Diarrhea with Vomiting also Constipation

 Chronic Diarrhea with occasional vomiting in Mastiff

 

Question: Dear Dr. Mike, I have a 2 1/2 yr. old male mastiff with digestive issues. His entire life he has had chronic diarrhea (most all the time)  and periodic vomiting (about once a week). I have had him on a variety of high grade kibbles with ingredients that were suppose to be highly digestible.) These last 2 weeks have seen an increase in vomiting and diarrhea with mucus and straining for about 3 days. We were able to get it under control by fasting, Metronidizol and then a bland diet of rice and lean beef. I added an enzyme formula (for humans)  He went several days without incidence, I added yogurt (not low fat) and this morning vomited again. We had his stool tested and he does have tape worms, but I have not treated him yet, as he had the latest bout of vomiting. I will be taking him to my local vet next week for an exam and tests and would like to be as prepared and as informed as possible. These are his primary symptoms (over the last yr. or more): Chronic cow pie stools (bright mustard yellow color) occasional vomiting (usually undigested food and/or lots of bright yellow liquid) energy level good,  not depressed, sometimes agitated eats rocks, leaves (I have always had a feeling this was a symptom and not a cause, especially since I do not give him the opportunity to do these things and he has still been sick) symptoms clear up with Metronidizol (only used recently as symptoms became severe) good appetite (generally quiet hungry and anxious to eat) gurgly stomach and gassy weight stable at about 220lb Could you give me some idea of what to look and test for first? Thanks, Jill

Answer: Jill- It is sometimes a bad idea to take shortcuts to a diagnosis, so be careful in using this advice, but there is a chance that the treatments used so far have already provided a diagnosis for your Mastiff's problems. The reason that I say this is that it is responsive to metronidazole. There are two or three conditions that are very responsive to metronidazole. The first is small intestinal bacterial overload, or SIBO. This condition can recur whenever antibiotics are not being used. It is a little odd that it would start so early in life but it is a condition that is responsive to antibiotics and low fat diets and then often recurs if the antibiotics and/or the diet are discontinued. Other inflammatory bowel disease conditions will also sometimes respond to the use of metronidazole and it also works for parasitic conditions caused by Giardia or possibly other species of protozoans. If you ignore the hint that the metronidazole provides and opt to do a diagnostic workup, which is a reasonable idea (probably a good idea) in a dog this young whose condition may affect it all its life, these are the basic steps to take to systematically rule in or rule out various possible causes: 1) Repeat fecal examinations looking for any type of cause. It is best to to a three part fecal examination in this type of case:  a) examination of a small amount of stool mixed with saline solution --- this tends to be the best way to find protozoans for many people and it gives an idea of bacterial activity, although this can be deceptive b) fecal floatation -- this is the best way to find worm eggs. Tapeworms don't always show up in fecal floatation's due to the way they release their eggs (as packets that look like little worms) but it is good for finding hookworms, whipworms, roundworms and sometimes other worms that might occur less frequently c) stained fecal smears -- this is a good way to see evidence of Clostridium perfringens bacteria and with special staining other bacteria, as well Fecal floatation's should be repeated at least three or four times in mystery cases as it is easy to miss some worms, especially whipworms. 2) Deworm with a broad spectrum dewormer like fenbendazole, even if you don't find worms. Why go to the trouble of looking for worms if you're going to deworm, anyway?  It is very helpful to know that worms are contributing to the problems if it is possible to demonstrate that but it is a good idea to eliminate them anyway as they sometimes can be present without being found. If no worms eggs are seen on flotation and there is no response to broad spectrum deworming it can be assumed that worms are not likely to be a contributing cause except in rare cases in which roundworm larvae seem to contribute to inflammatory bowel disease symptoms due to the dogs reaction to them  (roundworms can migrate in the body and not ever reach adulthood to produce eggs). 3) Try a food trial of consisting of a low fat diet for at least 2 weeks. Some dogs respond well to low fat diet alone. There are several good diets. Fit and Trim (tm) is easy to find but i/d (tm), w/d (tm) both by Hills and OM diet (Purina) are also good choices. There are probably several others, as well. 4) In a dog with problems starting this young it would be a good idea to consider testing for digestive enzyme deficiency. There is a blood test, called the TLI or trypsin-like immunoreactivity test, that is very good for diagnosing this condition. It can be combined with serum folate testing and serum cobalamin testing to get a better idea of whether SIBO or other malabsorption diseases are present.  I think that I would be tempted to run this test due to the early onset and continued problems. It doesn't seem to make sense that an enzyme deficiency would respond to antibiotic therapy but we have had a couple of patients who had marginal enzyme deficiency problems who would respond to low fat diets and antibiotics but who seemed to do a lot better when we also added digestive enzymes to their diets. 5) X-rays are usually not very helpful in cases of chronic diarrhea but there are occasional causes of chronic GI tract problems that do show up on X-rays and if you want to touch all the bases it is reasonable to have abdominal X-rays taken. 6) Ultrasound exam is a little more useful but still doesn't help much in a large number of cases but is also another reasonable choice to gain information, especially if the first few simple things don't help much. 7) A general chemistry panel and complete blood cell count is a good idea, as well. It also usually doesn't help much but when it does it can be very important, such as a patient with marginal kidney function contributing to the diarrhea or a liver problem. In a few cases it is necessary to get more specific blood testing done, such as bile acid response testing, if the general panel does show a problem with the liver, for instance. I would try to ensure that electrolyte levels are included in the panel because one very important cause of continued GI problems from a young age is hypoadrenocorticism (Addison's disease) and one way to screen for this is to check the sodium and potassium levels and the ratio between them. Even though this testing is low yield in terms of giving a diagnosis I would really want to have this information in a patient of mine as it doesn't harm the pet to draw the blood and there is a great deal of reassurance in finding normal values in the blood work. 8) It would be reasonable to put this step before going to through some of the earlier steps but I put it here because it is hard for most owners to do:   dietary food trials can be very helpful in making a diagnosis in continued digestive tract problems. Dietary food trials are very easy in theory but very very difficult to do well in reality.  The idea of food trial is to find a protein source (mandatory) and carbohydrate source (best) that the dog has not ever eaten before and to feed them and NOTHING ELSE for 6 to 8 weeks. Finding the protein source involves thinking carefully about what your dog has eaten in the past. Fortunately there are a lot of odd protein sources, like duck, salmon, alligator, ostrich, etc --- so if your dog has had a varied diet there is still usually some meat source that he hasn't eaten. Combine this with a carbohydrate like rice, mashed potatoes, peas or something else your dog hasn't eaten and then feed this diet (your vet can help you get the recipe right or you can buy a commercially prepared food). Most experts in the field of GI problems think it is best to use a home made diet for the food trial but the commercial foods are worth trying if that isn't possible. If your dog recovers completely or is obviously going to during the food trial then you know that food sensitivity of some type is likely. Then you can add back ingredients to the diet to figure out what the sensitivity is or just feed a diet that doesn't cause problems. The trick here is the NOTHING ELSE part --- dogs are very good at getting people to give them treats, finding cat food, or even cat poop, or other things to eat that make the food trial invalid. You have to be really dedicated to ensuring that your dog doesn't get anything but the diet during the food trial. It is worth making this effort because finding a food sensitivity gives you the ability to control the problem life long. But even with this knowledge many of my clients simply can't arrange for a good food trial due to having other pets, small children, dogs who can't be confined easily for 8 weeks (so no trips to the neighbors or hunting expeditions for food). 9) If all of the above tests fail to yield a diagnosis then intestinal biopsy may provide a diagnosis. This can be accomplished by endoscopy, which has the advantage of allowing biopsy samples with minimal invasion of the body but can only get samples from the digestive tract or by doing exploratory surgery, which is much more invasive but allows sampling of the pancreas, liver, intestines, intestinal lymph nodes and anything else the surgeon sees that looks like it might be best to biopsy. So with all this in mind, you have to decide how to proceed. You can accept that antibiotics work and try tylosin or sulfasalazine, which might be better choices for long term use than metronidazole (there is a suspicion that metronidazole can cause cancer with continuous use in some patients) and if that works out OK you can shortcut the diagnostic process. The other alternative is to go ahead and do a work-up. If you do that, it is probably most practical to repeat the fecal examinations, consider a general chemistry panel and complete blood count, including electrolyte measurement and consider a low fat diet for two or three weeks as first steps and then to work through the rest of the steps as you have to.  Your vet may have a different idea of the order or may have additional tests that he or she thinks might be more helpful and given that he or she has a much better idea of your pet's physical condition and medical history remember to keep in mind that their advice is more meaningful. I hope that this helps some.

Mike Richards, DVM

Diarrhea in shih-tzu 

Question: Dr. Mike, I want to thank you for your response to my question some time ago about my little Shih-tzu Zachary that was experiencing horrible diarrhea. If you remember, the only course my vet suggested was antibiotics and a strict diet of Hills Science Diet W/D.  Well a few weeks after your response my older Shih-Tzu who has never had any medical problems at all began experiencing similar diagraph.  While my Vet assured me that the two dogs' situations were not related, I felt that they were.  The vet then took blood, urine and fecal samples and had them evaluated. There were no abnormal bacteria or parasites, but both of the dogs had very, very high level of tryglycerides.  The vet's recommendation was again, Antibiotics and W/D for both dogs.  After the antibiotics ran their course, in a few days the diagraph returned, worse.  I have always felt that there was something in the food that little Zachary could not digest.  So my mom (an equally possessed dog lover who has 5 shih-tzus) developed a diet that would allow his little body to rest.  It consisted of Boiled Potatoes, Canola oil, Shredded carrots, Chicken Stock and minced garlic.  Immediately we noticed that my older dog, Zeus was digesting the food normally, but that little Zachary wasn't, it looked exactly as it had when he had eaten it, same color.  His body wasn't digesting it at all.  I have now added Solid Gold D-Enzymes, hoping that it would help him digest the food.  Do you have any suggestions as to what his condition could be?  I am stumped.  A friend of my mother's who promotes Holistic Veterinary medicine has suggested weaning the guys onto a raw food diet, and I have begun about a tablespoon with each meal. In your response to my previous question you mentioned IBD, does this still seem like IBD? If you have any suggestions , again it would be greatly appreciated.

Answer: Lisa- I am not a fan of raw meat diets. Personally, I don't see where the risk of infection with E. coli or Salmonella is worth whatever benefits the raw meat diets offer. It does seem like a good idea to add a meat source to the diet you are offering Zachary, though. I didn't see one in the list of ingredients and it is not a good idea not to feed at least one good protein source. The dietary approach that I would be wanting to take in a patient of mine would be to use a limited antigen (one protein source, hopefully one that the dog has never eaten before) or a hydrolyzed protein diet (Hill's z/d tm or Purina HA tm). These diets have small molecular weight proteins that are "hypoallergenic" and may help if there is a food sensitivity. It would be a good idea to repeat the fecal examinations at least once and preferably two or three times, especially since more than one dog had diarrhea in the household. Whipworms and giardia can be very hard to find on fecal examinations and it may take multiple tries to identify these parasites. Fecal smear examination for Clostridium species bacteria might be a good idea, too. It may also be a good idea to check serum trypsin-like immunoreactivity (TLI testing), which can detect a deficiency in digestive enzymes. This test is often combined with serum folate and cyanocobalamin testing, since rises in the levels of these vitamins in the blood stream can help to pinpoint the location of digestive tract disease.  If there does seem to be a digestive enzyme deficiency, treatment is possible. Endoscopic examination of the digestive tract, after localizing the problem to the large or small bowel, may enable a diagnosis to be made through biopsy samples taken as the examination is done. This usually involves a trip to a specialist but at Zachary's age it would be worth having a diagnosis since he will be living with this problem a long time. Some people can not afford a diagnostic workup. In these cases I think it is reasonable to treat for the likely problems and will often use a broad spectrum dewormer, such as Panacur (Rx) and then an antibiotic that is helpful in inflammatory bowel disease, such as sulfasalazine (Azulfidine Rx), tylosin (Tylan Rx) or metronidazole (Flagyl Rx). If this works but the problem occurs again when the antibiotics are stopped, I will keep patients on the antibiotic for extended periods, months to even years, if necessary. It is better to have a diagnosis and to consider specific treatment, when possible, prior to resorting to this approach, though. This is especially true before proceeding to the last step in treating inflammatory bowel disease, which is the use of corticosteroids and/or other immunosuppressive agents such as azathioprine (Imuran Rx). It can take a long time to work through the diagnostic process and then come up with a workable treatment plan for a dog with chronic diarrhea. Hang in there, keep working with your vet -- or possibly ask for referral to an internal medicine specialist -- and over time, I think this will work out. 

Mike Richards, DVM

Vomiting and Diarrhea

Question: Dear Dr. Mike, We have a 9.5 years old cocker spaniel. He got occasional vomiting (1-2 times a week) a few months ago. It was after he got teeth cleaning and extraction of two of them at vet clinic (may be unrelated). Previously it happend to him only when he has eaten something bad (like e.g. he likes eating paper napcking for some reason), but now it was happenning on a more regular basis. Otherwise he felt well. Two weeks ago he got severe vomiting (1-2 times every day) and diarrhea (a few times a day). Vomiting often is yellow, sometimes clear, often has food pieces. Diarrhea is often yellow. After a  few days we went to a vet, showed two fresh samples of vomiting and diarrhea (nothing was found in them), blood sample was taken (normal, a bit lower protein), urine sample (normal), X-ray (normal, a bit bigger prostate), pulpation did not show anything. We got a few cans of lite dogs diete. After one day of no food, and a few days on a diete he seems to become better. We gave him two days ago a bit of raw meat and on the same days the rest of the dog diete from a can. This seemed to trigger another (even stronger) iteration of vomiting/diarrhea. The current status (after one more day of almost no food) he refuses to eat dog's food (Science diete dry, Science Diete from cans),  eats some people dry crackers and would probably except other people food, but we are afraid to give it at this point. Still has a few loose stools per day.  Our vet does not have a constructive program of how to fight with this.  I read all your replies on vomiting/diarrhea cases and would like to  fight with possible causes of the desease one-by-one.  Should we start with metronidazole as a possible treatment of Giardia?  How long/how much for 22-24 pounds cocker? Should we also use Immodium, or better one  treatment at a time.  What would be the right order of treating possible reasons (Giardia, Coccidia,  inflammatory bowel desease?).  Should we do more stool samples?  Also we are afraid that he is loosing weight (since he was not fed normally for two weeks) and he does not like  dog's food (when he was a puppy we fed him with a home diete, and since then he eats dog's food only with some small addition of some people food - a few small pieces of bread or 1-2 spoons of veg. soup), so may  be we should try home diete. Where can I find Hill's or any other reasonable diete for cockers and what should be the diete for the first days (e.g. is cooked rice a good idea?).  Finally, unfortunately our vet seems to be not knowledgable enough. Do you have any recommendations  for a vet in Portland, OR. Thanks a lot for you help! - --Mike

Answer: Mike- I am not familiar with any veterinarians in the Portland area, so I can't help with that part of your request. If you are still having problems it would help a lot if you could obtain a copy of the lab results for the blood tests run so far and send them so that I can get an idea of what testing has already been done. I can give you a basic plan for working through the various causes of vomiting and diarrhea in the meantime. The first thing to do is to rule out intestinal parasites to the greatest degree possible. Checking a couple of stool samples for giardia, coccidia and intestinal worms is a good start to this. Giardia can be hard to find on a stool sample and it is reasonable to treat for it with metronidazole or fenbendazole even if it is not found in a stool sample. It is also important to try to determine if the diarrhea seems like it is a small intestinal or large intestinal disorder.  As a general rule of thumb, large intestinal diarrhea tends to have frequent bowel movements, often with straining, and small amounts of diarrhea at a time.  Small intestinal diarrhea tends to have a regular number of bowel movements per day, or perhaps a small increase in number and the quantity of diarrhea expelled at one time tends to be a larger amount. Causes of small intestinal diarrhea include parasites (roundworms, hookworms, whipworms, giardia, coccidia, tapeworms), bacterial infections, viruses,  malabsorption disorders, inflammatory bowel disorders, ulcers, fungal infections and systemic illnesses that make it difficult for the intestines to function properly. Causes of large intestinal diarrhea include parasites ( coccidia and whipworms), bacterial infections (more likely in the large intestine than the small), inflammatory bowel disorders, cancers, fungal illnesses and sometimes protozoans. If it is possible to decide if the diarrhea and vomiting are occurring due to a large bowel or small bowel problem, it can help with deciding which test to run and which treatments to try. In older dogs with a new problem of diarrhea and vomiting checking a general blood panel is a very good idea, so having normal test results in blood work is good.  It is worthwhile to consider running some specialized tests that are not included in a standard blood panel, too.  There is a test for pancreatic insufficiency (which is one of the malabsorption syndromes) called a trypsin like immunoreactivity (TLI) test, that is helpful in determining if pancreatic function is normal. It is often combined with  cobalamin and folate serum level tests to try to sort out other malabsorption problems.  Checking amylase and lipase levels to try to rule out pancreatitis is a good idea, too.  These tests are sometimes included in general panels but more often are not. After ruling out parasites as much as that is possible to do and after checking general blood panels and perhaps checking the more specialized lab values (depending on the signs seen), the next step, if necessary, is usually to consider intestinal biopsy by endoscopy.  Since this is an invasive procedure requiring general anesthesia, many veterinarians feel that taking a short break from diagnostic testing and just treating for logical possible problems, such as bacterial overgrowth or inflammatory bowel diseases is reasonable.  That is a judgment call that you and your vet have to make. Some vets and clients prefer to try a dietary food trial to be sure a food sensitivity isn't present before doing endoscopy. This is not a bad idea but a new food sensitivity in an older dog is not a common event so it may be better to skip that step. I am really hoping that this information isn't necessary anymore. If the problem is still going on it would be possible to help more with the lab results of tests run so far and with an updated history of what has happened. I apologize again for the delay in answering  your questions.

Mike Richards, DVM 

Vomiting and Diarrhea- continued

Question: Dear Dr. Mike Thank you very much for your reply and for your vet club activity. It took us long time to (as we hope know) overcome our dog's desease and therefore this long delay in my reply. When I received your message he was in the middle of the crisis. He was taking metranidazole for the last day. Low appetite, refusing to eat dog's food. He lost four pounds in a 6 weeks of his disease and eventually got a problem moving: his legs were not strong enough to keep him standing or walking. Since then we stoped metronidazole and switched his diet to boiled ground chicken, which we give him warm. We add some cottage cheese or boiled egg. Now, after a month from this crisis, he eats twice a day and his weight is close to normal. We also add one tab of Pet-Tabs to compensate for vitamins/minerals. Our vet told us that is close to the commercial diet, but we wonder if we should follow this diet since it works fine for our dog or switch it slowly to complete or partial commercial diet (cans, not dry food, it is clear at this point that the dry food is a problem to our dog, possibly because he lost some teeth and has difficulty eating it). Analyzing your reply with a help of our vet (we changed the previous one) we seems to agree that it was most likely the inflammatory bowel disorder (large bowel). Parasites seems to be ruled out (as far you can trust a few tests). Pancreatitis was ruled out, pancreatic insufficiency seems to be unlikely according to our vet. The list of tests: parvo antigen : negative salmonellosis: neg campylobacter: neg roundworms:neg hookworms/eggs:neg whipworms/eggs:neg giardia:neg coccidia:neg tapewarms?eggs:neg abnormal bacteria in stool:neg blood in stool:neg normal pH of Urine: 6500 protein in urine:neg other urine test parameters normal blood test - normal THey took a few different tests for parasites - all neg. Both vomiting and diarrhea stoped a month ago and did not recur so far. During tests our vets found that our dog's prostate is a bit bigger than normal and suggested us to go through endoscopy, but since our dog suffered already a lot during last months we are relactant to go through it at least for now when he feels good and fully enjoys life again. Thanks again for your help. I would really appreciate your advice on how long can we stay with this diet. With very best regards, Mike   

Answer: Mike- It is usually possible to feed a diet that is not providing complete nutrition for several weeks to several months (depending on what is missing from it) before there are problems. I suspect that the diet is deficient in some nutrients as it is primarily meat based unless you left out some ingredients (like vegetables or rice) that you are adding, too. I usually try to get dogs back on a commercial diet by slowly reintroducing it after they are eating well and feeling well for a couple of weeks. Commercial diets are easier for most of my clients and they offer a reliable mix of the necessary ingredients for a complete diet. Canned food is certainly acceptable if you or your dog prefer it, or need it. If you would prefer to continue to feed a homemade diet it would be best to find and follow a recipe that has been evaluated by a nutritionist. There are a number of these diets published in veterinary books or journals relating to liver disease. It is important to find and use the ingredients listed in the diets or to get a nutritionist to evaluate necessary changes, whether they are based on unavailability of ingredients or unwillingness of the patient to eat listed ingredients.  There are veterinary nutritionists who will evaluate diets for a reasonable fee and I can provide contact information if you need it. It would be reasonable to recheck the prostate size on a regular basis and reconsider further diagnostic testing if the size continues to increase or if any symptoms of prostate disease occur. These would include difficulty urinating, straining to have bowel movements, lameness in one or both rear legs, blood in the urine and fever.

Mike Richards, DVM

Giardia

Giardia is a protozoan parasite that lives in the intestine of affected animals. It is unclear whether there are several species of this parasite or whether there is one species that affect several different animals, including people. These small parasites are very easy to miss on a fecal exam and may not be present in the stool of animals infected with the organism. Repeated fecal exams are sometimes necessary to identify this parasite. Not all animals in which infection can be demonstrated have clinical signs. This leads some people to believe that the parasite may not cause disease . Most vets think that there may just be other factors, like the animal's immune response to the parasite that cause some animals to develop disease and not others. Clinical signs of giardia include weight loss, inability to gain weight appropriately during growth, diarrhea, vomiting, lack of appetite and greasy appearing stools. Them most commonly used medication for giardia infection is metronidazole (Flagyl). The organisms come from the environment and live in moist to wet areas. They are susceptible to quatenary ammonium disinfectants, Lysol and dilute chlorine bleach. Keeping the dog's environment dry helps a lot. This disease may be contagious to people from infected dogs so good sanitary practices, like washing your hands after handling an infected puppy, are very important. If a family member develops similar clinical signs, a physician should be consulted.

Mike Richards, DVM  

Diarrhea and Vomiting

Question:  Dr. Mike, I Have an 10 year old dog, under 20 pounds, diagnosed with pancreatitis. Periodically suffers severe bouts of diarrhea and vomiting, and has been under our vet's care for over a year for the condition. Finally managed to control the colitis with regular doses of prednisone (2.5 mg. @ day) but I'm wondering about the toxic results of taking so much of the drug. My dog is losing most of his hair across his back, still has bouts of diarrhea and vomiting (though not as severe) and really isn't a happy camper any more. Am I right to feel concerned about the effects of the drug long term, and/or is there any other treatment for what might be either the affects of the pancreatitis or an inflammatory bowel? I hate to see this little guy suffer. Thanks for you help.

Answer:  Once in a while, I find myself dealing with two problems for which the best treatments conflict. You seem to have this problem. It is best, if possible, to avoid the use of corticosteroids in pets prone to pancreatitis. On the other hand, inflammatory bowel disorders often respond best to corticosteroids. This makes the situation difficult. I can think of a number of approaches to this problem that I might try -- but a "trial and error" approach can be frustrating when diarrhea and vomiting are the symptoms. For instance, a high fiber diet may be beneficial in both pancreatitis and in inflammatory bowel disease (IBD) in some dogs, so this might be worth considering. It might be possible to control both conditions without the use of medications. This definitely doesn't work in all cases of IBD, though. If it doesn't work, it would be frustrating for awhile. Other medications that might be beneficial include metronidazole or Azulfidine (rx). These are useful in colitis and often pancreatitis is episodic rather than chronic so it may not be a factor at this time. The only other concern I see is that daily use of corticosteroids is generally a last resort. It is much better if they can be used on an every other day (every 48 hour) basis. This makes it less likely that your dog will develop Cushing's disease as a side effect of the treatment. The hairloss you are seeing could be a sign of Cushing's disease. Even the use of powerful immune suppressive medications like azathioprine might be better than daily use of corticosteroids.

Mike Richards, DVM   

Constipation

Q: What can I give a small dog for constipation?

A: The first thing to do when a little long haired dog has constipation is to check their rectal area. Many times we have seen constipation caused by hair getting stuck together across the rectum and blocking release of stool. If this isn't the problem, it is usually safe to use stool softeners containing dioctyl sodium sulfosuccinate (ducosate) such as Colace (Rx), 1 capsule twice a day. But it would be better to talk this over with your vet if possible before medicating since constipation is often a symptom of some other problem. It is a good idea to figure out what the underlying cause is if possible.

Mike Richards, DVM