15. Non-infective diseases of the small intestines in dogs and cats. Protein loosing enteropathies Flashcards
Acute Haemorrhagic diarrhoea syndrome?
ACUTE HAEMORRHAGIC DIARRHOEA SYNDROME
(AHDS)
Formerly known as haemorrhagic gastroenteritis
Aetiology & pathogenesis is unclear
Young-middle aged; Small & toy breeds; In winter months
May be acute; peracute; severe
Possible causes
§ Dietary indiscretion § Toxins
§ Immune-mediated § Pancreatitis
§ Hyperreactivity § Stress
§ Intestinal bacteria § Anxiety
§ Intestinal parasites § Trauma
§ Intestinal ulcer § Infection
§ Foreign body § GI tumour
§ Coagulation disorder § Gastric ulcer
Toxigenic Clostridium perfringens
Intestinal biopsies of dogs with AHDS have been taken, and 80% of
those tested with IHC/culture had C. perfringens testing positive.
Therefore, AHDS may be associated with Costridial overgrowth.
Pathophysiology: Not considered contagious; ↑ Intestinal
permeability → Leakage of fluid, plasma proteins and RBCs into the
intestinal lumen
Clinical Signs
§ Acute onset vomiting
§ Profuse haemorrhagic diarrhoea → Hypovolaemia (shock)
§ Anorexia
§ Lethargy
§ Abdominal pain
§ Fever
Diagnosis
§ History; CSx
§ Lab. D:
↑ PCV;
Neutrophilic leucocytosis (left shift);
Normal/↓ TP; Possible panhypoproteinaemia;
Hypoglycaemia; Electrolyte abnormalities
Treatment
§ Aggressive IVFT
§ Parenteral abx
§ Symptomatic treatment: Antiemetic; Analgesia
§ Intestinal diet
Chronic small intestinal disorders?
Chronic Small Intestinal Disorders
“Chronic inflammatory enteropathy (CIE)/ chronic enteropathy
(CE)”
Gastrointestinal diseases present for 3 weeks or longer (at this point,
extraintestinal diseases e.g. parasites & neoplasia are ruled out).
Subtypes
§ Food-responsive enteropathy
§ Antibiotic-responsive enteropathy
§ Immunosuppressant-responsive enteropathy/Steroidresponsive enteropathy
Food Responsive Enteropathy(FRE)?
FOOD RESPONSIVE ENTEROPATHY (FRE)
Enteropathy that improves by alteration of the diet
Food allergy (immune related)
§ Food may be the source of antigens “oral intolerance”
§ Cause: Genetics; ↑ Intestinal mucosa permeability;
Previous infections; Prolonged intestinal flora damage
Food intolerance (non-immune related)
§ E.g. Lactose intolerance in cats
Most common allergens: Proteins
§ Dog: Beef; Chicken; Wheat; Milk
§ Cat: Beef; Chicken; Wheat; Fish; Corn
Clinical signs: Pruritis; Recurrent chronic diarrhoea
Diagnosis & treatment work together:
§ Diagnosis by exclusion
§ Prescription diet: Hypoallergenic/hydrolysed mono diet
§ Homemade diet
§ Avoid hidden allergens: Drugs; Other pets; “Grandma
treats”
§ Successful diet: Provocation with the suspected protein
How long to trial diets
§ Pruritis: Trial the diet for 8-12 weeks → Evaluate
§ Diarrhoea: Trial the diet for 3 weeks → Evaluate
§ Trial diets: No more than one therapeutic change every 2-
3 weeks
Antibiotic responsive enteropathy?
ANTIBITOIC RESPONSIVE ENTEROPATHY (ARE)
Enteropathy that improves by administration of antibiotics
§ Primary: Loss of tolerance by the local immune system
(predisposed: G. Shepherd)
§ Secondary: Damage of microbiome; Dysbiosis
Consequences
§ Endotoxin secretion
§ Brush border enzymes become damaged
§ Competition for nutrients (e.g by Cobalamine)
Clinical signs
§ Chronic s. intestinal diarrhoea
§ Gas production
§ Fat malabsorption
§ Weight loss
§ Vomiting
Diagnosis
Ø Specific tests
Intestinal microbiotia: Mostly unculturable; Molecular techniques;
Antigen diversity
Microbiota dysbiosis index is used as a scoring system
Treatment
Aim is to ↓ the microbiome & ↓ dysbiosis
§ Antibiotics: Metronidazole; It is important to withdraw
these if there is any relapse
§ Intestinal diet
Immunosuppresant responsive enteropathy?
IMMUNOSUPPRESANT RESPONSIVE ENTEROPATHY
(IRE)
Enteropathy that improves with immunosuppressive treatment
In human medicine, this is known as irritable bowel syndrome (IBS)
Middle aged animals
Predisposed: German Shepherd; Terriers; Sharpei
Histopathological types
§ LPE (Lymphocytic-plasmocytic enteritis) (most common)
§ EGE (Eosinophilic gastroenteritis)
§ Neutrophilic gastroenteritis
§ Granulomatous gastroenteritis
Pathophysiology: Diffuse cellular infiltration; Mucosal
inflammation & oedema
Clinical signs
§ Chronic diarrhoea § Weight loss
§ Abdominal discomfort § Inappetence
§ Flatulence § Vomiting
In cases of severe IBD, protein-losing enteropathy may occur →
Ascites; Subcutaneous oedema (see later)
Diagnosis
Non-specific: Hypoproteinaemia; Leucocytosis (LPE);
Eosinophilia (EGE)
Specific
Intestinal biopsy → Histology; Sample collection by:
Endoscopy
Exploratory laparotomy
Treatment
Immunosuppressive drugs used for chronic enteritis
§ Prednisolone (use gastroprotectants)
§ Azathioprine (Ø In cats)
§ Budesonide
§ Cyclosporine
Non- responsive enteropathy?
NON-RESPONSIVE ENTEROPATHY (NRE)
Enteropathy that doesn’t respond to any treatment; Idiopathic
At this stage, perhaps reconsider the diagnosis
Possible choices of treatment
§ Pre- & Probiotics
§ Faecal transplantation
§ Mesenchymal stem cell treatment
§ Intestinal biopsy → Histology
Intestinal Neoplasia?
Intestinal Neoplasia
Middle /older-aged animals
Types
§ Alimentary lymphoma (cat)
§ Lymphosarcoma
§ Intestinal adenosarcoma
§ Intestinal leiomyoma/Leiomyosarcoma
Clinical signs
§ Chronic diarrhoea § Anorexia
§ Excess weight loss § Melaena
§ Haematemesis § Vomiting
Protein- Losing Enteropathies?
Protein-Losing Enteropathies
Any GI condition resulting in a net loss of protein from the body
CAUSES
§ Lymphangiectasia (most common)
§ IBD
§ Intestinal neoplasia/lymphoma
§ GI haemorrhage
General Clinical signs?
GENERAL CLINICAL SIGNS
§ Chronic diarrhoea
§ Intestinal protein loss
Ascites
Oedema
Cachexia
Lymphangiectasia?
LYMPHANGIECTASIA
Abnormal dilation & dysfunction of lymphatic vessels
Predisposed: Yorkshire terrier; Rottweiler
Classification
§ Primary: Lymphatic abnormality
§ Secondary
Intestinal: IBD; Neoplasia
Systemic: RS-HF; Hepatic failure
Clinical signs
§ Prolonged protein loss → ↓ Oncotic pressure → Ascites;
Hydrothorax; Oedema
§ Fat malabsorption & protein loss → Weight loss
§ Chronic diarrhoea
§ Thromboembolism (rare complication)
Diagnosis
§ Specific: Intestinal biopsy → Histology
§ Lab. D: Hypoproteinaemia; Hypocholesterolaemia;
Lymphopenia; Hypocalcaemia; Hypomagnesaemia
§ Endoscopy: Mucosal oedema; “Rice grain” nodules;
distended lacteals
§ Abdominal US: Mucosal thickening; Streaks in
submucosa; Distended lacteals (absorbing lymphatic
vessels)
Treatment
Protein loss: Ultra low-fat (ULF) diet with high
Bioavailability – Highly digestible; Chicken & rice;
If IBD ✓ → Hypoallergenic diet
Inflammation: Glucocorticoids; Cyclosporine
If IBD ✓ → Immunomodulation
Oedema/Ascites:
Diuretics: Spironolactone; Furosemide
IVFT
Plasma: Supply of antithrombin-III
Weekly monitoring of albumin
Generic treatment of Gastrointestinal diseases?
Generic Treatment of Gastrointestinal Diseases
These are better described as treatments of specific diseases (see
these diseases in topics 14 & 15)
§ Deworming – Anthelmintic therapy: Fenbendazole
§ Dietary management
§ Antibiotics
§ Anti-inflammatories
§ Immunosuppressants
§ Adsorbents; Intestinal protectants
§ Secretion & motility modifiers
§ Antiemetics & gastroprotectants
§ Vit. B12 supplement
§ Pro- & pre-biotics
Critically ill patients
§ IVFT
§ Colloid treatment (PLE/IBD)
§ Feeding tube
§ Parenteral Abx
