Dietary Sensitivity and Chronic Inflammatory Enteropathies

Question 1

Which dietary sensitivities are non-immunologically mediated?

Answer 1

Repeatable - food intolerance
Non-tolerance - dietary indiscretion, intoxication, contamination (poisoning)

Question 2

Which dietary sensitivities are immunologically mediated?

Answer 2

Food allergy (hypersensitivity) - repeatable, often suspected but rarely proven

Question 3

Describe adverse food reactions (food allergies).

Answer 3

Immunologically mediated, usually to a protein
Oral tolerance = complex series of signalling and processing events resulting in ‘tolerance’ of foreign antigens - failure of this leads to AFR
Most commonly manifest as delayed hypersensitivity (type 4)
Commonly affects dermatological and/or GI systems

Question 4

What are the clinical signs of a food allergy?

Answer 4

Pruritis/erythema - most common, usually seen without GI signs
GI - vomiting/diarrhoea, non-specific so need to differentiate from other causes
Systemic - anaphylaxis

Question 5

How do we diagnose and manage a food allergy?

Answer 5

Exclusion/limitation - choose specific diet with novel/hydrolysed proteins, limit to only specific diet
Challenge and rescue - put back on original diet to see if problems recur
Provocation and rescue - add in one allergen at a time to see which causes recurrence
Maintenance

Question 6

Define chronic inflammatory enteropathies (CIE).

Answer 6

Group of diseases with chronic GI inflammation
Symptoms = vomiting, diarrhoea, dysorexia, weight loss
>3 weeks duration

Question 7

What other diseases must be excluded before a diagnosis of CIE can be made?

Answer 7

Exocrine pancreatic insufficiency
Local abdominal inflammation (pancreatic, renal, hepatic)
Metabolic e.g. portosystemic shunts, hypoadrenocorticism, hyperthyroidism

Question 8

How can we diagnose chronic inflammatory enteropathies?

Answer 8

Exclusion of other causes of symptoms
Lab tests e.g. faecal analysis, bloods
Imaging e.g. abdo ultrasound
If normal - diagnosis of CIE
Biopsies indicating BOTH inflammation and architectural changes e.g. villi atrophy

Question 9

What are some causes of chronic inflammatory enteropathies?

Answer 9

Food responsive disease - diet trial
Antibiotic responsive disease - select breeds only
Idiopathic disease - endoscopy

Question 10

Describe idiopathic CIEs.

Answer 10

Previously termed IBD
Immunological disorder
Loss of tolerance to mucosal flora

Question 11

Describe laparotomy biopsies.

Answer 11

Enables multiple full-thickness biopsies
Enables full exploration of other organs
Surgical risk of dehiscence

Question 12

Describe endoscopy biopsies.

Answer 12

Minimally invasive
Small mucosal biopsies
May not reflect jejunal disease

Question 13

What are the consequences/complications of CIEs?

Answer 13

Dehydration
Protein losing enteropathy - hypoalbuminaemia (leads to pleural/peritoneal effusions, oedema, thromboembolic events)
Hypocobalaminaemia
GI haemorrhage +/- anaemia
GI perforation (rare)

Question 14

How can we supportively manage CIEs?

Answer 14

IVFT and electrolyte balance
Nutrition - exclusion diet, tube feeding in severely affected patients, anti-emetics/appetite stimulants

Question 15

What medications can we use to manage CIEs?

Answer 15

Immunosuppression - prednisolone +/- adjuncts
+/- fenbendazole
+/- metronidazole
+/- vitamin B12
+/- anti-platelet drugs

Question 16

How do we carry out a dietary trial?

Answer 16

Feed exclusively with water for 3-10 weeks
Derm typically responds within 10 weeks
GI typically responds within 3 weeks

Question 17

What are the two options for food intolerance trials?

Answer 17

Novel protein/carbohydrate
Hydrolysed protein

Question 18

What nursing considerations should we have for animals with CIEs?

Answer 18

Hydration status - ongoing losses e.g. vomiting/diarrhoea
Inappetance/nausea
Nutrition status
Abdominal discomfort
Hypoproteinaemia
Diarrhoea/faecal scald

Question 19

How can we help patients with abdominal discomfort?

Answer 19

GI ulceration - omeprazole, sucralfate
Reflux - manage oesophagitis, postural feeding
Opioids BUT may cause/worsen ileus
Buscopan, spasmolytics

Question 20

How can we manage diarrhoea / faecal scald?

Answer 20

Clean bottom and keep dry
Topical barrier e.g. Cavilon spray, Vaseline
Tail bandages/clip fluffy tails
Avoid patient grooming
Absorbent bedding, top layer should be soft blanket

Question 21

What should we monitor in hospitalised patients with CIEs?

Answer 21

Weight
Appetite
Demeanour
Vomiting/diarrhoea
Hydration/volaemic status
HR, RR
Comfort levels
Bloods e.g. electrolytes, proteins