10 year old Springer spaniel - haemorrhagic faeces and straining +++

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Anna Battek-Kosiorowska — Thu, 07 Jul 2016 18:09:44 GMT

Congratulations and all the best for you both!

Thank you for an update on that poor dog. I haven't heard from our patient for over a week so I am not sure what is going to happen, they should come back for re check and the dog needs more bloods for Vetoryl monitoring. We shall see then but my feelings are they heading towards PTS and need time to convince all members of family

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Rebecca MacMillan — Tue, 05 Jul 2016 21:02:49 GMT

Sorry that I forgot to come back and give an update! I've had a lot on lately an djust back from wedding/honeymoon!

Unfortunately the case didn't end well. Initial improvement was seen with antibiotics, more so when I added in nisamox alongside the metronidazole. Faecal samples came back negative for parasites/significant bacteria.

At a subsequent check up, the rectum was much less swollen and the dog much more comfortable, and it felt like the 'polyps' I could initially palpate had gone down. However it felt like there might be a mass there rather than a diffuse issue (I could just feel a localised area of swelling now). The owner reported much less blood (if any) but the faeces still looked narrowed and soft.

After lengthy discussion with owner, he decided he didn't want to go down the road of biopsy as if it were a cancerous mass, he was unlikely to be able to afford surgery, chemo or CT scans etc. We decided to trial steroids on the basis that we would see how she goes, however he was warned that if she strained excessively again she may be at risk of rectal prolapse.

After extended antibiotic course, we continued with just the steroids alone, with a plan to closely monitor her and PTS if deteriorating again.

She then presented as an emergency to a colleague of mine haemorrahaging, having prolapsed the mass/rectum. The other vet was able to replace it, but after further discussion the dog was PTS. So not a very happy ending I'm afraid!

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Anna Battek-Kosiorowska — Fri, 01 Jul 2016 17:57:13 GMT

I know it has been couple of months now but I'm curious what happened to Rebecca's patient. We have similar case in our practice, on and off with severe colitis and a severe bleeding. Nothing obvious on rectal though. Two vets and 3 rectals since May but nothing obvious. I offered referral, biopsy etc but declined so far. Dog has been on Nisamox, couple of times on Metronidazol, probiotics and diet is a nightmare (elderly Owner in charge). No, I don't think we can give it trial of steroids , we diagnosed it with Cushing and is on Vetoryl for around a month now. That is not a surprise that since then we have problems getting worse.

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Anthony Todd — Thu, 28 Apr 2016 01:40:52 GMT

[quote user="Seadna "]Can I ask why high dose? Genuinely curious, I often give a short course of steroids for diarrhoea but generally at a 'normal' anti-inflammatory dose (ie whatever it says on the bottle/box). [/quote]

Only that sometimes steroids are given at the low end because of the fear of them by most on here, which may mean a response, if any, is difficult to assess. I only suggested steroids because of the obvious pathology described, normally I wouldn't suggest any steroids in a simple D+.

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Rebecca MacMillan — Tue, 26 Apr 2016 11:48:21 GMT

Great! Thanks for all the replies! I was actually thinking I wonder if an otoscope might help in this scenerio...

I guess sometimes it's nice just to come on here and listen to other peoples suggestions, and just double check you are heading down the right path - maybe it's partly a confidence thing with myself at times.

I was all up for biopsy when I first saw the client, but then I read a page on colitis/proctitis in my 5-min consult book that sounded exactly like this dog, so on discussion with the owner we have opted for faecal samples (probably more than likely will just confuse things if there are secondary opportunistic infections and I'll wish I went straight to biopsy...) initially with tissue samples the next step. The dog has improved a bit on metronidazole, mainly chosen for it's immunomodulatory/anti-inflam effects, and it seems a bit more comfortable at present. A short course of steroids would be my other usual treatment of choice, I have held off for now in case we end up taking a biopsy soon.

I'll let you know how I get on in due course though

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Seadna — Sat, 23 Apr 2016 18:33:02 GMT

[quote user="Anthony Todd"]Can I make the obvious, but unpopular, suggestion of a corticosteroid course at a high dose for a few days as a trial.[/quote]

Can I ask why high dose? Genuinely curious, I often give a short course of steroids for diarrhoea but generally at a 'normal' anti-inflammatory dose (ie whatever it says on the bottle/box).

I would also like to echo the posts above that say that this forum is an incredible resource and to Rebecca: I try to ignore the few snarky, sarcastic comments which are usually in a minority compared to the helpful supportive ones :) I think it helps that I have kept myself anonymous so I don't feel like I, as an individual, am being ridiculed by those smarter and more experienced than me.

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Evelyn Barbour-Hill — Sat, 23 Apr 2016 15:39:01 GMT

[quote user="Christopher Saul"]It's only a gut feeling[/quote]

Indeed it is.......

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Anthony Todd — Sat, 23 Apr 2016 15:24:27 GMT

Can I make the obvious, but unpopular, suggestion of a corticosteroid course at a high dose for a few days as a trial.

At least it may make this old dog more comfortable and quickly.

What ever the final diagnosis I'll bet steroids help, and, as others have said, try 'em before the final solution.

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Christopher Saul — Sat, 23 Apr 2016 11:10:05 GMT

Hi Rebecca!

I would echo Andy's suggestion of using an otoscope to guide your biopsies. Even though you don't have an endoscope, you might find it useful to invest in a pair of endoscopic biopsy forceps (I found several examples for sale on GB medical's website for around £50).That way you don't have to worry about being too aggressive with your biopsy pinches as you won't cause any more trauma than you would have done if you had used an endoscope. You can also use it later when you do acquire a scope in the future. In the mean time you can use it for rectal biopsies and also for nasal biopsies, biopsies of oropharyngeal masses etc etc.

Regarding this particular case, you may well get an answer in this way - I think doing rectal pinch biopsies is a great next step - but I would be very reluctant to exclude neoplasia on the basis of a serum calcium alone as many neoplasms do not increase calcium. What worries me (other than the dog's age) is that this sounds like large intestinal diarrhoea (tenesmus, haematochezia, small volume) but the owners also mention loss of condition - and large intestinal disease typically doesn't cause weight loss. It's only a gut feeling and I could be wrong but I can't help thinking this may turn into a tumour hunt.

Should your initial rectal biopsies not provide an answer then full survey imaging (thoracic radiographs and abdominal ultrasound in particular looking at the intestinal walls and lymph nodes) would be my next step - you might find an answer or if not maybe something to FNA in this way. If you still are non the wiser at that stage then you may want to consider referring to somewhere with an endoscope.

I would also suggest a fenbendazole trial if you haven't already done so - unlikely to be parasitic but nice to exclude this and also gives the owner something to do and buys you time to see if it is self resolving.

just a few thoughts, hope it helps

Chris

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Neil Wheadon — Sat, 23 Apr 2016 10:51:12 GMT

[quote user="Rebecca Benge"] I find this forum an invaluable source of advice and support, as I don't have many colleagues to lean on or ask in passing at work, which I do miss at times. [/quote]

I think this is an extraordinarily valid point

Locumming in many single handed practices with no-one to lean on and ask is hard. I love working with other vets who get bombarded with questions, that's how I am

If we referred everything, the average single handed practice may as well turn into a vaccination and neutering clinic. We're a curious bunch of people and life becomes somewhat boring if we referred everything and this forum is a fantastic resource to 'reach out'

I feel the main weakness of this forum is the ability to ask a basic question. However what is a basic question. Would I criticise a referral surgeon for not knowing the in's and out's of 50 flea products?

Neil

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Will McMullan — Sat, 23 Apr 2016 09:50:40 GMT

I'm sorry I made you feel like that. If you can get samples with forceps then hopefully you'll get a diagnosis.

I guess partly my post came from a more general frustration at our profession's inability to work together for the best interest of the animals under our care. I'm talking in general philosophical terms here and didn't mean to direct my frustration at you specifically. Sometimes it just gets to me that we have to deal with the business/competition side of things and that potentially obstructs the animal receiving the optimal treatment. Wouldn't it be nice if you could ring your neighbouring practice up and send the dog over for an endoscope free of any worries about financials? Perhaps I should have been a doctor...

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Andrew Kent — Fri, 22 Apr 2016 19:48:17 GMT

Hi rebecca,

you could absolutely use some biopsy forceps under finger control or visualised with something like an otoscope to get some pinch samples.

You could also use a swab to get some cytology.

in an adult dog where we can feel an abnormality there I wouldn't think faecal analysis etc would be that useful, this could be severe inflammation or neoplasia and biopsy is the way to tell.

Do let us know what you find!

Andy

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Rebecca MacMillan — Fri, 22 Apr 2016 18:18:08 GMT

Well it was a little...

We're a new practice and don't have an endoscope as of yet. The client isn't insured and I don't particularly want to send him off to a competing neighbour practice if there's work I can do here myself first. Why should we always be rushing into referrals?

The question was really - should we even be worrying about getting biopsy samples yet, or as per a textbook I was reading - should I be doing faecal samples etc first anyway? Could this be a really bad colitis/proctitis case with an underlying trigger?

Also if the lesions are literally just inside the rectum, how much more would I learn from endoscopy anyway, rather than just blind sampling (or the technique mentioned above?)? I appreciate I might see more suspicious lesions, or assess the mucosa more thoroughly, but ultimately I can already feel masses/hypertrophy - I just want samples of it.

It is not my intention to deny this dog a thorough work up, it's just trying to work out what is feasible or safe to try or not in my own practice.

I am getting increasingly frustrated on here. For the most part I get useful/helpful comments but sometimes I just get made to feel silly for posting in the first place. I'm not normally grumpy, but it's happened a few times recently. As a predominantly sole charge vet, I find this forum an invaluable source of advice and support, as I don't have many colleagues to lean on or ask in passing at work, which I do miss at times.

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Will McMullan — Fri, 22 Apr 2016 15:38:55 GMT

I don't mean to be patronising, but you could refer it to a local practice or a referral centre that has an endoscope? Endoscopes are quite common in general practice now. High and mighty it might sound, but wouldn't that be in the best interest of the dog?

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

emma o'connor — Thu, 21 Apr 2016 16:05:43 GMT

When I didn't have access to endoscopy I used a technique whereby I would place a couple of sutures in the rectal mucosa just inside of the anus and use gentle traction on these to evert the rectal mucosa which would allow the mass to then prolapse through the anus in order to biopsy it.

RE: 10 year old Springer spaniel - haemorrhagic faeces and straining +++

Dagmar Steele — Thu, 21 Apr 2016 16:02:08 GMT

My approach would be faecal sample first, then ultrasound/biopsy. Calcium doesn't have to be elevated in cancer, it's only some tumors that generate high Ca levels.