Exam 1 - Weight Loss Due To Malassimilation

Question 1

what are the 3 main causes of weight loss in small animals?

Answer 1

decreased caloric intake

malassimilation

hypermetabolic state

Question 2

how can you differentiate protein losing enteropathy from other causes of severe hypoalbuminemia?

Answer 2

start with cbc/chemistry, fecal, urinalysis, gi panel, & baseline cortisol

must rule out other diseases that cause hypoalbuminemia

Question 3

what is malassimilation?

Answer 3

decreased ability of the gi tract to incorporate nutrients into the body

Question 4

what 2 components make up malassimilation?

Answer 4

maldigestion & malabsorption

Question 5

what is maldigestion? what is a common example of this?

Answer 5

failure of adequate degradation of dietary constituents within the gi tract

EPI

Question 6

what is malabsorption?

Answer 6

failure of passage of nutrients from the intestinal lumen into the bloodstream

Question 7

what is protein losing enteropathy?

Answer 7

loss of protein from the intestines due to intestinal disease - strictly any disease causing intestinal protein loss is a PLE

Question 8

T/F: in order to cause protein loss, there has to be a mucosal injury or lymphatic obstruction in the intestines

Answer 8

true

Question 9

what is the most common cause of PLE in dogs?

Answer 9

intestinal lymphangiectasia

followed by inflammatory bowel disease

Question 10

how is intestinal lymphangiectasia characterized?

Answer 10

dilation of the intestinal lymph vessels resulting in the leakage of protein rich fluids into the intestines

Question 11

what dog breeds are predisposed to primary intestinal lymphangiectasia?

Answer 11

yorkies, maltese, rottweilers, & norwegian lundehunds

can lead to secondary inflammation

Question 12

what causes secondary intestinal lymphangiectasia?

Answer 12

obstruction of the lymphatic vessels from either inflammation or increased venous pressure

Question 13

T/F: in practice, it is often impossible to differentiate between primary & secondary intestinal lymphangiectasia

Answer 13

true

Question 14

what are the most common causes of PLE in dogs?

Answer 14

intestinal lymphangiectasia

IBD

others: neoplasia (lymphoma), fungal, intussusception, & gi parasites

Question 15

when trying to diagnose inflammatory bowel disease, what other causes of inflammation should you rule out first?

Answer 15

food responsive enteropathy

antibiotic responsive enteropathy

parasites

Question 16

inflammatory bowel disease is characterized by ______ _________ ___ _____ ______ ____

Answer 16

chronic inflammation of the gi tract from things such as dietary antigens, their intestinal microbiome, & host-immune response

Question 17

what are the most common inflammatory cell types seen in IBD dogs?

Answer 17

lymphocytes & plasma cells

Question 18

how is IBD classified?

Answer 18

according to the predominant cell type

Question 19

T/F: in order to cause protein loss, the IBD must be severe

Answer 19

true

Question 20

what are the major consequences of PLE?

Answer 20

decreased oncotic pressure - leading to edema, ascites, & loss of fluid from the dog’s circulation

malnutrition

increased risk of thromboembolism

hypomagnesemia/hypocalcemia

Question 21

what dog breeds are at risk for developing IBD?

Answer 21

yorkies, soft-coated wheaten terrier, norwegian lundehund, basenji, & rotties

Question 22

T/F: some dogs with IBD have no clinical signs

Answer 22

true

Question 23

what clinical signs are commonly seen in dogs with IBD?

Answer 23

usually small bowel diarrhea, vomiting, weight loss, abdominal distension due to ascites, limb & ventral swelling due to edema, & respiratory distress due to thromboembolism

Question 24

T/F: PLE is a syndrome & NOT a disease

Answer 24

true - once the dog is diagnosed with PLE, important to try and identify the underlying cause usually by collecting intestinal biopsies

Question 25

if you suspect PLN in a dog that presents with a serum albumin <2.0 g/dL, what diagnostic test should be done next to investigate? what do you expect the the serum globulin concentration to look like?

Answer 25

urine protein to urine creatinine ratio - suspicious if > 2.0 normal to high

Question 26

if you suspect hepatic insufficiency in a dog that presents with a serum albumin <2.0 g/dL, what diagnostic test should be done next to investigate? what do you expect the the serum globulin concentration to look like?

Answer 26

serum bile acids - would expect to be very elevated normal to high

Question 27

if you suspect PLE in a dog that presents with a serum albumin <2.0 g/dL, what diagnostic test should be done next to investigate? what do you expect the the serum globulin concentration to look like?

Answer 27

rule out other causes/fecal alpha 1 proteinase inhibitor can be decreased, normal, or high

Question 28

T/F: hypoadrenocorticism is an important differential diagnosis for a dog that presents with serum albumin levels < 2.0 g/dL

Answer 28

true

Question 29

if you have a dog with IBD, and you do an ultrasound to investigate further and see this upon imaging, what do you suspect? why?

Answer 29

lymphangiectasia hyperechoic mucosal striations are present which is characteristic of lacteal dilation in dogs healthy dogs can have them after a fatty meal

Question 30

why do an intestinal biopsy for dogs with IBD? what criteria is used to evaluate the specimens?

Answer 30

it allows for a histomorphological diagnosis to be made - doesn't always give the etiology WSAVA criteria

Question 31

what should be provided in a sample submission for pathology for an intestinal biopsy for a dog with IBD?

Answer 31

detailed but succinct history signalment, history, lab test results, diagnostic imaging findings, & any questions that need to be answered

Question 32

what is the mainstay of treatment for intestinal lymphangiectasia in dogs? why? what drug is used?

Answer 32

feed an ultra low diet that is easy to digest, palatable, has a high energy density, & low in fiber the diets reduce the amount of fat that needs to be transported in the lacteals immunomodulatory drugs - prednisone at 2mg/kg/day with cyclosporine as an alternative or add-on drug at 5mg/kg/day

Question 33

why is a diet change sometimes not enough of a therapy for dogs with intestinal lymphangiectasia causing IBD?

Answer 33

the lymphangiectasia may be secondary to inflammation - even if it isn't the case, the drugs may help prevent lipogranuloma formation

Question 34

T/F: some dogs with intestinal lymphangiectasia may need a diet lower in fat that anything on the market indicating the need for a home cooked diet such as boiled fat free turkey, low fat cottage cheese, & egg whites

Answer 34

true - vitamins, minerals, & acids may need to be added in the longterm

Question 35

T/F: some critically ill patients with intestinal lymphangiectasia may benefit initially being fed an elemental diet which is low in fat & easy for them to digest

Answer 35

true

Question 36

why do a baseline cortisol in a patient you suspect PLE in?

Answer 36

rule out addison's disease!!

Question 37

what meds can you add on for a dog that has PLE & has a decreased appetite? what therapeutic procedure can you do?

Answer 37

maropitant & ondansetron place a feeding tube

Question 38

how is cobalamin supplemented for patients with serum cobalamin concentrations <400 ng/L?

Answer 38

cyanocobalamin given SQ weekly for 6 weeks & then once monthly

Question 39

T/F: cyanocobalamin can be used as an appetite stimulant

Answer 39

true

Question 40

what are some ways you can reduce the risk of thrombosis in PLE patients?

Answer 40

avoid placing unnecessary iv catheters check catheter sites daily for inflammation encourage patients to get up & move from time to time prophylactic treatment with aspirin (0.5-2mg/kg every 24 hours) or clopidogrel (1-3mg/kg every 24 hours)

Question 41

if you have a PLE dog that has low serum calcium levels on their biochemistry panel, what diagnostic test should you run?

Answer 41

ionized calcium - can see the correct calcium serum concentration

Question 42

if you have a PLE patient that is severely hypocalcemic or symptomatic for hypocalcemia, what medications can you treat it with?

Answer 42

calcitriol (vitamin D - 30 to 60ng/kg/day) or tums dual action which is 320 mg calcium/65 mg magnesium (1/4 to 1 tablet every 12 hours)

Question 43

you have a 1 year old female spayed border collie that presents with a history of chronic diarrhea that is voluminous, light tan in color, & no increase in frequency, weight loss (15% of body weight) over 2 months, & a good appetite - what diagnostics/treatment may you pursue?

Answer 43

fecal float prescribe metronidazole, loperamide, fenbendazole, & switch diet to hill's i/d

Question 44

you have a 1 year old female spayed border collie that presents with a history of chronic diarrhea that is voluminous, light tan in color, & no increase in frequency, weight loss (15% of body weight) over 2 months, & a good appetite - her fecal float was negative, & you prescribe metronidazole, loperamide, fenbendazole, & a switch diet to hill's i/d she has a slight improvement to this, but as soon as the metronidazole is stopped, there is a complete recurrence of the diarrhea what is your problem list/differentials?

Answer 44

small bowel diarrhea & severe weight loss despite a good appetite ddx - EPI, antibiotic-responsive enteropathy, dietary intolerance/allergy, & IBD

Question 45

you run a CBC/chem, urinalysis, fecal float & direct smear, giardia IFA, baseline cortisol, & gi panel on the 1 year old female spayed border collie with chronic small bowel diarrhea & severe weight loss despite a good appetite abnormal values on CBC - mild leukopenia, mild thrombocytopenia, mild neutropenia, & mild monocytopenia abnormal values on serum chemistry - mildly decreased lactate, moderate hypocholesteremia, & mildly elevated ALT fecal float & direct smear & giardia IFA - negative urinalysis - WNL baseline cortisol - 3.3 ug/dL (reference range is 1-6) cobalamin - decreased folate - normal cPLI - normal cTLI - severely decreased what is your diagnosis?

Answer 45

EPI with secondary hypocobalaminemia

Question 46

for the 1 year old female spayed border collie you diagnosed with EPI with secondary hypocobalaminemia, what do you treat her with?

Answer 46

pancreatic enzyme powder - 2.5 teaspoons with each meal tylosin - 400mg every 12 hours cyanocobalamin - 800 ug SQ once weekly for 6 weeks & then once monthly

Question 47

a 5 year old male neutered rottweiler presents with a 3 month history of chronic small bowel diarrhea & weight loss with a normal appetite - there has been no response to purina EN food or metronidazole TPR is WNL, BCS is 3/9, patient is BAR he has a fluid wave upon abdominal palpation & subcutaneous pitting edema of the distal hind limbs what diagnostics should you run?

Answer 47

cbc/chemistry urinalysis fecal float & direct examination gi panel

Question 48

for the 5 year old male neutered rottweiler presenting with a 3 month history of chronic small bowel diarrhea & weight loss with a normal appetite - with no response to purina EN food or metronidazole you ran a CBC/chem, urinalysis, fecal float and direct smear, & a gi panel with these results CBC - total solids moderately decreased, mild neutrophilia, severe lymphopenia chemistry - mild hypocholesteremia, decreased total protein, hypoalbuminemia urinalysis - USG was 1.028 & UPC <0.4 fecal float & direct smear was negative cobalamin - decreased folate - decreased cTLI - normal cPLI - normal what diagnostics should you do next?

Answer 48

ultrasound

Question 49

this is seen upon abdominal imaging of the 5 year old male neutered rottweiler presenting with a 3 month history of chronic small bowel diarrhea & weight loss with a normal appetite - with no response to purina EN food or metronidazole what is this?

Answer 49

intestinal thickening & peritoneal effusion

Question 50

after seeing the intestinal thickening & peritoneal effusion on the 5 year old male neutered rottweiler presenting with a 3 month history of chronic small bowel diarrhea & weight loss with a normal appetite - with no response to purina EN food or metronidazole - you decide to do endoscopy to get biopsies of the stomach, duodenum, ileum, & colon you receive this back - what do you see? what is this indicative of?

Answer 50

dilation of the central lacteals suspected primary intestinal lymphangiectasia resulting in PLE

Question 51

after seeing the intestinal thickening & peritoneal effusion on the 5 year old male neutered rottweiler presenting with a 3 month history of chronic small bowel diarrhea & weight loss with a normal appetite - with no response to purina EN food or metronidazole what is your major problem & differentials for it?

Answer 51

PLE with secondary peritoneal effusion ddx - lymphangiectasia, IBD, neoplasia, & histoplasmosis/another infectious disease

Question 52

how do you treat the 5 year old male neutered rottweiler presenting with a 3 month history of chronic small bowel diarrhea you've diagnosed with primary intestinal lymphangiectasia?

Answer 52

cobalamin - 1,500 ug SQ once weekly for 6 weeks ultra low fat highly digestible diet tylosin - 800mg every 12 hours for 6 weeks

Question 53

T/F: dogs with PLE may not have clinical signs consistent with gi disease

Answer 53

true

Question 54

T/F: PLE is usually diagnosed by ruling out other causes of severe hypoalbuminemia

Answer 54

true

Question 55

you see this on abdominal ultrasound of a patient with PLE - what are you suspicious of?

Answer 55

intestinal lymphangiectasia - hyperechoic mucosal striations are characteristic of lacteal dilation in dogs

Question 56

what is the purpose of using a fecal alpha-1 proteinase inhibitor test for a dog with PLE?

Answer 56

increased fecal alpha(1)-PI concentration may signal the need to obtain gastrointestinal biopsies for a final diagnosis of PLE fecal alpha(1)-PI concentration may be a useful test for early detection of protein-losing enteropathy before decreases in serum albumin concentration can be detected

Question 57

what are 3 common causes of a dog having a serum albumin concentration <2.0?

Answer 57

PLN hepatic insufficiency PLE use diagnostic tests!!! for PLN - urinalysis & UPC ratio for hepatic insufficiency - bile acids for PLE - rule out other causes/fecal alpha-1 proteinase inhibitor test

Question 58

why is the importance of fecal alpha-1proteinase inhibitor?

Answer 58

it is synthesized by the liver & it inhibits a variety of proteins - it is similar in size to albumin so if gi disease is severe enough for albumin to be lost, fecal alpha-1 proteinase inhibitor will be lost as well, but unlike albumin, it IS NOT hydrolyzed by digestive & bacterial proteinases, so it can be used as an estimate of gi protein loss

Question 59

what are the indications for running a fecal alpha-1 proteinase inhibitor test?

Answer 59

should be measured in dogs and cats with hypoalbuminemia that do not have clinical signs of gastrointestinal disease and where an extra-gastrointestinal source of protein loss cannot be identified also dogs belonging to a breed that is associated with a high prevalence of protein-losing enteropathy (e.g., Norwegian Lundehund, Soft Coated Wheaten Terrier, Yorkshire Terrier) that don't have any clinical signs of gastrointestinal disease, but are intended for breeding