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Monday
Apr172017

Take a walk through a case

Thank you to Victoria Demello from The University of Georgia College of Veterinary Medicine for sharing this very interesting case which was one of the winning submissions from the cases and abstracts category. 

History

A 2-year-old 22.7kg female spayed mixed-breed dog was referred to the Internal Medicine service of the University of Georgia College of Veterinary Medicine for evaluation after being seen by the referring veterinarian 1 month prior. At the time of the referring veterinarian visit, the dog had a 2-day history of inappetence and vomiting. The animal would vomit 3-4 hours after eating and the vomitus was undigested food. Other than these gastrointestinal signs, the dog seemed systemically healthy. The dog was not taking any medications other than once monthly Tri-Heart heartworm preventative and a Seresto Collar. The dog was adopted 1.5 years prior to presentation from a local shelter, and was current on Rabies, Lepto, DHPP, and Bordetella vaccinations.

Initial Diagnostics

A CBC, serum biochemical analysis, and a urinalysis were performed by the referring veterinarian at the time of initial presentation for gastrointestinal symptoms. The bloodwork and urinalysis were unremarkable except for elevated Total T4 3.8µg (reference range, 0.8-3.5 µg/dL).

The referring veterinarian’s initial physical exam was unremarkable. The dog was fed Hill’s Ideal balance (chicken and brown rice, 1.5 cups BID). The referring veterinarian noted a possible food allergy.Royal Canin Ultamino (a hydrolyzed protein diet) was prescribed and a food trial was started. The referring veterinarian also administered injectable Cerenia, prescribed Omeprazole, and discussed taking radiographs. The owner declined radiographs at that time.

Approximately 2.5 weeks after the initial presentation to the referring veterinarian, the dog presented for recurring vomiting, inappetence and weight loss due to the previously mentioned symptoms. The dog was eating Purina EN (canned) as the dog had developed a food aversion to Royal Canin Ultamino. Abdominal radiographs and a Barium Series were performed. Although the dog was fasted prior to taking radiographs, the stomach still appeared to have food in it. The Barium Series revealed no megaesophagus or anatomical filling defects in the stomach. The Barium Series was completed over 8 hours with 2 view (lateral and V/D) radiographs taken every hour. All of the barium did not leave the stomach and enter the Duodenum until hour 8. The dog was diagnosed with a gastric motility problem. The dog was prescribed a prokinetic agent (metoclopramide). The owner was told to keep the dog on Purina EN and slowly switch the diet from canned food to a mash with Purina EN kibble, and then dry kibble exclusively over the next few weeks.

   

Lateral and V/D views before Barium administration.

 

Lateral and V/D views 3 hours post-Barium administration.

Food is still in the stomcach and able to be appreciated radiographically.

Lateral view 8 hours post-Barium administration. All of the Barium has not left the stomach and is in the intestines.

2 days after the start of administration of Metoclopramide the dog began vomiting undigested food again. The referring veterinarian stopped the Metoclopramide administration and referred the dog to UGA CVM’s veterinary teaching hospital.

Referral to Internal Medicine department

On presentation to the veterinary teaching hospital, the dog’s physical exam was unremarkable. The animal presented as BAR, but very nervous and shaking. The referring veterinarian’s bloodwork was reviewed (repeat bloodwork was not performed). Abdominal ultrasound and abdominal radiographs were performed to visualize any foreign objects or masses that might be causing a partial obstruction, but no abnormalities were found.

 

Due to the nervousness of the dog and the lack of a stress leukogram on the bloodwork, Addison’s disease was the top differential followed by IBD and parasitism. A cortisol level test was performed and the results were normal 2.90µg/dl (reference range, 0.50-3.00µg/dl).

Discussion

Due to all the normal diagnostic tests, therapeutic trials were initiated. This includes a dietary trial to rule out a food allergy (Hill’s Z/D), empiric deworming to clear any parasites that may be irritating the bowel (Fenbendazole), and antibiotics to decrease gut inflammation that could be due to abnormal gastrointestinal flora (Metronidazole). IBD is diagnosed through exclusion. Foreign bodies were ruled out, the animal was empirically dewormed, and started on a hydrolyzed diet, and antibiotics. The animal was re-evaluated one month after presentation to UGA.

At the follow-up appointment, the owner wanted an endoscopy and biopsy to have a better idea of what initially caused the gastrointestinal symptoms in the dog. Gastroduodenoscopy was performed. The stomach was visually unremarkable, the duodenum was severely inflamed with enlarged papilla even after a month of treatment prior to the Gastroduodenoscopy. Biopsies of the stomach and duodenum were taken and submitted for histopathology.

 

Biopsy Report

Duodenum: Enteritis, eosinophilic and lymphoplasmacytic, mild, diffuse, subacute with globule leukocytes

Pyloric Stomach: Rare lymphoid nodules and minimal superficial proprial eosinophils and globule leukocytes

Comments:

There is mild inflammation in the duodenum but no significant architectural changes so the significance of the infiltrate is uncertain. Changes in the stomach are minimal but also contain very small numbers of eosinophils and globule leukocytes. The presence of increased eosinophils admixed with globule leukocytes could indicate the presence of hypersensitivity. Since the animal has a history of chronic vomiting and vomiting after eating food, food allergy should be ruled out.

Diagnosis

After interpreting the biopsy report in light of the animal’s recurring symptoms, this dog was diagnosed with IBD with concurrent gastric motility disorder. The dog was sent home with instructions to continue to feed Hill’s Z/D, and administer oral Metronidazole 250mg BID for life. Low dose prednisone was administered for short-term use to reduce the inflammation in the duodenum (5mg BID).

1 month after the confirmed IBD diagnosis, the dog presented to UGA for a follow up appointment. The dog was BAR and seemed to be tolerating the treatments well. Even on low dose prednisone, the dog experienced severe polyuria and polydipsia. The prednisone dose was tapered and discontinued beginning at this visit.

2 months after the confirmed IBD diagnosis, the dog was healthy and BAR. The dog’s weight had improved as well. After stopping administration of Prednisone, the dog did not relapse into vomiting and inappetence. The dog will be maintained on Metronidazole (250 mg BID) and Hill’s Z/d (hydrolyzed protein diet).

 

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