Chronic disorders of small intestine Flashcards
List of chronic SI disorders
- CIE: chronic inflammatory enteropathy
- lymphangiectasia
- neoplasms of small intestine
- subileus (partial obstruction)
- infectious (rare)
- protein losing enteropathy is a special consequence of severe chronic SI disorders when protein (esp albumin) is lost through GIT
Chronic inflammatory enteropathy. Definition
- ## persistent or intermittent chronic GI signs
CIE. Pathomechanism
- important function of GIT is to be able to tolerate the content of the lumen
- if local immune system loses this tolerance -> abnormal response -> chronic inflammation
Possible reasons of losing tolerance:
- primary problem of the local immune system
- severe destruction of gut barrier integrity (e.g. parvo)
- severe dysbiosis
CIE. Types based on response to the therapy
- Food -responsive enteropathy (
- ~80% of patients will respond to dietary management - Dysbiosis treatment responsive enteropathy
- includes antibiotic responsive enteropathy - Steroid/immonusuppressant responsive enteropathy
- includes inflam bowel disease - Non-responsive enteropathy
What is present in all groups of chronic inflam enteropathy ?
- inflammation
- diet response
- dysbiosis
BUT it will be with different significance among the group. For example diet change alone will help in food responsive enteropathy but it wont be enough for others but diet management still should be applied to all groups !!!
THERE IS NO CIE TREATMENT WITHOUY SPECIAL DIET
Food responsive enteropathy. Forms, types
THERE IS NO CIE TREATMENT WITHOUY SPECIAL DIET
Background: adverse food reaction (AFR)
Forms:
- cutaneous form (CAFR): pruritis
- non-cutaneous form (nonCAFR) : GI signs > resp signs, other
Types:
1. Food allergy: immune system involved
2. Food intolerance: immune system NOT involved (e.g. lactose intolerance)
But clinical consequences are similar
FRE. Symptoms, allergens
Chronic GI signs +- skin lesions (pruritis), otitis externa
Most common allergens = proteins:
Dogs: beef, CHICKEN, dairy, wheat (egg, soy, lamb)
Cat: beef, dairy, FISH, lamb, chicken, wheat
FRE. Diagnosis
- elimination -> provocation -> elimination
- length of elimination is min 2 weeks (if skin is affected - min 8 weeks); if diarrhea improve - continue for 12 weeks
- food allergen specific IgE serology IS NOT APPROPRIATE
- often owners don’t do provocation because problem is gone
Why is food allergen specific IgE serology is not appropriate to diagnose FRE?
- Not always its allergy reaction (intolerance)
- Even if its allergic reaction usually its usually not mediated by IgE( delayed type of hypersensitivity and not immediate)
How does elimination diet work
Types:
- one, NOVEL protein (never fed before)
- hypoallergenic diet: limited ingredient or hydrolysed protein (wont cause reaction)
- home made
Diet should be highly digestible, “hidden” allergens should be avoided (treats, flavoured drugs)
Dysbiosis treatment responsive enteropathy
Earlier was called antibiotic responsive enteropathy
Was renamed because now usage of ABs in this condition is very limited (resustant strains)
Intestinal microbiota
- ~ organ
- huge number and diversity
- very complex function: gut function and integrity, local and systemic immunity, protection from pathogens, production of nutrients and vitamins, influence other organs
Dysbiosis. Pathomechanism
Imbalance in the composition of microbiome. Exact pathomechanism is not clear
- trigger (food, drugs, stress)
- genetic predisposition may also play a role
- dysbiosis can become cause of CIE and CIE can become cause of dysbiosis
- trigger —> dysbiosis —> toxic metabolites production, nutrient deficiency (SCFA, B12), decrease of antipathogenic activity)
- consequences are various: nothing, CIE, malabsorption, extraintestinal disorders (still researched)
ARE (antibiotic responsive enteropathy)
- only in idiopathic from of dysbiosis whn no background van be distinguished
- ABs can be used (tylosine, metronidazole)
- German shepherds are predisposed
Dysbiosis. Diagnosis
- routine culture is not suitable
- microbiota dysbiosis index: quantitative PCR (if number is negative: healthy; if more than 2 -> severe dysbiosis)
Dysbiosis. Treatment
- goal: to reach a balanced microflora
- pre, pro, symbiotics
- fecal microbiota transplantation best treatment; can be done through rectal enema or per os with capsule
- support of GIT function: highly digestible diet, vitamins (e.g. B12)
- antibiotics: nowadays try to avoid: tyrosine, metronidazole; common that patients relapse after stop of using ABs
Steroid/immunosuppressant responsive enteropathy vs inflammatory bowel disease
- not very big difference (often used interchangeably)
- if confirmed with histopathology —> IBD: idiopathic inflammatory bowel disease
IBD. Histopathology
Based on predominant infiltrating cell type
- LPE: lymphocytic-plasmacytic enteritis: most common
- EGE: eosinophilic gastroenteritis
- neutrophilic and granulomatous quite rare
-
IBD. Clinical signs
- Chronic diarrhea, recurrent
- often weight loss
- usually polyphagia but can be inappetance in case of pain
- gastroesophageal reflux is common
- severe IBD may lead to PLE (protein losing enteropathy): hypoalbuminemia, ascites
IBD. Diagnosis
Definitive diagnosis: HISTOPATH
NOT specific:
- hypoproteinemia
- eosinophilia (EGE)
- cobalamin decreased, folate decreased
- thicken SI loops, lymphadenopathy
Specific: endoscopic findings, diagnostic laparotomy
CIE. Treatment.
- Deworming (to exclude parasitic background)
- Diet: if improves: 12 weeks; in no ->
- Dysbiosis treatment: min 1 month, if no improvement ->
- Immunosuppression: prednisolone
PLE. Causes
Cause:
- dilatation and dysfunction of intestinal lymphatic vessels (primary lymphangiectasia, Yorkshire terrier)
- severe diffuse infiltrative enteropathy (severe CIE, intestinal neoplasia)
PLE. Clinical signs
- protein loss -> oncotic pressure drops -> ascites, hydrothorax
- fat malabsorption + muscle loss -> weight loss, malnutrition
- +- chronic diarrhea
- thromboembolia: rare and severe complication
PLE. Diagnosis
Lab findings:
- hypoproteinemia
- hypocholesterolemia
- lymphopenia
Endoscopical findings:
- “rice-grain” nodules (dilated lecteals)
Abdominal USG:
- hyperechoic mucosal striation (dilates lacteals)
Specific diagnosis:
- intestinal biopsy -> histopathology
PLE. Treatment
- diet: ultra low fat to decrease work of lacteal, if no response ->
- steroid anti-inflammatory dose, if not enough + immunosuppressant (cyclosporine)
- increase oncotic pressure: colloid infusion, plasma, enteral feeding
- high risk of thrombosis: clopidrogel
Neoplasms of the small intestine
- alimentary lymphoma
- intestinal adenocarcinoma
- leiomyosarcoma
- GIST: gastrointestinal stromal tumour
Clin signs: chronic diarrhea, weight loss, Melendez, vomiting
What are differences in alimentary lymphoma in cats and dogs
Cat:
- low grade intestinal T-cell lymphoma (LGITL)
- common
- less severe than in dogs
- similar to severe IBD
Dog:
- more severe and much more malignant
Ileus. Definition
Disruption of the normal propulsive GI motor activity —> blockage of nutrients delivery
Ileus. Classification
-
Mechanical Ileus = intestinal obstruction
- = lumen is occluded partially or completely
- intraluminal/intramural/extramural -
Functional Ileus
- =lumen is open but peristalsis is stopped
- paralytic/vascular bowel daises (thrombosis, shock)/spastic bowel segment
Intestinal obstruction. Cause
Usually foreign body
- solid or cavitation object
- linear foreign body (can get stuck under tongue or at area of pylorus —> check them!)
Foreign body Ileus. Pathophysiology
- intestinal spasm, ischemia —> pain
- impaired peristalsis —> vomiting, dysbiosis
- fluid, acid-base and electrolyte imbalance (dehydration, hypokalemia, hypochloremia)
- impaired gut barrier integrity (bacterial translocation, endotoxemia, septicemia, septic peritonitis, perforation)
Foreign body obstruction. Clinical signs and diagnosis
- more common among young dogs of large breeds
- inappetance, depression, abdominal pain
- vomiting (more proximal obstruction -> more severe vomiting)
- can be palpated but not always
- unequally wide intestines
- plain radiography, contrast radiography
- USG : unequally wide loops, pendular movement (peristalsis-antiperistalsis alternate)
- diagnostic laparotomy
Intususception
= invagination (telescoping) of one part of the intestines into another
- most often young animals
- idiopathic or secondary to diseases causing dysmotilty
- hematochesia, vomiting, abdominal pain
- sausage- shaped mass may be palpable
- abdominal USG: transverse view: ”target sign”
- treatment: surgery
Foreign body Ileus. Treatment
Preoperative:
-fluid therapy
- ABs
Surgical:
- resection of necrotic parts
- sterile lavage of peritoneal cavity
Postoperative
- fluid therapy, analgesia
- enteral feeding asap
- prokinetic drugs sometime
