Treatment of inflammatory bowel disease in dogs. Inflammatory bowel diseases (IBD). Possible complications and consequences of EPB

IBD is a real syndrome and it is important for the veterinary practitioner to understand this. However, it often turns into an excuse rather than a real diagnosis. More and more evidence is accumulating to show that the main causes of inflammation in dogs and cats with this disease are bacteria and diet. See Antibiotic-Responsive Enteropathy section below.

Elimination diets

An elimination diet for a disease that is responsive to dietary changes is often helpful in cases of malabsorptive disease not associated with protein loss. There is no commercial food that is a suitable elimination diet (hypoallergenic and suitable for screening for non-allergic intolerances) for all dogs. We often see cases in which they did the right thing (i.e., use an elimination diet), but it was so poorly planned and executed that the whole effort was in vain. It is necessary to carefully analyze the history and find out what the patient ate before. However, even if you have determined what food ingredients a patient has previously been exposed to, it can sometimes be difficult to find a diet that will be effective for that particular patient. In some cases, all of our well-planned hypoallergenic diets are ineffective, but by chance a certain brand of commercial food is effective.

When placing a patient on an elimination diet, homemade food or commercial food can be used. There are many excellent commercial foods available and they are usually effective. Homemade elimination diets are sometimes effective when commercial diets are ineffective; however, this is very rarely the case. Therefore, you will have to decide what is best for the patient you are treating. Hydrolyzed feeds are usually good, but not always best choice for any patient. Some animals respond better to new protein foods than to hydrolyzed foods, and vice versa. Whatever elimination diet is chosen, it is necessary to expect that the animal will have to feed only this food for at least 3-4 weeks (the absolute minimum) before its effectiveness can be accurately determined. In rare cases, the diet may have to be used for 6-8 weeks before a reaction occurs, but this happens in less than 5% of cases. If the diet appears to be effective (i.e., weight gain occurs and diarrhea resolves), it should be continued for at least the next 3-4 weeks to ensure that changes are due to the diet and not a temporary improvement in the patient's condition. which can happen for many reasons.

Antibiotic-responsive enteropathy

Antibiotic-responsive enteropathy (ARE) appears to be a relatively common problem in dogs. It can best be described as a syndrome in which the upper small intestine A large number of bacteria are present, and the host reacts to them in such a way that intestinal dysfunction occurs. These bacteria are not always obligate pathogens. On the contrary, they can belong to any species, and E. coli, Staphylococcus, Streptococcus And Corynebacterium are the most common aerobic/facultative aerobic bacteria, whereas Clostridium And Bacterioides are particularly common anaerobic bacteria. These bacteria appear to be commensals, or they may result from contamination from ingested material that is not eliminated by the host's normal defense mechanisms. The symptoms they cause (if any) are likely to depend on (at least) two factors:

What bacteria are present?
How the host organism reacts to them.

The relationship between ARE and IBD is unclear, but it seems very possible that bacteria may be responsible for starting and/or maintaining the intestinal inflammation we call IBD. The term “dysbiosis” has been proposed as a bridge between ARE and IBD. That is, the presence of bacteria that are somehow capable of causing problems (usually intestinal bacteria such as E. coli), as opposed to the presence of obvious pathogenic microorganisms.

Antibiotic-responsive enteropathy is difficult to definitively diagnose based on laboratory tests. Histopathology and cytology of the intestinal mucosa are extremely insensitive for detecting ARE. Serum cobalamin and folate concentrations were used to make the diagnosis, and the simultaneous detection of low cobalamin concentrations and elevated serum folate concentrations was considered relatively specific for ARE. However, measurement of serum cobalamin and folate concentrations is relatively insensitive and nonspecific method detection of ARE. There are many dogs with chronic antibiotic-responsive gastrointestinal disease whose cobalamin and/or folate concentrations are normal. It appears that treatment of ARE is appropriate regardless of whether serum cobalamin and folate concentrations are normal or abnormal, raising the question of whether their measurement is useful in making the diagnosis of this disease. Detection of hypocobalaminemia or low serum folate concentration is useful when attempting to detect occult gastrointestinal disease. Supplementation with cobalamin can lead to a marked improvement in the condition of cats and a reduction in diarrhea. In fact, we almost always find that there is nothing wrong with giving any sick cat an injection of cobalamin, regardless of the level of this vitamin in the blood. Severe hypocobalaminemia has always been considered a poor prognostic sign. But if the value of cobalamin supplementation in cats is obvious (in fact, it is almost never harmful to give a sick cat additional cobalamin), then clinical significance administration of cobalamin to dogs with low serum cobalamin concentrations remains unclear.

Because of the apparent difficulty in diagnosing ARE using laboratory tests, empiric antibiotic therapy is often chosen as a diagnostic tool instead of laboratory tests.

The obvious disadvantages of this approach are:

the patient’s clinical “reaction” to administered antibiotics can be due to both antibiotics and other reasons;
If the patient does not respond to an antibiotic, you may have used the wrong antibiotic;
Even if a patient has ARE, he may also have some other disease (for example, a tumor causing partial intestinal obstruction) that predisposes the patient to ARE.

Since any bacteria can be present in the upper small intestine, the types of bacteria in the upper small intestine can change weekly, and we rarely know which bacteria we are trying to target, antibiotics are indicated wide range actions designed to reduce the total number of bacteria.

We will never be able to sterilize the gastrointestinal tract. However, since clinical signs are due to a combination large number bacteria and an impaired host response, simply reducing the number of bacteria is often beneficial. Oral aminoglycosides are generally considered a poor choice for the treatment of ARE because... anaerobic bacteria (which presumably cause the most problems) are resistant to aminoglycosides. But this opinion is not absolutely correct, since occasionally there are patients who clearly feel better after taking oral amikacin.

Tetracycline is often effective; however, tetracycline is inconvenient to give. Tetracycline must be given separately (i.e. without any food) and ensured that it is washed away with water so that the capsule or tablet does not become lodged in the esophagus and cause esophagitis.

Tylosin powder has also been used and is accepted by many doctors.

Some doctors like to use metronidazole; but I was not impressed with the effectiveness of metronidazole as monotherapy for ARE. However, metronidazole has real benefits for many gastrointestinal disorders, presumably because it effectively kills many anaerobic bacteria.

For treating patients who are very sick and need to know immediately whether they will respond to antibiotics (that is, in the case of patients who are so sick that you cannot wait 2-3 weeks to see if they respond). no treatment), I use a combination of enrofloxacin and metronidazole. This doesn't mean I use this combination for long periods of time. I use this combination when I absolutely need to know whether I will get a clinical response within the next 2-3 weeks or lose the patient.

No matter what medicinal product is used, a trial treatment should be carried out for (at least) 2-3 weeks before a conclusion can be drawn regarding its effectiveness. Remember that you must not only reduce the number of bacteria, but also give the intestinal lining time to heal. In addition, concurrent use of a high-quality elimination diet can significantly increase the effectiveness of antibiotic therapy, so we routinely use both approaches in our treatment attempts.

If a patient responds to a trial treatment with an elimination diet and antibiotics, then it is probably best to leave nothing for the next 2-4 weeks to ensure that the patient is actually responding to this therapy (as opposed to a patient who has had an accidental temporary improvement in unknown reasons). If the patient feels well during this period, then you can stop taking antibiotics and see if diet alone will be enough to eliminate the symptoms; or slowly reduce the dose of antibiotics to the lowest effective dose (for example, reduce the dose every day or every other day). It all depends on how often they occur clinical symptoms. In cases where symptoms occur every 2 months or less, it is advisable to treat only if the patient has symptoms. If symptoms persistently return several days after you stop taking antibiotics, you may need to continue treatment almost continuously. This second situation is one of two situations in veterinary medicine where I believe it is appropriate to define a minimum effective dose antibiotic. Some patients only need to take an antibiotic every 2-3 days to control symptoms. In some patients, clinical symptoms suddenly reappear after a few weeks or months, in which case a different antibiotic must be used. If the decision is made to stop taking antibiotics, pet owners should be warned that symptoms may recur over time. As for the ARE, there is usually some kind of defect defense mechanisms host organism that allows commensal bacteria to cause clinical symptoms, and this defect is unlikely to disappear. The question is how serious is this defect (that is, will the dog's problems be constant or intermittent)? You should warn clients that they will likely have to deal with the problem again and explain the difference between “cure” and “control” the disease.

It may be a good idea to routinely treat all dogs with chronic small intestinal disease on an ARE regimen, even if you have histologic evidence of IBD or other disease. I treat a dog with an ERA regimen almost always when I diagnose a dog with malabsorptive disease because there is no test for ERA that can reliably rule out this disease, including cobalamin and folate.

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Inflammatory diseases intestines in dogs

Tkachev-Kuzmin A.A.

Inflammatory bowel diseases - a general name for a whole group chronic diseases intestines, characterized by persistent or recurrent gastrointestinal symptoms and inflammation. Variants of inflammatory bowel disease in dogs include conditions such as gluten-sensitive enteropathy, intestinal pathologies responsive to antibiotic therapy, immunoproliferative disease of the small intestine, protein-losing enteropathy, lymphangiectasia, atrophic gastiritis, gastric carcinoma, cyanocobalamin deficiency, and granulomatous colitis.

It is generally accepted that inflammatory bowel disease occurs due to a complex interaction of a number of causes, such as genetic predisposition, intestinal microenvironment (mainly bacteria and food components), the immune system and components environment, causing intestinal inflammation. However, the exact sequence of events leading to IBD in dogs, as well as the variations in disease presentation and unpredictability of response to treatment, are still unknown.

This article will look at inflammatory bowel disease in dogs, Special attention will focus on the interaction between genetic factors and the gut microenvironment (bacteria and diet), prognostic criteria and standard treatment approaches.

Pathophysiology

Genetic predisposition

The most predisposed breeds are: Irish Setter, German Shepherd, Basenji, Rottweilers, Yorkshire Terrier, Shar Pei, Boxers, French Bulldog. However, any specific genetic defect has not yet been identified.

Intestinal microflora

Bacteria

Although bacteria found in the intestines play a definite, significant role in the development of IBD in both humans and animals, the specific characteristics of these bacteria (factors leading to the development of IBD) still remain unclear. The latest advances in molecular microbiology allow for in-depth analysis of bacterial microflora without cultivation. Studies based on the cultivation of microflora in humans have shown that more than 70% of microorganisms contained in feces are not amenable to cultivation (impossible to grow on nutrient medium). And that in healthy patients there was a significant variation in the composition of the microflora in different segments of the gastrointestinal tract, and differences were also revealed between the composition of the microflora in the intestinal lumen and on the intestinal mucosa. More and more research confirms that inflammation in the intestines occurs due to a shift in the composition of microflora from gram-positive to gram-negative. inflammatory bowel disease diet dog

Diet (components of the diet) for dogs

There is growing evidence that diet plays a significant role in the development of inflammatory bowel disease in dogs and cats. For example, Irish setters are susceptible to enteropathy associated with gluten intake. And West Highland white terriers show a reaction to corn, tofu, cottage cheese, milk, and lamb meat.

In a controlled study of 65 dogs with IBD and chronic diarrhea (minimum 6 weeks), 39 dogs showed benefit over 10 days of feeding a diet consisting of salmon and rice. Relapse occurred in only 8 dogs, after provocation by returning the previous diet. And not a single dog in this group was sensitive to beef, lamb, chicken, or milk.

Diagnostics

Diagnosis of inflammatory bowel diseases usually includes a thorough analysis of all symptoms, history, conditions of detention, clinical examination data, data laboratory research, visual diagnostics (X-ray and ultrasound) and the results of histopathological examination of intestinal biopsy. Dogs with inflammatory bowel disease typically present to the clinic with diarrhea, weight loss, and/or vomiting. The initial approach to a patient with chronic diarrhea or vomiting is based on identifying the causes of these symptoms, determining their severity and specific or localized symptoms, which helps to clarify the location of the disease. For example, differences between small intestinal and large intestinal diarrhea, the presence of melena in bleeding or ulcers upper sections Gastrointestinal tract, pain abdominal wall, difficulty breathing, peripheral edema in enteropathies leading to protein loss, help to more accurately determine the location inflammatory process.

If signs of both diarrhea are present, then the patient should be considered to have diffuse gastrointestinal disease.

Chronic small intestinal diarrhea is the most common symptom in dogs with IBD, the diagnostic approach is described in the table:

Intestinal biopsy

A biopsy can be taken endoscopically or surgically. In patients without direct indications for surgery (intestinal neoplasms, anatomical or structural changes, perforation), endoscopy is performed to evaluate the esophagus, stomach and intestinal mucosa and collect a sample for biopsy. Some studies, but not all, show a positive correlation appearance(endoscopic) picture of the small intestine with prognosis. If there is suspicion of involvement in a pathological process ileum (low level cobalamin, ultrasound signs of the disease), then in addition to the standard endoscopic examination of the upper gastrointestinal tract, examination of the ileum is added. Techniques for taking intestinal biopsies have been described and published. The experience of the physician performing the endoscopy and specimen collection, as well as the quality and quantity of specimens collected, are critical to the histopathological diagnosis. A surgical biopsy is performed if the submucosal and muscular layers of the intestine are involved in the inflammatory process or if these conditions are suspected, as well as if endoscopic samples do not allow adequate assessment clinical condition(or do not correspond to the clinical picture).

The therapeutic approach to this group of patients will vary and depend on the severity of clinical symptoms such as frequent severe diarrhea, severe weight loss, decreased activity and appetite, together with the presence of hypoalbuminemia or hypocobalaminemia, as well as thickening of the intestinal wall or mesenteric lymphadenopathy. In patients with these abnormalities, intestinal biopsy is indicated to determine the cause (eg, lymphangiectasia, lymphoma) and optimize treatment.

The severity of clinical symptoms and the severity of the disease can be assessed using a special index (including assessment of habit, activity, appetite, vomiting, stool consistency, frequency of bowel movements, weight loss). Measurement of serum protein levels correlates with clinical IBD activity and implies that severe IBD is accompanied by systemic inflammation. An initial assessment of disease activity may be useful in assessing therapy/response to treatment. Clinical studies have shown that hypoalbuminemia is associated with a poor prognosis in dogs with chronic enteropathy. Serum cobalamin and folate concentrations can be determined to guide decisions about dietary or parenteral vitamin supplementation. Low performance Serum cobalamin (less than 200 ng|L) indicates the severity of the disease and poor prognosis. Blood coagulation assessment is recommended to determine both hyper- and hypo-coagulability that may develop due to intestinal protein loss.

In stable patients with chronic diarrhea (normal body habitus, appetite, moderate/minor weight loss, normal serum protein levels, no thickening of the intestinal wall or lymphadenopathy) and those with no known weight loss, measurement of serum cobalamin and folate levels can help determine the location and the location of the process is in the intestine (since cobalamin is absorbed in the ileum), which may be an indication of the need for additional administration of vitamin B 12 and assessment of the prognosis.

Stable patients with chronic diarrhea and normal cobalamin concentrations can be treated with a trial diet followed by antibiotic therapy (if there is no response to the diet). Insufficient response to empirical therapy or deterioration of the condition is an indication for endoscopy and intestinal biopsy.

In stable patients with chronic diarrhea but with reduced performance cobalamin and folate, endoscopy with biopsy is preferred over empirical treatment.

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Diagnosis of the disease

If one or more symptoms occur, you should go to veterinary clinic. But before that, the owner is able to independently provide first aid to his pet. First of all, it is necessary to provide your pet with sufficient water, because diarrhea and vomiting indicate dehydration.

You can restore the water-salt balance in the body with the help of diluted Polysorb. They should feed their pet small doses over an hour. Castor oil will help cleanse your dog's intestines, making it easier for your veterinarian to diagnose the disease.

Upon arrival at the clinic, the doctor will need to answer the following questions:

Was there a sudden transition of nutrition from one type to another?
Has the animal had contact with other animals?
Have you ever taken long trips with your dog?
Does your animal like to dig into trash cans and trash cans?
Is it possible to walk on a leash or without it?

The veterinarian must know about all the painful symptoms of the animal, as well as those marked. After a conversation and examination of the dog, tests are prescribed.

A blood test for biochemistry will allow the doctor to assess the condition and possible disturbances in activity internal organs– kidneys, liver, pancreas. The results will show the level of nutrients in the body. If there is a deficiency of any element, vitamins may be prescribed. Biochemistry also reveals dehydration. This analysis is given in the morning on an empty stomach, but in in case of emergency Blood sampling can be done in disregard of these rules.

If you suspect foreign object stuck in the gastrointestinal tract, an x-ray is prescribed. It is this study that can guarantee the presence or absence of foreign bodies in the body. There is no need to specially prepare your dog for an x-ray.

The doctor may also order an ultrasound of your pet's abdomen. You need to prepare for this study:

The dog should not eat for 10-12 hours, as possible flatulence in the stomach will affect the result.
The intestines are cleansed activated carbon the day before the ultrasound.
In some cases, a few hours before the examination - this makes it easier to examine the colon.

A modern method for diagnosing diseases associated with the gastrointestinal tract is endoscopy. During this test, the doctor has the opportunity to take tissue for a biopsy. The operation is low-traumatic and is performed under general anesthesia. Microcameras are inserted into the dog's abdominal cavity, while the doctor evaluates the picture visually on the monitor.

Based on the results of tests and studies, the veterinarian makes a diagnosis for the dog and determines subsequent treatment.

Treatment of enterocolitis in dogs at home

Therapy primarily depends on the type of causative agent of the disease. In most cases, the veterinarian will prescribe a special diet for a sick dog. A day or two may be recommended therapeutic fasting, only drinking is allowed. The pet should receive enough drinking water - this will prevent dehydration.

If the animal has previously eaten, the doctor can advise special food for dogs with gastrointestinal problems. If the pet is accustomed to natural products, the veterinarian will provide a list of allowed products.

During rehabilitation the following are allowed:

Lean meat, chicken, turkey.
Cottage cheese with minimal fat content.
Decoctions of cereals, oatmeal or rice are suitable.
Egg yolks.

During rehabilitation the following are prohibited:

Egg white.
Products with high sugar content.
Bones.
Fatty meat and fish.

Prevention of enterocolitis

First of all, prevention consists of selecting a dog that is appropriate for the age and health of the dog. If the animal consumes natural products, then you should give up fatty meats and fish and give preference to broths that are easily absorbed by the body.

Timely vaccinations will protect your dog from a number of infections and bacteria that cause intestinal inflammation.

It is necessary to monitor the dog during a walk, you should not allow the animal to dig through garbage cans, it is not advisable to allow it to come into contact with other animals, they can be carriers of diseases.

Prevention will reduce the risk of enterocolitis, and it is easier to prevent any illness than to treat it later.

Olivier Dossin, DVM, PhD, DECVIM-CA Internal Medicine
National Veterinary School - Institut National Polytechnique, University of Toulouse, France

Protein-losing enteropathy (PLE) is clinical syndrome, in which there is a chronic loss of proteins (albumin and, in most cases, globulin) in the gastrointestinal tract. The diagnostic sign is hypoalbuminemia.

Hypoalbuminemia as a cause of ELD

Typically, the diagnosis of EPD begins with the determination of hypoalbuminemia in dogs that are losing weight and, in most cases, suffering from chronic diarrhea and sometimes vomiting. Obvious clinical signs from digestive system are not always present, sometimes dogs experience pastiness, enlargement of the abdominal cavity, or shortness of breath secondary to effusion in the pleural cavity. Once hypoalbuminemia is detected, the degree of decreased protein synthesis (liver failure) or the degree of increased protein loss must be determined. Increased protein loss occurs through the kidneys - protein-losing nephropathy (PLN), through the intestinal mucosa (EPL), through the skin in severe and extensive exudative lesions - severe burns, and in severe purulent peritonitis or pyothorax. Albumin is also an indicator of inflammation, but hypoalbuminemia accompanied by inflammation is rare. If there are no obvious clinical signs indicating hypoalbuminemia, then PPE can be excluded during diagnosis. The exclusion of NBP is based on a urinalysis, which determines the protein-creatinine ratio in the urine. Liver failure is ruled out using bile acid testing (pre- and post-prandial) before diagnostic tests for PLE begin. Dogs with EPD do not always have a combination of hypoalbuminemia and hypoglobulinemia (panhypoproteinemia). In some cases, ELP (eg, in the Soft Coated Wheaten Terrier) or liver failure (an atypical bile acid test result) is observed and raises suspicion for ELD. In this case, you can verify the presence of PPE by doing a stool test to determine the level of proteinase inhibitor Alpha-1 (1PI). The test is highly specific, so it is strongly recommended that you read the instructions provided by the University of Texas Gastroenterology Laboratory (see http://vetmed.tamu.edu/gilab). This test can also be used as a screening test to detect latent disease in dog breeds with a high prevalence of EPD, such as Soft Coated Wheaten Terriers, and as a follow-up test to assess response to treatment. Once ELD is diagnosed, it is necessary to identify the cause of the disease that caused ELD in order to subsequently select appropriate treatment. In this case, any complications associated with EBP must be recorded in the patient’s chart.

Cause of EBP

Fungal diseases such as histoplasmosis or pythiosis are usually associated with focal or multifocal increase in the thickness of the intestinal walls with or without loss of stratification or individual parts of the intestine, but they cannot be distinguished from neoplasia on ultrasound.

Diffusion neoplasia of the intestine, such as lymphoma, can be reflected on ultrasound; changes in this disease are similar to changes in inflammatory bowel diseases (increased wall thickness). Although a decrease in the layering of the walls most likely indicates intestinal neoplasia. Obviously, ultrasound is not a diagnostic tool in determining the causes of PEP. Therefore, additional tests must be performed to prescribe the correct treatment. If there is a significant increase in the thickness of the intestinal walls, a puncture biopsy of the damaged parts or lymph nodes is performed. A biopsy can diagnose mycosis or intestinal neoplasia, especially in the case of lymphoma. Although, in most cases, an intestinal biopsy is needed to make a final diagnosis. PEP is also associated with chronic intussusception or chronic gastrointestinal ulcerations secondary to neoplasia or gastrinoma.

Types of biopsy

The use of endoscopic biopsy for hypoalbuminemia is preferable to biopsy performed at surgery for many reasons. First of all, surgery always carries the risk of possible suture dehiscence, and the recovery period after surgery is always longer. However, if endoscopy does not allow access to focal changes in the intestine, surgical biopsy may be the best option when making a final diagnosis and, especially when excluding neoplasia. Laparotomy is the only way to take a biopsy for lipogranuloma, which can develop along the mesentery. To prevent suture dehiscence during EPB, it is recommended to use a serous “patch” at the biopsy site. If an abdominal ultrasound shows little or no changes, then endoscopy should be used. The author of the article prefers to do endoscopy not only at the site of the lesion, but also around it, because the distribution of the lesion is not always homogeneous, and the most obvious lesions can be found in the ileum (eg, lymphangiectasia). It is recommended to take approximately 8-12 good quality biopsies to establish crypt pathology and lymphangiectasia. Crypt pathology often accompanies PEP in dogs and consists of expansion of the crypts filled with protein-like material, desquamated epithelial cells and inflammatory infiltrate cells. Lymphangiectasia is not always seen in dogs with PLE, the distribution of this lesion is focal and therefore not easily found by localized surgical or endoscopic biopsies. Increased lymphatic vessel can be easily damaged if the biopsy is performed incorrectly, in addition, an incorrectly performed biopsy will give a false negative diagnosis of lymphangiectasia. It is also possible that other changes in intestinal mucosal permeability, such as enterocyte blocking zones, lead to protein loss.

Possible complications and consequences for EPD

Hypocobalaminemia is observed in almost all dogs with EPD, therefore, it must be reflected in the patient's chart. Hypocobalaminemia is a prognostic factor for the disease. In some cases, hypocobalaminemia can be extremely severe and contribute to further deterioration of the intestines, since cobalamin is very important for the rapid division of cells such as enterocytes. Therefore, for dogs with EPD, cobalamin support is recommended as long as the amount in the blood is below the level normal values. One injection of cobalamin can be given while waiting for test results (250 - 1500 mcg depending on the dog's weight).

Hypocalcemia is sometimes observed in dogs with EPD. A decrease in ionized calcium can cause a seizure, especially in Yorkshire Terriers, therefore, are required intravenous injection calcium. The simultaneous development of hypomagnesemia is possible due to impaired absorption of magnesium in the intestine and, probably, due to its increased excretion from the intestinal cavity. Dogs with EPD also have decreased vitamin D concentrations, which is likely contributed to by hypocalcemia.
Pleural effusions sometimes complicate cases of PEP, so they should always be documented before anesthesia is used for procedures such as endoscopy and surgery to take biopsies of the intestinal mucosa.

Dogs with EPD may exhibit a hypercoagulable state, which is associated with decreased plasma antithrombin III concentrations as well as increased thrombin-antithrombin complexes and possibly other complex mechanisms.

Thromboembolic complications have been reported in 10% of dogs with EPD. Sudden death related to pulmonary thromboembolism, is a possible fatal complication of PEP.

PEB forecast

The prognosis of the disease in dogs is always predictable. In most cases, PEB is associated with chronic intestinal inflammation, with proper treatment passes and the condition improves dramatically. But sometimes, despite aggressive treatment, the health of some dogs never improves. Initial response to therapy is an important prognostic factor; If the dog's condition does not improve two weeks after starting treatment, the prognosis is generally poor. If PEP is accompanied by severe coagulation disorders such as thrombosis, then the prognosis is also unfavorable. Clinical index A Canine Chronic Enteropathy Activity (CCECAI) score greater than 12 may be an indicator of treatment failure or even an indication for euthanasia if the index score remains the same for 3 years after diagnosis of EBD with inflammatory bowel disease. For a definition of the CCECAI, see Allenspach K et al. Chronic enteropathies in dogs: assessment of risk factors for adverse outcomes. J Vet Int Med 2007, 21(4):700-708. The presence of enlarged lymphatic capillaries in intestinal biopsy specimens has recently been associated with more for a long time survival.

Types of treatment:

Nutritional support

Dogs with EPD are often severely deficient in energy and protein. It is strongly recommended to provide the animal with high-energy, high-carbohydrate diets with low content fiber and fat, because digestibility of protein and fats is difficult. You can also add boiled egg whites to your diet. To improve absorption, frequent feeding in small doses is usually recommended. Because PEB is often associated with inflammatory bowel disease, new protein diets. Elemental diets including oligopeptides and amino acids or parenteral nutrition can be used in extreme cases, because they are very expensive.

Treatment of complications

With a sharp decrease in anthrithrombin activity and the risk of developing thrombosis in a patient, fresh frozen plasma and standard heparin therapy (200 units/kg subcutaneously 3 times a day with coagulation monitoring) can be used.
Oncotic support is provided in the most severe cases hydroxyethyl starch or purified albumin for dogs (www.abrint.net). In some cases, this temporary support may improve response to treatment by reducing the swelling of the intestinal wall associated with lymphangiectasia.

However, if antithrombin or albumin are constantly removed from the intestines, then these procedures will not provide long-term effect. Deficiencies of magnesium, calcium and cobalamin are corrected by parenteral nutrition.

Treatment of chronic enteropathy

When found infectious disease or neoplasia, specific treatment must be prescribed. At chronic inflammation associated with PEP, or in the case of lipogranuloma, treatment with immunosuppressive drugs is recommended. First, a combination of corticosteroids (prednisolone: 2-3 mg/kg per day with gradual dose reduction) and cyclosporine (5 mg/kg per day) is used.

This treatment is necessary because the disease threatens the life of the animal. If this fails, azathioprine can be used along with steroids. Chlorambucil (0.1-0.2 mg/kg followed by tapering to the lowest dose) together with prednisolone has been reported to be a possible treatment option and has been shown to improve survival with the prednisolone-azathioprine combination. By starting treatment with intravenous steroids, the effectiveness of treatment can be increased, because Intestinal absorption of drugs is always questionable in EPB. In extremely rare cases, PED partially responds to antibiotic therapy, so metronidazole (10 mg/kg twice daily for 2-3 weeks) may help.

Follow-up and decision to discontinue treatment

In conclusion, it should be added that cases with EPD can be effectively treated if diagnosis and treatment were undertaken in a timely and adequate manner.

Prepared based on materials: “PROCEDINGS OF THE MOSCOW INTERNATIONAL VETERINARY CONGRESS, 2012.”

Chronic diarrhea is the frequent passage of loose (or loose) stools for more than 3 weeks. The condition can have a relapsing course, with periodic exacerbations and periods of remission.

By origin, chronic diarrhea can be small intestinal or large intestinal, and diarrhea can also be associated with a combined disease of all parts of the intestines and even the stomach, in which case they speak of enterocolitis or gastroenterocolitis, respectively. There are 4 main mechanisms for the development of chronic diarrhea: increased secretion of fluid into the intestinal lumen, decreased absorption of fluid, increased permeability of the intestinal wall and increased motility (peristalsis of the gastrointestinal tract).

In chronic diarrhea, the process may involve not only the intestines, but also endocrine system, which is manifested by a violation of the water-electrolyte balance and acid-base state.

Digestive disorders accompanied by diarrhea may be caused by exocrine pancreatic insufficiency (juvenile acinar atrophy, chronic pancreatitis), changes in diet or fatty, poorly digestible food, feeding the dog food that is not typical for carnivores, etc. Exocrine pancreatic insufficiency is common in large breed dogs and has a breed predisposition, especially in German Shepherds, which can also develop this serious pathology, such as pancreatic atrophy.

The cause of chronic diarrhea can be food allergies, gluten-dependent enteropathy (celiac disease) in Irish setters, metabolic disorders due to hypocortisolism, uremia, intoxication, and the use of medications (anticholinergic drugs, antibiotics).

The disease can be caused by nutritional (nutritional) and idiopathic (immunological) causes, errors in the diet or changes in it, foreign bodies (bones, wool), large amounts of fiber in the feed, irritable bowel syndrome, as well as metabolic disorders (uremia, hypoadrenocorticism, intoxication ) and taking certain medications.

The key and most important factor in the formation of chronic inflammatory bowel diseases is a violation of the immunological status of the animal and, as a consequence, dysbiotic conditions in the intestines, which in turn always accompany other diseases of the gastrointestinal tract. On the one hand, the intestine, as the most important lymphoid organ in diseases, does not provide adequate resistance to the body, and on the other hand, other factors of decreased immunity contribute to the occurrence of chronic inflammatory diseases of the digestive tract.

Clinical picture and diagnosis of inflammatory bowel diseases

Small intestine. The volume of bowel movements is significantly increased, defecation 2-4 times a day. The animal loses weight or does not gain weight due to a decrease in the absorption of nutrients, since it is in the small intestine that this process occurs. There may be melena (black stool due to bleeding in the thin section), but there is no admixture of fresh blood and mucus in the stool. There is no tenesmus (painful urge), there may be no pain or difficulty during bowel movements. There may be an accumulation of gas and rumbling in the stomach. Sometimes there is vomiting.

The severity of the general condition is due to malabsorption (impaired absorption), impaired digestion and hypoproteinemic (exudative) enteropathy. Palpation reveals spasmodic intestinal loops, which may be associated with infiltrative diseases of the intestine, effusion in the abdominal cavity due to protein loss during exudative enteropathy, or with space-occupying formations (foreign body, tumor, intussusception, enlarged mesenteric lymph nodes).

Serum trypsin-like immunoreactivity is the test of choice when exocrine pancreatic insufficiency is suspected. Diagnostic level is more than 2.5 mg/l. Even a slight increase in the content of para-aminobenzoic acid in the blood plasma during the bentiromide test confirms exocrine pancreatic insufficiency.

The D-xylose absorption test is insensitive and nonspecific. A peak plasma xylose level of less than 45 mg/dL indicates malabsorption, but a normal value does not exclude it. Serum folate and cobalamin (vitamin B12) are tested. Low cobalamin levels are due to exocrine pancreatic insufficiency and malabsorption in the distal small intestine, and low folate levels are due to malabsorption in the proximal small intestine. Enhanced growth of microflora in small intestine may lead to decreased cobalamin levels and increased serum folate levels.

Plain radiography of the abdominal cavity can detect intestinal obstruction, organ enlargement, mass formations, foreign bodies or ascites. Contrast radiography (barium suspension for the upper gastrointestinal tract of the animal, barium enema) reveals intestinal spasm, ulcerative defect, unevenness of the mucous membrane, space-occupying formations, X-ray negative foreign bodies, strictures.

Ultrasound can detect intestinal spasm, space-occupying formations of the gastrointestinal tract, foreign bodies, intestinal obstruction, ascites, and enlarged mesenteric lymph nodes.

Stool analysis ( Coprology) is a non-instrumental method that allows you to evaluate a number of factors

Clinical blood test

It should be remembered that most often the number of blood cells is within normal limits.

Electrolyte composition of blood

Allows you to diagnose hypokalemia (for example, in acute secretory gastroenteritis, chronic renal pathology) or hyperkalemia with hyponatremia (in the case of vomiting and/or diarrhea due to hypoadrenocorticism).

Blood chemistry

Low levels of proteins, including albumin, indicate inflammatory bowel disease with reduced absorption of nutrients and depressed digestion; very low levels of albumin may be a sign of intestinal lymphoma, bowel diseases accompanied by protein loss; a normal total protein level, but a low albumin level allows you to diagnose chronic disorders of the kidneys or liver; absolute hypoproteinemia is observed with bleeding.

— High level liver enzymes are sometimes observed in chronic diseases of internal organs, with liver failure in case of portosystemic shunt, with pancreatitis; their excessively high level accompanies diseases of the liver itself. Animals with liver disease may have normal or little increased content enzymes.

- Hyperglycemia with diabetes mellitus or hypoglycemia, which occurs with septicemia accompanied by diarrhea (may require several samples for an accurate diagnosis).

Analysis of urine usually carried out in conjunction with a blood test - allows you to identify specific disorders and determine protein levels

— Normal concentration urine (may occur with renal azotemia) or low concentration (with various diseases kidney).

— High proteinuria in combination with hypoproteinemia (nephrotic syndrome), moderate proteinuria (systemic diseases) or absence of protein in the urine (chronic inflammatory enteropathy, lymphangiectasia, intestinal lymphoma)

In general, the hemogram biochemical analysis blood and urine tests are carried out in cases where the patient shows signs of any systemic disease, for example, polyuria and polydipsia, loss of appetite, weight loss, vomiting, profuse diarrhea. Even if symptoms are mild or intermittent, the screening tests described are always very valuable as they give a good idea of general condition patient's health.

Functional tests

— Determination of trypsin-like immunoreactivity (TI) is used for functional diagnostics pancreatic conditions. Sometimes with pancreatitis, TI is quite high, but lower than with EPI (exocrine pancreatic insufficiency).

— Determination of pancreatic lipase immunoreactivity (PLI) has become available only recently and can be considered very accurate and useful in the diagnosis of pancreatitis.

— Determination of the level of cobalamin and compounds in the dog’s blood serum folic acid may be useful in diagnosis, but should not be overestimated. A low cobalamin content is observed with EPI, as well as with a slightly increased growth of microflora in the proximal parts of the digestive tract and with minor pathologies in its distal parts. A high level of folic acid compounds is determined with a slight increase in the growth of microflora, while a low level is determined with minor pathologies of the proximal digestive tract.

— A comparative analysis of the concentration of bile acids in the blood serum on an empty stomach and after a meal helps to determine liver function if liver failure is suspected.

Specific biochemical tests are prescribed if, based on the results of the clinical examination and previous tests, there is a possibility of a certain local or systemic disorder and the clinician needs to confirm or refute his assumptions. The list of specific tests includes the following:

- ACTH stimulation - performed in dogs suffering from diarrhea and vomiting due to suspected hypoadrenocorticism;

Physical examination after patient sedation

In some cases it is necessary to further investigate:

— oral cavity, larynx, pharynx and tonsils (for dysphagia);

- abdominal area, especially if palpation should be carried out on someone who is excited or suffering overweight animal;

- anorectal area, for example, with symptoms of dyschezia, hematochezia, when a routine examination is painful for the animal.

Therapeutic methods

Therapeutic diagnostic methods are used in a variety of cases:

— when determining a nonspecific reaction to food (use food based on hydrolyzed proteins or exclude some components from the diet) or food intolerance (use a diet that does not contain lactose or gluten). Different feeding regimens and food quality are also used to determine nutritional (or dietary) causes of diarrhea.

Colon. A small volume of stool with each bowel movement. The animal does not lose weight if there is no combined pathology in the small intestine. There may be an admixture of mucus and fresh blood in the stool, tenesmus and the urge to defecate, pain, difficulty defecating in diseases of the rectum and distal parts of the colon. Vomiting is not typical. Most diseases of the large intestine manifest as severe diarrhea, tenesmus and/or dyschezia (i.e. painful and difficult bowel movements). Diarrhea is characterized by frequent (normal - 1-3 times) urge to defecate, during which a small amount of feces is released, which mainly consists of mucus, and sometimes contains traces of fresh blood (i.e. hematochezia). In diseases of the colon and rectum, the disorder may be observed, while dyschezia often occurs in diseases of the rectum. Due to the fact that the main function of the large intestine is the adsorption of water and electrolytes, in the pathology of this part of the intestine, signs such as impaired absorption of nutrients (for example, frequent and bulky stools, significant weight loss) are uncharacteristic. Animals are generally alert and active, of normal fatness, with good appetite. Sometimes, dogs experience abdominal pain or discomfort due to colitis. In addition, some diseases (inflammation of the intestines, lymphoma of the digestive tract, fungal enterocolitis) simultaneously cause minor signs of intestinal disorder.

Typically, palpation of the intestines in animals does not cause pain. It is necessary to conduct a thorough rectal examination of the rectum for the presence of stool, diverticulum (perineal hernia), stricture (rarely), check pain reaction and clarify the condition of the mucous membrane, as well as examine the perineal area for possible pathologies. In addition, a rectal examination provides an opportunity to examine the stool for blood and mucus and to collect fresh stool samples for cytological testing.

Digital examination of the rectum may reveal irregularities or thickening of the mucous membrane, mass formations within the lumen of the intestine or in its wall, stricture or enlarged lymph nodes.

Differential diagnosis. The first step is to determine whether the diarrhea is small intestinal or colonic.

The cytological method of stool analysis involves assessing the staining of scraping elements from the rectum and colon under high magnification and oil immersion to identify the causative agent of the disease and inflammatory cells. A flat conjunctival staple is used to collect the required number of stool samples, place them on a glass slide, dry and stain. An increase in the number of white blood cells indicates a possible inflammatory or infectious etiology. The presence of fungal organisms (Histoplasma), tumor cells, predominance of spirochetes or Clostridial spores also suggests a possible cause for the development of clinical signs of intestinal disorders. Stool microscopy is indicated in cases where the cytological method confirms diarrhea with signs of inflammation or in cases of suspected infectious diarrhea. One of the main bacterial infectious agents in dogs and cats are Campylobacter jejuni, salmonella and clostridia. It is important that fecal samples for microscopy are fresh and in appropriate quantities. It is also necessary to transfer the sample to nutrient media as quickly as possible.

For intestinal diseases in animals, visual diagnostic methods are rarely used. Colonoscopy and biopsy of the mucous membrane of the large intestine often help to make an accurate diagnosis when other methods do not make a definitive diagnosis. Flexible endoscopy is preferred because it allows assessment of the entire colon, cecum, and possibly the distal ileum using retrograde ileoscopy.

Particular diseases of the colon

Fungal colitis

Histoplasmosis is a fairly rare disease caused by a dimorphic fungus that affects dogs and cats. The infection develops after pathogen spores enter the body from the environment. The pathogen affects the lungs, but can also infect the gastrointestinal tract and other organs. Diseases of the large intestine are common in dogs with disseminated lesions, when fungal infection causes extensive granulomatous tissue reaction. Clinical signs in dogs varies depending on the degree of gastrointestinal involvement and the severity of diarrhea (moderate, chronic, severe) causing tenesmus, bloody stools and fecal mucus, fever and weight loss. Special staining techniques (eg PAS) may be required to confirm that the organism is present in histological samples. Treatment is usually with intraconazole (10 mg/kg PO every 12-24 hours) alone or in combination with amphotericin B (0.25-0.5 mg/kg IV every 48 hours to a total cumulative dose of 5-10 mg/day). kg in dogs and 4-8 mg/kg in cats). The prognosis depends on the spread of the disease, but usually after long-term antifungal therapy (4-6 months) recovery occurs. Other mycoses affecting the intestines are rare. Both Pythium (pythium) and several species of Zygomycetes (zygomycosis) can penetrate deeply into the tissues of the digestive tract, causing severe granulomatous gastroenteritis. Clinical signs include chronic severe diarrhea and vomiting, anorexia, depression and weight loss. During clinical examination, compactions can be detected in abdominal area or regional thickening of the intestine. The diagnosis is made based on the detection of the microorganism during histological examination of a biopsy of the mucous membrane. Treatment is radical surgical excision of the granulomatous formation, because these fungal pathogens are resistant to standard antifungal drugs. The forecast is cautious.

Inflammatory diseases of the large intestine (Chronic colitis)

Inflammatory bowel diseases (IBD) mainly include a group of idiopathic chronic gastrointestinal diseases accompanied by the presence of chronic inflammatory cells.

Lymphocytic plasmacytic colitis (LPC) is the most common form of chronic colitis in dogs and cats. Thus, in most cases, LPK affects middle-aged or older animals. Clinical signs are usually cyclical, with tenesmus, mucus and blood in the stool often observed. During endoscopic diagnostics abnormalities such as increased friability and granulation of the mucous membrane, vascular disorders of the submucosal layer and erosion are observed. However, the absence of all of the above signs does not eliminate the diagnosis, so it is necessary to do a biopsy and conduct laboratory diagnostics.

Chronic histiocytic ulcerative colitis (CHUC) is the most commonly diagnosed type of IBD. Affected dogs have severe diarrhea, bloody stools, or tenesmus of varying severity. Apathy, anorexia and loss of body weight of the animal are also noted. Boxers are predisposed to CGUC more than other breeds, and males under the age of 1 year are most often affected by this disease. Histological examination of the affected tissues demonstrates a mixed inflammatory infiltration of PAS-positively stained histiocytes of the mucous membrane. During colonoscopy, increased granularity of the mucous membrane, damage to the integrity of the mucous membrane and diffuse erosion are noted. The prognosis for this disease is usually poor. Recent studies have shown that clinical signs can be controlled with antibiotic therapy (rather than traditional immunosuppressive therapy), including supportive care. normal microflora intestines with intestinal inflammation.

Treatment of chronic colitis

Diet therapy, although it is used in conjunction with other drugs, it is extremely important for the long-term treatment of most diseases of the large intestine. Medical nutrition includes a protein (hypoallergenic) or high-protein diet, as well as a diet based on easily digestible foods. Each diet is effective in its own way and is used depending on the clinical manifestations. During treatment, one of the diets is used for 3-4 weeks. If the chosen diet does not give positive result, you should try a different diet. Most often, when treating dogs and cats with diseases of the large intestine, a group of diets with high content dietary fiber. This approach is justified because dietary fiber, depending on its fermentability, affects both the production of luminal short-chain fatty acids, and on colonic motility, which together have a positive effect on colon health and function.

There is quite convincing and constantly confirmed evidence that feeding dogs food containing increased amounts of fiber has a beneficial effect on the state of the gastrointestinal tract. The question arises as to which type of fiber is most suitable. Trials of diets both hypoallergenic (for example, a new source of protein) and easily digestible have confirmed a positive effect on the intestinal mucosa due to their mild effect and good tolerability in inflammatory bowel processes. However, most dogs or cats with food allergies or intolerances exhibit clinical signs of small intestinal dysfunction (eg, vomiting, anorexia, weight loss, and sometimes chronic diarrhea); thus, symptoms characteristic only of pathology of the large intestine are unlikely to occur due to allergic intolerance.

There are several components of drug treatment for colitis associated with immunological disorders in dogs and cats, where reduction of the inflammatory process is the main means of control clinical manifestation diseases. One of these components in the treatment of dogs is the use of anti-inflammatory and immunosuppressive drugs. With long-term use (months) or high doses (>2 mg/kg per day) of steroid drugs, side effects may occur that require limiting their use or finding an alternative treatment method. In general, it is preferable to use prednisone or methylprednisone rather than dexamethasone, betamethasone, or triamcinolone.

Budesonide has been tried in the treatment of intestinal disease in a small number of dogs and cats, so data on its effectiveness is limited. Besides, clinical researches uses of this drug have not been published. The addition of immunosuppressants to the treatment regimen for severe or difficult-to-treat forms of colitis is a prerequisite. Typically, azathioprine (Imuran) or chlorambucil is used in such cases, but cyclosporine is another treatment option. These medications may cause significant side effects. Therefore, it is necessary to monitor the animal appropriately and, if necessary, adjust the recommended treatment regimen. In order to achieve the best results in the treatment of colitis, you may need complex treatment using steroids, immunosuppressants.

Antibiotics that are effective against anaerobic bacteria (tylosin or metronidazole) often interfere with bacterial growth and enterotoxin production. In dogs or cats with acute form disease, elimination of clinical signs usually occurs after 3-5 days of antibiotic therapy. To maintain remission in animals with chronic colitis, a long course of treatment with metronidazole is required. The effect of metronidazole is directly related to its ability to inhibit cellular immunity or its antimicrobial effect on inflammatory resident microflora.

Tumors of the large intestine

Both malignant and benign forms of neoplasms occur in dogs and cats. In dogs, adenocarcinoma (AC) is more often diagnosed in combination with lymphosarcoma (LS) and leukomyosarcoma. In most dogs, neoplasms are localized in the descending colon and rectum, although leukomyosarcoma is often found in the cecum. Adenocarcinoma and lymphosarcoma are the most common malignant formations, accompanied by tumors mast cells, registered in cats. Cancers in cats are usually located in the ileocolon and descending colon. Local metastases in AK occur in the peritoneum and mesenteric lymph nodes in 50% of cats.

Most malignant tumors occur in older dogs and cats. Clinical signs often do not differ from those of chronic colitis. Clinical examination of animals with malignant tumors in the colon and rectum includes dyschezia, a palpable abdominal mass, mesenteric lymphadenopathy, and rectal examination reveals the presence of stool in the rectum or excessive granularity of the mucous membrane upon palpation. Imaging (diagnostic radiology and ultrasonography) provides important information about the stage of the disease. Colonoscopy with mucosal biopsy provides an accurate diagnosis. Treatment for colorectal neoplasia depends on the type of tumor, location, and extent of metastases. Surgical excision is recommended for focal abdominal enlargement and leukomyosarcoma. The long-term prognosis for most malignancies is guarded. Surgical resection or endoscopic polypectomy is recommended for dogs with benign (adenomatous) polyps and demonstrates an excellent prognosis.

Feed a highly digestible, low-fat diet for 3-4 weeks. may relieve symptoms of colonic diarrhea.

In case of dehydration, fluid replacement with balanced electrolyte solutions (isotonic sodium chloride solution, Ringer's solution), correction of water-electrolyte balance and acid-base status are necessary.

Contraindications. Anticholinergic drugs aggravate most cases of chronic diarrhea and should not be used without bacterial confirmation. However, they are sometimes used to relieve intestinal colic in irritable bowel syndrome.

Surgical methods. Exploratory laparotomy and surgical biopsy should be performed when there is evidence of intestinal obstruction, a mass, or when the diagnosis established by endoscopic biopsy is equivocal.

It is necessary to control the frequency of defecation, the volume and nature of feces, as well as body weight. In case of hypoproteinemic enteropathy, control total protein blood and monitor for pleural effusion or ascites. Diarrhea usually improves gradually after treatment. Otherwise, the diagnosis should be reconsidered. Sometimes, with inflammation of the intestine or exocrine pancreatic insufficiency, the growth of microflora increases, which must be suppressed simultaneously with the treatment of the underlying disease.