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IBD in Dogs
IBD in Sheba Inu - getting a diagnosis
IBD in Shih-Tzu
Irritable bowel syndrome in Dalmatian
IBD and anorexia in Dobe mix with congestive heart failure
IBD and Lymphangectasia
also see Heart problems
also see Diarrhea
also see digestion problems
IBD in Shiba Inu - getting a diagnosis
Question: Dear Dr. Richards
I have a very bright and normally highly energetic 3 year old Shiba Inu
named SaSi who has some sort of digestive difficulty. Our veterinarian is
trying to stabilize her on MediCal Gastro Formula and, if successful, plans
to try to get her back on an adult maintenance diet, and if not, is planning
blood tests and endoscopy. The lipase amylase test was done and levels were
slightly elevated.
Sasi has always been a finicky eater, self feeding, and enthusiastic about a
new dog food at first. Her breeder fed the puppies homemade rice and
hamburger mixture. I have changed SaSi's food regularly as she seemed to
become disinterested over time, but always fed good quality brands and
transitioned slowly. She has been difficult to train and we used a variety
of treats to reward good behavior. She also has a habit of picking up all
kinds of ugly stuff on the street. She has had regular bouts of tummy upset
and diarrhrea and a couple of episodes of bright red blood in the stools.
During these upsets she would be desperate to get outside and eat a lot of
grass. I started to give her pepto bismal tablets instead and this seemed
to help settle her down in a day and a bit. I first became concerned that
these upset episodes were increasing in frequency and then she had an
episode over Christmas where she seemed to be in a lot of pain over a couple
of days.
Our veterinarian recommended that we switch her to the Gastro formula and
try to feed three meals a day. I stopped the pepto bismal and all other
foods and treats, and have been somewhat successful in training her to stop
picking up crap on the street. Since Christmas I have watched her closely,
and she is still up and down. Recently she seemed back to normal for about
four days and then relapsed (possibly as a result of something she ate
during an unsupervised play in a neighbor's backyard).
The episodes consist of listless behavior, a characteristic odor,
occasionally vomiting bile in the middle of the night, and formed but very
soft stools. She still wants to eat, and walk and play, but with less
enthusiasm than normal and occasionally seems quite depressed. Also
periodically she has extreme flatulence. Many nights I hear her making
mouth sounds and otherwise restless activity as if she is uncomfortable even
though she does not vomit. (When she does vomit it almost always bile, or
before, bile and grass.) During the period over Christmas when she seemed
to be in a lot of pain and not improving, I stopped her food for twelve
hours during which she tried to get me to feed her and after which she
vomited a lot of very yellow bile. At that point our vet advised trying her
on rice and a bit of honey until we could start the gastro, and she really
liked it.
I would appreciate, as well as your impressions, some help in deciding
whether or not to do the endoscopy. For this procedure, what are the
tentative diagnoses and resulting treatments.? What other blood work would
be helpful, and in what order? How long and under what circumstances is the
wait and watch approach acceptable? In human medicine I read about bacteria
as a cause of ulcers and irritable bowel syndrome. Is this a possibility in
dogs also? My main concerns are to not subject SaSi to unnecessary testing
particularly where it is likely to be stressful. I am hoping that a detailed
history will help narrow the range of diagnoses and treatments. I am, of
course, speaking with our veterinarian regularly, but appreciate the
opportunity to consult with you.Dianne
Answer: Diane-
I think it is hard to decide when it is necessary to really pursue a
diagnosis hard when dogs have digestive problems that don't result in
weight loss or seriously affect their quality of life. In SaSi's case,
there does seem to be some discomfort based on the periods of being
lethargic or depressed, though.Inflammatory bowel disease is kind of a catch-all term for a number of
individual conditions that have similar symptoms. These include food
allergies, food sensitivities that are not allergic in origin, small
intestinal bacterial overgrowth, plasmacytic/lymphocytic gastroenteritis,
colitis, eosinophilic gastroenteritis or colitis. Sometimes, problems like
persistent parasitism with whipworms, giardia or some other parasite are
present and are not showing up in fecal testing. This isn't really
inflammatory bowel disease but it does have sometimes have similar effects.
Systemic illnesses such as liver disease, diabetes or kidney
insufficiencies can sometimes produce these effects as secondary problems
but these usually show up in blood chemistry examinations. Helicobacter
infections, responsible for ulcers in humans, have not been conclusively
demonstrated to cause ulcers in dogs or cats. When these parasites are found
during diagnostic procedures it is hard to decide whether treatment is
necessary but often it is attempted, on a "just to be sure" basis.Working through the possibilities and getting to a diagnosis is the
frustrating part of dealing with inflammatory bowel disease. This is often
a process of trial and error, especially when it is not possible for
patients to have endoscopic examination and biopsy of the intestinal tract.The first step is to try to figure out if this is a small intestinal or
large intestinal problem. In general, if diarrhea occurs more than three or
four times a day the problem is large intestinal. Usually, the volume of
stool is lower for large intestinal diarrhea, since there are more frequent
bowel movements. Bright red blood is suggestive of large intestinal disease
and maroon colored or black colored blood is more suggestive of small
intestinal disease. If it is possible to localize the problem it helps in
choosing where to take biopsy samples and it also can help in eliminating
some of the potential causes of problems.We do some things for almost all patients with chronic diarrhea, prior to
referring them for endoscopic examination. We usually deworm them with a
dewormer capable of killing whipworms and giardia, fenbendazole (Panacur
Rx), whether we find parasites, or not. We try limited antigen diets if
owners are able to keep their pet from eating other foods and we use these
for six to eight weeks before deciding that they are not helpful. We often
try a course of metronidazole and if dogs respond but the problem returns
on withdrawal of the medication we use sulfasalazine (Azulfidine Rx) for a
while to see if that will resolve the problems. At this point, we usually
want to have intestinal biopsy samples. We refer patients for endoscopy or
take the samples surgically when referral is not possible. Many of our
clients refuse either of these tests and in this case, we continue to try
to figure out what is wrong through trial and error treatments. If we feel
that we have eliminated most other causes, we treat for the
lymphocytic/plasmacytic and/or eosinophilic enteritis diseases, usually
using prednisone or other immunosuppressive medications such as
azathioprin. I really prefer to have a diagnosis at the time we start
using these medications, whenever possible. There is strong potential for
adverse side effects with immunosuppressive medications and it seems better
to have good reason to use them. Despite this, there are lots of times when
we go ahead in the absence of a diagnosis and usually this works out OK.Obtaining a diagnosis makes it possible to direct treatment at a specific
condition and it also helps to eliminate the possibility of using a
medication with serious side effects for long periods of time when it might
not be necessary. Those are the advantages. The disadvantages of pursuing
a diagnosis through endoscopy or surgery are the risks of anesthesia and/or
surgery and the possibility that biopsy samples won't be diagnostic. It is
not always easy to decide which way to go but I do like to try for a
diagnosis prior to using immunosuppressive medications, when it is possible
for us to do that.Mike Richards, DVM
1/29/2001
Question: Great Web Site!
I have read most of the questions and answers and couldn't find any that
offered an answer to my problem. So, I'll ask and see if you can help me!I purchased a 6 month old Shih-tzu (*Zachary) from a Pet store (I was
already well aware of the fact that the puppy was from a puppy mill, but the
thought of a 6 month old puppy spending every day of its life in a cage
upset me and I whipped out the credit card, and he became my own little
rescue). From the time I got him home (Early July) he has experienced
diarrhea. Initially I accredited this to a change in diet. The pet store
fed him Eukanuba, and I changed him to Innova, as Several shih-tzus of my
mother's have severe allergies and have done much better on Innova. At his
initial vet visit, my vet did not seem alarmed and also felt that the
diarrhea would most likely be caused by a change in diet, however he took a
blood sample and fecal sample just to ease my fears. The blood test and the
fecal sample all proved to be normal. When it did not clear up within a
week and had actually gotten worse, I took him back, and another fecal
sample was taken, again no signs of anything unusual, but he was put on a
medication (I can't remember the name, I want to say it was Panacur, but I
may be wrong, it was a thick white fluid). His stool was not compacted,
very runny, there was blood and mucous present in every stool and he would
usually have to poop every 2-3 hours and would normally have one large ...
poop and several small ones.This medication did not seem to help, and so I took him off the dog food and
began him on rice boiled with a small amount of beef, and also began giving
him Pepto Bismol. This made no difference whatsoever. I then took back to
the vet and another fecal sample was taken, this time they found Coccidia
and he was promptly put on an antibiotic for that. After the full round of
the medication (which did not stop or change the diarrhea in any way) he was
pronounced healthy, no parasites. Yet still had diarrhea. The vet and I
decided to keep with the Rice and beef mixture and continue with Kaopectate
after each bowel movement.Two weeks ago little Zachary woke me up needing to go out. When he pooped,
the feces was more than 50% bloody mucous, there was no form whatsoever. I
took him immediately to the vet and the vet was also at a loss... But had a
feeling that the problem was originating from his colon. She prescribed him
a bland Diet (Science Diet ID) and an antibiotic, Metronidazole.
Immediately the symptoms ceased, the feces compacted, and little zach was
only having a bowel movement twice a day. However, now that the medication
has ended, the diarrhea and blood and mucous has returned.Unlike other situations that have been asked about on your website, Zachary
is a typical puppy, happy, go lucky, and full of life. He is always
playful, drinks a normal amount of water. No prior medical history, He
doesn't get any treats, he doesn't chew on any bones other than a nylon bone
(which he knaws at for a few seconds then gets bored), we live in an
apartment and he gets crated during the day, so I know he doesn't get into
anything. I am very strict about his food bowl, I have a 3-ish year old
Shih-tzu who eats a normal diet (and does not show any symptoms that Zachary
has) so I am very careful not to let the puppy near his bowl.I have been told that he isn't sick and he is healthy, however, a healthy
dog doesn't have diarrhea for this long without a reason. Are there any
possibilities that I am overlooking? If it is "just the way he is" I can
deal with that but something is telling me that there is a cause to this
problem, and I want to know for sure. Also, are there any additional tests
other than a fecal exam and blood work that would show an underlying
illness?
If you can lend any advice, it would be greatly appreciated!
LisaAnswer: Lisa-
It seems pretty likely that this puppy could have one of the inflammatory
bowel diseases (IBD) that lead to chronic diarrhea. These can be
frustrating problems but it is a good sign that Zachary responded well to
metronidazole, since it gives you an option for therapy.When puppies have chronic diarrhea it is usually a good idea to run fecal
examinations on several occasions to look for intestinal worms and other
intestinal parasites. This is necessary because the life cycles of several
intestinal parasites make it possible for them to be present but not
identifiable in a stool sample, because they are not shedding eggs (worms)
or are in an intracellular stage (protozoans). Even when stool samples are
negative it is sometimes a good idea just to go ahead and use a broad
spectrum dewormer, like fenbendazole (Pancur Rx), to try to eliminate worms
and giardia as possible problems. Your vet has already done these things,
so this part of the diagnostic process is done.The next thing to think about is whether the diarrhea seems to be large
intestinal in origin, or small intestinal in origin. In small intestinal
disease, there are usually a normal number of bowel movements each day but
diarrhea is present. Dogs can usually control the urge to have a bowel
movement with small intestinal diarrhea and there usually isn't a lot of
straining associated with the diarrhea. Really awful smelling diarrhea
tends to be from small intestinal disease. In large intestinal diarrhea,
there usually is a some straining or discomfort, there are multiple bowel
movements per day, often of smaller volume than normal bowel movements, the
urge to go is strong and the dog may not be able to control it, straining
is common and vomiting is occasionally present. In Zachary's case, the
diarrhea seems to be large intestinal based on these signs.The next step is to figure out what diagnostic tests might be useful in
determining what is going on and deciding which tests are necessary at this
time.In a shih tzu, even though it is not a likely cause of the signs seen, it
would be a good idea to do a general blood chemistry panel to rule out
kidney problems, since there is congenital kidney disease in the breed.
This is actually a pretty good idea in any case of chronic diarrhea, since
it also helps rule out liver problems and to screen for less common
problems like hypoadrenocorticism (Addison's disease).Some dogs with chronic diarrhea have clostridial bacteria overgrowth in
their colon. A fecal smear to check for clostridial spores can help to
identify this problem. It may respond to treatment with metronidazole or
amoxicillin, if it is present. Sometimes, withdrawal of the antibiotics
leads to a quick recurrence but usually a second treatment will resolve the
problem. So it might be worth one more round of metronidazole, just to see
if it helps, before going on to further testing, although you should follow
your vet's advice on this. In some cases, fecal cultures to determine what
type of bacterial might be present are a good idea, although most of the
time these don't work out to be all that helpful.Food sensitivities would have to be considered in a patient this young.
Sometimes it helps just to switch to a low fat diet, such as Hill's
w/d. For other patients it is necessary to use a diet containing protein
sources that the pet has never been exposed to before. Examples of diets
that might work are duck/potato, venison/potato, lamb/rice and similar
combinations. Alternatives are hydrolyzed diets such as Purina's HA and
Hill's z/d diets, which are made from very short protein chains that should
not cause allergic responses. It can take up to six weeks for limited
antigen diets to help, so you have to be patient during this part of the
treatment process.There are a lot of other possible tests that can be done, including testing
for maldigestion with trypsin-like immunoreactivity (TLI) testing, testing
serum folate levels, testing the stool for digestive enzyme activity, for
fats and for starches. Most of these problems are not likely in a pet who
has responded well to metronidazole, though. Routine X-rays of the abdomen
and ultrasonagraphy can give an indication of problems that might be
present but do not commonly provide a definite diagnosis. They are still
reasonable tests on the road to a diagnosis, though.The best test to obtain a diagnosis is probably endoscopic examination and
biopsy sampling. This does not always yield a diagnosis, but it is the best
way to get one.In a dog this young, obtaining a diagnosis prior to long
term therapy is a really good idea, especially since most of the time, the
use of immunosuppressive agents like prednisone and azathioprine (Imuran
Rx) are necessary for long term control of the diarrhea if sulfasalazine
(Azulifidine Rx), which is the usual "first line" medication, does not work
well. Some vets use long term metronidazole therapy, as long as the dose
can be kept fairly low, such as 15 to 30mg/kg/day.Hope this helps some. I do think that you will be able to control this
since metronidazole worked well when it was used.Mike Richards, DVM
9/20/2000
Irritable bowel syndrome in Dalmatian
Question: Dear Dr. Mike,
I wrote to you a few times in October, November and December about my Dalmatian Mr.
Bojangles. Bo went through many tests, procedures and diagnosis and ended up in kidney failure
and contracting aspergillos. His chance were very slim to known and your help was vital in
helping me make and cope with decisions. I am happy to say Bojangles had a healthy fourth
birthday celebration and has seems to regained all of his kidney function and have beaten the
aspergillos. He is kept on prescriptions of urocit, allopurinal and itraconazol for maintenance and
is expected to be so for the rest of his life. He is still having some problems though and our vet
now feels that he might have been suffering from irritable bowel syndrome all along and went
undiagnosed. His symptoms are pain when getting up or down, flatulence and bloating that
causes tightness around his abdomen. Our vet suggested finding a diet that would work best for
treating him but has not got back to us for seven weeks now. The veterinary clinic says they are
under staffed and she is attempting to do research for us and just hasn't found the time,
meanwhile I am trying to keep my dog as pain free and comfortable as possible. During this 7
week wait, I have began cooking chicken and rice (white and brown) for Bo. He takes a 1/2 multi
vitamin, the prescribed medicines and glucomsimine (to help repair his collapsed discs from the
aspergillos). It has been suggested to me to try some natural enzymes, peppermint oil,
pancreatin and/or acidophilus. I have not been able to find much information on the safety of
using any of these for Bo yet. What treatments should I be considering or asking my vet to look
into? I appreciate your help and thank you for helping me save Bojangles life. You told me
previously that it didn't hurt to try treatment but to be realistic about his chances for survival. I
was able to get through his original ordeal and hope to find help for him now to live a long and pain
free life now. Thank you!!!Stephanie
Answer: Stephanie-
Dietary control of gastrointestinal disease is sometimes possible and dietary changes are often
helpful even when full control of inflammatory bowel disease (IBD) can't be obtained.The first step, when possible, is to figure out if the diarrhea is a small bowel or large bowel
problem. Small bowel diarrhea usually causes large volume stools but dogs usually have a
relatively normal number of bowel movements per day. Large bowel diarrhea usually produces
low volume of stool but very frequent bowel movements.The problem is that a diet that helps one dog may not help another. It may take several tries to
discover which diet helps Bojangles the most. It helps if you already have some idea about food
ingredients that might cause problems. It may help to carefully think about what you have been
feeding in the past and to write down a list of all the foods and treats that you can remember
giving. If it is obvious that one of these caused problems, make a note of that, too. Discussing
this list with your vet can help determine if food sensitivity is likely to be a problem.Some dogs with IBD have food sensitivities or food allergies. These dogs can be helped by
using diets that are designed to reduce the possibility of a reaction to them. A diet containing a
protein source that the dog has not been exposed to previously may be very helpful. An example
of a diet like this would be one using duck as the meat source and potato as the carbohydrate
source. These are ingredients that are not usually found in dog foods so they are unlikely to
cause reactions. Purina makes a diet (HA tm) that utilizes very small molecular weight protein
sources that are not likely to cause reactions. This is another approach to the problem of making
a diet that is "hypoallergenic". Sometimes the response to these diets is temporary and it is
necessary to change protein sources again. Hills d/d (tm) diets, Purina HA and LA (tm),
Waltham Select Protein (tm), Innovative Diets (tm) and others produce foods that are
acceptable for food trials. In addition, homemade diets will work if well designed.Another approach to IBD causing colitis is to try to use foods that are not irritating to the colon.
Low fat diets can help a lot with colitis, no matter what the cause is. Rice is supposed to be
helpful in digestive diseases so it is commonly recommended as part of diets to control colitis.
Avoiding highly fermentable foods like beans and other vegetables associated with gas
production can be helpful. There are several commercial diets that are low fat and contain easily
digested ingredients. Your vet can provide one of these if hyopallergenic diets are not helpful.
Hill's w/d (tm) diet and Walthams Low Fat (tm) diet are examples of low fat diets and I am sure
there are others.Gluten intolerance occurs in some dogs. Diets containing wheat, rye or barley can cause this
problem. I don't know how common this problem is but it can be discovered using the same diet
to rule out food sensitivities as is used for food allergies, by making sure that thee carbohydrate
source is not wheat, rice or barley.Dairy products should be avoided in dogs with gastrointestinal disease, since lactose intolerance
is very common in dogs and it may lead to gas pain, diarrhea and vomiting in susceptible dogs.Highly digestible diets can be helpful in some dogs. These contain ingredients that produce
minimal irritation to the digestive tract. Examples of these diets include Iam's Low Residue (tm),
Hill's i/d diet (tm) and Purina EN (tm) diet.If you decide to try a food trial it would be best not to use supplements during the time of the
food trial. There isn't too much information on things like peppermint oil and enzyme
supplements there are recommendations to use these in digestive problems and it seems
reasonable to try them.It is helpful in some dogs to use famotidine (Pepcid AC tm), ranitidine (Xantac tm) or nizatidine
(Axid tm) to decrease gastrointestinal irritation. Even the use of an anti-diarrhea medication like
loperamide (Immodium AD tm) is helpful in many dogs and can sometimes be used intermittently
to control problems with good success.I am not sure if there is a very best general approach to sorting through these diets. We usually
start with the hypoallergenic diets, then try low fat diets and then highly digestible diets but I'm
sure that some vets use a different order.Good luck with this.
Mike Richards, DVM
7/17/2000
IBD and anorexia Dobe mix with with congestive heart failure
Question: Hi, Dr. Richards -
I'm a new subscriber to your site. My 13-year old mixed Doberman-beagle
spayed female dog "Topper" has some serious problems with anorexia and
inflammatory bowel disease which I would like some advice on. I've checked
various items on IBD and anorexia on your site, but haven't found a case
mentioned for which the symptoms match Topper's.As background:
We adopted Topper 12 years ago from a local shelter. We found about 10
years ago that she was hypo-thyroidic, and she has been on daily thyroxin
(Soloxine) since that discovery (original dosage 1 mg/day; reduced in
March, 2000 to .5 mg/day due to high T4 levels). She has had occasional
periodic episodes of diarrhea with blood and/or mucous; a proctoscopy in
1994 revealed ulcerations and she was diagnosed then with chronic colitis.
She received Tylan and Medrol during her acute GI distress in 1994, and
her diet was changed permanently to Canine I/D prescription diet, which
she was fed twice a day. She was occasionally on Tylan briefly whenever
she had symptoms of recurring colitis (about once or twice a year,
diarrhea with mucous/drops of right red blood, with straining after) and
that plus strict adherence to the I/D diet seemed effective in controlling
it. She has always had a good appetite, but has been a physically trim dog
(her heaviest weight was about 62 lbs; she has averaged around 58-60 lbs
for the past 5 years). She has had several surgeries (1998 and 1999) to
remove subcutaneous masses from her sides, flank and neck; all were
biopsied and diagnosed as benign lipomas. She also had a pre-malignant
papilloma on one teat surgically removed in 1993. She is up to date on all
her shots and on Interceptor for heartworm (last heartworm test was March
14, 2000). She is primarily an indoor dog, walked on a leash. We live in a
suburban area, though woods and a creek back onto our property; she likes
swimming in - and unfortunately drinking from - the creek. She co-habits
with another, unrelated, adopted dog (also female, mixed breed) who is
about two years younger.In 1995, during a routine exam our vet noticed in a chest x-ray that
Topper's heart appeared enlarged. We were referred to a cardiologist, who
found via echocardiogram that she had mild mitral, tricuspid & pulmonic
valve leakage. She was monitored yearly with echocardiograms by the same
cardiologist, without his finding any degradation in heart function until
October, 1999, when he determined that her valve leakage was increasing
and put her on Zestril (10 mg a day in the evening).In mid-January, 2000, we noticed that she appeared to be drinking and
urinating more than usual and took her to an internist for an exam.
Nothing definitive was diagnosed although a urinary tract infection was
suspected (her urine pH was high); she was put on Baytril for a few days.
We took her back in early February for re-checks of her bloodwork and
urinalysis; nothing abnormal came up. About the same time we started her
on Rimadyl since we'd noticed her stiffness on going up stairs had
increased. (We checked with the cardiologist first for potential
interaction with the Zestril, and were told Rimadyl would be safe.) A few
days after the visit to the internist, on February 12th, Topper developed
an occasional retching, non-productive cough which would occur when she
was sleeping or lying down. It disappeared for a day or so, but then
recurred. Thinking it might be a drug reaction, we took her off Rimadyl
(she'd been on it only 1 1/2 days) and back in to the internist on
February 17th for chest x-rays, and those, plus consultation with the
cardiologist at that facility who did an echocardiogram, resulted in a
diagnosis of congestive heart failure. She was put on Lasix at 80mg a day
and Coreg (carvedilol) at 6.25 mg a day on February 17th. We took her
back to our regular cardiologist about 10 days afterwards, and he, after
further chest x-rays and exam, decided to supplement the Lasix and Coreg
with Digoxin (Lanoxin, at 187.5 mcg a day). We kept a close eye on her and
noticed in late March some trembling; our cardiologist halved her Coreg
dose to 3.125 mg/day, suspecting it might be causing low blood pressure.
On May 30th after another exam the cardiologist added Hydralazine
(starting at 2.5 mg/day increasing gradually over 10 days to 15 mg/day)
after noting hypertension and a continued increase in her heart size. On
June 6th we noticed her breathing appeared deeper and more labored, and
the cardiologist increased her Hydralazine to the full dose for her size
(3/4 tablet two times a day for a total of 15 mg/day).From about mid-March on Topper was getting increasingly finicky about her
food. Her weight was about 59 lbs on March 23rd. In the past she has
always had a good appetite for I/D diet; usually we fed her twice a day
the dry food soaked in warm water, but sometimes alternated it with the
canned variety. She has also always enjoyed boiled rice as a treat,
usually mixed with fish. Our regular vet suggested trying Purina EN diet,
which we did in mid-March with some initial success, but her interest soon
waned. Often to get her to eat we found we had to mix her regular food
with a substantial portion of fish or rice. Our cardiologist suggested
IVD diet - we tried both the duck/potato and the venison/potato, with not
much interest on her part. By mid-May she was eating probably about a half
of the food she would normally be getting on a daily basis - and much of
this was not what we would normally have fed her, but whatever she seemed
interested in (rice, fish, pizza, crackers, spaghetti, bread, cooked
vegetables, etc.) We were worried that this diet would cause a recurrence
of her colitis - how to balance getting her to eat ANYTHING to get
calories into her vs. the potential of aggravating the GI tract problems?
To get her to take her pills (she'd never had any problem when just on
daily Thyroxin) we began to have to hide them in ground meat or some other
treat; she soon became wary of this, and from about late June on we have
had to force her to take her pills.On June 14th in the evening Topper had an incident of tussive syncope -
she fainted while being walked. We were told by our cardiologist this was
not uncommon, and was due to her lowered blood pressure, possibly a side
effect of the Hydralazine. She was now sometimes totally refusing food for
a day or so at a time. We felt it was imperative to get her to consume
calories, no matter what the source. During the experimentation with
various foods, Topper developed diarrhea - no blood in it or vomiting,
though. We could see about this time (late June) that she was losing
muscle mass in her hips and getting weaker. Our cardiologist said to stop
her Lanoxin for three days (we did this from June 21 to June 23rd), and if
her appetite did not improve to schedule an exam with an internist, since
he did not feel her anorexia was due to either her heart condition or her
medications.We saw an internist on June 23rd - Topper's weight was 56 lbs. She had
abdominal x-rays, a complete blood profile and urinalysis, but nothing
abnormal showed up to explain the anorexia. The internist had us resume
her Lanoxin at the previous dosage, and reduce her Hydralazine dosage to
10 mg/day because of low blood pressure. The internist said she did not
think Topper's chronic colitis was involved, but that it appeared from the
symptoms to be more related to the upper GI tract. She suggested the
possibility of food allergy or lymphoma. Our next step would be an
abdominal ultrasound.Topper had her abdominal ultrasound the next week, on Wednesday, June
28th. We noted that she had lost two pounds within one week - her weight
was now 54 lbs. The ultrasound showed nothing abnormal; the internist put
Topper on Flagyl and gave us a wormer (Panacur), giving us also a recipe
for a rice and cottage cheese diet. We were given the options of either
trying the Flagyl for a few weeks or scheduling an endoscopy as a further
diagnostic. Realizing she would probably only get weaker, we tentatively
scheduled an endoscopy for Saturday, July 1st. We began Flagyl at 250 mg
2 times a day. Meanwhile, Topper refused the rice and cottage cheese
mixture and most other foods, finally eating some Purina baby food.The night before the endoscopy Topper had a prolonged congestive episode
(i.e. coughing and gurgling), and we gave her an extra Lasix. The
internist checked her lungs the next morning and said they were clear, and
said that without the endoscopy as a diagnostic she would die. She had the
endoscopy of her upper GI done the morning of July 1. The visual results
were inconclusive - the internist said her duodenum, esophagus and stomach
all looked "abnormal" but would not comment further without biopsy
results. We were told we would have to wait at least five days for the
biopsies to be returned from pathology since this was over the July 4th
weekend, and Topper was sent home with us that afternoon without any
advice on how we might coax her to eat.The evening after the endoscopy (July 1st) she had frequent, very small
amounts of dark ruddy colored watery diarrhea with a lot of straining
afterwards. She refused all food. We gave her some Pepcid AC that evening.
Her diarrhea with straining continued every 2 hours all that night and
into the morning.The next morning (Sunday, July 2nd) she still refused all food. She was
still alert and able to get around, but was obviously uncomfortable and
getting weaker. Around noon that day we took her to an emergency animal
hospital. The vet there gave her a shot of B-complex vitamin and showed us
how to syringe-feed her Nutri-Cal and A/D diet - we purchased some of
each. He also recommended starting her on Pepto Bismol, which we did that
evening. Her diarrhea and straining continued through that night.Monday morning, July 3rd, her diarrhea was now dark brown in color, but
she had less straining. We were still feeding her A/D and Nutri-Cal by
syringe, since she was refusing other food. She did eat a small piece of
cracker, and drank a large quantity of ice water, eating all the ice cubes
as well. Tuesday evening, July 4th, she ate some canned "gourmet" dog
food - other than the syringe force feeding, this was the first time she'd
eaten in four days.When the biopsy results came in (on Friday, July 7th) they were
inconclusive, and "inflammatory bowel disease" was diagnosed. The
internist suggested putting Topper on Immuran as the next step, saying
that otherwise surgically opening her and getting full biopsies would be
the next diagnostic. I read up on Immuran and saw some of the side effects
relating to stomach upset and infection, and we felt that this would not
be prudent given Topper's weakened condition. We went to another internist
on July 14th for a second opinion. She recommended against the use of
Immuran, partly because of the time it would take to become effective. At
her suggestion, we stopped Topper's Lanoxin for several days, but this did
not affect her appetite, and when fluid built up in her lungs after a few
days we re-started her on Lanoxin. The internist increased her Flagyl to
500 mg 2 times a day.Since the endoscopy (July 1st) Topper has had a great appetite for ice
cubes and water but little else. For the period of about three weeks after
the endoscopy we could tempt her with small amounts of various canned
"gourmet" dog foods for small dogs, but she is now rejecting those. Her
weight is about 48 lbs now. Our current internist has put her on
Prednisone (25 mg/day) and Tylan (1/2 teaspoon 2 times a day mixed in
food) since July 26th. We have had to mix the Tylan with A/D diet and
syringe feed her in order to get the medication into her. Twice she has
vomited after receiving the Tylan (vomiting up her pills as well) - but
these have been the only instances of her vomiting. She has had a small
appetite for plain boiled spaghetti and occasionally pieces of cooked
chicken liver or small pieces of cooked steak, but little else. When she
is not eating at all we syringe feed her one can of A/D diet and 60cc's of
Nutri-Cal in the morning and evening; although she doesn't like this
process, she doesn't try to spit out the food. When we're cooking dinner
she will often act interested and hungry, but then will reject the food.
Her stool now is small in quantity, but firm (probably due to the Pepto
Bismol we occasionally give her when she has diarrhea). The internist said
to call her if there was no change in her appetite within a week of
starting the Prednisone; I called today to report no progress. Our current
course is to stop the Coreg and Flagyl for a few days, and to check in on
Friday with the internist for a follow-up exam.Although she is very thin, Topper still has enjoys her normal interests
(stalking squirrels, for instance). She prefers being outside and is often
reluctant to come indoors, where she appears bored and sleeps a lot.
Outside, she will often try to eat grass. Indoors, she will come trotting
when she hears ice cubes being put in her water bowl; she will drink a
large bowl full of ice water at a time. I have noticed some extra shedding
from her the past two to three weeks. Could this be due to her lowered
Thyroxin levels?Any ideas or suggestions on other medications which we might try, or what
might be causing her intestinal distress and/or lack of appetite? Also,
any ideas or suggestions in coaxing her to eat? Could the hydralazine be
causing such a cessation in appetite? We obviously do not want to put
Topper through any more invasive diagnostics without some good certainty
that they will prove helpful in her treatment. Our current internist had
suggested Topper is in what she termed "end-stage heart disease" but our
cardiologist does not feel Topper's heart condition has deteriorated that
much. Her congestive episodes are infrequent, and it is really her lack of
appetite and weight/muscle loss and accompanying weakness which are of
most concern.Many thanks for your time -
Susan
Answer: Susan-
It is very frustrating to deal with two conditions for which treatment
goals are sometimes at odds. This is a problem with Topper's two
conditions. It is easy to see why this has been difficult. Your vets have
all been advising good approaches to these problems, especially stopping
the digoxin and some of the other medications briefly to be sure they are
not the cause of problems. This is especially important when digoxin is
being used because the first sign of toxicity is a decrease in appetite.For heart disease, a low sodium diet is ideal but many dogs are reluctant
to eat these diets. Prednisone, which helps with inflammatory bowel
disorders, can complicate treatment for chronic heart failure because it
causes sodium retention and can weaken heart muscles slightly.Heart disease, especially in dobermans who have cardiomyopathy, can cause
weight loss, sometimes really rapid weight loss. This condition is referred
to as cardiac cachexia. It is important to get patients with cachexia to
eat and most of the time it is recommended to feed dogs anything they
really want to eat rather than trying to work for a specific diet. Cardiac
cachexia is sometimes lessened by the use of marine fish oils (essential
fatty acid supplementation). Supplements higher in Omega-3 fatty acids
such as 3V (tm) are most beneficial. Coenzyme Q10 is recommended by some
cardiologists for patients with cardiac cachexia, using dosages between 30
and 90 mg every twelve hours. If there is any concern that dilated
cardiomyopathy is present (dobermans are prone to this) supplementing with
l-carnitine might be worthwhile, too. It is expensive, but based on all you
have done so far, it doesn't look like that would be a big problem. It is
unlikely to cause harm even if it doesn't help. A lot of this information
came from "Kirk's Current Therapy XIII", which your vet might have. It has
a good chapter on nutrition and heart disease.I would strongly recommend placing your primary emphasis in treatment on
the weight loss and heart disease and putting up with the diarrhea from
colitis. We had several patients with chronic colitis whose owners can not
handle treatment for. They have diarrhea a lot but are not extremely thin
and are not over bothered by the condition. So I would think of this as the
secondary problem.In most dog breeds, sulfasalazine (Azulfidine Rx) is the first line of
defense against inflammatory colon conditions. In dobermans, sulfa drugs
can cause unusual reactions sometimes, so I can see why no one has tried
this approach. It may be worth considering, though. If joint pain, joint
swelling, dry eyes or other problems occurred this medication would have to
be discontinued, though. Prednisone is helpful and if it isn't causing a
worsening of the heart problems it is a reasonable choice. Usually this
will help with appetite, but isn't in Topper's case, I guess. Tylan (Rx)
can be used continuously, if necessary. Metronidazole helps with
inflammatory bowel conditions, sometimes, too.I always worry about cancers in patients with normal lab work and
unexplained weight loss who are in Topper's age range. When cancer is hard
to find (and you allowed testing that might have discovered it) that
doesn't mean it isn't present. It is something you have to keep in the back
of your mind and continue to watch for signs of, such as lymph node
enlargement, changes in lung X-rays, etc. Honestly, I think that your vets
have done a lot to try to eliminate this possibility -- it is just hard to
be sure it isn't there. The same nutritional advice given for heart origin
cachexia is also given for cancer origin cachexia, though.Supposedly the fish oils can cause big gains in appetite quickly in some
patients with cachexia signs. I definitely think it would be worth trying
these.Hydralazine may cause vomiting or diarrhea in some patients (this is listed
as a side effect). I don't know if it would be a good idea to stop it to
see if it is the problem, though. I would recommend talking to the
cardiologist prior to considering that option.I don't know of any reliable appetite stimulants in dogs. I like using
Hill's a/d (tm) diet to supplement feeding because it can be given with a
syringe and has normal amounts of protein. It is necessary to take the
plunger completely out of the syringe and load the a/d into the syringe
with a finger or spoon, though.I wish that I had more to offer. I hope this information helps. If your vet
has the Kirk's book, it is definitely worth reading the chapter on
nutritional support in it.Mike Richards, DVM
8/7/2000
Q: I hope you can answer a question or two from Canada. I've read through the section on digestive troubles but can't find anything exactly like the symptoms my dog has. They are not really serious, but are annoying and indicate that something is just not right with her digestive system. Intestinal lymphangectasia runs in her family (she is line bred and gets it from both sides). This diagnosis was made for both her great-grandmother and her grandmother at Guelph University Veterinary Clinic, so I'm sure it is accurate. I'll give you a brief history to date. The dog spent her first two years of life outdoors at a kennel (she was to be used for breeding, but was never bred). She was fed Purina Pro Plan for 1 1/2 years and then the breeders switched their dogs to an all-meat diet (raw). I knew the dog during this time and she was prone to occasional bouts of diarrhea. The dog was then given to me, at the age of 2, and I switched her back to Pro Plan as I had some concerns about the nutritional completeness of the all-meat diet. While on Pro Plan, she had constant diarrhea, ate a lot of grass, and had some vomiting. I took her to a vet who put her on pills that were antibiotic and stopped the diarrhea (can't remember the name of them) and switched her food to Science Diet Prescription ID. While on the pills, she was fine, but when they were finished, she was right back to the way she'd been. He then switched her food to Science Diet Adult Maintenance and she was worse than ever. He then seemed to run out of answers, so I did some sleuthing on my own and discovered that all the food had chicken in common, and suspecting a food sensitivity, I switched her to Nutro Lamb and Rice. She's done a lot better on it, no more vomiting, hardly any grass grazing and the stools, on the whole, firmer. If she is not walked during the day, she has about 2 bowel movements, both of which are firm. If she is exercised, she has 4 or 5, the first two usually normal, the next quite soft, and the rest have no form at all. She recently had a 3-day bout of diarrhea, so I took her to a different vet. He put her on Pepto-Bismal (2 tbsp, 3 times a day for 2 days) and on Solazopyrin (500 mg, 3 times a day for 5 days). She is now back to what is normal for her. He wants to switch her food to the Medi-Cal Hypoallergenic Diet. He doesn't think she has intestinal lymphangectasia, he thinks it could be chronic inflammatory bowel disease, but says they are essentially the same thing anyways, and can be treated the same way.
My questions are:
1) Is it possible for the diarrhea to be strictly exercised-induced or does there have to be an underlying condition to cause this? There is definitely a connection between the amount of exercise she has and the number and consistency of bowel movements. I have asked three different vets about this and no one seems to be able to give me a satisfactory answer.
2) Are inflammatory bowel disease and intestinal lymphangectasia one and the same and are the treatments the same?
3) Could these symptoms indicate the beginning of intestinal lymphangectasia?
Other than the few symptoms I've described, my dog looks great. Her weight is fine, she keeps easily on not a lot of food, her coat is outstanding in softness and glossiness, she is the picture of health. I've had her to three different vets for this problem and the first two seemed to think nothing serious was going on. The vet I'm taking her to now is a lot better and seems like he's starting on the right track, but I'd like to be armed with all the knowledge possible this time. Any light you could shed on this would be greatly appreciated. Caroline
A: Caroline- It took me a while to research your questions. I am not an expert on inflammatory bowel conditions but I'll try to explain what I understand about them.
In answer to your first question, I could not find any information explaining a link between exercise and diarrhea but this seems to be a fairly common observation from pet owners and I believe that there is a link. Nervousness and anxiety are sometimes linked to diarrhea as well and some dogs get excited at the opportunity to exercise so that may be a factor, too.
I do not think of inflammatory bowel disease and lymphangectasia as "one and the same" but the part of the treatment plan for the conditions is similar. I think it would be reasonable to say that lymphangectasia is a form of inflammatory bowel disease since it is the infiltration of white blood cells into areas of the intestine where they do not belong in large numbers. There are a lot of other possible inflammatory bowel disease conditions, though. In fact, inflammatory bowel disease (IBD) is sort of a "catch-all" term that is sometimes difficult to interpret. The most common forms of IBD are probably lymphocytic/plasmacytic enteritis and colitis. These are sometimes responsive to "single antigen" diets -- the hypoallergenic diets with a single protein source, usually in combination with anti-inflammatory medications like metronidazole or corticosteroids. Lymphangectasia is a blockage of the lymphatic system of the intestinal tract which leads to problems with protein absorption and protein loss. It would be very unusual for a dog to be able to maintain weight easily, look good and have this condition. This can be very hard to treat. Lowfat diets are the primary therapy used in the treatment of lymphangectasia.
Although your dog had problems before the raw meat diet it might be a good idea to consider the possibility of toxoplasmosis or a bacterial condition such as chronic E. coli or Salmonella infection. These problems are associated with raw meat diets and could be contributing to the problem.
It does sound like you are on the right track and I hope that you have gained even better control of the problem by now.
Mike Richards, DVM
Last edited 07/21/05