Small Intestinal Disease Flashcards
1
Q
What comprises the small intestine?
A
Everything from the pyloric sphincter to the ileocolic junction
Duodenum- Jejunum- Ileum
2
Q
What is the function of the small intestine?
A
- Digestion of ingesta/food
- Secretion of water and mucous
- Absorption of nutrients- peptidases, nucleases, disaccharides, bile acids, pancreatic enzymes
- Barrier to infection
3
Q
What are villi?
A
Protrusions of the intestinal mucosa to increase surface area
4
Q
What are the villi comprised of?
A
- Mucosal immune system
- Lamina propria
- Enterocytes
- Digestive enzymes, carrier proteins, goblet cells
- Crypt cells
5
Q
How long does it take for enterocytes to completely turn over?
A
3 days from the base of crypts
6
Q
What do crypt cells do?
A
- Some secretory capacity
- Make undifferentiated epithelial cells
7
Q
What is the main energy requirement of enterocytes?
A
Glutamine
8
Q
What will happen to enterocytes if they do not have enough glutamine?
A
- Decline in villi structure
- Loss of epithelial integrity
- Decreased immune function
- Decreased absorptive function
9
Q
What are some clinical signs of small intestinal disease?
A
- SI diarrhea
- Melena or steatorrhea
- Inappetence
- Systemic illness
- Abdominal distension or pain
- Borborygmi
- Flatulence (usually mild)
- Vomiting and weight loss
- Ravenous appetitie
- Coat changes
10
Q
What are acute enteropathies typically caused by?
A
- Dietary indiscretion or change
- Infection
- Medications
- Stress
- Pancreatitis
11
Q
What are chronic enteropathies typically caused by?
A
- Food allergy or hypersensitivity
- Inflammatory bowel disease
- Lymphangiectasia
- Infections (SIBO or parasites)
- Neoplasia
- EPI
12
Q
What is HGE and AHDS?
A
HGE= Hemorrhagic gastroenteritis AHDS= Acute hemorrhagic diarrhea syndrome
13
Q
What are the animals predisposed to AHDS and how does it typically present?
A
Small breed dogs
Marked hemoconcentration with fluid shifts
Typically require hospitalization
14
Q
T/F: Dogs with AHDS will typically enter hypovolemic shock prior to having clinical evidence of dehydration.
A
True
15
Q
What are the clinical signs of AHDS?
A
Hematemesis and hematochezia
Typically profuse and very hemorrhagic
16
Q
What is the etiology of AHDS?
A
Usually viral, hypersensitivity, or clostridium perfringens
17
Q
What are the expected PCV and TS levels in AHDS patients?
A
PCV >60% and TS not horribly elevated due to GI loss
18
Q
How do you treat AHDS?
A
IV fluids, antibiotics, gastroprotectants, antiemetics, nutritional support
19
Q
What is the prognosis of AHDS?
A
Good with aggressive supportive care
Decreases with severe hypoproteinemia or signs of sepsis
20
Q
What helminths are found in the small intestine?
A
Toxocara canis Trichuris vulpis Ancyclostoma caninum Dipylidium caninum Strongyloides stercoralis
21
Q
What is the best test when you suspect worms?
A
Fecal (if negative do 3 consecutive days testing)
Can just deworm empirically
22
Q
All the things about Diplydium caninum.
A
- Ingestion of fleas with immature worms
- Shed proglottids with in 2-3 weeks
- Peri-rectal irritation and rarely small intestinal impactions
- Teat with praziquantal or fenbendazole
Other tapeworm species: Taenia or Echinococcus
23
Q
All the things about Toxocara canis/cati.
A
- Ingestion of eggs or maternal transmission
- Adults in small intestine
- Babies most affected and can be fatal
- Small intestinal obstruction are possible but rare
Clinical signs: vomiting or defecating live worms, unthrifty, rounded belly, diarrhea
Treatment: fenbendazole, pyrantel
24
Q
What protozoa live in the small intestine?
A
Giardia Tritrichomonas foetus Coccidia Cryptosporidium Toxoplasma gondii
25
What are the primary clinical signs and pathophysiology of protozoa infections?
Clinical signs: Diarrhea +/- weight loss
Pathology: Destruction of enterocytes and villi
26
How do you diagnose Giardia?
Direct smear to visualize cysts or trophozoites, IFA, Antigen/ELISA
27
How do you diagnose Tritrichomonas foetus?
Direct fecal smear, culture, PCR preferred
CATS ONLY
28
T/F: Giardia is non-species specific so it can be passed between dogs and cats and to humans.
False- species specific so any cross infections would be self-limiting
29
T/F: Subclinical infection of Giardia are very common.
True
30
What is the goal of treatment of Giardia?
Stop diarrhea
Fenbendazole or metronidazole effective
Elimination of infection is very difficult
31
What are the clinical signs of coccidia infections?
Weight loss, dehydration, may be hemorrhagic
Typically self limiting in a healthy adult animal
Worse in young or immune compromised patients
32
How do you diagnose coccidia?
Direct smear or fecal floatation
33
How do you treat coccidia?
Sulfadimethozine, ponazuril, supportive care
34
What is the prognosis of coccidia?
Good in adults with mild symptoms
| Guarded in systemically ill patients
35
How is cryptosporidium transmitted and what are the clinical signs?
Transmission: fecal oral or contaminated food/water; zoonotic potential
Clinical signs: self limiting small bowel diarrhea, can be severe/life threatening in immunocompromised patients
36
How do you diagnose cryptosporidium?
Direct smear or fecal float, ELISA, PCR, biopsy
37
How do you treat cryptosporidium?
Paromomycin or tylosin
38
What is a major concern with toxoplasma?
Zoonosis
39
What are the parasitology facts about toxoplasma?
- Oocysts require 1-5 days to become infectious
- Disease only seen in immunecompromised patients
- Disease mostly seen in cats
- Transmission: predation or fecal contamination
40
What are the clinical signs of toxoplasma?
- Pneumonitis
- Vomiting or diarrhea
- Encephalitis
- Lymph node, liver issues
- Chorioretinitis
- Fever, weight loss, lethargy
41
T/F: Animals are unlikely to be shedding oocysts while they are significantly ill.
True- they have to have intestinal disease in order to shed oocysts and will typically show severe clinical sings only when extra-intestinal
42
How is toxoplasma diagnosed?
Fecal flotation and antibody titers (more useful)
Antibody titers do not predict oocyst shedding or clinical disease
43
How do you treat toxoplasma?
Clindimycin or trimethoprim-sulfonamide
Supportive care
44
What fungal infections do you see in the small intestine?
Pythiosis, histoplasmosis, candidiasis
45
What is pythium insidiosum?
An aquatic oomycete that will infect mammal hosts, typically in gulf coast states
Lives in standing water and infects via skin or mucosal penetration by motile zoospores
Most common in dogs and zoonosis has not been documented
46
What are the clinical signs of GI pythiosis?
Vomiting, weight loss, diarrhea, hematochezia, abdominal pain
Palpable abdominal mass, dehydration, poor body condition
47
What are the clinical signs of cutaneous pythiosis?
Non-healing skin lesion, Very ulcerated and granular looking with draining tracts
May have LN involvement
Dogs: base of tail, extremities, ventral neck, and perineum
Cats: cervical, inguinal, and truncal
48
T/F: Skin and GI pythiosis often occur together.
FALSE- very rarely occur together
49
What will your diagnostics show in pythiosis?
CBC: eosinophilia, anemia
Chem: hypoalbuminemia, hyperglobulinemia
Pythium ELISA (culture difficult)
Biopsy- severe transmural segmental thickening with pyogranulomatous and eosinophilic inflammation ; GMS stain to observe organisms
Rads: poor serosal detail with weight loss, mass lesion in abdomen or esophagus
Ultrasound: segmental thickening of GI, thickened gastric outflow tract, enlarged LN
50
How do you treat pythiosis?
Surgical removal or effected tracts
Iraconazole, terbinafine +/- immunotherapy for at least 2-3 months
51
What is the prognosis of pythiosis?
Poor with disseminated disease and no resection
less that 20-25% respond to medical management
Overall pretty grave
52
What is histoplasmosis?
Dimorphic fungus that occurs worldwide
Occurs in dogs and cats
Transmission: aerosols into lungs and thoracic LNs, GI tract, may enter bloodstream from primary site and cause wide spread disease
53
What are the clinical signs of histoplasmosis?
```
Diarrhea (usually large)
Weight loss to emaviation
Chronic cough
Fever
Anemia, hepatomegaly, splenomegaly, lymphadenopathy
Nasopharyngeal and GI ulceration
Lameness
Respiratory difficulty
Skin lesions
```
Cats do not get GI signs
54
How do you diagnose histoplasmosis?
Chest rads: nodules, enlarged LNs
US: spleen liver and LN enlargement with thickened LI/SI wall
FNA or biopsy of abnormal tissues
ELISA antigeen tests
CBC, CHEM, and UA all have non-specific findings
55
How do you treat histoplasmosis?
Prolonged therapy with anti-fungals
Intraconazole, fluconazole or ketoconazole
Amphotericin B in severe cases
56
What is the prognosis of histoplasmosis?
Acute: may be fatal after 2-5 weeks
Poor condition/multisystem involvement: guarded to poor
One organ involved: still not great but better
57
What are all the things with candidiasis?
Normal flora but opportunistic infections associated with the disruption of mucosal integrity can be seen
Cats- oral and URI, pyothorax, ocular, intestinal, cystitis
Dogs- Peritonitis and fungemia, perforating lesions after sx, mucosal and cutaneous candidiasis has been noted in immunosupressed animals
58
What bacterial diseases are associated with the small intestine?
```
Campylobacter
Salmonella
Clostridium
E. coli
Yersinia
Mycobacterium
```
59
What are the top 3 bacteria associated with intestinal disease?
Campylobacter
Salmonella
E. coli
All associated with acute diarrhea
60
What animals are prone to bacterial infections?
Young, kenneled, immunocompromised
Can happen in apparently healthy pets
61
Are fecal cultures useful when diagnosing bacterial infections of the GIT?
Not really since most pathogenic bacteria can be found in small numbers in a healthy GIT
Must be interpreted with clinical signs and other lab data
Performed only in chronic diarrhea or severely debilitated animals
62
What is salmonella?
Gram - facultative anaerobic bacteria that is part of the normal flora of the intestinal tract
Seen in young, parasitized, immunocompromised, or stressed animals
Ingestion of raw/contaminated food
Zoonoticc
63
T/F: Salmonella destroys intestinal villi.
True- just like protozoa
64
What are the clinical signs of Salmonella?
Acute transient diarrhea - can be supportively treated
Septic, shock, hospitalized from illness
65
How do you diagnose salmonella?
Culture: blood or feces depending on disease type
PCR: lacks validation
66
How do you treat salmonella?
None if primary and transient
| IV abx and supportive care with severe illness
67
What is the pronosis for salmonella?
Good unless septic
68
What is E. coli?
Normal flora gram - anaerobic rod shaped bacterium that is mostly non-pathogenic
Rarely causes disease unless immunocompromised or particularly virulent strain
69
What are the clinical signs of E. coli infections?
Diarrhea, vomiting, dehydration, lethargy
70
How do you diagnose E. coli?
Culture of blood or feces
71
How do you treat E. coli and what is the prognosis?
IV supportive care and antibiotics
Good prognosis unless septic
72
What is the causative agent of salmon poisoning disease?
Neorikettsia helminthoeca or elokominica transmitted by Nanophyetus salmincola
73
What are the clinical signs of salmon poisoning disease?
High fever, hematemesis, diarrhea +/- hematochezia, vomiting, lethargy, anorexia, nasal and ocular discharge, enlarged lymph nodes
74
How do you diagnose salmon poisoning disease?
- Fluke eggs in feces
- History of ingested fish
- Inclusion bodies on macrophages in lymph nodes
- PCR or serology
- Thrombocytopenia
Chem and UA non specific
75
How do you treat salmon poisoning disease and what is the prognosis?
Hospitalized support and antibiotics (oxytetracycline, doxycycline) and praziquantel for the fluke
Prognosis is fair to good with aggressive supportive care but death in 90% of untreated cases
76
What viruses effect the small intestine?
Parvo, distemper, feline panleukopenia, coronavirus, FIV, FELV
77
All things canine parvo.
- Type 2 pathogenic
- Fecal oral transmission highly contagious
- Infects enterocytes and bonemarrow
- Typically seen in puppies
- Severe hemorrhagic diarrhea
- Dx: ELISA test useful but can cross react with vaccine
- Tx: Aggressive supportive care
- Prog: full recovery if they survive the first few days
78
All things feline parvo.
- Clinical signs similar to canine parvo but less severe enteritis usually
- 50-90% fatal without aggressive support
- Causes cerebellar hypoplasia in peri-natal infection
- Can use canine snap test to diagnose
79
All things coronavirus.
Canine- limited enteric pathology
| Feline- self-limiting to moderate diarrhea and rarely causes CS; may mutate and manifest as FIP
80
What are the most common intestinal neoplasms in cats?
Lymphoma, adenocarcinoma, mast cell
81
What are the most common intestinal neoplasms in dogs?
Lymphoma, adenocarcinoma, smooth muscle tumors
82
All things small cell lymphoma.
Infiltrative /diffuse type disease diagnosed via biopsy
Tx: chlorambucil and prednisone
Prognosis: survival up to 3 years with treatment
83
What are the criteria that you can classify intestinal obstruction by?
Extraluminal vs Luminal
| Mechanical vs. Functional
84
What are some conditions that can cause intestinal obstruction?
- Mass lesions
- Foreign bodies
- Ganulomatous disease
- Inflammatory disease
- Hypertrophy
- Inussusceptions
- Hypomotility or ileus
- Volvulus or torsion
- Hernia
85
What is an intussusception?
Telescoping of one bowel loop into the adjacent segment
Often associated with parvovirus, masses, or diffuse ileus
86
T/F: Intussuscpetion is the most common cause of extraluminal obstruction.
True- most commonly at the ileocolic junction
87
What animals are predisposed to intussusceptions?
- Young animals with severe gastroenteritis
- Causes of gasteroenteritis
- Neoplasia
- Postparturient bitches
88
What are the clinical signs and physical exam findings of animals with intussusceptions?
CS: vomiting, diarrhea, anorexia
PE: Abdominal pain, tube like structure, associated illness
89
How do you diagnose and treat intussusceptions?
Dx: palpation of tube like mass, radiographs, ultrasound (double walled structure)
Tx: spontaneous reduction possible, surgery, treat underlying disease
90
All things intestinal volvulus.
Rare often fatal twisting of the intestines
Acute onset of CS, patients typically present in shock
Surgery is obligatory as bowel is mot often diffusely necrotic
91
What is an intestinal hernia?
Intestinal loops slip outside abdominal cavity into the SQ tissues
Can lead to strangulation and necrosis of intestines with intermittent GI signs
92
What is the difference between direct and indirect intestinal hernias?
Direct- rent in the body wall from trauma or surgery
Indirect- existing ring of tissue such as umbilical ring, inguinal ring, or scrotum
Aka congenital and acquired
93
How do you diagnose and treat intestinal hernias?
Dx: Palpate, radiographs, ultrasound
Tx: Sugery
94
What is EPI?
Exocrine pancreatic insufficiency
Insufficient secretion and production of pancreatic enzymes leading to maldigestion
95
What are some etiologies of EPI?
- Acinar atrophy
- Chronic pancreatitis
- Aplasia or hypoplasia
Congenital in GSD, rough coated collies, eurasians
96
What are the clinical signs of EPI?
#1 is weight loss
```
Loose stools and steatorrhea
Ravenous appetitie
Poor hair coat
Borborygmi
Flatulence
Can be subclinical
```
97
How do you diagnose EPI?
CBC, CHEM, UA: rules out other causes
TLI levels: species specific
B12: often low in EPI and requires supplementation
98
How do you treat EPI?
Dried pancreatic extract powder or fresh pancrease in the diet (pancrealipase powder)
B12 supplementation
99
Why does EPI treatment fail?
Concurrent intestinal disease
Too much acid in the stomach (start on antacid)
Prognosis usually excellent but requires lifelong therapy
100
When should you biopsy a patient with a suspected primary enteropathy?
To prioritize and optimize therapy or when empiric therapy fails or patient status dictates definitive answer
101
What are examples of empiric therapy?
Deworming
Diet change
Antibiotic trial
Probiotics
102
What conditions are extremely responsive to diet change?
Food allergies or hypersensitivity
103
How do you diagnose and what are treatment options for food allergy or hypersensitivity?
Dx: resolution of CS with diet change
Tx: Hydrolyzed diets, novel antigen diets
104
How long will it take to see a clinical response to a food responsive disease?
Around 2 weeks
May take a couple different diets before medication trial
105
What are hydrolyzed diets?
Proteins are split up into a very small sized so that the immune system cannot recognize them as foreign
Most are around 7-10 KD
106
What is idiopathic antibiotic responsive diarrhea?
Due to small intestnial bacterial overgrowth
No reliable test or specific etiology
107
What are some mechanisms that cause IARD?
Host-bacterial interactions or bacterial overgrowth secondary to defects in mucosa, aberrant mucosal immune response, qualitative changes in enteric flora (dysbiosis)
108
What are the clinical signs of ARD?
- Small bowel diarrhea
- +/- colitis and weight loss
- Stunted growth
- Borborygmi and flatulence
- Appetite change
- Vomiting
109
How do you treat ARD?
Metronizadole, tylosin, oxytetracycline
Diet trials can be done but has a variable response- high quality protein with low fat seems to have the best outcome
110
What are the most common diseases diagnosed on biopsy?
Inflammatory bowel disease
Lymphangectasia
Lymphoma
111
What parts of the GIT can be accessed with gastroduodenoscopy?
Esophagus, stomach, proximal duodenum
112
What parts of the GIT can be accessed with colonoscopy?
Anus, rectum, colon, +/- ileum
113
What are some reasons to perform endoscopic biopsies?
- Concurrent concerns for colitis
- Concerns for lower SI disease
- Concerns for neoplasia
114
Why would a surgical biopsy be better than an endoscopic biopsy?
- When disease is deeper than the mucosal layer
- When other organs are affected
- When you have a diffuse lesion requiring surgical removal
115
What are the pros and cons of endoscopy?
Pro: minimaly invasive, same day GI and recover well, can biopsy many regions
Con: deeper layers missed, cannot access jejunum, cannot sample/assess other organs
116
What tests can be done to evaluate a biopsy?
H&E staining
IHC for cellular contents and differentiation of inflammation
Special stains for organisms
FISH analysis- for AIEC on colonic biopsy
117
What is AIEC?
Adherent invasive E. coli
118
What is inflammatory bowel disease?
- Chronic GI disease of dogs and cats
- Fails to respond to deworming, antibiotics and diet
- Histopath reveals mucosal changes and inflammatory infiltrate
- Can involve any or all of the GIT
119
What causes IBD?
1. Disruption of physiologic interaction of innate and adaptive immune response
2. Defective mucosal barrier
3. Inappropriate reaction to normal GIT components
120
What are pattern recognition receptors?
Health: maintain hyporesponsiveness to luminal contents, diet, and protects the mucosa
121
What is the most common infiltrate in IBD?
Lymphoplasmacytic infiltrate
122
What is the pathogenicity of IBD?
- Loss of normal villous structure
- Goblet cell changes
- Crypt abscesses and cysts in advanced disease and lymphangectasia
- Moderate to severe infiltrates are often associated wit protein losing disease
123
What are the types of IBD?
1. Minimal change
2. Granulomatous or neutrophilic
3. Lymphoplasmacytic
4. Eosinophilic
5. Lymphangectasia
124
What are the characteristics of minimal change enteropathy?
- Low clinical disease score
- Albumin >2.0
- Normal B12
- Normal to minimal inflammation on histopathology
125
What is the treatment for minimal change enteropathy?
- Deworm
- Diet trial
- Antibiotic trial with probiotics (chronic therapy may be necessary)
126
What are the characteristics of granulomatous or neutrophilic enteropathy?
- Infrequent diagnosis
- Macrophages/histiocyticc and/or neutrophilic infiltrate
- Prompts to look for infectious disease (must rule out)
127
How do you treat granulomatous or neutrophilic enteropathy?
- Treat underlying infectious disease
- Antibiotic trial
- Immunosupressive medications if infectious disease is excluded
Guarded to poor prognosis if underlying etiologic agent isn't identified
128
What are the characteristics of lymphoplasmacytic enteropathy?
- Lymphocyte and plasma cell infiltrate
- Variable clinical presentation
- May be PLE
- Typically systemically ill
- Typically diet responsive (60-88%)
129
What is the treatment for lymphoplasmacytic enteropathy?
- Hydrolyzed or novel antigen diet
- Antibiotics trial
- Immunosuppressants when no response to above
- Anti-clotting medications with hypoalbuminemia
Better response when younger dogs with normal albumin
130
What are the characteristics, prognosis, and treatment of eosinophilic enteropathy?
- Eosinophil infiltrates
- Typically reaction to parasites or food allergy
- Good prognosis in dogs
- Guarded to poor prognosis in cats
- Tx: deworm, diet, immunosuppressant therapy
131
What are characteristics of lymphangectasia and crypt cell cysts?
Local or generalized lymphatic disease
Common cause of PLE
Basenhi, SCWT, Torkie, and Lundehunds over represented
132
What does lymphangectasia look like on endoscopy?
- White granules/blebs on mucosal surface
| - Abnormal distension of lymphatic vessels within mucosa
133
What is the treatment for lymphangectasia and crypt cell cysts?
```
Diet: hydrolyzed and low fat
Antibiotics: metronidazole or tylosin
Immunosuppresants: prednisolone or cyclosporine may need parenteral administration
Anti-clot medications
Diuretics- in cases of ascites
```
134
What is the prognosis of lymphangectasia and crypt cell cysts?
Fair to guarded pending response to treatment and severity of clinical signs
135
What are potential causes of protein losing enteropathy?
- Inflammatory disease
- Lymphangectasia
- Infiltrative neoplasia
- Infectious disease
- Endoparasites
- Intussusception
- Portal hypertension
136
What is the treatment for protein losing enteropathy?
- Treat the underlying disease
- Diuretics as needed
- Abdominocenteisis (do not remove all the way)
137
What is the prognosis of PLE?
-Guarded to good
Depends on severity of pets condition and response to therapy
138
What are some negative indicators for prognosis?
Low albumin, low B12, Neoplasia
139
What are the best way to provide enteral nutrition in a GI disease patient?
Nasogastric or nasoesophageal tubes
Esophagostomy tubes
PEG tubes- used more for chronic cases
