Chronic vomiting , helicobacter?

Re: Chronic vomiting , helicobacter?

Stigen — Fri, 13 Feb 2015 13:22:31 GMT

[quote user="Andrew Kent"]

There is no easy answer to helicobacter! For me the times that I treat it are when it is clearly associated with gastritis and so I can satisfy myself that the two things are linked. Otherwise without knowing the full story about cause/effect and with the knowledge that most dogs get re-infected with it very quickly it is a difficult sell.

So I would acknowledge it but work-up the dog like any other chronic vomiting dog:

Exclude systemic causes - Addison's, systemic disease

Exclude food responsive disease through an appropriate diet trial.

Ideally image the abdomen to exclude structural disease (e.g. tumour)

Biopsy - ideally by endoscopy as it allows you to sample multiple areas and so you are less likely to miss lesions. Could you refer for this?

If you see gastritis associated with the helicobacter organisms on histo then I would treat with an antacid (I usually use omeprazole) plus combination antibiotics (clarithromycin/metronidazole/amoxicillin).

Andy

[/quote]

I talked to the histopathologist at the lab. She said she would not reccomend starting treatment for helicobacter even with positive serology, only if the symptoms were more severe. Most dogs have helicobacter anyways. I`m going to focus on the kidney for now,maybe azotemia is the reason for destroyed stomach mucosa, combined with helicobact. I would like to se a gastric mucosal biopsy with live organisms before heavy doses of antibiotics.
She said some of the measurements were incorrect due to hemolysis, particularly the phosphorous, that was over 5, sounds unlikely.

I`ve sent a urine sample of for full analysis + protein/creatinine, and plan to get the dog in for fluid treatments and repeat blood samples in-house. Also worming as it had high eosinophil count. The owner seems happy to give it antepsin and omeprazole for now, and thinks it has made some difference.

Re: Chronic vomiting , helicobacter?

Anthony Todd — Thu, 12 Feb 2015 18:12:27 GMT

[quote user="Andrew Kent"]

So I would acknowledge it but work-up the dog like any other chronic vomiting dog:

Exclude systemic causes - Addison's, systemic disease

Exclude food responsive disease through an appropriate diet trial.

Ideally image the abdomen to exclude structural disease (e.g. tumour)

Biopsy - ideally by endoscopy as it allows you to sample multiple areas and so you are less likely to miss lesions. Could you refer for this?

Andy

[/quote]

Surely one would start with the weird owner's and dogs management and history of vomiting for 4 years?

Re: Chronic vomiting , helicobacter?

Andrew Kent — Thu, 12 Feb 2015 17:57:05 GMT

So I would acknowledge it but work-up the dog like any other chronic vomiting dog:

Exclude systemic causes - Addison's, systemic disease

Exclude food responsive disease through an appropriate diet trial.

Ideally image the abdomen to exclude structural disease (e.g. tumour)

Biopsy - ideally by endoscopy as it allows you to sample multiple areas and so you are less likely to miss lesions. Could you refer for this?

Andy

Re: Chronic vomiting , helicobacter?

Miriam Lodewyks — Thu, 12 Feb 2015 16:29:46 GMT

Interesting case. Not something I would have considered, but will bear it in mind in the future. Be interesting to hear more from some of the Internal medicine boffs...

From biochem info I'd be wondering if there's a chronic renal issue here, and/or parathyroid problem? Urea not that high on this sample, but can be variable, so would keep an eye on the Urea, Creat, Phos, Calcium, and definitely need to get a urine SG.

I will follow this thread closely.

Re: Chronic vomiting , helicobacter?

Hannah Wynne Richards — Thu, 12 Feb 2015 09:14:49 GMT

Amoxycillin metronidazolr (close to toxic dose) and antacid.

Wynne

Re: Chronic vomiting , helicobacter?

Anthony Todd — Thu, 12 Feb 2015 08:56:28 GMT

Any response to antiemetics, say, Maxolon?

If that doesn't stop the vomiting then I would always pursue the cause further; if it did, then usually it resolved the problem.

I'm suspicious of the "difficulty in getting any of the dogs to eat". Pretty unusual for dogs.

I'd suspect the management of the dogs too. That's NOT yours, but the owner's, to avoid previous confusion.

It's a wierd history with three dogs with poor appetites and all now intermittent vomiting......

Re: Chronic vomiting , helicobacter?

Stigen — Thu, 12 Feb 2015 08:22:41 GMT

[quote user="Kate Richardson"]

[quote user="Stigen"] high eosiniophil, high phos., low platelets, high CK and high Creatinine and Bun.....

[/quote]

Eosinophilia, parasites, hypersensitivity most likely

Phos could be artefactual so would recheck on fresh in house samples if poss. I wouldn't expect the phos as high as that given the level of azotaemia. Urine sample needed to determine if azotaemia is pre renal or renal (assuming not post renal as no mention of urinary obstruction.) HCT is high so would fit with pre renal.

CK wouldn't be concerned about at that level. Monitor platelets

BUT Calcium is low with the high phosphate so would look more closely at parathyroid disease.

[/quote]

Thanks for the input :) I`ll ask the reference lab to run another Calcium and phosphate to check for errors, and consider doing bloods in house.
Parasites...I will cerainly worm it with milbemax...but think it has been done before.
I`ll get a urine sample and check prot/creatinine ratio and SG etc.

The helicobacter serology came back positive, but I don`t know if this is enough of an incentive to start treatment, as most dogs will have some level of helicobacter anyways...but considering the poor state of the gastric mucosa I guess it is likely. I wish the other vets would have done a mucosal biopsy ,would have been easier to see helicobacter. What is the current reccomended treatment for helicobac..?

"
Helicobacter antibodies (IFT):

H.pylori-titer: 1:80 < 1:20
Interpretation:
The test for Helicobacter antibodies is indicative for the
confirmation/exclusion of an infection with Helicobacter pylori,
an organism associated with gastric ulcers in humans.
Titers 1:40 and higher are considered positive.
With serological testing the Helicobacter species most commonly
detected in dogs and cats, H.heilmannii and H.felis,
cannot be detected reliably.
"

Re: Chronic vomiting , helicobacter?

Kate Richardson — Wed, 11 Feb 2015 12:42:50 GMT

[quote user="Stigen"] high eosiniophil, high phos., low platelets, high CK and high Creatinine and Bun.....

[/quote]

Eosinophilia, parasites, hypersensitivity most likely

CK wouldn't be concerned about at that level. Monitor platelets

BUT Calcium is low with the high phosphate so would look more closely at parathyroid disease.

Re: Chronic vomiting , helicobacter?

Thomas Johnson — Wed, 11 Feb 2015 10:41:57 GMT

I think I would want to check urine specific gravity to see if there is any renal disease. The mild eosinophilia could be due to GI inflammation. I don't think I'd be worried about that platelet count.

Is it losing weight? Could it have a malabsorption that means its breaking down muscle for energy, might explain the elevated CK and phos? Have you thought about checking folate and cobalamin levels?

Re: Chronic vomiting , helicobacter?

Stigen — Wed, 11 Feb 2015 10:33:49 GMT

So got some blood samples back now,but they are not what I expected...and they forgot to do the helicobacter test,so won`t get that until tomorrow.

I would appreciate some input from someone who is better in clinical pathology than I am

The dog has been vomiting intermittenly for years, has a "abnormal" gastric mucosa according to another vet who did gastroscopy...and now the blood sample is showing indiction of chronic kidney disease and/or muscular/cellular aptosis considering the high creatinine kinase and high phosphorous.
The dog is already opn kidney food, but not wanting to eat it. Any diseases that should be in the differentials here..?
I have problems connecting the dots with high eosiniophil, high phos., low platelets, high CK and high Creatinine and Bun.....

Clinical Chemistry (photometric)

Parameter               Value                  Reference value
Amylase                    531    U/l              < 1650
Lipase                      68.4  U/l              < 120
Glucose                   -       mmol/l           3.05-6.1
Fructosamins               225.7  µmol/l           < 374
Triglycerides                1.10 mmol/l           < 3.9
Cholesterol                  8.9  mmol/l           3.1-10.1
Bilirubin total              0.8  µmol/l           < 3.4
AP                          23    U/l              < 108
GLDH                         5.4  U/l              < 6
g-GT                    < 0.1     U/l              < 5
ALT(GPT)                    27.4  U/l              < 55
AST(GOT)                    22.4  U/l              < 25
CK                         232.0  U/l          +   < 90
Total protein               72.9  g/l              54-75
Albumin                     41.6  g/l              25-44
Globulins                   31.3  g/l              25-45
Urea                         9.9  mmol/l       +   3.3-8.3
Creatinine                 131.0  µmol/l       +   35-106
Phosphate                    5.2  mmol/l       +   0.7-1.6
Magnesium                    1.0  mmol/l           0.6-1.3
Calcium                      2.0  mmol/l       -   2.3-3.0
Sodium                     148    mmol/l           140-155
Potassium                    4.6  mmol/l           3.5-5.1
Na-/K quotient              32.5  .                > 27
Iron                        44.9  µmol/l           15-45

Due to changed reagents for the determination of lipase, new
reference ranges exist. The new test detects the activity of
the pancreatic lipase, but do not reach the high sensitivity
and specificity of the PLI. With corresponding clinical
symptoms the result should be confirmed by a PLI test.


Blood Count (Laser-light scatter hematology system)

* Erythrocytes               6.98 T/l              5.5 - 8.5
* Hematocrit                 0.59 l/l          +   0.44-0.52
* Hemoglobin               165    g/l              150-190
* Leucocytes                 8.2  G/l              6.0-12.0
* Neutrophils               51    %            -   55-75
* Lymphocytes               38    %            +   13-30
* Monocytes                  1    %                0-4
* Eosinophils               10    %            +   0-6
* Basophiles                 0    %                0
* Band Neutrophils           0    %                0-4
* Hypochromasia         neg.                   neg.
* Anisocytosis          neg.                   neg.
* Thrombocytes             120    G/l          -   150-500

Differential Blood Count (absolute)

* Neutrophils                4.2  G/l              3.0-9.0
* Lymphocytes                3.1  G/l              1-3.6
* Monocytes                  0.1  G/l              0.04-0.5
* Eosinophils                0.8  G/l          +   0.04-0.6
* Basophils                  0.0  G/l              < 0.04
* Bands                      0.0  G/l              < 0.5

Re: Chronic vomiting , helicobacter?

Richard Carter — Fri, 06 Feb 2015 12:45:21 GMT

penicillin will cure most bacterial damage/ opportunistic gastritis as well - if you remember that was the surprise finding with human gastric ulcers after years of the mantra of not using penicillin/antibiotics - trial 2 weeks with H1 blocker

If appetite and enthusiam for food improves on antibiotics then another pointer towards maybe doing a bile acid stim test to rule out PSS

Re: Chronic vomiting , helicobacter?

Stigen — Fri, 06 Feb 2015 11:44:58 GMT

[quote user="Anthony Todd"]

[quote user="Richard Carter"]

and the other usual history - what does it eat, what consistency is it better on, does it get treats, especially any with colourings/ preservatives/jellies/ gravies or high fat content, does it get milk, have the owners tried single source diet for at least 2 - 3 weeks?

does feeding multiple times a day to reduce reflux help?

The breed is also over-represented for PSS and other hepatic congenital abnormalities

[/quote]

+1 in that order

[/quote]It has been on a variety of dry and wet foods. s currently on Specific Kidney/heart diet, as she has 3 dogs, and one of them has problems with uroliths. She has tried a variety of "gastro"-foods, wet and dry, not made much difference. Vomiting is intermittent, noe really assosiated with feeding., Usually just yellow bile/mucous. Owner says she has problems getting her dogs(all 3) to eat anything, she has to work hard to get anything in them, and have tried many foods. So this dog is not on a set feeding pattern, but will only eat very sporadically. Clinically all is well, not lethargic/anorexic.

What made me consider an infectious causative is that she mentioned that this dog has been vomiting/regurgitating as long as she has had it(4 years), but the other 2 dogs she has only had for 6 months, and now they have started the same thing.

I just had it here now...done some bloods for biochemistry and hematology, as well as helicobacter antibodies. IF it is positive I will get a mucosal biopsy by gastroscopy to confirm. Today I just gave her some antepsin , and put it on 1mg/kg dose daily omeprazole.

Re: Chronic vomiting , helicobacter?

Hannah Wynne Richards — Fri, 06 Feb 2015 09:53:38 GMT

Either do a proper gastroscopy, or try response to treatment - remember the metronidazole dose for helico is close to the danger level.

Wynne

Re: Chronic vomiting , helicobacter?

Anthony Todd — Fri, 06 Feb 2015 09:29:59 GMT

[quote user="Richard Carter"]

does feeding multiple times a day to reduce reflux help?

The breed is also over-represented for PSS and other hepatic congenital abnormalities

[/quote]

+1 in that order

Re: Chronic vomiting , helicobacter?

Richard Carter — Fri, 06 Feb 2015 09:13:14 GMT

does feeding multiple times a day to reduce reflux help?

The breed is also over-represented for PSS and other hepatic congenital abnormalities

Re: Chronic vomiting , helicobacter?

Anthony Todd — Fri, 06 Feb 2015 09:02:02 GMT

When does it vomit?

What does it vomit?