Thursday, April 21, 2011

Diagnosing Precious: GI Issues That Are Not Going Away

My friend has asked me for help for her beloved Rottie Precious. Precious has been ill since the end of the last year. Today, an exploratory surgery, three vets, four months, and several treatments later, he is not getting any better.

I realize that a dog cannot get diagnosed over the internet but they are working with a third vet now and it doesn't seem that they are any closer to a solution than when they started.

We are looking for are any ideas or suggestions you might have.

***

Precious is a 3 year old Rottweiler, happy and always healthy prior to this event. He weighs 40kg.

The problem started on the 29th of December 2010 after Precious overindulged at the Christmas dinner on the 27th of December.

On the 29th he woke up feeling miserable threw up and had diarrhea.

His vet prescribed Enroxil [enrofloxacin] 150mg, 2 per day for 5 days. The problem got better for a while only to return with something worse after only a few days.


The vet suggested we change his diet to Hill's i/d.

In a few days the condition got worse.  

The vet prescribed Metronidazole 250mg 8per day.

Still the condition continued to worsen. Precious was straining unproductively and when he did manage to pass something it was an explosion of terrible smelling greenish liquid.

I went to the vet again and was told that it could be another month of taking this medicine before I could see some improvement. Asking what do I expect during the month I was told that his condition may worsen or get better at times.

The vet who has known him since he was a puppy never examined him.  

I wasn't comfortable with this, a month had passed and Precious was worse than day 1. I couldn't imagine let him suffer for another month.

I took a video of Precious doing his thing and I called another vet who visited Precious at home. 

He said he suspected IBD but recommended we take x rays and ultrasound just in case there was an obstruction. And so we did on the 29th of January 2011.

Xrays didn't show any swollowed object and I was confronted with the difficult decision of an exploratory surgery. 

I was told that something could be hidden in his colon like for example a ball of bones and precious could die if we don't act immediately.

I signed the paper for surgery.

After a while I was told that no object was found but his intestines are very sick.  

I asked if it was cancer and the answer was definitely not but his whole intestines and the colon are very inflamed.

I asked for a biopsy but the vet said that the inflammation was so bad that he would be risking perforation.  

Precious was given Rodogyl [Spiramycin, Metronidazole a combination of two antibiotics] for 10 days after the operation.

His incision healed well and things were for the following 2 weeks. 

The straining was gone and the stools were solid.

After the two weeks, however, the straining and explosive diarrhea came back.  

Precious was given one medicine after another, Rodogyl, Salazopyrin [Sulfasalazine], Rodogyl again.

Up to all this time besides this problem, Precious remained quite happy looking forward for his drives and walks, playtime and ate as usual.

The vet decided to give him 20mg of Prednisolone a day. 

In the evening of the 2nd day I noticed that Precious was panting and was very restless. His tummy was very hard and felt swollen.

I took him out walking and he passed a lot of gas and the biggest explosion of poo ever.  

The color was yellow and the smell terrible!

I reported this the next morning and prednisolone was to be tailed off.

After this the vet wanted to try another medicine. after another course of Flagyl, Prifinial chien, he said, would help regulate intestinal motility.

Although hesitant I gave him this medicine and this was the end of happy Precious. 

He would just lay there, miserable, his tummy swollen  and he didnt even pass gas.

On his walks he strained and strained only to pass a few drops of poo. 

I just couldn't keep up the trial and error of different medication and decided I should after all seek another opinion. I hoped to find someone who wasn't scared of my baby.

So I finally got to the 3rd vet on the 1st of April. 

Although I hoped for a miracle medicine that could make my Precious better the vet told me that he will definitely not give Prednisolone to Precious unless further testing is done and he is sure of his organs, mainly the liver. He sent out for more labs.


He gave Precious Hyoscinth to help with the flatulance problem and Lactulose to cleanse him whilst reducing the straining. 

The following week was the worst ever!  

Precious just lay on a quilt and just slept. He ate very little and didnt even want to go for his walks.

His lips and mouth were cold and he just stayed curled up alone.

On the 7th of April Precious woke up and vomited something that looked like plastic.

I thought I was imagining things, afterall it was just 4AM, but in the afternoon during his little walk he vomited again.

My dad was with me and said I should probably keep it and show it to the doctor. I kept it in a bag and the vet told me to take a picture, however I did not and just threw it away thinking it was all in vain.

On Saturday 9th April after some serious straining, I couldn't believe what went out of Precious' behind!

With an explosion of poo came out what looked like a whole roasting bag all covered in mucus!!!

After that Precious seemed to have been gaining back his health. He was eating and up from his quilt again.

It seemed that with the plastic the problem went away.

However, it did not. Precious seemed fine, however, his stools were still watery and they looked like clay!!

Precious was put on Denosyl [S-Adenosylmethionine] 225mg tablets twice a day and

While it could be a coincidence, explosive greyish stools appeared on the same day. 

The lab results suggested possible EPI (Exocrine Pancreatic Insufficiency) combined bacterial overgrowth.

We started Precious on a sulphur antibiotic and some digestive enzymes.

Precious refuses to eat the "enzyme tainted" food and is back to straining and explosive diarrhea.

Where to go from here?

Update on Precious
April 27, 2011

Unfortunately the ultrasound didn't happen yesterday, long story. Scheduled for tomorrow. Meanwhile, Precious' stools started smelling of ammonia ...

Update on Precious
April 28, 2011

Nothing detected in ultra sound. Waiting for blood work result.

The doctor said Precious needs to be taking the digestive enzymes and gave me in pill form. He said Precious is suffering from Irritable bowel disease and when I said I wanted to find out what is causing the inflammation he said the only way is a biopsy and test it abroad, the test is not available in Malta.

He suggested I give Precious digestive enzymes twice a day and see what happens. About the ammonia or rancid smell, he said since the food is not being digested it is causing fermentation in the intestine hence the bacterial overgrowth. He is almost certain that there is no obstruction  however we could do a barium x ray. Am not willing to take the risk for this (Precious won't drink it).

Update on Precious
May3, 2011

Precious is getting better, he's taking the digestive enzymes in capsule form and eating ZD hypoallergenic diet 4 times a day. Still taking antibiotics.

His stools yesterday and today: no explosion, not watery, still greenish in colour but no ammonia smell and solidifying. checking for Giardia again.

Nothing abnormal in blood work.

Although Precious is still a little slow and sleeps more than he used to, he's barking again, happy with his new toys and playing, and looks forward to his walks even at 3 in the morning

Hugs to everyone thinking of him. Marthese

Update on Precious
May9, 2011

Precious is improving every day. Even his energy is coming back and his lovely barks are back. stools still greenish but forming, no explosions and no ammonia or rancid smell. He is taking 4 meals a day ZD which surprisingly is looking forward to. I give him also Florentero every day and digestive enzymes before each meal.


***


Precious' fecal results:

Stools culture and microscopy
Salmonella/Shigella species Negative
Campylobacter species Negative

No parasites and ova observed using high power magnification.

pancreas elastase (EIA):
PE-Konz.: > 180.00 µg/g > 40 (fragl. 10-40)
*Interpretation
Pancreas elastase reflects the endocrine function and is not influenced by sample age or inflammatory processes like the TLI-test.
The test is specific for the dog and not suitable for other species.


Microscopical examination
Starch granules : negative
Starch : negative
Neutral fat : negative
Fatty acids : negative
Fatty soaps : negative
Muscel fibres : moderate concentration
Connective tissue : negative
Elastic fibres : negative


total fatty acid (near-infrared-spectrography):
total fat faeces / g/24h < 4.5g/24h
total fat faeces 3.38 g/100g < 2.5
Gallensäuren
total bile acids 3.6 µmol/g < 2.5


Interpretation of results:

The identification of muscle fibres in faeces indicates an altered  digestion. In the differential diagnosis a pancreas insufficiency,  resorption abnormalities in the small intestine or an impaired stomach digestion are to be considered.  High concentrations of fat in faeces are indication for insufficient fat  digestion. One reason can be EPI, quite common cause as well is bacterial  overgrowth Estimation of bileacids in the feaces can give further  information.

High bile acid values are found as a consequence of a bacterial deconjugation in the small intestine or in short small intestine cases. Because of the hygroscopic properties of bile acids,aqueous explosive diarrhoea can be produced.

Initially an antiobitic treatment with sulfonamide and trimethoprim (3-5 days) should be performed.

By clinical signs of bacterial overgrowth of the small intestine an antibiotic treatment with sulfonamids and trimethoprim or tylosin should be performed (3-5 days).

Phenole, nitrosonaphthole and indican: the result shows a bacteriological overgrowth in the small  intestine or an increased protein decomposition in the small and large intestine.

28 comments

  1. Poor Precious, and I can only try to imagine how difficult this must be for your friend. I cannot be of much help I am afraid, other then sending positive thoughts. Hope that reaching out through this article gives some new input and insights that can help.

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  2. Thank you, Kenzo, positive thoughts always help.

    I can certainly feel their frustration, as we've been there, done that.

    I haven't tried something like this before, but I'm hoping somebody will be able to come up with some good suggestions.

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  3. It is indeed very difficult, doing our best to try and get a clue of what's this nasty thing inside of precious making him so ill, yet seeing him waste away everyday.Precious has changed from the mischievous naughty pup keeping our house alive to a sleeping unhappy one :(

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  4. I try not to be critical of how a case is handled when I wasn't there, don't have all the facts, and especially when I haven't even seen the patient. It appears to me that there is no diagnosis, just trial and error with drug therapy (mostly with drugs I don't recognize because they are Canadian trade names.) This is how we handle chronic GI cases in our practice, especially those that seem to be getting worse rapidly or go on for more than a week.

    Initially, a complete physical examination is performed an a fecal sample is obtained to look for parasites. At that point we will trial a course of medication and diet change and most dogs with simple gastroenteritis will resolve.

    For those that don't, we will get a full CBC/Chem, a GI panel from Texas A&M (TLI, PLI, Cobalamine, Folate levels)and repeat the fecal. If there is vomiting, we get an abdominal ultrasound. If the plastic was there at the time of the ultrasound it is more likely to pick it up than an x ray. I had a case like that last month and we pulled a large amount of plastic out of a dog's stomach and intestines after a 3 hour surgery that involved repairing a bowel perforation at the same time. (dog is doing well)
    If imaging and lab work to this point doesn't give the answer, we need to get a biopsy of the intestines. This can either be done open (exploratory) or by scope. Both procedures require general anesthesia and have different benefits and downsides. I cannot comment on the results of the exploratory that was performed as I wasn't there. I have certainly seen intestines that I would be reluctant to biopsy due to their condition. However, without a tissue diagnosis, we are just continuing to guess what is going on, and from the sounds of it, not effectively.

    The differential diagnosis list would include Exocrine Pancreatic Insuffeciency (treated by addition of digestive enzymes to the food to pre digest it), Inflammatory Bowel Disease, Neoplasia, Parasite, Infection, or some sort of toxin exposure (possibly on going) I don't know what role the plastic bag played unless there is still some in there.

    Good luck to your friend and Precious. Hope this insight helps. Once again, I'm just saying how I might have approached this case and do not mean to infer that anything improper was done.

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  5. This is such a detailed report, I hope someone will be able to help Precious. Having 2 dogs with recurring tummy troubles, (including suspected food allergies and pancreatitis), I understand how awful it must be.

    Just wondering if there's been any thoughts on a home cooked diet? Rufus has zero tolerance for commercial food these days, even high end organic holistic types! Actually, perhaps a holistic vet might be able to offer a different perspective?

    Good luck with finding an answer soon.

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  6. Dear Dr. Keith

    Thank you so much for taking the time going through this! (((hugs)))

    Yes, there isn't really any diagnosis, apart from the last fecal results where the lab made the suggestion of EPI and bacterial imbalance.

    The drugs Precious has been on were different types of antibiotics, de-worming meds, steroids ...

    I was also surprised how very few values were checked on the blood panel when I saw it.

    There was a diet change.

    Good to know that ultrasound would pick up the plastic, I wasn't sure whether it would and I am wondering whether some more plastic could be there.

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  7. Hi Georgia, thank you for your kind words! I think the most awful is how long this has been going on and there still isn't a solid diagnosis.

    I did suggest trying to give a simple bland home-cooked diet (they tried rice and fish). Precious liked it but didn't seem to have made any difference for the GI tract.

    Apparently there don't seem to be any holistic vets in Malta (that's where Precious lives).

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  8. This is another suggestion from one of my vet friends:

    Please ask her if they ran a PCR and did a wet fecal smear looking for Giardia and Trichomonas. Questioning not doing biopsy.

    None of the drugs mentioned would treat Trichomonas. Metronidazole (Flagyl) and Rodogyl treats Giardia but need it longer.

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  9. Poor Precious! Poor family! Sounds like very valid workups have been done-I wonder if an internal medicine specialist is next?

    That material he vomited could have caused or started so much of his problem-but a primary GI issue could still be at play.

    Would endoscopy with biopsy be an option? dvm is right that you do not want to further harm a super inflammed GI tract...

    But if biopsy can be done safely it may be worth considering - anxious to hear he is ok!

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  10. Hi Shawn, thank you for taking the time to contribute! (((hugs)))

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  11. Often fecal screens don't include the protozoans. Usually one must ask specifically for the PCR & wet slides to looks for them

    Ronidazole is the only proven effective treatment for Trichomonas.

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  12. I am not a vet, but when dealing with my rescue animals, yellow or green in the stool or vomit means too much bile (liver) and gray stool means not enough or no bile (also liver). Have they done an MRI to look for more plastic? Even a very tiny piece might still be causing trouble higher up in the GI tract, and MRI's are more detailed than Xrays or ultrasounds. Exploratory surgery may not find something like a tiny piece of clear plastic lodged in a bile duct or something like that. Did Doggie absorb toxins from that plastic or from anything else he ate? Have the liver or related organs been damaged by the overproduction of bile, toxins from the plastic, or the plastic itself? Just some ideas, hope they help. Good luck to you guys!

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  13. Thank you so much for contributing, your experience is priceless. The blood results are on that little pic, if you click it it will show full size.

    This panel looks quite different (and has less values) than I'm used to seeing, I'm not sure what the first two values are.

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  14. Hi Y'all,

    I'm wondering pretty much the same thing as in a prior comment...is there a specialist available to look at Precious?

    BrownDog's Momma

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  15. Another vet opinion:

    The problem with ultrasound is gas. Gas is a ultrasound's enemy. If there is a lot of gas in the intestinal tract, it can be difficult to see. Also, a piece of plastic could be easily missed. I suppose a experienced radiologist may see an "obstructive" pattern or other changes in the ultrasound to support some foreign body being present, but it would not be easy.

    If there are digestive symptoms lasting over several months, a ultrasound is certainly one test to consider, but if there is no explanation and there is any vomiting or diarrhea persisting for months, an endoscopy may be necessary.

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  16. Thanku all for contributing to this blog. Your comments and suggestions will be passed on to the vet that is presently taking care of Precious. I keep blaming myself for not taking a second opinion earlier but I would never have guessed that Precious would be opened up on suspicion of swallowing a foreign object and than overlook the plastic. I guess next step would be an ultra sound to determine there is no more plastic. I don't think MRI is available for dogs in Malta, we are very limited in a lot of things here. With regards to an internal specialist I also don't think there is one, however the vet that is now taking care of Precious is one of the most experienced on our island. I tried to chose the best for my baby just hope am not too late. I long to see my mischievous Precious back he is more like a cat now than a rottweiler, he sleeps all the time and his eyes are so sad and yet remains so gentle and loves his cuddles especially from the little kids that come to my house or at the park.Another concern I have is that every time Precious is to be tested he has to be heavily sedated and I don't know how much more he can take. I have no words to thank u enough for your contributions to this and your kind words and support. A special thanks to Jana for putting up Precious story on her blog cannot thank her enough. Will keep everyone posted re what's happening.
    Hugs from Marthese and Precious in Malta

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  17. Poor Precious! I don't have any insight to offer, but I will be adding my good vibes to the ones everyone else is sending. I hope that Precious gets well soon!

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  18. How sad. I've been a victim of "trial and error medicine" with my former vet, and it was upsetting...and expensive. The only advice I have is to give your pup's digestive system a rest and put them on a bland food diet. poach chicken breast and pulse it in the food processor until finely ground. Mix it with well cooked rice. After a few days add a dollop of a high quality, plain yogurt. I'm not an expert, just a puppy mama.

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  19. Hi Maggie. While I appreciate that "sometimes" trial and error is all that is left, I don't think this should have been the case...

    Sorry you had to go through something like this also. We had our share of misgivings with vets, but fortunately when the situation was really bad we found a good one.

    Precious already is presently on a bland home-cooked food - fish and rice. The yoghurt was also added. Good tip though! But clearly there is more going on there.

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  20. Ultra sound scheduled for today at 3pm. Yet another clinic and another veterinary.
    Precious stools at times are smelling of ammonia and some other time have a rancid smell. Precious is tired but still looks forward to his meals at least, which are small and frequent. I've changed from rice to well cooked potatoes may be I see some change. Still giving florentero and also 0%fat live greek yoghurt. Precious is still on antibiotics, hyochinth and lactulose. Today he had his meal and medicines at 5am so he'll have an empty stomach by 3 this afternoon.
    Will keep you posted on what happens at the clinic.
    hugs Marthese and Precious

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  21. It seems that precious received lots of Antibiotics all the time.why don't you give Probiotics for 3 days and some antacids? I bet this will work like Magic.All the best!

    Ahc.dbhss.

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  22. Dear Dr. Wati,

    thank you for taking the time reading and commenting! :-) Yes, this is a valid point, Precious was put on Florentero though.

    The situation seems contained with the enzymes in pill form now, fingers crossed.

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  23. Dear Dr.Wati,

    Thanks for your comments. Precious is still taking Florentero and I've added fat free yogurt to the science plan ZD diet. Since he's been having digestive enzymes he improved a great deal, however I still think his intestinal flora needs to be back on track again. He has been taking antibiotics for the past 4 months. Now he is having hopefully the last course of antibiotic (Enroxyl) hoping to clear the bacterial overgrowth. Recently I looked up slippery elm on the net and came across a probiotic which seems perfect for Precious, the name is Gastriplex and has a combination of slippery elm, L-Glutamine and a couple more ingredients to rebuilt a healthy GI.
    In the meantime in the past 7 days, stools are forming, no ammonia or rancid smell,no tummy gurgling and no gas, no watery explosive diarrhea and no loss of weight.

    Precious is coming back to the forever pup he's always been. This morning we even had the famous drill, where he runs from one end of the house to the other at full force repeatedly chasing nothing at all. He looked so happy and so was I :)
    Thanks and regards
    Marthese

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  24. Hi, I just wanted to share with everyone that Precious is still on the right track to gaining his health back. Digestive enzymes (Creon 10000) increased to two before each meal and he's having 3 meals a day. He is only on ZD diet, cans and dried) He is also on Florentero but no more antibiotics. He is again playful,alert and getting very strong in his pull again :)

    regards Marthese

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  25. So happy to hear that Precious keeps getting better! Thank you for the update,

    (((hugs))) to Precious,
    Jana

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  26. Sharing some good news.

    This week Precious was special guest to Dr.Pierson from Royal Canine. Dr.Pierson is an Internal expert and came to Malta to give lectures to Maltese vets re GI problems in dogs. His words for precious were " He's in Top Form " So proud of my boy!!
    Precious has also put on 3 kilos in weight and his energy level is back. He is walking and enjoying the long walks again and his toys are allover the place at home again :} Dr. Pierson told me that eventually Precious could go back to a normal diet again and most probably without medication as well. He reckons the problem was more SEBO than EPI(according to what he read in the results) and it was all due to the foreign body moving trough the system. He advised to go slow because precious' intestines are still healing. We are to start adding a little fibre to the diet to prevent the stools getting too dry now.
    He congratulated me on my perseverance.
    Thanks God for Jana for her advice on having a second opinion and for keeping my hopes up when I had nearly lost hope Precious will ever make it trough this.
    Hugs from Marthese and Precious in Malta

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  27. Hi Marthese. Love hearing such news, yay for Precious!

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  28. Hi all!!It's been 5 months since I've been here last. Prcious has since May gained more than 7 kilos and is back to the happy, playful pup he'll always be. He's become more of a mummy's boy since than :) He is still on a hypo allergenic diet but is allowed chicken broth and some chicken once a week. He is taking 2 meals a day and only 4 digestive enzymes a day. Thanku all for contributing to this blog.
    hugs from Marthese and Precious in Malta

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