Posted by Aaron
Friday, March 5, 2010
Posted by Aaron
Thursday, March 4, 2010
- First things first - a good history. When does the diarrhea and vomiting happen? Is there any kind of temporal connection? Travel? Diet change? What about weight loss or gain? Is the vomiting immediately after a meal? First thing in the morning on an empty stomach? Is the diarrhea characterized by sudden urgency or constant straining? Did the vomiting or diarrhea respond to previous treatments? If so, what treatments and in what way did it respond? Did the problem resolve and then recur, or did it only resolve while ON the medications? What other medications is the patient on? What foods do the other animals in the house eat? Does this pet eat the other pet's food (either before it's eaten or after it's pooped out - IOW is your dog a poo-eater?)? Is your pet also having urinary problems? What breed(s) is your pet? All of these things help narrow down the list of likely suspects.
- Physical exam. Weight gain? Weight loss? How does the abdomen feel on palpation? Is the pet dehydrated? How does the patient "as a whole" look? Does the patient have other diagnosed problems that could be causing this problem? Are there any lumps or bumps that would cause concern? How does the anus and rectum feel on examination? Is there lots of gas? Constipation?
- Examine the poo. As was said on one of the funniest episodes of the sitcom Scrubs, "If you want to know what's wrong with you, it all comes down to Number 2!" Seriously, though, the poo can tell us a lot. This would be the best way for us to identify most parasites. Not all parasites can be found at all times, and fecal exams are never 100% sensitive. Repeat fecal exams at different times and on GOOD SIZED samples is critical. I get totally chapped when I see people take these little, itty, bitty, tiny samples and then declare that "the fecal is negative." NO NO NO. You must take a good sized sample, use good technique in your fecal examination, and then you can declare that "no parasites were seen." Seems like I'm splitting gnat weenie hairs, but it's a big distinction. No whipworms today doesn't mean much. They're a booger to find on a good day. Most would agree that you need a total of 5 fecals done on 5 different days to say that there are no whips present. Many times, submitting the stool to the lab for advanced diagnostics is smart. The labs can now look for parasite DNA in many cases and this makes the test very sensitive. You still have to submit a LARGE ENOUGH sample. You want to know how to make your veterinarian's job easier and help get a proper diagnosis? Bring stool with you! Fresh, stinky, warm poo makes me happy to see. Now I've got a big sample and I don't have to go fishing for it. It drives me crazy when someone come in with a complaint of stool problems, but then doesn't bring a sample.
- Basic blood workup. Look at my previous post on this one. We're looking for things like increased eosinophils (allergic reaction), low albumin (loss of protein), changes in cholesterol (poor absorption), abnormal lipids (funky fat absorption) and such.
- Gastrointestinal specific bloods include things like a "pancreatitis test" also known as a Spec cPL, Trypsin Like Immunoactivity (TLI), cobalamine, and thiamine. These each help identify if there is evidence of chronic mal-absorption and tell us more about if the pancreas is functioning normally.
- Endoscopy or abdominal exploratory surgery. The idea here is that we may need to LOOK at the gut and take biopsies to get a diagnosis. Endoscopy/colonoscopy is where we drive a camera down or up (depending on the end you start at :) ) and it allows you to see the lining of the gut. You can look for ulcerations, polyps, thickening, and any number of abnormalities. You can also use a little biopsy tool to take a tiny piece of the lining of the gut. The major benefits of endoscopy are 1) You get to see the inside of the gut up close and personal, 2) you don't have to open up the abdomen, and 3) it gives you nice biopsy samples that are only partial thickness - there's less of a defect to heal. The major downsides are 1) you can only get SO far down or up before you just can't get any farther with the camera. This means that there are large lengths of bowel you can't see. You will, therefore, totally miss problems if they are segmental and the segment that's a problem is out of reach. 2) the biopsy taken is only partial thickness. This means that you miss some of the deeper tissues. You may, therefore, miss out on part of the diagnosis. However, it should be noted that endoscopic biopsy is nearly always diagnostic, but it's not 100%. The major benefit of abdominal explore is that you can run the ENTIRE gut and can take full-thickness biopsy. The major disadvantages are that you can't see the INSIDE of the gut (major disadvantage), and you actually have to open up the belly (not a huge deal, but there is more healing involved).
- There is NO way to diagnose IBD properly without biopsy samples. IBD is a diagnosis made using the microscope AND the rest of the physical exam and bloodwork findings. Biopsy is also the only way to try and differentiate between things like lymphocytic lymphoma (tumor in the gut) and true lymphoplasmacytic inflammatory bowel disease in cats. In other words, is this cancer or is this just inflammation.
- Ultrasound of the abdomen. This can be considered in lieu of the endoscopy or explore, but it isn't the kind of thing that allows you to visualize how the inside of the gut looks and it is impossible to get biopsy samples of the gut. You can often times get aspirates and those may be diagnostic. Ultrasound is typically used if we have a patient that is a poor anesthesia risk or if we happen to be ultrasounding for some other reason and can try to get information on the gut as well. Ultrasound does have a great benefit from being able to measure the thickness of the bowel.
- Bacterial cultures of the gut. These have varied applications. There are lots of arguments both for and against cultures and what they mean. If I find salmonella, is that bad? Just how many bacteria in the small bowel are TOO many? If I don't find campylobacter on a culture, does that mean it's not there? I believe that bacterial cultures aren't used as much as they could be because we don't always know what to do with the results.
Posted by Aaron
Wednesday, March 3, 2010
As I started writing this, I began to wonder why it is I seem to spend so much time talking about poop. I pondered the poop for a while and have determined that I am not, in fact, obsessed with the tailpipe. Vomiting and diarrhea are far and away one of the most common complaints we see. I can't decide if scratching/itching/ears are more common or it it's vomiting/diarrhea. So although I may seem to blog often on puke and poo, there's a reason. It's what I see all day :)
- Parasites. giardia, coccidia, cryptosporidium, hookworks, and whipworms start the list. These parasites each attack separate portions of the gut and their specific symptoms depend of severity. The moral of the story is that they body react to a parasite and there is inflammation generated at the site of parasitic infection. Imagine the mosquito bite or the cut/scratch you see on your skin. Imagine that same thing happening (albeit microscopically) in the gut. Same idea.
- Dietary problems. True food allergy is a major cause of IBD and it is, IMHO, one of the more common problems. Food allergies can be insidious and kind of "creep up" on you. Owners say, "he's always eaten this food so it can't be food allergy." Nope, wrong. Food allergies almost always develop over time after chronic exposure to the same protein. Meat proteins are more likely to be the culprit. Folks like to blame grains. From what we understand now, grains are less frequently a problem than are the major meat proteins. In other words, beef, chicken, eggs, soy are more likely a problem than corn, wheat, barley, or rice. The other really important point about diet is that abrupt CHANGES in diet can also trigger inflammation. If your body is not adjusted to digesting a particular food, it can cause incomplete digestion and this can trigger issues like bacterial overgrowths or excessive stimulation of gut contractions.
- Stress. This is more a problem in people than in pets, but I think more cats are affected by stress than we truly appreciate. Chronic stress causes chronic increases in stress hormones like cortisol. There are also increases in the body's autonomic nervous system and you get increases in epinephrine and norepinephrine (adrenalin). These nervous signals cause changes in gut motility. Parts of the gut may contract more than they should, others may not contract at all. The result is poor digestion, unpredictable absorption of nutrients, and inappropriate populations of bacterial growth.
- Bacterial overgrowth. This is very hard to prove. You are covered from head to toe in bacteria and your intestines are no exception. The balance of bacteria in the gut plays a big role in how "happy" your gut is and how well you digest your food. There are "good bacteria" that play a positive role in your immune response, and there are "bad bacteria" that tend to generate lots of upset.
Posted by Aaron
Tuesday, February 23, 2010
There's lots of big news here in Texas. I found out last week that I have been accepted into an Internal Medicine Residency at Oklahoma State University in Stillwater, OK. I will be studying for my PhD and obtaining board certification at the same time.
Posted by Aaron
I have a question for you regarding urinary issues. I have a 4 year old pug, Pearl, with chronic urinary issues.
History-wise, our first issue was about 8 months ago when she suddenly could not urinate one morning. We rushed her to the vet, where they surgically removed a blockage caused by struvite stones. She had shown no signs of discomfort and we had no idea she had any stones up until that day. He placed us on Hill's W/D because she needed to lose a few pounds and thought it would also help regulate her urinary issues.
She always has a clean water source available to her, we get her outside very often to use the bathroom, and I am just feeling exhausted with this process. I want her to feel better, and it seems like this current diet is just not helping.
I have been uncomfortable with the Hill's diet this entire time, because the ingredients just do not seem wholesome to me. I am not necessarily insistent that she be on a grain-free diet or anything, but surely there is a more nutritious food that could work similarly. I am willing to make her food at home, if that would help.
Can you offer me any advice on food/supplementing, and any other general advice for her urinary health? She is otherwise very healthy and we are so eager to rid her of these infections.
Thanks so much for any help you can offer!
-Pearl & family in Oklahoma
- Urethral length - it's easier for a female to develop infection than a male (in most species - cats are an exception) because the urethra is much longer in the male.
- Normal and complete emptying of the urinary bladder. Simply put - you don't pee often enough, you set yourself up for infection.
- Insufficient water intake. Soupy, concentrated urine ain't helpful.
- Normal immunity along the lining of the urethra. This is a combination of antibodies the body produces (Specifically, IgA), the mucous layer of the urethra and bladder (made up of PSGAGs, glucosamine, and other large starch and protein molecules), and the anatomy of the vulva, vagina, urethra, and urinary bladder. There are all kinds of plumbing issues that can pre-dispose to urinary tract infections. If the vulva is "tucked" up high and urine pools in the vestibule or vagina, then you are pre-disposed to issues. If you're male - having testicles pre-disposes you to problems because of that annoying prostate. Intact male dogs are at higher risk than neutered male dogs (generally speaking).