Clinical Conference I

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A Step-wise Approach of Diagnosis of Cat and Dog with Chronic

Diarrhoea

A Step-wise Approach of Diagnosis of Cat and Dog with Chronic

Diarrhoea

Ishwor Dhakal B.V.Sc & A.H. Eighth Semester, TU/IAAS, Rampur Campus

Ishwor Dhakal B.V.Sc & A.H. Eighth Semester, TU/IAAS, Rampur Campus

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Abstract

Chronic Diarrhoea is one of the most common reason for dogs or cats to be presented to a veterinarian. It is generally regarded as the most common clinical sign of intestinal disease in the cat/dog and one of the most frustrating maladies for many veterinarians to diagnose and manage. Incomplete resolution of the problem can result in frustration and dissatisfaction for the owner and potential suffering for the animal. Antibiotics and antiprotozoals are commonly administered injudiciously to diarrheic animals, with resolution of clinical signs often wrongly attributed to eradication of an infectious pathogen. This presentation has been carried out mainly aiming to review some of the more common causes and to discuss the best approach for appropriate diagnosis and treatment of diarrhoea in dogs and cats. It presents the differentiation of small intestine diarrhoea and large intestine diarrhoea and systematic approaches to correlate the history, etiopathology, and therapeutics for diarrhoea. From this it is concluded that Chronic diarrhoea is a change in the frequency, consistency and volume of the dog's feces for more than three weeks; and timely diagnosis of etiology is only solution of diarrhoea. These approaches will help veterinarian for satisfactory treatment with use of medicine judiciously, and reduce the cost of treatment to owner along with satisfaction.

Key Word : Step-wise Approach, Chronic Diarrhoea, Cat and Dog, Veterinarian, Injudiciously. 9/1/153

Introduction

DIARRHOEA: passage of unformed stools at an increased frequency , increased volume and increased fluid content .

Acute Diarrhoea : < 3 wks

:is often self-limiting Chronic diarrhea : persistent > 3 to 4 wks (NAVC/WVC

2013)

: justify a step-by-step approach to obtain a diagnosis and formulate an optimal therapeutic plan.

Patients with chronic diarrhea has a much bigger diagnostic challenge. 9/1/154

Cont...

The most common clinical sign of intestinal disease in the cat/dog

The most common reason for dogs or cats to be presented to a veterinarian.

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Rationales

The most frustrating maladies for many veterinarians to diagnose and manage

Incomplete resolution of the problem can result in frustration and dissatisfaction for the owner and potential suffering for the animal.

Antibiotics and antiprotozoals are commonly administered injudiciously

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Objectives

General Objectives Discuss different approaches of appropriate

diagnosis of Chronic Diarrhoea.

Specific Objectives To know different causes of Chronic

Diarrhoea. To differentiate small intestinal diarrhoea with

large intestine diarrhoea.

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Mechanisms of diarrhoea/ types of CD :

Osmotic: maldigestion or malabsorption eg Drugs / toxins, indigestion of lactose/ sucrose

Secretory: Secretion> absorption ; abnormal ion transport due to hormones, toxins, eg enteropath E Coli, IBD

Inflammatory d/r : Leukocytosis eg erosive, ulcerative enteropathies, IBD, neoplasia

Motility dependent d/r : reduced contact betwn absorptive mucosa and luminal content eg abnormal ileal and colonic motility in IBD( Inflammatory Bowel Disease )

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Table: Causes for chronic diarrhoeaPrimary causes of chronic

diarrhoeaSecondary causes of chronic

diarrhoea

Infectious:• Endoparasites(helminths,giardia etc)• Enteropathogens ; bacteria• Small intestinal dysbiosis

Exocrine pancreatic disease: • Exocrine pancreatic insufficiency• Chronic pancreatitis

Inflammatory:• Idiopathic inflammatory bowel disease (IBD)

Hepatic disease:• Liver failure

Neoplastic:• Intestinal lymphoma Other

Kidney disease:•Chronic kidney disease

Mechanical:• Sliding intussusception

Adrenal disease:• Hypoadrenocorticism

Toxic Thyroid disease:• Hyperthyroidism in cats• Hypothyroidism in dogs

Other rare conditions • Cardiovascular disease• Central nervous system disease

Table: Causes for chronic diarrhoeaTable: Causes for chronic diarrhoea

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Ohh!!! From today this is my home.

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Differentiation of Acute Diarrhoea with Chronic Diarrhoea

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Table . Differentiation of SI Diarrhoea from LI DiarrhoeaTable . Differentiation of SI Diarrhoea from LI Diarrhoea

Signs Small Intestine diarrhoea Large Intestine diarrhoea

Faeces

Volume Markedly increased Normal or decreased

Mucus Rarely present Common

Melaena May be present Absent

HaematocheziaAbsent except in acutehaemorrhagic diarrhoea

Fairly common

Steatorrhoea Present with malabsorption Absent

Undigested food

May be present Absent

ColourColour variations occur e.g.creamy brown, greenorange, clay

Colour variations rare;may be haemorrhagic

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DefaecationUrgency Absent except in acute or

verysevere disease

Usually but not invariablypresent

Tenesmus Absent Frequent but notinvariably present

Frequency 2 to 3 times normal for thepatient

Usually greater than 3times normal

SignsSmall Intestine diarrhoea

Large Intestine diarrhoea

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SignsSmall Intestine diarrhoea

Large Intestine diarrhoea

Ancillary signs

Weight loss May occur in malabsorption

Rare except in severecolitis and diffusetumours

Vomiting May be present ininflammatory diseases

Uncommon? Probablyoccurs in ~30% of dogswith colitis

Flatulence (gas in Intestine)

May occur Absent

Halitosis in the absenceof oral cavity disease

May be present withmalabsorption

Absent unless perianallicking

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Figure . Diagnostic approach to dogs presenting with chronic diarrhoea at the veterinary school in Helsinki, Finland9/1/1515

Table : Systematic work-up for dogs and cats with chronic diarrhea.

Step Diagnostic step

1 History and physical examination

2 Rule-out and treat for endoparasites

3 Differentiate primary from secondary causes of chronic diarrhea

4 Characterize disease process

5 Therapeutic trial (if not contraindicated)

6 Histopathologic evaluation of biopsies

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1. History and physical examination

History of any previous illness as well as the current problem.

Focused on duration; appearance ; worming & vaccination Hx defecation frequency; urgency

History of severity, probable cause of d/s process?? Small bowel or large bowel origin?? History of diet, enviroment (predisposing factor) In addition the diarrhea should be well-characterized,

which can be simplified by using a chart with pictures of different stool qualities.

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Example of a faecal scoring chartfor cats and dogs.

Physical examination

Observe the animal’s posture and attitude, State of alertness; fever ; weakness or lethergy; dehydration.

Animals with severe pancreatitis may assume the “praying” position in an effort to alleviate cranial abdominal pain.

Pallor (blood loss anaemia), edema (hypoalbuminemia), palpation of thyroid,Liver palpation- hepatomegaly

Rectal examination to detect tumors, thickening, or foreign materials.

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2. Rule-out and treat for endoparasites : faecal examination, stool Culture

Endoparasites may remain an important cause of chronic diarrhea and one that can be easily diagnosed and treated in most cases by faecal examination ie. direct smear and flotation

Regardless of the outcome, each patient should be treated with a broad-spectrum anthelminthic agent.

It should be noted that Tritrichomonas fetus is an important, if not the most important, endoparasite in cats.

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3. Differentiate primary from secondary causes of chronic diarrhea

Preliminary laboratory tests should first be performed e.g. haematology, serum biochemistry, virology, total T4 measurement and urinalysis , TLI , PLI for Dx of pancreatic function.

Imaging

Abdominal ultrasound (evaluation of the pancreas, intestinal wall thickening, layering of the wall, echogenicity of the layers, mesenteric lymph nodes, liver, spleen, kidneys, evaluation for peritoneal fluid)

Abdominal radiographs : Foreign body, intussusceptions, gas distension/ torsion of GIT9/1/1521

3. Differentiate primary from secondary causes of chronic diarrhea

Condition Diagnostic test Exocrine pancreatic insufficiency Decreased serum TLI concentration Chronic pancreatitis Increased serum PLI concentration (as measured by Spec

cPL and Spec fPL assay)

Liver failure Decreased serum albumin, cholesterol, BUN, and/or glucose concentrations; increased serum bilirubin concentration

Chronic kidney disease Increased serum creatinine and BUN concentration; decreased urine specific gravity

Hypoadrenocorticism Decreased serum sodium and increased serum potassium osmolality and lack of a stress-leukogram (> 2,500 lymphocytes/ mL or > 500 eosinophils/mL); baseline cortisol concentration if any suspicion; confirmation with ACTH stimulation test

Hyperthyroidism in cats Total T4, if not increased then free T4; thyroid scan may be needed if unable to rule out hyperthyroidism

Hypothyroidism in dogs Total T4, if low then free T4; further diagnostics may be needed if thyroid status is still unclear

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4. Characterize disease process

Small bowel (increased volume, weight loss common, possible

melena) or large bowel diarrhea (increased frequency, increased mucous, possible hematochezia)

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5. Therapeutic trials (if not contraindicated)

Cobalamin should be supplemented by parenteral application of pure vitamin B12

Dietary trials are effective in up to 60% of dogs and cats with chronic diarrhea.

Use of high-fiber or low-carbohydrate diets.

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Dietary types that may be effective for a dietary trial

Diet type Characteristics

Hydrolyzed protein diet Contains protein that has been broken down into smaller peptides or even amino acids; diets differ in protein source, degree and consistency of hydrolization

Easily digestible diet Low-residue diet; contains prebiotics; may contain other nutraceuticals (e.g., antioxidants)

High-fiber diet Limited to patients with isolated colitis

High fat/low carbohydrate or moderate fat/ moderate carbohydrate diet

Mechanism of action unknown; chosen diet must be digestible

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Various strategies to alter the gastrointestinal microbiota.

Prebiotic: Substances that are non digestible, but fermentable; e.g., fructo oligo saccharides (FOS)

Probiotics: Live beneficial bacteria; must be safe, stable, and effective

Synbiotic: A combination of a prebiotic and a probiotic

Antibiotic: Tylosin is the antibiotic of choice 9/1/1526

Anti-inflammatory and immunosuppressive agents

Corticosteroids : Prednisone in dogs and prednisolone in cats

Cyclosporine : Immunosuppressive agent;

Metronidazole : May have immunosuppressive activity

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6. Histopathologic evaluation of biopsies

Biopsy samples for histopathological evaluation can be collected by endoscopy (least invasive), laparoscopy (least desirable), or exploratory laparotomy (most invasive).

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Conclusion

Chronic diarrhoea is a complex disease process.

Symptomatic therapy for simple disorders is often attempted in the early stages of management; ie. food trial and anti-parasitic medication, but antibacterial and steroids therapy should ideally be avoided.

Clients appreciate the interest shown by the clinician, and are more accepting of the advice, than when communication is poor subsequent to diagnosis.

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Chronic diarrhoea is a change in the frequency, consistency and volume of the dog's feces for more than three weeks

Timely diagnosis of etiology help to save animal from death.

Appropriate approaches help to satisfactory treatment with judicious use of drugs.

Proper diagnosis help to reduce cost of treatment to owner.

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ReferencesReferencesAckerman, N., (2014) Canine GI disorders: causes, management, treatment and diet, Clinical

VN Times.

German, A.J. , DIAGNOSTIC APPROACH TO THE CAT WITH CHRONIC DIARRHOEA, Proceedings of the Southern European Veterinary Conference and Congreso Nacional de AVEPA, oct. 18-21, 2012

German, A.J. , MANAGEMENT OF THE CAT WITH CHRONIC DIARRHOEA, Proceedings of the Southern European Veterinary Conference and Congreso Nacional de AVEPA , oct. 18-21, 2012

Lappin, M.R. , Greco, D.S., Gutsy Move: Solving Those Complex Gastrointestinal CasesConference Proceedings Critical Updates on Canine & Feline Health

Marks, S.L. , Medical approach to puppies and kittens with diarrhoeaAdvances in Puppy & Kitten Health Care, Iams Clinical Nutrition Symposium 2005 Seville, Spain January 29, 2005

Marks, S.L. , Rational Approach to Chronic Diarrhea in Cats Symposium Proceedings Critical GI Updates From 2013 NAVC and WVC Conferences

Steiner J (2013). A step-wise approach to dogs and cats with chronic diarrhea, Veterinary Focus 23(2): 54-56.

Steiner, M.J. BASIC WORK-UP FOR DOGS & CATS WITH CHRONIC DIARRHEA, Western Veterinary Conference 2013. 9/1/1531

Acknowledgement

Chet Raj Pathak Ganesh Pun Bharat Regmi And other helping hands.

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Thank YouFor Your Patience

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Any Question???

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