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3. Cat & Dog > Gastroenterology, Pt. 6 (chronic diarrhea) > Flashcards

Gastroenterology, Pt. 6 (chronic diarrhea) Flashcards

(52 cards)

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1
Q

Problem: Chronic small bowel diarrhea
- ways to classify

A

many ways to classify
- eg. primary GI vs. extra GI
- Maldigestion vs malabsorption
- Protein losing vs non-protein losing
- Specific cause
- Response to treatment

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2
Q

chronic enteropathy classification for maldigestion vs malabsorption - which is which? what does maldigestion look like and what animals are at risk?

A

Maldigestion (exocrine pancreatic insufficiency):
* Dog - young, thin, polyphagia, coprophagia
> German shepherds at risk
* Cats - any age, weight loss, only 2/3 have diarrhea

Malabsorption (all other causes)

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3
Q

chronic enteropathy classification for Protein-losing vs. non-protein losing
- how does this relate to panhypoproteinemia and Lymphangiectasia

A
  • Panhypoproteinemia (albumin & globulin lost)
  • Many causes of malabsorption may present either way
  • Lymphangiectasia may be primary (idiopathic), and due to portal hypertension and thoracic duct obstruction
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4
Q

how can Lymphangiectasia arise? what are the different types and the associated signs?

A

Lymphangiectasia may be primary (idiopathic), and due to portal hypertension and thoracic duct obstruction
* In primary lymphangiectasia GI signs may be minimal, and ascites and pleural effusion may be pronounced
* Lymphangiectasia may also be secondary to causes of mucosal inflammation/infiltration (ex IBD, neoplasia)

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5
Q

mechinisms of protein losing enteropathy (3)?

A
  • Lymphatic obstruction or rupture
  • Increased mucosal permeability due to mucosal infiltrates
  • Mechanical causes (ulcers, erosions, congestion)
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6
Q

Most common causes: of protein losing enteropathy

A
  • IBD, lymphangiectasia, lymphoma
  • Consider histoplasmosis or pythiosis in endemic areas
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7
Q

Classifications of chronic enteropathy based on specific cause

A
  • Infectious
    >bacterial
    >protozoa
    > helminth
  • neoplasia: lymphoma
  • inflammatory bowel disease
    > Lymphocytic-plasmacytic
    > Eosinophilic
    > Granulomatous
  • Villus atrophy
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8
Q

bacterial causs of chronic enteropathy

A

v Campylobacter jejuni
v Clostridium perfringens & C. difficile
v Yersinia
v Small Intestine Bacterial Overgrowth (SIBO, antibiotic-responsive enteropathy [ARE])
v Dysbiosis

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9
Q

protozoal causes of chronic enteropathy

A

Giardia, Cryptosporidium

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10
Q

helminth causes of chronic enteropathy

A

Toxocara sp., Ancylostoma sp., Uncinaria, Strongyloides

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11
Q

classifications of chronic enteropathy based on response to treatment

A

¡ FRE: Food-responsive enteropathy
¡ ARE: Antibiotic-responsive enteropathy
¡ IRE: Immunosuppressant (steroid)- responsive enteropathy
¡ NRE: Non-responsive enteropathy

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12
Q

IBD vs chronic enteropathy

A

Chronic enteropathy:
* Used in animals where intestinal inflammation is suspected but biopsies have not been taken
* Does not infer which treatment will be needed to control clinical signs

IBD:
* Implies treatment trials with diet, deworming, and antibiotics have failed
* Inflammation has been demonstrated histologically
* Immunosuppressant will be needed

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13
Q

should we do a work-up for chronic enterophathy

A

Work-up always indicated, how aggressive depends on earlier criteria

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14
Q

conservative work up for chronic enteropathy includes:

A

¡ Fecal parasitology
¡ Response to fenbendazole
¡ Dietary change (novel protein vs hydrolyzed protein)
¡ Risk for rendering more proteins antigenic with novel protein diet
* Can use hydrolyzed protein diet instead
* Often see improvement in 2 weeks if going to respond

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15
Q

how soon will we see improvements in chronic enteropathy from novel diet if the animal is a responder?

A

Often see improvement in 2 weeks if going to respond

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16
Q

chronic enteropathy work up bloodwork

A

¡ CBC, biochemistry
¡ Testing for hypoadrenocortism (resting cortisol)
¡ Consider bile acids to assess for hepatic dysfunction

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17
Q

chronic enteropathy work up - why look at TLI?

A

To assess for EPI
¡ TLI is decreased in patients with EPI

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18
Q

chronic enteropathy work up - why look at serum B12?

A

¡ Absorbed in ileum
* May be decreased with SIBO/ARE or severe mucosal inflammation/infiltration

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19
Q

chronic enteropathy work up - why look at serum folate?

A
  • Absorbed in proximal small intestine
  • May be decreased with mucosal inflammation/infiltration
  • May be increased­ in SIBO/ARE (production)
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20
Q

if a dog has EPI, what will we see for TLI, B12, and folate values?

A

decreased TLI, ± decreased B12, N folate

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21
Q

if a dog has SI malabsorption, what will we see for TLI, B12, and folate values?

Study These Flashcards
A

N TLI, ± decreased B12 (distal), ± decreased folate (proximal)

22
Q

if a dog has SIBO (ARE), what will we see for TLI, B12, and folate values?

Study These Flashcards
A

N TLI, ± decreased B12 (distal), ± ­increased folate]

23
Q

chronic enteropathy - what is the use of radiographs? barium series use?

Study These Flashcards
A
  • Abdominal radiographs often unrewarding in chronic diarrhea with normal PE
  • May reveal mass, foreign body, plication
  • Barium series not recommended
    > Most useful to diagnose obstruction
    > Expensive and tendency to over-interpret
    > Superseded by ultrasound and endoscopy
24
Q

chronic enteropathy - what is ultrasound good for?

Study These Flashcards
A

¡ Distribution of lesion (enteritis more
diffuse)
¡ Thickness of intestine (neoplasia thicker)
¡ Loss of layering (neoplasia)
¡ Lymphadenopathy (neoplastic larger)
¡ Ultrasound in this case → enteritis

25
what infectious disease tests can we run in a chronic enteropathy case?
- Fecal culture for pathogens > Campylobacter, Clostridium, Salmonella, Yersinia - IDEXX fecal PCR panel > Parvovirus > Coronavirus > Canine distemper virus > Salmonella > Clostridium enterotoxin A gene > Cryptosporidium > Giardia
26
optional next steps for chronic enteropathy treatment (empiric)
Options: * Empiric deworming * Empirical treatment with dietary change * Empirical treatment with tylosin or metronidazole? * Gastrointestinal biopsies (endoscopic vs surgical) * Empirical treatment with prednisone if biopsies declined
27
chronic enteropathy example plan / next steps
1. complete bloodwork > CBC, biochem, hypoadrenocorticism testing (dog), hyperthyroidism (cats) 2. endoparasitism testing - fecal floatation - empiric deworming 3. hypoallergenic vs novel protein dietary trial (2 weeks) 4. surgical / endoscopic biopsies vs immunosuppressive trial
28
causes of IBD and treatment options that target them
- Genetics > nothing much - Dietary antigens > hypoallergenic diet - The microbiota > fecal microbial transplantation - dysregulated immune response >immunomodulatory therapy
29
how important is dietary therapy for chronic enteropathy? how successful can it be?
¡ ESSENTIAL!!!!! ¡ First-line treatment ¡ Remission rates of over 67% with diet alone (Mandigers, 2010) ¡ Many prospective studies demonstrating response to diet alone
30
chronic enteropathy (IBD) diet reccomendation? how soon do we often see improvement?
Dietary change: * Highly digestible, novel protein, hydrolyzed protein * Numerous brands with different proteins * Easily digested carbohydrate (reduces osmotic effect) * Fats may be reduced –unabsorbed fats aggravate diarrhea * Strict diet trial for at least 2 weeks * Often see some improvement within a few days to up to 2 weeks SUMMARY - highly digestible - high fibre - novel protein - hydrolized protein - etc...
31
if we get a poor response to a diet change for IBD does that mean we should give up on diet options? what should we do?
¡ Response to different diets varies ¡ Insufficient response to one diet does NOT exclude response to another ¡ Can consider a 2nd diet trial before additional diagnostics/treatment in stable patients
32
chronic enteropathy treatment options
- Dietary change - Immunosuppression > Prednisone - Treatment of dysbiosis > Antibiotics > Probiotics > Fecal transplantation
33
methods of treating chronic enteropathy via immunosuppression
Prednisone: - High quality evidence to support steroids for induction treatment of IBD * If resistant, consider other immunosuppressives > azathioprine, mycophenolate, chlorambucil, cyclosporine * Budesonide – potentially less systemic side-effects than prednisone
34
methods of treating chronic enteropathy via treatment of dysbiosis
¡ Antibiotics * Ex tylosin, metronidazole ¡ Probiotics ¡ Fecal transplantation * Easy to perform and in some clinics is an early treatment * Not standardized (dosage, administration method, donor screening)
35
are antibiotics a good choice for treating chronic enteropathy? possible drawbacks? what do we do if we dont see results in 2 weeks?
¡ Utility unclear: ¡ Response to antibiotics often short lived ¡ Antibiotic resistance ¡ **Granulomatous colitis of Boxers and French bull dogs ¡ If antibiotic trial not successful within 2 weeks, reassess
36
possible treatments for chronic enteropahty that are considered less often
¡ Vitamin B12 injections ¡ Vitamin D? * Hypovitaminosis D negative prognostic factor ¡ Intestinal lymphoma - Consider surgical removal of focal lesions - Chemotherapy > Diffuse GI lymphoma has a poor prognosis in dogs > Indolent T-cell lymphoma has a good prognosis in cats
37
WHEN TO SUPPLEMENT COBALAMIN? for chronic enterophathy
1. When measuring B12 levels isn’t an option 2. When cobalamin measures low 3. When cobalamin measures low- normal (<400ng/L)
38
EXOCRINE PANCREATIC INSUFFICIENCY (EPI) - is due to:
¡ destruction of acinar cells due to chronic pancreatitis (dogs and cats) ¡ Depletion of acinar cells due to pancreatic acinar atrophy (dogs) > GSD, rough coated collies
39
at what point do we see clinical signs of EPI?
¡ Clinical signs of EPI do not occur until more than 90% of the exocrine pancreatic function has been lost
40
exocrine pancreases is a major source of what that influences cobalmin?
Exocrine pancreas is major source of intrinsic factor: ¡ Assess for hypocobalaminemia
41
most common sign of EPI, and antoher common observatin
¡ Most common sign is weight loss* ¡ Loose stools commonly observed
42
EPI: DIAGNOSIS
TLI ¡ Low TLI is highly sensitive and specific for EPI
43
EPI: TREATMENT
¡ Pancreatic enzyme supplementation ($) ¡ Treat for concurrent SIBO/ARE/Dysbiosis ¡ May need to treat for concurrent IBD ¡ Diets with high fiber should be avoided (interferes with fat absorption) ¡ If patients not responding to therapy, antacid treatment can be considered
44
negative prognostic factor for EPI
marked hypocobalaminemia
45
PLE IN YORKSHIRE TERRIERS; what do we see?
- Emerging disease in Yorkshire terriers ¡ Females > males ¡ Median age 7 years (1 – 12) ¡ Diarrhea ± ascites > Dyspnea (Ascites, pleural effusion, collapsing trachea) - Low albumin, globulin, magnesium, calcium > Dogs with PLE may also have low iCa, occasionally signs of hypocalcemia - Response of Yorkie PLE to prednisone and diet change varies from none to good
46
LYMPHANGIECTASIA; what is primary vs secondary, and what signs are associated with each?
Can be primary or secondary ¡ Secondary to IBD, lymphoma > Diarrhea a prominent feature > Initial treatment of IBD more aggressive ¡ Primary > Minimal GI signs > Ascites > Pleural effusion
47
LYMPHANGIECTASIA breeds at risk
small terrier breeds, rottweilers, lundehunds
48
LYMPHANGIECTASIA - what do we see on ultrasound? on endoscopy?
Ultrasound – may see speckling Flexible or capsule endoscopy - dilated lymphatics
49
LYMPHANGIECTASIA - what will we see with diagnostic surgery?
- dilated lymphatics, serosal granulomas > Full-thickness biopsies high- risk leakage
50
LYMPHANGIECTASIA TREATMENT and prognosis
¡ *Dietary fat restriction* ¡ Prednisone (anti-inflammatory dosage) ¡ ± medium-chain triglycerides ¡ Response to treatment unpredictable ¡ Guarded prognosis
51
Which of the following is NOT typically a cause of a protein losing enteropathy? A) Lymphangiectasia B) Histoplasmosis C) Lymphoma D) Campylobacter
D) Campylobacter
52
Identify the true statement in regard to EPI: A) A high TLI is suggestive of EPI B) High fiber diets are an important component of treatment C) Chronic pancreatitis is a common cause of EPI in cats D) Hypocobalaminemia is uncommon in patients with EPI
?C) Chronic pancreatitis is a common cause of EPI in cats?

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