chronic diarrhoea (a step-wise approach of diagnosis of cat and dog with chronic diarrhoea)
TRANSCRIPT
Clinical Conference I
WELCOMEWELCOME
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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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