Chronic diarrhea case

Re: Chronic diarrhea case

ilanit — Tue, 02 Dec 2014 20:02:46 GMT

update on case:

Dog is doing very well. He's been a month on i/d low fat and did not have any diarrhea at all.

I rechecked the liver values yesterday and they were normal! (alkp was around 1000 before!)

Re: Chronic diarrhea case

Emily Nightingale — Thu, 30 Oct 2014 10:01:34 GMT

I see :-)

Re: Chronic diarrhea case

Anthony Todd — Thu, 30 Oct 2014 09:46:19 GMT

[quote user="Emily Herskind Nightingale"]I would most often than not run a faecal screen on chronic diarrhoea[/quote]

So would I but only after I was pretty sure the diet wasn't the cause, not before, which is where I've been coming from from the start.....

Re: Chronic diarrhea case

Hannah Wynne Richards — Thu, 30 Oct 2014 09:37:23 GMT

I find the compliance problem with hypoallergenic diets is often the dog not the owner! The particles have been hydrolysed so small, the taste buds can't recognise them either!

Wynne

Re: Chronic diarrhea case

Emily Nightingale — Thu, 30 Oct 2014 08:21:27 GMT

Hi- yes both patients that I have had recently were well in themselves but with sporadic cases of diarrhoea. Clinically though, both patients are cushingoid, and one Is diabetic, the other sufferers from dry eye too but are currently well managed. I would most often than not run a faecal screen on chronic diarrhoea patients for peace of mind if nothing else as opportunistic infections are a possibility as a secondary infection? Non invasive, easy to procure and usually if you do get a positive sample then most things easy to treat. Either that or I just like receiving little blue pots with poo in :-)

Re: Chronic diarrhea case

Anthony Todd — Wed, 29 Oct 2014 23:30:37 GMT

[quote user="Emily Herskind Nightingale"]Have you considered doing a faecal culture? I would start with microscopy to assess ova/larvae or protozoans and culture for Salmonella and Campylobacter just to be on the safe side. I've had several coccidiosis/campylobacter positive cases recently. You could also consider TLI/Folate and cobalamin testing on serum. Good luck!

[/quote]

I'm probably wrong but do the positive cases cited above fit the presenting signs in the OP case or are they "sick" and "under par etc" on presentation.

The OP case is totally normal apart from soft stools; is this the case in yours above?

If so I've learnt something.

Re: Chronic diarrhea case

Emily Nightingale — Wed, 29 Oct 2014 20:20:04 GMT

Have you considered doing a faecal culture? I would start with microscopy to assess ova/larvae or protozoans and culture for Salmonella and Campylobacter just to be on the safe side. I've had several coccidiosis/campylobacter positive cases recently. You could also consider TLI/Folate and cobalamin testing on serum. Good luck!

Re: Chronic diarrhea case

Andrew Kent — Wed, 29 Oct 2014 15:48:41 GMT

The problem is that if the owner doesn't feel that there are other steps after a diet trial if it doesn't work they tend to lose faith in you and compliance. I think it's important to know there are further steps if needed.

Andy

Re: Chronic diarrhea case

Rob Loxley — Wed, 29 Oct 2014 13:53:29 GMT

[quote user="Andrew Kent"]what percentage of dogs would respond to diet if the owners were as compliant as they say they are![/quote]

I've wondered in the past if high cost of the intervention makes some owners less compliant to avoid seeing a benefit? Though at the same time we have clients giving plenty of dubious supplements that they swear by, more so if they're expensive... Go figure!

Re: Chronic diarrhea case

Anthony Todd — Wed, 29 Oct 2014 13:35:42 GMT

[quote user="Andrew Kent"]That's because this dog had a novel protein diet trial already.[/quote]

Accepted, but I'd persist, given the presentation of a pretty happy animal and the flaky owner rather than dilute the elimination of a dietary sensitivity by testing or even mentioning the unlikely possibilities.

I'd still bet it's solely diet related and easy and cheap to fix.

Trouble is with such a lot of these threads we never hear the final outcome.

Re: Chronic diarrhea case

Andrew Kent — Wed, 29 Oct 2014 11:14:29 GMT

That's because this dog had a novel protein diet trial already. What we don't know is whether that was an appropriate choice (based on dietary history etc).

now you could do a second diet trial (which I do in some cases) but the compliance is likely to be even worse.

this is also a slightly older dog than many who have chronic enteropathies so perfectly reasonable to then start looking at other things.

Re: Chronic diarrhea case

Anthony Todd — Wed, 29 Oct 2014 05:10:17 GMT

[quote user="Andrew Kent"]Who do you need to persuade? There's not one person on this thread who hasn't suggested diet is critical in these cases. Convincing the owners is the real challenge![/quote]

But few so far, except the last, have suggested just ,and only a diet trial to start with, which is all I've ever been banging on about.....

Full bloods 2 months ago were normal apart from raised Alkp

Repeat blood test last week

If the owner is reluctant to do more investigations I would probably put the dog on a low fat diet, metronidazole and potentially ursodeoxycholic acid for the next month and then repeat the bloods.

Lipase/amylase were normal. But in chronic pancreatitis this is not sensitive enough... haven't done cpli

+1 for diet to start with but I may be tempted to do CPL/TLI and a urine cortisol:creatinine ratio to rule out (or in) chronic pancreatitis/HAC.

etc.

Hardly banging the diet trial drum?

I agree that compliance is almost impossible with most owners but if the vet orders tests and goes on about all the other things that, conceivably, cause D++ in the dog as described, the chance of the owner taking heed of the diet advice is unlikely.

I still wonder whether the response to metronidazole was due to ancillary diet advice given at the time [or even the ***y owner taking it upon herself to "try something different".]

It seems unlikely that the response wasn't connected to the drug though?

Re: Chronic diarrhea case

Andrew Kent — Wed, 29 Oct 2014 01:28:50 GMT

[quote user="Anthony Todd"]Phew, at last someone sees the wood from the trees. All I need to do is persuade people to try a diet trial first and not after all the tests and remote possibilities have been eliminated at no little expense and while the patient squits on, [the carpet....[/quote]

Who do you need to persuade? There's not one person on this thread who hasn't suggested diet is critical in these cases. Convincing the owners is the real challenge!

[quote user="Stephen Courtney"]Of course i also have several clients where nothing seems to work, and the cynical part of me wonders if perhaps this is because they are cheating on the diets.....surely not???[/quote]

I have to say I often wonder this myself - what percentage of dogs would respond to diet if the owners were as compliant as they say they are! I also find it peculiar that many owners would rather have the dog on steroids than stick to a diet trial.

Andy

Re: Chronic diarrhea case

Anthony Todd — Wed, 29 Oct 2014 01:19:33 GMT

[quote user="Stephen Courtney"]

There are a lot of high quality novel protein diets available that don't involve prescription its - Canagan, Wainwrights, Barking/ miaowing heads, Arden Grange just to name a few - and the usually give options like fish and potato, rice etc, or venison/ other game, and are grain free ( yes i know rice is a grain...)

I have several clients who have found a suitable diet easily, by looking for on that contains things that are not in their current diet - and because it's a relatively affordable commercial diet, this builds more trust than trying to flog a 15kg bag of HA to everyone....

Of course i also have several clients where nothing seems to work, and the cynical part of me wonders if perhaps this is because they are cheating on the diets.....surely not???!

[/quote]

Phew, at last someone sees the wood from the trees. All I need to do is persuade people to try a diet trial first and not after all the tests and remote possibilities have been eliminated at no little expense and while the patient squits on, [the carpet....]

Re: Chronic diarrhea case

Stephen Courtney — Tue, 28 Oct 2014 20:46:45 GMT

Of course i also have several clients where nothing seems to work, and the cynical part of me wonders if perhaps this is because they are cheating on the diets.....surely not???!

Re: Chronic diarrhea case

Martin Atkinson — Tue, 28 Oct 2014 19:36:15 GMT

[quote user="Thomas Johnson"]And I have to admit I'm not completely convinced by them and will usually look for a diet with a novel protein and carbohydrate source first, which usually works out a lot cheaper as well.[/quote]Most dermatologist and gastro-enterologists, who would be the main sources of advice on this, would agree. A significant number of dogs will actually react adversely to hydrolysed diets so it is wise to take a safer (and cheaper) option of an exclusion/novel protein diet first.

Re: Chronic diarrhea case

Thomas Johnson — Tue, 28 Oct 2014 16:27:32 GMT

[quote user="Malcolm Ness"]

[quote user="Thomas Johnson"]The hypoallergenic diets are usually hydrolysed, i.e. the proteins have been broken down to the point where they are too small to be recognised by the immune system and trigger a response.[/quote]

That is what the dog food sellers (a too-dominant source of "information" on this subject) would like you to believe.

[/quote]

And I have to admit I'm not completely convinced by them and will usually look for a diet with a novel protein and carbohydrate source first, which usually works out a lot cheaper as well.

Re: Chronic diarrhea case

Martin Atkinson — Tue, 28 Oct 2014 10:29:42 GMT

[quote user="Anthony Todd"]I wonder whether the original response to metronidizole was due to the ancillary dietary advice or change given at the same time as the drug?[/quote]The original response to the metronidazole was probably more to do with the immuno-modulatory effect and it did no more than a judicious dose of cortico-steroids would have done.

Now don't get exited Anthony and think I'm condoning the use of the 'roids just stating a fact, but the diet is probably still the way to go. I'd just, as stated previously, like to be certain there wasn't a medical cause.

Re: Chronic diarrhea case

Malcolm Ness — Tue, 28 Oct 2014 10:28:48 GMT

That is what the dog food sellers (a too-dominant source of "information" on this subject) would like you to believe.

"At this time, hydrolysate-containing diets are probably best used in dogs suspected not to be hypersensitive to their individual components." So said Prof T Olivry, a prominent dermatologist in a systematic literature review wrt adverse food reaction in skins. Is there any good information out there to suggest that they are a whole lot better for GI signs related to adverse food reaction?

I believe that at a time when in human general practice the mood is to ignore drug-company evidence, far too much of the "information" coming into vet practices still comes directly or indirectly from corporations with a vested interest.

Re: Chronic diarrhea case

Thomas Johnson — Tue, 28 Oct 2014 08:43:42 GMT

[quote user="Anthony Todd"]

[quote user="Stephen Courtney"]ID type diet, hypo allergenic type diet, novel protein type diet [/quote]

I can never understand why a so-called hypoallergenic diet works when the offending allergen can be literally anything unless you say the animal is just fat or starch sensitive [er, milk...which is so common].

[/quote]

The hypoallergenic diets are usually hydrolysed, i.e. the proteins have been broken down to the point where they are too small to be recognised by the immune system and trigger a response.

Re: Chronic diarrhea case

Anthony Todd — Mon, 27 Oct 2014 22:54:04 GMT

[quote user="Stephen Courtney"]ID type diet, hypo allergenic type diet, novel protein type diet [/quote]

Don't they work by being composed of an unusual protein source and low fat?

A single protein source and water always worked best for me. Chicken or fish was the easiest but I suppose either could rarely be the allergen, if no good then I changed from one to the other.

This was often after vets had been through the "hypoallergenic" processed prescription diets ad nauseam.

I think the problem with diet trials is the owners think t's related to quantity so a lick or two of ice cream cannot possibly do any harm and all tinned food is the same.

Don't be surprised if the OP animal goes into the garden and gorges on apples or horse poo in the fields either....

I had a cat that vomited only after dried food, thousands spent even stomach biopsies etc. etc. [and tests for HAC and pancreatic disease etc] only to find and advise that not feeding dried food [which a locum had noted!!!!] might fix it, which it did.

But changing the food is so dinosaureal and I only treated the common things which were the only ones I could think of before I got on to vetsurgeon.org

Re: Chronic diarrhea case

Stephen Courtney — Mon, 27 Oct 2014 22:11:09 GMT

My diet choices follow the route similar to how you have ended up - ID type diet, hypo allergenic type diet, novel protein type diet ( which may or may not be hydrolysed) then low fat, then high fiber. intermittent courses of panacur, metronidazole and possibly other treatments based on faecal results, but i almost never get useful results from faecal exams in adult animals.

Re: Chronic diarrhea case

ilanit — Mon, 27 Oct 2014 20:49:49 GMT

She was originally just started on i/d food with probiotics, which did nothing. Then given metronidazole. Diarrhea resolved but started again as soon as 10 day course was over. Then she was started on d/d. After 4 weeks there was still no improvement, but obviously too early to change. Because owner was going abroad she was given another course of metronidazole which worked as a charm, but again once stopped diarrhea returned (still on d/d). Stopped d/d after 8 weeks. So it seemed metronidazole was working and not the diet.

However I started i/d low fat last week (no other meds apart from SAM/sylibin) and owner reported today that diarrhea stopped as soon as she started the food! Seems almost too good to be true, but obviously keeping on this with no other meds for now and planning to retake liver values in couple of weeks.

Maybe there is some sort of chronic pancreatitis or hyperlipemia or lymphangiectasia with secondairy bacterial overgrowth?? Maybe that's why there was a response to metronidazole? Still not sure why the ALKP is that high though because even with chronic pancreatitis I wouldn't expect such an enormous increase. It just doesn't fit in the jigsaw.

anyway. for now dog is happy, owners are happy... so I guess I have to be happy too :) eventhough I still have question marks and holding my breath for recurrence! We'll see :)

Thanks for your input. I appreciate it.

Re: Chronic diarrhea case

Anthony Todd — Mon, 27 Oct 2014 19:33:23 GMT

[quote user="Martin Atkinson"]

[quote user="Anthony Todd"]I'd just do a careful [and complied with!] diet trial as above every time, but I suppose it's too easy and not "goldstandard now.[/quote]Well Anthony even dinovets are right sometimes even if simply by inertia and the fact that common things occur commonly!

+1 for diet to start with but I may be tempted to do CPL/TLI and a urine cortisol:creatinine ratio to rule out (or in) chronic pancreatitis/HAC.

[/quote]

If trying the obvious thing first in a case like this

Diarrhea is once daily, soft but not like water. No blood, no mucous. Dog in herself is bright energetic and not effected by this. She's a little overweight, but there is no loss or gain over the last months.

is inertia" then I'm all for it but how, in your wildest dreams would you even consider on the first consult any chronic serious condition in a dog presenting as above.

At last someone illustrates my point exactly viz: common things aren't common now, they never are, all animals with the most obvious of mild signs could have a really serious and rare condition which must be tested for and eliminated with usually a battery of expensive tests whilst the obvious condition rolls on.

PS. I wonder whether the original response to metronidizole was due to the ancillary dietary advice or change given at the same time as the drug?

Re: Chronic diarrhea case

Martin Atkinson — Mon, 27 Oct 2014 12:52:58 GMT

+1 for diet to start with but I may be tempted to do CPL/TLI and a urine cortisol:creatinine ratio to rule out (or in) chronic pancreatitis/HAC.