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Small Animal Final Year > SA Large Intestinal Disease > Flashcards

SA Large Intestinal Disease Flashcards

1
Q

Define tenesmus

A

a continual or recurent inclination to evacuate the bowels

painful/ineffectual straining

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2
Q

What is the function of the LI with regards to fluid/electrolyte balance?

A
  • Resorption of water: colon esp asc & TV
  • Step in for what the LI hasn’t done
  • Segmented contractions
  • Retrograde peristalsis
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3
Q

What is the function of the large intestine with regards to population of bacteria? What do the bacteria do?

A

Large population of bacteria:

  • Fibre fermentation àSCFA production
  • Reduces risk of colonisation by pathogenic bacteria
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4
Q

What is the function of the rectum?

A

Faecal storage

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5
Q

Define:

  • Diarrhoea
  • Tenesmus
  • Constipation
  • Dyschezia
  • Haematochezia
A
  • Diarrhoea
  • increased fluidity, volume or frequency of defecation
  • Tenesmus
  • painful/ineffectual straining
  • Constipation
  • decreased frequency/difficult defecation
  • Dyschezia
  • difficult/painful defecation
  • Haematochezia
  • fresh blood in faeces
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6
Q

If the clinical feature is weight loss,

is the problem more likely SI or LI?

A

Small intestine problem - commonly causes weight loss

Large intestine problem - rarely does

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7
Q

What would the faecal consistency be like if there was:

  1. A problem with the SI
  2. A problem with the LI
A

SI - watery/soft/bulky/undigested food/variable colour

LI - variable/colour ususally unchanged

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8
Q

How does the faecal volume change with a SI problem or a LI problem?

A

SI - volume increased

LI - normal or decreased volume

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9
Q

How does borborygmi/flatulence change with a SI problem and a LI problem?

A

SI problem - not uncommon to have these

LI - borborygmi/flatulence absence

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10
Q

How does the frequency of defecation change with a SI problem and a LI problem?

A

SI - 1-3x a day, increased urgency if acute or severe

LI - >6x a day, increased urgency

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11
Q

Is tenesmum absent or present with a SI problem or a LI problem?

A

SI - absent

LI - present

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12
Q

Is mucus present with a SI problem or a LI problem?

A

SI - mucus absent

LI - mucus present

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13
Q

Is there any blood with a SI problem or a LI problem?

A

SI - usually as melaena i.e. black, tarry stools *fresh blood might be seen if massive bleed and/or increase rate of transit e.g. AHDS (acute haemorrhagic diarrhoea syndrome.)

LI - fresh blood can be seen

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14
Q

Give some differential diagnoses of LI diarrhoea

A
  1. Inflammatory/colitis (IBD)
  • Lymphoplasmacytic*
  • Eosinophilic
  • Granulomatous/histiocytic
  • Inflammatory infiltrates in the mucosal lining
  1. Dietary indiscretion…especially dogs!

•This is actually more common than IBD

  1. Infections: think about signalment, immune compromise, environment
  • Bacterial: salmonella, campylobacter, clostridia
  • Salmonella and clostridia are rarely seen in SA
  • Protozoal: giardia, isospora, tritrichomonas (cats)
  • Parasitic: trichuris, hookworm
  • Easy to overlook!!!!!! DO NOT FORGET ABOUT THESE.
  1. Secondary to fat maldigestion in SI*:

•EPI, SIBO/ARD, IBD, lymphangiectasia, liver disease, pancreatitis

  1. Secondary to portal hypertension: liver Dx

•Anything that reduces perfusion to the LI

  1. Local irritation: pancreatitis*, prostatitis, mass

•Not only vomiting signs but colitis signs too

  1. Colonic polyps- proximal cats, distal dogs
  2. Colonic neoplasia-adenocarcinoma, lymphoma
  3. Motility disorder: ‘irritable bowel syndrome’

•Normally diagnosis when we cannot think of anything else. Motility disorder. Not inflammatory (which is IBD)

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15
Q

Give some examples of inflammatory/colitis (IBD) that can be a differential diagnosis for LI diarrhoea

A
  • Lymphoplasmacytic*
  • Eosinophilic
  • Granulomatous/histiocytic
  • Inflammatory infiltrates in the mucosal lining
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16
Q

What are some eamples of infections that can be a differential diagnosis for LI diarrhoea?

A
  • Bacterial: salmonella, campylobacter, clostridia
  • Salmonella and clostridia are rarely seen in SA
  • Protozoal: giardia, isospora, tritrichomonas (cats)
  • Parasitic: trichuris, hookworm
  • Easy to overlook!!!!!! DO NOT FORGET ABOUT THESE.
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17
Q

With regards to the investigation for LI disease, what kind of things should you ask about in the history?

What is the aim of taking a thorough history in these cases?

A
  • Vaccination- less relevant to LI disease…
  • Worming
  • Diet history – any change, any scavenging
  • Medication- anything we have given? anything the owner has given?
  • In contact animals (or people) affected
  • Previous or concurrent illnesses?
  • Questions relating to other body systems?
  • Is your patient vomiting?
  • vomiting is often associated with SI disease but~10- 30% of dogs with colitis may vomit
  • Is your patient generally well?
  • most cases with LI diarrhoea are systemically well

Aim: determine if the diarrhoea is SI or LI if possible

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18
Q

When investigating potential LI disease, what should you do on your physical exam?

A
  • Full physical examination:
  • Assess possible causes and consequences
  • Consequences less likely than in SI diarrhoea
  • Caudal abdominal palpation is important but often unrewarding
  • Any evidence of concurrent disease
  • One example….Any petechiation/ecchymoses?
  • Perineal exam: is there any evidence of
  • Perineal rupture
  • Wounds/swelling/mass
  • Faecal incontinence (tritrichomonas infection in cats)
  • Anal sac disease
  • Palpate and empty and palpate again! Assess the anal tone?
  • Self trauma
  • Anal furunculosis
  • Link between this and IBD of the LI
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19
Q

As part of investigating LI disease, you should perform a rectal exam. What should you be looking/feeling for?

A
  • Provides a faecal sample/evidence to support LI disease
  • Rectal mucosa:
  • Smooth or roughened?
  • Any mass lesions?
  • Any evidence of a stricture?
  • Can you feel the lumbar (medial iliac) LN
  • In a male dog can you feel the prostate?
  • Would you expect to?
  • Palpate the pelvic urethra ventrally
  • Could there be tenesmus due to a urethral calculus?
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20
Q

Why might you take rectal cytology as a diagnostic test for investigation LI disease?

A
  • Might document inflammatory or neoplastic cells?
  • Often not helpful but some clinicians advocate this for completeness
  • Collect sample with a gloved finger as part of the rectal exam or with a cytology brush?
21
Q

How should you analysis a faecal sample when investigation LI disease?

A
  • Visual assessment of the sample
  • does it support the clinical history you have taken?
  • Microbiology: what do you expect to find in faeces?
  • beware of over diagnosing bacterial infection
  • think about commensals
  • enteropathogens only suspected
  • in severe disease
  • if there are worrying systemic signs
  • Parasitology: young dog/cat? (immunocompromised)
  • Nematodes-T.vulpis
  • Giardia – multiple or pooled samples?
  • faecal flotation, faecal antigen SNAP test, PCR
  • Tritrichomonas (cats)-PCR (see notes for links on more info)
  • Chronic LI disease history especially in young cats. Can be self limited. Leak mucoid stool.
  • Do a PCR if the history matches
22
Q

Why might you do biochemistry and urinalysis when investigating LI disease?

A

Often very unhelpful but something to consider if your patient is unwell:

  • Could there be a concurrent disease? Ie are these 2ry GI signs?
  • Consider underlying causes such as liver disease, pancreatitis
  • Is this part of AHDS or more generalised IBD?
  • Are there any significant consequences of the li problem:
  • Signs of fluid and electrolyte imbalance?
  • Azotaemia (high creatinine and urea) + concentrated urine sgà dehydration
  • High urea only –> GI bleed
23
Q

Why might you use haematology as part of the diagnostic tests for investigating LI disease?

A

Often very unhelpful but occasionally is something to consider?

Neutrophillia – stress reponse? Or is it inflammatory???

Might see supporting evidence for

  • Inflammation
  • Parasitism (or hypoadrenocorticism…)
  • Anaemia
  • Blood loss - just a colitis this is not enough to cause anaemia. Have you got a polyp or tumour which is bleeding more than you think.
  • Chronic disease
24
Q

How useful is radiography for investigating LI disease?

When would you consider them?

A

Often unhelpful….

  • Consider plain abdominal radiographs if there is anything suggesting systemic illness
  • Abdominal pain
  • Weight loss
  • Contrast studies might be more useful but rarely done:
  • Barium enema may be helpful
  • Pneumocolon

Why might you consider thoracic radiographs? Which views would you want?

Met check if you think you have neoplasia!! Always do before surgery.

25
Q

How useful is abdominal radiography for investigating LI disease?

What would you be looking for if you chose to do it?

A

Often unhelpful…. Air and U/S are not a good match!! But air and radiographs work well

  • Look for mass lesions
  • Any evidence of
  • Increased wall thickness
  • Loss of layering
  • Disease elsewhere?
  • Lymph nodes
  • Prostate – good for U/S
  • Pancreas
  • SI….
  • More to go on – know what to do next
26
Q

How useful is endoscopy/proctoscopy for investigating LI disease?

A
  • Can be very helpful but most cases do not need this level of investigation
  • Can be very useful but Bowel preparation is crucial to the likely value of this investigation
  • “if a job’s worth doing, it’s worth doing well”
  • Colonoscopy is not as common as in humans –you can tell a human to have laxatives and not eat etc.. Hard to create an empty colon in a dog/cat. Can starve for 48 hours or give laxative..
  • Appearance will vary but won’t predict the diagnosis
  • normal?
  • cobblestone appearance?
  • focal mass?
  • lost visibility of mucosal vessels?
  • Cant find anything but have a high clinical suspicion?? Repeat again tomorrow!!
27
Q

What is the rationale for high fibre diets for colonic disease?

A
  • Colonocytes use volatile fatty acids (butyrate and proprionate) for energy metabolism
  • VFAs are derived from fibre fermentation
  • “Fibre –> improved colonic health” (needed)
28
Q

Plant polysaccarides and lignins are resistant to digestion.

What happens if they are fermentable or unfermentable?

A
  • Fermentable:
  • fermented by bacteria to short chain fatty acids (SCFAs)
  • binds bile acids to reduce colonic irritation and bind water
  • lower colonic pH:
  • encourages beneficial bacterial
  • reduces NH3 absorption
  • Unfermentable: passes through unchanged
  • ­ increased faecal bulk –> stretches colon –> normalises motility
29
Q

How can you use diet to manage acute colitis?

A

Manage with a highly digestible, low fat diet

Fibre

30
Q

Would you use fenbendazole and anti-bacterials for the management of acute colitis?

A
  • Fenbendazole treatment trial? – can be very useful
  • Consider treatment for trichuris vulpis?
  • Intermittent shedding of eggs –> false –ve faecal flotation tests
  • Rule out giardia?
  • More commonly a si problem
  • Anti-bacterials: less easy to justify
  • Enteropathogens or commensals?
  • Except maybe metronidazole – as can help dampen down inflammation in colon
31
Q

What is the most common cause of CHRONIC LI disease?

A
  • Inflammatory bowel disease
  • Lymphocytic-plasmacytic-commonest cause of chronic colitis in dogs
  • any age but esp 6mths- 4 yrs
  • any breed but esp GSDs, rough collies, labs
  • Eosinophilic
  • Histiocytic/granulomatous

Try to find/rule out an underlying cause before calling this idiopathic or assuming you need to treat for immune mediated disease

32
Q

With the management of chronic colitis, where should you start every time?

Give some examples of this and what it should contain

A

Start with diet every time

  • Most intestinal disease diets
  • are highly digestible and low fat
  • low residue –> reduced faecal bulk
  • Consider need to increase fibre
  • Like SI IBD there can be a dietary intolerance component
  • “Hypoallergenic diets”
  • single source, novel or hydrolysed protein
  • Low fat
33
Q

When trying to manage CHRONIC colitis, if management as for acute colitis & diet alone are not successful, what next?

A

Drugs

  • Corticosteroids (prednisolone)
  • 1st line treatment in dogs and cats
  • Don’t give out on day 1. Mass number of side effects
  • +/- Other immunosuppressive drugs
  • Ciclosporin
  • Azathioprine (not cats-ever!)
  • Chlorambucil (cats)
  • Metronidazole
  • For immune modulating effects?
  • Sulphasalazines- uncommonly used
  • Side effects include KCS
  • May be useful in colitis cases – but there are better things like diet etc
  • Antibiotics: controversial if not unwell?
  • Anerobes especially therefore tend to choose metronidazole
  • Amoxicillin, ampicillin?
34
Q

What is granulomatous colitis?

Which dogs have a genetic predisposition to it?

A
  • Granulomatous colitis = histiocytic ulcerative colitis
  • Aggressive!!!
  • Young Boxers and French Bulldogs (anything that looks like a boxer on small legs)
  • genetic predisposition therefore potential in other breeds
  • Originally thought to be severe idiopathic IBD
  • very severe and progressive disease
  • weight loss common (unusual for LI!) – very active and the colon is so inflamed! Dog is so sad they go off their food L
  • many dogs PTS
  • poor response to management for IBD
35
Q

What is granulomatous colitis now recognised to be associated with?

A
  • Now recognised to be associated with adherent and invasive Escherichia coli (AIEC) burrows into mucosa of the gut!! So wont pick up on the faeces. Need a mucosal biopsy.
  • Dogs may have an underlying problem with neutrophil function
36
Q

What is the diagnosis for granulomatous colitis?

What is the treatment?

A
  • Diagnosis:
  • biopsies
  • granulomatous inflammation
  • accumulation of PAS stain +ve macrophages
  • FISH technique identifies colonic mucosal invasion by EColi
  • Treatment: must be sure of your diagnosis!
  • 8 weeks of enrofloxacin –? cure
  • We need to be certain why we are using this and for this period of time!!!
  • May relapse
  • poor response might mean resistance?
37
Q

Where do 40-60% of all GI tumours occur in dogs?

What are the most common ones seen?

A
  • Dogs: 40-60% of all GI tumours occur in the LI
  • Commonest are benign adenomatous polyps
  • Also see adenocarcinoma, lymphoma, leiomyoma, others
  • Usually found in the distal colon/rectum
38
Q

Where do 10-15% of all GI tumours occur in cats?

What are the most common ones seen?

Where is the most common place?

A
  • Cats: 10-15% of all gi tumours occur in the LI
  • Lymphoma, adenonoma and others
  • Usually found in the proximal colon
  • Ileocaecal junction is fave place of a cat tumour
39
Q

What is the diagnosis for LI neoplasia?

A
  • Diagnosis
  • History- flattened stool? surface blood?
  • Rectal examination, especially dogs
  • Radiography, including met check (sub-lumbar LN and thorax)
  • Ultrasonography
  • Endoscopy and biopsy
40
Q

What is the treatment for LI neoplasia?

A
  • Treatment
  • Surgery
  • Control with NSAIDs such as piroxicam. Meloxicam is often used too
  • chemo protocols for lymphoma
  • prognosis can be reasonable
41
Q

What is constipation?

What are some causes?

A
  • Decreased frequency and/or difficult defecation
  • Many different causes and often multifactorial especially in cats
  • may develop into irreversible megacolon – esp. cats
  • Problem is it gets left and left then needs surgery
  • Very often these cats are also dehydrated – obese, lazy, kidney cats!!
42
Q

Give a DAMNIT-V list of causes of constipation?

A
43
Q

What things do you need to try and get from the history when trying to diagnose a constipation case?

A
  • History
  • Ask the right questions
  • Differentiate from colitis + cystitis
  • Previous episodes and response to therapy
  • Any history of RTAs
  • Any degree of pelvic narrowing… We now attend to the width of the pelvic canal of an RTA cat
  • Any change in diet, behaviour
  • Think about concurrent disease
44
Q

Give a diagnostic plan for a possible constipation case

A
  • Radiography
  • Ultrasound
  • Blood samples
  • for underlying diseases e.g. kidneys in the older cat
  • Proctoscopy

Note that evacuation of colon may be difficult: rehydrate your patient first (maybe 24 hours) if there is nay doubt about hydration status!

45
Q

What is primary and secondary feline megacolon?

A

Primary “dilated” (60%)

•Primary smooth muscle defect?

Secondary “hypertrophic” 40% due to

  • Multiple causes including…
  • Pelvic malunion
  • Dietary
  • Spinal
  • Dysautonomia
  • Manx sacrum
  • Initially reversible- important to treat effectively if possible
  • Some cats have it removed????????????
46
Q

What are some causes of secondary hypertrohic feline megacolon?

A

Multiple causes including…

  • Pelvic malunion
  • Dietary
  • Spinal
  • Dysautonomia
  • Manx sacrum
47
Q

What is the management of constipation?

A
  • Treat underlying cause
  • Rehydration
  • Enemas water ± soap (lubricate is much better as soap is an irritant to the mucosal lining) ± lactulose (act as an osmotic and draw water into the colon)
  • Dietary fibre (eg RC Satiety Support)
  • Laxatives
  • Prokinetics?
  • Surgical colectomy
48
Q

Give some examples of laxatives that are used for the management of constipation?

A

Laxatives:

  • Dietary fibre supplements: bulk-producing agents
  • poorly digestible polysaccharides/celluloses
  • psyllium (1–4 tsp per meal)
  • pumpkin (1–4 tblsp per meal)
  • Sterculia granules (Peridale 98 % w/w Granules)
  • takes up ~60 times its own volume of water –> gelatinous mass (softer)
  • ­ increased bulk promotes peristalsis
  • Stool softeners / surfactants
  • anionic detergents
  • enhance lipid absorption and impair water absorption
  • Lubricants / emollient
  • White soft paraffin e.G. Katalax
  • Impede colonic water absorption à easy passage of faeces
  • Only beneficial if mild constipation
  • Hydrating agents (osmotic action)
  • Poorly absorbed polysaccharides
  • E.G. Lactulose 0.5 ml/kg q8–12h
  • Traps water
  • Stimulate colonic fluid secretion
  • Stimulate propulsive motility
49
Q

Give some examples of prokinetics for the management of constipation

A

Prokinetics – not particularly helpful

  • Cisapride
  • Serotonin 5-HT4 receptor agonist
  • Not always available
  • Ranitidine?
  • Stimulates GI muscarinic receptors, esp colon
  • May help but wont help if the colon is concrete full

Small Animal Final Year (317 decks)

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