Commonly seen cases referred to internal medicine include animals with diseases of the endocrine, gastrointestinal, urinary, and hematologic systems.  Frequently the internal medicine service will treat animals with problems that are hard to define and which involve multiple body systems.

If an animal is showing GI signs and extra-intestinal problems have been ruled out, ultrasound followed by endoscopy of the GI system is often indicated.  The pediatric gastroscope uses a video chip rather than fiber optics to transmit the image to the video monitor resulting in a clearer picture.

A biopsy channel in the scope allows us to collect pinch biopsies of the mucosa.  This channel can also be used with tools such as various baskets and forceps to allow removal of foreign objects from the esophagus or stomach.  It’s great to send an animal directly home after removing a gastric foreign body compared to a day or two of hospitalization following a laparotomy.

The most difficult part of endoscopy is learning how to manipulate the scope to see subtle lesions like these ulcers in the stomach of dog.  Fluid and secretions in the GI tract, respirations, tone at the gastroduodenal junction, and less than 360 degree mobility of the scope tip conspire against getting good visualization.

Cystoscopy is indicated in many diseases of the lower urinary tract including chronic infection,  incontinence, and idiopathic hematuria.   We have found that  mild thickening of the bladder wall on ultrasound may be clearly seen as infiltrative masses when viewed with the scope.  The scope is inserted through the urethra and cold saline is used to flush the urine out of the bladder.  The saline makes it easier to see the walls of the system and the cold temp causes mild vasoconstriction.

The monitor shows the entrance to both the urinary system and the reproductive tract in a female dog.  This dog was being evaluated for chronic urinary tract infections.  The cystoscopy ruled out any internal problems and the culprit was bad external conformation of the vulva.

Dr. Gartrell is reviewing one of The  4-6 abdominal ultrasound examinations that we perform each day.  The internal medicine doctors will use our unit and call upon consulting radiologists if they need a second opinion.

	Copies of ultrasound examinations can be burned onto a CD for viewing at your practice.  One of the key aspects of an ultrasound examination is tying the radiologic diagnosis with the history and clinical signs of the case.  This patient had slightly distended hepatic veins and a small amount of peritoneal effusion.  These changes were eventually linked to right sided heart failure.
An abnormal ultrasonographic appearance does not necessarily correlate to clinical disease.  We feel that we can provide the best service to the patient by reviewing the history and performing a physical examination so we can choose the most appropriate sedative or limit complications associated with biopsy collection.

Nutritional support is very important to a large percentage of VSH patients.  Chronic illness, GI disease, anorexia and catabolic illness are commonly seen.  VSH can supplement nutrition in many ways from the most basic methods – hand feeding around the clock by nursing staff – to providing intravenous nutrition (PPN and TPN).  In this picture Dr. Gartrell is being assisted by several members of the nursing staff in placement of an esophageal feeding tube.  The tube can be placed under sedation and can remain for months if necessary.  Anesthesia +/- invasive surgery would be required for placement of a stomach tube which carries the additional risk of  abdominal leakage.