{"id":5844,"date":"2021-09-02T15:37:24","date_gmt":"2021-09-02T19:37:24","guid":{"rendered":"https:\/\/todaysveterinarynurse.com\/?post_type=articles&#038;p=5844"},"modified":"2022-05-13T20:41:36","modified_gmt":"2022-05-13T20:41:36","slug":"inflammatory-bowel-disease-and-sequelae","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/gastroenterology\/inflammatory-bowel-disease-and-sequelae\/","title":{"rendered":"Inflammatory Bowel Disease and Sequelae"},"content":{"rendered":"<p class=\"p1\"><span class=\"s1\">M<\/span><span class=\"s2\">any conditions treated<\/span> in veterinary hospitals are associated with good prognoses. However, sometimes one condition and\/or its treatment leads to another, thereby decreasing the chances of a positive outcome. This article reports the case of a dog whose initial condition and its treatment led to sequelae that affected his overall prognosis.<\/p>\n<hr \/>\n<p class=\"p1\"><strong>Who Will Win the Grand Prize?<\/strong> A panel of judges will choose 4 finalists whose case reports will be published in <i>Today\u2019s Veterinary Nurse<\/i> in 2021. <i>TVN<\/i>\u2019s Facebook followers will then select the Grand Prize winner from among the 4 finalists; the winner gets free registration for VMX 2022. <strong><a href=\"https:\/\/todaysveterinarynurse.com\/case-report-challenge\/\">2021 Case Report Challenge<\/a><\/strong> sponsored by <strong><a href=\"https:\/\/assisianimalhealth.com\/\">Assisi Animal Health<\/a><\/strong>.<\/p>\n<hr \/>\n<h2 class=\"p1\">The Case<\/h2>\n<p class=\"p2\"><span class=\"s1\">\u201cDanger,\u201d a 9-year-old castrated male Shih Tzu, was presented to our hospital with a history of weight loss and decreased appetite for 3 weeks. His referring veterinarian had administered <strong><a href=\"https:\/\/todaysveterinarypractice.com\/maropitant-use-in-cats\/\">maropitant<\/a><\/strong> (1 mg\/kg SQ; initial prescription had been 2 mg\/kg PO, but the clients were not able to administer oral medications), <strong><a href=\"https:\/\/todaysveterinarypractice.com\/cefovecin-sodium-for-skin-and-soft-tissue-infections\/\">cefovecin<\/a><\/strong> (48 mg SQ), and <strong><a href=\"https:\/\/todaysveterinarypractice.com\/the-use-of-capromorelin-for-the-clinical-problem-of-inappetence\/\">capromorelin<\/a><\/strong> (dosage unknown) to stimulate his appetite. Results of thoracic radiography, abdominal ultrasonography, fecal flotation, serum biochemistry, and T4 testing performed in the past month were within normal limits. Complete blood count revealed neutrophilic leukocytosis (white blood cells 17.8 K\/\u00b5L [reference range 4 to 15.5 K\/\u00b5L]), neutrophilia (14<\/span><span class=\"s2\">\u2009<\/span><span class=\"s1\">418\/\u00b5L [reference range 2020 to 10<\/span><span class=\"s2\">\u2009<\/span><span class=\"s1\">600\/\u00b5L]), and thrombocytosis (549 K\/\u00b5L [reference range 170 to 400\u00a0K\/\u00b5L]). Danger had no other pertinent history.<\/span><\/p>\n<h3 class=\"p3\">Referral Examination<span class=\"Apple-converted-space\">\u00a0<\/span><\/h3>\n<p class=\"p2\"><span class=\"s1\">Danger was bright, alert, and responsive. He weighed 5.72 kg and had a body condition score of 3\/9, temperature of 101.7\u00b0F, respiratory rate of 24\u00a0breaths\/min, and a heart rate of 120 beats\/min. His mucous membranes were pink and moist, capillary refill time was &gt;2 seconds, and cardiothoracic auscultation was unremarkable. Danger\u2019s skin, hair coat, eyes, nose, ears, and throat seemed normal for his\u00a0breed.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Abdominal palpation indicated that his abdomen was slightly tense, but no obvious masses were noted. Danger\u2019s history and previous laboratory findings led to the following lists and subsequent workup.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p4\"><strong>Problem List<\/strong><\/p>\n<ul>\n<li class=\"p5\"><span class=\"s1\">Leukocytosis<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Thrombocytosis<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Anorexia<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Occasional vomiting<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Lethargy<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Dehydration<\/span><\/li>\n<li class=\"p6\"><span class=\"s1\">Melena<\/span><\/li>\n<\/ul>\n<p><strong>Differential Diagnoses<\/strong><\/p>\n<ul>\n<li class=\"p5\"><span class=\"s1\">Addison\u2019s disease<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Inflammatory bowel disease (IBD)<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Pancreatitis<\/span><\/li>\n<li class=\"p6\"><span class=\"s1\">Neoplasia<\/span><\/li>\n<\/ul>\n<h3 class=\"p3\">Initial Diagnostics and Interventions<\/h3>\n<p class=\"p2\"><span class=\"s1\">To explore a definitive diagnosis, the veterinarians performed endoscopy of Danger\u2019s upper gastrointestinal (GI) tract, including his esophagus, stomach, and proximal duodenum. No abnormalities were noted during the preanesthetic examination. I then placed an IV catheter and ran a biochemistry panel, results of which were within normal limits. The anesthetic plan included premedication with maropitant (1 mg\/kg IV).<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">To induce anesthesia, midazolam (0.2\u00a0mg\/kg IV) was administered as a sedative and propofol (5 mg\/kg IV) as a general anesthetic agent. Induction was uneventful. Danger was easily intubated with a 5.5-mm Murphy eye endotracheal tube, and anesthesia was maintained by administering oxygen at 1 L\/min, isoflurane at 1%, and lactated Ringer\u2019s solution at 5 mL\/kg\/h IV. While Danger was under general anesthesia, the veterinary medical team monitored his arterial and venous blood flow with Doppler ultrasonography, heart function with electrocardiography (ECG), end-tidal carbon dioxide levels with capnography, oxygen levels with pulse oximetry, and manual techniques (e.g., palpating pulses, checking palpebral reflex to monitor anesthetic depth, visually assessing the patient).<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Because opioids can make pyloric intubation difficult, it is sometimes advisable to wait until pyloric intubation has been achieved before administering opioids to small animal patients. Thus, after the endoscope was passed into Danger\u2019s duodenum, he was given 0.02 mg\/kg buprenorphine IV for pain control. Examination revealed severely thickened and irregular gastric and duodenal mucosa and 2 small polypoid growths in the pylorus. Biopsy samples were collected, which I prepared for laboratory examination. I also collected appropriate samples for <strong><a href=\"https:\/\/todaysveterinarypractice.com\/cobalamin-in-health-and-disease\/\">cobalamin<\/a><\/strong> (B12) and resting cortisol testing, results of which came back within normal limits.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">A few minutes after buprenorphine administration, Danger\u2019s heart rate dropped from 130 beats\/min to 86\u00a0beats\/min and his systolic blood pressure dropped to 80 mm Hg. Due to the sudden drop, he was administered a crystalloid fluid bolus (10 mL\/kg IV), and because his plane of anesthesia (stage III, plane 3) was deeper than necessary, the isoflurane was discontinued.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Shortly thereafter, the procedure was completed. However, during recovery, Danger became bradycardic (56 beats\/min), and ECG indicated second-degree atrioventricular block, Mobitz type II. He was also hypotensive (systolic pressure 58 mm Hg). To improve his heart rate, a single dose of atropine (0.02 mg\/kg IV) was administered. After a few minutes of no improvement, the dose was repeated and he was given naloxone (0.04 mg\/kg IV) to reverse the cardiovascular effects of the buprenorphine. A few minutes after he received the second round of IV medications, his heart rate and rhythm and blood pressure returned within normal limits.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">The rest of Danger\u2019s recovery was smooth and uneventful. During his recovery, to start treating presumptive IBD, we administered dexamethasone-SP (0.2 mg\/kg IV). We also administered cobalamin (87\u00a0mg\/kg SQ) to help with protein absorption while we waited for the results of cobalamin level testing.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Danger was sent home with prednisolone, to be given at 1.3 mg\/kg PO q12h for 1 week, and then q24h. This decision was made to control GI inflammation enough to increase his appetite and later institute dietary changes to assist in treatment.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Danger\u2019s biopsy results indicated changes consistent with IBD. His pyloric mass was a benign inflammatory mass. No infectious agents or neoplastic cells were detected.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<h3 class=\"p3\">Follow-Up<span class=\"Apple-converted-space\">\u00a0<\/span><\/h3>\n<p class=\"p2\"><span class=\"s1\">Two weeks after endoscopy, Danger\u2019s appetite returned and his vomiting decreased. Ultrasonography indicated that his GI tract was much less thickened. A complete blood count and blood chemistry indicated leukocytosis, thrombocytosis, neutrophilia, monocytosis, increased reticulocytes (<\/span><strong><span class=\"s3\">TABLE 1<\/span><\/strong><span class=\"s1\">), and hypoalbuminemia and hypoproteinemia (<\/span><strong><span class=\"s3\">TABLE 2<\/span><\/strong><span class=\"s1\">). His total protein level had decreased substantially (to 5.3 g\/dL) since his referring veterinarian\u2019s finding of 6.4 g\/dL before the endoscopy procedure, which the internist who performed his endoscopy believed represented a need for increased therapy. Prednisolone was thus increased back to his original dosage of 1.3\u00a0mg\/kg PO q12h. Famotidine (1 mg\/kg PO q24h) was recommended to decrease the likelihood of gastric ulcer formation.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table1.png\"><img fetchpriority=\"high\" decoding=\"async\" class=\"aligncenter wp-image-8119 size-full\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table1.png\" alt=\"\" width=\"2134\" height=\"1583\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table1.png 2134w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table1-300x223.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table1-1024x760.png 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table1-768x570.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table1-1536x1139.png 1536w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table1-2048x1519.png 2048w\" sizes=\"(max-width: 2134px) 100vw, 2134px\" \/><\/a><\/p>\n<p class=\"p2\"><span class=\"s1\">Four days later, Danger\u2019s appetite again declined, and the clients began having trouble administering his medications. Danger began regurgitating white foam and passing dark stool. When returned to the hospital, he seemed dull and lethargic. Physical examination determined that he was 7% dehydrated. Subsequent abdominal ultrasonography revealed a hypoechoic pancreas surrounded by hyperechoic fat. This finding, along with examination findings, led to a diagnosis of mild GI ulceration and pancreatitis secondary to the corticosteroid therapy for IBD.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table2.png\"><img decoding=\"async\" class=\"aligncenter wp-image-8120 size-full\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table2.png\" alt=\"\" width=\"2103\" height=\"2002\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table2.png 2103w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table2-300x286.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table2-1024x975.png 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table2-768x731.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table2-1536x1462.png 1536w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2021\/09\/Hickey_TVNFall21_IBDCaseReport_Table2-2048x1950.png 2048w\" sizes=\"(max-width: 2103px) 100vw, 2103px\" \/><\/a><\/p>\n<p class=\"p2\"><span class=\"s1\">Danger was hospitalized for 2 days. On the first day, he received Normosol-R (3 mL\/kg\/h IV) with potassium chloride (0.6 mEq\/kg\/h) to correct his dehydration and electrolyte imbalances, pantoprazole (1 mg\/kg q12h) to protect his GI tract, and sucralfate (100 mg\/kg PO q8h) to protect the lining of his GI tract and promote repair of the presumed ulceration. On the second day, buprenorphine (0.02 mg\/kg IV q8h) was added to reduce the pain of pancreatitis, ondansetron (0.5 mg\/kg IV q24h) to decrease stomach acid production, and <strong><a href=\"https:\/\/todaysveterinarypractice.com\/mirtazapine-addressing-appetite-in-cats\/\">mirtazapine<\/a><\/strong> (7.5 mg PO q24h) to stimulate appetite.<\/span><\/p>\n<h3 class=\"p3\">Outcome<\/h3>\n<p class=\"p2\"><span class=\"s1\">During his 2-day hospital stay, Danger clinically improved and his dehydration resolved. We recommended a <strong><a href=\"https:\/\/todaysveterinarynurse.com\/articles\/supportive-feeding-methods-for-small-animals\/\">feeding tube<\/a><\/strong> to facilitate adequate nutrition and consistent medication administration; however, the clients declined and took him home. Unfortunately, Danger did not regain his appetite. Because financial constraints limited the clients\u2019 ability to commit to extensive treatment for Danger, they elected <strong><a href=\"https:\/\/todaysveterinarynurse.com\/articles\/the-euthanasia-experience\">euthanasia<\/a><\/strong>.<\/span><\/p>\n<h2 class=\"p1\">Discussion<\/h2>\n<p class=\"p2\"><span class=\"s1\">Danger\u2019s concurrent conditions were diagnosed as pancreatitis, IBD, and presumed GI ulceration. It is possible that his severe intestinal inflammation led to the pancreatitis and that the treatment received during Danger\u2019s hospitalization led to the presumed GI ulceration.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\"><b>IBD<\/b> consists of a group of immune-mediated conditions of the intestines. It is a diagnosis of exclusion and can overlap many other conditions. IBD causes chronic and recurrent GI signs such as vomiting, diarrhea, weight loss, delayed gastric emptying, and poor appetite. The cause of IBD is not well understood, so it is often labeled idiopathic. Many factors are involved in IBD, including diet, genetics, immune function, and microbiota.<sup>1<\/sup> Danger\u2019s IBD was diagnosed as the most common form: lymphocytic plasmacytic enteritis. IBD is treated with anti-inflammatory medications and dietary changes (e.g., switching to novel protein or hydrolyzed protein diets). The drugs most often used to treat this group of disorders are corticosteroids, tylosin, and metronidazole.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\"><b>Pancreatitis<\/b> is an inflammatory condition in which the pancreas secretes fewer digestive enzymes, which enables the digestive enzymes to activate prematurely (before they have reached the intestinal lumen), which in turn increases inflammation, causing clinical signs such as edema, fat necrosis, bleeding, and sometimes death.<sup>2<\/sup> The clinical signs of pancreatitis vary and include anorexia, vomiting, weight loss, dehydration, lethargy, and abdominal pain. Although most cases of pancreatitis are idiopathic, IBD can predispose patients to pancreatitis, and corticosteroid therapy may increase its severity.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\"><b>GI ulceration<\/b> may be common in patients with IBD because the inflammation increases the permeability of GI mucosa and the delayed gastric emptying increases the amount of time that gastric acid remains in contact with the mucosa. Signs of ulceration can include vomiting, diarrhea, anorexia, lethargy, melena, abdominal pain, hematemesis, hematochezia, shock, anemia, and even death. Ulcers can develop secondary to a disease process or drug therapy. Diseases that predispose small animals to ulcers include IBD, neoplasia, and liver disease. Drugs that have been implicated in GI ulceration include nonsteroidal anti-inflammatory drugs and corticosteroids. GI ulceration is typically treated with histamine H<sub>2<\/sub>\u2013receptor blockers (e.g., famotidine), proton pump inhibitors (e.g., omeprazole), and cell-protective agents (e.g., carafate).<sup>3<\/sup><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">For many patients with IBD, the prognosis is good; however, Danger\u2019s lack of response to treatment and his pancreatitis made his prognosis much worse. Treatments needed to control his IBD would have continued to worsen his pancreatitis and GI ulceration. Because his appetite, from presentation through euthanasia, was never good, diet change was never an option for assisting his recovery.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Cases like Danger\u2019s are challenging. Although the prognosis for each individual comorbidity can be positive, the concurrence of IBD, pancreatitis, and GI ulceration decreased his chances of a successful outcome.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>This case report highlights the difficulty in managing multiple comorbidities.<\/p>\n","protected":false},"author":187,"featured_media":5819,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":0,"footnotes":""},"categories":[170],"tags":[145],"class_list":["post-5844","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-fall-2021","tag-peer-reviewed","column-case-reports","clinical_topics-gastroenterology"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO 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