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GI Part 4 - Diarrhea

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sihirlifil's version from 2018-02-04 11:27

Acute D+

Question Answer
Approach to D+ patientUn/stable: PE
Need to be isolated?: Parvo, zoonoses
Cause?: Intra vs extra-GI, DAMNIT-V
Extra-GI causes of D+Hepatobiliary: Portal hypertension (fibrosis & cirrhosis)
Exocrine Pancreas Insufficiency
Pancreatitis
Endocrine: HyperT4, Addisons
Vascular dz
Anaphylaxis (liver & GI tract are shock organs)
Intra-GI causes of D+Vasc: Lymphangiectasia
Infx: Viral, bact, parasitic, fungal
Toxin or medication
Autoimmune: IBD
Metabolic: (related to extra-GI)
Motility: functional or mechanical obstruction
Inflam: acute enteritis/colitis
Neoplasia
Developmental/genetic: Certain PLE disorders
SI vs LI: FREQUENCYSmall: Same as normal
Large: Increased frequency
SI vs LI: AMOUNTSmall: More than normal
Large: Less than normal
SI vs LI: STRAINING/TENESMUSSmall: No
Large: YES
SI vs LI: MUCUS a/o BLOODSmall: No
Large: YES
SI vs LI: WEIGHT LOSSSmall: YES
Large: No
Melena: site of bleed? character of stool?Blood from somewhere orad to jejunum (nasal, gastric, duodenum)
Small bowel signs
Hematochezia: site of bleed? character of stool?Blood form jejunum & aborad (towards butt)
Large bowel signs
Melena: ddxUlcer
Inflam dz
Parasitism
Gastric, intestinal, or MCT neoplasia
Hematochezia: ddxInflam dz
Parasitism
Polyp
Colonic neoplasia
Acute D+: treatment if STABLEDeworm
+/- SQF 10mL/kg
Bland diet: chicken & rice, Hill's ID or RC GI for 3-5 days
Probiotic/antibiotic
Acute D+: treatment if UNSTABLEHospitalize + IV fluids
+/- antibiotics
Further diagnostics
#1 most common cause of D+? Others?Dietary indiscretion
Diet change, new/different food, trash
Enteritis can also be caused by infxn, drugs/toxins, extra-GI dz
Coronavirus causes what in who?Acute self-limiting enteritis in kittens 4-12 weeks old, incidence 50-100%
What is FIP?Mutant fatal variant of coronavirus
How does FIP come about?Internal mutation FCoV suspected
T/F: Mutated coronavirus easily transmits from cat to catFALSE!
**Tipoff for young cat with BOTH GI & NEURO signsFIP (noneffusive)
D+ may be main clinical sign!
What age typically get FIP, whats weird about it?Bimodal distribution: 3 mo - 3 years, then >10 years old
FIP: How does the 'wet' form present?Acute GI signs
Effusion is big clue
FIP: How does the 'dry' form present?Chronic GI signs
Lymphadenopathy
+/- GI masses
Dx of FIP: CLUES ON BLOODWORK?LOW ALBUMIN, HIGH GLOBULINS (should be 1:1)
Dx of FIP: what does the FCoV serum titer tell you?If NEGATIVE, FIP is unlikely. NOT DIAGNOSTIC IF POSITIVE!
Dx of FIP: what is the effusion like?Protein >3.5g/dL
<5000 cells
Pyogranulomatous
DEFINITIVE DX of FIP?PCR the effusion or CSF
Biopsy immunohistochemistry
In progress: immunocytochemical staining (cytology) (FNA = less invasive)
**Why is PCR of CSF diagnostic for FIP?Coronavirus is supposed to be in the GUT, not the BRAIN JUICE! So if its in CSF its probably the mutant
**If dry form of FIP suspected, what dx test is helpful?No effusion, so FCoV serum titer (negative result = automatic r/o)
Agent of parvo & panleukopeniaParvoviruses lol
Which viruses can be tested via SNAP test?PARVO AND PANLEUKOPENIA! So can use in cats and dogs
Parvo SNAP test: false + means? false -?False pos: recent vax
False neg: Ag bound by Ig (ton of antibodies doin their job)
Parvo SNAP test: if comes back neg and youre still suspicious, what do?Check CBC! Parvo affects BM --> profound neutropenia, pancytopenia
How is the vax efficacy for parvo?HIGH! 7-14 days to immunity
Pathogenesis of parvoFecal-oral --> Tonsils --> Lymphatics --> GI, Bone marrow
GI signs, neutropenia, myocarditis in dogs <3 weeks old (permanent damage!!!)
Parvovirus presentationDehydration, lethargy, hypovolemia, shock, profuse D+, V+, anorexia, fever
Hypovolemic shock common, septic shock possible
Hypoglycemic shock: not a lot of fat stores
Prognosis of parvovirusUntreated: 10% :(
Treated: 90%
Parvo: Which comes first, neturopenia or GI signs?Usually neutropenia present by the time CS occur
Parvo: why neutropenia?GI demand (all neutrophils migrate there)
Bone marrow necrosis (decr production)
Endotoxemia = GI bacteria
If you see this on necropsy??
Parvo
Canine distemper: who gets it? how?Any age, including wild canids,,, and ferrets
Spread via oronasal & aerosol, in all secretions for 3 months (makes isolation hard)
High mortality
Distemper: is there a vax?YES!! High efficacy
How does distemper present?Clinical course varies on intitial immune response! Poor/moderate/good
Distemper: Poor immune response -->Lymphatics & BM --> Death or CNS signs
Distemper: Moderate immune response -->GI & respiratory --> recovery or CNS signs, death
Distemper: Good immune response -->No CS, or CNS signs develop later in life
Distemper: what acute signs are CLUES GI+Resp
GI+CNS
Resp+CNS (no GI!!!!)
GI+Ocular
What kind of random CS can happen with distemper?Hyperkeratotic footpads, crusty nose
Diagnosis of distemperPCR (can have false positives if recent vax)
Antigen detection via tissues/fluid IHC or Fluorescent antibody test
Treatment of distemperISOLATE and start treating right away! Takes a while for dx results
Supportive: GI, neuro (antiseizure)
Gut microbiome & bact infx: whats the debate?Natural flora vs causative agent, or both?
Is tx with antibiotics the wrong approach? Shift to probiotics
Zoonosis: MUST give antibiotics!
#1 risk factor for SalmonellaRaw food diet
80% of raw chicken has Salmonella isolated
CS of SalmonellosisAcute GI, fever, lethargy
Watery, mucoid, bloody diarrhea
Sepsis
.....or asymptomatic lol
Dx of salmonellaCulture isolation PLUS CS!!!
Treatment of salmonellaISOLATION! (not recommended if d+ is self-limiting!)
SYSTEMIC: IV ampicillin + fluoroquinolone until C& S results
What's the problem with antibiotic tx for salmonella?Ampicillin & fluoroquinolones are good at giving resistance strains to each other (high resistance rates)
T/F Campylobacter is definitely pathogenicFalse. Pathogen or commensal conroversy, there are healty pts with a ton of campy & show no CS
IMPORTANT ABOUT CAMPY:ZOONOTIC
Bacterial shedding for 4 months, so quarantine from children!
If CS are present for campy, what are they?Small bowel character, +/- hematochezia
Fever & lethargy
Dx of campylobacterFecal smear & culture
Tx of campylobacterErythromycin/azithromycin
Enteric E. coli infection: causes what?Granulomatous colitis = histiocytic ulcerative colitis
(Enteric E. coli breed predisp)(Boxers, Frenchies, Border Collies <2yo)
CS of E. Coli infxnChronic large colon signs +/- weight loss (**WAXING & WANING)
How to dx E. Coli?Treatment trial
After r/o other causes, can do colonoscopy with biopsies & culture
How to treat E. coliEnrofloxacin 10mg/kg PO q24 x 8 weeks
Tritrichomonas foetus: who gets it? clue?CATS <2yo
New cat in house!
T. foetus: CS?Subclinical to intermittent to intractable large bowel D+
How to dx T. foetus?Direct smear
PCR
Culture
If this comes back on fecal smear...
Tritrichomonas foetus
How do you treat T. foetus?Ronidazole (dont really use this drug for anything else)
What is HGE?(Hemorrhagic Gastorenteritis) The old name for Acute Hemorrhagic Diarrhea Syndrome
CS of HGE aka AHDS?Acute onset severe hemorrhagic diarrhea (oddly enough)
HEMATOCHEZIA CAN BE MARKED! **Dark red 'raspberry jam,' O is concerned about anemia
Triggers of AHDS? More common in whoNew food, dietary indiscretion... or none!
Small breed dogs
Hows the fluid status of a patient with AHDS?Marked GI fluid loss --> dehydration, hemoconcentration
GI protein loss --> hypoalbuminemia
Can you make a definitive dx of AHDS? How?PRESUMPTIVE dx based on CS & typical acute d+ diagnostics (No specific etiology identified)
PCV > 60% (Dehyd)
R/o pancreatitis, addisons, etc
AHDS: treatment?SUPPORTIVE. IV fluids, anti-emetics... +/- antibiotics?
Prognosis of AHDS is good unless...Sepsis
Complications of hypoproteinemia
Stress colitis: what is it? how do you treat is?Acute or chornic, intermittent LARGE BOWEL signs treggered by "stress" (what is stress, to a dog?)
Tx: prevention (start probiotics a few days before known stressor, bland diet, time)
memorize

Chronic D+ (Part 1)

Question Answer
Definition of chronic diarrheaLasting longer than 3 weeks
Chronic D+: Extra-GIAddisons
Pancreatitis
EPI (etc...)
Chronic D+ Intra-GIInflam: IBD, food-responsive, lymphangiectasia
Infx: Parasit, bact, fungal, 'antibx-responsive'
Neoplastic
Functional motility disorders
Anatomic: chronic FB, strictures
GI microbiome: theories?Older: Dx may be caused by imbalance
More likely: Dz leads to imbalance
GI microbiome: what happens with IBD?Microiome/immune system interaction
Only evidence-based treatment with focus on microbiome?VSL #3 (probiotic)
Indications for probioticsAcute: D+ after antibiotic use, dietary indiscretion, stress colitis
Chronic: eneropathis (evidence-based!)
Microbiome-focsus: other weird tx possibility besides probioticsFecal microbiota transplant (label your blender really well)
Antibiotic-responsive D+: defined as?Chronic D+ that responds to antibx long-term (though no bacterial cause has been ID'd yet)
SIBO?
Antibiotic-responsive D+: which drugs?Metronidazole keep total daily dose <20mg/kg
Tylosin (Tylan)
Consider probiotic treatment trial
Risk of metronidazole?NEURO! Looks central vestibular
Food-responsive enteritis: defined as?Chronic GI signs, no ID'able cause on diagnostics, responds to diet trial
Novel protein diet =
Hydrolyzed protein diet =
**Which diet trial is better to start with?Hydrolyzed
Pts on novel protein diets can sensitize to the protein later in life, then have to start over
Fiber-responsive colitis: typical signalment? How to tx?CATS with chronic colitis signs (tenesmus, dyschezia...)
No identifiable cause on diagnostics, responds to high fiber diet trial (add psyllium granules i.e. Metamucil, try Royal Canin Ultamino)
(remember characteristics of IBD)(from chronic vomiting)
(remember how to dx IBD)(from chronic vomiting)
**Annoying thing about dx IBDSome patients dont respond to Prednisone, but do have IBD (so, no decr in CS with immunosupp tx)
Approach to IBD txStart with diet (no SEffx), then work up to probiotics/antibx, THEN steroids if still no response. TIS CUMULATIVE! So if you work up to steroids you keep them on the diet and pro/antibx.
**Approach to IDB tx: do you always start with diet and work up to steroids?Start with steroids if really sick (i.e. hypoalbuminemia), b/c you dont have 6 weeks to spare to see if the food change is going to work (and if they arent eating it obv wont help)
Do more dianostics sooner, can biopsy right away, and work down to get off steroids over time
IBD is refractory when? How do you handle?No improvement with 'standard therapy'
Refer to internist, consider other ddx, fecal transplant (or edema if large bowel signs), 2ry immunosuppression (Chlorambucil, cyclosporine)
Fungal infections: look like what in bloodwork & US findings?IBD and GI neoplasia (signs of obstruction, colonic mass)
Dx of fungal infectionsRectal scraping: Cheapter & less invasive than endoscopy!
Whats on this rectal scrape? Histoplasma
Whats on this rectal scrape?
Prototheca
T/F it's possible to diagnose and animal with PLEFALSE! PLE is a syndrome caused by many etiologies
Etiologies of PLEIBD
Lymphangiectasia
Neoplasia
Infx (fungal, viral, parasitic)
T/F any acute GI disease can cause PLETrue
(chronic forms require extensive dx investigation)
What is 1ry lymphangiectasia?A cause of PLE (dilated lymph vessels, normally absorb fat from GI). There are hereditary & acquired idiopathic (Yorkies, other toy) forms
**Special about diagnosing 1ry lymphangiectasiaENDOSCOPY is better than surgical biopsy!
Tx of 1ry lymphangiectasiaULTRA low-fat diet
memorize

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