Approach to Diarrhoea in Companion Animals PDF

APPROACH TO… DIARRHOEA IN C O M PA N I O N A N I M A L S PRIYA SHARP LEARNING OBJECTIVES Construct a differential diagnosis list based on diarrhoea as a clinical presentation and choose appropriate diagnostics. Determine appropriate medical and surgical interve...

APPROACH TO… DIARRHOEA IN C O M PA N I O N A N I M A L S PRIYA SHARP LEARNING OBJECTIVES Construct a differential diagnosis list based on diarrhoea as a clinical presentation and choose appropriate diagnostics. Determine appropriate medical and surgical interventions in the management and treatment of diseases characterized by diarrhoea. Determine appropriate prognosis, and the welfare implications of treatment options. Determine control measures appropriate for disease prevention. 2 DEFINITION What is diarrhoea? When do you call it diarrhoea? Where is it originating from? What form of diarrhoea is it? REVISION Osmotic: excess fluid within the lumen Secretory: excessive secretion within the SI affects absorption. Increased intestinal permeability: disruption to gut wall increasing permeability of protein,fluid, bacteria, blood. Dysmotility: increased motility usually secondary to other forms. https://www.akc.org/expert-advice/health/doggie-diarrhea/ 3 SMALL VS LARGE INTESTINAL DIARRHOEA Small Intestinal Large Intestinal Frequency Normal to mild increase Increased Urgency Normal Increased Mucous No Yes Straining No Yes Blood Melena Haematochezia (fresh blood) Volume Increased Normal to mild increase 4 SMALL INTESTINAL DIARRHOEA ACUTE CHRONIC Infectious Obstructive Dietary Ulceration of GI mucosa Bacteria Foreign body Food –responsive Acute infectious Parasites Intussusception chronic enteropathy enteritis Viruses Volvulus Gluten-sensitive Gastric ulcers Toxic Extra intestinal enteropathy Parastitic enteritis Drugs Renal failure Inflammatory diseases Intestinal carcinoma Insecticides Hepatic disease Chronic gastritis Disorders of intestinal Heavy metals Acute pancreatitis Chronic enteritis lymphatics Dietary Plasmacytic- Mesenteric Change in diet lymphocytic enteritis neoplasms Overfeeding Eosinophilic Congestive heart Intolerance gastroenteritis failure Sensitivity Haemorrhagic Congestive gastroenteritis pericarditis Lymphosarcoma 5 ACUTE SI DIARRHOEA Infectious Bacteria Parasites Viruses 6 ACUTE SMALL INTESTINAL DIARRHOEA Toxic Drugs Insecticides Heavy metals Bark post 7 ACUTE SMALL INTESTINAL DIARRHOEA Dietary Change in diet Overfeeding Intolerance Sensitivity Warrendale wagyu 8 ACUTE SMALL INTESTINAL DIARRHOEA Obstructive Foreign body Intussusception Volvulus 9 ACUTE SMALL INTESTINAL DIARRHOEA Extra intestinal Renal failure Hepatic disease Acute pancreatitis All Adobe stock images 10 CHRONIC SMALL INTESTINAL DIARRHOEA Dietary Food –responsive chronic enteropathy Gluten-sensitive enteropathy 11 CHRONIC SMALL INTESTINAL DIARRHOEA Inflammatory diseases Chronic gastritis Chronic enteritis Plasmacytic-lymphocytic enteritis Eosinophilic gastroenteritis Haemorrhagic gastroenteritis PDSA 12 CHRONIC SMALL INTESTINAL DIARRHOEA Ulceration of gastrointestinal mucosa Acute infectious enteritis Gastric ulcers Parastitic enteritis Intestinal carcinoma 13 CHRONIC SMALL INTESTINAL DIARRHOEA Disorders of intestinal lymphatics Mesenteric neoplasms Congestive heart failure Congestive pericarditis Lymphosarcoma 14 LARGE INTESTINAL DIARRHOEA ACUTE CHRONIC Acute non-specific colitis Inflammatory bowel disease Obstructive Parasitic Infectious Neoplasia Parasitic (whipworm, hookworm, giardia, tritrichomonas) Bacterial (Campylobacter, Clostridia) 15 SMALL VS LARGE INTESTINAL DIARRHOEA Parameters Small intestinal diarrhoea Large intestinal diarrhoea Frequency Normal to mild increase Increased Volume Increased Normal to mild increase Blood Digested (Melaena) Fresh (Hematochezia) Mucus No Yes Gaseous Present No Weight Loss More likely Less likely Straining No Yes Undigested food Occasionally Absent 16 I N V E S T I G AT I O N - L A R G E I N T E S T I N A L D I A R R H O E A History taking Diet ( Feed & feeding, changes) Behaviour (scavenging? obsessive compulsive?) Worming status Vaccination (don’t just ask- check!) Activity or management change Individual or herd? Extra intestinal? Chronic? Acute? LI? SI? 17 I N V E S T I G AT I O N - L A R G E I N T E S T I N A L D I A R R H O E A Physical examination aminotransferase, alkaline phosphatase Hydration status and creatinine/ urea. Cobalamin levels? TPR Urinalysis BCS Emergency?? Faecal culture MM colour PCR Abdominal palpation Radiographs (Thorax included if Faecal examination – Microscopy , Faecal oesophageal dysfunction suspected). flotation, SNAP test (Giardia, Parvo) Contrast study? FeLV / FIV test Ultrasound Haematology – non-regenerative anaemia, Biopsy (endoscopic vs surgery) inflammatory cells, eosinophilia Biochemistry - sodium, potassium, albumin, globulin, alanine 18 DIAGNOSTIC PLAN-LARGE INTESTINAL DIARRHOEA Infectious History taking Toxic Dietary Physical examination Obstructive Hydration status Extra intestinal Temperature, pulse, respiration Inflammatory diseases Ulceration of GI mucosa Body condition Mucous membranes colour Abdominal palpation Haematology & biochemistry ( Low Alb, Glo, folate, cobalamin) mild elevation on ALT, ALP Faecal examination – Microscopy, Faecal flotation, SNAP test (Giardia, Parvo, FeLV, FIP) Faecal culture 19 RULE OUT EXTRA INTESTINAL CAUSES Exocrine pancreatic insufficiency Pancreatitis – Pancreatic lipase immunoreactivity test Renal disease – Urea, Cr, SDMA, Urinalysis Hepatic insufficiency – Urea, cholesterol, bilirubin, bile acid stimulation test Hyperthyroidism – Total T4, TRH stimulation Hypoadrenocortism – ACTH stimulation test Infectious Toxic Dietary Obstructive Extra intestinal Inflammatory diseases Ulceration of GI mucosa 20 DIAGNOSTIC PLAN-LARGE INTESTINAL DIARRHOEA Radiography – Is contrast useful? Ultrasonography Biopsy Endoscopic vs surgical see WSAVA template for histologist Exclusion diet trial (4-8 weeks) Restricted novel protein Infectious Hydrolysed protein trial Toxic Dietary Obstructive Extra intestinal Inflammatory diseases Ulceration of GI mucosa 21 T R E AT M E N T - L A R G E I N T E S T I N A L D I A R R H O E A Fluid therapy – Crystalloids / Colloids? GI protectants Blood transfusion H2 receptor antagonist (Cimetidine) Antibiotics – when to use? Proton pump inhibitors (Omeprazole) Oxytetracycline Mucosal binding (Sucralfate) Metronidazole Probiotics / Prebiotics Infectious Tylosin Vitamin supplementation Toxic Anthelmintics Folate Ulceration of GI mucosa Dietary Praziquantel Cobalamin Obstructive Extra intestinal Pyrantel Nutrition Inflammatory diseases Milbemycin Antispasmodic Fendbendazole / Metronidazole for Giardia Buscopan Adsorbents Steroids? To use or not? Kaolin Montmorillonite 22 T R E AT M E N T - L A R G E I N T E S T I N A L D I A R R H O E A Surgical treatment Infectious Toxic Dependent on site of neoplasia Dietary Correction surgery for intussusception Ulceration of GI mucosa Obstructive Removal of foreign body Inflammatory diseases Extra intestinal Keep healthy margin Immunosuppressive therapy - IBD Azathioprine Corticosteroids Treat extra intestinal conditions – eg Pancreatic enzyme therapy 23 PROGNOSIS & WELFARE Dependent on severity, comorbidities Neoplasia dependent on stage and grade Dietary dependent on compliance. Easy for remission. Consider animals in chronic condition and cannot be managed well Pain/ discomfort management is very important 24 PREVENTIVE MEASURES Control infectious agents via vaccination, deworming. Good hygiene and herd health management Behaviour management of compulsive, scavenging dogs. Client education about dietary change, nutrition and feeding methods. Senior health monitoring for co-morbidities 25