RETROGRADE JEJUNAL INTUSSUSCEPTION IN ONE YEAR OLD CAT AFTER TREATMENT WITH METOCLOPRAMIDE AND MENBUTONE 
Barbara Lukanc1, Estera Pogorevc1, Andreja Kastelic2, Vladimira Erjavec1* 
1Clinic for small animals and surgery, Veterinary faculty, University of Ljubljana, Gerbiceva 60; 2Knezova ulica 14, 1000 Ljubljana, Slovenia *Corresponding author, E-mail: vladimira.erjavec@vf.uni-lj.si 
Summary: Intussusception refers to invagination or prolapse of one portion of the intestine into the part of the tract that either 
precedes or follows it. Young cats may be more likely to have idiopathic intussusception, and older cats with intussusception may be more likely to have primary gastrointestinal tract disease, i.e. neoplasia. An intussusception will result in either a partial or complete intestinal obstruction and this will lead to a variety of clinical signs depending on the chronicity, size and location of the intussusceptions. In the literature no suggestion has been made to show association between intussusception and prokinetic or choleretic drug. A one year old male Maine Coon cat was presented with a history of anorexia, depression and inability to defecate for few days. On two consecutive days the cat was treated with metoclopramide, ranitidine, hyoscine butylbromide and menbutone. On the same day of therapy vomiting started and continued for three days before the moribund cat was presented to the clinic. In transverse ultrasonographic view, a target-like mass with multiple concentric hypo- and hyperechoic rings consistent with intussusception was seen in the left mesogastrium. 
This paper describes that possible cause of intussusception may be iatrogenic by application of prokinetic metoclopramide and 
choleretic menbutone given to an obstipated cat. 

Key words: cat; jejunal intussusception; surgery; prokinetic; choleretic 
Introduction 

Intussusception refers to invagination or prolapse of one portion of the intestine into the part of the tract that either precedes or follows it and may occur anywhere in the gastrointestinal tract (1). 
Intussusceptions have been reported as sequelae to a number of conditions, including intestinal parasitism, viral-induced enteritis, alimentary foreign bodies (1, 2, 3, 4, 5) intestinal masses (1, 2, 
4) recent abdominal or extra-abdominal surgery (1, 
Received: 16 March 2014 Accepted for publication: 18 September 2014 
2, 4, 5, 6) and nonspecific gastroenteritis (1, 4, 5). 
There is a bimodal age distribution of cats 
presented with intussusception. In older cats, 
most likely intussusceptions were associated 
with neoplasia or IBD in some cases. Underlying causes for younger cats are ill defined and may be 
idiopathic in many cases, but associations with parasitism and, in one case, a linear foreign body 
have been made (4, 7). An intussusception will result in either a partial or 
complete intestinal obstruction and this will lead to a variety of clinical signs depending on the chronicity, 
size and location of the intussusception (5). 
Diagnosis is established using a combination of history, physical examination and diagnostic imaging, including survey and contrast radiography 

and ultrasonography. Ancillary testing such as 
haematology, biochemistry, urinalysis, and faecal examination is frequently performed to try and 
identify an underlying cause (7). 
Case description 
A one year old, 4.9 kg, castrated, indoor, male Maine Coon was presented with a history of anorexia, vomiting, depression and unable to defecate for one week. Micturition was normal. He was regularly vaccinated but dehelmintisation was not carried out. The cat was treated on the other clinic four and three days previously with metoclopramide 1.0 mg/kg (Reglan, Alkaloid, Skopje, Macedonia), ranitidine 4.0 mg/kg (Ranital, Sandoz, Ljubljana, Slovenia), hyoscine butylbromide (Buscopan, Boehringer Ingelheim, Ingelheim, Germany) and menbutone (Genabil, Boehringer Ingelheim, Ingelheim, Germany). After therapy vomiting started and lethargy worsened 
therefore the cat was presented to our faculty clinic. On clinical examination the cat was depressed 
and unresponsive, unable to stand, hypothermic 
(T=37.0°C), tachycardic (200bpm) with weak pulse, 
eye bulbs were sunken with scleral injection, 
capillary refill time was prolonged (> 4 sec) and skin turgor decreased. The cat was assessed 10% dehydrated. On auscultation heart murmur was detected. Lymph nodes were normal. Abdominal palpation was painful. The cat was hospitalised for stabilisation and further diagnostics. 
Abnormalities on the complete blood count included leucocytosis with mature neutrophilia and lymphopenia, erythrocytosis, elevated hematocrit and haemoglobin. Blood chemistry abnormalities included decreased activity of ALP (alkaline phosphatase), hyperproteinemia, hyperalbuminemia, hypochloremia, hyponatremia, elevated urea and creatinine (Table 1). 
Survey radiography of the cat in right lateral recumbency was performed (Figure 1). In thorax a microcardia was seen. In abdomen there was some air in the stomach and caudal to the liver a mass of soft tissue opacity. Some parts of small intestine were dilated. In transverse and descending colon formed faeces were present. In transverse ultrasonographic view (Figure 2), a target-like mass with multiple concentric hypo- and hyperechoic rings was seen in the left mesogastrium. The small intestine was fluid filled and dilated consistent with obstruction (Figure 3). 
For the stabilisation of the cat we used saline (500 ml 0.9% NaCl, B Braun, Melsungen, Germany) in which we added 10 mmol potassium chloride (KCl) (University Medical Centre Ljubljana, Slovenia). It was administered with perfusion pump at rate of 20 ml/h for 7 hours, and then increased to 30 ml/h. A solution of vitamin B complex, electrolytes, amino acids and dextrose for injection (Duphalyte, Fort Dodge Veterinaria S.A., Girona, Spain) at dose of 50 ml was administered slowly intravenously. For analgesia tramadol 1 mg/kg (Tramal 50 mg/ml, Grenthal GmbH, Germany) subcutaneously was given. Antibiotic therapy was started with cefazoline 20 mg/kg/8h (Cefamezin 1g, Krka, Novo mesto, Slovenia) intravenously. 
The next day the cat underwent exploratory surgery, he was premedicated with methadone 
0.18 mg/kg (Heptanon, Pliva, Zagreb, Croatia) 
subcutaneously two hours before intravenous 
induction with propofol 3.6 mg/kg (Norofol 10 mg/ ml, Norbrook, Newry, Ireland). Five minutes before 
induction with propofol the cat was preoxygenated 
with oxygen 2 l/min. After induction the cat has vomited a lot of fluid and some of that was aspirated. 
The cat was intubated with cuffed endotracheal 
tubus with internal diameter 4.5 mm. Fluid from 
trachea, bronchi and oral cavity was aspirated and the cat was then connected to the anaesthetic 
machine via circle breathing system. Anaesthesia was maintained with isoflurane (Forane, Abbott, Berkshire, UK) in 100 % oxygen for 145 minutes. End tidal isoflurane was 1.4 – 1.3%. Lactated Ringer’s solution (RL) (Hartmannova raztopina Braun, B Braun, Melsungen, Germany) was given at rate 10 ml/kg/h. 
On surgery a ventral midline laparotomy had been performed. We found that the large portion of the jejunum has telescoped into the oral part of intestine (Figure 4). As traction failed to reduce the jejunojejunal intussusception, resection of the affected bowel was deemed necessary, with anastomosis of the healthy tissue. Approximating end-to-end intestinal anastomosis was created with simple interrupted suture pattern with monofilament synthetic absorbable suture material Glycomer 631 (Biosyn 4/0, Syneture, Grimsby, UK) (Figure 5). The large bowel was filled with formed hard dry faeces which were milked out through the anus. Abdominal wall was closed in 
three layers with absorbable monofilament suture. Intravenous fluids RL with KCl supplementation 
were administered at 30 ml/h on the day of surgery and 20 ml/h next two days, during 
hospitalisation. Duphalyte solution for injection 
(50 ml) was administered on the day of surgery and 
discontinued after. Cefazolin was discontinued 
and broad-spectrum antibiotic therapy was started with amoxycilin and clavulanic acid 20 mg/kg/12h 
(Synulox, Pfizer, Roma, Italy) subcutaneously and metronidazole 10 mg/kg/12h (Efloran, Krka, Novo mesto, Slovenia) intravenously. Both 
antibiotics were discharged for another 12 days 
postoperatively. Pain was treated with methadone 
0.2 mg/kg/12h and fentanyl patch (Durogesic 12 µg/h, Janssen pharmaceutica, Beerse, Belgium). Two days postoperatively meloxicam 0.1 mg/ kg/24h (Loxicom 1.5 mg/ml, Norbrook, Newry 
UK) was started intravenously and continued 
orally three consecutive days. He was also treated with sucralfate 0.25 g/8h (Venter 1g, Krka, Novo mesto, Slovenia) orally. 

Table 1: Laboratory findings from the day of operation to the first postoperative day 
Unit  Reference range  Preoperative day  Day of operation  Postoperative day  
WBC  x 109 /l  5.5 – 19.5  26.84  22.56  40.48  
RBC  x 1013 /l  5 - 10  10.89  9.74  7.07  
HGB  g/l  80 - 150  171  151  111  
HCT  l/l  0.3 – 0.45  0.49  0.44  0.33  
MCV  fl  39 – 55  45.1  45.6  46.3  
MCH  pg  12.5 – 17.5  15.7  15.5  15.7  
MCHC  g/l  300 – 360  348  339  339  
RDW  %  15.2  14.9  14.6  
HDW  g/l  29.1  29.3  27.6  
PLT  x 109 g/l  300 - 700  360  144  263  
MPV  fl  9.2  8.2  8.4  
PDW  %  36.4  36.3  44.5  
PCT  l/l  0.003  0.001  0.002  

Differential cell count 

NEUT  x 109 /l  2.2 – 12.8  23.84  20.19  35.42  
LYMP  x 109 /l  1.5 – 7  1.02  0.98  2.41  
MONO  x 109 /l  0.1 – 0.85  0.55  0.49  0.16  
EOS  x 109 /l  0.1 – 1.5  1.57  0.87  2.45  
BASO  x 109 /l  0.06  0.03  0.04  
LUC  x 109 /l  0  0  0  
Urea  mmol/l  5.3 – 12.1  76.24  26.5  11.9  
Creatinine  mmol/l  70.7 – 159  328.4  127.7  112.0  
Na  mmol/l  147 – 156  128.8  154.1  147.8  
K  mmol/l  4.0 – 4.5  4.13  3.42  4.12  
Cl  mmol/l  117 – 123  69.0  110.6  114.3  
ALP  U/l  25 – 93  7.4  
ALT  U/l  6 – 83  80.8  
Total protein  g/l  54.0 – 78.0  90.2  
Albumins  g/l  21.0 – 33.0  46.17  

Legend: WBC – white blood cells, RBC – red blood cells, HGB – haemoglobin, HCT – haematocrit, MCV – mean corpuscular volume, MCH – mean corpuscular haemoglobin, MCHC – mean corpuscular haemoglobin concentration, RDW – red cell distribution width , HDW – hemoglobin distribution width, PLT – platelets, MPV – mean platelet volume, PDW – platelet distribution width, PCT – plateletcrit, NEUT – neutrophils, LYMP – lymphocytes, MONO – monocytes, EOS – eosinophils, BASO – basophils, LUC – large unstained cells, Na – sodium, K – potassium, Cl – chloride, ALP – alkaline phosphatase, ALT – alanine aminotransferase 

Figure 1: A right lateral thoracic and abdominal radiograph. In ventral abdomen, caudal to the liver, a mass of soft tissue opacity is seen. Some loops of small intestine are dilated. Large intestine is filled with 
formed faeces 
Figure 2: Transverse sonogram of jejunal intussusception. 
Note the multilayered appearance of the intestinal wall (called also concentric rings). Only a small amount of fat is invaginated. There is some gas in the lumen 
Figure 3: Longitudinal sonogram of jejunal intussusception 
Figure 4: Intra-operative appearance of a retrograde jejunojejunal intussusception of a cat at laparotomy 
Figure 5: Apposing the wound edges with simple 
interrupted appositional sutures after resection of affected jejunum 

Discussion 

Because cats and dogs differ in their anatomy, physiology and behaviour, there may be differences in the clinical presentation of intestinal intussusceptions (7). It usually occurs in the direction of normal peristalsis, these are referred to as direct or normograde intussusceptions (8, 9, 10). In our case intussusception occurred against the direction of normal peristalsis, referred to as indirect or retrograde intussusception. 
The most common location of intussusception is ileocolic and jejunojejunal (4, 6, 7, 8, 9, 11, 12). Burkitt et al., 2009, found that 40% intussusceptions in cats were jejunojejunal (4). Levien and Baines, 2011, reported, that two of 18 cats presented with jejunojejunal intussusception were Maine Coon breed aged 17 and two months with no underlying cause detected (11), which was consistent with our case, Maine Coon, 13 months old of jejunojejunal intussusception detected. Unpublished data from our clinic show that two of three cats presented with jejunojejunal intussusception in last year were Maine Coons, suggesting that Main Coons may be overrepresented; however the number of cats was too small to make any conclusions. 
The cat in our study had signs of shock 
consistent with findings in previous study (4). 
The most consistent clinical signs seen in cats in one study were a palpable abdominal mass and anorexia (7, 12) however other study reported that palpable abdominal mass was evident only 
in three of nine cats presented (6). In our case 
abdomen was painful on palpation without 
resistance. Most common clinical signs in cats 
were also vomiting, depression, weight loss and dehydration (4, 6, 7) which were all present in 
our cat. Bellenger and Beck, 1994, suggested that 
cats with intussusception are less likely to eat and drink and, therefore, there is less ingesta to 
result in diarrhea (7). Abdominal radiographs revealed intestinal 
dilatation in all cats and gastric dilatation in two of 10 cats with intussusceptions (4), and consistent 
with those findings our cat had intestinal and gastric dilatation. Our final diagnosis based on 
ultrasonographic examination was jejunojejunal 
intussusception. 

Surgical treatment in our cat involved unsuccessful simple manual reduction, resection 
and anastomosis of the involved portion of the 
intestine. Manual reduction of the intussusception 
was attempted by gentle “milking” of the 
intussusceptum from within the intussuscipiens. 
This technique should employ more pressure on the intussuscipient in an effort to reduce the intussusceptum by pushing it out rather than using traction on the intussusceptum (8, 
9). However gentle milking failed to reduce the 
jejunojejunal intussusception, because there 
was significant venous infarction, edema, and congestion as well as adhesions from fibrin and effusions from the affected bowel. Adhesions 
between the intussusceptum and intussuscepiens that we observed are reported to be common in cats, but there is no relationship evident between the duration of clinical signs and the presence or 
absence of adhesion (6). We performed resection 
and anastomosis of the intussusception, which is reported to lessen the incidence of recurrence 
when compared with manual reduction (6, 13, 14). A simple interrupted appositional suture that 
we used incorporates all tissue layers and gently 
apposes the wound edges. Interrupted pattern 
is generally easier to perform, but the simple continuous pattern minimizes mucosal eversion and therefore provides better serosal apposition 
and primary intestinal healing. Regardless of the 
suture technique used, proper incorporation of the tough submucosa and reduction of mucosal eversion are vital in performing consistently 
successful intestinal anastomosis (15). Recurrence 
of intussusception is not related to intestinal 
plication performed at the initial surgery (6). 
In our cat the plication was not performed and 
intussusception has not recurred. The decrease 
in incidence of intussusception was hypothesized to be the result of increased smooth muscle tone along the whole gastrointestinal tract together with a decrease in propulsive peristalsis secondary to 
opioid administration (16, 17). Although the results of histological 
examination are not commonly reported in the literature, they may identify an underlying cause and allow diagnosis of associated or concurrent 
diseases (11). In our case a portion of the affected 
intestine had been submitted for histology 
examination. Intussusception was considered 
idiopathic because the results revealed only 
inflammatory changes considered secondary to the intussusception. Major limitation of the 
present case report is the lack of faecal parasite examination which may have ruled out parasitism 

as cause of intussusception. Metoclopramide stimulates motility of the 
upper gastrointestinal tract; gastric emptying and 
intestinal transit time can be significantly reduced but has no effect on colon motility. It also increases 
duodenal and jejunal peristalsis (18), therefore it should not be used when gastrointestinal obstruction is suspected (19), as metoclopramide 
may cause constipation itself (18). Side effects are 
uncommon in metoclopramide therapy but occur 
more often in cats than in dogs (19). Menbutone is indicated for constipation and 
intestinal atony in dogs and large animals (20) and should according to manufacturer’s instructions 
never be given to cats. The product contains cresol 
and cats have limited ability to glucoronidate it 
(21). Menbutone increases the excretion of the 
bile, the gastric and the pancreatic juice into 
the gut by two- to five-fold the normal secretion, 
stimulates the function of the gastrointestinal 
tract and increases peristalsis (22). With regard to the fact that metoclopramide was 
given to our cat in overdose (1 mg/kg) compared 
to 0.2 – 0.4 mg/kg, which is recommended dose for cats by Plumb, 2011, and vomiting 
occurred after overdosed therapy with it we assume that metoclopramide was the cause of 
vomiting. However, vomiting in a cat may have 
also appeared due to formation of jejunojejunal intussusception as a result of application of both drugs metoclopamide and menbutone, which increased jejunal peristalsis, since the cat was 
already unable to defecate for seven days. On the 
other hand initially intussusception, if already present, might have caused only partial intestinal obstruction, which had progressed to complete obstruction after the prokinetic and choleretic therapy and to worsening of clinical signs, which 
had already been present for four days. It was 
in our cat impossible to discern whether the cat was initially presented with intussusception, because the duration of illness in cats varies 
from 12 hours to three weeks (7). Application of 
metoclopramide in gastrointestinal obstruction may delay diagnosis (19), in general in jejunojejunal intussusception the duration of signs is longer 
than in ileocolic intussception (7). However due to 
acute worsening of clinical signs after the therapy we assume that prokinetic and choleretic therapy 
caused intussusception. Intussusception should 
be included in the differential diagnosis of all cats presented with typical signs of intussusception, 
i.e. anorexia, lethargy and vomiting. We conclude 
that metoclopramide should be given with caution or not given at all in cats presented with obstipation as it may cause the intussusception or, if already present, partial intestinal obstruction 
may progress to complete obstruction (23). The 
prognosis for cats with intussusception appears to be good given appropriate medical and surgical 
treatment (7). 


References 
1. Applewhite AA, Hawthorne JC, Cornell KK. Complications of enteroplication for the prevention of intussusception recurrence in dogs: 35 cases (1989–1999). J Am Vet Med Assoc 2001; 219: 1415–8. 
2. Oakes MG, Lewis DD, Hosgood G, Washabau RJ. Enteroplication for the prevention of intussusception recurrence in dogs: 31 cases (1978–1992). J Am Vet Med Assoc 1994; 205: 72–5. 
3. Weaver AD. Canine intestinal intussusception. Vet Rec 1977; 100: 524–7. 
4. Burkitt JM, Drobatz KJ, Saunders HM, Washabau RJ. Signalment, history, and outcome of cats with gastrointestinal tract intussusception: 20 cases (1986–2000). J Am Vet Med Assoc 2009; 234: 771–6. 
5. 
Lamb CR, Mantis P. Ultrasonographic features of intestinal intussusception in 10 dogs. J Small Anim Pract 1998; 39: 437–41. 

6. 
Levitt L, Bauer MS. Intussusception in dogs and cats: a review of 36 cases. Can Vet J 1992; 33: 660–4. 

7. 
Bellenger CR, Beck JA. Intussusception in 12 cats. J Small Anim Pract 1994; 35: 295–8. 

8. 
Hedlund CS, Fossum TW. Surgery of the digestive system. In: Fossum TW, ed. Small animal surgery. St. Luis: Mosby, 2007: 339–530. 

9. 
Radlinsky MG. Surgery of the digestive system. In: Fossum TW, ed. Small animal surgery. St.Luis: Mosby, 2013: 386–583. 


10. Applewhite AA, Cornell KK, Selcer BA. 

Diagnosis and treatment of intussusceptions in 
dogs. Compend Contin Educ Vet 2002; 24: 110– 26. 
11. Levien AS, Baines SJ. Histological 

examination of the intestine from dogs and cats 
with intussusception. J Small Anim Pract 2011; 52: 599–606. 
12. 
Patsikas MN, Papazoglou LG, Papaioannou NG, Savvas I, Kazakos GM, Dessiris AK. Ultrasonographic findings of intestinal intussusception in seven cats. J Feline Med Surg 2003; 5: 335–43. 

13. 
Larsen LH, Bellenger CR. Stomach and small intestine. In: Archibald J, ed. Canine surgery. 2nd ed. Santa Barbara: American Veterinary Publications, 1974: 583–5. 

14. 
Wolfe DA. Recurrent intestinal intussusceptions in the dog. J Am Vet Med Assoc 1977; 171: 553–6. 

15. 
Ellison GW. Intestine. In: Boyrab MJ, El­lison GW, Slocum B, eds. Current techniques in small animal surgery. Baltimore: Williams & Wil­kins, 1998: 246–56. 


16. McAnulty JF, Southard JH, Belzer FO. Prevention of postoperative intestinal intussusception by prophylactic morphine administration in dogs used for organ transplantation research. Surgery 1989; 105: 494–5. 
17. 
Hammamond R, Christie M, Nicholson A. Opioid analgesic. In: Maddison JE, Page SW, Church DB, eds. Small animal clinical pharmacology. Edinburgh: Saunders, 2008: 309–29. 

18. 
Plumb DC. Plumb's veterinary drug handbook. 7th ed. Stockholm, Wisconsin: PharmaVet, 2011: 677–80. 


19. 
German AJ, Maddison JE, Guilford G. Gastrointestinal drugs. In: Maddison JE, Page SW, Church DB, eds. Small animal clinical pharmacology. Edinburgh: Saunders, 2008: 469–97. 

20. 
Menbutone. El Oubor, Egypt: Adwia Pharmaceuticals, 2011. http:// www.adwia.com/index.php?option=com_ tent&view=article&id=151&Itemid=169&lang=en (accessed 14 March 2013) 


21. Andersen A. Final report on the safety as­sessment of sodium p-chloro-m-cresol, p-chlo­ro-m-cresol, chlorothymol, mixed cresols, m-cre-sol, o-cresol, p-cresol, isopropyl cresols, thymol, o-cymen-5-ol, and carvacrol. Int J Toxicol 2006; 25: 29–127. 
22. Committee for veterinary medicinal pro­ducts. Menbutone. London: EMEA, European Agency for the Evaluation of Medicinal Products, 1996. http://www.ema.europa.eu/docs/en_GB/ document_library/Maximum_Residue_Limits_-_ Report/2009/11/WC500015023.pdf (10 march 2013) 
23. Batchelor DJ, Devauchelle P, Elliott J, et al. Mechanisms, causes, investigation and mana­gement of vomiting disorders in cats: a literature review. J Feline Med Surg 2013; 15: 237–65. 

RETROGRADNA INVAGINACIJA JEJUNUMA PRI ENO LETO STARI MAČKI PO ZDRAVLJENJU Z METOKLOPRAMIDOM IN MENBUTONOM 
Povzetek: Invaginacija je uvihanje ali prolaps enega dela crevesja v drugi del pred ali za njim. Pri mladih mackah je navadno idiopatska, medtem ko je pri starejših pogostejši vzrok primarno gastro-intestinalno obolenje, t.j. neoplazija. Posledica invaginacije je delna ali popolna obstrukcija, ki se kaže z razlicnimi klinicnimi znaki, odvisno od trajanja, obsega in lokacije invaginacije. V literaturi nismo zasledili neposredne povezave med invaginacijo in prokinetiki ali holeretiki. Leto star macek, pasme main coon je bil pripeljan na kliniko z anamnezo, da nima apetita, da je apaticen in že nekaj dni ne more odvajati blata. Dva zaporedna dneva je bil zdravljen z metoklopramidom, ranitidinom, hioscinijevim butilbromidon in menbutonom. Dan po zdravljenju je zacel bruhati. Po treh dneh bruhanja je bil moribunden pripeljan na kliniko. Z ultrazvocnim pregledom trebuha smo v levem mezogastriju našli maso z multiplimi koncetricnimi hipo- in hiperehogenimi krogi, ki je znacilna za invaginacijo crevesja. Predstavljamo primer invaginacije crevesja pri obstipirani macki po aplikaciji prokinetika metoklopramida in holeretika menbutona. 
Ključne besede: macka; invaginacija jejunuma; kirurgija; prokinetik; holeretik