Lecture 8 2/6/25 Flashcards by Danika Boltz

What are the characteristics of chronic enteropathy?

-greater than or equal to 2-3 weeks of gastrointestinal signs
-requires ruling out metabolic causes and maldigestion
-should evaluate a resting cortisol in all dogs and T4 in all older cats presenting with GI signs

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What are the clinical manifestations of chronic enteropathy?

-diarrhea
-vomiting
-weight loss
-changes in appetite
-melena
-hematochezia
-tenesmus/straining
-hematemesis
-constipation

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Which type of chronic enteropathy is responsible for the most cases?

food-responsive enteropathy

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What does use of the term IBD imply in dogs?

-exclusion of extra-GI dz
-exclusion of parasitism
-exclusion of diet-responsive dz
-exclusion of antibiotic-responsive dz
-confirmation of inflammation on intestinal biopsy
-requirement for immune-modulators

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What is chronic enteropathy used to describe?

chronic GI signs for which an underlying etiology has not yet been determined

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What is protein-losing enteropathy?

small intestinal malabsorptive syndrome characterized by excessive protein loss, including hypoalbuminemia and hypoglobulinemia +/- hypocholesterolemia

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What are the possible pathophysiologies/etiologies of protein-losing enteropathy?

-increased mucosal permeability due to inflammatory or neoplastic infiltration
-mechanical causes; ulcers, erosion, congestion
-lymphatic obstruction or rupture; lymphangiectasia w/ low cholesterol

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What are the severe chronic enteropathies that can cause PLE?

-lymphoplasmacytic enteritis
-lymphangiectasia
-alimentary lymphoma
-infectious enteropathies

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What are the clinical signs of protein losing enteropathy?

-small intestinal diarrhea
-weight loss despite good appetite
-panhypoproteinemia
-edema/pleural effusion/peritoneal effusion
-hypercoagulability
-refractory to treatment

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What is lymphangiectasia?

subtype of protein-losing enteropathy in which there is both panhypoproteinemia and hypocholesterolemia

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What are patients with lymphangiectasia at risk for?

hypocalcemia secondary to vitamin D malabsorption

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What can be seen on abdominal ultrasound in patients with lymphangiectasia?

striations perpendicular to the intestinal lumen

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What are the clin path findings in an uncomplicated chronic enteropathy?

-possible weight loss
-normal serum proteins
-normal cholesterol
-no third spacing
-normal electrolytes

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What is the treatment for uncomplicated chronic enteropathy?

elimination diet +/- glucocorticoids

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What are the clin path findings in protein-losing enteropathy?

-weight loss that may be profound
-panhypoproteinemia
-normal to low cholesterol
-edema and effusions if albumin is severely low
-normal electrolytes

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What is the treatment for protein-losing enteropathy?

-elimination diet
-glucocorticoids +/- second agent
-manage risk of thrombosis

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What are the clin path findings in lymphangiectasia?

-weight loss that may be profound
-panhypoproteinemia
-low cholesterol
-peritoneal and pleural effusion regardless of how low albumin is
-ionized hypocalcemia possible

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What is the treatment for lymphangiectasia?

-low fat diet +/- elimination
-glucocorticoids +/- second agent
-manage risk of thrombosis

What is the minimum database when working up chronic enteropathy?

-CBC
-biochem panel
-UA +/- UPC

What are the characteristics of hypocalcemia in protein-losing enteropathy?

-decreased calcium is possible
-often low total calcium since hypoalbuminemia decreases total calcium
-confirm with ionized calcium measurement to determine if functional calcium is truly low

What are the characteristics of abdominal radiographs as a diagnostic tool for chronic enteropathy?

-often unrewarding
-screens for concurrent dz and obstructions
-may find gas and/or fluid in intestinal loops
-does not allow for evaluation of intestinal wall thickness and structure

What are the goals of abdominal ultrasound as a diagnostic tool for chronic enteropathy?

-screen for underlying and concurrent dz
-assess GI tract and associated lymph nodes; look for masses, wall thickness abnormalities, and wall layering abnormalities
-presence/absence of intestinal wall thickening does not rule chronic enteropathy in or out

What does a thickened intestinal muscularis on ultrasound indicate?

severe inflammation or small cell GI lymphoma; cannot differentiate on ultrasound

What does loss of normal layering on ultrasound indicate?

severe inflammation or neoplasia; cannot differentiate on ultrasound

What do mucosal hyperechoic striations perpendicular to the lumen indicate on ultrasound?

-increased suspicion of lymphangiectasia -can be a normal postprandial change

Why should all patients with chronic diarrhea be dewormed (unless contraindicated)?

fecal testing is not 100% sensitive; it is better to empirically deworm than to miss a parasite causing clinical signs

Which anthelmintic medications can be used for empirical deworming in patients with chronic enteropathy?

-fenbendazole -drontal plus -profender

Why is endoscopy not routinely done as an early diagnostic tool in chronic enteropathy cases?

biopsy results can look the same for many different etiologies; treatment trials are often better for making an accurate diagnosis

When should a biopsy be obtained in chronic enteropathy workup?

-once food-responsive enteropathy, parasites, and idiopathic dysbiosis have been ruled out as potential causes -when IBD, lymphangiectasia, and neoplasia are remaining possible differentials -after completing therapeutic trials in patients that are stable, eating, and otherwise well

Which patients have an indication for an earlier biopsy?

-hyporexic or anorexic patients -patients with 10% or greater unintended weight loss -moderate to severe hypoalbuminemia -young boxers and french bulldogs -loss of intestinal wall layering, especially if focal

Why are biopsies typically sought earlier in a patient with protein-losing enteropathy?

-dropping albumin puts pressure on the timeline -patient is more stable early on -allows for early diagnosis and initiation of proper treatment -rules out lymphoma and histoplasmosis early

What is the caution in doing biopsies in patients with protein-losing enteropathy?

albumin is important for healing; want to avoid full thickness biopsies when possible

What signs can help you to localize dz prior to doing a biopsy?

-small vs large bowel diarrhea -serum folate and cobalamin measurements -abdominal ultrasound findings

Which GI locations can be biopsied via scope?

-gastric (upper GI scope) -duodenal (upper GI scope) -ileum (lower GI scope) -colon (lower GI scope)

Which GI location always requires surgical biopsy?

jejunum

What are the characteristics of endoscopic biopsy?

-no incisions -faster recovery -can access esophagus, stomach, duodenum, and ileum w/ minimally invasive procedure -no full thickness biopsies; better healing, but chance to miss dz -can biopsy multiple sites per segment

What are the characteristics of surgical biopsy?

-chance for poor healing, especially with low albumin -longer recovery -provides access to jejunum, liver, pancreas, associated lymph nodes, and potential masses -allows for full thickness biopsies -typically can only biopsy one site per segment

Which intestinal neoplasias are most common?

-intestinal adenocarcinomas -gastrointestinal lymphoma

What are the clinical signs of intestinal neoplasia?

-non-specific GI signs -anorexia -weight loss -vomiting and/or diarrhea -possible hematochezia and/or melena

How is intestinal neoplasia diagnosed?

-palpation of mass or diffuse intestinal thickening -rectal exam to find polyps and adenocarcinomas -abdominal radiographs -abdominal ultrasound -cytology -histopathology

What is the treatment of choice for intestinal adenocarcinoma?

surgery

What is the treatment of choice for high grade/large cell GI lymphoma?

chemotherapy +/- surgery

What is the treatment of choice for low grade/small cell GI lymphoma?

chemotherapy