13. Diarrhoea & Haematochezia

Question 1

History/questions to ask the owner?

Answer 1

History:
Duration?
Acute or chronic
Any weight loss, vomiting, blood In, diarrhoea, lethargy?
Determine the severity.
Description of diarrhoea?
Determine If small or large Intestinal, both
Diet history, vaccination, deworming, concurrent medication?
Determine the possible cause?

Question 2

Small intestinal features?

Answer 2

Increased faecal bulk/water
No straining
Projectile
Melaena
Not urgent

Question 3

large intestinal features?

Question 4

Mixed Bowl features?

Answer 4

. Increased faecal bulk/water
. Straining
. Fresh blood
. Mucous
. Not urgent

Question 5

Acute gastrointestinal disease?

Question 6

Acute extra gastrointestinal disease

Question 7

Chronic gastrointestinal disease?

Question 8

Chronic extra gastrointestinal disease?

Question 9

Large intestinal causes?

Answer 9

*Infectious:
>Parasites: Whipworm, Tritrichomonas, Cryptosporidia
»Bacterial: Clostridia
> Fungal: Pythiosis, Histoplasmosis
* Diet:
> Fibre-deficiency
> Food Intolerance
> Indiscretion
* infiltrative:
> Inflammatory bowel disease
> Lymphangiectasia
»- Neoplasia - lymphoma, adenocarcinoma)
* Structural obstructions:
> Foreign body
> lntussusceptions
* Strictures

Question 10

Causes of Haematochezia?

Answer 10

Causes of haematochezia:
Inflammatory - Inflammatory bowel disease, histiocytic ulcerative colitis (boxers)
./ infectious:
> Parasites: Whipworm, hookworm, Giardia
> Bacterial: Clostridia
> Viral: Parvovirus
> Fungal: Histoplasmosis, Pythiosis
./ Neoplasia:
Lymphoma
Adenocarcinoma
Trauma and coagulopathy
Haemorrhagic gastroenteritis
Anal gland disorders

Question 11

All cases of dlarrhoea/haematochezla:
Diagnostics?

Answer 11

All cases of dlarrhoea/haematochezla:
Diagnostics:
>General physical examination and rectal examination
>PCV/TP
>Coagulation testing If haematochezla
> Faecal smears and faecal floatation:
>Assess for parasitic causes
>Stained: Normal bacterial population Is mixed, uniform population Is abnormal, large >spore-forming
>gram positive rods (clostridia - look like safety pins”)
> Wet preparation: Assess for motile bacteria (shoot through the field)
>Giardia ELISA test
>Virus testing:
>Parvovirus/coronavirus antigen test

Question 12

Indications for further diagnostics?

Answer 12

Indications for further diagnostics:
>Hypoproteinaemla (DOx: protein losing enteropathy/nephropathy, liver disease)
>Anaemia
>Systemic signs of illness and abdominal pain
>Reoccurring alter symptomatic therapy
> Older animal
> Polyphagia, steatorrhea
> Weight loss
> Palpable abdominal or rectal abnormality

Question 13

Other diagnostics for chronic diarrhoea/hematochezia?

Answer 13

> Biochemistry and haematology, urinalysis
UPC to rule out extra-gastroIntestinal causes of hypoproteinaemia
Total T4: Hyperthyroidism
Trypsin-like Jmmunoreactivity: To assess for exocrine pancreatic Insufficiency
FIV and FeLV
Imagery:
Radiography
Ultrasound +/· aspirate
Serum folate:
Decreased can be due to Jejunal abnormalities leading to malabsorption of folate
Increase can be consistent with Increased bacterial population e.g. Bacterial overgrowth
Serum cobalamin:
Decreased can be due to Heal abnormalities leading to malabsorption of cobalamin
» Important in feline chronic gastrointestinal disease as supplementation can Improve clinical
outcome
Endoscopy and mucosal biopsy
Laparotomy and full-thickness biopsy

Answer 14

Treatment according to clinical signs:
Acute and not severe, systemically well:
* Symptomatic treatment:
,. Diet change to a novel or hydrolyzed diet
,. Smaller meals of increased frequency
,. +/- Fenbendazole 50mg/kg SID for 5 days
,. +/· Antibiotics if large breed or suspecting antibiotic responsive enteropathy
* Melronidazole 1 Omw!<g PO BID
Acute and severe, small lnteatlnal:
* Hospitalise: Supportive therapy, IV fluid support and IV antibiotics
* Bowel rest (adults 24 hours, NOT In puppies)
* Furd’ler diagnostics

Answer 15

Chronic, large lntestlnal: . * Rectal examination: Palpate for any abnorrnalltles such as mass lesions or narrowing
* Symptomatic treatment.
:,. Fibre supplementation psyltlum 1-2 tablespoons per day o·r low residue diet
> Fenbendazole SOmg/kg SID for 3 days
* Fallure to respond try hydrolysed or novel protein diet
* Endoscopy and biopsy
Chronic, amall lntesUnal:
* Failure to respond lo empirical trials:
> Diet change lo novel or hydrolyzed diet
,. Fenbendazole 50mg/kg SID for 3 days
,. Antibiotics for 2-3 wee,ks H large breed or suspecllng antibiotic responsive enteropathy (SIBO)
* Metronidazole 1 Omg/kg BIO OR
* Tylosin 20mg/kg BID OR
* Oxytetracycline l5mg/kg BID
* Bloo”d profile: Assessment of systemic disease
* TU: Assessment of EPI
* Imagery and endoscopy and biopsy

Answer 16

Parasitic aastro9nter1t1si
Giard/a (Zoonotlc):
-I’ Fenbendazole SOmg/kg PO SID for 3 days
-I’ Metronldazole 20mg/kg PO BID for 1 O days (higher dose required - but beware neurologlcal signs)
Intestinal worms:
-I’ Roundworm, Hookwonn, Whfpworm:
;.. Fenbendazole 50mg.lkg PO SID for 3 days, off label In cats
./ Tapewonns:
· :> Praziquantel 3·7mg/kg PO
> 4 times label dose for Spirometra
Coccidla spp:
./ 10 - 40µm In length depending on the species
-I’ Toltrazuril 20mg/kg PO SID for 2 days
Cryptosporldlum (Zoonotlc) (5pm In length):
./ Can be present In low numbers normally, and may be associated with other causes of diarrhoea e.g.
parasites (worms and Giard/a) and viruses but can contribute to the severity of the diarrhoea
./ Most commonly In young animals
./ Treat underlying disease process and manage symptomatically
Campylobacter (Zoonotlc):
./ Small, gram negative, curved rod, motile bacteria
./ Can be present In low numbers normally, and may be associated with other causes of diarrhoea e.g.
parasites (worms and Gfardla) and viruses but can contribute to the severity of the diarrhoea
./ Erythromycln 1 Omg/kg PO TID for 1 to 2 weeks
./ Tylosln 15mg/kg PO BID for 7 days

Answer 17

Haemorrhagic gastroenterUIBi
Palhophyslology:
./ Thought to be due to either a hypersensitivity or Clostridla toxins
./ Inflammation leads to rapid loss of fluid Into gastrolntestfnal tract leadlng to marked
haemoconcentratlon and dehydration
./ Associated with acute vomiting and then diarrhoea with blood, symptoms of shock
./ Must rule out other causes of haemorrhagic vomiting and diarrhoea
Treatment:
., Aggressive IV fluld therapy, correction of perfusion and dehydralion deficits and electrolyte
abnormalit!es
., Antibiotics: Ampicllltn 22mg/kg TIO or metronidazole 10mg/kg IV BID
., Ant!emetlc: Meloclopramlde CAI 1-2mg/kg/day IV and others
./ Gastric protectants: Ranltldlne 2mg/kg BID, sucralfate 0.5-1gm PO TIO, proton pump Inhibitors
./ Anaemia: Blood transfusion, see “Transfusion therapy”
./ +I· Colto!d therapy: II hypoprotelnaemia develops either synthetic colloid or plasma transfusion

Answer 18

Viral diarrhoea:
Features:
./ Typ!cally, In young unvacc!nated puppies
./ Parvovrrus is a very severe debllitatlng disease, coronavlrus rs usually less severe

Answer 19

Paryoylrus:
Pathophyslology:
v Parvovlrus targets and destroys rapidly dividing cells such as Intestinal lining and bone marrow
./ Typically, Jn young unvacclnated dogs, but can occur in previously vaccinated animals
./ False positives: Can occur up to 12 days post-vaccination especially if a modified live vaccine was
used. Still manage as a positive if consistent clinical signs and history. Leukopenla can help provide
supportive evidence .
./ Fellne panleucopenia virus: Rare in cats, use canine parvovirus test to diagnose
./ 90% mortatlty rate wllhout treatment, 80% survival rate with aggressive management
./ ResUient viruses, persist In the environment lot up to a months, likely to be a major source of Infection
./ Highly contagious viruses that are spread prlmarily by ingestion of affected anlmal’s faecal material:
Diagnostics:
./ Parvovlrus antigen ELISA
./ PCV/TP, haematology, biochemistry
./ Others listed above (e.g. faecal analysis)

Answer 20

Treatment:
,; lsolatlon and barrier nursing
,; Supportive therapy: Keep warm and quiet
,1 Fluid therapy: Aggressive IV lluid therapy, correction of perfusion and dehydration deflCits and
electrolyte abnormalities
,1 Antiemetlc: Metoclopramlde CAI 1-2mg/kg/day IV, maropitant 1mg/kg SC SID for <5 days
,1 Gastric protectants: Ranitldine 2mg/kg BID, sucralfate 0.5-1gm PO TIO, protOn pump-Inhibitors
../ IV antibiotics:
> Broad spectrum bactericidal
), If not leukopenla: Cephalothln 22mg/kg IV T\D and metronldazole 10mg/kg IV BID
> If leukopenia: Tlcarcillln 50mg/kg IV CJD
./ Transfusions:
> Blood it anaemia develops
> +I- Plasma for oncotic support If hypoalbuminaemia is present
,1 Early enteral nutrition:
l1> Important, start If anorexic >2 days
»- Mlcro-entera\ leading with electrolyte solutions via tube feeding (naso-0esophageal tubes) then
progress to fOOd
Monitoring:
./’ Temperature, pulse and respiration, hydration status OID, body weight, PCV/TP and electrolytes SIDBID
Prevention:
./’ Vaccination ls very effective, vaccinate all animals
./’ lsolatlon of Infected animal as they can shed virus for up to 40 days after recovery
./’ Beware the virus can remain in the environment for up to 8 months, do not allow unvaccinated animals
access to that environment
./’ Isolation of puppies away from other unvacclnated animals at least 2 weeks after final vaccination
./’ Clean and disinfect the environment

Answer 21

Prgtejn lqslng aptergpgthy (PLE)j
Pathophyalology:
‘ A cause of hypoprotelnaemia, due to a loss of protein through the gastrointestinal tract.
./’ Always see a loss of albumln but usually also globulln
‘ . Diarrhoea with hypoalbumlnaemla suggests PLE bu! li)’Poalbumlnaemla wittiout diarrhoea does not·
rule out PLE · ·
./ May lose antithrombin Ill and predispose to thromboembolism
Caused:
‘ Generally,. by chronlcgastro!ntestinal .disease such as inllammatoiyboweJ disease, neoplasla : ·. ·::
(lymphoma and adenocarclnoma), Infectious diseases (parasites, fungal infections), lymphangleclasja_,
gastric ulcerations, cardiac disease (RHS). May also be caused by acute gastrolntestlnal dlsease_su.ch
as canine haemorrhagic gastroenteritis. · · ·
Clinical signs:
./ Weight loss
./ +I· Diarrhoea, +/- vomiting
» Lack of vomiting or diarrhoea does not rule out PLE
./ +I- Abdominal or pleural effusions, peripheral oedema
Diagnostics:
./ Require full diagnostic work-up, Including biopsies (via endoscopy or laparotomy) and hlstopatho!cigy

Answer 22

loflamroatgry b9wel disease {IBD):
,1 lnflammatlon of the small and large Intestine
,1 Diagnosis Is based on biopsy and hlstopathology
,1 Types of Inflammation:
), Small Intestine: Lymphocytic plasmacytic (most common form In both dogs and cats), but can be
eoslnophilic
»- Large Intestine: Lymphocyttc plasmacytlc, eosinophilic, hlstfocytlc ulcerative colitis (boxers and
French bulldogs), fibre-responsive
./ Feline IBD Js commonly associated with chronic pancreatitis or chofangiohepatitfs

Answer 23

Lymphocytlc plasmacytlc Inflammatory bowel disease:
./ Small Intestinal:
), Diet change to novel or hydrolysed diet:
* Important ln cats
) lmmunosuppressive therapy:
Prednisolone at 1-2mg/kg PO BID until resolution, then 20% reduction every couple weeks
o Dogs: Azathloprlna or budesonide can be used for long term control or adjunctive therapy
o Cats: Chlorambuci1 good for long tenn but monitor for lmmunosuppresslon
> +I· Metronidazote 10mg,’kg PO BID
) Supplement:
* Omega 3/6 latty acids
Vitamin 812 injection at 250µg SC weekly or fortnightly
./ Large Intestinal:
> Diet change to novel or hydrolysed diet
) II no response:
Trial fibre supplementatlon and sulfasatazine
Prednisolone at 1·2mg/kg PO BID until resolution, then 20% reduction every couple weeks

Answer 24

Eoslnophlllc Inflammatory bowel disease:
./ Must rule out hypersensitivity, hypereoslnophilic syndrome and parasites
,1 lmmunosuppression therapy and novel or hydrolysed diet
Hlsllocytlc ulcerative colitis:
./ Usually in Boxers and French Bulldogs, associated with haematochezla
./ Responsive to enrofloxacln 5mg/kg/day PO 6·8 weeks