Introduction. Introduction 11/7/16. Up to 5 members: $599/year. Up to 1 0 members: $999/year. > 10 members: Ping u s

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1 11/7/16 Introduction Justine A. Lee, DVM, DACVECC, DABT CEO, VETgirl Peter S Chapman BVetMed DECVIM- CA DACVIM MRCVS Introduction Garret Pachtinger, VMD, DACVECC The tech- savvy way to get online veterinary CE! A subscription- based podcast and webinar service offering veterinary RACE- approved CE COO, VETgirl Up to 5 members: $599/year Up to 1 0 members: $999/year podcasts/year plus 24+ hours of webinars! $199/year 40+ hours of RACE- CE > 10 members: Ping u s 1

2 11/7/16 n Type in questions n ed to y ou 48 hours after t he webinar Active participation = no quiz Watching video later, must complete quiz n ELITE members only n n n / contact with A NY questions n garret@vetgirlontherun.com n justine@vetgirlontherun.com 2

3 Introduction Dr. Peter Chapman BVetMed(Hons), DECVIM- CA, DACVIM, Differential diagnoses Discussion of common causes Protein-losing enteropathy Diagnostic plan Minimum database Further diagnostics Treatment Focus on IBD Dietary Infectious SIBO/ARD Inflammatory bowel disease Neoplasia Systemic disease EPI Infectious Food allergy/intolerance Systemic disease Foreign body/obstruction Inflammatory bowel disease Neoplasia Inflammatory bowel disease Food allergy/intolerance Neoplasia Systemic disease Infectious Foreign body/obstruction 3

4 Giardia Parasites Intolerance Allergy Mild/early inflammatory bowel disease Appetite good Weight stable Signs may be intermittent/waxing waning and Bacterial Viral Fungal Canine strains probably have very low zoonotic potential! HIGH RISK GSD Chow CKCS Rough Collie LOW RISK Boxer Labrador Golden Retriever Rottweiler Weimaraner Inappropriate inflammatory response to normal antigens in GI tract Loss of tolerance Autoimmunity 4

5 Findings Hypoalbuminem ia Hypoglobulinemia Hypocholesterolemia Ddx Protein-losing nephropathy Liver failure Hypoadrenoc ortic ism Neoplasia Exudative loss Inflammatory disease Acute gastroenteritis Inflammatory bowel disease Lymphangiectas ia Lymphoma Infectious Gastrointestinal hemorrhage Exocrine pancreatic insufficiency Effusions Pure transudate SG <1.018, protein <2.5g/dL Low cellularity Thrombosis Especially distal aortic Hypocalcemia Presumed vitamin D malabsoption Check ionized calcium 5

6 Initial approach History Physical examination CBC/chemistry panel Fecal analysis Fecal flotation Giardia ELISA Helminth ELISA? PCR? Urinalysis +/- Urine protein:creatinine ratio Resting cortisol +/- ACTH stimulation test Bile acids Ionized calcium Fecal alpha-1 antiprotease Chronic diarrhea: 15% cases - ultrasound examination vital or beneficial 17% cases - not vital but gave additional information 67% cases - ultrasonography did not affect diagnosis Ultrasound more likely to be higher yield if: Weight loss Abdominal or rectal mass Leib et al. Journal of Veterinary Internal Medicine (2010), 24:

7 Case selection can increase diagnostic utility Weight loss Mass Age Hypoalbuminemia Weight loss Mass Age Hypoalbuminemia Ascites Ascites 50mg/kg SID 3 days Metronidazole 10 mg/kg BID Tylosin 20mg/kg BID 1/8 tsp 325 mg tylosin Large dog = ¼ tsp BID Psylium husk 1 tsp 1 TBSP BID 7

8 Large intestine Tenesmus Hematochezia Decreased volume Increased frequency Urgency Small intestine Weight loss Further work-up TLI - Check if Severe weight loss Polyphagia B12 - Check if Weight loss PLE Suspicion of malabsorption EPI Folate Check if? Focal vs diffuse changes? Upper vs lower GI? Lymphadenopathy? Mass? Other organ changes? Severe clinical signs Weight loss, inappetance PLE Failure to respond to treatment trials Ultrasound findings? 8

9 Severe thickening Lymphadenopathy Ascites Accessible mass Ulceration Endoscopy Access limited Surgery Can biopsy all regions Superficial mucosal biopsies Full thickness biopsies Can evaluate mucosal lesions GI tract only Low morbidity Low invasiveness Can only evaluate serosal surface Full abdominal exploration Risk of dehiscence More invasive Chronic gastrointestinal signs Biopsy evidence of mucosal inflammation No evidence of other underlying disease Inadequate response to therapeutic trials Clinical response to immunosuppress ives ACVIM Consensus Statement: Endoscopic, Biopsy, and Histopathologic Guidelines for the Evaluation of Gastrointestinal Inflammation in Companion Animals. JVIM 2010;;24:

10 Prednisone vs Prednisolone Delayed release in ileum/colon Metabolized by first pass metabolism Compounded? Metronidazole 10 mg/kg BID Azathioprine 2 mg/kg SID 2 weeks then EOD Cyclosporine 5 mg/kg BID Chlorambucil 4 to 6 mg/ m 2 every 24 hours Sulfasalazine 25mg/kg TID) <10kg 250μg 10-20kg 500μg >20kg 1000μg Weekly for 6 doses then monthly Recheck after 3-6 monthly doses If low then continue lifelong If high then try discontinuing and recheck Try oral? Antithrombotics Aspirin 0.5mg/kg SID Clopidogrel 1mg/kg SID Calcitriol 20-30ng/kg per day for 2-3 days then 5-15ng/kg per day Diuretics Limited utility 10

11 11/7/16 Dr. Justine Lee CVC (KC), October 2016 Dr. Garret Pachtinger IVS (Aruba), Dec 2016 NAVC, Feb 2016 WVC, March 2016 Th i s ma te ri a l i s c o p y ri g h te d b y VETg i rl, L L C. No n e o f th e ma te ri a l s p ro v d i e d ma y b e u se d, re p ro d u ce d o r tra n smi tte d, i n wh o l e or i n p a rt, in a n y fo rm o r b y a n y me a n s, e l e c tro n i c o r o th erwi s e, i n cl u d i n g p h o to c op y i n g, re c o rd i n g o r th e u se o f a n y i n fo rma ti o n sto ra g e a n d re tri e v a l s y ste m, wi th o u t th e c o n s e n t o f VETg i rl, L L C. Un l e s s e x p re s sl y sta te d o h t e rwi s e, th e fi n d i n gs, i n e t rp re ta ti o n s a n d co n c l us i o n s e x p re ss e d d o n o t n e ces s a ril y re p re se n t the v i e ws o f VETg i rl, L L C. Me d i c a l i n fo rma ti o n h e re s h o u l d be re fe re n c es b y th e p ra c tit i o n e r p rio r to u s e. Un d e r n o c ri c u ms ta n c e s s h a l l VETg i rl, L L C. b e l i a b l e fo r a n y l o s s, d a ma g e, l ia b i l it y o r e xp e n s e i n c u rre d or s u ffe re d th a t i s c l a ime d to h a v e re s ul te d fro m th e u s e o f th e in fo rma ti o n p ro v i de d i n cl u d i ng, wi th o u t l i mi ta ti o n, a n y fa u l t, e rro r, o mi s s i o n, i n te rru p tio n o r d e l ay wi th re s pe c t th e re o t. If y ou h a v e a n y q u es ti o ns re g a rd i ng th e i nfo rma ti o n p ro v i d ed, p l e a s e c o n ta c t i n e tg i rlo n th e ru n.co m 11