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 anyway, and can be treated the same way.
My questions are:
1) Is it possible for the diarrhea to be strictly exercise-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. Low fat 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
Q: I read your section on enlarged lymph nodes but still have a question. Our three year old Maltese has had marble sized nodes come and go for six weeks under the chin. Our vet doesn't know what to think but is not concerned because other nodes are not affected, but we am still very concerned. We have changed food and shampoo. He acts fine. We would appreciate your thoughts
A: The lymph nodes under the jaw (usually at the junction of the jaw and throat, not actually at the chin area) collect lymph drainage from the head region. When they are inflamed it is a good idea to look for problems in this region. Chronic ear infection, tooth disease, sinus infections and problems of this sort are all possible. In some cases lymph nodes enlarge when allergies are present and sometimes they enlarge for no discernible reason. Since it sounds like they have gone down you vet's approach might be best -- worry about them if they enlarge again.
Mike Richards, DVM
Q: Dr. Mike My 10 year old miniature schnauzer had swollen glands by her jaw so I took her to the vet, who aspirated the lumps and said it was consistent with the way he would expect cancer cells to look. He examined her and found swollen lymph glands under her jaw, at the tops of her front legs, and on the back of her legs. He gave me some prednisone (sp) to give her, but I would like to get a second opinion on his cancer diagnosis before I start the medication. Is there any way to know, if it is in fact cancer, how far along it is, and what her life expectancy would be on the medication? She is in great shape and doesn't act sick *at all*. She had a tick bite on her chin and I thought the swelling was from that, so that's the only reason I took her to the vet.
A: We send the aspirates from lymph nodes we suspect to be cancerous to a clinical pathologist for review. If the pathologist agrees with our assessment and the clinical signs are consistent with lymphoma or other cancer we feel content that the diagnosis is correct. If some question remains, we remove a lymph node and send that. This allows the pathologist a better look at the architecture of the gland which can help determine if cancer is present.
Lymphoma is often discovered pretty much the way you did - by accident. It does not seem to cause much pain or discomfort in the early stages. It therefore comes as a shock to many owners expecting a minor problem and going home coping with a diagnosis of malignant cancer.
Prednisone therapy will usually allow a couple of months of comfortable time when used as the sole agent for lymphoma. If another cancer other than this has metastasized to the lymph nodes there would be no way to give you any sort of prediction without knowing the exact cancer involved. Combined chemotherapy is much more effective for lymphoma, giving reasonably comfortable lifespans of 12 to 18 months. There is a bigger expense and time commitment to the pet with this decision but for many people chemotherapy is an option to consider.
This is the sort of situation in which some sort of second opinion - either from the pathologist or through examination by another vet -- is a good idea. Whenever a fatal illness is diagnosed and there is any question in your mind about the diagnosis, it is best to be certain.
Mike Richards, DVM
Q: Dear Dr. Mike, Our 8 year old German Wirehaired Pointer has just been diagnosed with lymphoma. Thus far she seems to feel well, and is both exercising and eating normally. The only outward evidence we see is that all the lymph glands are enlarged. This appeared quite suddenly about three weeks ago. A CBC run a few days ago showed a normal white cell count. The only anomalies were somewhat low platelet numbers and an elevated blood calcium level. One lymph gland was removed and sent to Iowa State University. Lymphoma was confirmed. Our vet offered two treatment options: 1) Giving Prednisone alone or 2) Administering vincristine once every other week for twelve weeks combined with daily doses of Cytoxan and Prednisone in dosages he has not yet specified. He reported that, in the aggregate, remission and survival rates with either option do not differ greatly. However, he suggested that, given the dog's vigor, the combination chemotherapy may be worthwhile. He spoke of perhaps gaining her an additional month or two to as much as six to eight months. We've been scouring veterinary web sites for relevant information so as to make the most informed decision possible yet this week. Unfortunately the research summaries we've found on the Internet are somewhat fragmentary. The reported results of various chemotherapy protocols do not seem readily comparable due to differences in sample size, severity of illness, etc. From what we've seen, at least in terms of median survival times, it does not appear that the more elaborate chemotherapies offer statistically significant improvement over administration of Prednisone alone.Our rural location makes it difficult to quickly access the original journal articles to verify this. Are you aware of any protocol that has shown significantly greater survival time than treatment with Prednisone alone? Our objective is to make the time she has left as painless and stress free as possible. Reported results of the more elaborate protocols don't seem to warrant the potential side effects or stress to the animal. Are we missing something here? We'd appreciate your thoughts on this. We are really in a quandary. Thanks. Jim
A: Jim- I am sorry for the delay in replying to your question, since time is important in these decisions. Real life sometimes intrudes on my cyber-life.
There is not much question that the combined chemotherapeutic approaches to lymphoma work markedly better than prednisone alone. However, the hope for a "cure" is slim with either protocol. The mean survival times for prednisone therapy alone are somewhere in the neighborhood of 8 to 9 weeks (this is from memory but shouldn't be too far off). The mean survival times for combined protocols is between 12 and 18 months at the current time. The most commonly recommended protocol is the COAP protocol described in Kirk's Current Therapy X, I think.
Most dogs tolerate chemotherapy fairly well. I think it is legitimate to question the merits of extending life for a relatively short period of time but that is a question that you have to answer for yourself. Everyone feels differently about the importance of those months. When chemotherapy works well, most owners are glad they tried it. When it doesn't work well (and it doesn't always) people question the decision. You have to make up your mind in advance which approach is best for you and your dog and then try hard not to second guess yourself too much.
You should be able to get the most recent information on chemotherapy from ISU's oncologist or internal medicine specialists. This information constantly changes, usually for the better.
Mike Richards, DVM
Q: Dr. Mike: Still looking for advice. Took Casey to University of PA Veterinary Hospital yesterday. Routine exam showed enlarged lymph nodes, but the balance of her examination was reported as "unremarkable". She is reportedly bring, active and appears otherwise healthy. Vet recommended complete blood count and chemistry screen and aspiration (thanks to you, I knew what she was talking about) of three lymph nodes. The results of the blood work showed an elevated lymphocite (sp) count that the vet believed may be significant due to the swelling. Also, here liver enzymes were elevated, making Cushing's Disease a possibility. The aspirations did not show any definitive results - same as the removal. The U of P vet is going to request the slides from the lymph node removal to have them re-evaluated at her facility again.
I have several questions, if you have the time to answer.... 1 - Casey was placed on prednisone over the last month...could this potentially be the cause of the elevated lymphocite or liver enzyme? 2 - I recently had to put our 18 year old beagle down, she had Cushing's Disease. Can this disease be passed from one pet to another? 3 - do you have any recommendations for me.... Thank you so much for your time and advise. I really appreciate it greatly. A: I am nearly certain that there is not a contagious form of Cushing's disease so that isn't a concern.
Prednisone can cause rises in the alkaline phosphatase (ALKP) enzyme levels in the blood. These can be really significant rises. This is not due to liver damage, though. Prednisone apparently induces the production or release of alkaline phosphatase from other sources ( I think muscle and GI sources). Prednisone can cause increases in white blood cell counts but it usually suppresses lymphocytes and promotes other wbcs (neutrophils in particular).
I don't know what to tell you on the rest of this except that the more times you get ambiguous results from lymph node aspirates/exams the more likely it is that cancer is NOT the problem.
Hopes this holds true for you. Mike Richards, DVM
Q: Dr. Mike: Over the past three months I've noticed that my 10 yr old Shih's lymph nodes began to swell. Only other behavior difference is an increased appetite. Did take her to vet and had largest lymph note removed and sent to Cornell for evaluation. Reports states that they were unable to determine cause. May be precancerous or an infection. She was put on antibiotic for several weeks with no effect. Next came predisone and still no effect. Vet would like to remove another lymph node and retest. Should other testing be performed prior to another removal? Could there be another cause? Thank you for help.
A: There are few things more frustrating than swollen lymph nodes and a non-specific pathology report on them. It is unfortunate, but lymph nodes enlarge for a lot of reasons. It is always a good idea to carefully repeat the physical exam, looking for new clues as to what is going on. Sometimes, a general lab panel, X-rays or bacterial cultures can be helpful in finding the cause of the lymph node enlargement. We see this pretty frequently in our practice secondary to allergies. I am not sure if the lymph nodes enlarge as a direct result of the allergy or because secondary skin infections are common with allergies -- but they are frequently enlarged in dogs with chronic allergy problems. The most serious concern is lymphoma (cancer of the lymph nodes). Removal of the node is helpful in diagnosing this, obviously.
An intermediate step prior to removal of another node might be to aspirate several of the lymph nodes and send smears of the aspirates to the pathologist. We do this before removing lymph nodes in many cases and often the diagnosis can be made from the aspirate.
Another consideration is referral of the whole dog to the veterinary school. They have lots of specialists in different fields and can often figure out problems that elude general practitioners like myself.Good luck with this. Mike Richards, DVM