessment of viability
  • Wait 10 minutes after relief of obstruction before assessment
  • If the serosal surface remains grey, green, purple or black or there is evidence of seromuscular tearing, ischaemia is suspected
  • The intestine should bleed briskly when cut and arteries should be pulsating
  • CAUTION Any tissue for which there are concerns about viability should be removed
    [48]
Discrete foreign body
  • Incision in small intestine immediately distal to the foreign body
  • CAUTION Do not incise over the foreign body
  • Necrosis of the bowel may necessitate enterectomy and anastomosis
  • Place the first and last suture outside the incision
    [4][7]
Linear foreign body
  • If gastrotomy identifies the proximal end of the LFB, gentle traction is applied in order to remove the entire foreign body through the stomach
  • If the LFB is not easily retrieved this way, make an enterotomy at the area of plication
  • Multiple enterotomies may be necessary
  • An alternative method is described whereby the LFB is anchored to a red rubber catheter and milked out through to the colon and per rectum
  • CAUTION Always carefully inspect the mesenteric border for perforation and if present perform enterectomy and anastomosis
    [1][4][5][7][9][10][24][25]
Enterectomy and anastomoses
Postoperative care
  • General supportive care to include fluids and electrolyte management, analgesia and wound care
  • Monitor for hypoproteinaemia
  • Monitor for signs of dehiscence, critical period 3–5 days postoperatively
  • Early enteral nutrition indicated
    [7][9][23][27][28][45][46][50][51]
Emerging therapies
  • Canine-specific albumin (CSA) / Lophilized canine albumin
    [78][85][89][90][91][92][93]
Treatment plan
  • CAUTION Surgical intervention is not always required with small intestinal foreign bodies83
  • The decision to proceed to surgery will depend upon many factors including the type of foreign body, the problems associated with the material of the foreign body and the degree of obstruction that it causes83
  • A small referral-based study (N=14 dogs N = 3 cats) suggested that conservative management through close monitoring and repeated radiographic studies may be a valid treatment option for straight metallic sharp-pointed gastrointestinal foreign bodies in dogs and cats who are stable and when there is no evidence of gastrointestinal perforation or other complications83
  • When clinical signs consistent with small intestinal foreign body obstruction have persisted for more than 5 days, strong recommendations should be made to rule this diagnosis out as a study showed that when the duration of clinical signs prior to definitive care approached 6 days, there was an associated increase in complications84
Fluid therapy
  • i/v isotonic crystalloids56,87
  • Fluid therapy aims at correcting dehydration and improving tissue perfusion7
  • Manage electrolyte abnormalities7,10 In particular, supplement fluids with potassium chloride when hypokalaemia is present.87
    Electrolyte imbalances should be addressed prior to surgery87
  • Fluid resuscitation plan
Analgesia
  • Visceral and abdominal pain can be severe17
  • Opioids are the first choice analgesics17
  • e.g. Methadone
    0.1–0.5 mg/kg i/m or 0.1–0.3 mg/kg i/v prn18
  • Dose should be titrated to effect in sick animals to minimise the risk of cardiovascular and respiratory compromise
  • Paracetamol (not in cats)
    Dogs 10–20 mg/kg p/o , i/v q12h18
  • CAUTION Avoid NSAIDs54
Antibiotics
  • Antibiotic prophylaxis is not necessary for clean-contaminated surgery, e.g. simple enterectomy
    (Incision of small intestinal wall, no peritonitis or spillage and < 90 mins)44,48
  • Otherwise broad-spectrum prophylactic antibiotics should be given against Gram-positive and Gram-negative bacteria
  • However, due to difficulty in predicting spillage, prophylactic antibiotics may be may be justified in all bowel surgery7,43,47
  • Administer 30–60 mins pre-induction43
  • e.g. Cefuroxime18,42,43
    Dogs and cats 20 mg/kg slow i/v
    Repeat every 120–180 minutes until end of surgery
  • e.g. Co-amoxiclav43
    Dogs and cats 22–25 mg/kg i/v
    Repeat every 90–120 mins until end of surgery
    Reported more adverse effects than with cefuroxime in dogs26
  • Additional prophylactic antibiotics should not be administered after the incision is closed unless spillage of intestinal contents occurred41 or there is free fluid present (a swab should be taken for bacterial culture and broad-spectrum antibiotics given therapeutically, pending results)
  • Antibiotic use in critical illness
Use of antiemetics?
  • No safety studies have been performed evaluating the administration of maropitant to dogs and cats with gastrointestinal foreign body obstruction
  • Antiemetic therapy in patients with gastrointestinal foreign body obstructions has been shown to increase the time to definitive care and to increase the length of hospitalisation because their use can “mask” clinical signs84
  • It has also been shown that there is an increased risk of complications associated with a delay of definitive care84
  • A retrospective study concluded that antiemetics are not inherently contraindicated in patients for whom gastrointestinal foreign body obstruction is a differential, so long as appropriate diagnostic evaluations are employed and the progression of clinical signs is closely monitored and followed up accordingly84
General principles for enterotomy or enterectomy
  • CAUTION Evaluate the entire gastrointestinal tract4,7
  • Isolate the affected area of bowel using moist laparotomy swabs
  • Manually express the contents away from the incision site and place atraumatic clamps (e.g. Doyen) oral and aboral48

Suture pattern

  • Single-layer19,22,23
  • Simple interrupted, simple continuous or a modified Gambee suture pattern19,22,23,48
  • Sutures placed no more than 3 mm apart23
  • Sutures placed 5 mm from the wound edge
  • Appositional suture patterns preserve luminal diameter and have the same strength as inverting patterns after 24 hours23
  • CAUTION Sutures should incorporate the submucosa, which is the strongest layer of the intestinal wall. It is sometimes visible as a white line between the mucosa and serosa4,23

Suture material

  • Use synthetic, absorbable monofilament4,7,23
    e.g. Polydioxanone, poliglecaprone, glycomer 631 or polyglyconate
  • If prolonged wound healing is anticipated, then suture materials with prolonged tensile strength such as polydioxanone or polyglyconate should be used
  • Use 1.5 metric (4/0 USP) in  cats and small dogs22,23
  • Use 2 metric (3/0 USP) in larger dogs23
  • Swaged-on taper-point needle48

Stapling

  • Mechanical staplers such as the gastrointestinal anastomosis (GIA) stapler and thoracoabdominal stapler (TA) have been shown to be a viable, rapid, safe alternative to suturing for anastomoses;60,61 however, their use is often limited by cost, availability and surgeon experience62
  • An ex-vivo study demonstrated that a 3-row stapler may be superior to a 2-row construct in reducing leakage through the transverse suture line in particular75
  • A method using disposable skin staplers has been described in the literature for gastrointestinal surgery (enterotomies and anastomoses)21,62,63 but is not widely used. It has been shown to be of equivalent bursting strength, lumen diameter, lumen circumference and healing characteristics to traditional hand-sewn techniques in dogs;35 the dimensions of the feline small intestine limit their application64
  • A small prospective clinical trial demonstrated that stapling enterectomy sites does not lead to greater vascular compromise than hand-suturing techniques80
  • Three full-thickness stay sutures are placed at 120-degree intervals around the anastomosis site, with the first one placed at the mesenteric border. Tension was applied between two stay sutures, and skin staples are placed at intervals of 2–3 mm using a skin stapler between each of the stay sutures62,63
  • Inexperience with the technique may result in anastomotic dehiscence so adequate training is essential in staple alignment and depth control63
  • If a linear technique is used to perform a functional end-to-end stapled anastomosis, crotch sutures may decrease the risk of leakage. A study on cadavers found that surgery augmented by crotch sutures (simple interrupted, two simple interrupted or simple continuous PDS sutures placed at the crotch of the side-to-side anastomosis) could sustain higher intraluminal pressures than those without crotch sutures76
  • Shorter surgery time is a recognised advantage of stapling37

Leak testing 

  • Leak testing is recommended to assess suture line security40
    Normal peristaltic pressure is 15–25 mmHg in the dog
  • Saline infusion
    To achieve a pressure of 22 mmHg, occlude 10 cm of bowel and inject 16–19 ml saline (digital compression) or 12–15 ml saline (Doyen forceps)23,40
    CAUTION A standard approach to leak testing in dogs may not be ideal as a cadaveric study demonstrated that the volume of saline required to reach maximum intraluminal peristaltic pressure of 25mmHg  peristaltic pressure is greater in dogs >20kg versus dogs <20kg. (It was reported that for each 1kg increase in bodyweight the intestinal diameter increased by 0.19mm and the volume of saline required to achieve 25mmHg increased by 1.06ml). Further studies are necessary to establish a reliable scale for calculation of the saline volume necessary for leak testing in dogs73
    In the latest study however, no significant difference in dehiscence was found between anastomoses that underwent intraoperative leak testing versus those that did not, regardless of anastomotic technique68
  • Air insufflation
    Air insufflation (whilst submerging the intestinal segment in NaCl in the abdominal cavity) is more commonly performed in humans. A defect is identified by the presence of bubbles, and an ex-vivo study in dogs showed it to be a more sensitive and precise method than saline infusion to both detect and locate inadequate small intestinal closure70

Probe Testing

  • Utilises a mosquito haemostat to gently probe the space between sutures and has been shown to be highly sensitive at detecting gaps compared with leak testing in canine simple continuous anastomosis71

Omental wrapping

  • Omental wrapping of the enterotomy/enterectomy site is advised23,49
  • No suturing is necessary
  • There is minimal risk of complications; however, in human medicine, there is no evidence it reduces leakage/dehiscence57,58

Before closure

  • Perform abdominal lavage and suction excess fluid48

Risks for dehiscence

  • Reported dehiscence rates are 2-3.8% for enterotomy8,67 and 14-18.2% for enterectomy37,67 with an overall dehiscence rate for both surgeries of 6.6%67
  • Anastomotic dehiscence and mortality rates in cats following intestinal surgery seem to be lower than in dogs59,64 A 2023 retrospective study reports no cases of dehiscence in 56 cats undergoing GI foreign body surgery in a referral setting81
  • Dogs with two or more of the following risk factors are predicted to be at high risk for developing anastomotic leakage: preoperative peritonitis, intestinal foreign body, and serum albumin concentration ≤25 g/l59
  • ASA score > 3 and an older age were significantly associated with greater odds of intestinal dehiscence for both enterotomy and enterectomy, in one study (for each year increase in age, the odds of dehiscence increased by 1.24)67
  • Reports comparing the dehiscence rates for hand-suturing and stapled intestinal anastomoses are conflicting, with some showing a decreased rate with stapling36,38 and others showing no significant difference between the two methods37
Reproduced with permission from the BSAVA Manual of Canine and Feline Abdominal Surgery ©BSAVA

Reproduced with permission from the BSAVA Manual of Canine and Feline Abdominal Surgery ©BSAVA

Alternative to enterotomy
  • A method of laparotomy assisted transoral foreign body removal has been described in a small number of animals and may be an alternative to enterotomy or gastrotomy in some cases66,77
  • If a foreign object is able to be safely manipulated into the stomach it could be removed via an orogastric tube using an appropriate retrieval instrument (endoscopic or laparoscopic forceps)
  • It has been shown to be a technically straightforward procedure that may reduce operating times,66,77 and hospitalisation times77
  • CAUTION Serosal tears can occur due to foreign body manipulation77 and case selection is therefore paramount. Foreign objects that are sharp or abrasive should not be removed in this way unless they can be retracted reliably into the orogastric tube or safely oriented prior to removal66
Assessment of viability
  • Wait 10–15 minutes after relief of obstruction before assessment48
  • If the serosal surface remains grey, green, purple or black or there is evidence of seromuscular tearing, ischaemia is suspected48
  • Assess for pulsation of the jejunal arteries48
  • The intestine should bleed briskly when cut48
  • CAUTION Any tissue for which there are concerns about viability should be removed
Discrete foreign body

Discrete foreign body (DFB)

  • CAUTION Make incision in small intestine immediately distal to the foreign body (aboral) NOT over the FB itself or proximal to it4,7
  • Necrosis of the bowel may necessitate enterectomy and anastomosis4
  • Place the first and last suture outside the incision
Reproduced with permission from © B. Eastwood

Linear foreign body

Linear foreign body (LFB)

  • In dogs, LFB account for 161–36%10 of foreign bodies, with 671–87%24 anchored at the pylorus
  • In cats, LFB account for 331–50%5 of foreign bodies, with 63% anchored around the tongue1
  • If gastrotomy identifies the proximal end of the LFB, gentle traction is applied in order to remove the entire foreign body through the stomach7
  • If the LFB is not easily retrieved this way, make an enterotomy at the area of plication7
  • Multiple enterotomies may be necessary4
  • If the LFB is thin, e.g. string/dental floss then an alternative method may be used whereby the LFB is anchored to a red rubber catheter and milked out through to the colon and per rectum7,25
  • CAUTION Carefully inspect the mesenteric border for perforation and if present perform enterectomy and anastomosis9
Reproduced with permission from the BSAVA Manual of Canine and Feline Abdominal Surgery ©BSAVA

Reproduced with permission from the BSAVA Manual of Canine Practice ©BSAVA

Enterectomy and anastomoses
Postoperative care
  • General supportive care to include fluids and electrolyte management, analgesia and wound care
  • Monitor for hypoproteinaemia. Albumin maintains oncotic pressure, binds proteins and other substances critical for wound healing and is used as a marker for disease and nutritional status27
  • CAUTION Monitor for signs of dehiscence, critical period 3–5 days postoperatively7
  • Early enteral nutrition indicated7,23,45,46,50
  • Feeding tubes may be needed, e.g. oesophagostomy feeding tube9
  • Current guidelines are to meet RER but not exceed it9
  • If unable to provide complete enteral feedings then consider using glutamine as a source of energy. Dose for enterocytes 0.3 mg/kg i/v q24h in maintenance fluids28
  • Glutamine may also enhance the immune system, decrease bacterial translocation and has been shown to decrease morbidity in certain critically ill human patients51
Emerging therapies

Canine-specific albumin (CSA) / Lyophilized canine albumin (LCA)

  • Is available in the United States
  • Hyperoncotic CSA can significantly increase serum albumin levels in critically ill dogs with hypoalbuminaemia, which has many advantages. However, the impact of CSA treatments on survival rates is yet to be established. In addition, further studies examining the safety of CSA therapy are required.78
  • A 2023 retrospective study described the use of CSA in canine patients with a variety of underlying pathologies causing hypoalbuminaemia. In this study, the median increase of serum albumin levels post-transfusion was 3 g/l (range 7-11 g/l). Transfusion reactions occurred in 22.6% of cases (12/53), with seven of these being severe or life-threatening85

Dose

  • The reported dose range is 0.5-2.5 g/kg/day91,93 given as a transfusion over 4-8 hours in hypotensive patients and over a longer period in normotensive patients85
  • CSA manufacturers’ recommended doses vary and are drawn from a small number of limited veterinary studies.89,90 The recommended dose of LCA manufacturer Animal Blood Resources International92 is:
  • Hypotensive dogs (for volume expansion): 0.45-0.8 g/kg, diluted with saline to a 16% solution (as per drug insert directions)92
  • Hypoalbuminemic normovolemic dogs: 0.45 g/kg, diluted with saline to a 5% solution92
  • These doses are expected to increase serum albumin by 5 g/l (0.5 g/dl)92
  • The goal of albumin supplementation in hypoalbuminemic dogs should be to raise plasma albumin to a maintenance level of 20-25 g/l (2.0 – 2.5 g/dl)92
  • It is suggested not to exceed a maximum of 2 g/kg/day92
Complications
  • Complications include intestinal injury requiring resection/anastomosis, surgical site infection, septic peritonitis, incisional dehiscence, postoperative ileus/pancreatitis, short bowel syndrome, aspiration pneumonia, acute respiratory distress syndrome, zinc toxicosis and death
    [1][6][8][10][20][36][49][52][81][84][88]
  • Intestinal injury requiring resection/anastomosis84
  • Bowel wall necrosis, septic peritonitis and death1
  • Incisional dehiscence8,20,36,49
  • Postoperative ileus49
  • Postoperative pancreatitis10
  • Aspiration (pneumonia)10,84
  • Acute respiratory distress syndrome6
  • Extensive resection can cause short bowel syndrome (diarrhoea, weight loss) but this is rare even if > 50% of the intestine is resected and is usually only transient52
  • A 12-year retrospective study comparing 56 cats with linear versus discrete foreign bodies demonstrated the former had higher body condition scores, higher albumin, longer surgery time with higher ASA score, higher total cost of visit, higher rates of surgical site infection and required more intensive post-operative care but this did not affect survival81
  • Metal foreign bodies containing zinc may lead to zinc toxicosis. This may manifest as haemolytic anaemia, acute liver injury, coagulopathy, thrombocytopenia, AKI and acute pancreatitis88
  • Death84
Prognosis
  • Prognosis is good with early appropriate surgery
  • Without prompt treatment, there is a risk of decreased bowel perfusion and bowel wall necrosis, septic peritonitis and death
  • Reported survival for pets with DFB (dogs 94–96%, cats 100%)
  • Reported survival for LFB (dogs 80-96%, cats 63-100%)
  • Reported dehiscence rate are 2-3.8% (enterotomies) and 14-18.2% (enterectomies)
  • Increased risk of dehiscence if hypoproteinaemia, preoperative peritonitis, multiple gastrointestinal incisions, the presence of a LFB, ASA score >3 and an older age
    [1][2][5][6][7][8][21][27][37][67][81]
  • Prognosis is good with early appropriate surgery5,7,81
  • Without prompt treatment, there is a risk of decreased bowel perfusion and bowel wall necrosis, septic peritonitis and death1
  • Reported survival for pets with DFB (dogs 94–96%,1,6 cats 100%1,81)
  • Reported survival for LFB (dogs 80-96%1,6, cats 63-100%1,81)
  • Increased mortality has been reported when multiple enterotomies are required/performed1, with a longer duration of clinical signs1,2 and for LFB vs DFB in a charity hospital;1 however, in a referral population, 96% of dogs survived to hospital discharge, with no difference in dogs with linear and nonlinear foreign bodies6
  • Reported dehiscence rates are 2-3.8%8,67(enterotomy) and 14-18.2%37,67(enterectomy) with an overall dehiscence rate for both surgeries of 6.6%67
  • Increased risk of dehiscence associated with hypoproteinaemia (serum albumin < or equal to 25 g/l),27 preoperative peritonitis,27 multiple gastrointestinal incisions21 and the presence of a LFB21 ASA score > 3 and an older age (for each year increase in age, the odds of dehiscence increased by 1.24)67
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83. Crinò, C., Humm, K. and Cortellini, S. (2023)
Conservative management of metallic sharp-pointed straight gastric and intestinal foreign bodies in dogs and cats: 17 cases (2003-2021)
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84. Puzio CE, Rudloff E, Pigott AM.
Delay of definitive care in cats and dogs with gastrointestinal foreign body obstruction following antiemetic administration: 537 cases (2012-2020)
Journal of Veterinary Emergency and Critical Care 33(4):442-446
Abstract

85. Terradas Crespo, E., Martin, L.G., Davidow, E.B. (2023)
Retrospective evaluation of indications, transfusion protocols, and acute transfusion reactions associated with the administration of lyophilized canine albumin: 53 cases (2009-2020).
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87. Lozano, B.A., Yankin, I., Perry, S., et al. (2023)
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88. Henke, C.S., Beal, M.W., Walton, R.A.L., et al. (2023)
Retrospective evaluation of the clinical course and outcome of zinc toxicosis due to metallic foreign bodies in dogs (2005-2021): 55 cases.
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89. Craft, E.M., Powell, L.L. (2012)
The use of canine-specific albumin in dogs with septic peritonitis.
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90. Enders, B., Musulin, S., Holowaychuk, M., et al. (2018)
Repeated infusion of lyophilized canine albumin safely and effectively increases serum albumin and colloid osmotic pressure in healthy dogs.
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91. Mathews, K.A., Barry, M. (2005)
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92. Lyophilized canine albumin, 5gr, datasheet.
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93. Peterson, K.L., Hardy, B.T., Hall, K. (2013)
Assessment of shock index in healthy dogs and dogs in hemorrhagic shock.
Journal of Veterinary Emergency and Critical Care 23(5), 545-550
Abstract

94. Yuen, F., Dennison, S. (2024)
Radiographic identification of challenging gastrointestinal tract foreign bodies: a descriptive study of how appearance varies in air versus water to aid interpretation.
American Journal of Veterinary Research 85(7)
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95. Costello, S., McRae, B., Olive, M., et al. (2024)
Stapled enterectomy reduces surgical time when compared with sutured enterectomy: a retrospective review of 54 cats.
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Full text available

How this topic was developed

Primary search terms

  • title:((“foreign body”)) AND title:(((dog or dogs or canine or canines) OR (cat or cats or feline or feline) OR (“small animals”))) AND yr:[1989 TO 2020]
  • title:(intestinal AND (“foreign body”) OR enterotomy) AND title:(((dog or dogs or canine or canines) OR (cat or cats or feline or feline) OR (“small animals”))) AND yr:[1989 TO 2020]
  • title:(intestinal AND (“foreign body”) OR enterotomy) AND title:(((dog or dogs or canine or canines) OR (cat or cats or feline or feline) OR (“small animals”))) AND yr:[1950 TO 2020]
  • title:(enterotomy) AND title:(((dog or dogs or canine or canines) OR (cat or cats or feline or feline) OR (“small animals”))) AND yr:[1989 TO 2020]
  • title:((intestinal OR intestine) AND surgery) AND title:(((dog or dogs or canine or canines) OR (cat or cats or feline or feline) OR (“small animals”))) AND yr:[1989 TO 2020]
Contributors

Writers

  • Zoë Coker BSc (Hons) CertGP (EM&S) BVM&S MRCVS

Specialist reviewers

  • Sophie Adamantos BVSc CertVA DACVECC DipECVECC MRCVS FHEA
  • Nicola Kulendra BVetMed CertVDI DipECVS MRCVS
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