Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Lucy K — Wed, 02 Jun 2010 11:40:42 GMT

Thank you for this thread. It was so informative and so great to be able to start practically using pathophys knowledge! Actually taking the knowledge and applying it to a clinical situation is like using a new set of muscles.

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Richard Carter — Wed, 10 Feb 2010 10:33:23 GMT

Could just take him off the aspirin his owner has been religiously giving every day but completely failed to mention

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

pete coleshaw — Tue, 09 Feb 2010 08:41:47 GMT

Clive

many thanks - very much enjoyed the case, even if I have been sitting quietly on my hands

always interesting to see how others think

[quote user="Clive Elwood"]Mick was treated with a combination of corticosteroids, ongoing iron supplementation and an exclusion diet [/quote]

what was the exclusion diet - and were the steroids continued or short-term?

without wanting to 'score politically' on the dietary front (which is being beaten to death elsewhere on this site) I would like to comment again on Malcolm Ness's sarcastic dietary & RMB comments - particularly as it seems he did win the prize - it was the nasty toxic canned food!

I believe we really have no understanding of how many problems we are creating with our processed high carb diets, and IBD has to be high up on the list of potentially man-made diseases.

Exclusion diets are either hydrolised proteins (and by all accounts we dont even know with any certainty how small the breakdown has to be to render particular proteins non-antigenic) or home made diets - again usually using cooked proteins. Cooking by definition denatures proteins - a raw protein is much more 'natural' and there is every possibility that a dog or cat might tolerate raw beef even if it cannot tolerate it cooked - and yet I have never seen this mentioned anywhere.

Squitty kitties, in particular, are a therapeutic challenge - until you try whole raw minced carcase or a RMB diet. I wont bore you with the rest of my list of conditions which I believe respond similarly.

pete

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Roberta Prina — Mon, 08 Feb 2010 21:17:58 GMT

Thank you for discussing this case with us. It was really interesting

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Hannah Wynne Richards — Mon, 08 Feb 2010 17:08:13 GMT

Thanks for the case-at least I got the treatment right

Wynne

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Clive Elwood — Mon, 08 Feb 2010 14:03:06 GMT

Difficult to argue with either an ACTH stimulation test or bile acids, but I did neither. I did not see any strong evidence of hypoadrenocorticism or liver disease sufficient to cause GI bleeding (normally there is severe liver disease, portal hypertension, low albumin, low cholesterol etc.).

On the other hand, IBD is sufficient to cause iron deficiency anaemia and I was happy with that as the primary diagnosis. I presume we are looking at very low grade blood loss over a very long period, with a true iron-deficiency (as opposed to blood loss) anaemia as a consequence. This has been reported previously:

Ristic JM, Stidworthy MF (2002) Two cases of severe iron-deficiency anaemia due to inflammatory bowel disease in the dog.J Small Anim Pract. 2002 Feb;43(2):80-3.

Mick was treated with a combination of corticosteroids, ongoing iron supplementation and an exclusion diet and did very well, perhaps because we were treating the hypoadrenocorticism

So, I do not have much more to say, other than to thank everyone for joining in the discussion around this case. I have enjoyed it, I hope others have too.

Clive

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Robin Grimmer — Fri, 05 Feb 2010 18:42:26 GMT

Hi Clive,

we haven't completely ruled out hypoadrenocorticism. I would do an ACTH stim test. It's not the typical signalment and electrolytes were normal, but it could explain the GI blood loss and also the insidious onset and vomiting.

Also we are assuming the moderate increase in liver enzymes is secondary to g/i disease, but it's possible there could be primary liver disease as this can be a cause of g/i blood loss ( although there was no evidence of ulceration on endoscopy, and I'm assuming the liver was normal on a scan). I would do dynamic bile acids to rule out liver disease.

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Hanna Bennett — Fri, 05 Feb 2010 13:56:25 GMT

we had a dog with chronic IBD who had been on budesonide for a long time who developed a similarly horrid anaemia. This was purely due to blood loss from the GIT and resolved over time with iron supplementation and tweaking of her IBD meds so yes, think this could explain the anaemia.

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Hannah Wynne Richards — Fri, 05 Feb 2010 11:46:16 GMT

Unless considerably worse later on in small intestine, I don't think it is bad enough to explain anaemia, so would carry on diagnostics.

If this is only pathology, I would manage with preds, and iron supplementation (if necessary ). With this level of duodenal pathology (no overt bleeding, and gastric mucosa normal ), don't see much point in sucralfate or antacids. I would, however be slightly scared to start therapy with preds until I was reasonably certain that there wasn't something worse further on

Given the significant risk from full thickness biopsies, I would probably do a barium series, so as to see if any narrowing later on-if there was, I would feel justified in an ex lap, and full thickness biopsies. If not, I would start on preds, but monitor closely-haems at daily intervals to start

Wynne

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Clive Elwood — Thu, 04 Feb 2010 19:08:40 GMT

Interesting and thought provoking responses. There was no loss of layering of layering of the intestine on the ultrasound scan and change appeared diffuse.

The thing I did next on this dog was treat the severe anaemia by supplementing iron, initially by an injection of iron dextran and then by oral iron tablets. I wanted to preserve pathology so I did not use any anti-ulcer medication.

After three weeks, PCV was 32% and Mick was feeling much better.

So, to do an endoscopy or to do an exploratory? Well, like everything else, there is no 'right' answer. I, however, chose to do an endoscopy for the following reasons:

1) If intestinal disease was the cause, it appeared diffuse, so duodenal biopsies stood a reasonable chance of being useful.

2) I believe it might be easy to miss a bleeding gastric lesion such as an ulcer or a leiomyoma when doing a laparoscopy or laparotomy, whereas endoscopy gives good visualisation of the entire gastric mucosal surface.

3) Endoscopy carries a very low risk.

4) Risks of septic peritonitis from full-thickness biopsies are significant. A JSAP paper by Shales and others in 2005 quotes 12% death or euthanasia after intestinal biopsy. Now, whilst the study population may not have been typical, septic peritonitis is, neverthless, a very serious complication and one I would like to avoid.

5) Diagnostic yield is usually very good, in my hands at least. You need to be able to access the duodenum, get good samples and have them read by a good pathologist.

6) There was likely to be time to perform exploratory laparotomy in Mick if endoscopy was not diagnostic i.e. he is not so sick that we have to chose one or the other.

I will post results.

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Lucy Crosby — Mon, 01 Feb 2010 22:40:37 GMT

Is there loss of layering on the ultrasound (I can't see clearly on this computer)? Given the increased thickness of this section of intestine, I would either go for endoscopy with grab biopsies, or laparotomy for full thickness biopsies. The decision would be based on finances and the owners wishes.

Whilst awaiting results I would start him on sucralfate, antacids and metronidazole plus a sensitivity diet.

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Helen Bowes — Mon, 01 Feb 2010 17:12:00 GMT

The case that I dealt with was similar to this. We ultrasounded it and biopsied thickened intestinal walls. We also did endoscopy and took biopsies of stomach and duodenum. In our case, the stomach had digested blood in it but we were unable to find a causative lesion.

I would look to medically manage it with PPI (omeprazole) and sucralfate.

If I concerned over intestinal lymphoma (I belive more of a problem in cats than dogs) I would offer the owner the option of ultrasound guided biopsy or ex-lap. I think at this stage I would have to be guided by the owners wishes for the dog and their finicial considerations.

The ideal route to get most diagnostic information would be an ex-lap and full thickness biopsies of areas of supicion but this is potentially not feasible for many owners

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Laurence Webb — Mon, 01 Feb 2010 16:39:28 GMT

Clive- was this a generalised finding or just one part of the intestine. Also what part was it? If it's the duodenum then I'd endoscope. If it's in the jejunum/ileum then you aren't going to reach it with an endoscope. Any other findings on ultrasound or was that it?

Ultrasound guided FNA may be useful if it's a lymphoma, but I think it would be fairly unhelpful to differentiate inflammatory disese or other neoplasia. Endoscopy is relatively non-invasive (as long you you don't get a perforation) compared to an ex-lap although it's only going to get the mucosa and submucosa so would miss deeper pathology. Ex-lap is the most sensitive investigation and will enable you to get full thickness samples plus biopsy lymph nodes and examine all the viscera, but is also quite a major procedure to perform if you've got athernatives to try 1st.

I'd go for endoscopy if the area of interest is within reach. If not I'd consider laparotomy and bung it full of H2 antagonists and sucralfate whilst waiting for results

Also weere there enlarged lymph nodes? You could aspirate those too.

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

J G Wray — Mon, 01 Feb 2010 16:27:32 GMT

Dear Doc,

What's the morbidity associated with intestinal biopsy by laporotomy, by endoscopy and by endoscopic laporotomy?

What's the rate of useful histological yield with each technique compared with, say, ultrasound guided needle aspiration (on a moving target)?

Just curious is all

JGW

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

jason davidson — Mon, 01 Feb 2010 16:22:42 GMT

At this point it seem that the most likely diagnosis is either neoplasia or ulceration in the GIT. Examination of the stomach and intestines either by exlap or laparotomy and biopsies of the stomach and intestine should give more information.

I would start treatment with H2 blockers and GI protectants and also analgesics - avoiding NSAIDs.

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

anneke van stee — Mon, 01 Feb 2010 15:50:59 GMT

I agree with Wynne: endoscopic or laparoscopic biopsy

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Hannah Wynne Richards — Mon, 01 Feb 2010 15:18:20 GMT

So far I haven't exactly covered myself with glory on this one!!!!!!!!!!!!!!

I would try a GA and endoscopy with biopsy next. Flexible endo if acsessible, otherwise endoscopic laparoscopy

Wynne

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Clive Elwood — Mon, 01 Feb 2010 15:08:49 GMT

Well, I think most people have got there. This is a microcytic, hypochromic anaemia that is regenerative, but incompletely. Even adjusted reticulocytes and indices indicate a regenerative picture. Iron deficiency is a strong possibility. Thrombocytosis can be a feature of iron deficiency.

The high blood urea is consistent with intestinal blood loss, and the raised ALP and ALT do point to the abdomen, and there is no evidence of urinary loss on one sample.

I did not do a bone marrow because the leucocytes and platelets (as well as the red cell picture) did not suggest it would be of benefit.

Similarly, there was little evidence of a haemolytic disease.

So I opted to determined serum iron and do a faecal occult blood test which were consistent with iron deficiency. I then wanted to look for causes of positive faecal occult blood and chronic blood loss (note that this includes occult respiratory tract bleeding and swallowing of blood) and I have posted additional results and the next question for you.

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Lucy Crosby — Mon, 01 Feb 2010 09:22:43 GMT

To summarise, there is a moderate to severe anaemia which appears to be hypochromic and microcytic. There is also anisocytosis and some nucleated red blood cells. This suggests to me that there is some regeneration and I am suspicious that the anemia reflects iron defficiency. This could be secondary to chronic blood loss or reduced iron intake (probably less likely)

The biochemistry shows mildly elevated urea, phosphorus, ALP and ALT.

I would want to rule out an intestinal lesion next given the results so far. I would therefore go for imaging - radiographs and ultrasound.

(PS. what happened to the rest of the urinalysis?)

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

anneke van stee — Mon, 01 Feb 2010 08:26:13 GMT

on second thought I am going along with the Iron deficiency anemia (IDA), which is semi-regenerative. (microcytic, hypochromic, mild reticulocytosis (1-5%) high red cell blood distrubition width, thrombocytosis)

A test of the serum iron would be helpful

I would like to look for occult blood loss in the feces, when the result is negative I would evaluate again when the dog isn't eating canned dog food

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Utlendigur — Sun, 31 Jan 2010 22:57:57 GMT

An absolute reticuocyte count might be helpful.

It appears to be a regenerative anaemia (anisocytosis, polychromasia, reticulocytes) but microcytosis and hypochromic would tend to imply iron deficiency anaemia/chronic blood loss - so maybe still regenerative before the iron stores are totally depleted? Given the slight increase in urea with normal creatinine, mild thrombocytosis. low normal albumin and intermittent vomiting I would put chronic GI bleed fairly high on the differentials. I'd also want to rule out haematuria (rest of the urinalysis), then survey xray abdomen and chest for masses.

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Noweia — Sun, 31 Jan 2010 19:22:52 GMT

Microcytic hypochromic anaemia is characteristic of iron deficiency anaemia. Cause of Fe deficiency - chronic blood loss, absence in diet or absorption problem?

The elevated platelets can occur with iron deficiency doesn't neccessarily rule out a bleed somewhere. Though it would have to be a slow bleed as there is no melaena or haematuria. Increased BUN suggests alimentary bleed?

So a chronic blood loss, possibly through gut, in an old dog - I'd perhaps start a tumour hunt by imaging the abdomen. And get a value for serum iron to confirm diagnosis?

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Laurence Webb — Sun, 31 Jan 2010 14:47:19 GMT

[quote user="Hannah Wynne Richards"]Def of RMBs ?

[/quote]Or a RMB induced intestinal tear causing the bleed?

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

Hannah Wynne Richards — Sun, 31 Jan 2010 12:48:39 GMT

On 2nd thoughts, I'm now going along the iron def line of thought. What's the diet ? Def of RMBs ? Test serum iron b4 anything else. If not absolute dietary insufficiency, is it a weird malabsorption type thing ?

And to think Roberta asked me to be her mentor, and she got there 1st !!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Wynne

Re: Jan 2010 Case of the Month: Lethargy & malaise in 12 yo collie x- Discussion and Answers

pete coleshaw — Sun, 31 Jan 2010 10:36:31 GMT

[quote user="Malcolm Ness"]a rub down with an organic raw meaty bone and he will be right as rain[/quote]

Malcom

with regard to supportive nutrition, you might be just be in the money with a nice bit of red meat & fresh liver!!

Pete