IBD in Dogs

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

IBD in Shih-Tzu

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! Lisa

Answer: 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

IBD and Lymphangectasia

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