Body

VetInfo Digest December 2003

Table of Contents:
    Diagnosis of Gastrointestinal disease:
        Parasites
        Bacterial Infection
        Viral Infection
        Dietary Disorders
        Trial and Error Tx
        Difficulties in Dx
    Gastrointestinal Obstruction
    Asking Questions
    Good Months for Vet Care

This Month's Note:
I noticed the other day when discussing the treatment and prognosis for a mast cell tumor with a client that I was giving information from memory that I was not absolutely clear on. This is something that can happen in a veterinary practice on a busy day. I interrupted the office visit long enough to find a recent reference that I could depend on for accurate statistical information on mast cell tumors. After this exam, I tried to keep track of how many times in a day I am asked questions that I can't answer accurately without checking reference materials. On this day, it happened three times. Because I was thinking about it, I did check references. However, I know that some busy days I give the best response I can from memory and move on. Unfortunately, I know that this means that sometimes I have given a client inaccurate information without meaning to. In addition to sometimes giving inaccurate information, there are lots of times when I feel strongly that I gave a client insufficient information. To be fair, this is sometimes impossible to avoid as most people can't take in great quantities of information at one time, especially on topics they are not familiar with. Still, it is important to try to provide clients with sufficient understanding of a disease or disorder for them to adequately care for their pet.
One solution to these problems is to schedule a follow-up office visit when pets have a problem that is going to be ongoing or that requires informed decisions on the part of the pet owner. I think that this is something that clients can do for themselves when they feel that they are leaving the veterinarian's without a full understanding of their pet's health needs. If you find yourself feeling this way, call and schedule a recheck examination or ask for a phone consultation with the vet or someone at the practice who can explain the problems facing your pet. Over time, understanding the disorders affecting your pets could make a huge difference in the level of care you are able to provide. Most veterinarians really do want you to understand your pet's health care needs and will take the time to help you if you show an interest.

Diagnosis and treatment of gastrointestinal disease in dogs and cats

Acute diarrhea or vomiting episodes
Perhaps the most important decision that your veterinarian makes when initially presented with a pet with diarrhea is whether the problem is acutely life threatening or not. Veterinarians suspect that diarrhea and/or vomiting are more likely to be a serious problem when the pet is obviously depressed, in obvious pain, if dehydration is moderate to severe, or if large quantities of fresh blood or visible quantities of digested blood (looks like coffee grounds in vomitus, reddish purple liquid diarrhea or black color in formed stools) are present. On a physical examination palpation of enlarged or obstructed intestinal loops, a mass in the abdomen, jaundice or signs of systemic illness are reason to suspect that diarrhea or vomiting may be part of a more serious disease process. Pets with these symptoms may need immediate intensive care. Don't take chances if your pet's diarrhea or vomiting is occurring in conjunction with any of these signs, see your vet.
If a pet seems normal in behavior and activity but suddenly develops diarrhea or vomiting the situation is different. For pets who do not have signs of a more serious illness, it is usually reasonable to wait 24 to 48 hours to see if the symptoms will persist or if they will clear up without treatment before contacting your vet. It is a good idea to think about an earlier visit if this happens on a Friday or the day before a holiday, though.
For dogs it is usually safe to withhold food for up to 48 hours to see if resting the digestive tract will help to resolve the problem. Water should be given in small quantities but access to water allowed frequently, so that dehydration doesn't occur. One way of limiting the amount of water that a pet can take in at once is to put ice cubes in the water bowl instead of water. As the ice melts water is available in small quantities at a time.
Cats are a little different. Cats do not utilize body fat for energy very efficiently, so it is usually best to skip no more than one or two meals for cats and then to consider a diagnostic process if the cat isn't better. While it is OK to use ice cubes to limit the amount of water that can be ingested at once some cats won't drink cold water -- making this a less than ideal method of providing water for cats with this personality quirk. Feeding a low fat diet during the initial stages of a diarrhea or vomiting episode can sometimes be used to provide some gastrointestinal relief instead of withholding food.
Acute episodes of diarrhea and vomiting are generally considered to be a single episode that lasts less than 5 to 6 days, although definitions do vary some. It is acceptable to treat acute diarrhea episodes and to try to figure out why they occurred at any time, After a week it is reasonable to assume that the diarrhea could be a chronic problem. Chronic diarrhea and vomiting in dogs and cats are among the most frustrating problems for veterinarians and pet owners. In many instances it is possible to treat these conditions successfully without really making a diagnosis. It is likely that a "trial and error" approach to control of diarrhea and vomiting is the most common method for the initial treatment. Since this works most of the time it is reasonable to try the most likely treatments first and then to worry about a diagnosis when it becomes apparent that the problem doesn't respond to treatment or returns quickly once the treatment is stopped. However, at some point it makes sense to switch to a more thorough diagnostic process and try to arrive at a diagnosis. Once a diagnosis is made it is easier to choose the appropriate treatment. The real trick is knowing when to give up on the trial and error approach and how to correct for the effects of treatment in making the diagnosis. These things are enough of a problem that it is also possible to make a good argument for pursuing a logical diagnostic process in all but the most transient of diarrhea and vomiting episodes.

Think Parasites
It is always a good idea to eliminate parasites as a cause of chronic diarrhea in pets. It may seem unlikely that an indoor cat would harbor roundworms or giardia, but it sometimes happens. It is always a good idea to check for parasites early in the diagnostic process when attempting to treat or diagnose chronic diarrhea. There are several ways to examine feces in order to identify parasites:
Examination of the stool visually. Tapeworm segments, which are actually small egg sacs, can be seen with the naked eye. They resemble small grains of rice when they dry up in the hair around the rectum and they look like small white worms about 1cm in length when they have just been expelled from the anus. Occasionally there are other clues to digestive problems found in the stool. Maldigestion can cause the stool to look tan with a clay-like consistency. Objects the dog might have eaten can show up, as well.
The simplest fecal examination is microscopic examination of a small amount of stool mixed with saline. This is often the best method for finding giardia and other protozoan parasites. Sometimes worm eggs also show up in saline smears of the stool.
A fecal floatation is a test that is performed by mixing a small amount of stool with a solution that has a specific gravity that is heavier than worm eggs. This makes the eggs float. The eggs from each type of worm are distinctive in appearance, so it is possible to determine which worms are present and which medications are used by identification of the eggs. When roundworms and hookworms are present there are usually eggs in the stool sample. Whipworms produce eggs intermittently, making it possible for whipworms to be present but for fecal samples to be negative for worm eggs. For this reason, it may be necessary to perform several fecal examinations before it is possible to rule out whipworms as a cause of chronic diarrhea.
There is a definite value to identifying a parasite problem and eliminating it. However, even when parasites can not be diagnosed with certainty it can be worthwhile to go ahead and use a broad spectrum dewormer, usually fenbendazole (Panacur Rx) to help eliminate the possibility of roundworms, hookworms, whipworms and giardia infection. We often try this even when we have had a series of negative fecal samples in patients with chronic diarrhea or unexplained weight loss and once in a while it makes a big difference in a patient's condition.

Check for Common Bacterial Disorders
Examining thin smear of feces microscopically can be very useful. Common stains used for white blood cell differentiation can be used to make bacteria more obvious on the smear. Clostridium perfringens bacterial spores look like a safety pin and Campylobacter organisms look like little seagulls in the smear. It is possible to identify Cryptosporidum bacteria using acid-fast stains. These are not commonly used in general veterinary practices but may be more likely to be used by specialty hospitals and practices with an emphasis on feline medicine.
Bacterial cultures are not a routine part of most veterinarian's work-ups for diarrhea or vomiting but they can be useful in some instances. Cats who are good at catching birds can acquire Salmonella infections, sometimes referred to as "song bird fever". Salmonella is relatively easy to culture and the bacteria will usually survive shipment to a reference laboratory if that is necessary. Campylobacter species tend to be relatively hardy and therefore easy to find in culture samples if they are present, as well. E. coli is often easy to culture but it is harder to identify the pathogenic strains of this bacteria without more specialized testing, so it is questionable whether a diagnosis of E. coli infection based on fecal culture is meaningful.
It is highly likely that food poisoning occurs more often in dogs and cats than it is recognized, in part because of the reluctance on the part of veterinarians to spend their client's money on bacterial culture when the findings can be ambiguous or even misleading. The tradeoff for not doing bacterial cultures is a lack of knowledge about how often bacterial food poisonings occur.

Rule out Viral Infections
Viral diarrhea in dogs is most commonly caused by parvovirus. This is usually a disease of puppies. Typically parvovirus starts with a period of depression or lethargy lasting a few hours to a day or so and then progresses to either vomiting or diarrhea. Within a short time the diarrhea becomes reddish brown in color with a strong odor that is not exclusive to parvovirus but which becomes very familiar to anyone who has smelled it more than once or twice. This is always an acute disease. It is sometimes necessary to rule out other causes of diarrhea in puppies while treating for this disease but the diagnostic process is not too difficult. Canine distemper also causes diarrhea at times and in situations such as a puppy adopted from a shelter it can be hard to decide early on which disease is present. Typically canine distemper virus will cause upper respiratory signs such as a runny nose and eyes before diarrhea occurs but sometimes the digestive signs come first.
Cats should always be tested for feline leukemia virus (FeLV) and feline immunodeficiency virus (FIV) even if these seem unlikely. FeLV can be dormant and undetectable for long periods of time in some cats and then be activated by stress, immunosuppressive medications or concurrent disease. FIV has a latent period making it difficult to be sure that it isn't present until two or more tests are negative over a three to four month period.

Think Diet
Diarrhea and vomiting can occur for a great many reasons. Many of these disorders are susceptible to treatment by dietary manipulation, even if the diet didn't cause them in the first place. Diets made to be easily digestible and low in fat, such as Hill's i/d (tm) or w/d (tm) diets and Purina's OM (tm) diet are examples of diets that meet these criteria. These diets help with diarrhea often enough that we usually try them as first step in evaluating the role of diet.
Some pets have dietary sensitivities that can be avoided or treated. Among the recognized dietary sensitivities are wheat sensitive enteropathy in Irish setters and fiber responsive colitis dogs. There are some dogs with chronic diarrhea who will respond to low fat diets supplemented with fiber. A commercial diet like Fit and Trim (tm) or Hill's r/d (tm) may be helpful or a low fat diet supplemented with psyllium (Metamucil (tm), 1 to 3 tablespoonfuls per day) may be necessary.
We try hard to follow the manufacturer's recommendations for foods in most cases but we do make some exceptions when treating diarrhea, especially in kittens. For some kittens with chronic diarrhea we have the best success using w/d diet to control the diarrhea but this is not a recommended use. We try to use it for less than two weeks. This usually isn't a problem because it generally works within 2 to 3 days when it is going to be helpful.
Inflammatory bowel disease is sometimes responsive to the use of limited antigen diets and these work for food allergies, as well. Antigens are substances that can stimulate the immune system. Most proteins can do this, along with a few other substances. When dogs are allergic to a particular type of protein, such as beef or chicken, they will react to any dog food containing that protein. A diagnostic food trial using a diet that contains only proteins that the dog or cat has never eaten before is necessary to rule out food allergies. This can be accomplished by picking unusual protein sources, like alligator, duck, salmon (for dogs) or lamb (not as useful as it used to be since it is in more pet foods now). Purina (HA, LA tm) and Hills (z/d tm) both make low molecular weight protein diets now that are thought to be unable to cause food allergies. This diet has to be fed for about 6 to 8 weeks with NO other foods, treats or medications that contain flavorings. In multiple pet households this can be an extremely difficult diagnostic test to carry out successfully as it is hard to keep pets from eating each other's foods.

Trial and Error Treatment can be Reasonable
Metronidazole (Flagyl Rx) and fenbendazole (Panacur Rx) are the workhorses among medicines for initial treatment of diarrhea. Fenbendazole is a wide spectrum deworming agent. It is often used even when fecal exams are negative because it treats the two common parasites that are hardest to find on fecal examinations, whipworms and giardia. Metronidazole is an antibiotic that may also have anti-inflammatory properties. It is useful in the treatment of several causes of diarrhea and therefore it is tempting to use it without attempting to make a specific diagnosis. When this works it can spare a pet from endoscopic or surgical examination. There is a very wide range of published dosages for metronidazole, depending on the condition is it being used to treat -- so sometimes it is used once in a trial and error approach without success but then used after a more specific diagnosis is made but with a higher or lower dosage that is appropriate to the condition being treated. The biggest problem with metronidazole is that it isn't actually approved for pets and is made in pill sizes more appropriate for people than pets. It is sometimes necessary to break pills into 16ths or even smaller sizes to treat pets. When this is necessary it can be helpful to use a compounding pharmacy to make the tablets into a flavored form. Alternatively, putting the small pill segments into a capsule can be helpful as metronidazole tastes very bad and breaking the pills can make this problem worse.
Other antibiotics that are sometimes used to try to treat intestinal disease include amoxicillin for suspected Clostridial infections, tylosin (Tylan Rx) for bacterial overgrowth and Clostridial infections, tetracyclines for nonspecific infection, sulfa based antibiotics for coccidia infections and sulfasalazine (Azulfidine Rx) for chronic colitis. It is sometimes reasonable to try these antibiotics without a specific diagnosis but since they tend to work better for certain conditions than for others, it is usually best to have at least a good idea which disorder is being treated before using these antibiotics.

Searching for a Diagnosis
Once it becomes obvious that diarrhea or vomiting is going to be a chronic or intermittent problem and the basic steps have been taken to rule out parasites, dietary sensitivities aren't present and the most common treatments are not going work, it is usually necessary to begin a diagnostic work up to figure out the cause for chronic vomiting or diarrhea. It is OK if this process takes some time. Diarrhea and vomiting are annoying but most pets with either symptom can live with their problems for months to years before there are serious side effects.
There are several diagnostic tests that are helpful in ruling in, or ruling out, various causes of chronic diarrhea and vomiting. Some of these tests are for specific conditions that might be present and other tests are more general in their application. It is usually better to work from general testing to specific testing but there are some exceptions based on breed tendencies, the case history and other factors.
Endoscopic examination of the digestive tract is probably the procedure that provides the best chance to diagnose a variety of disorders. It is important to try to find an endoscopist who has enough experience to be able to detect subtle changes in the appearance of the digestive tract and who can properly identify appropriate tissue for biopsy samples. In many areas of the country this will involve finding an internal medicine specialist who does endoscopy on a routine basis. Many of my clients try to avoid endoscopy but it really is the best procedure for diagnosis of chronic vomiting and diarrhea in most cases.
Endoscopy does not always provide a diagnosis and can on occasion provide a misleading diagnosis due to the small size of biopsy samples that can be obtained through the endoscope. There are times when it is necessary to consider obtaining larger tissue samples through exploratory surgery when an endoscopic biopsy is inconclusive or response to treatment for the condition identified is not as good as is expected for that condition. It is reasonable to obtain biopsy specimens surgically first if there is other reason to perform surgery or if endoscopy is not an option for some reason. It is probably better to consider the following imaging techniques prior to going to surgery, though.
Ultrasound examination can be helpful in some intestinal and gastric disorders. A good ultrasonagrapher can often detect inflamed intestinal loops suggestive of inflammatory bowel disease well enough to make this method of diagnosis nearly as sensitive as endoscopy, although without the ability to do biopsies at the same time the procedure is still limited. Ultrasonagraphy is the best way currently available to evaluate the pancreas and it can be very helpful for evaluation of the architecture of the liver and kidney, which can help rule out systemic illness as a cause for the diarrhea or vomiting.
X-rays (radiographs) are not nearly as useful in diagnosis of chronic diarrhea and vomiting as endoscopy or ultrasound examination but there are times when they do show a specific problem, especially when ingestion of a foreign object is likely or when large abdominal tumors are present. Using barium or other contrast dyes to enhance intestinal X-rays is useful but still doesn't provide enough additional information to make X-ray procedures as useful as ultrasound or endoscopy. In most veterinary practices X-rays are still the most widely available imaging technique and it is usually better to go ahead and get radiographs before sending a pet to a specialist, just to rule out the things that can be seen on them, as long as everyone understands that the odds of identifying a specific problem aren't very high.
Serum testing for folate, Vitamin B12 (cobalamin) and trypsin-like immunoreactivity (TLI) can all be helpful in ruling in or ruling out some causes of chronic diarrhea.
Trypsinogen is an enzyme that is manufactured by the pancreas. When levels of this enzyme are very low in the serum it is likely that the pancreas is not functioning properly. This is a fairly common problem in young to middle-aged German shepherds and can occur in other breeds. Without sufficient pancreatic enzymes food can't be digested. When undigested food makes its way through the digestive tract it causes diarrhea, often a very severe diarrhea. Dogs with pancreatic insufficiency have chronic diarrhea, weight loss, dull hair coats and sometimes vomiting. It is unusual for TLI levels to be too high but sometimes this seems to occur when pancreatitis is present and some veterinarians do use this test to help them decide if pancreatitis is a problem. Serum folate and cobalamin may be normal or low in patients in pancreatic insufficiency.
Folate is absorbed from the upper portions of the small intestine. Cobalamin is absorbed from the lower (farther along) portions of the small intestine. At times differences in the absorption of these substances can help in identifying the type of disease that is present. While low cobalamine and folate levels are helpful in confirming that intestinal disease is present, they don't specifically identify the type of problem in most cases. Low levels of both folate and cobalamin occur with diseases like inflammatory bowel disease and lymphocytic-plasmacytic enteritis because absorption of many nutrients is affected by the disorder over time.
Older cats should be tested for hyperthyroidism, especially when chronic vomiting is the primary problem. Older dogs will sometimes have diarrhea associated with the hormonal diseases such as hypothyroidism and hyperadrenocorticism (Cushing's disease), although these do not frequently cause either diarrhea or vomiting.

Why is it so hard to get a diagnosis sometimes ?
I sometimes see clients who are coming to me after seeing as many as four or five other veterinarians in a quest to discover a cause for their pet's chronic diarrhea or vomiting. These people are often very frustrated by the difficulty in obtaining a diagnosis. While you can see from the information presented so far that getting to a diagnosis can take some time and effort, it is also possible to see a pretty straight path to a diagnosis, consisting of testing for parasites, deworming with a broad spectrum dewormer, trying a low fat diet, then a moderate to high fiber diet, then a hypoallergenic diet, using some medications in a trial and error process and then going to specific diagnostic testing procedures, especially endoscopy with biopsies when possible.
So why does this process fail? I think that lack of patience on the part of the pet owner and/or the veterinarian is the most common reason. The pet owners who come to me after seeing several vets have usually only had part of the diagnostic process done at any of the veterinarian's before moving on. In some cases this is because the veterinarian is attempting to take short cuts through the diagnostic process for convenience sake or in an effort to save the client money. In other cases it is because the need for a specific step in the diagnostic process isn't clear enough to the client to make them willing to participate. This is particularly true of the period in which various food trials are necessary. If your vet has a plan to get to a diagnosis, has explained it and is helping you through it then the need for patience falls on you. Work with your vet to get through the necessary diagnostic steps, even if it does take several months to do this in an orderly fashion. The other common mistakes made by veterinary clients are to avoid endoscopy due to the cost or worry over the procedure itself and to balk at doing repeated testing for the same problems because it is hard to understand that some of these tests really do give more information when they are done several times, even if the results are "negative" each time.
If your veterinarian just isn't patient enough to help you through the entire diagnostic process he or she is likely to be willing to refer you to a board certified internal medicine specialist who will be. This is an option that shouldn't be overlooked. Specialists are available in many areas of the country now.
It is almost always possible to find a way to help pets with chronic vomiting or chronic diarrhea, but it can take a great deal of patience along the way. It can be quite difficult to do good dietary trials, especially when there are multiple pets in the household but an effort should be made to do them whenever possible. If one of the "trial and error" medications works well a diagnosis may not be necessary but it may be necessary to accept that the medication will have to be used continuously or intermittently for long periods of time. While I didn't mention corticosteroids earlier, they are commonly used when a diagnosis of inflammatory bowel disease is made and long term use may be necessary. Occasionally intermittent use of corticosteroids works well to control chronic vomiting in cats and this is another instance in which a definitive diagnosis may not be absolutely necessary.
I didn't attempt to cover all of the medications that might be helpful or all of the possible diagnoses in this issue of the VetInfo Digest. Many of the medications are only used in the case of specific diagnoses. If it is possible to reach the point that diagnosis is made your veterinarian will provide the best medication or diet for that disorder.

Gastrointestinal Obstruction
If your veterinarian is suspicious that your pet has ingested something that it shouldn't that may still be present in the digestive tract (a gastrointestinal foreign body) it is important to keep a few things in mind.
For cats, any suspicion of a foreign body should prompt a careful inspection of the cat's oral cavity, including a search under the tongue for evidence of a linear foreign body. These are objects like string or tinsel that cats will sometimes swallow. If one end of a linear foreign body hangs up anywhere from the mouth to the colon the other end may continue down the digestive tract. Eventually the peristaltic motion of the intestine that is meant to move food through will result in bunching up of the intestines around the foreign body and either perforation of the intestine or interference with the blood supply that causes death of a section of intestine.

Dogs can ingest linear foreign bodies as well. Sometimes long objects such as pantyhose that might not be thought of as a linear foreign body will cause similar problems in dogs to those seen in cats. More commonly, though, dogs swallow things like toys, stones, peach pits and corn cobs that can make it out of the stomach but are too large to move through the intestines. Often the initial sign of a problem like this is simply that the dog refuses to eat. This is followed by vomiting and sometimes diarrhea (especially when a partial obstruction is present). As the intestine becomes more seriously damaged the vomiting may stop and ingestion of great quantities of water may occur. This is a sign that a section of the intestine is dead or near death and bacterial toxemia is occurring.
The intestine can not tolerate the presence of a foreign body large enough to impact on the blood supply for very long. The time span between being able to remove an object fairly easily from healthy intestine to the time when it is necessary to remove large sections of damaged intestine can be very short. It is critically important to allow exploratory surgery when your vet suspects a foreign body. This is so important that you have to be prepared to encourage your veterinarian to go ahead with surgery by not showing any sign of hesitation to commit to the procedure. It is far better to do an exploratory surgical procedure and find no obstruction that to wait to see if clear signs of an obstruction occur when sections of the intestine have already died.

Most of the time I am fairly conservative about surgery but over the years it has become apparent that I have harmed more patients by waiting to do surgery until I was absolutely certain it was necessary than by doing surgery when a foreign object wasn't found. In many cases we are able to take biopsy samples or to find a diagnosis that we didn't expect when we started the surgery -- but even this isn't necessary to justify the value of the surgical procedure. It is hard to think of surgery as a diagnostic procedure but in this case it is one -- and it is a very valuable option to have.

Asking Questions
I have finally had to break down and use a spam filter to sort through my mail. I am not sure why there has been such a huge jump in the amount of spam that I am getting, but the volume of mail is just too much to sort through every day. For this reason it is especially important that you put "Subscriber Question" or use some sentence that contains the word "Subscriber" when writing to me. I scan the mail that is designated junk but I know that it is inevitable that I will miss some questions asked by subscribers if they aren't easy to identify. Please note that I answer questions addressed to mervet@inna.net. Mail that is sent to vetinfo@vetinfo.com, editor@vetinfo.com or any other address at vetinfo.com goes to Michal first and makes it to me only if it contains a subscriber question.

At the present time I am able to answer questions in most cases within a day or two, so please feel free to send your question again if you don't receive an answer within two days. With the note on the site that we do not offer the "Ask Dr. Mike" feature anymore, the volume of subscriptions is down enough that I am comfortable with it. I appreciate it that most of you have honored our request not to post that I am answering questions on web sites or bulletin boards. I need to continue to practice full time for at least a few more years. After that it might be possible to reconsider offering the "Ask Dr. Mike" pages again when I have time to answer many more questions that I currently get. We are appreciative of the support that you provide for the web site. It allows us to keep most of the information available to the public without having to bear the entire cost of the site ourselves.

The Best Months for Veterinary Care are Coming Soon
It may seem odd that bringing your pet to the vet at different times of the year would affect the care that it gets but I am pretty sure that it does. I know that in the months of December, January and February in our practice we are not as busy as we are most other months. It is possible for us to spend more time to ask questions, do testing procedures or to take a little extra time on a physical examination during these months. While I wish that I could provide this extra care during every single month it is hard to do this and get through a really busy day, too. Veterinary clients who wish to have a little more time to ask questions or who want the most thorough examinations possible might do best to schedule yearly physical examinations during the slow months at the veterinary practice. In general the slow months occur during the winter but this can be variable, especially in areas in which tourist seasons impact on the business climate or where the local economy is highly dependent on particular seasons. For routine visits avoid the busy season and improve your pet's health care.

The VetInfo Digest is published by:
TierCom, Inc.
P.O. Box 476
Cobbs Creek, VA 23035.

The opinions expressed in this newsletter are those of Michael Richards, DVM., author.
Copyright 2003, TierCom, Inc. Thanks for your support!

This page was last edited 06/21/04
Subscriber homepage |Backissues | Breed index |
Vetinfo | vetinfo4cats| vetinfo4dogs

| Canine Encyclopedia |
Feline Encyclopedia| VetInfo Digest |Links |Zoonotic info

Please do not send anything in attachment form. We will not be able to open it due to security risks.

This page is authored by
Dr Michael Richards, DVM
and produced by TierCom, Inc.
Opinions expressed are those of Dr. Richards.
Designed and edited by Michal Justis
copyright �1996,1997,1998,1999,2000,2001,2002- TierCom, Inc