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3. Cat & Dog > Gastroenterology, Pt. 6 (chronic diarrhea) > Flashcards

Gastroenterology, Pt. 6 (chronic diarrhea) Flashcards

1
Q

Problem: Chronic small bowel diarrhea
- ways to classify

A

many ways to classify
- eg. primary GI vs. extra GI
- Maldigestion vs malabsorption
- Protein losing vs non-protein losing
- Specific cause
- Response to treatment

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2
Q

chronic enteropathy classification for maldigestion vs malabsorption - which is which? what does maldigestion look like and what animals are at risk?

A

Maldigestion (exocrine pancreatic insufficiency):
* Dog - young, thin, polyphagia, coprophagia
> German shepherds at risk
* Cats - any age, weight loss, only 2/3 have diarrhea

Malabsorption (all other causes)

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3
Q

chronic enteropathy classification for Protein-losing vs. non-protein losing
- how does this relate to panhypoproteinemia and Lymphangiectasia

A
  • Panhypoproteinemia (albumin & globulin lost)
  • Many causes of malabsorption may present either way
  • Lymphangiectasia may be primary (idiopathic), and due to portal hypertension and thoracic duct obstruction
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4
Q

how can Lymphangiectasia arise? what are the different types and the associated signs?

A

Lymphangiectasia may be primary (idiopathic), and due to portal hypertension and thoracic duct obstruction
* In primary lymphangiectasia GI signs may be minimal, and ascites and pleural effusion may be pronounced
* Lymphangiectasia may also be secondary to causes of mucosal inflammation/infiltration (ex IBD, neoplasia)

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5
Q

mechinisms of protein losing enteropathy (3)?

A
  • Lymphatic obstruction or rupture
  • Increased mucosal permeability due to mucosal infiltrates
  • Mechanical causes (ulcers, erosions, congestion)
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6
Q

Most common causes: of protein losing enteropathy

A
  • IBD, lymphangiectasia, lymphoma
  • Consider histoplasmosis or pythiosis in endemic areas
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7
Q

Classifications of chronic enteropathy based on specific cause

A
  • Infectious
    >bacterial
    >protozoa
    > helminth
  • neoplasia: lymphoma
  • inflammatory bowel disease
    > Lymphocytic-plasmacytic
    > Eosinophilic
    > Granulomatous
  • Villus atrophy
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8
Q

bacterial causs of chronic enteropathy

A

v Campylobacter jejuni
v Clostridium perfringens & C. difficile
v Yersinia
v Small Intestine Bacterial Overgrowth (SIBO, antibiotic-responsive enteropathy [ARE])
v Dysbiosis

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9
Q

protozoal causes of chronic enteropathy

A

Giardia, Cryptosporidium

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10
Q

helminth causes of chronic enteropathy

A

Toxocara sp., Ancylostoma sp., Uncinaria, Strongyloides

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11
Q

classifications of chronic enteropathy based on response to treatment

A

¡ FRE: Food-responsive enteropathy
¡ ARE: Antibiotic-responsive enteropathy
¡ IRE: Immunosuppressant (steroid)- responsive enteropathy
¡ NRE: Non-responsive enteropathy

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12
Q

IBD vs chronic enteropathy

A

Chronic enteropathy:
* Used in animals where intestinal inflammation is suspected but biopsies have not been taken
* Does not infer which treatment will be needed to control clinical signs

IBD:
* Implies treatment trials with diet, deworming, and antibiotics have failed
* Inflammation has been demonstrated histologically
* Immunosuppressant will be needed

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13
Q

should we do a work-up for chronic enterophathy

A

Work-up always indicated, how aggressive depends on earlier criteria

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14
Q

conservative work up for chronic enteropathy includes:

A

¡ Fecal parasitology
¡ Response to fenbendazole
¡ Dietary change (novel protein vs hydrolyzed protein)
¡ Risk for rendering more proteins antigenic with novel protein diet
* Can use hydrolyzed protein diet instead
* Often see improvement in 2 weeks if going to respond

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15
Q

how soon will we see improvements in chronic enteropathy from novel diet if the animal is a responder?

A

Often see improvement in 2 weeks if going to respond

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16
Q

chronic enteropathy work up bloodwork

A

¡ CBC, biochemistry
¡ Testing for hypoadrenocortism (resting cortisol)
¡ Consider bile acids to assess for hepatic dysfunction

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17
Q

chronic enteropathy work up - why look at TLI?

A

To assess for EPI
¡ TLI is decreased in patients with EPI

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18
Q

chronic enteropathy work up - why look at serum B12?

A

¡ Absorbed in ileum
* May be decreased with SIBO/ARE or severe mucosal inflammation/infiltration

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19
Q

chronic enteropathy work up - why look at serum folate?

A
  • Absorbed in proximal small intestine
  • May be decreased with mucosal inflammation/infiltration
  • May be increased­ in SIBO/ARE (production)
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20
Q

if a dog has EPI, what will we see for TLI, B12, and folate values?

A

decreased TLI, ± decreased B12, N folate

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21
Q

if a dog has SI malabsorption, what will we see for TLI, B12, and folate values?

A

N TLI, ± decreased B12 (distal), ± decreased folate (proximal)

22
Q

if a dog has SIBO (ARE), what will we see for TLI, B12, and folate values?

A

N TLI, ± decreased B12 (distal), ± ­increased folate]

23
Q

chronic enteropathy - what is the use of radiographs? barium series use?

A
  • Abdominal radiographs often unrewarding in chronic diarrhea with normal PE
  • May reveal mass, foreign body, plication
  • Barium series not recommended
    > Most useful to diagnose obstruction
    > Expensive and tendency to over-interpret
    > Superseded by ultrasound and endoscopy
24
Q

chronic enteropathy - what is ultrasound good for?

A

¡ Distribution of lesion (enteritis more
diffuse)
¡ Thickness of intestine (neoplasia thicker)
¡ Loss of layering (neoplasia)
¡ Lymphadenopathy (neoplastic larger)
¡ Ultrasound in this case → enteritis

25
Q

what infectious disease tests can we run in a chronic enteropathy case?

A
  • Fecal culture for pathogens
    > Campylobacter, Clostridium, Salmonella, Yersinia
  • IDEXX fecal PCR panel
    > Parvovirus
    > Coronavirus
    > Canine distemper virus
    > Salmonella
    > Clostridium enterotoxin A gene
    > Cryptosporidium
    > Giardia
26
Q

optional next steps for chronic enteropathy treatment (empiric)

A

Options:
* Empiric deworming
* Empirical treatment with dietary change
* Empirical treatment with tylosin or metronidazole?
* Gastrointestinal biopsies (endoscopic vs surgical)
* Empirical treatment with prednisone if biopsies declined

27
Q

chronic enteropathy example plan / next steps

A
  1. complete bloodwork
    > CBC, biochem, hypoadrenocorticism testing (dog), hyperthyroidism (cats)
  2. endoparasitism testing
    - fecal floatation
    - empiric deworming
  3. hypoallergenic vs novel protein dietary trial (2 weeks)
  4. surgical / endoscopic biopsies vs immunosuppressive trial
28
Q

causes of IBD and treatment options that target them

A
  • Genetics
    > nothing much
  • Dietary antigens
    > hypoallergenic diet
  • The microbiota
    > fecal microbial transplantation
  • dysregulated immune response
    >immunomodulatory therapy
29
Q

how important is dietary therapy for chronic enteropathy? how successful can it be?

A

¡ ESSENTIAL!!!!!
¡ First-line treatment
¡ Remission rates of over 67% with diet alone (Mandigers, 2010)
¡ Many prospective studies demonstrating response to diet alone

30
Q

chronic enteropathy (IBD) diet reccomendation? how soon do we often see improvement?

A

Dietary change:
* Highly digestible, novel protein, hydrolyzed protein
* Numerous brands with different proteins
* Easily digested carbohydrate (reduces osmotic effect)
* Fats may be reduced –unabsorbed fats aggravate diarrhea
* Strict diet trial for at least 2 weeks
* Often see some improvement within a few days to up to 2 weeks

SUMMARY
- highly digestible
- high fibre
- novel protein
- hydrolized protein
- etc…

31
Q

if we get a poor response to a diet change for IBD does that mean we should give up on diet options? what should we do?

A

¡ Response to different diets varies
¡ Insufficient response to one diet does NOT exclude response to another
¡ Can consider a 2nd diet trial before additional diagnostics/treatment in stable patients

32
Q

chronic enteropathy treatment options

A
  • Dietary change
  • Immunosuppression
    > Prednisone
  • Treatment of dysbiosis
    > Antibiotics
    > Probiotics
    > Fecal transplantation
33
Q

methods of treating chronic enteropathy via immunosuppression

A

Prednisone:
- High quality evidence to support steroids for induction treatment of IBD
* If resistant, consider other immunosuppressives
> azathioprine, mycophenolate, chlorambucil, cyclosporine
* Budesonide – potentially less systemic side-effects than prednisone

34
Q

methods of treating chronic enteropathy via treatment of dysbiosis

A

¡ Antibiotics
* Ex tylosin, metronidazole

¡ Probiotics

¡ Fecal transplantation
* Easy to perform and in some clinics is an early treatment
* Not standardized (dosage, administration method, donor screening)

35
Q

are antibiotics a good choice for treating chronic enteropathy? possible drawbacks? what do we do if we dont see results in 2 weeks?

A

¡ Utility unclear:
¡ Response to antibiotics often short lived
¡ Antibiotic resistance
¡ **Granulomatous colitis of Boxers and French bull dogs
¡ If antibiotic trial not successful within 2 weeks, reassess

36
Q

possible treatments for chronic enteropahty that are considered less often

A

¡ Vitamin B12 injections

¡ Vitamin D?
* Hypovitaminosis D negative prognostic factor

¡ Intestinal lymphoma
- Consider surgical removal of focal lesions
- Chemotherapy
> Diffuse GI lymphoma has a poor prognosis in dogs
> Indolent T-cell lymphoma has a good prognosis in cats

37
Q

WHEN TO SUPPLEMENT COBALAMIN? for chronic enterophathy

A
  1. When measuring B12 levels isn’t an option
  2. When cobalamin measures low
  3. When cobalamin measures low- normal (<400ng/L)
38
Q

EXOCRINE PANCREATIC INSUFFICIENCY (EPI)
- is due to:

A

¡ destruction of acinar cells due to chronic pancreatitis (dogs and cats)
¡ Depletion of acinar cells due to pancreatic acinar atrophy (dogs)
> GSD, rough coated collies

39
Q

at what point do we see clinical signs of EPI?

A

¡ Clinical signs of EPI do not occur until more than 90% of the exocrine pancreatic function has been lost

40
Q

exocrine pancreases is a major source of what that influences cobalmin?

A

Exocrine pancreas is major source of intrinsic factor:
¡ Assess for hypocobalaminemia

41
Q

most common sign of EPI, and antoher common observatin

A

¡ Most common sign is weight loss*
¡ Loose stools commonly observed

42
Q

EPI: DIAGNOSIS

A

TLI
¡ Low TLI is highly sensitive and specific for EPI

43
Q

EPI: TREATMENT

A

¡ Pancreatic enzyme supplementation ($)
¡ Treat for concurrent SIBO/ARE/Dysbiosis
¡ May need to treat for concurrent IBD
¡ Diets with high fiber should be avoided (interferes with fat absorption)
¡ If patients not responding to therapy, antacid treatment can be considered

44
Q

negative prognostic factor for EPI

A

marked hypocobalaminemia

45
Q

PLE IN YORKSHIRE TERRIERS; what do we see?

A
  • Emerging disease in Yorkshire terriers
    ¡ Females > males
    ¡ Median age 7 years (1 – 12)
    ¡ Diarrhea ± ascites
    > Dyspnea (Ascites, pleural effusion, collapsing trachea)
  • Low albumin, globulin, magnesium, calcium
    > Dogs with PLE may also have low iCa, occasionally signs of hypocalcemia
  • Response of Yorkie PLE to prednisone and diet change varies from none to good
46
Q

LYMPHANGIECTASIA; what is primary vs secondary, and what signs are associated with each?

A

Can be primary or secondary
¡ Secondary to IBD, lymphoma
> Diarrhea a prominent feature
> Initial treatment of IBD more aggressive

¡ Primary
> Minimal GI signs
> Ascites
> Pleural effusion

47
Q

LYMPHANGIECTASIA breeds at risk

A

small terrier breeds, rottweilers, lundehunds

48
Q

LYMPHANGIECTASIA - what do we see on ultrasound? on endoscopy?

A

Ultrasound – may see speckling
Flexible or capsule endoscopy - dilated lymphatics

49
Q

LYMPHANGIECTASIA - what will we see with diagnostic surgery?

A
  • dilated lymphatics, serosal granulomas
    > Full-thickness biopsies high- risk leakage
50
Q

LYMPHANGIECTASIA TREATMENT and prognosis

A

¡ Dietary fat restriction
¡ Prednisone (anti-inflammatory dosage)
¡ ± medium-chain triglycerides
¡ Response to treatment unpredictable
¡ Guarded prognosis

51
Q

Which of the following is NOT typically a cause of a protein losing enteropathy?
A) Lymphangiectasia
B) Histoplasmosis
C) Lymphoma
D) Campylobacter

A

D) Campylobacter

52
Q

Identify the true statement in regard to EPI:
A) A high TLI is suggestive of EPI
B) High fiber diets are an important component of treatment
C) Chronic pancreatitis is a common cause of EPI in cats
D) Hypocobalaminemia is uncommon in patients with EPI

A

?C) Chronic pancreatitis is a common cause of EPI in cats?

3. Cat & Dog (33 decks)

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