Chronic disorders of small intestine

Question 1

List of chronic SI disorders

Answer 1

• CIE: chronic inflammatory enteropathy
• lymphangiectasia
• neoplasms of small intestine
• subileus (partial obstruction)
• infectious (rare)
• protein losing enteropathy is a special consequence of severe chronic SI disorders when protein (esp albumin) is lost through GIT

Question 2

Chronic inflammatory enteropathy. Definition

Answer 2

• ## persistent or intermittent chronic GI signs

Question 3

CIE. Pathomechanism

Answer 3

• important function of GIT is to be able to tolerate the content of the lumen
• if local immune system loses this tolerance -> abnormal response -> chronic inflammation

Possible reasons of losing tolerance:
- primary problem of the local immune system
- severe destruction of gut barrier integrity (e.g. parvo)
- severe dysbiosis

Question 4

CIE. Types based on response to the therapy

Answer 4

1. Food -responsive enteropathy (
   - ~80% of patients will respond to dietary management
2. Dysbiosis treatment responsive enteropathy
   - includes antibiotic responsive enteropathy
3. Steroid/immonusuppressant responsive enteropathy
   - includes inflam bowel disease
4. Non-responsive enteropathy

Question 5

What is present in all groups of chronic inflam enteropathy ?

Answer 5

• inflammation
• diet response
• dysbiosis

BUT it will be with different significance among the group. For example diet change alone will help in food responsive enteropathy but it wont be enough for others but diet management still should be applied to all groups !!!

THERE IS NO CIE TREATMENT WITHOUY SPECIAL DIET

Question 6

Food responsive enteropathy. Forms, types

Answer 6

THERE IS NO CIE TREATMENT WITHOUY SPECIAL DIET

Background: adverse food reaction (AFR)
Forms:
- cutaneous form (CAFR): pruritis
- non-cutaneous form (nonCAFR) : GI signs > resp signs, other

Types:
1. Food allergy: immune system involved
2. Food intolerance: immune system NOT involved (e.g. lactose intolerance)
But clinical consequences are similar

Question 7

FRE. Symptoms, allergens

Answer 7

Chronic GI signs +- skin lesions (pruritis), otitis externa
Most common allergens = proteins:
Dogs: beef, CHICKEN, dairy, wheat (egg, soy, lamb)
Cat: beef, dairy, FISH, lamb, chicken, wheat

Question 8

FRE. Diagnosis

Answer 8

• elimination -> provocation -> elimination
• length of elimination is min 2 weeks (if skin is affected - min 8 weeks); if diarrhea improve - continue for 12 weeks
• food allergen specific IgE serology IS NOT APPROPRIATE
• often owners don’t do provocation because problem is gone

Question 9

Why is food allergen specific IgE serology is not appropriate to diagnose FRE?

Answer 9

1. Not always its allergy reaction (intolerance)
2. Even if its allergic reaction usually its usually not mediated by IgE( delayed type of hypersensitivity and not immediate)

Question 10

How does elimination diet work

Answer 10

Types:
- one, NOVEL protein (never fed before)
- hypoallergenic diet: limited ingredient or hydrolysed protein (wont cause reaction)
- home made

Diet should be highly digestible, “hidden” allergens should be avoided (treats, flavoured drugs)

Question 11

Dysbiosis treatment responsive enteropathy

Answer 11

Earlier was called antibiotic responsive enteropathy

Was renamed because now usage of ABs in this condition is very limited (resustant strains)

Question 12

Intestinal microbiota

Answer 12

• ~ organ
• huge number and diversity
• very complex function: gut function and integrity, local and systemic immunity, protection from pathogens, production of nutrients and vitamins, influence other organs

Question 13

Dysbiosis. Pathomechanism

Answer 13

Imbalance in the composition of microbiome. Exact pathomechanism is not clear
- trigger (food, drugs, stress)
- genetic predisposition may also play a role
- dysbiosis can become cause of CIE and CIE can become cause of dysbiosis
- trigger —> dysbiosis —> toxic metabolites production, nutrient deficiency (SCFA, B12), decrease of antipathogenic activity)
- consequences are various: nothing, CIE, malabsorption, extraintestinal disorders (still researched)

Question 14

ARE (antibiotic responsive enteropathy)

Answer 14

• only in idiopathic from of dysbiosis whn no background van be distinguished
• ABs can be used (tylosine, metronidazole)
• German shepherds are predisposed

Question 15

Dysbiosis. Diagnosis

Answer 15

• routine culture is not suitable
• microbiota dysbiosis index: quantitative PCR (if number is negative: healthy; if more than 2 -> severe dysbiosis)

Question 16

Dysbiosis. Treatment

Answer 16

• goal: to reach a balanced microflora
• pre, pro, symbiotics
• fecal microbiota transplantation best treatment; can be done through rectal enema or per os with capsule
• support of GIT function: highly digestible diet, vitamins (e.g. B12)
• antibiotics: nowadays try to avoid: tyrosine, metronidazole; common that patients relapse after stop of using ABs

Question 17

Steroid/immunosuppressant responsive enteropathy vs inflammatory bowel disease

Answer 17

• not very big difference (often used interchangeably)
• if confirmed with histopathology —> IBD: idiopathic inflammatory bowel disease

Question 18

IBD. Histopathology

Answer 18

Based on predominant infiltrating cell type
- LPE: lymphocytic-plasmacytic enteritis: most common
- EGE: eosinophilic gastroenteritis
- neutrophilic and granulomatous quite rare
-

Question 19

IBD. Clinical signs

Answer 19

• Chronic diarrhea, recurrent
• often weight loss
• usually polyphagia but can be inappetance in case of pain
• gastroesophageal reflux is common
• severe IBD may lead to PLE (protein losing enteropathy): hypoalbuminemia, ascites

Question 20

IBD. Diagnosis

Answer 20

Definitive diagnosis: HISTOPATH
NOT specific:
- hypoproteinemia
- eosinophilia (EGE)
- cobalamin decreased, folate decreased
- thicken SI loops, lymphadenopathy

Specific: endoscopic findings, diagnostic laparotomy

Question 21

CIE. Treatment.

Answer 21

0. Deworming (to exclude parasitic background)
1. Diet: if improves: 12 weeks; in no ->
2. Dysbiosis treatment: min 1 month, if no improvement ->
3. Immunosuppression: prednisolone

Question 22

PLE. Causes

Answer 22

Cause:
- dilatation and dysfunction of intestinal lymphatic vessels (primary lymphangiectasia, Yorkshire terrier)
- severe diffuse infiltrative enteropathy (severe CIE, intestinal neoplasia)

Question 23

PLE. Clinical signs

Answer 23

• protein loss -> oncotic pressure drops -> ascites, hydrothorax
• fat malabsorption + muscle loss -> weight loss, malnutrition
• +- chronic diarrhea
• thromboembolia: rare and severe complication

Question 24

PLE. Diagnosis

Answer 24

Lab findings:
- hypoproteinemia
- hypocholesterolemia
- lymphopenia

Endoscopical findings:
- “rice-grain” nodules (dilated lecteals)

Abdominal USG:
- hyperechoic mucosal striation (dilates lacteals)

Specific diagnosis:
- intestinal biopsy -> histopathology

Question 25

PLE. Treatment

Answer 25

- **diet: ultra low fat** to decrease work of lacteal, if no response -> - steroid anti-inflammatory dose, if not enough + immunosuppressant (cyclosporine) - increase oncotic pressure: colloid infusion, plasma, enteral feeding - high risk of thrombosis: clopidrogel

Question 26

Neoplasms of the small intestine

Answer 26

- **alimentary lymphoma** - **intestinal adenocarcinoma** - leiomyosarcoma - GIST: gastrointestinal stromal tumour Clin signs: chronic diarrhea, weight loss, Melendez, vomiting

Question 27

What are differences in alimentary lymphoma in cats and dogs

Answer 27

Cat: - low grade intestinal T-cell lymphoma (LGITL) - common - less severe than in dogs - similar to severe IBD Dog: - more severe and much more malignant

Question 28

Ileus. Definition

Answer 28

Disruption of the normal propulsive GI motor activity —> blockage of nutrients delivery

Question 29

Ileus. Classification

Answer 29

1. **Mechanical Ileus** = intestinal obstruction - = lumen is occluded partially or completely - intraluminal/intramural/extramural 2. **Functional Ileus** - =lumen is open but peristalsis is stopped - paralytic/vascular bowel daises (thrombosis, shock)/spastic bowel segment

Question 30

Intestinal obstruction. Cause

Answer 30

Usually foreign body - solid or cavitation object - linear foreign body (can get stuck under tongue or at area of pylorus —> check them!)

Question 31

Foreign body Ileus. Pathophysiology

Answer 31

- intestinal spasm, ischemia —> **pain** - impaired peristalsis —> vomiting, dysbiosis - fluid, acid-base and electrolyte imbalance (**dehydration, hypokalemia, hypochloremia**) - impaired gut barrier integrity (bacterial translocation, **endotoxemia, septicemia, septic peritonitis**, perforation)

Question 32

Foreign body obstruction. Clinical signs and diagnosis

Answer 32

- more common among young dogs of large breeds - inappetance, depression, **abdominal pain** - **vomiting** (more proximal obstruction -> more severe vomiting) - **can be palpated but not always** - **unequally wide intestines** - **plain radiography, contrast radiography** - USG : **unequally wide loops, pendular movement** (peristalsis-antiperistalsis alternate) - **diagnostic laparotomy**

Question 33

Intususception

Answer 33

= invagination (telescoping) of one part of the intestines into another - most often young animals - idiopathic or secondary to diseases causing dysmotilty - **hematochesia**, vomiting, abdominal pain - **sausage- shaped mass** may be palpable - abdominal USG: transverse view: **”target sign”** - treatment: surgery

Question 34

Foreign body Ileus. Treatment

Answer 34

Preoperative: -fluid therapy - ABs Surgical: - resection of necrotic parts - sterile lavage of peritoneal cavity Postoperative - fluid therapy, analgesia - enteral feeding asap - prokinetic drugs sometime