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GI Part 5 - Tenesmus Constipation

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sihirlifil's version from 2018-02-05 11:26

(Chronic D+ Part 2) Lymphoma & biopsy

Question Answer
Small cell lymphoma: common in?CATS (rare in dogs) 10-13yo
Which form of small cell lymphoma is most commonT-cell mucosal lymphoma, usually in FeLV-neg cats
Small cell lymphoma: diffuse infiltrative form looks like?IBD!
Can create masses --> looks like other neoplasia, fungi
Small cell lymphoma: risks associated with masses?Perforation
Mechanical obstruction
Ulceration
Small cell lymphoma: looks how on US?(Can have normal appearance!!!)
Small cell lymphoma: found where?GI only, OR in other organs! Liver, LN, pancreas
May have clues on bloodwork if other organs involved
**Which dx test for small cell lymphoma?BIOPSY! Tempting to FNA LN or liver, but hard to diagnose because lymphocytes are normal size & shape
FNA cannot diagnose...Small cell lymphoma
Small cell lymphoma: which biopsy is ideal?Full thickness
+/- LN/other organ involvement... May still need IHC/PARR to tell apart
IF endoscopic: take as many sites as possible
Small cell lymphoma: additional diagnostics? (besides biopsy)B12 levels
FeLV/FIV testing
Small cell lymphoma: TreatmentPrednisolone & chlorambucil
Oral chemotherapy, 1 pill every 2 weeks, or MWF
Monitor CBC (BM supp!!)& liver values
May need B12 supplements
Small cell lymphoma: PrognosisMST 19-29 months! Pretty good for a cancer. And remission usually achieved :)
Most common Intestinal/colonic neoplasia in CATSLymphoma (small/large cell)
MCT
AdenoCA
Most common Intestinal/colonic neoplasia in DOGSAdenoCA
Lymphoma
Leiomyo(sarco)ma
Chronic D+ patient: treatment trialsDiet
Deworming
Antibiotic
Probiotic
(Ddx IBD vs neoplasia vs fungal)
(Definitive dx needed: Biopsies, endoscopic vs. surgical, especially if not responding to tx trials)
**Something to keep in mind if wanting to biopsy a hypoalbuminemic patientCould have problems healing from full thickness
**Which biopsy for leiomyoma?Full thickness! Can't get muscular layer with endoscopic (only submucosa at most)
**Which biopsy for jejumum?Full thickness- cant reach with scope
Where do you find B12 (cobalamin)?In food
Bound by intrinsic factor (which is made by stomach (dogs) & pancreas (both) ) and absorbed in ileum
Where do you find folate?In food
Absorbed in proximal jejunum
LOW B12 =Decrease in ileum or pancreas
HIGH FOLATE =SIBO
**LOW FOLATE =Not absorbing in upper SI
If you can only pick either folate or B12, test, which one?B12! gives more information
Congenital B12 deficiency = ? in who?Selective malabsorption of B12
Border Collies: mild signs in adulthood
Beagle, Aussie, Giant Schnauzer: SEVERE signs as juveniles
Congenital B12 deficiency: hematologic effxNon-regenerative anemia (cofactor for RBC mb synth)
Neutropenia w/ hypersegmentation (Right shift, neutrophils have to last longer in blood) --> ~Succumb to infxn
Congenital B12 deficiency: metabolic effxHepatocyte dysfxn, hyperammonemia --> GI & neuro signs
Hypoglycemia, ketonemia, hypoproteinemia --> failure to thrive
Acidemia --> lethargy, death
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*Infectious Causes of GI Signs*

Question Answer
Parasitism:Roundoworms
Hookworms
Heartworm (cats)
Protozoal:Giardia
Coccidia
Bacterial:Salmonella
Campylobacter
E.coli
Fungal:Histoplasma
Blastomyces
Pythium
Coccidiomycosis
(Protetheca)
Viral:Parvo
Panleukopenia
Coronavirus/FIP
V+ or D+: ParasitismV+ &/o D+
V+ or D+: ProtozoalD+
V+ or D+: BacterialD+
V+ or D+: FungalD+ (+/- V+)
V+ or D+: ViralV+ & D+
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Tenesmus & Constipation (Colon, Rectum, Anus)

Question Answer
Ddx for constipationURETHRAL OBSTRUCTION! Especially cat
Tenesmus (not const)
Narrowing of colonic lumen (intra/extra)
Idiopathic megacolon
Dehydration 2ry to other dz (CKD)
Neurogenic (spinal cord, LMN)
Constipation ddx: possible causes of narrow colonic lumen?Intra: stricture, mass, FB
Extra: Pelvic narrowing, LN, masses
Constipation: diagnosticsFull neuro exam!
Blooodwork (CBC/Chem/UA) looking for dehydration; T4
Spinal & pelvic rads & abdominal US: Extraluminal space-occupying mass or pelvic narrowing
Intraluminal evaluation
Constipation dx: what does an intraluminal eval entail?Sedated/ANX rectal exam (ALWAYS IN CATS!)
Pos/neg contrast radiographs
+/- Colonoscopy
Constipation dx: when is colonoscopy indicated?Hematochezia persistent
Tenesmus (not constipation!)
US/rads findings indicate intraluminal mass
Megacolon: cause? in who?Cats, M>F, 6yo
Idiopathic! suspected neural plexus/smooth musc dz
How does megacolon present?Constipation a/o vomiting
Megacolon (rads rule out pelvic abnorm, extraluminal causes)
How to dx megacolonDx of exclusion & repeat episodes
Treatment of megacolonDe-obstipation, rehydration, enemas (no Phos!)
Prevention of megacolonHigh fiber diet (Royal Canin GI Fiber response)
Laxatives (Miralax, lactulose)
Prokinetics (Cisapride)
If medical management of megacolon fails / there is recurrence...Subtotal colectomy
Anal sacculitis: CSScooting, licking, +/- tenesmus
Causes of anal sacculitis?Infxn (random) or inflam (food allergy, IBD)
Impacted anal sac =Contents thick, hard to express
Abscessation of anal saces =Infection clogs the duct, may break through skin
Tx of anal sacculitisManual expression
Antibiotics
Anti-inflammatory steroids
Surgery if recurrence or abscess
Diet change (hypoallergenic, just in case it's an immun dz)
Anal sac dz: when would you use systemic antibx?ABSCESS
Anal sac dz: when you use local antibx?Sacculitis, impaction
Anal sac dz: what kind of steroids would you use?LOCAL
Anal furunculosis aka? CS?Perianal fistula
Presents as painful defecations, scooting, licking, bleeding/pus from anal region, tenesmus, +/- acute obstruction (stricture)
What is the cause of this grossness?
(Anal furunculosis) Immune-mediated
>80% of anal furunculosis patients are...?GSD, 4-7yo
Diagnosis of anal furunculosisPresentation & PE
SEDATED rectal exam: exclude anal sac abscess (can be concurrent though!), evaluate for fistulous tracts, stricture
Prognosis of anal furunculosis is worse if...Concurrent perineal hernia
How would you treat a patient with anal furunculosis & concurrent IBD/food allergy? how often does this happen?~50% of cases. Hypoallergenic diet trial
Anal furunculosis: treatment optionsTacolimus ointment
Systemic Cyclosporine
Hypoallergenic diet
Surgery
**Extra consideration with Tacrolimus ointmentIt's TOPICAL, so has fewer SEffx, but can LICK & tox from ingestion! ECOLLAR!
Anal furunculosis: sx if...Anal sac involvement, and no improvement with 6 weeks medical management
Anal furunculosis: PrognosisRare to have complete remission w/o lifelong meds
Many cases refractory to therapy, frustrating, $$$
Anal sac neoplasia: most common in dogs?Apocrine gland adenoCA
Apocrine gland adenoCA: in who? How does it act?9-11yo dogs
Locally aggressive & HIGH metastatic rate: 50% have mets at time of dx (lungs, lumbar LN. do rads!)
Special thing apocrine gland adenoCA can doParaneoplastic hypercalcemia in 27% (PTH-rp)
**ALWAYS DO WHAT ON PHYSICAL EXAM ON DOGRECTAL EXAM
3 categories of weight loss with INCREASED appetiteNot digesting
Not absorbing
Increased metabolic demand
Wt loss + incr appetite: Not digesting =EPI
Wt loss + incr appetite: Not absorbing =Chronic enteropathy (IBD, neoplasia...)
Wt loss + incr appetite: Incr metabolic demand =Parasitism
Neoplasia
Endocrine (HyperT4, DM)
EPI: whats happening?Pancreas not making enzyme --> food not digested --> osmotic D+
Cats: Chronic pancreatitis --> fibrosis --> EPI
EPI: CSSTEATORRHEA, large volume
Weight loss & INCREASED appetite
EPI: who?Young dogs (GSD, Collie) & OLDER cats!
EPI: TEST OF CHOICETLI
High specificity & sensitivity
A false normal on TLI means what?Selective enzyme deficiency
EPI with pancreatic duct obstruction
**How to prevent false negs with TLI test12 hour fast!!!
If you have a patient with EPI, and LOW B12 levels, this tells you...Intrinsic factor also not being made (made by the pancreas in cats and dogs)
**Why does every cat with EPI have low B12 levels?Cats can only make intrinsic factor in the pancreas! Dogs also make some intrinsic factor in the stomach, so they can still bind some B12
EPI: Treatment failure troubleshootingType of enzyme
Hypoallergenic diet
Antibx course for SIBO
B12 supplementation (important cofactor, usually no improvement with just pancreazyme)
Suspect EPI in CATS when...Weight loss with INCREASED appetite
Cats with IBD that were doing well & start losing weight again
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