Gastrointestinal Flashcards
Regarding GI bleeding:
–Most common in purebred vs working dog vs mixed breed?
–Most common in stomach vs duodenum vs both?
–Association with liver dz, kidney dz, IBD? (mild/moderate/none)
–Working dogs
–Stomach 88%, duodenum 12%, both 6%
–No association with liver or kidney disease, IBD
JVIM 2021, Pavlova
Regarding a small study of NSAID treated dogs:
–Proportion of dogs with gastric ulcers?
–Proportion that were symptomatic?
–Conclusion to draw regarding NSAID tx?
–10/12 (83%) had gastric ulcers
–None symptomatic
–Be cautious if dog has other factors predisposing to GI ulceration, otherwise do not withhold NSAIDs just because GI ulceration is common
JVIM 2021, Mabry
When does BUN peak and normalize post blood ingestion? Overall, how useful is BUN/creat ratio to detect occult GI bleeding?
BUN peak 4.5-10hrs, back to baseline at 24hrs
Overall BUN/creat ratio is not useful
JVIM 2021, Stiller
Regarding video capsule endoscopy:
–Diagnostic yield for dogs with clinically overt GI bleeding?
–Most common complication and prevalence? At least one thing that helps with this?
–77%
–Incomplete study 46%. Endoscopic deployment into SI can help. No standardized GI prep (fasting time, colon prep, etc) in human or vet med and there is conflicting data regarding prokinetics.
JVIM 2021, Stiller
What is the proportion of calcium in each category? Which are biologically active, and which can be measured?
–Protein bound
–Complexed
–Ionized
–Protein bound 55% – inactive, measurable
–Complexed 10% – active, not measurable
–Ionized 35% – active, measurable
JVIM 2021, De Witte
How do tCa and adjusted Ca (aCa) compare in terms of relative sensitivity and specificity for ionized hypocalcemia (ie, which is a better screening test, and which is a better “confirmatory” test)?
For the latter, if low, does that suggest the iCa is at least (mild, mod, or severely) low?
tCa more sensitive (better screening), aCa more specific
If aCa is low, probably at least moderately (and clinically relevant) low iCa
JVIM 2021, De Witte
Regarding feeding tube placement around the time of PLE diagnosis:
–At least 3 theoretical benefits?
–Frequency of significant complications?
–Impact on MST?
Theoretical benefits
–Improved mucosal function/integrity
–Improved mucosal immune function
–Vit D
–Essential AA
No significant complications with placement in a study of 21 dogs
Improved survival – feeding tube dogs MST 1.5yrs, no tube MST 9mo
JVIM 2021, Economu
In IBD dogs who clinically improve with treatment, do endoscopic appearance of GI and/or GI histo also improve?
Gross appearance improves, GI histo does not
JVIM 2021, Lee
High-mobility group box 1 (HMGB1) is a chromosomal protein that is released from damaged cells. It is a useful marker in human IBD (feces used more than serum) and canine HMGB1 is identical.
–As a noninvasive test for IBD, is it better for screening or confirmation?
–Does it correlate with CIBDAI score and/or histopath?
–Screening test (sens/spec 96/76) – can be affected by pancreatitis
–Correlates with histopath but not CIBDAI
JVIM 2021, Lee
Performance of contrast-enhanced ultrasonography to differentiate IBD vs healthy dogs?
No difference
JVIM 2021, Linta
Regarding TEG findings in chronic inflammatory enteropathy (CIE) dogs with and without hypoalbuminemia:
–Which were hypercoagulable?
–Are they hypo- or hyperfibrinolytic?
–What ref lab coag test positively correlates with max amplitude, and can thus potentially be used as a surrogate if TEG not available?
–CIE dogs with and without hypoalb are hyprecoagulable
–Hyperfibrinolytic
–Fibrinogen
JVIM 2021, Wennogle
The AA homocysteine can be increased in IBD patients with low ____(x)_____. Homocysteine can (incr vs decr) coagulability in human IBD.
Measuring (x) as a surrogate for homocysteine, does this correlate with TEG in IBD dogs? What conclusion can be drawn from this?
High homocysteine if low folate, B12, B6
High homocysteine –> hypercoagulable
B12/folate do not correlate with TEG –> so homocysteine may not be playing a major role in dog IBD hypercoagulability
JVIM 2021, Wennogle
Does low vit D in IBD dogs contribute to coagulation abnormalities?
Yes – hypercoagulable
JVIM 2021, Wennogle
Regarding clinical presentation, which was more common in feline IBD vs LSA, vs no difference?
–Signalment
–Duration of signs
–Polyphagia
–Hematochezia
–LSA: males > females; otherwise no difference (age, breed, body weight)
–LSA longer duration of signs
–Polphagia – LSA
–Hematochezia – IBD
JVIM 2021, Freiche
Regarding bloodwork and AUS, which was more common in feline IBD vs LSA, vs no difference?
–CBC/Chem abnormalities
–Hypocobalaminemia
–Jejunal lymphadenopathy
–Scant peritoneal effusion
–Jejunal mucosal thickening
–Jejunal muscularis thickening
–LSA: hypocobalaminemia, jejunal lymphadenopathy, FF, jejunal mucosal thickening
–No difference CBC/Chem or jejunal muscularis thickening
JVIM 2021, Freiche
Which is the minimum deepest intestinal layer affected in feline low grade intestinal lymphoma (LGITL)?
Are epitheliotropism and intraepithelial lymphocytes/nests/plaques more common in IBD or LGITL?
Are IBD and LGITL primarily T cell, B cell, or mixed?
Lamina propria
LGITL
LGITL – T cell; IBD – mixed
JVIM 2021, Freiche
In a study of surgically biopsied IBD vs LGITL cats:
–Which had more significant fibrosis?
–Gradient of LGITL? (apical to basal vs basal to apical)
–Frequency of submucosal lesions in IBD?
–Did IBD or LGITL have more homogenous lesion distribution?
–LGITL
–Apical to basal
–9%
–IBD
JVIM 2021, Freiche
In a study of surgically biopsied IBD vs LGITL cats:
–What is Ki67 a marker of? Is it higher in IBD or LGITL?
–Is PARR reliable for differentiation?
–Marker of proliferation – higher in LGITL
–No
JVIM 2021, Freiche
Regarding abx use for acute hemorrhagic diarrhea syndrome (AHDS):
–When should these be considered? How is this criteria somewhat misleading?
–One study showed which single abx may be sufficient?
–Overall survival rate? How did abx impact this?
–Consider if suspicion for sepsis – but many criteria are nonspecific and could be due to hypovolemia (incr HR, RR, hypotension)
–Ampi
–96% survival, no difference in abx vs non-abx group
JVIM 2021, Dupont
How do previous GI insult (parvo, AHDS, etc) or abx use early in life, respectively, potentially predispose to chronic enteropathy later in life?
–Previous GI insult: GI barrier breakdown –> exposure to food and flora Ag –> decr tolerance
–Early abx: decr flora diversity –> decr immunoregulation
JVIM 2021, Skotnitzki
What is the proportion of dogs that will have chronic/recurrent GI signs later in life after an episode of acute hemorrhagic diarrhea? What proportion will resolve with an elimination diet?
28% chronic GI signs
81% diet responsive
JVIM 2021, Skotnitzki
Regarding subtotal colectomy in cats:
–Risk of dehiscence?
–How long post op does it take for stool quality to improve? Proportion of cats with long term liquid stool?
–Frequency of constipation recurrence and time frame? Usually refractory or amenable to medical management?
–Frequency of death/euth due to megacolon despite sx? At least three factors that impacted survival?
–2% risk of dehiscence
–2mo for ileum to adapt for incr water absorption. 17% of cats have long term liquid stool.
–32% constipation recurrence at median ~1yr. Most amenable to medical management.
–14% death/euth due to megacolon. Shorter survival with preop heart disease, postop tenesmus, thin BCS, long term liquid feces, or major postop complications (resulting in death or re-cut)
JVIM 2021, Grossman
What is the impact of ICJ resection (vs retention) on the following aspects in constipated cats treated with subtotal colectomy:
–Recurrence of constipation
–Long term liquid feces
–QoL
–Survival time
–No impact on recurrence of constipation (ie, ICJ resection did not prevent)
–Incr risk of long term liquid feces
–Worse QoL
–Shorter survival
JVIM 2021, Grossman
Is primary or secondary hyperlipidemia more common?
What are at least two drugs and four disease states that can cause secondary hyperlipidemia?
Primary is more common
Secondary:
–Drugs (steroids, phenobarb)
–Endocrine
–Cholestasis
–PLN
–Pancreatitis
–Obesity
JVIM 2021, Munro
Is hyperlipidemia usually clinical or subclinical? What are at least four possible complications?
Usually subclinical
Complications:
–Pancreatitis
–GB mucocele
–Vacuolar hepatopathy
–Insulin resistance
–Proteinuria
–Seizures
JVIM 2021, Munro
What are at least 3 MoAs of fibrates for treatment of hyperlipidemia?
What is the minimum goal TG for successful tx?
MoAs:
–Incr lipoprotein lipase
–Incr liver FA uptake
–Decr liver GT produciton
–Incr removal of low-density lipoprotein cholesterol (LDL-C)
–Incr production of HDL-C
Goal = TG <500
JVIM 2021, Munro
Fibrates have some drawbacks.
–Adverse effects are common in people – which organ system is usually affected? What organ is less commonly affected but potentially more serious?
–What are two problems with bioavailability?
–GI side effects are common
–Idiosynchratic hepatotoxicity – variable LE patterns, asymptomatic to chronic liver disease
–Bioavailability – lipophilic (give with food), unpredictable absorption depending on formulation (TriCor fenofibrate is fairly predictable)
JVIM 2021, Munro
Regarding a small study of hyperlipidemic dogs treated with fenofibrate (TriCor):
Efficacy:
–Proportion of dogs with normalized TG?
–Impact of starting TG on outcome?
Safety:
–Relative frequency and severity of clinical and biochemical adverse effects?
Efficacy: all dogs had normalized TG independent of starting TG (incl some not fed a low fat diet)
Safety: 1 dog had quiet demeanor and firm stools; no biochem issues
JVIM 2021, Munro
A recent study in PLE dogs looked for predictors of who would and wouldn’t respond to low fat diet.
–Which dogs is it worth trying for?
–What finding on workup was most common in nonresponders?
–Was alb different in responders vs nonresponders?
–Does food responsiveness affect prognosis?
–Full responders tended to be younger and have lower CCECAI scores but it couldn’t differentiate full vs partial responders, AND overall only a few dogs didn’t respond to diet at all. Bx (ex: presence of lymphangiectasia) didn’t predict response. Ultimately, reasonable to try diet in everyone.
–Mesenteric lymphadenopathy – 60% nonresponders, 13% responders
–No difference in albumin
–Food responsive PLE had longer survival
JVIM 2020, Nagata
Regarding gastric wall edema in hypoalbuminemic dogs:
–Prevalence?
–Compare its appearance with what is seen with acute pancreatitis
–Correlation with albumin?
–21%
–Hypoalb –> more diffuse edema, add’l layering within the submucosa (prob separation of collagen fibers). Panc –> focal/peripancreatic, no extra layers. Both –> intact wall layering.
–Prevalence did not correlate with severity of alb; and can resolve despite no change in alb
JVIM 2020, Murakami
True or False:
–Fecal culture should be included in the routine workup for chronic diarrhea in dogs to rule out enteropathogenic bacteria (such as salmonella, camp, C. perf, C. diff, pathogenic E. coli).
–C. perf can be found in 94% of healthy dogs via PCR and 80% via culture.
–Fecal culture and PCR perform similarly in assessment of the microbiome.
–False. A study of 18 dogs found zero positives (except E. coli of questionable significance) – doesn’t seem to be a major cause.
–True – presence of the bacteria is not a problem, rather certain associated enterotoxins
–False – cultures perform horribly, massively underestimate anaerobes, etc
JVIM 2020, Werner
What three breeds are overrepresented in E. coli granulomatous colitis? What defect in their defenses predisposes them?
–Boxers, Frenchies, Mastiffs
–Defect in macrophage sensing/killing intracellular (intramacrophage) E. coli
JVIM 2020, Manchester
Abx penetration into what cell type is essential for clearance of E. coli granulomatous colitis?
Macrophages
JVIM 2020, Manchester
What was the prevalence of fluoroquinolone resistant E. coli in a recent study about E. coli granulomatous colitis?
What was the long term prognosis for dogs treated with culture-directed abx? Did age play a role?
–62%
–Good; also, all dogs that made it to 4yrs old did well long term
JVIM 2020, Manchester
True or False regarding E. coli granulomatous colitis:
–If a dog does not respond to abx in the first 4 weeks, it is considered a treatment failure and a different abx is indicated.
–Resistant abx MIC in vitro does not necessarily mean it won’t work in vivo.
–Not necessarily – 60% may go on to have partial or complete response
–True – some abx combos can act synergistically, and in vitro may underestimate in vivo susceptibility
JVIM 2020, Manchester
Nuclear scintigraphy is a highly sensitive method to detect reflux and microaspiration.
–What proportion of 12 healthy mesocephalic dogs had reflux? Microaspiration?
–For those with reflux, what part of the esophagus did it typically reach? How does this compare with what is typically seen in fluoro studies? How often were these large volume?
–100% had reflux, none had microaspiration (but r/o type II error)
–Middle esophagus, occ large volume. Fluoro studies found usually no higher than distal esophagus (r/o incr sensitivity of scintigraphy).
JVIM 2020, Grobman
Ileocecocolonic perforations secondary to endoscopy are a rare but significant possible complication.
–What two physical processes at the time of scope can cause this?
–Do species, disease process, and/or operator affect risk? How does this compare with risk of gastroduodenal perf?
–3 clues at the time of scope that an ICC perf has occurred?
Mechanical trauma (most common; scope, forceps), barotrauma (excessive insufflation)
Risk:
–Dogs overrepresented in the study BUT cats at higher risk for gastroduodenal endoscopic perfs. R/o bias (less likely to do lower scope in cats).
–No significant underlying disease (worst = mod IBD) at the site of perfs in this study. Gastroduodenal perfs are more likely with severe IBD, ulceration, or LSA.
–Two thirds of cases were with residents/interns – r/o incr risk with inexperienced operator vs reporting bias
Directly see tear, unable to hold insufflation, abdominal distension refractory to suction
JVIM 2020, Woolhead
Ileocecocolonic perforations secondary to endoscopy are a rare but significant possible complication.
–Post scope, what would put ICC perf on your ddx list? (Generally speaking)
–Diagnostic test of choice?
–Treatment of choice? How likely is recovery if dx is delayed up to 5 days post scope?
–Consider ICC perf if patient does not recover as expected. Vague CS (leth, inapp, abd pain, retching).
–AXR – see free gas
–Surgery. Most did well with perf repair, some had ICJ resection. Most animals with delayed diagnosis still did well.
JVIM 2020, Woolhead
When incorporating IHC and PPAR, what proportion of definitely IBD cats (based on histopath alone) were reclassified to LSA?
Almost half
JVIM 2020, Chow
–Rank intestinal segments according to how commonly they are affected by LSA in cats. How does this affect the recommendation for endo vs sx bx?
–When using histopath, IHC, and PARR to classify IBD vs LSA, how often is LSA only found in the ileal bx? (frequently, sometimes, rarely)
–Jejunum > duodenum > ileum. Endoscope can reach the jejunum in most cats though.
–Rarely – upper GI bx are usually adequate
JVIM 2020, Chow
Regarding iron deficiency:
–What is the difference between functional and absolute iron deficiency?
–What changes to iron parameters (%TSAT, ferritin) are expected with each? Which parameter can also be affected by inflammation, making interpretation difficult?
–Can FID and AID exist concurrently?
Functional iron deficiency (FID):
–Normal or incr iron stores but unavailable for heme synth
–Inflammation –> hepcidin –> decr ferroportin on GI cells –> decr iron absorption
–Expect decr %TSAT with normal to incr serum ferritin
Absolute iron deficiency (AID):
–Chronic blood loss esp GI (most common), decr intake, malabsorption
–Expect decr %TSAT with decr serum ferritin
Difficult to truly dx FID vs AID because they can coexist, and ferritin is an acute phase protein.
JVIM 2020, Hunt
In cats with chronic enteropathy, which RBC parameter correlated with iron deficiency?
Retic Hb; not MCV, some iron deficient cats were not anemic
JVIM 2020, Hunt
Why is methylmalonic acid a more sensitive marker of hypocobalaminemia?
In normalcy: Methylmalonyl-CoA –[methylmalonyl-CoA mutase + cobalamin]–> succinyl-CoA
No B12 –> MMA builds up. So, high MMA = low B12 at a cellular level.
JVIM 2020, Kook
What clinical sign is associated with hypocobalaminemia in cats with chronic enteropathy?
Polyphagia + weight loss
JVIM 2020, Kook
A recent study looked at the efficacy of B12 supplementation with hydroxocobalamin.
–When did Cobal normalize?
–When did MMA normalize?
–Did this perform similarly, worse, or better than a similar study using cyanocobalamin? What is one possible reason for the difference?
–At 2 weeks, MMA normal and cobal high (normal at end of study – 3mo). MMA still normal at end of study (1mo after last inj).
–Better than cyanocobalamin – didn’t normalize MMA in over half of cats after 5 weekly injections and increased after cobal inj were d/c’d.
–Much of cyanocobalamin is lost in the urine, hydroxocobalamin has higher retention.
JVIM 2020, Kook
Regarding hypertriglyceridemia:
–Usually asymptomatic but what are at least 5 potential sequelae?
–TG therapeutic target and why?
–Efficacy (low, moderate, high) of low fat diet alone in reaching that target? How soon can you expect it to see a response?
–Efficacy for reducing cholesterol?
–Vacuolar hepatopathy, GB mucocele, pancreatitis, insulin resistance, glomerular lipidosis, ocular lipid deposits, lipemic uveitis, seizures
–TG <500 – threshold for risk of sequelae
–Diet is highly effective within 2mo for TG (15/16 dogs responded). Chol decr in some dogs, but not as reliably or sustainably.
JVIM 2020, Xenoulis
True or false:
Some dogs with chronic rhinitis have complete remission of signs with stomach acid reducers and/or hydrolyzed diet, even in the absence if GI signs.
True
JVIM 2020
In a small cohort of N=8 dogs/cats with esophageal stent placement following unsuccessful balloon dilation of esophageal stricture, what proportion had good long term outcome?
How frequent were short term complications, and what was the most common?
88% good long term outcome
75% had short term complications esp discomfort. Cutting the mesh at follow up improved this.
JSAP 2021 Riz
Regarding esophageal varices:
–Most common way to diagnose?
–Basic underlying cause?
–CS? How common is hemorrhage?
CT
Hypertension – pulmonary, portal, caval, systemic
Nonspecific and usually related to cause of EV rather than the EV itself. No hemorrhage (major complication in people).
JVIM 2021 Slead
Regarding LES achalasia like syndrome:
–Proportion that have megaesophagus? Relative motility?
–Proportion with the “bird beak”?
–Proportion that respond to botulinum toxin? How long does it take, and how long does it last?
–How many respond to follow up myotomy and fundoplication?
–Do esophageal changes tend to resolve or persist if signs improve?
75%, variable motility (none to hyper) but most are none to hypomotile
Two thirds
All responded by 3 weeks with 80% reduction in regurge. Lasted 5 weeks.
Those that had sx maintained their improvement
All had persistent esophageal dilation/dysmotlity
JVIM 2019 Grobman
True or False: Esophageal perforations are often amenable to medical management, but only if a PEG tube is placed and there are no secondary complications such as pneumothorax or pneumomediastinum.
What is the most common FB to cause esophageal perf?
False. Most do well with med mgmt alone, even if pneumothorax/mediastinum and no PEG tube.
Fish hook
JVECC 2018 Teh
JAVMA 2018 Sterman
What are the four types of hiatal hernia?
Type I (sliding): esophagus and part of stomach slide cranially through the esophageal hiatus
Type II (paraesophageal): a bit of stomach herniates through the esophageal hiatus alongside the esophagus
Type III: characteristics of I and II (rare in dogs and cats)
Type IV: Liver, stomach, and SI herniate
JVIM 2019 Phillips
Which is the most common type of hiatal hernia in cats?
Average age?
What proportion have comorbidities?
Do they tend to do better with medical or surgical management?
Type I (85%)
<3yrs old
75%
Med (but maybe b/c these cats are less severely affected?)
JVIM 2019 Phillips
Regarding gastroesophageal intussusception in dogs:
Signalment? (age, sex, overrepresented breed)
PC?
% of dogs who respond to tx (usually sx)? How many needed follow up medical management?
% that died related to their GE int.? MST? Most common reason? Two risk factors?
Young (~1yr), male, GSD
Vomiting, regurge
88% initially responded to tx. 70% had persistent regurge but improved with f/up med mgmt (ex: elevated feedings).
Overall MST 2.7yrs. 25% died related to persistent regurge. Incr risk of persistent regurge if acute CS at initial presentation or if megaesophagus.
JAVMA 2020 Grimes
What is the likely underlying cause for gastric lymphofollicular hyperplasia (LPH) in dogs with chronic gastritis? Evidence?
Excessive intrathoracic negative pressure
LPH is more common in young, brachycephalic dogs with inspiratory dyspnea and exercise intolerance (compared with chronic gastritis dogs without concurrent LPH)
JAVMA 2020 Faucher
What is one PE finding and two blood markers that would help increase suspicion for gastric carcinoma over chronic gastritis in a dog?
Gastric carcinoma
–Older (>8yrs)
–Thinner (BCS <4)
–Lower folate
–Higher CRP
JAVMA 2019 Seim-Wilkse
True or False: Video capsule endoscopy usually identifies bleeding lesions that would not have been apparent on endoscopy.
False – would have seen most on scope
JVIM 2019 Mabry
Young brachycephalic dog are prone to esophageal dysmotility. Name at least three specific findings on fluoro swallow study that are more common in brachy vs mesaticephalic dogs with regurge or dysphagia.
Hiatal hernia
Prolonged esophageal transit time
Decr propagation of secondary peristaltic waves
GERD
JVIM 2019 Elvers
What three breeds are prone to primary hypercholesterolemia?
Sheltie
Rough collie
Briard
JVIM 2019 Heilmann
What breed is prone to primary hypertriglyceridemia?
Mini schnauzer
JVIM 2019 Heilmann
Elevations in which are associated with idiopathic hyperlipidemia? Do they decrease with successful diet therapy?
S100A12
Calprotectin
cPL
S100A12
Calprotectin
No association with high cPL
None changed with tx (but may have needed more time)
JVIM 2019 Heilmann
Based on two large studies in dogs and cats:
–How frequent are e-tube complications and what is the most common?
–How often are complications fatal or requiring significant intervention?
Complications in ~50% that survive to discharge
E-tube site infection ~15%
Complications are rarely fatal. Most can be managed conservatively (ex: abx, e-tube removal).
JVIM 2019 NBreheny
JVIM 2019 Nathanson
Which GI biomarkers are associated with PLE and may precede onset of clinical signs?
SERUM ONLY
Methylmalonic acid
CRP
Perinuclear anti-neutrophilic cytoplasmic antibodies (pANCA)
3-bromotyrosine
FECAL ONLY
Fecal dysbiosis index
Soluble RAGE
FECAL/SERUM
Alpha1 proteinase inhibitor
S100A8/A9 (calprotectin)
S100A12 (calgranulin C)
Fecal/serum alpha1 proteinase inhibitor (same MW as albumin, resistant to proteolysis)
pANCA – high in soft coated wheaton terriers with PLE, PLN >2yr before onset of hypoalbuminemia
2018 JVIM GI Biomarkers
Which GI biomarker is the best for cellular cobalamin status? Why? What is one additional explanation besides enteropathy or EPI?
SERUM ONLY
Methylmalonic acid
CRP
Perinuclear anti-neutrophilic cytoplasmic antibodies (pANCA)
3-bromotyrosine
FECAL ONLY
Fecal dysbiosis index
Soluble RAGE
FECAL/SERUM
Alpha1 proteinase inhibitor
S100A8/A9 (calprotectin)
S100A12 (calgranulin C)
Methylmalonic acid
Cobalamin is a cofactor for a reaction that uses MMA as a substrate. No cobal –> high MMA. Can be diverted to urea cycle –> hyperammonemia.
MMA can also be high if renal disease
2018 JVIM GI Biomarkers
Which two genera of fecal bacteria are most significantly decreased in CIE?
Faecalibacterium
Fusobacteria
Both are SCFA producers
2018 JVIM GI Biomarkers
Which GI biomarkers could potentially be used in tx monitoring for CIE?
SERUM ONLY
Methylmalonic acid
CRP
Perinuclear anti-neutrophilic cytoplasmic antibodies (pANCA)
3-bromotyrosine
FECAL ONLY
Fecal dysbiosis index
Soluble RAGE
FECAL/SERUM
Alpha1 proteinase inhibitor
S100A8/A9 (calprotectin)
S100A12 (calgranulin C)
CRP
Calprotectin - fecal only
Calgranulin C - fecal only
Soluble RAGE (CIE –> low)
2018 JVIM GI Biomarkers
Which is higher in immunosuppressant responsive enteropathy vs food responsive enteropathy?
SERUM ONLY
Methylmalonic acid
CRP
Perinuclear anti-neutrophilic cytoplasmic antibodies (pANCA)
3-bromotyrosine
FECAL ONLY
Fecal dysbiosis index
Soluble RAGE
FECAL/SERUM
Alpha1 proteinase inhibitor
S100A8/A9 (calprotectin)
S100A12 (calgranulin C)
3-bromotyrosine (biomarker of eosinophilic inflamm)
2018 JVIM GI Biomarkers
What is the basic cause of high homocystein?
Is the reference interval in cats narrow or wide?
Low B vits (cobal, folate, B6)
Wide RI – lots of interindividual variability
JFMS 2020 Drut
What are three common CS and four common CBC/Chem changes associated with refeeding syndrome?
In a small study of N=11 cats, what was the average hospital stay and % survival to discharge?
Two risk factors for death?
CS:
–Tremors, encephalopathy
–Arrhythmia, heart failure
–Anorexia, vomiting
Labs:
–Low phos, K, Mg
–Thiamine deficiency (cofactor in anabolic metabolism)
–Hyper- or hypoglycemia
–Hemolytic anemia
2 weeks in hosp, 73% survived to discharge. Worse px if AKI or hyperbilirubinemia.
JFMS 2021 Cook
What two factors (one lesion factor, one technique) that increase your chances of a diagnostically useful GI FNA/cyto?
How often does it have complete agreement with histo?
Incr lesion thickness
More slides
66%
JSAP 2021 Turner
What % of sialoceles are idiopathic? % recurrence after sx? How should this be managed?
88% idiopathic
22% recurrence – med management
JAVMA 2020 Ortilles
True or False: C. perf alpha toxin and enterotoxin can distinguish AHDS from other causes of hematochezia.
False. No increase compared to other causes of hematochezia or to healthy dogs.
JSAP 2021 Allen-Deal
What are 4 risk factors (2 PE, 2 labwork) for constipation in cats?
What PE finding was associated with lack of defecation following an enema?
Old, overweight, CKD, higher iCa
Abd pain
JFMS 2019 Benjamin
True or False: Rectal bougienage and psyllium is sufficient in some dogs and cats with benign rectal strictures.
True
JSAP 2021 Lamboureux
True or False: PLE dogs refractory to steroids can achieve durable remission with diet alone.
True
8/10 dogs remission, 7 maintained for at least 4yrs
JSAP 2021 Wennogle
True or False: PLE dogs have a higher chance of remission and longer survival if treated with pred+cyclo+diet, rather than pred+diet alone.
False
JVIM 2019 Schmitz
How can lymphatic endothelial cell IHC be used in the diagnosis of PLE cases?
Increased sensitivity for lacteal dilation compared with H&E
JVIM 2019 Wennogle
Which three proteins are most significantly depleted in PLE and why?
Albumin
Prealbumin
Ceruloplasmin
Clotting factors
Immunoglobulins
Transferrin
Alb, Ig, ceruloplasmin b/c long T1/2.
The others have short T1/2 and liver makes more to compensate for losses.
JVIM 2018 PLE review
Which two SI lesions make up the majority of canine PLE findings?
Lymphoplasmacytic enteritis
Neutrophilic enteritis
Lipogranulomatous enteritis
Crypt disease
Lymphangiectasia
LP enteritis 68%, lymphangiectasia 58%
**Granulomatous lymphangitis is rare and tend to have fever, abd pain, +/- infxn (ex: Boxer E. coli colitis)
JVIM 2018 PLE review
Approximately what proportion of PLE dogs ultimately succumb to the disease?
Name at least four negative prognostic factors.
Half
CCECAI >5
Weight loss
High or low BUN
Decr alb
Decr vit D
Need for immunosuppressives
JVIM 2018 PLE review
Name at least three breeds prone to primary intestinal lymphangiectasia.
Which one is strongly associated with lymphangitis?
Soft coated wheaton terriers – many have lymphangitis
Norwegian Lundehund
Yorkie
Maltese
Shar pei
JVIM 2018 PLE review
What are two potential deficiencies you might see with a long term ultra low fat diet?
What type of fat is rapidly absorbed and does not stimulate CCK release?
What proportion of PLE/lymphangiectasia dogs respond to low fat diets?
Need LCFAs for essential FAs and vits A, D, E, K
MCTs
80%
JVIM 2018 PLE review
JAVMA 2018 CIE nutrition
How might prokinetics be of benefit in dogs with intestinal lymphangiectasia?
Peristalsis passively facilitates lymph transport
JVIM 2018 PLE review
Which groups of dogs can be differentiated with contrast enhanced ultrasonography?
Healthy
CIE sympotomatic
CIE remission
LSA
CIE symptomatic has higher contrast than the other groups
No difference CIE vs LSA or LSA vs healthy dogs
JVIM 2019 Nisa
Which are probably NOT a major cause of low vit D in CIE dogs?
Low intake
Malabsorption
Low vit D binding protein
Inflammation
Low intake, low vit D binding protein
JVIM 2019 Wennogle
Which two interleukins are underexpressed in GSD CIE biopsies?
IL-33 – early warning of mucosal breach, prevents autoimmunity (influences Tregs and Th cells)
IL-13 – unclear role and is incr in non-GSD CIE dogs
JVIM 2019 Kathrani
What is the significance of Ki-67 and CD3 IHC on GI bx of CIE dogs?
Where in the bx are these cells most prevalent?
Does this correlate with clinical scores, histologic scores, both, neither?
CD3 is a T cell receptor that binds MHC II + Ag. Ki-67 is expressed during active cell phases, absent in resting (G0).
CD3+Ki-67 double positive cells = active T cells. Should mostly be in the villous tips (exposure to luminal Ag) BUT CIE dogs had incr expression in the crypts.
Correlated with CCECAI score but not WASAVA score.
JVIM 2019 Karlovits
Is anemia more common in dogs with IBD or LSA?
What morphologic abnormality is especially common? What causes this?
LSA
Eccentrocytes
–Clear crescent shape along one side of the periphery
–Membrane leaflets fuse with no Hb in between
–Caused by oxidative damage
JAVMA 2019 Parachini-Winter
What staining method is superior to H&E for detection of eosinophils on GI bx?
IHC for eosinophil peroxidase
Dogs with eosinophilic enteritis have more degranulated eos in the lamina propria
JVIM 2018 Bastan
What is one reason why CIE dogs have more primary than secondary BA in feces, other than dysbiosis?
How do steroids affect this?
Downregulated Na-dependent BA transporter in the ileum
Steroids –> incr transporters
JVIM 2018 Garietta
JVIM 2019 Guard
True or False: There is strong evidence in favor of metronidazole use as part of the treatment in dogs with IBD.
True
Young, large breed dogs are most likely to respond
JVIM 2018 CIE therapies review
True or False: If an IBD dog does not respond adequately to steroids, adding cyclosporine is unlikely to help.
False – cyclo can be used in pred refractory IBD
JVIM 2018 CIE therapies review
Which two factors increase the likelihood of food responsive rather than steroid responsive CIE?
Younger
Older
Vomiting
Small bowel diarrhea
Large bowel diarrhea
Lower albumin
Normal albumin
Younger, large bowel diarrhea, normal alb
JVIM 2018 CIE therapies review
How long does it typically take for dogs with food responsive CIE to respond to diet?
Approximately what proportion of dogs and cats will respond to diet?
1-2 weeks
~two thirds
JVIM 2018 CIE therapies review
JAVMA 2018 CIE nutrition
True or False: Fat content is important in some dogs with CIE, but generally not a concern in CIE cats.
True – cats tolerate fat better than dogs
JAVMA 2018 CIE nutrition
What two breeds are prone to gluten intolerance?
Irish setters (essentially Celiac)
Border terriers (multisystemic gluten sensitivity)
JAVMA 2018 CIE nutrition
Would you choose endoscopic or sx GI biopsies for cats with the following AUS findings?
Mucosal changes
Muscularis changes
Lack of muscularis changes
Mid-ileal changes
Mucosal changes - endo (AUS had high PPV)
Muscularis changes - endo (AUS had low PPV)
Lack of muscularis changes - endo (AUS had high NPV – no AUS changes = no histo changes either)
Mid-ileal changes - consider sx but endo could be fine (high PPV; BUT poor NPV for all GI segments, meaning lack of AUS changes =/= lack of histo changes)
JVIM 2019 Guttin
What is haptoglobin?
Is it high, low, or no difference IBD vs LSA vs healthy cats?
Acute phase protein
High in IBD and LSA vs healthy, but could not differentiate IBD vs LSA
JFMS 2021 Love
True or False: Abdominal lymph node FNA/cytology is an accurate screening test for LSA.
False. Most bx-confirmed LSA LNs were negative on cytology.
JFMS 2020 Correa
How is cobalamin absorbed into enterocytes? (passive diffusion, facilitated diffusion, active transport, endocytosis)
What protein is it bound to in circulation?
Endocytosis at cubam receptor with intrinsic factor
Transcobalamin
2019 Cobalamin review
How does hypocobalaminemia affect homocystein levels?
What are at least three other conditions that affect homocystein levels?
In normalcy, cobal is a cofactor in homocystein –> methionine.
No cobal –> high homocystein. Also functional folate deficiency.
High homocystein also in renal disease, heart disease, hypothyroidism, Cushing’s, Greyhounds
2019 Cobalamin review
10mo MI Giant schnauzer
PC: chronic diarrhea, hyporexia, oral ulcers
PE: small for age, thin, dull mentation
Labwork: pancytopenia, hypoglycemic ketoacidosis, hyperammonemia, proteinuria
–What is your primary differential? Underlying mechanism?
–What are at least four other breeds predisposed to this condition?
–How quickly will he respond to treatment?
–What labwork abnormality will NOT normalize?
Imerslund-Grasbeck syndrome. Dysfunctional Cubam receptor –> can’t take in cobal+intrinsic factor.
Border collie, Shar-Pei, Beagle, Aussie, Yorkie
Give B12 (can be oral or inj). Clinical improvement within 2 days, MMA normal within a week
Proteinuria will persist due to abnormal renal tubular Cubam
2019 Cobalamin review
Which gut bacteria competes with host for cobalamin?
Bacteroides. Can use cobal-intrinsic factor complex. Can result in incr folate production.
2019 Cobalamin review
What are the five main phyla in dog/cat gut flora?
Which is the main phylum in cats?
Which three are particularly suppressed in dysbiosis?
Which one is particularly suppressed in IBD dogs?
Firmicutes – main phylum in cats
Actinobacteria
Suppressed in dysbiosis:
Bacteroidetes
Proteobacteria
Fusobacteria – esp in IBD dogs
JVIM 2018 Microbiome review
Answer the following regarding SCFA.
–How are they generated?
–At least 3 important functions?
–Three specific SCFAs?
–At least 4 genuses of SCFA producers?
–What happens to these bacteria during dysbiosis?
Bacterial fermentation of carbs
Feed colonocytes, tight junctions, motility, mucus, downregulate inflamm, acidic
Proprionate, butyrate, acetate
PHYLUM FIRMICUTES
Faecalibacterium
Turicidbacter
Blautia
OTHERS:
Bacteroides
Fusobacterium
Bifidobacterium (phylum Actinobacteria)
Dysbiosis –> fewer SCFA producers
JVIM 2018 Microbiome review
What are four bacteria that are increased in dysbiosis? Which are suppressed by secondary BA?
Strep (phylum Firmicutes)
Suppressed by secondary BA:
C. diff (phylum Firmicutes)
C. perf (phylum Firmicutes)
E. coli (phylum Proteobacteria)
JVIM 2018 Microbiome review
What bacteria is the main BA converter?
C. hiranonis
JVIM 2018 Microbiome review
Which are pro-inflammatory and which are anti-inflammatory?
Treg
Th1
Th17
IL-8
IL-10
IL-12
IL-23
Pro:
Th1, Th17
IL-8, 12, 23
Anti:
Treg
IL-10
JVIM 2018 Microbiome review
True or False: SCFA concentrations are altered in CIE dogs, but cannot be used to differentiate healthy vs CIE in a given individual dog.
True
JVIM 2019 Minamoto
How do fecal total primary bile acids and total secondary bile acids compare in CIE vs healthy dogs?
Does this change with steroid treatment?
How did their dysbiosis index respond to steroid treatment?
In a study of food responsive CIE dogs, how did their dysbiosis index respond to a vegetarian diet?
CIE – no difference total primary BA; less total secondary BA
Improves within a month of steroids. No change to dysbiosis index even after 3mo.
Food responsive dogs – after 2mo, partial improvement of DI (to the point of no difference between CIE vs healthy dogs)
JVIM 2019 Guard
JVIM 2019 Bresciani
In a 2mo study of healthy dogs, what were the effects of Tylosin with respect to:
–Fecal consistency
–Dysbiosis index
–C. perf
–Total primary BA and primary/secondary BA ratio
–No change fecal consistency
–Higher DI, unpredictable recovery, may be permanent
–Did not consistently decr C. perf
–Higher total BA and primary/secondary BA ratio
JVIM 2019 Manchester
What is the effect of Pro-Kolin probiotic paste (e. faecium) vs placebo in dogs with acute diarrhea?
Slightly faster resolution and decr risk of needing additional intervention. Overall minor clinical benefit BUT more benign than abx.
JVIM 2019 Nixon
