The Frustrations of
IBD
Its cause is
unknown, its diagnosis difficult
by Lexiann Snider
Copyright 2003 Belvoir Publications Inc. Posted with permission, Your Dog.
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Debilitating, costly, frustrating, heartbreaking – those are the terms owners of dogs with inflammatory bowel disease (IBD) use to describe the condition. Veterinary texts define IBD as a group of disorders resulting in chronic stimulation of inflammation in the gastrointestinal tract. The inflammation causes frequent, recurring episodes of vomiting and/or diarrhea. But diagnosing and treating the condition can be difficult. What’s
unknown about IBD is probably greater than what’s known, including its
cause. Some researchers believe it’s an autoimmune response where the
body either overreacts to a foreign antigen -- a substance that provokes
an immune response -- or reacts inappropriately to a normal antigen, such
as a food protein. Possible
precipitators of the inflammatory response can be a bacterial, viral or
protozoal infection, parasitic infestation, hypersensitivity or
intolerance to dietary ingredients, digestive enzyme deficiencies or
intestinal wall defects. “No
one really knows what the most frequent or likely triggers are,” said
Mary Labato, DVM, Dip. ACVIM, clinical associate professor at Tufts
University School of Veterinary Medicine. “There is no single,
overwhelming type or cause.” |
Ame suffered from whip- and round- worm infestation along with inflammatory bowel disease. |
Because
IBD can affect different portions of the GI tract, symptoms vary greatly
from pet to pet, making it even more difficult to identify. Besides diarrhea
or vomiting, other signs may include gurgling stomach, belching or gas, loss
of appetite, desperation to get outside or soiling in the house, pain with
bowel movements, weight loss and mucous, or blood in the stool. Most cases of vomiting and diarrhea have a benign cause. They start suddenly and resolve quickly. “Acute gastro-enteritis is self-limiting,” Dr. Labato said, “but IBD is chronic. It comes and goes, and it keeps recurring.” Search for
Answers Ame’s problems
began when Michelle Barton, a rescue volunteer from Edmonton, Alberta,
Canada, brought her home at 9 months. “First I noticed large amounts of
stool that soon became mucous covered,” Barton said about her German
Shepherd. “This was followed by vomiting of undigested food and her not
wanting to eat. Her stools progressed to a pudding-like consistency, then
explosive diarrhea and at its worst to blood-only diarrhea.” Barton continually consulted the veterinarian who put Ame though many tests, including a biopsy, to reach a conclusive diagnosis. The Shepherd was treated for severe whip- and round-worm infestation and appeared to improve for a while. Within
weeks she went downhill. Ame lost about 20 percent of her normal weight. She
stopped eating and drinking, and was hospitalized, with the expectation she
would die. “She
was non-responsive,” Barton said. “She laid in her kennel and had
terrible, bloody diarrhea. The vet gave her IV fluids and wrapped her in
heated blankets. She could not fight anymore,” Barton said. “I asked to
take her home.” Today,
thanks to Barton’s efforts and veterinary care, Ame hasn’t had a
flare-up in nearly two years. To
reach a diagnosis, veterinarians do blood work to rule out other problems,
such as pancreatitis, Addison’s and kidney disease or malignancy. They
examine fecal samples for worms or infections, such as giardia. They also
may take X-rays and use ultrasound to check for obstructions or other
abnormalities. Although some dogs like Ame have parasites or infections,
often test results are normal except for minor thickening of the intestinal
walls, an occasional elevation in liver enzymes or mild anemia. A
diagnostic test for IBD is a positive biopsy, obtained through an endoscopy
of the stomach or a colonoscopy of the lower GI tract. But results still may
be unclear. Ambiguous
Results “Even
among pathologists, there’s a great deal of difference in scoring the
amount of white blood cells found in the intestinal lining to say, ‘This
is IBD,’” Dr. Labato said. “One may read test findings as abnormal, or
another one will describe the inflammation as mild or a slight increase but
normal.” If a biopsy report comes back positive for inflammation, it’s not necessarily IBD, said Matthew Krecic, DVM, a researcher in gastrointestinal disease and speaker on IBD at the 2002 American College of Veterinary Internal Medicine Forum. “Lots of things, such as infection, cause inflammation, which can be treated. “If
it’s true IBD, you treat it a little differently,” said Dr. Krecic with
Alabama Veterinary Specialists, a referral-only practice in Birmingham.
“Food sensitivity may respond with diet alone, but you may have to manage
IBD with other medications, also.” Because
of the ambiguity of biopsy results, veterinarians may try dietary changes
and drugs to see if symptoms improve before doing the biopsy. The
first line of defense in the treatment of possible IBD is an elimination
diet. If food sensitivity is a contributing factor, it’s likely the
ingredient has been in the diet for many months. All foods used in the past
or being currently fed, including treats, are eliminated. Then
a “novel protein,” a source never eaten previously and one that is easy
to digest, is substituted. Rabbit, duck, venison and kangaroo are common
sources. Fats are moderately restricted because they lengthen the time it
takes to digest food, increasing the likelihood of nausea. Special products
that meet these requirements are available from a variety of commercial
manufacturers and veterinarians offering prescription IBD diets. Veterinarians
may suggest a bland diet while getting vomiting or diarrhea under control.
Dr. Labato recommends a mixture of cottage cheese and rice for her patients.
Other options are boiled hamburger and rice or chicken and rice – along
with short-term use of Kaopectate or Pepto-Bismol, anti-diarrheal liquids. Worse
Symptoms Because it can take two- to six weeks for improvement, dogs who are showing worse symptoms or who have lost too much weight will likely take other medications simultaneously. A staggering variety of drugs can be used to treat IBD. “Which drugs are best depends on the severity of signs, how recurrent they are and the animal’s overall condition,” Dr. Labato said. “I’m inclined to use Flagyl (an anti-protozoal anti-biotic also known as metronidazole) and steroids (corticosteroids, cortisone, prednisone, Prednisolone, etc.), or a combination of drugs based on the symptomology.” Additional categories of drugs that may help include: compounds containing a sulfa anti-biotic, anti-inflammatory and mild immunosuppressants (sulfasalzine, mesalamine); other antibiotics such as Tylan or tetracycline; other immunosuppressants to suppress an over-reactive immune system (azathioprine, chlorambucil); anti-spasmodics or anti-hypermotility agents that relieve abdominal cramping or slow the digestive tract; or prescription-strength acid inhibitors like Pepcid, Prilosec or Prevacid “A
pet’s signs may be exacerbated by rapid changes in diets or
medications,” Dr. Labato said. “If you have a lot of changes at once,
they may go right back to episodes of vomiting or diarrhea. You need to go
slowly so you can see what’s working.” Veterinarians
may change the diet, prescribe drugs, watch for a few weeks, then assess the
changes. If no improvement is shown, they will suggest a different food or
drug. But when a dog becomes emaciated or debilitated, the time for
wait-and-see trials are over. “This may be when a referral is made,” Dr. Labato said. It
took six months, a general practice veterinarian and two veterinary
specialists to diagnose Frankie, a Clumber Spaniel, owned by Kristin Caruso
of Denver, Colo. Refused Food“Frankie’s
symptoms began at age 4 months with consistently loose stools that
progressed to diarrhea,” Caruso said. “He frequently refused his meals,
vomiting what he did eat. A vet visit resulted in a switch to a prescription
diet and Tylan to treat a possible clostridium (bacterial) infection.” Improvement was brief. In a few weeks, Frankie became lethargic, vomited large quantities of food and had explosive diarrhea. Although a young dog, he failed to gain weight. Caruso consulted a veterinary specialist in internal medicine who ran a series of tests, including blood, urine, fecal, bile acid, ultrasound and endoscopy, which confirmed a diagnosis of IBD. The
Spaniel was placed on prednisone, Reglan (a drug that decreases acid reflux
into the esophagus, helping to reduce nausea) and Flagyl, and put on a new
prescription diet. For the next two years, Frankie had to be kept on
steroids and given different diets as he continued to have flare-ups. The treatment goals in IBD are to eliminate an identifiable cause, reduce diarrhea and vomiting, decrease bowel inflammation and stabilize the dog’s weight. After gaining control over acute episodes, long-term management may come down to diet. “An
animal may be doing fine then accidentally get a crumb that isn’t part of
their [prescribed] diet,” Dr. Labato said. “Sometimes it just takes one
or two bites to trigger a Although
some dogs may need maintenance drugs, veterinarians prefer to prescribe a
minimum dosage, then taper the amount until the animal is off the drug,
especially steroids. “We don’t like to keep animals on these drugs for life,” Dr. Krecic said. “If we can control diet, maybe we can reduce the drugs. Pets can never go back to their old diet because they can relapse. We look to control the symptoms and severity since this is a lifelong illness that you are never done treating.” |
|
Daily MonitoringThe health of her
dog became Caruso’s daily priority. “When he was sick, I’d hug him and
massage his belly,” she said. “When he was in pain, I’d sleep with
him, waking every hour to check his condition. I thought I might lose
him.” Her
vigilance paid off. “He has been off prednisone for several months, and
Frankie’s IBD is now under control. I stuck with the plan and his diet,
and he’s doing great.” Perseverance worked for Barton, too. Before releasing Ame from the hospital, the veterinarian administered a steroid injection. Armed with daily doses of prednisone, Pepcid and Flagyl, Barton took Ame home, where she ate for the first time since becoming so ill. Two weeks later, Barton changed the dog’s diet one last time. |
Frankie, a Clumber Spaniel, experienced symptoms of inflammatory bowel disease at the age of 4 months. |
“At first it was hard cleaning the constant messes in and around the house,” Barton said. “However, Ame was my responsibility no matter what. With that attitude, we made it through the ups and downs of the disease. It took two years of medication and a strict diet, but she made an incredible recover.” Finding the right food is a matter of trial and error, one change at a time, at the veterinarian’s direction. “No one diet is suitable for all patients,” Dr. Krecic said. In addition to special foods, IBD dogs do well when owners add fiber in the form of cooked potatoes, sweet potatoes or pumpkin to their meals. Although
management of IBD symptoms can be elusive, it’s critical to control them
to prevent complications, such as liver damage, ulcers, anal sac infections
and malnutrition. “Be diligent in finding a diagnosis,” Caruso advised.
“Develop a relationship with your veterinary team and understand what you
need to do.” “When
Frankie’s health began to improve, I showed him and finished his AKC
[American Kennel Club] Champion title. It was meaningful because he’d been
through so much with his health,” Caruso said. “We’ve begun tracking
and he loves it. I’m a firm believer that an IBD dog can enjoy and
participate in life as much as any other dog.” Regardless
of its challenges, both owners and veterinarians say, the condition can be
managed, and IBD dogs can lead quality lives. It simply takes patience. Lexiann Snider, who lives in Ohio, is an eight-time recipient of the Maxwell Award for excellence in dog writing, presented by the Dog Writers Association of America. |
|
Breeds Likely To Develop IBD
Researchers don’t always
agree on the breeds prone to developing inflammatory bowel disease, but
these seem to be diagnosed with the condition more than others: Basenji, Boxer, Cocker
Spaniel, Dalmatian, German Shepherd, Irish Setter, Lundehund, Shar-Pei,
Rottweiler, Soft-coated Wheaton Terrier and Yorkshire Terrier. The types of IBD they develop are sometimes considered variants of the more common form of the condition, with different types of inflammatory cells attacking different gastrointestinal tissue. Treatment is nearly identical but depends on the type of cells affected, location of the inflammation and the dog’s symptoms. Although a dog can
have IBD at any age and show subtle signs when young, the average age at
diagnosis is about 6 years. The disease affects males and females equally. |
|
$18,000
Later, A Boxer Still At
the tender age of 2, Kia, a Boxer belonging to Gerry Langgut, was frequently
gassy and had episodes of diarrhea, vomiting and lack of appetite. When she
was 5, the dog also developed gastro-esophageal reflux (GER), immediately
followed by uncontrollable salivation. Langgut
of Oak Park, Ill., consulted several veterinarians. Some dismissed the
problem as the dog having eaten something unusual. A few told Langgut her
dog needed only more fiber. One veterinarian suspected inflammatory bowel
disease and changed Kia’s diet, supplementing with probiotics, substances
that promote the growth of natural bacteria in the intestinal tract that aid
in digestion, and Pepto-Bismol. But
Kia showed no improvement. She was referred for allergy testing and was
determined to be hypersensitive to several protein sources, including beef,
lamb, venison, milk and fish. Once again her diet was changed. Although she
ate voraciously, Kia lost 12 pounds. A
veterinary internal medicine specialist performed a biopsy and confirmed she
had IBD. “It took six years to receive a diagnosis,” Langgut said. “I
don’t know what caused it, but I was told it could be linked to food
allergies.” The
veterinarian started Kia on large doses of prednisone and Flagyl, which
brought an immediate cessation of symptoms. The dog also took
phenylpropanolamine (a sympathetic nerve stimulant used to increase muscle
tone and help prevent GER), azathioprine (an immunosuppressant), Sucralfate
(an anti-ulcer medicine) and Pepcid (an anti-acid). “Kia
is very stoic, so it’s hard to tell if she’s in pain,” Langgut said.
“There have been times when she wouldn’t eat for a couple days, or she
would flinch when she had a bowel movement. With the salivation, she was in
distress and couldn’t lie down for hours at a time, drooling so much she
soaked carpets and herself. It’s difficult to tell how much discomfort she
has because of the medication’s side effects.” Attempts
were made to wean Kia off prednisone, but she always relapsed. As a result
of long-term steroid usage, she developed Cushing’s disease, causing her
to be lethargic, lose hair and muscle tone, and become hypothyroid.
Additionally, Kia has had changes in skin color, reduced alertness, joint
stiffness and started defecating in the house. Her
veterinarian prescribed Thyroxine, a synthetic form of thyroid to replace Kia’s
inadequate level of the hormone. Although it’s too early to tell,
Langgut is hopeful it will improve her dog’s condition. “I vacillate
between feeling overwhelmed and helpless, and feeling envious of owners
whose dogs are healthy and energetic. Mostly I feel very sad. “Kia
doesn’t do things most dogs do, and she spends the majority of her time
sleeping. Her quality of life is certainly compromised,” Langgut said of
her now 8-year-old dog. “But she still loves spending time with us,
follows us around the house and eagerly greets us. She is an extraordinarily
wonderful dog who’s a part of our family.” Langgut spends much of her time caring for Kia. She buys special food and prepares all her meals from boiled buffalo meat and potatoes. She regularly cleans up messes on the rug. Kia takes 18 different drugs and nutritional supplements twice daily. She’s been hospitalized on occasion and has had surgeries to repair problems related to IBD complications. In all, Langgut has spent about $18,000 on medical bills and food. “Would
I do it over again?” Langgut asked. “Part of me thinks not; I wouldn’t
want another dog to go through what she has. But having experienced the joy
that she’s brought, I would do it all again in a flash.” |
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