Gastrointestinal Disease Management€¦ · Appendix A: Evaluating Gastrointestinal Diseases...

Gastrointestinal Disease Management

Nigel C. Swift, BVetMed, MRCVS, Dipl. ACVIM

Karen L. Johnston, VMD, MRCVS, PhD

GastrointestinalDisease Management

Nigel C. Swift, BVetMed, MRCVS, Dipl. ACVIMKaren L. Johnston, VMD, MRCVS, PhD

The Animal Referral HospitalSydney, Australia

Designed and published by Veterinary Learning SystemsTrenton, New Jersey

© 2000 Ralston Purina Company.All rights reserved.

Printed in the United States of America.Ralston Purina Company, Checkerboard Square, Saint Louis, Missouri 63164

Cover slide courtesy of Dr. Karen L. Johnston

The algorithms in this publication are intended to provide guidelines for the evaluation of

vomiting or regurgitation and diarrhea in dogs and cats. However, an algorithm can never include

all clinical possibilities and there is no substitute for careful clinical judgment and experience.

Contents

INTRODUCTION ..............................................................................................iv

AN APPROACH TO VOMITING OR REGURGITATION IN CATS AND DOGS..........................................................1

Evaluating Oral or Pharyngeal DysphagiaAlgorithm — History/Physical Exam............................................................4

Evaluating Regurgitation (Esophageal Dysphagia)Algorithm — Juvenile Onset .........................................................................5Algorithm — Adult Onset .............................................................................6

Evaluating VomitingAlgorithm — Physical Exam ........................................................................7Algorithm — Lab Work................................................................................9Algorithm — Endoscopy..............................................................................10

AN APPROACH TO DIARRHEA IN CATS AND DOGS ................................11

Evaluating Acute DiarrheaAlgorithm — Mild......................................................................................18Algorithm — Moderate to Severe .................................................................19

Evaluating Chronic Small Bowel Versus Large Bowel DiarrheaAlgorithm — Chronic Small Bowel..............................................................20Algorithm — Chronic Large Bowel ..............................................................21

APPENDICESAppendix A: Evaluating Gastrointestinal Diseases

Patient History/Client Worksheet ................................................................22Patient History/Clinician Checklist/Complement to Client Worksheet............23Physical Exam/Clinician Checklist..............................................................24

Appendix B: Product InformationPurina Veterinary Diets™ EN GastroENteric™ brand Canine Formula ..........25Purina Veterinary Diets™ HA HypoAllergenic™ brand Canine Formula..........26Purina Veterinary Diets™ DCO Diabetes COlitis™ brand Canine Formula .....27Purina Veterinary Diets™ EN GastroENteric™ brand Feline Formula ............28

Ralston Purina Company Gastrointestinal Disease Management iii

Introduction

Vomiting and diarrhea are common presenting complaints of patients seen by the small animalclinician. The initial goal in the diagnosis and management of these cases is to identify all potentialcontributing factors. A critical first step is to obtain a complete history so that a diagnostic approach canbe determined. The history is also a diagnostic tool for the evaluation of chronicity and severity of theanimal’s condition.

CASE HISTORIESBecause cases of vomiting and diarrhea take extra time to work up, instructing technicians in the art of

obtaining a thorough history would help keep a clinic schedule on track. A sample patient history form forthe client as well as the veterinarian is provided, and includes questions about the pet’s environment andhealth status; changes in eating habits, diet, attitude, behavior, exercise, and stool quality. The breed of theanimal can be important as some breeds have predispositions to vomiting or diarrhea (see chart on p. 11).A clinician checklist for the physical exam is also provided.

DIFFERENTIATION OF CLINICAL SIGNSThe following descriptions may help to assist the clinician in distinguishing between vomiting and

regurgitation, and acute and chronic diarrhea.Regurgitation is a passive process and is often the result of an esophageal disorder. Animals with this

condition often have a normal appetite and the regurgitated contents are undigested and usually coveredwith mucus and saliva.

Vomiting is an active reflex leading to the “ejection” of contents from the stomach or proximalduodenum. Loss of appetite may be part of the history. The contents are partially digested and are oftenfrothy and bile stained.

Acute Diarrhea: Animals with mild forms of acute diarrhea typically present with a normal attitude andminimal signs of debilitation. Patients with moderate to severe acute diarrhea present with one or more ofthe following clinical signs: debilitation, weight loss, fever, anorexia, depression, weakness, and dehydration.

Chronic Diarrhea: Animals with chronic diarrhea of the small bowel (more than 2 to 3 weeks) exhibitweight loss and no evidence of fresh blood or mucus. Patients with chronic diarrhea of the large bowelexhibit signs of tenesmus, increased frequency, small stool volume, and the presence of fresh blood ormucus.

MANAGEMENTManagement of both vomiting and diarrheic patients depends on whether the condition is acute or

chronic and whether the clinical signs and symptoms are mild or severe. In cases where the patient hasdiarrhea, the diagnostic approach and therapeutic intervention also depend on whether the diarrhea isfrom the small or large bowel. In severe cases of vomiting and/or diarrhea, immediate implementation ofsupportive therapy with hospitalization is often necessary.

Hospitalization should be considered not only for critical cases, but also in the initial period for lesssevere cases. This approach is a good practice builder because owners are given a reprieve from cleaningup after the pet. It also provides them with a feeling of good will because trained staff will be monitoringtheir pet through the initial phases of treatment.

Once the appropriate diagnosis has been made, therapy can be initiated, which can include surgery,medical, or dietary intervention. Certain etiologies of vomiting and diarrhea are responsive to dietaryintervention, these include fiber responsive large bowel disorders such as colitis and some chronic smallintestinal diseases, such as lymphangiectasia and food allergies or intolerance.

USING THE ALGORITHMSThe algorithms in this publication have been developed as a tool for differentiating between often

similar clinical signs and for developing a therapeutic plan for animals presenting with vomiting ordiarrhea. Many of these cases can be extremely complex, and many steps may be necessary before anaccurate diagnosis can be made and therapy initiated. The algorithms assist in the differentiation ofproblems (regurgitation versus vomiting, large versus small bowel diarrhea), chronicity, and severity.

iv Ralston Purina Company Gastrointestinal Disease Management

Ralston Purina Company Gastrointestinal Disease Management 1

An Approach to Vomiting or Regurgitation in Cats and Dogs

Cases of vomiting or regurgitation are frequently seen insmall animal clinical practice, both in first-opinion and referralsettings. The clinician’s primary goals during initial assessmentof the affected animal are:

■ To differentiate vomiting from regurgitation.■ To establish the severity of the problem.■ To determine the chronicity of the problem.

Determining this limited amount of information helps tocategorize the condition (for example, severe acute vomition)and enables the clinician to assign a priority to variousdiagnostic approaches according to a list of appropriatedifferentials. The differential diagnosis for severe, acute signsmay differ substantially from the differential diagnosis for apatient with mild chronic vomiting or regurgitation.

Owners frequently have their own ideas about a possiblecause or exacerbating factors. Although owner speculationforms an important part of the pet’s history in any case, it isimportant for the clinician to remain objective and open-minded in the early diagnostic stages to avoid missing signs orbeing sidetracked.

VOMITING VERSUSREGURGITATION/DYSPHAGIA

Many owners fail to distinguish vomiting from regurgitation/dysphagia or have an incorrect perception of each category. Theopening questions in any case of vomition should establishwhether a dog or cat that is “bringing up its food” is indeedvomiting or is regurgitating (See Table 1). History takingshould address the key differences between the two acts,which require totally dissimilar diagnostic approaches. Otherconditions to consider at this stage are dysphagia, retching,gagging, and expectoration.

Regurgitation is the passive retrograde movement of foodor liquid through the oral cavity, nasal cavity, or both, usuallyas the result of an esophageal disorder. It occurs afterswallowing or repeated attempts at swallowing. Often it ishelpful to observe the patient while it is eating solids andliquids if regurgitation is likely.

Vomiting, unlike regurgitation, is an active neural reflex-mediated act that requires a coordinated effort of thegastrointestinal, musculoskeletal, and nervous systems, leadingto the ejection of ingesta, usually through the mouth from thestomach or proximal duodenum.

Dysphagia is difficult or painful eating or swallowing andis classified as oral, pharyngeal, or esophageal. To an owner, a

patient that prehends and then drops food from its mouth mayappear to be vomiting.

Gagging, a reflex contraction of the constrictor muscles ofthe pharynx, may result from pharyngeal swelling, pain, ordifficulty swallowing.

Retching is an involuntary and ineffectual attempt to vomitand involves all of the same motor events that cause actualvomiting.

Expectoration is the ejection of airway andlaryngopharyngeal discharge or debris. Pet owners mayconfuse gagging, retching, or vomiting with the loud andforceful expectoration of small amounts of white foamassociated with tracheobronchitis.

CHRONICITY OF THE CONDITIONAge at onset is of major significance in deciding whether to

consider a congenital disorder as the cause of regurgitation orvomiting. History taking should address the age at which thesigns were first noted in the pet, and whether at that or any other times there was any dietary change that exacerbated theproblem. Congenital disorders causing regurgitation includecricopharyngeal achalasia, congenital idiopathic megaesophagus,vascular ring anomalies (e.g., persistent right aortic arch), andmyasthenia gravis. These conditions are often noticed first atweaning, when the patient changes from ingesting liquid toeating solid foods. Congenital causes of vomiting are lesscommon but include pyloric stenosis and other systemic diseases.

Acute onset of disease signs in a previously healthy animalsuggests reaction to a foreign body, toxins, infectious causes,or dietary indiscretion (“garbage gut”). A more chronic courseof signs is consistent with such infiltrative diseases aseosinophilic gastritis or neoplasia and typically warrantsdiagnostic testing.

Regurgitation Vomition

No associated nausea Nausea or inappetenceor inappetence (prodromal signs) may be present

Passive process Active process involving contraction of theabdominal muscles and diaphragm

Undigested ingesta Partially digested ingesta

Regurgitus usually covered Vomitus usually frothy and bile with mucus and saliva stained

TABLE 1Distinguishing Between

Regurgitation and Vomition

2 Ralston Purina Company Gastrointestinal Disease Management

SEVERITY OF DISEASEWhen evaluating patients with vomiting, the clinician must

differentiate between:

■ Acute or chronic conditions■ Healthy or sick pets

After obtaining a complete history, the clinician mustconsider the significance of the condition: Is this an animalthat vomits once or twice a week but is otherwise healthy, oris there evidence of debilitation? Prolonged, frequentvomition; depression; weight loss; anorexia; weakness;dehydration; fever; tachycardia; weak pulses; slow capillaryrefill; congested mucous membranes; melena; palpableorganomegaly; pain; or effusions all serve as indicators of asystemically ill patient that requires immediate furtherevaluation and supportive care.

In assessing animals that regurgitate, the clinician shouldalso maintain a high index of suspicion and evaluate fully forconcurrent aspiration pneumonia. Elevated respiratory rate,moist lung sounds or crackles, or uncertainty about a coughshould lead the clinician to pursue thoracic radiographs. Ifempiric therapy is considered, then gram-negative entericorganisms are most common. However, gram-positiveorganisms and anaerobes are relatively common, and resistantstrains frequently occur. Ideally, antimicrobial therapy shouldbe based on culture results of a transtracheal aspirate.

ACUTE VOMITINGHealthy pets with sudden-onset vomiting. In a general

small animal practice, the majority of vomiting patients will beotherwise healthy household pets that have shown a sudden andrecent onset of the problem. A large proportion of the cases willbe attributable to “garbage disease” (i.e., dietary indiscretion).

Clinical goals for the vomiting patient are to rule out aforeign body, potential toxins, underlying systemic disease, orsigns of systemic complications that require attention. Withthe ruleouts accomplished, these “healthy acute vomiters”can cautiously be discharged with directives for rest; nothingby mouth for the first 12 hours; then small, frequent meals of a highly digestible low-fat diet (e.g., Purina Veterinary

Diets™ EN GastroENteric™ Canine Formula). Thisrestricted program is continued for two to three days, and thepatient is gradually switched back to its regular diet.

Sick pets with acute vomiting episodes. The second groupof acute vomiters are those that are systemically ill. These“sick acute vomiters” may have severe intestinal disease, suchas is associated with an obstructing foreign body, a gastriculcer, or parvovirus. They may have an underlying systemicdisease, such as pancreatitis or Addison’s disease, or besuffering from diabetic ketoacidosis or acute renal failure.

Conversely, sick acute vomiters may simply be suffering themetabolic disturbances of persistent vomiting. Constantvomiting alone can lead to dehydration, acid-basedisturbances, including metabolic acidosis or alkalosis, andelectrolyte disturbances that include hypokalemia,hypochloremia, and hyponatremia. These patients typicallyrequire early evaluation with abdominal imaging, blood tests,and intravenous fluid therapy.

CHRONIC VOMITINGUsually, animals suffering from chronic vomition should be

approached in a manner that is similar to assessment of thesick acute vomiter. A thorough history and physicalexamination in these cases should always be followed withabdominal imaging and the minimum laboratory workup of aCBC, serum biochemical analysis, and urine and fecalanalyses. Requesting a buffy coat evaluation along with theCBC allows the clinician to look for systemic mastocytosis. Acareful analysis of the laboratory results is important in rulingout systemic disease. Certain infiltrative fungal diseases, suchas pythiosis, may require evaluation of biopsies taken duringeither endoscopy or surgery.

After extraintestinal and infectious diseases are ruled out or areconsidered insufficient to account for the clinical signs observed(see algorithms on page 4, 5, 6, and 9), endoscopy of the uppergastrointestinal tract with biopsies is generally the next step (seealgorithm on page 10).

THE DEFINITIVE DIAGNOSISAs can be seen in the endoscopy algorithm (page 10), a

histologic description does not necessarily imply adefinitive diagnosis. Use of the term inflammatory boweldisease (IBD) should be restricted to an idiopathic class ofdisease after ruling out all potential underlying causes ofthe animal’s vomiting. Completion of the ruleoutsfrequently involves:

■ Reassessing the patient for systemic diseases, such ashypothyroidism, toxoplasmosis, FeLV, or FIP in cats.

■ Consulting with the pathologist to find out whether anunderlying neoplastic process may have been missed.

■ Patients that chronically regurgitate frequently struggle to maintain adequate caloricand nutrient intake. General feeding recommendations include changing the diet to anutrient-dense food (e.g., Purina Veterinary Diets™ CV CardioVascular™brand Feline Formula) and experimenting with various food consistencies (solid, meatballs, gruel) and feeding positions.

■ Patients that cannot be managed through oral feeding may do better if fed through agastrostomy tube directly into the stomach. Newer silicone PEG (percutaneousendoscopically placed gastrostomy) tubes are suitable for long-term use, and theauthors have numerous megaesophagus patients that have been successfully PEG-tube fed for 2 to 5 years.

General Nutritional Recommendationsfor the Regurgitating Patient


■ Ruling out food allergies or intolerance. Rule out foodallergies by initiating a 10- to 16-week trial duringwhich the pet is fed a “hypoallergenic” diet. The dietaryhistory should be carefully evaluated, and the new dietshould not contain protein or carbohydrate sources towhich the animal has previously been exposed. The dietmay be home-prepared by the owner (ideally balancedby a nutritionist) or it may be carefully selected from avariety of commercial single-protein-source diets.Purina Veterinary Diets™ HA HypoAllergenic™

Canine Formula is a good exclusion diet for use indogs. Patients with severe intestinal inflammation maynot respond initially to a restricted diet alone. Withmoderate to severe infiltrate, or where the infiltrate isprimarily eosinophilic, the authors recommend startingthe new diet along with a tapering course of prednisoneover the first three to four weeks.

The clinician should keep in mind that prednisonetherapy masks inflammation and lymphoma, precludesinterpretation of an ACTH stimulation test, andsignificantly compromises a patient’s future response tochemotherapy if it is eventually diagnosed with lymphoma.Therefore, it is crucial that those differentials are ruled outbefore starting prednisone therapy.

WHEN TO REFER A PATIENT WITH GASTROINTESTINAL DISEASE

It is never too soon to refer a patient with gastro-intestinal disease to a specialist. Referral is dependent on theavailability of specialists and equipment and the wishes of aclient to take advantage of those options. The client should begiven the opportunity to see a specialist, if that choice isavailable. However, most owners initially elect to work withtheir local veterinarian, with whom they have established arelationship.

In general, if a definitive diagnosis has not been reached bythe second or third patient visit, referral is both logical andappropriate.

SUMMARY OF APPROACHHistory■ Diet■ Drugs■ Environment■ Previous medical history■ Concurrent disease■ Onset■ Duration■ Severity■ Exacerbating factors■ Description of process to differentiate:

Vomiting/regurgitationDysphagia/gagging/retching/coughing/expectorating

Physical Examination■ Primary gastrointestinal vs. signs of systemic disease■ Evidence of aspiration pneumonia■ Consider observing dysphagic animals while they eat■ Careful oral examination, abdominal palpation, rectal

examination■ If patient is painful or tense, then sedate or use diagnostic

imaging

Diagnostic Testing■ Minimum database (CBC, biochemistry profile, urinalysis,

fecal examination)■ Thoracic radiographs if esophageal disease or aspiration

pneumonia is suspected■ Abdominal radiographs to rule out/in foreign bodies, masses,

partial obstructions■ Fluoroscopy for swallowing disorders■ Abdominal ultrasound to evaluate abdominal viscera■ Computer tomographic imaging of masses/bullae/

temporomandibular joint■ Specific serologic tests, such as feline leukemia virus/FIV/

heartworm/toxin assays/endocrine tests ■ Endoscopic evaluation and biopsy■ Reevaluation of differential diagnosis according to biopsy

results

The following algorithms are intended to provide guidelines for the evaluation of vomiting or

regurgitation in dogs and cats. However, an algorithm can never include all clinical possibilities

and there is no substitute for careful clinical judgment and experience.

Action steps in red. Treatment steps in blue. (Some steps overlap)

EVALUATING ORAL AND PHARYNGEAL DYSPHAGIA(difficulty prehending, masticating, or swallowing)

HISTORY/PHYSICAL EXAMVomiting?

Gagging? Retching?

Esophageal dysphagia(p. 5)

Expectorating?

± Thoracic radiographsif aspiration pneumonia possible

Culture and cytology of transtracheal aspirate

Antimicrobial treatment according to results

Cannot/will noteat, oral pain

ORAL/PHARYNGEALDYSPHAGIA

Tries to eat but hasdifficulty, no pain

Possibility of rabies?

Quarantine, observeObserve animal eating

Takes infood

Cannottake infood

Swallowingfluoroscopy

Mouth pain,cannotexaminemouth

Fracture orno obviousabnormality

FractureForeign bodyChemicalexposure

Painful,swollenmuscles

Serum for Type 2M(for masticatorymuscle myositis)antibody test;muscle biopsy

Oraldysphagia

Sedation/anesthesia

Look forunderlyingcause;trigeminalneuropathy?

Watch the patient eatWatch the patient breathe. Any cough?

Any increase inrespiration rate?

Crackles? Wheezes?

Ulcers,stomatitis,masses

Biopsy;systemicdisease?

Lab work(p. 9)

Abscess, dental disease*

Drain abscess;Perform dentaltreatment

Foreign body

Endoscopic/surgicalretrieval

Still unable to open mouth

Chronic myositis† TMJ disease‡

Biopsy Radiographs/Computed

Tomography

Radiographs,computedtomography (CT)scan;temporomandibularjoint (TMJ) and bullae

Ultrasound ofretropharyngeal/retrobulbar region§

Pharyngealdysphagia

Look forunderlyingcause;neuropathy,myopathy,myastheniagravis?

Cricopharyngealdysphagia

Rule outunderlying cause

Myotomy

*Oral ulcers should trigger an evaluation for systemic disease, e.g.,renal disease, feline immunodeficiency virus, calicivirus infection. Ifnegative for these, a biopsy may indicate immune-mediated disease.†Immune-mediated myositis should be treated withimmunosuppressive doses of corticosteroids tapered over four to eightweeks according to clinical signs.‡CT scan is an excellent modality by which to evaluate thetemporomandibular joint for bony changes, including malunion,

osteoarthritis, fractures, and neoplasia. It also provides sharp detail ofthe auditory canals and bullae, including fluid accumulations, polyps,and masses that require surgical intervention.§Retrobulbar masses and abscesses are common causes of dysphagia.They can be imaged with ultrasound or CT, either of which allowsguidance for aspiration and subsequent cytology and culture. Contrast-enhanced CT provides superior evaluation of the extent of a neoplasticinfiltrate should surgical intervention be considered.


Dysphagia?

RADIOGRAPH NECKAND THORAX(UNSEDATED)

Dilated, air-filledesophagus

Rule outvascular ring

Toxin exposure?

Soft tissue mass

Ultrasound-guided fine-needleaspirate

Foreign body

Emergencyendoscopyand removal

No abnormalities


Abscess ➞ Aerobic/anaerobic culture• Surgical drainage

Granuloma ➞ Acid fast stain/culture for mycobacteria,fungi • Fungal serology

Thymoma ➞ Surgery ± radiation

Other neoplasia ➞ Metastatic screen• Consider CT to evaluate margins• Chemotherapy/surgery/radiation as appropriate

Cholinesterase

Serum lead

Neurologicexamination

Normal

Acetylcholinereceptorantibody test

Positive• Acquired myasthenia

gravis

Negative• Congenital idiopathic megaesophagus• Congenital myasthenia gravis

EVALUATING REGURGITATION (ESOPHAGEAL DYSPHAGIA)(normal prehension, mastication, swallowing)

JUVENILE ONSET


Rule outbrainstem disease,polyneuropathy,myasthenia gravis

EVALUATING REGURGITATION (ESOPHAGEAL DYSPHAGIA)(normal prehension, mastication, swallowing)

ADULT ONSET

RADIOGRAPH NECKAND THORAX(UNSEDATED)

Dilated, air-filledesophagus

Acquired megaesophagus

Soft tissue mass

Ultrasound-guided fine-needleaspirate

Foreign body

Emergencyendoscopyand removal

No abnormalities


Obstructive disease• Strictures• Foreign body Endoscopy• Spirocerca granuloma• Luminal/mural mass

Toxins• Lead ➞ Serum lead level• Anticholinesterases ➞ Blood cholinesterase level• Thallium ➞ Serum level• Botulinum toxin ➞ Mouse bioassay

Neuromuscular disease • Neuropathies ➞ Neurologic exam, consider nerve conduction studies, nerve biopsy • Dysautonomia ➞ Neurologic and physical examination• Myasthenia gravis ➞ Acetylcholine receptor antibody test• Systemic lupus erythematosus (SLE), other major and minor signs ➞ Antinuclear antibody (ANA) test • Myositis and myopathies ➞ Electromyelogram (EMG), serum chemistry, muscle biopsy

Endocrine disease • Hypoadrenocorticism ➞ ACTH stimulation test• Hypothyroidism (poorly documented cause, low T4 level difficult to interpret in a sick animal)

Inflammation – esophagitis• Gastroesophageal reflux disease• Recent medication (e.g., doxycycline)• Excessive acidity (mast cell tumors or gastronomas)

Evaluate patient on individual basis to determine likelihood of potential underlying disorders:


PHYSICAL EXAMINATION

Neurologic exam Vestibular signs

Normal

Other CNS signs

Oral exam String foreign body• Image abdomen• Endoscopy or surgery

Normal Oral ulceration• Consider caustic toxins, renal

failure, virus infection

EVALUATING VOMITING HISTORY AND PHYSICAL EXAM

Ototoxin exposure, e.g., gentamicin?

• Otoscopic exam• Bullae radiographs• CSF exam• Image brain

• Reevaluate toxin exposure• Evaluate for systemic disease,

then intracranial disease

(CONT’D ON P. 8)


DRUG EXPOSURE GUIDELINES

For all drugs, assess whether signs, dose, route, and timing of a drug arecompatible with observed effects. Withdraw drug. For ulcerogenic drugs, consider symptomatic treatment withprotectants; consider endoscopy if signs include hematemesis or melena. For antibiotics, reevaluate therapy and consider different class of drug.For mitotane, consider addisonian crisis. For cancer chemotherapeutics, ensure that signs are related to drugrather than neoplasia or septicemia. Consult with oncologist/ internist.

HISTORY

Drug exposure• Ulcerogenics (NSAIDs: aspirin, phenylbutazone, carprofen,

flunixin, ketoprofen, corticosteroids)• Irritants (NSAIDs; antibiotics, including tetracyclines,

erythromycin; o,p'-DDD, piperazine• Centrally acting drugs, including doxorubicin, cisplatin

Toxin exposure • Fertilizers, cleansing agents, insecticides, pesticides, antifreeze,

ornamental plants, toxic mushrooms

CONSULT PRODUCT LABEL IF AVAILABLE FOR DETAILS ABOUTINGREDIENTS. TREAT ACCORDINGLY. IF CONTACT WAS TOPICAL, WASHANIMAL THOROUGHLY.

Garbage exposure

Foreign body exposure• Sticks, string, balls, plastic toys, nuts, corncobs

THOROUGH ORAL EXAM, INCLUDING UNDER TONGUE FOR STRING;PALPATE ABDOMEN; USE RADIOGRAPHY/ULTRASOUND IF UNCERTAIN.

Environment • Other dogs sick indicates infectious etiology• Parvovirus vaccination history?

CONSIDER PARVOVIRUS ELISA/FECAL ELECTRON MICROSCOPY ANDISOLATE ANIMAL UNTIL RESULTS CONFIRMED.

Other signs• PU/PD • diarrhea • nasal discharge• weight loss • coughing • occular discharge

CONSIDER PROBLEMS THAT MAY INDICATE SYSTEMIC DISEASE.

EVALUATING VOMITINGHISTORY AND PHYSICAL EXAM (cont’d)

Normal

Systemic signs Abdominal palpation

Stabilize patient pending results. Think fluid balance, electrolyte balance; withhold food; antibiotic therapy if animal appears septic (usually gram-negative); after culture samples obtained, antiemetics only if obstruction ruled out.

Could this be Addison’s?• Consider ACTH stimulation test

• TPR elevated• Pale/injected mucous

membranes• Slow CRT (capillary refill time)• Weakness• Shivering• Icterus• Lymphadenopathy

None Animal relaxed,normal, no pain,no masses

Animal tense, showsdiscomfort; or mass noted

No history thatwarrants furtherevaluation

Abdominalradiographs± ultrasound

Symptomatic therapy for “healthy acute

vomiter” (see page 2)Draw samples for • CBC• Serum chemistry profile• Urinalysis• ± blood culture

Foreign body Endoscopy/surgery

Hepatomegaly Evaluate liver enzymes,coagulation panel ± biopsy

Small Liver Consider portosystemic shunt

Bile duct obstruction Consider pancreatitis, abscess,neoplasia, calculus, medical versussurgical Rx

Pancreatitis Nothing by mouth; IV fluids

Renomegaly Evaluate for acute renal failure orportosystemic vascular anomaly

Splenomegaly Rule out RBC parasites(evaluate blood smear for Babesia,Haemobartonella); if negative, thenaspirate spleen

Splenic torsionPyometra Stabilize medically,Intestinal volvulus then surgeryGDVAbscessFree gas

LymphadenopathyProstatomegaly Fine-needle aspirateFocal intestinal cytology ± biopsy

thickening

Fluid Abdominocentesis

No abnormalities Cytology plus fluid chemistry,if indicated, e.g., creatinine

Reevaluate for if urine leakage suspected spinal pain

LAB WORK(Cont’d on p. 9)


(CONT’D FROM P. 7) Oral exam (cont’d)

Urine• Specific gravity: >1.025 dogs/>1.030 cats azotemia, suggests prerenal disease.• Glucosuria: diabetes mellitus, acute renal failure, severely stressed cat• Ketonuria: diabetic ketoacidosis• “Active” urine sediment: acute renal failure, pyelonephritis, cystitis• Bilirubinuria: hepatic disease, hemolysis• Urate crystalluria: portosystemic vascular anomaly (PSVA)

CBC• Anemia: classify as regenerative/nonregenerative with reticulocyte count

Distinguish hemolysis from hemorrhage with PCV/TPHemolysis: consider splenic torsion, AIHA (autoimmune hemolytic anemia), Babesia, Haemobartonella, lead Hemorrhage: consider GI ulceration, warfarin poisoning, or other coagulopathy

• Hemoconcentration: likely dehydration secondary to vomiting• Neutrophilia: stress, infection, inflammation, neoplasia• Neutropenia: sepsis, neoplasia, toxin, virus• Eosinophilia: Addison’s disease, parasites (enteric, heartworms), mast cell disease, food hypersensitivity reactions, hypereosinophilic syndrome

ChemistryBUN Increased (Azotemia): Use urinalysis and abdominal imaging to distinguish causes as prerenal (dehydration, Addison’s

disease), renal (lymphoma, Leptospira, ethylene glycol, toxin, pyelonephritis), or postrenal (particularly obstruction and rupture) Decreased: hepatic disease, portosystemic shunt, starvation, polyuric conditions

Liver enzymes Increased: (ALT, ALP, AST, GGT): nonspecific; consistent with hepatopathy, biliary disease, pancreatitis, peritonitis,vascular occlusion, septicemia, diabetes mellitus

Albumin Decreased: protein-losing enteropathy, nephropathy, hemorrhage, effusionsIncreased: dehydration

Calcium Increased: lymphoma, other tumors, Addison’s disease, vitamin D rodenticide toxicity, hyperparathyroidismDecreased: renal disease, pancreatitis, intestinal malabsorption

Phosphorus Increased: azotemia (see above), vitamin D rodenticide, young animals Decreased: hypercalcemia of malignancy, diabetic ketoacidosis, inappropriate IV fluid therapy

Glucose Increased: diabetic ketoacidosis, stressed cat, hyperadrenocorticism, IV supplementation, e.g., total parenteral nutrition (TPN)Decreased: sepsis, Addison’s disease, hepatic failure, neoplasia, toy breeds, artifact

Lipemia Postprandial: diabetes mellitus, pancreatitis, cholestasis, nephrotic syndrome; idiopathic in miniature schnauzersSodium Increased: vomiting, diabetes mellitus, drugs, inappropriate IV fluid therapy

Decreased: vomiting, diabetic ketoacidosis, inappropriate IV fluid therapy, Addison’s disease, effusionsPotassium Increased: postrenal obstruction/rupture, anuric renal failure, Addison’s disease, drugs (e.g., ACE inhibitors),

inappropriate IV fluid therapyDecreased: vomiting or diarrhea, renal disease, inappropriate IV or SQ fluid therapy, drugs (e.g., loop diuretics),diabetes mellitus, insulin administration

Total CO2 Increased: vomiting of gastric contents (especially with GI obstruction), diuretic therapyDecreased, normochloremic: diabetic ketoacidosis, renal failure, lactic acidosis, ethylene glycolDecreased, hyperchloremic: Addison’s disease, diarrhea, IV NaCl bolus

Amylase or lipase Increased: pancreatitis, azotemia (see above), intestinal disease, occasionally hepatic diseaseT4 (cats)Heartworm antibody (cats)Fecal flotation (ZnSO4)• Rule out Giardia, helminths

Endoscopy (see Algorithm on page 10)

Author’s Note: The lists in the preceding algorithm are not intended to be exhaustive with regard to the differentials for various laboratory-identified abnormalities.Rather, they are intended to highlight those differentials that are most commonly evaluated or are considered important in diagnosing and treating a vomiting animal.

EVALUATING VOMITINGLAB WORK


(CONT’D FROM P. 8)Lab Work–Systemic signs (cont’d)

ENDOSCOPY

Foreign body ➞ Endoscopic or surgical retrieval

Mass ➞ Biopsy and submit for histopathologic results ➞ If neoplastic, stage tumor and consider treatment options

Ulcer ➞ Biopsy nonnecrotic tissue, as ulcers may result from neoplastic and infectious processesSymptomatic therapy for ulcer: H2-blocker, sucralfate, omeprazoleReevaluate drug history and workup for systemic disease, including renal disease, hepatic disease, gastrinoma, hypoperfusion

Hypertrophic pylorogastropathy ➞ gastronoma ➞ Consider surgery ➞ benign

Parasites ➞ May require microscopic evaluation of gastric fluid (e.g., Ollulanus tricuspis in cats) ➞ Rx: fenbendazole;Physaloptera ➞ treatment: pyrantel pamoate

Rugal thickening ➞ Consider chronic gastritis, infiltrative neoplasia, paraneoplastic secondary to gastronoma

Thin, discolored gastric mucosa with submucosal vessels noted ➞ atrophic gastritis? ➞ Biopsy

No gross findings, cellular infiltrate on biopsy

Neoplastic infiltrate Granulomatous infiltrate• Lymphoma (especially cats) • Chronic foreign body• Carcinoma (especially dogs) • Chronic infection, e.g., FIP, histoplasmosis, Campylobacter, • Leiomyoma Salmonella, toxoplasmosis• Other tumors

Stain for fungal/acid-fast organisms, culture,Stage tumor, consider treatment options polymerase chain reaction

• Parasites• Immune-mediated• Idiopathic

Eosinophilic infiltrates Lymphoplasmacytic infiltrates • Parasites • Underlying neoplastic disease• Mast cell disease • Parasites (e.g., Giardia, Cryptosporidium)• Immune disease • Immune disease

–Food allergy –Food allergy–Hypersensitivities –FeLV –Idiopathic • Chronic bacterial infection (Campylobacter)

EVALUATING VOMITINGENDOSCOPY

Neutrophilic infiltrates• Bacterial infections

–Campylobacter–Toxigenic E. coli

• Underlying neoplasia• Foreign bodies• Toxins/ingestion of caustic substance• Immune mediated


AN APPROACH TO DIARRHEA IN CATS AND DOGS

A patient that is presented for the complaint of diarrhea isapproached just as in any other case—by first taking acomplete history and then following up with a thoroughphysical examination. With these two items in hand, adiagnostic plan can be executed with a goal toward treatment.

DEVELOPING A COMPLETE PET HISTORYSpecific questions, designed to elicit a detailed history,

should be directed to the pet owner. Besides seekinginformation regarding the pet’s environment and health status,for the diarrheic patient it is especially important to determinea factual picture of the dietary and nutritional history. Moretime is required to complete this kind of case assessment thanis necessary to handle a routine office visit and should be builtinto the clinic scheduling process.

General History Taking Good investigation is the key to successful case

management regardless of the presenting problem. Beforequestioning the owner about the pet’s history, the veterinarianshould record general observations about the animal’sappearance and behavior as well as any additional outwardsigns of its present health status. Any breed factors that maybe pertinent to the case should also be noted. It is usually wiseto confirm the pet’s breed with the owners rather than relysolely on observation. See Table 2 for a list of suspected orconfirmed breed predispositions.

In further developing an accurate and meaningful petrecord, helpful terms and phrases that prompt the client’smemory and lead the discussion are essential (see ClientWorksheet on page 22). Appropriate questions for theclinician or veterinary technician to ask during the historytaking are listed on the Clinician Checklist form on page 23.

Obtaining a Specific Nutritional History Although the detailed general history is fundamental to

patient assessment, questions about the pet’s dietary andnutritional history can be of particular significance in the caseof diarrheic animals. The clinician should cover the followingpoints by questioning the owner and evaluating each answer,considering whether the answers are appropriate to thespecies and life stage.

After completing the history-taking interview, the next stepis a thorough physical examination of the animal. Specialareas of interest or concern may be identified during thehistory taking and may help direct any nonroutine aspects ofthe examination.

PERFORMING THE PHYSICAL EXAMINATIONThe physical examination should result in a complete

head-to-tail assessment of the animal. Again, while examiningthe animal, the primary objectives are to determine thecondition, the bowel involvement, the level of debilitation,and the source of the problem. Overall visual evaluation is


Breed Condition

Basenji lymphocytic/plasmacytic enteritis

Bedlington terrier copper hepatotoxicosis

Belgian shepherd gastric carcinoma

Boxer gingival neoplasia, mastocytoma, histiocytic ulcerativecolitis

Chow chow exocrine pancreatic insufficiency

Cocker spaniel chronic hepatitis

Doberman chronic hepatitis

English bulldog vascular ring anomaly

German shepherd megaesophagus, vascular ring anomaly, exocrinepancreatic insufficiency, perianal fistula

Great dane (giant breeds) gastric dilatation-volvulus

Irish setter megaoesophagus, vascular ring anomaly, gluten-sensitive enteropathy

Breed Condition

Irish wolfhound megaesophagus, porto-systemic shunt

Lundehund lymphangiectasia

Miniature schnauzer pancreatitis, haemorrhagic gastroenteritis

Persian cat portosystemic shunt

Rough collie gastric carcinoma, exocrine pancreatic insufficiency

Sharpei gastroesophageal intussusception, inflammatory boweldisease, (IgA deficiency), hiatal hernia

Siamese cat megaesophagus, inflammatory bowel disease, intestinaladenocarcinoma

Soft-coated wheaten terrier lymphangiectasia, protein-losing nephropathy/enteropathy

West Highland white terrier chronic hepatitis

Yorkshire terrier portosystemic shunt, lymphangiectasia

TABLE 2Some Suspected or Confirmed Breed Predispositions to Gastrointestinal Diseases

one factor in the approach, with palpation and auscultationother key aspects.

Throughout the examination, the clinician should keep inmind the four basic questions that are of concern:1. Is the condition acute or chronic?2. Is it more likely a problem of the small or the large

bowel?3. Is the problem mild or moderate to severe?4. Is the problem truly gastrointestinal, or is it an

extraintestinal problem?

DEVELOPING A DIAGNOSTIC PLANAfter recording a full history and making a thorough

physical assessment, the next step is development of aproblem list, with a list of differential diagnoses for eachproblem. The diagnostic plan is then formulated to rule out orrule in the differentials for each problem on the list. Thehistory will have indicated whether the animal’s condition isacute or chronic, and the physical examination whether thediarrhea is a mild problem or a moderate to severe conditioncausing weight loss, weakness, anorexia, or other signs ofdebilitation (See Table 3).

For patients with acute disease, it is important to determineif the problem is mild or moderate to severe before thediagnostic workup. In cases of chronic diarrhea, differentiatingbetween the large bowel and small bowel as the primary causeis mandatory, as case approach and management depend onthat information. Many diseases involve both aspects of theintestinal tract.

Step-By-Step Case AssessmentClassifying the severity of disease is the first step in the

decision-making process. Clinicians can use Table 3 as a guideand the following algorithms to further refine the decision-making process in reaching a specific diagnosis:

• If the diarrhea is acute, turn to the algorithms on pages18 and 19;

• If the diarrhea is chronic, turn to the algorithms onpages 20 and 21.

Animals with mild disease need to be evaluated for foreignbodies and parasitic causes of diarrhea. If no foreign body orsigns of parasites are found, it is often possible to send theanimal home with instructions to feed a highly digestible, low-fiber, low long-chain triglyceride diet such as PurinaVeterinary Diets™ EN GastroEnteric™ Canine Formula.The majority of acute diarrheic pets recover well with thisrecommendation, and the presumptive diagnosis is “garbagegut” (dietary indiscretion).

DIAGNOSING AND TREATING MILD ACUTE DIARRHEA

The clinician first palpates the animal for evidence ofintussusceptions or foreign bodies. If the veterinarian suspectsintussusceptions or foreign bodies, confirmation withradiography is appropriate. If positive, surgery is performedafter the animal is stabilized with intravenous fluid therapy(sometimes endoscopy is an alternative to surgery for removalof a foreign body, depending on its size and location).

The next step is to determine any other underlying cause(such as parasites, neoplasia, granulomas, parvovirus, ormotility disorders).

To rule out the presence of parasites, a zinc sulfate fecalanalysis is performed and repeated three times. This allowsthe clinician to rule out Giardia as well as the more commonintestinal parasites. If parasites are present, the animal is giventhe appropriate antiparasitic agent.

If no diagnosis is found following physical examination,fecal evaluation, and dignostic imaging, a diagnosis of dietaryintolerance is assumed and the patient is treatedconservatively with EN GastroENteric™, with or without theaddition of loperamide (0.1-0.2 mg/kg orally twice daily fordogs). Reevaluate the patient in two to three days.

Feeding Through Diarrhea Adapted from data recorded in human pediatric

gastroenterology, the “feeding through” approach to diarrheais a relatively new concept in veterinary medicine. Thismanagement system has begun to replace the “withhold foodfor 24 hours” strategy previously recommended by manyveterinarians before instituting a bland diet.

The premise behind “feeding through” is to start the patientimmediately, without any waiting period, on a highly digestible

Mild Moderate to Severe

Minimal debilitation Debilitation

No weight loss Weight loss

Normal attitude FeverAnorexiaDepressionWeaknessDehydration

TABLE 3Classifying Severity of Disease


diet, low in long-chain triglycerides and low in fiber. Behind thisnutritional management system is the concern that starving thepatient also starves the enterocytes and debilitates the patient.

Withholding food from the gastrointestinal tract maylogically reduce fecal output but concurrently withholdsnutrition from the enterocytes and the patient. As theenterocytes derive the majority of nutrition from thegastrointestinal tract, the healing process is dependent onample substrates in the lumen of the bowel. Of particularimportance are amino acids, such as glutamine. Thereforestarting to feed early in the disease process provides a betteropportunity to heal the enterocytes and restore the patient tohealth. Many owners might opt for hospitalization in anisolation ward, rather than the carpet cleaning fees that couldresult from keeping their diarrheic pets at home. This strategyshould not be used with patients that have vomiting associatedwith diarrhea.

DIAGNOSING AND TREATING MODERATE TO SEVERE ACUTE DIARRHEA

The clinician should check the patient for fever, tachycardia,injected mucous membranes, and lethargy. All of these signs areindicative of more severe disease than occurs in mild cases, andfluid therapy is indicated. Alterations in hydration status andelectrolyte and acid-base abnormalities must be addressed byinitiating fluid replacement while further investigating theproblem.

Infectious CausesIf the animal tests negative for parvovirus, the clinician must

consider other infectious causes, such as Salmonella or salmonpoisoning (in the northwestern US). A selective fecal culture isused to check for Salmonella. It is important to interpret cultureresults cautiously because Salmonella can be found in normal,healthy animals. Also, feces represent flora from the lowerintestine and not the upper intestine. In cases of infection,treatment following a positive test result includes dosing withappropriate antibiotics and feeding EN GastroENteric™.

Feline Considerations A young or debilitated cat with diarrhea should be checked for

toxoplasmosis and cryptosporidiosis. If positive for toxoplasmosis,treat with clindamycin (12.5-25 mg/kg orally twice daily for threeto four weeks); or parenterally to avoid further gastrointestinalupset. If positive for cryptosporidiosis, tylosin can be tried at 11mg orally twice daily for 28 days. The veterinarian should look forconcurrent FIV/FeLV infection and consider the potential publichealth risks of any zoonotic disease.

Foreign Bodies If there is no evidence of infection or parasites, the

clinician must rule out the presence of a foreign body by usingultrasound or radiography. When a foreign body is detected,the next steps are as follows:• Stabilize the patient with fluid therapy, correcting acid/base

or electrolyte disturbances.• Perform surgery or endoscopy to remove the foreign body. • Withhold food for 24 hours postsurgery, and then feed

using enteral nutrition.

AscitesIf the animal is negative for a foreign body, but

ultrasound examination shows ascites:• Tap abdomen and perform fluid cytology. • Rule out feline infectious peritonitis, neoplasia, or portal

hypertension.

Biochemistry Results The veterinarian should carefully evaluate the biochemistry

results. Abnormalities that show up in baseline evaluationsshould prompt further diagnostic workup:• Rule out Addison’s disease (sodium-potassium ratio may be

< 27:1), liver disease, or kidney disease. • Perform an ACTH stimulation test if Addison’s disease is

possible, even if the Na:K ratio is normal.If the animal tests positive for Addison’s disease:• Initiate the recommended therapeutic management for

acute adrenal crisis.• Feed EN GastroENteric™ for diarrhea.

Supportive Care Supportive care while performing any of the described

procedures on a patient with acute moderate to severe diseaseincludes intravenous fluid therapy with potassiumsupplementation and may require dextrose if patient is septic,


1. Replacement requirementBody weight (kg) × Percentage dehydration = Fluid deficit (liters)

2. Maintenance requirement40 to 60 ml/kg/day

3. Contemporary (ongoing) losses• Secondary to diarrhea• Secondary to vomiting

The sum of 1, 2, and 3 equals 24-hour fluid

SOURCE: The Compendium, p. 1562, Dec 1994.

TABLE 4Calculation of Fluid Replacement Requirements

■ Baseline Evaluation. Blood is also drawn for a CBC,biochemical profile, and trypsin-like immunoreactivity(TLI); and a urinalysis is performed. Results of these testswill enable the clinician to decide if the diarrhea is associatedwith liver or kidney disease or some other extraintestinalproblem(s). Cats should also be checked for thyroidfunction, feline immunodeficiency virus (FIV), and felineleukemia virus (FeLV).

Trypsin-like ImmunoreactivityA TLI test can rule out exocrine pancreatic insufficiency

(EPI). If the test is positive for EPI, treat with enzymesupplementation (enzymes mixed into a high-quality, completeand balanced pet food, such as Purina® Dog Chow® or ProPlan®

brands).

Abnormal Baseline Results Serum biochemical evaluation is continued with

measurements of albumin, globulin, calcium, and cholesterollevels (look for lower than normal values to support evidenceof lymphangiectasia or protein-losing enteropathy). Referralcan be considered for quantitation of 51Cr-labeled albuminlost into the gastrointestinal tract or assay of alpha-1 proteaseinhibitor. Obtaining intestinal biopsies is necessary to reach adefinitive diagnosis of lymphangiectasia or to find theunderlying cause of protein-losing enteropathy. The clinicianshould consider giving intravenous colloid support beforeperforming surgical biopsy.

A dog with lymphangiectasia is given prednisone at 1-2mg/kg twice daily for one to two weeks, after whichmedication is tapered to the lowest possible dose.Nutritionally, the pet should be fed EN GastroENteric™ or HA HypoAllergenic™ Canine Formula because of theinclusion of medium-chain triglycerides in these diets.

Accompanying Sign Small Bowel Large Bowel

Vomiting Common Occasional

Fecal volume Usually increased Normal to decreased

Frequency Mildly increased Greatly increased

Appetite Decreased to increased Normal

Tenesmus/urgency Absent Present

Fecal blood Digested Frank

Excess mucus Absent Present

Steatorrhea Sometimes Absent

Weight loss Common Uncommon

TABLE 5Small Bowel vs. Large Bowel Chronic Diarrhea

young, or a toy breed. Before instituting fluid therapy, it isnecessary to measure urine specific gravity, serum electrolytes,blood urea nitrogen, total protein, albumin, packed cell volume,and total solids. The clinician should also obtain a blood smear orCBC.1 If the blood smear shows evidence of neutropenia orparvovirus is a prime consideration because of the animal’s age, orfecal blood is present, a parvovirus ELISA test should be done.

Treatment of parvovirus cases includes fluids (lactatedRinger’s) with 5% dextrose and potassium chlorideadministered to the animal as needed. Therapy should includeantibiotics only if there is evidence of sepsis or if bacterialtranslocation is considered a problem (many parvovirus-infected puppies are blood-culture positive). Afterrehydration, gentamicin (6 mg/kg subcutaneously once daily)can be given for the first 5 to 10 days with concurrent IVfluids. Routine use of antibiotics is not recommended, as theydisturb the normal, protective indigenous gastrointestinal floraand can potentially cause fungal overgrowth. If an antibiotic isused, then it should be given parenterally. Veterinariansshould avoid administration of enrofloxacin to growinganimals, because the drug affects cartilage development.

Nutrition for the animal with moderate to severe acute diarrheais based on an easily assimilated diet such as the EN diet. Refer to“Feeding Through Diarrhea” on page 12.

DIAGNOSING AND TREATING CHRONIC DIARRHEA

Case management of chronic and acute diarrhea differsmarkedly. For patients with acute disease, it is important todetermine whether the problem is mild or severe beforeinitiating a diagnostic workup. For patients with chronicdiarrhea, the clinician must first decide whether the primaryproblem originates in the small bowel or the large bowel, as theoverall approach depends on which aspect of the gastro-intestinal tract is involved. Of course, many diseases can involveboth the large and small bowel. Clinicians may find it helpfulto use Table 5 as a guide.

EVALUATING CHRONIC SMALL BOWEL DIARRHEA■ Fecal Examination. As a first step, the clinician performs a

fecal examination (zinc sulfate), running three samples torule out giardiasis, cryptosporidiosis, and other parasites. Ifthe result is positive for one or more parasites, the animal istreated with the appropriate antiparasitic agent and fed anenteric diet until signs resolve.


1Alan H Rebar, DVM, PhD: Hemogram Interpretation for Dogs andCats.Purina.

If the animal’s calcium level is elevated, the clinicianshould consider lymphoma as a primary differential diagnosis,particularly if the serum phosphate level is normal to low.Further diagnostic procedures that include radiographic andultrasound examination should be initiated to detect a tumoror other causes of hypercalcemia.

Normal Baseline Results If no abnormalities are found on baseline evaluations, the

next step is to image the abdomen radiographically orultrasonographically. Signs of gas distention or a gravel sign(a radiographic term for an accumulation of radiodensematerial) is evidence of a partial obstruction, and the clinicianshould consider the possibility of a mass, foreign body, ortumor as the cause of the diarrhea. Further evaluation mayrequire the use of contrast media, such as a barium series orbarium-impregnated polyethylene spheres (BIPS), to confirmmotility disorders.2 An ultrasound or computer tomographicscan is sometimes used to detect evidence of bowel thickening.However, a biopsy must be performed to reach a definitivediagnosis.

If imaging is normal, biopsies are indicated. Ideally theclinician should obtain biopsy samples from all sections of thegastrointestinal tract, including the stomach, duodenum,jejunum, ileum, and colon, whether abnormalities are foundon imaging or no answers result from the tests describedpreviously. Biopsy allows the clinician to rule in or out suchconditions as neoplasia, pythiosis, histoplasmosis, and otherfungal diseases as well as inflammatory bowel disease (IBD).The clinician should remember to include biopsy of themesenteric lymph nodes, liver (and possibly the pancreas incats) if performing an exploratory laparotomy.

Treatment for Inflammatory Bowel Disease (IBD) A diagnosis of inflammatory bowel disease can only be

made with histology. It is commonly used to refer to any

cellular infiltrate of the intestine, but is probably best reservedfor those cases where the underlying causes of a cellularinfiltrate have been ruled out (examples are given in algorithmon page 10) and the infiltrate is considered truly idiopathic.This finding is, in itself, no reason to condemn a patient to alife of corticosteroids. Successful management of IBD lies infinding, or at least trying to find, a reason for the inflammation,an objective that can be difficult if not impossible.

Initially, the clinician should attempt to rule out parasites,food intolerance or allergies, and infectious agents such astoxoplasmosis and FeLV. A feeding trial to diagnose foodallergies consists of feeding the animal Purina VeterinaryDiets™ HA HypoAllergenic™ for up to 16 weeks, makingcertain that the patient receives no other food during this period.Recent research conducted at the University of California, Davisillustrates that HA can markedly improve clinical signs of dogssuffering from IBD. This diet modification was also shown toeliminate and/or reduce the dose of concurrent steroid therapy.3

If all test results are negative and idiopathic IBD issuspected with supportive biopsy results, the veterinarian canthen consider trial therapy with corticosteroids ormetronidazole (10-20 mg/kg twice daily). Corticosteroidsshould not be administered without a histologically confirmeddiagnosis of IBD, as the patient may have neoplasia or fungaldiseases. Prednisone, for instance, causes resistance to the


3Dietary Trial in Dogs With Inflammatoary Bowel Disease Utilizinga Hydrolized Protein Diet. Stanley L Marks, University ofCalifornia-Davis, School of Veterinary Medicine, and DP Laflamme,Ralston Purina Company.

2Jerry M Owens, DVM and Darryl N Biery, DVM: RadiographicInterpretation for the Small Animal Clinician. Purina.

■ Diet characteristics–Easily digestible–Low fiber–Low fat–Fat provided as MCT’s (dogs)–Appropriate caloric density to prevent weight loss–Complete and balanced–Formulated for all life stages

TABLE 6Dietary Management of Chronic Diarrhea

LCT MCT(16-22 (6-12

Function carbon chains) carbon chains)

DigestionHydrolysis by gastric lipases Slow FastHydrolysis by pancreatic lipases Fast Very fast

Luminal transportWater solubility of free fatty acids Low HighRequires bile acid micellarization Yes No

AbsorptionParacellular absorption None SomeRe-esterification and chylomicron Yes No

formationPrimary transport route from gut Lymphatic Portal

DP Laflamme, Use of Medium-Chain Triglycerides in Clinical Nutrition, Purina Research Report

TABLE 7Summary of Digestion and Absorption of

Long-Chain and Medium-Chain Triglycerides

effects of antineoplastic drugs and may prevent successfultreatment of lymphoma. In addition, administering prednisoneto a patient with histoplasmosis or other fungal diseases mayresult in death of the patient.

Feeding the Patient with Chronic Small Bowel Disease

Feeding a highly digestible diet is the most important thing theclinician and pet owner can do in the nutritional management ofanimals with small bowel disease. The job of the enterocyte andthe bowel is primarily to digest and absorb nutrients.

No matter what diagnosis is reached in the case workup,the key to dietary manipulation for an animal with chronicproblems is to provide a complete and balanced, extremelydigestible, palatable meal (See Table 6). Table 7 shows thebenefits of providing a diet containing medium-chaintriglycerides as an energy source for animals with anycategory of small bowel disease.

Purina Veterinary Diets™ EN GastroENteric™ and HAHypoAllergenic™ are the commercial diets of choice forfeeding patients with chronic small intestinal disease, even whilethe clinician is still investigating the etiology of the problem.Both diets are highly digestible and contain the preferred lowlevels of fiber and long-chain triglycerides, plus both containmedium-chain triglycerides to help maintain caloric density.

Case Referral In pursuing an unresolved case of chronic small bowel

diarrhea, another option is to refer the animal to a board-certifiedinternist (American College of Veterinary Internal Medicine) atany time during the case evaluation. The referring veterinarianwill need to provide a detailed medical history that includesresults of all diagnostic tests. Notes should be added on progressto date and should include an opinion about possible next steps.

Some additional diagnostic aids may be helpful and areavailable only through referral centers:• Breath hydrogen test—to evaluate for motility disorders

and malabsorption or maldigestion.• Intestinal permeability test—to evaluate intestinal damage

and decreased intestinal surface area. • Culture of intestinal fluid—to detect unusual bacteria, or

fungi.

EVALUATING LARGE BOWEL DIARRHEA■ Evident Clinical Signs. If the diarrheic patient is

dehydrated, appears depressed, or shows signs ofabdominal pain, the initial evaluation should includeabdominal imaging to rule out pancreatitis. Because of the

location of the transverse colon, patients with pancreatitiscommonly present with large bowel diarrhea.

If the patient also presents with lymphadenopathy,clinicians in the northwest USA should consider salmonpoisoning as a possible rule out. The preferred treatment forsalmon poisoning is parenteral oxytetracycline (5-10 mg/kgonce or twice daily for 10 days) and praziquantel (10-30mg/kg as a single dose). The associated diarrhea is managedwith fluid therapy and EN. In cases of severe hemorrhage,blood transfusions may be necessary.

■ Absence of Clinical Signs. If the diarrheic patient does notshow signs of dehydration, depression, or abdominal pain,the initial evaluation should consider the animal’ssignalment and include further investigation related tobreed predisposition. Is the pet a young cat with thepossibility of rectal polyps? Is it a Boxer or French bulldogwith histiocytic colitis? That is, do the signs warrantproctoscopy early in the course of diagnostic evaluation?

Breed predisposition can be a weighty factor in chroniclarge bowel disorders. Refer to Table 2, page 11, for a listof suspected or confirmed breed predispositions to chroniclarge bowel disorders.

Progressive Investigation of Large Bowel Disease 1. Digital Rectal Examination. The clinician’s first step in large

bowel investigation is a digital rectal examination during theinitial overall physical assessment. This simple step can assistthe clinician in evaluating the patient for polyps, masses,foreign bodies, or stricture as well as evaluation of the prostategland. If the animal’s prostate gland feels abnormal or if thereare abnormal findings in the colon, a proctoscopy/colonoscopyor ultrasound and biopsy may be indicated.

2. Rectal Scrape. Also during the initial physical examinationthe clinician should obtain a rectal scrape for cytology. Theslide is evaluated for Prototheca, Histoplasma, and neoplasticcells. If fungal elements are identified, the patient should beassessed for signs of systemic disease and can be treatedwith antifungal medications. If neoplastic cells are evident,the clinician must confirm the diagnosis with biopsies.Assessment of bacteria on a smear is of no diagnostic value.

3. Fecal Flotation. After the previous checks have been done,the clinician should remove some feces from the rectumand perform a fecal flotation with zinc sulfate. If the resultis positive for intestinal parasites, the animal is treatedaccordingly. If the result is negative, the procedure isrepeated two more times to assure accuracy.

4. Fecal Enteric Panel. A fecal enteric panel should berequested from a microbiology laboratory at the same time


as fecal parasite analysis. Positive cultures for Salmonella,Campylobacter, and possibly Clostridium perfringens andClostridium difficile toxins are noteworthy. Interpretation isdifficult, as these organisms are also found in healthy pets;and clostridial toxins have been found with the samefrequency in both healthy dogs and dogs with diarrhea.4

5. Trial Therapy. When the initial evaluations reveal no causefor a bowel disorder, it may be logical to consider trialtherapy with diet, sulfasalazine, or a combination of both.Many cases of large bowel diarrhea are fiber responsive.Some patients improve with a moderate-fiber dietcontaining both soluble and insoluble fiber sources. Fibercan alter intestinal transit time and can produce short-chainfatty acids to nourish the colonocytes. Onerecommendation, therefore, is to feed Purina® VeterinaryDiets™ DCO Diabetes COlitis and check forimprovement within two weeks. If no correction is evidentafter feeding a moderate-fiber diet alone, then the additionof sulfasalazine may be effective (dogs: 12.5-50 mg/kg, up to1 gram every 8 hours; cats: with care because of salicylatesensitivity: 10-20 mg/kg every 24 hours). Patients onsulfasalazine should be checked for “dry eye.” An alternateplan is to feed a highly digestible diet, such as EN, or ruleout food allergies by feeding HA.

6. Abdominal Radiography. If the animal is too ill to tolerate twoweeks of trial therapy, the clinician should radiograph theabdomen to rule out the presence of a mass or any foreignbodies. Ultrasound examination is less helpful thanradiography in investigating large bowel diseases because ofthe intestinal gas and fecal material that are present.

7. Colonoscopy. As a final step, the clinician performs acolonoscopy with biopsy, looking for evidence of inflammatorybowel disease or the presence of neoplasia, granulomas, cecalinversion, or other disease signs. If not already determinedduring the case workup, it is essential to establish a baselinefor kidney and liver function before placing the animal undergeneral anesthesia to perform the biopsy.

CONCLUSIONUsing the algorithms and guidelines in this publication, it

should be possible for the practicing veterinarian to make adiagnosis of the diarrheic cat or dog and restore the patient togood health based on appropriate dietary therapy andsupportive medical treatment as needed. If at any stage theveterinarian feels uncomfortable with the diagnostic procedureor treatment, referral to an American College of VeterinaryInternal Medicine board-certified internist is a rational option.


SUMMARY OF APPROACH

Presenting Complaint Diarrhea (change in fecal frequency, consistency, or volume)

DefinitionsAcute—illness of short duration. Chronic—problem ongoing for 3 weeks or more; may be an intermittentoccurrence.Mild disease—patient has normal attitude, no debilitation or weight loss.Moderate to severe disease—patient has one or more of the following:weakness, weight loss, fever, anorexia, depression, or dehydration.

Case AssessmentHistory and Examination

Start with history taking and physical examination. During both, theclinician is trying to choose between the following:■ Acute or chronic?■ Small or large bowel?■ Mild or moderate to severe?■ Gastrointestinal or extraintestinal?

Diagnostic PlanAfter obtaining a good history and completing a physical examination,

the next step is a diagnostic plan to rule in or rule out the major differentialson the problem list. Having considered the patient carefully during the aboveprocedures, the clinician is already likely to have good idea where to start.The algorithms in this book will help determine specific diagnostic steps.

The following algorithms are intended to provide guidelines for the evaluation of

diarrhea in dogs and cats. However, an algorithm can never include all clinical possibilities

and there is no substitute for careful clinical judgment and experience.

Action steps in red. Treatment steps in blue. (Some steps overlap)

4Marks S: Proc ACVIM 16:694, 1998.

GENERAL APPROACH TO LOWER URINARY TRACTDISEASES OF DOGS AND CATS


EVALUATING ACUTE DIARRHEA—MILDPatient has normal attitude, no debilitation, no weight loss


Palpation

Positive palpationEvidence of

intussusceptionor foreign body

Radiograph orultrasound to confirm

Stabilize

Endoscopy Surgery

Negative palpation Fecal flotation

PositiveNegative

Repeat twice more

Feed EN GastroENteric™± loperamide(0.1-0.2 mg/kg orally twice daily for 2-3 days. See “Feeding ThroughDiarrhea” on page 12.)

Reevaluate in 2-3 days

Treat accordingto findings




Palpation

Collect minimum database (blood, urine, and feces)

Melena

Evaluate hemostasis:– Platelet count– Prothrombin time– Partial thromboplastin

time– BMBT (buccal mucosa

bleeding time)

Neutrophil count

Reduced

Suspect viral or bacterial sepsis

Canine parvovirus ELISA

Serum biochemicalprofile and urinalysis

Na–K <27:1

ACTH stimulation test

Kidney or liver disease

Supportive care whileinvestigating case

Positive

Treat

Negative

Blood andFecal culturefor infectious

diseases (e.g.,Salmonella)

Fecal flotation

Positive


Negative

Repeat twice more

Repeat palpate abdomen

Positive Negative

Empiric therapywith IV fluids

Reevaluate in 6 hours

Fluid in abdomen

Abdominocentesisand cytology

Evidence of intussusceptionor foreign body

Radiograph or ultrasound to confirm

Stabilize

Surgery

EVALUATING ACUTE DIARRHEA—MODERATE TO SEVEREPatient has one or more of the following signs: weakness, weight loss, fever, anorexia, depression, dehydration, debilitation



High calciumsuggests lymphoma

Image

Biopsy(consider anal sacadenocarcinoma,Addison’s or primaryhyperparathyroidismas causes ofhypercalcemia)

EVALUATING CHRONIC SMALL BOWEL DIARRHEAPatient probably shows weight loss, increased fecal volume, no fresh blood or mucus


Fecal examination (ZnSO4)

Negative

Repeat twicemore

Positive


Melena

Platelet count– Prothrombin time– Partial

thromboplastintime

Collect minimumdatabaseCBC, biochemicalprofile, urinalysis,TLI (trypsin-likeimmunoreactivity),T4, FIV, FeLV

Na–K <27:1

ACTHstimulation test

Albumin, calcium, globulin,lymphocytes

TLI

Low

Exocrine pancreatic insufficiency– Treat with enzyme

supplementation– Feed Dog Chow®, ProPlan®

CBC, biochemical profile,urinalysis; then radiology or ultrasound

Thickened bowel Normal bowel Motility disorder?

Biopsy Negative biopsy findings

Ruleout neoplasia, pythiosis, histoplasmosis,other fungal disease

Supportive care while pursuing diagnosis–EN GastroENteric™HA HypoAllergenic™

Rule out foodintolerance or allergy with HA HypoAllergenic™feeding trial

Low values suggestlymphangiectasia/protein-losing enteropathy

Biopsy

Inflammatory infiltrate (seealgorithm in vomiting sectionon p. 10 under Endoscopy)

Borderline (repeatin 2 months)

Yes



EVALUATING CHRONIC LARGE BOWEL DIARRHEAPatient probably shows tenesmus, increased frequency of elimination, small feces volume with fresh blood or mucus.


Collect minimum database (blood, urine, and feces)

Dehydration, depression, abdominal pain

Image abdomen(including pancreas)

Digital rectal examination– Assess for polyps, masses,

foreign bodies, strictures

Lymphadenopathy Renal disease

Negative

Check for breedpredisposition

Positive

Aspirate lymphnode

Negative

Rectal scrape/cytology

Melena or fresh blood

Evaluate hemostasis

Positive

Proctoscopy orcolonoscopy and biopsy

Evidence of Rickettsia

Fecal flotation

Salmon poisoning

Lymphoblasts

Lymphoma

Fecal examination (ZnSO4) and culture

Negative

Repeat twicemore if negative

Positive


Sulfasalazine trialDCO Diabetes COlitis™, EN GastroENteric™,or HA HypoAllergenic™

– Platelet count– Prothrombin time– Partial thromboplastin time– BMBT (buccal mucosa bleeding time)

Is animal well enoughto attempt therapy?

No

No response in 2 weeks


Pet Name __________________________________________ Breed _________________________________ Cat ❑ Dog ❑

Has your pet lost weight? _________ How much? ______________Is your pet’s appetite normal? ❑ increased? ❑ or decreased? ❑How long has your pet been ill? ____________________________Is your pet neutered? ___________________________________Is your pet exclusively outdoors or indoors? ___________________How many pets are in your household? _______________________What is your pet’s vaccination history? _______________________What is your pet’s travel history? ___________________________Is your pet taking other drugs? (heartworm preventive or dewormers,

digoxin, painkillers, etc.) ________________________________Does your pet have access to garbage/“people food”? _____________Has there been any change in water

consumption/urination? ________________________________

Has there been access to poisons such as insecticides? ___________Are any children’s toys/needle and thread/other

small objects missing? _________________________________Has your pet’s feeding pattern been changed? __________________Any recent change in diet? ________________________________Any change in exercise? _________________________________Any change in behavior, apparent change in eyesight,

tilting of the head? ____________________________________Has there been any change in your household environment

(e.g., remodeling, relocation, new residents, family member gone)? _________________________________

Does your pet seem to react to certain foods? ___________________

What type of food does your pet consume? – Brand ___________________________________________– Dry ❑– Canned ❑– Semi-moist ❑

Is the brand changed frequently ❑ or is the diet constant? ❑How many meals are given per day? _________________________What type of feeding bowls are used? ________________________How often are the feeding/water bowls cleaned? _________________Is fresh water provided daily? ______________________________Is milk given? ______ How much? ________________________

Any other beverages given? _______________________________Does your pet drink from the toilet? __________________________Are snacks given? ______________________________________

– What types? _______________________________________– How many/much per day? _____________________________

Is your pet fed human food? _______________________________Does your pet receive vitamin supplements? ❑

– Herbals? ❑– Neutraceuticals? ❑

How much food is eaten per day? ___________________________Are the amounts measured? Yes ❑ No ❑

NUTRITIONAL HISTORY

Approved for copying by Ralston Purina® for veterinary use only.

PATIENT HISTORY – CLIENT WORKSHEET

Vomiting or Regurgitating?

How many times per day does your pet vomit? __________________What is the character of the vomitus? _________________________Is there any fresh blood? _________________________________Does the vomitus look like “coffee ground” material? ______________What is the shape of the vomitus? ___________________________Does your pet show abdominal effort during vomition or is it more of a passive act? ______________________________Have you noticed that your pet has “bad breath”? ________________

Diarrhea?

How many stools are produced each day? _____________________What is the character of the stools? __________________________

– What color is the stool? ______________________________– Is the color “normal”? ________________________________– Is there fresh blood present in the stools? Mucus? ___________– Are the stools bulky? ❑ Scant? ❑– Are the stools “normal” shape? _________________________


■ What are the number, color, and character of the stools? ___________________________________________________________

• Number per day ____________________________________• Color____________________________________________• Fresh blood? ❑ Melena? ❑ Mucus? ❑• Voluminous? ❑ Scant? ❑• Steatorrhea? ❑ • Normal shape to feces? _______________________________THINK large intestinal mass or stricture, bleeding, large or small bowelinvolvement.

■ Is weight loss a feature of the problem? ________ How much weight has the patient lost? ________ Is the appetite normal, increased, or decreased? ________THINK small intestine, malabsorption/maldigestion; perhaps neoplasia orinadequate caloric intake.

■ How long has the patient been ill? _________________________THINK acute or chronic problem?

■ Is the animal neutered? _________________________________THINK pyometra.

■ Is the patient exclusively outdoors or indoors? ________________THINK Giardia, parasites, and access to garbage and toxins.

■ How many household pets? _____________________________THINK does pecking order account for lack of food consumption?

■ What is the vaccination history? ___________________________

_________________________________________________

_________________________________________________

_________________________________________________THINK infectious agents.

■ What is the travel history? _______________________________THINK regional diseases.

■ Is there a history of concurrent drugs? ______________________THINK is patient receiving heartworm preventive or other anthelmintics, digoxin,NSAIDs, or other drugs known to cause gastrointestinal upset?

■ Has there been access to poisons? _________________________THINK what is the patient’s age? (Poisoning is more common in young dogs.)

■ Any missing children’s toys/needle and thread/other small objects? __THINK foreign bodies.

■ Any change in exercise? _______________________________THINK is this a possible reason for weight loss?

■ Any signs of neurological disease? ________________________THINK Is this an extraintestinal problem?

■ Any change in the household environment? __________________THINK “stress colitis.”

CLINICIAN CHECKLIST Complement to Client Worksheet

Pet Name __________________________________________ Breed _________________________________ Cat ❑ Dog ❑


PATIENT HISTORY

Nutrition

■ Has there been any change in water consumption/urination? ______THINK Addison’s disease/renal disease/liver disease.

■ Does the pet have access to garbage/“people food”? ___________THINK dietary intolerance.

■ Any recent change in diet? _____________________________THINK dietary intolerance. (Information on yesterday’s food intake may beenough to make the diagnosis.)

■ Any change in feeding pattern? __________________________THINK is this a possible reason for weight loss?

■ Does the pet seem to react to certain foods? _________________THINK diet hypersensitivity.

■ Is the brand of pet food used appropriate for the species, body condition score, age? ____________________________

– Feeding trials by AAFCO (Association of American Feed ControlOfficials) ❑ or chemical analysis only ❑ ? ________________

■ How much food is eaten per day? ________________________(Have the owner show you his/her idea of a “cupful.”)

■ Calculate the number of calories the pet eats per day. ___________

■ Is there a difference in consumption vs. need that would account forweight loss? _______________________________________

■ Is there evidence to suggest that food allergy or intolerance is probable? _______________________________


■ Weigh the patient. Is the weight appropriate for the breed and the age? __________If this is a regular patient, has there been any change since the last visit? ______________________________________________________________

■ Determine the ideal body condition score. __________________________Is the animal at that score? __________________________________________

THINK small bowel if weight loss is a problem.

■ Check the animal’s demeanor. Is the patient bright and alert or debilitated?______________________________________________________________THINK is this a mild problem or more a moderate-to-severe illness?

■ Check the skin and haircoat. Is the skin healthy? ________________________Is the haircoat healthy? _____________________________________________THINK do the dietary protein and fat appear to be adequate?

■ Look for evidence of external parasites? Are there signs of fleas? Are tapewormsevident? Any integumentary problems? Masses? ______________________________________________________________THINK internal parasites, neoplasia.

■ Assess the patient’s eyesight. _____________________________________THINK can the patient see its food?

■ Check the nostrils. Are they clear or full of mucus/blood? ___________________THINK can the patient smell the food?

■ Perform a neurological examination. Is the problem extraintestinal? ______________________________________________________________THINK is there a brain tumor causing anorexia?

■ Look into the ears. Are they clean? ___________________________________THINK are ear mites present and annoying enough to keep the patient fromwanting to eat?

■ Examine the mouth and teeth carefully. Are any teeth missing or broken? If thepatient is a dog, does it eat or chew on rocks or other objects? Are there additional signsof foreign body consumption? Is there evidence of gingivitis? In cats, are there any signsof periodontal disease or neck lesions?______________________________________________________________THINK are the teeth so painful that the patient does not want to eat?

■ Look under the tongue. Any thread or string present? Can masses be detected? ___THINK foreign body, neoplasia.

■ Examine the mucous membranes. Are they pink? What is the capillary refill time?Any signs of shock? Bleeding? Is the pet dehydrated?______________________________________________________________THINK mild vs. moderate-to-severe disease.

■ Palpate all of the lymph nodes. Are any enlarged? If indicated, further rule outtumors by imaging, aspirating, or both. (A mass does not necessarily mean a tumor.Confirm the condition via cytology/histopathology.)______________________________________________________________THINK could this be salmon poisoning or lymphoma?

■ Palpate the animal’s neck. Is there evidence of a thyroid nodule? _____________THINK hyperthyroidism.

■ Listen to the heart. Check the rate and the rhythm. Is there any indication ofdehydration? Is the animal septic? In shock? Anemic?______________________________________________________________THINK mild vs. moderate-to-severe disease.

■ Listen to the lungs. Is there a reason to radiograph the chest? ________________THINK aspiration pneumonia secondary to megaesophagus.

■ Palpate the small intestine. Is the gut thickened? Are there any nodules? Is theanimal relaxed enough to examine or is sedation necessary? Is there any evidence of aforeign body? Masses? Intussusception? Does the animal show signs of pain onpalpation? Any abnormalities of the pancreas? ______________________________________________________________THINK mass, tumor. (As noted previously, masses do not always mean tumors. Forexample, cats with feline infectious peritonitis can have a discrete granuloma that isresponsive to removal. Dogs or cats may have fungal diseases, such as pythiosis.)

■ Palpate the large intestine. Any masses? Is the intestine thickened? Painful? __________________________________________________________________THINK foreign body, mass, tumor?

■ Palpate the bladder, assess size. Is the patient well hydrated? ______________THINK pu/pd conditions or dysuria mimicking fecal tenesmus.

■ Palpate the kidneys. Is either kidney small or enlarged or are both normal size?Painful? ________________________________________________________THINK uremic gastritis/enteritis.

■ Palpate the liver. Is the size normal? __________________________________THINK any masses?

■ Evaluate the anus/rectum. Is there evidence of diarrhea at the present time? Melena?Fresh blood? Anatomical abnormalities? Perform a digital rectal examination. Any signsof hernia? Blood? Masses? Mucus? Pain? ________________________________THINK causes of tenesmus/upper versus lower gastrointestinal blood loss.

■ Examine the pet’s genitalia. ______________________________________THINK Is there evidence of pyometra in a female? Testicular masses in a male?

■ Take the animal’s temperature. Is it elevated? __________________________THINK infectious/autoimmune/neoplasia.

CLINICIAN CHECKLIST PHYSICAL EXAM

Pet Name _____________________________________ Breed _________________________________ Cat ❑ Dog ❑

PHYSICAL EXAM


CLINICAL CONSIDERATIONSThe role of dietary management in canine gastrointestinal conditions is to

provide a proper balance of total nutrients while meeting the special dietaryneeds of the patient. Dietary fats from long chain triglycerides (LCT) can beone of the most complex nutrients to digest, and fermentation of undigested fatscan contribute to diarrhea. Medium chain triglycerides (MCT) provide areadily digested and utilized energy source. Feeding a properly formulated dietdesigned to be highly digestible yet restricted in long chain triglycerides may bebeneficial in the management of certain gastrointestinal conditions whilemeeting the nutritional needs of the animal.

DIET CHARACTERISTICSPurina Veterinary Diets™ EN GastroENteric™ brand canine formula

provides complete and balanced nutrition for growth of puppies andmaintenance of the adult dog and have been formulated to achieve thefollowing characteristics:

■ High digestibility ■ Source of MCTs (22-34% of fat)■ Low LCT content ■ Source of omega-3 and omega-6 fatty acids■ Low fiber

MEDICAL INDICATIONSDiets with these nutritional modifications have been recommended for dogs

with some forms of the following conditions:■ Enteritis, gastritis, and diarrhea■ Pancreatitis■ Exocrine Pancreatic Insufficiency ■ Hyperlipidemia■ Inflammatory Bowel Disease ■ Malabsorption and maldigestion■ Lymphangiectasia■ Hepatic disease not associated with encephalopathy

MEDICAL CONTRAINDICATIONS■ None


INGREDIENTS (DRY)Brewers rice, ground yellow corn, corn gluten meal, beef and bone meal,

coconut oil, animal digest, beef tallow preserved with mixed-tocopherols(source of vitamin E), glyceryl monostearate, L-Lysine monohydrochloride,potassium chloride, sodium bicarbonate, fish oil, salt, choline chloride,calcium carbonate, ferrous sulfate, vitamin supplements (A, D-3, E, B-12),zinc oxide, riboflavin supplement, niacin, calcium pantothenate, ferrousfumarate, manganese sulfate, biotin, thiamine mononitrate, folic acid,pyridoxine hydrochloride, garlic oil, copper sulfate, menadione sodiumbisulfite complex (source of vitamin K activity), calcium iodate, sodiumselenite.

INGREDIENTS (CANNED)Water sufficient for processing, beef, brewers rice, egg product, vegetable

oil, defluorinated phosphate, choline chloride, calcium carbonate, salt,potassium chloride, L-Lysine monohydrochloride, vitamin supplements (A,D-3, E, B-12), ferrous sulfate, niacin, biotin, calcium pantothenate, riboflavinsupplement, zinc oxide, menadione sodium bisulfite complex, manganesesulfate, thiamine mononitrate, pyridoxine hydrochloride, folic acid, coppersulfate, calcium iodate, sodium selenite.

Digestibility: Dry CannedTotal, % 88.0 87.9Protein, % 87.0 85.1Fat, % 92.0 95.6Carbohydrate, % 94.0 92.2Calories, % 90.5 89.7Percentage of Metabolizable Energy from:Protein, % 23.4 25.2Fat, % 26.0 31.0Carbohydrate, % 51.6 43.8

Dry Canned

Protein, % 23.32 25.83 9.03 30.52Carbohydrate, % 49.76 55.11 14.46 48.87Fat, % 10.56 11.69 4.07 13.75Fiber, % 1.01 1.12 0.27 0.91Calcium, % 1.25 1.38 0.26 0.88Phosphorus, % 0.81 0.90 0.16 0.54Sodium, % 0.33 0.36 0.11 0.37Potassium, % 0.53 0.59 0.18 0.61Chloride, % 0.79 0.87 0.23 0.78Magnesium, % 0.07 0.08 0.02 0.07Omega 6:3 ratio 9.6:1 9.6:1 11:1 11:1Total omega-6, % 1.87 2.07 0.33 1.11Total omega-3, % 0.16 0.18 0.03 0.10

Dry Canned

Protein 6.15 24.48 7.59 32.39Carbohydrate 13.12 52.24 12.15 51.87Fat 2.78 10.18 3.41 14.43Fiber 0.27 1.06 0.23 0.97Calcium 0.33 1.31 0.22 0.93Phosphorus 0.21 0.85 0.13 0.57Sodium 0.09 0.34 0.09 0.40Potassium 0.14 0.56 0.15 0.63Chloride 0.21 0.83 0.19 0.82

*Based on digestiontesting conductedat the Purina PetCare Centerbetween 1988-1991(canned), 1994(dry).

AVERAGE NUTRIENT CONTENTON SERVING AND 100 CALORIE BASIS

AVERAGE NUTRIENT COMPOSITION

As Fed

Gramsper

100 KcalM.E.

DryMatter As Fed

DryMatter

Gramsper

8-oz. cup

Gramsper

100 KcalM.E.

Gramsper

12.5-oz.can

DIGESTION TEST RESULTS*

1 Adjustments to foodintake must be madefor environmentalconditions, activitylevel, body conditionand breed size. Asreflected in the feed-ing tables, smallerbreed dogs can require 15% to 25% more kilocalories per pound body weight thanlarger breed dogs. Provide fresh water in a clean container daily.

2 Kilocalories of metabolizable energy (ME).3 This daily amount should be divided among several small meals throughout the day.4 For each additional 10 pounds of body weight, feed an additional 175 kilocalories.

5 2.3 5/8 5/810 4.5 1 120 9.1 1 3/4 1 5/830 13.6 2 3/8 2 1/440 18.2 2 7/8 2 3/450 22.7 3 1/2 3 1/460 27.3 4 3 3/4804 36.4 4 7/8 4 5/8

ME2 3788 kcal/kg 1194 kcal/kgME2 1722 kcal/lb 543 kcal/lbME2 397 kcal/8-oz cup 424 kcal/12.5-oz can

ADULT MAINTENANCE1

Dry

Approximatenumber of

8-oz. cups/day3

BodyWeight

lbs. kg.

Canned

Approximatenumber of

12.5-oz. cans/day3

6 weeks – 26 weeks 4[(30 x Body weight (kg))+ 70]26 weeks – 52 weeks 3[(30 x Body weight (kg))+ 70]

PUPPY GROWTH1,4

Age of puppyApprox. number of kilocaloriesM.E. recommended per day

FEEDING ANDADMINISTRATION

The followingfeeding program isrecommended as aguideline only, withdiscretionary clinicaladjustments forproper weightmaintenance.

PACKAGINGCases of 24, 12.5-oz. cans. Bags of 8, 20 and 35 pounds.

APPENDIX B: PURINA VETERINARY DIETS™EN GastroENteric™ Canine Formula

Brand


Digestibility:Total, % 87.8Protein, % 89.9Fat, % 92.2Carbohydrate, % 96.2Calorie, % 92.2Percentage of Metabolizable Energy from:Protein, % 19.2Fat, % 23.6Carbohydrate, % 57.2

*Based on digestion testingconducted at the Purina PetCare Center 1997.

Protein, % 19.30 21.33Carbohydrate, % 53.80 59.45Fat, % 9.54 10.54Fiber, % 1.43 1.58Calcium, % 1.28 1.41Phosphorus, % 0.96 1.06Sodium, % 0.22 0.24Potassium, % 0.62 0.69Chloride, % 0.62 0.69Magnesium, % 0.1 0.11Omega 6:3 ratio 9.7:1 9.7:1

AVERAGE NUTRIENT COMPOSITIONAs Fed Dry Matter


Protein 5.33 21.25Carbohydrate 14.85 59.23Fat 2.63 10.50Fiber 0.39 1.57Calcium 0.35 1.41Phosphorus 0.26 1.06Sodium 0.06 0.24Potassium 0.17 0.69Chloride 0.17 0.69Magnesium 0.03 0.11


Grams per100 Kcal M.E.

Grams per 8-oz. cup

5 2.3 3/410 4.5 1 3/820 9.1 2 1/430 13.6 3 1/840 18.2 3 7/850 22.7 4 1/260 27.3 5 1/4803 36.4 6 1/2

(ME)2 3621 kcal/kg(ME)2 1646 kcal/lb(ME)2 302 kcal/cup

ADULT MAINTENANCE1

Body Weightlbs. kg.

Approximate number of 8-oz. cups/day3

1 Adjustments must bemade for environmen-tal conditions, activitylevel, body conditionand breed size. Asreflected in the feedingtables, smaller breeddogs can require 15%to 25% more kilocalo-ries per pound body weight than larger breed dogs. Provide fresh water in a clean con-tainer daily.

2 Kilocalories of metabolizable energy (ME).3 For each additional 10 lbs. of body weight, feed an additional 175 kilocalories.

6 weeks – 26 weeks 4[(30 x Body weight (kg))+ 70]26 weeks – 52 weeks 3[(30 x Body weight (kg))+ 70]

PUPPY GROWTH1

Approx. number of kilocaloriesM.E. recommended per day

CLINICAL CONSIDERATIONSThe role of dietary management in canine food allergy is to provide a

proper balance of total nutrients while meeting the special dietary needs ofthe patient. Most common food allergens are proteins with a molecularweight of 18,000 to 36,000 daltons. Protein modification is a process thatalters the physical characteristics of protein molecules, reducing theantigenicity and rendering them less able to elicit an immune response. Byreducing the molecular weight of the protein molecule below 18,000 daltons,this process can result in a protein that is truly hypoallergenic.

DIET CHARACTERISTICSPurina Veterinary Diets™ HA HypoAllergenic™ brand canine formula

provides complete and balanced nutrition for the growth of puppies andmaintenance of the adult dog and has been formulated to achieve thefollowing characteristics:

■ Modified protein source with an average molecular weight below 12,200 daltons

■ Source of omega-3 and omega-6 fatty acids■ Single protein source■ High digestibility■ Source of Medium Chain

Triglycerides (MCTs)-23% of fat

MEDICAL INDICATIONSDiets with these nutritional modifications have been recommended for

the following uses or for dogs with the following conditions:■ Elimination diet for food trials■ Inflammatory Bowel Disease■ Dermatitis associated with food allergy■ Lymphangiectasia■ Gastroenteritis associated with food allergy■ Malabsorption■ Pancreatic exocrine insufficiency■ Hyperlipidemia■ Protein losing enteropathy

INGREDIENTS (DRY) Corn starch, modified isolated soy protein, water, coconut oil, canola

oil preserved with TBHQ, calcium carbonate, cellulose, dicalciumphosphate, potassium chloride, vegetable gums (gum arabic and guargum), choline chloride, DL-methionine, magnesium oxide, lecithin, salt,zinc oxide, ferrous sulfate, vitamin supplements (E, A, B-12, D-3),manganese sulfate, riboflavin supplement, niacin, calcium pantothenate,zinc sulfate, copper sulfate, biotin, thiamine mononitrate, garlic oil, folicacid, pyridoxine hydrochloride, calcium iodate, menadione sodiumbisulfite complex (source of vitamin K activity), sodium selenite.

PACKAGINGBags of 8, 18.5 and 35 pounds

FEEDING ANDADMINISTRATION

The followingfeeding program isrecommended as aguideline only, withdiscretionary clinicaladjustments forproper weightmaintenance.

Age of puppy

APPENDIX B: PURINA VETERINARY DIETS™HA HypoAllergenic™ Canine Formula

Brand

1 Adjustments must bemade for environmen-tal conditions, activitylevel, body conditionand breed size. Asreflected in the feed-ing tables, smallerbreed dogs canrequire 15% to 25%more kilocalories perpound body weightthan larger breeddogs. Provide freshwater in a clean con-tainer daily.

2 Kilocalories of metab-olizable energy (ME).

3 This daily amountshould be dividedamong several small meals throughout the day.

4 For each additional 10 lbs. of body weight, feed an additional 175 kilocalories.


CLINICAL CONSIDERATIONSThe role of dietary management in canine diabetes mellitus and colitis is

to provide a proper balance of total nutrients while meeting the specialdietary needs of the patient. Complex carbohydrates and dietary fiber help todelay the absorption of glucose from the intestinal tract and minimizepostprandial fluctuation of glucose in dogs with diabetes mellitus. Solublefiber in the diet may also prolong gastrointestinal transit time, allow greaterwater absorption, and promote the production of short chain fatty acids,which nourish the intestinal mucosa.

DIET CHARACTERISTICSPurina Veterinary Diets™ DCO Diabetes COlitis™ brand canine formula

provides complete and balanced nutrition for maintenance of the adult dogand has been formulated to achieve the following characteristics:

■ High level of complex carbohydrates■ Increased fiber including soluble fiber ■ Moderate total dietary fat & calories■ Source of omega-3 and omega-6 fatty acids

MEDICAL INDICATIONSDiets with these nutritional modifications have been recommended for

dogs with some forms of the following conditions:■ Diabetes mellitus■ Constipation■ Fiber responsive colitis■ Large bowel diarrhea

MEDICAL CONTRAINDICATIONS■ Conditions associated with catabolic states

FEEDING AND ADMINISTRATIONThe following feeding program is recommended as a guideline only, with

discretionary clinical adjustments for proper weight maintenance.

INGREDIENTSGround yellow corn, dried beet pulp,* poultry by-product meal, corn

gluten meal, barley, beef tallow preserved with mixed-tocopherols (sourceof vitamin E), pea fiber, dicalcium phosphate, dried whey, potassiumchloride, salt, fish oil, animal digest, L-Lysine monohydrochloride,calcium carbonate, choline chloride, vitamin supplements (E, A, B-12, D-3), zinc oxide, ferrous sulfate, riboflavin supplement, niacin, calciumpantothenate, manganese sulfate, biotin, thiamine mononitrate, folic acid,pyridoxine hydrochloride, copper sulfate, menadione sodium bisulfitecomplex (source of vitamin K activity), calcium iodate.*15% – A source of fiber.

5 2.3 3/410 4.5 1 1/420 9.1 230 13.6 2 3/440 18.2 3 1/250 22.7 4 1/860 27.3 4 5/8

804 36.4 5 3/4(ME)2 3342 kcal/kg(ME)2 1519 kcal/lb(ME)2 338 kcal/8-oz. cup

ADULT MAINTENANCE1

Body Weightlbs. kg.

Approximate number of 8-oz. cups/day3

Protein 6.87 23.23Carbohydrate 12.99 43.94Fat 3.37 11.41Fiber 2.08 7.02Calcium 0.33 1.12Phosphorus 0.25 0.86Sodium 0.09 0.31Potassium 0.19 0.64Chloride 0.22 0.76Magnesium 0.03 0.12



Grams per8-oz. cup


**Based on digestion testing con-ducted at the Purina Pet CareCenter 1995.

Protein, % 23.00 25.26Carbohydrate, % 43.51 47.79Fat, % 11.30 12.41Fiber, % 6.95 7.63Calcium, % 1.11 1.22Phosphorus, % 0.85 0.93Sodium, % 0.31 0.34Potassium, % 0.64 0.70Chloride, % 0.75 0.82Magnesium, % 0.11 0.13Omega 6:3 ratio 8.8:1 8.8:1Total dietary fiber, % 20.20 22.18Soluble fiber, % 3.65 4.01Insoluble fiber, % 16.60 18.23Vitamin E, IU/kg* 192 213


DIGESTION TEST RESULTS**

*Calculated value

PACKAGINGBags of 8 and 20 pounds

APPENDIX B: PURINA VETERINARY DIETS™DCO Diabetes COlitis™ Canine Formula

Brand


*Based on digestion testingconducted at the PurinaPet Care Center 1995.



Protein 9.48 11.09Carbohydrate 7.27 8.51Fat 3.85 4.51Fiber 0.24 0.28Calcium 0.38 0.44Phosphorus 0.45 0.53Sodium 0.07 0.08Potassium 0.18 0.21Chloride 0.12 0.14Magnesium 0.03 0.04Taurine 0.04 0.05



Grams per 1.5-oz. pouch

Protein, % 26.10 41.89Carbohydrate, % 20.02 32.13Fat, % 10.60 17.01Fiber, % 0.67 1.08Calcium, % 1.05 1.69Phosphorus, % 1.25 2.01Sodium, % 0.20 0.32Potassium, % 0.50 0.80Chloride, % 0.34 0.55Magnesium, % 0.08 0.13Taurine, % 0.12 0.19Omega 6:3 ratio 5:1 5:1Total Omega-6, % 1.38 2.21Total Omega-3, % 0.28 0.45


1 Adjustments must bemade for environmen-tal conditions, activitylevel and body condi-tion. Provide freshwater in a clean con-tainer daily.

2 Kilocalories of metab-olizable energy (ME).

3 This daily amountshould be dividedamong several smallmeals throughout theday.

4 For each additionalpound of body weight,feed an additional 24kilocalories.

3 1.4 3/45 2.3 1 1/48 3.4 2

10 4.5 2 1/215 6.8 3 3/4

204 9.1 5(ME)2 2750 kcal/kg(ME)2 1250 kcal/lb(ME)2 117 kcal/1.5-oz pouch

ADULT MAINTENANCE1

Body Weightlbs. kg.

Approximate number of1.5-oz. pouches/day3

CLINICAL CONSIDERATIONSThe role of dietary management in feline gastrointestinal conditions is to

provide a proper balance of total nutrients while meeting the special dietaryneeds of the patient. Feeding a high quality diet that is easily digested andlow in crude fiber provides readily available nutrients for cats withcompromised gastrointestinal tracts. Added soluble fiber in the diet mayprolong gastrointestinal transit time, allow greater water absorption, andpromote the production of short chain fatty acids, which nourish theintestinal mucosa.

DIET CHARACTERISTICSPurina Veterinary Diets™ EN GastroENteric™ brand feline formula

provides complete and balanced nutrition for adult maintenance and has beenformulated to achieve the following characteristics:

■ High digestibility■ Low fiber■ Moderate fat■ Source of omega-3 and omega-6 fatty acids■ Source of soluble fiber■ Promotes acidic urine

MEDICAL INDICATIONSDiets with these specific nutritional modifications have been

recommended for cats with the following conditions:■ Enteritis, gastritis, and diarrhea■ Exocrine pancreatic insufficiency■ Inflammatory bowel disease■ Malabsorption and maldigestion■ Hepatic disease not associated with encephalopathy

MEDICAL CONTRAINDICATIONS■ History of calcium oxalate urolithiasis

FEEDING AND ADMINISTRATIONThe following feeding program is recommended as a guideline only, with

discretionary clinical adjustments for proper weight maintenance.

INGREDIENTS (SOFT-MOIST)Water sufficient for processing poultry by-product meal, soybean

meal, corn gluten meal, fish, wheat flour, brewers rice, beef tallowpreserved with BHA, phosphoric acid, brewers dried yeast, fumaric acid,tricalcium phosphate, sorbic acid (a preservative), vegetable gums (gumarabic, guar gum), choline chloride, salt, calcium propionate (apreservative), potassium chloride, taurine, zinc oxide, ferrous sulfate,niacin, vitamin supplements (E, A, B-12, D-3), calcium pantothenate,riboflavin supplement, manganese sulfate, biotin, thiamine mononitrate,folic acid, pyridoxine hydrochloride, copper sulfate, menadione sodiumbisulfite complex (source of vitamin K activity), calcium iodate.

PACKAGINGCases of 6, 12-oz. boxesBoxes contain 8, 1.5 oz. pouches

APPENDIX B: PURINA VETERINARY DIETS™EN GastroENteric™ Feline Formula

Brand

Ralston Purina Company

®

Gastrointestinal Disease Management€¦ · Appendix A: Evaluating Gastrointestinal Diseases...

Documents

Transcript of Gastrointestinal Disease Management€¦ · Appendix A: Evaluating Gastrointestinal Diseases...