{"id":1310,"date":"2013-05-01T16:20:36","date_gmt":"2013-05-01T16:20:36","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=1310"},"modified":"2022-02-17T19:08:54","modified_gmt":"2022-02-17T19:08:54","slug":"gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/","title":{"rendered":"GI Intervention: Approach to Diagnosis &amp; Therapy of the Patient With Acute Diarrhea"},"content":{"rendered":"<p class=\"p1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2016\/09\/T1305F02.pdf\"><img decoding=\"async\" class=\"alignnone size-full wp-image-9886\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png\" alt=\"pdf_button\" width=\"110\" height=\"27\" \/><\/a><\/p>\n<hr \/>\n<p class=\"p1\"><em><span class=\"s1\">P. Jane Armstrong, DVM, MS, MBA, Diplomate ACVIM<\/span><\/em><\/p>\n<p class=\"p1\"><span class=\"s1\">Diarrhea can be defined as increased fecal fluidity, usually accompanied by increased defecation frequency and volume of feces. Most cases of diarrhea are mild and self-limiting, requiring minimal diagnostics and therapy. Life-threatening cases can occur, however, that require greater diagnostic efforts and intensive care.<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>ACUTE VERSUS CHRONIC<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Diarrhea is considered:<\/span><span class=\"s2\"><sup>1<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><b><\/b><span class=\"s1\"><b>Acute<\/b> if it lasts for less than 14 days<\/span><\/li>\n<li class=\"li1\"><b><\/b><span class=\"s1\"><b>Chronic<\/b> if it persists for longer than 14 days. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Historical and clinical findings and appearance of the feces are used to differentiate whether the diarrhea is of small bowel or large bowel origin (<b>Table 1<\/b>). This differentiation is most important in cases of chronic diarrhea, when selection of diagnostic tests is influenced by the presumed location of enteric pathology. Additionally, many pets with acute diarrhea display signs of enterocolitis (mixed small and large bowel signs).<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>PREVALENCE &amp; INCIDENCE<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">While diarrhea is a very common presenting problem in companion animal practice, it is either more common in dogs than cats, or dogs with diarrhea are more likely to be examined by a veterinarian. A report of diagnoses from over 2 million dogs and almost 430,000 cats in 2011 indicated that &#8220;gastroenteritis (GI upset)&#8221; and &#8220;colitis&#8221; both ranked in the top 19 diagnoses for dogs, but were not among the most common diagnoses in cats.<\/span><span class=\"s2\"><sup>2<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Incidence of diarrhea and vomiting was investigated prospectively in a Norwegian study of 585 large-breed dogs followed from birth to 2 years of age.<\/span><span class=\"s2\"><sup>3<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Most dogs had only one episode of diarrhea and\/or vomiting during the study period; those suffering from several episodes demonstrated relatively long periods between episodes. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">There was a positive association between occurrence of diarrhea and vomiting in the same dog, but episodes of diarrhea and vomiting did not usually occur at the same time. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Diarrhea and vomiting had a much higher frequency in young puppies despite complete vaccination and deworming protocols.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Risk for diarrhea decreased from 16% in 7-to-12-week-old puppies to 5.4% in 12-to-18-month-old dogs.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">An early study showed that frequency of both vomiting and diarrhea were highest in puppies and declined with increasing age<sup>4<\/sup>; this is supported by Banfield data demonstrating that &#8220;gastroenteritis (GI upset)&#8221; was common in dogs up to 3 years but much less common in dogs above that age.<\/span><span class=\"s2\"><sup>2<\/sup><\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>OWNER IDENTIFICATION<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Diarrhea is generally recognized by owners, as long as the feces are observed. Most owners realize that diarrhea is usually self-limiting and may be more prone to &#8220;wait and see&#8221; when pets develop gastrointestinal (GI) signs, compared to clinical signs that are not as familiar.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">In a study of 772 pet dogs in England, 70% of the reports of diarrhea involved only 1 or 2 episodes, and 78% lasted 2 days or less. Veterinary attention was sought for only 10% of dogs with diarrhea (and 5% of vomiting dogs).<\/span><span class=\"s2\"><sup>5<\/sup><\/span><span class=\"s1\"> All dogs with diarrhea persisting for 7 days or longer were presented to a veterinarian.<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>PATHOPHYSIOLOGY<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Four major pathophysiologic mechanisms can cause diarrhea. Osmotic forces and changes in mucosal permeability are the most important mechanisms in dogs and cats. In most small animal diseases, multiple mechanisms contribute to diarrhea, and it can be difficult to determine the predominant mechanism.<\/span><\/p>\n<p class=\"p1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Screen-Shot-2015-06-04-at-3.06.02-PM.png\"><img fetchpriority=\"high\" decoding=\"async\" class=\"alignnone wp-image-4298 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Screen-Shot-2015-06-04-at-3.06.02-PM-e1456517084112-300x219.png\" alt=\"Screen Shot 2015-06-04 at 3.06.02 PM\" width=\"300\" height=\"219\" \/><\/a><\/p>\n<ol class=\"ol1\">\n<li class=\"li1\"><b><\/b><span class=\"s1\"><b>Osmotic diarrhea:<\/b> The number of osmotically active particles in feces determines water content, and presence of increased numbers of these particles within the intestinal lumen leads to osmotic diarrhea.<\/span><span class=\"s1\">Osmotic diarrhea occurs with many malabsorptive disorders, such as exocrine pancreatic insufficiency, in which poorly digested nutrients are malabsorbed, remain within the GI lumen, and attract water. It can also occur with overeating and dietary indiscretion if poorly absorbed nutrients are ingested.<\/span><span class=\"s1\">Retention of nutrients in the GI tract can also lead to dysbiosis (see below) and fermentation of carbohydrates, which further increases the number of osmotically active particles. A hallmark of osmotic diarrhea is that it resolves when the patient stops ingesting poorly absorbable solute.<\/span><\/li>\n<li class=\"li1\"><b><\/b><span class=\"s1\"><b>Secretory diarrhea:<\/b> Stimulation of crypt enterocytes results in secretion of large volumes of fluid that exceeds the absorptive ability of the intestine. This occurs most commonly with infectious diseases, such as enteropathogenic <i>Escherichia coli<\/i> and salmonellosis, but is also a mechanism of diarrhea related to inflammatory bowel disease (IBD). By-products of dysbiosis can also stimulate intestinal secretion. One distinguishing feature of secretory diarrhea is its persistence despite fasting, which is due to abnormalities in ion transport not related to food.<\/span><\/li>\n<li class=\"li1\"><b><\/b><span class=\"s1\"><b>Increased mucosal permeability:<\/b> Increased permeability of the intestinal mucosa causes loss of fluids, electrolytes, proteins, and blood into the intestinal lumen. It commonly accompanies erosive, ulcerative, neoplastic (intestinal lymphoma), and inflammatory processes, such as IBD and hookworm infection.<\/span><\/li>\n<li class=\"li1\"><b><\/b><span class=\"s1\"><b>Abnormal motility:<\/b> Deranged motility is often secondary to disorders that cause diarrhea. Decreased segmental contractions result in transport of ingesta at a rate too fast for normal digestion and absorption. Platelet-activating factor, synthesized and released from several immunocytes, may be one of the inflammatory response mediators that stimulates giant aboral contractions, the powerful contractions that propagate\u2014uninterrupted\u2014from the small intestine to the ileum or colon.<\/span><span class=\"s1\">Tremendous fluid loss can occur when the small and\/or large intestine are not functioning normally. Mild diarrhea causes few metabolic consequences; however, moderate or severe diarrhea can lead to profound dehydration, hypovolemic shock, electrolyte abnormalities (hypokalemia, hypochloremia, and hyponatremia), and acid\u2013base disturbances.<\/span><span class=\"s1\">Metabolic acidosis typically develops secondary to loss of intestinal bicarbonate and dehydration leading to hypovolemia, anaerobic metabolism by tissues, and production of lactic acid.<\/span><\/li>\n<\/ol>\n<h2 class=\"p3\"><span class=\"s1\"><b>ACUTE DIARRHEA: CAUSES<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">There are many causes of acute diarrhea in dogs and cats (<b>Table 2<\/b>). In many cases of acute diarrhea, signs resolve spontaneously or with symptomatic therapy without a specific cause being discovered.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">In animals with chronic diarrhea, a thorough diagnostic evaluation and appropriate dietary and therapeutic trials for diagnostic purposes are much more important. It is beyond the scope of this review to discuss causes and diagnostic approach to pets with chronic diarrhea; however, watch for evidence of chronicity even at first presentation of a pet with diarrhea.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Endoparasites<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">It is well documented that endoparasitism is primarily a concern in young animals.<\/span><span class=\"s2\"><sup>2,6-8<\/sup><\/span><span class=\"s1\"> Batchelor, et al, documented that dogs with GI signs had a higher prevalence of intestinal parasites, including <i>Giardia<\/i> and <i>Toxocara<\/i>.<\/span><span class=\"s2\"><sup>6<\/sup><\/span><span class=\"s1\"> In a referral population, however, dogs with GI signs had no greater odds of endoparasitism than healthy animals; instead, age and median household income were the strongest predictors of endoparasitism, and dogs from heavily populated ZIP codes had the greatest risk for endoparasitism.<\/span><span class=\"s2\"><sup>9<\/sup><\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Dietary Indiscretion<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Dietary indiscretion is a common cause of acute diarrhea. One study reported that feeding a home-cooked diet, recent history of scavenging, or change of diet all increased the risk for diarrhea in dogs.<\/span><span class=\"s2\"><sup>10<\/sup><\/span><span class=\"s1\"> Another study found a positive correlation between development of diarrhea and\/or vomiting and reports of scavenging behavior (stealing food; eating trash; or eating feces from horses, farm animals, or cats).<\/span><span class=\"s2\"><sup>5<\/sup><\/span><span class=\"s1\"> No correlation was found between GI signs and eating table food.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Bacterial Enteritis<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">A variety of bacteria are known or suspected to cause enteritis in dogs and cats (<b>Table 2<\/b>). Establishing a diagnosis of bacterial enteritis creates a significant challenge due to:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Limitations in understanding the complex intestinal microflora<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Inadequate investigation of many potential pathogens. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Screen-Shot-2015-06-04-at-3.06.29-PM.png\"><img decoding=\"async\" class=\"alignnone wp-image-4299 size-full\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Screen-Shot-2015-06-04-at-3.06.29-PM-e1456517389144.png\" alt=\"Screen Shot 2015-06-04 at 3.06.29 PM\" width=\"365\" height=\"561\" \/><\/a><\/p>\n<p class=\"p1\"><span class=\"s1\">The fact that the microorganisms responsible for enteritis can be found in healthy individuals, and may not be found at a higher prevalence in animals with diarrhea, confounds diagnosis, treatment decisions, and assessment of infection control and zoonotic risk (<b>Table 3<\/b>).<\/span><\/p>\n<p class=\"p1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Screen-Shot-2015-06-04-at-3.06.55-PM.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-4300 size-figure_img\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Screen-Shot-2015-06-04-at-3.06.55-PM-e1456520108640-623x300.png\" alt=\"Screen Shot 2015-06-04 at 3.06.55 PM\" width=\"623\" height=\"300\" \/><\/a><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Cytology.<\/b> Microscopic examination of fresh feces has been used by some clinicians for presumptive diagnosis of disease by evaluating pathogen appearance. However, fecal cytology is now considered of no diagnostic utility for bacterial enteropathogen identification because:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">These bacteria can be present in normal animals<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Appearance does not differentiate between pathogenic strains and harmless commensal species<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">In the case of <i>Clostridium perfringens<\/i>, no studies have reported a correlation between presence or number of spores and signs of disease. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Enterotoxin has received the most attention in relation to <i>C perfringens<\/i>, and some association has been found between the presence of <i>C perfringens<\/i> enterotoxin (CPE) and diarrhea in dogs.<\/span><span class=\"s2\"><sup>11<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Intestinal Microbes.<\/b> Intestinal microbes play a crucial role in maintenance of host health. They: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Act as a defending barrier against transient pathogens<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Support the host in digestion and energy harvest from the diet<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Stimulate the immune system<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Provide nutritional support for enterocytes.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">The total microbial load in the intestine is estimated at 10<\/span><span class=\"s2\"><sup>12<\/sup><\/span><span class=\"s1\"> to 10<\/span><span class=\"s2\"><sup>14<\/sup><\/span><span class=\"s1\"> organisms, about 10x the number of host cells in the entire body.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">New technologies have enhanced our understanding of the microorganisms harbored by mammalian GI tracts. Massive parallel 16S rRNA gene pyrosequencing has provided the tool for molecular-phylogenetic characterization of the GI tract&#8217;s complex microbial community.<\/span><span class=\"s2\"><sup>12<\/sup><\/span><span class=\"s1\"> The gene content of these microbes is defined as the <i>intestinal microbiome<\/i>.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">There is mounting evidence that changes in microbial populations play an important role in pathogenesis of acute and chronic enteropathies of dogs. In a recent study, dogs with acute diarrhea, especially those with acute hemorrhagic diarrhea, had the most profound alterations in their fecal microbiome compared to healthy dogs, and observed changes differed between acute and chronic disease states.<\/span><span class=\"s2\"><sup>13<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Recognition of fecal biome alterations (dysbiosis) in pets with various GI disorders opens the door to future studies that evaluate the ability of probiotics, prebiotics, antibiotics, and other therapies to restore the balance of bacterial flora.<\/span><\/p>\n<div class=\"orange-box\">\n<p class=\"p1\"><span class=\"s3\"><b>Hemorrhagic gastroenteritis<\/b><\/span><span class=\"s1\"> (HGE) is a diarrheal syndrome of unknown etiology that has a predilection for small breed dogs; it has not been reported in cats. Speculation regarding pathogenesis includes type-1 hypersensitivity reaction to food components, CPE, and <i>C difficile<\/i> toxins A\/B.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">HGE is distinctively characterized by peracute onset of bloody diarrhea and vomiting accompanied by marked hemoconcentration. Packed cell volume of an affected dog can reach 75% or higher within hours of onset of signs, yet total plasma protein often remains within reference range. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Symptomatic therapy, primarily aggressive IV fluid therapy and gastroprotectants, results in marked clinical improvement within 24 to 48 hours. Antimicrobial therapy is usually administered, although in a recent study, clinical response was not improved in dogs that received antibiotics (amoxicillin\/clavulanic acid).<\/span><span class=\"s2\"><sup>14<\/sup><\/span><span class=\"s1\"> With appropriate therapy, mortality is low despite severity of signs.<\/span><\/p>\n<\/div>\n<h2 class=\"p3\"><span class=\"s1\"><b>ACUTE DIARRHEA: HISTORY &amp; PHYSICAL EXAMINATION<\/b><\/span><\/h2>\n<p class=\"p3\"><span class=\"s1\">Signalment and history often contain the information necessary to make a tentative diagnosis or help rank differential diagnoses (<b>Tables 1 and 2<\/b>). Puppies and kittens, especially from shelters, are prone to viral diseases and GI parasites.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Physical examination may detect:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Abdominal masses<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Dilated loops of bowel<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Foreign bodies<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Intussusception<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Abdominal pain. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">When patient size permits, routinely performing digital rectal palpation aids recovery of feces for observation of the presence of blood (digested [melena] or fresh) and\/or mucus.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Dehydration (at least 5% to be clinically noted) may be evident by dry mucous membranes, loss of skin turgor, prolonged capillary refill time, or enophthalmos. More pronounced alterations in these parameters indicate moderate dehydration (7%\u20139%); extreme alterations denote severe dehydration (10%\u201312%) approaching hypovolemic shock (tachycardia with poor peripheral perfusion and weak peripheral pulses).<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>ACUTE DIARRHEA: DIAGNOSTICS<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">The most important initial step in evaluating animals with acute diarrhea is to determine if they have a self-limiting or potentially life-threatening problem (<b>Table 2<\/b>). This distinction is crucial as it guides the level of diagnostics and therapy indicated, and should be based on a thorough history, careful physical examination, clinical experience and judgment, and a sound understanding of the differential diagnoses for acute diarrhea.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Initial Diagnostics<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><b>Fecal Flotation.<\/b> Animals with suspected self-limiting diarrhea should always be tested for GI parasites by centrifugation fecal flotation using zinc sulfate, paired with indirect fluorescent antibody testing for <i>Giardia<\/i> cysts and <i>Cryptosporidium<\/i> oocysts.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Cytology.<\/b> Fecal cytology, a low-yield diagnostic test, is not useful for detection of potential bacterial enteropathogens (<b>Figure<\/b>). In contrast, exfoliative rectal cytology can be useful in dogs and cats with signs of colitis, especially when chronic, to identify fungal organisms or colonic neoplasia.<\/span><\/p>\n<div id=\"attachment_3171\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/GI-Intervention-Figure.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3171\" class=\"wp-image-3171 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/GI-Intervention-Figure-300x226.jpg\" alt=\"GI Intervention Figure\" width=\"300\" height=\"226\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/GI-Intervention-Figure-300x226.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/GI-Intervention-Figure.jpg 399w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-3171\" class=\"wp-caption-text\">Figure. Photomicrograph of fecal cytology showing sporulated organisms compatible with Clostridium perfringens. Fecal cytology, however, is not considered to be diagnostically useful for bacterial enteropathogen identification.<\/p><\/div>\n<p class=\"p1\"><span class=\"s1\"><b>Laboratory Analysis.<\/b> Measuring total plasma protein and hematocrit will help assess hydration and provide a baseline for reference if clinical signs persist or progress.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Symptomatic Therapy<\/b><\/span><\/h3>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">If dietary indiscretion has occurred, removal of the incriminating factors and\/or feeding a highly digestible diet for 3 to 5 days usually helps resolve diarrhea. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">If parasites are detected, diarrhea should improve 2 to 3 days after appropriate treatment<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">If an etiology is not found, a presumptive diagnosis of acute idiopathic self-limiting diarrhea may be made. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Symptomatic therapy usually relieves clinical signs in 1 to 3 days. If diarrhea persists or other clinical signs develop or intensify, a more serious problem may exist, requiring thorough evaluation and more intensive therapy.<\/span><\/p>\n<div class=\"orange-box\">\n<p class=\"p3\"><span class=\"s1\"><b>A patient may have a potentially LIFE-THREATENING PROBLEM<\/b><\/span><span class=\"s4\"> if some of the following are present:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Moderate to severe dehydration<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Abdominal pain<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Depression<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Melena or hematochezia<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Presence of an abdominal mass or dilated loop of bowel<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Frequent vomiting<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Signs of systemic illness, such as: <\/span>\n<ul class=\"ul2\">\n<li class=\"li1\"><span class=\"s1\">Ascites<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Lymphadenopathy<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Coughing<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Ocular and nasal discharge<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Hepatomegaly<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Oliguria\/anuria<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Icterus<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Pyrexia<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">If the distinction is not clear cut, it is better to be cautious and initially manage the patient as if it has a life-threatening problem.<\/span><\/p>\n<\/div>\n<h3 class=\"p4\"><span class=\"s1\"><b><strong>Additional Diagnostics<\/strong><\/b><\/span><\/h3>\n<p class=\"p4\"><span class=\"s1\"><b>Laboratory Analysis.<\/b> Laboratory evaluation helps rank differential diagnoses as well as assess severity of dehydration and electrolyte disorders; it may include:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Complete blood count <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Serum biochemistry profile<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Urinalysis <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Baseline cortisol (to exclude hypoadrenocorticism)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">SNAP Parvo Test (idexx.com).<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">In chronic or recurrent cases of diarrhea, serum concentrations of cobalamin and folate and canine or feline trypsin-like immunoreactivity (cTLI or fTLI) can be measured. Depending on clinical signs, patients may be evaluated for hyperthyroidism (cats) and pancreatitis. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Radiography.<\/b> Survey abdominal radiographs may demonstrate an abdominal mass, dilated loop of bowel, ileocolic intussusception, foreign body obstruction, or linear foreign body requiring surgical intervention.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Specific Identification.<\/b> Additional diagnostic tests may be indicated to definitively diagnose a specific organism or disease or to pursue diagnosis if a cause is not yet evident (eg, abdominal ultrasound).<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Identification of <i>Tritrichomonas foetus<\/i>; several diagnostic tests are available <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Serologic testing for feline leukemia and immunodeficiency viruses may be warranted in diarrheic cats based on housing and origin <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Partial analysis for enteric pathogens, usually reserved for diarrheic pets that are systemically ill or in contact with an immunosuppressed person:<\/span>\n<ul class=\"ul2\">\n<li class=\"li1\"><span class=\"s1\">Fecal enteric panel: Gram-stained fecal smear, CPE enterotoxin enzyme-linked immunosorbent assay (ELISA), <i>C difficile<\/i> toxin A\/B ELISA <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Fecal culture or polymerase chain reaction (PCR): For potential bacterial pathogens, such as <i>Salmonella<\/i> and <i>Campylobacter<\/i><\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">It is very difficult to establish evidence for a causal association between the presence of a specific bacterium in the feces and occurrence of diarrhea (<b>Table 3<\/b>).<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>ACUTE DIARRHEA: MEDICAL THERAPY<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Most cases of self-limiting diarrhea resolve within 1 to 5 days, following correction of the underlying cause and\/or symptomatic treatment.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Nonspecific symptomatic therapy may include one or more of the following:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Nutritional management<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Therapeutic deworming<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Antidiarrheal<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Antiemetic and\/or gastroprotectant<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Probiotic<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Antimicrobial (selected cases)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Fluid therapy.<\/span><\/li>\n<\/ul>\n<div class=\"orange-box\">\n<p class=\"p1\"><span class=\"s5\"><b>A recent British study documented the prescribing habits of veterinarians for dogs with acute diarrhea<\/b><\/span><span class=\"s1\"> seen in general practice.<\/span><span class=\"s2\"><sup>15<\/sup><\/span><span class=\"s1\"> A total of 371 dogs of various breeds, ages, and sexes were represented. See <b>Box<\/b> for study results.<\/span><\/p>\n<p class=\"p1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/050613-gi-therapy-table.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-9233 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/050613-gi-therapy-table-e1456518553890-300x86.png\" alt=\"050613 gi therapy table\" width=\"300\" height=\"86\" \/><\/a><\/p>\n<p class=\"p1\"><span class=\"s1\">The frequent use of antibacterials for acute diarrhea is surprising and somewhat alarming. There is evidence that resistance to antimicrobials is increasing among bacteria isolated from pets.<\/span><span class=\"s2\"><sup>16<\/sup><\/span><span class=\"s1\"> Nutritional management, therapeutic deworming, and probiotic therapy, accompanied in some cases by an antidiarrheal agent, should be considered first-line therapies (<b>Table 4<\/b>).<\/span><\/p>\n<\/div>\n<blockquote>\n<p class=\"p4\"><span class=\"s1\">For dosages of antiemetics and gastroprotectants (for diarrhea cases with concurrent vomiting, hematemesis, and\/or melena), see <\/span><span class=\"s5\"><b>Medications for Acute Vomiting: Dogs and Cats<\/b><\/span><span class=\"s1\">, available at <b>todaysveterinarypractice.com\/resources.asp#resources<\/b>.<\/span><\/p>\n<\/blockquote>\n<h3 class=\"p4\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/050613-gi-table-4.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-9236 size-figure_img\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/050613-gi-table-4-e1456519631544-386x300.png\" alt=\"050613 gi table 4\" width=\"386\" height=\"300\" \/><\/a><\/h3>\n<h3 class=\"p4\"><span class=\"s1\"><b>Nutritional Management<\/b><\/span><\/h3>\n<p class=\"p4\"><span class=\"s1\"><strong>Administration<\/strong>. Animals with acute diarrhea often benefit from withholding food for 6 to 12 hours followed by frequent (3\u20136 small meals\/day) feeding of small amounts of a highly digestible, so-called &#8220;bland,&#8221; diet; amount fed per meal can be slowly increased.<\/span><\/p>\n<ul>\n<li class=\"p4\"><span class=\"s1\">Such diets for dogs should have a low or modest fat content; fat restriction is not required for cats. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Useful choices include boiled rice with lean chicken, low-fat cottage cheese, or tofu; Prescription Diet i\/d Low Fat GI Restore (hillsvet.com); Purina Veterinary Diets EN Gastroenteric (nestlepurina.com); and Veterinary Diet Intestinal Low Fat (royalcanin.us).<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">When diarrhea resolves, the animal&#8217;s usual diet can be slowly reintroduced over a 2- to 3-day period by adding 25%, 50%, 75%, and finally 100% of the usual diet. If vomiting is concurrently present, an antiemetic can be administered.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>High-fiber diets.<\/b> For pets with signs of acute large bowel diarrhea (<b>Table 1<\/b>), a high-fiber diet is often used instead of a bland diet as fiber may be beneficial in reducing tenesmus and facilitating colonic epithelial repair. Commercial products with increased mixed (soluble and insoluble) fiber are ideal. Soluble fiber (psyllium mucilloid, 1 tsp\/10 kg body weight) may be added to a bland diet.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Therapeutic Deworming<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><b>Parasite Identification<\/b>. If a GI parasite is identified on fecal examination, the appropriate antiparasiticide should be prescribed.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">In many dogs and cats with acute diarrhea, parasitic infection remains a possibility despite negative test results because:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Testing is not 100% sensitive<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Not all parasites shed ova continuously. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\"><b>Antiparasiticide Selection<\/b>. For these reasons, a good therapeutic strategy to consider is administration of a broad-spectrum dewormer, such as fenbendazole, which is also an excellent choice for treating giardiasis, showing better efficacy and a greater safety margin than metronidazole. If a response to therapeutic deworming is seen, a second course of fenbendazole in 3 months is needed for some parasites, such as whipworms.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Antidiarrheals<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><b>Indications.<\/b> If diarrhea is frequent enough to interfere with the animal&#8217;s (or sometimes the owner&#8217;s) ability to rest, causes apparent pain or discomfort, or results in large fluid losses, an opioid may be given to alter intestinal motility.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Mechanism of Action.<\/b> Opioids prolong intestinal transit time, allowing increased fluid absorption and reduction in the frequency of diarrhea. They act by:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Increasing colonic segmentation, fluid absorption, and anal tone<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Decreasing propulsive peristaltic contractions and secretion<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">These drugs are particularly effective in patients with large bowel diarrhea (colitis). <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Specific Drugs.<\/b> Diphenoxylate or loperamide is very effective in reducing frequency of diarrhea. <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Both are available as elixirs, making dosing convenient for small dogs and cats. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Loperamide is more potent and has faster onset and longer duration of action than diphenoxylate. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">In dogs, both drugs\u2014at recommended doses\u2014are safe and have few side effects. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">In cats, excitatory behavior can occur, but appears to be rare; for this reason, though, these drugs should be used with caution in cats. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">If a toxin or possibly pathogenic bacteria are the suspected cause of acute diarrhea, opioids are contraindicated because they may increase toxin absorption or time for bacterial proliferation.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Probiotics<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><b>Definition<\/b>. Probiotics are live microorganisms that, when administered in adequate amounts, confer a health benefit on the host (World Health Organization definition). Probiotics include a wide variety of organisms, such as various species of <i>Lactobacillus, Bifidobacter, Bacillus, E coli, Streptococcus, <\/i>and<i> Saccharomyces<\/i>.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Mechanism of Action<\/b>. Both live and dead cells in probiotic products can generate beneficial biological responses.<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Live probiotic cells influence both GI microbiome and the immune response. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Components of dead cells may have anti-inflammatory effects in the GI tract. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">In the case of live probiotic organisms, bacterial levels in feces disappear within days when supplementation ceases.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Clinical Evidence.<\/b> To date, limited clinical trials with probiotics have been performed in dogs and cats with GI disorders (see <b>Probiotic Studies in Companion Animals<\/b>).<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Antimicrobial Therapy<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><b>Nonspecific Use.<\/b> Routine use of antibiotics in cases of acute uncomplicated diarrhea is strongly discouraged. If an antibiotic is selected for nonspecific use in such cases, metronidazole or tylosin is an appropriate choice.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Specific Use.<\/b> In acute intestinal diseases, antimicrobials are specifically indicated only in animals with:<\/span><span class=\"s2\"><sup>19<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Confirmed bacterial infection (eg, positive blood culture and\/or presence of enteropathogenic bacteria on fecal culture, along with signs of sepsis)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Predisposition for bacterial translocation (eg, disruption of intestinal epithelial barrier) <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Increased risk for sepsis (eg, immunosuppression, portosystemic shunting). <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Pets with acute bloody diarrhea of unknown cause are usually treated with an antibiotic, such as amoxicillin\/clavulanic acid, or monitored very closely because:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Ruling out enteric bacterial infection is challenging<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Bacterial translocation is a potentially life-threatening complication.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Markedly hemorrhagic diarrhea is often interpreted as evidence of a breach of intestinal integrity, justifying use of antimicrobials, although no studies document an increased risk for bacterial translocation or sepsis in these patients.<\/span><\/p>\n<h3 class=\"p3\"><span class=\"s1\"><b>Fluid Therapy<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><b>Administration.<\/b> An animal&#8217;s deficit due to dehydration can be calculated by multiplying the percent of estimated dehydration (from physical examination) times body weight (kg). Maintenance fluids (44\u201366 mL\/kg\/day) should be added to this deficit. Continued losses from diarrhea should be estimated and added to the fluid volume administered.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">If mild dehydration is present, a balanced isotonic polyionic fluid (lactated Ringer&#8217;s) can be administered subcutaneously, but animals with severe dehydration caused by life-threatening acute diarrhea require intravenous fluid therapy.<\/span><span class=\"s2\"><sup>20<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Further Diagnostics<\/b>. If diarrhea worsens or other clinical signs develop, the animal should be re-evaluated and further diagnostics considered. Any underlying conditions should be specifically treated. If further diagnostic testing is needed, fluid therapy consisting of crystalloids and possible addition of colloids should be instituted <i>prior<\/i> to obtaining a definitive diagnosis.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Feeding.<\/b> Food should be withheld for no more than 12 hours and an antiemetic administered if vomiting occurs to allow feeding as soon as possible. Puppies with parvoviral diarrhea treated by early enteral feeding showed more rapid clinical improvement than puppies held off food.<\/span><span class=\"s2\"><sup>21<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Monitoring.<\/b> Careful monitoring is required during fluid therapy. <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Physical examination findings that indicated dehydration should gradually improve as the patient is rehydrated during the first 24 hours of therapy. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Hematocrit and total protein should decrease. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Body weight should be measured frequently, as changes accurately reflect hydration. <\/span>\n<ul class=\"ul2\">\n<li class=\"li1\"><span class=\"s1\">After hydration has been reestablished, body weight should remain relatively stable throughout the treatment. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Falling weight suggests dehydration while increasing weight supports overhydration. <\/span><\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s1\">Serum electrolytes should be monitored daily for several days in animals with profuse diarrhea or severe electrolyte abnormalities.<\/span><\/li>\n<\/ul>\n<h2 class=\"p3\"><span class=\"s1\"><b>SUMMARY<\/b><\/span><\/h2>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Dogs and cats frequently develop diarrhea that starts abruptly and lasts for less than 7 days. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Most cases are mild and self-limiting, and likely associated with changes to the intestinal microbiota.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">In mild cases, in which there is no indication for antimicrobial therapy, nutritional management, therapeutic deworming, and probiotic therapy, sometimes in conjunction with an antidiarrheal agent, should be considered. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">In cases with more severe, sometimes life-threatening, signs, a thorough and logical diagnostic plan must be followed to obtain an accurate diagnosis and guide appropriate therapy.<\/span><\/li>\n<\/ul>\n<div class=\"orange-box\">\n<h2><b>Probiotic Studies in Companion Animals<\/b><\/h2>\n<h3 class=\"p4\"><span class=\"s1\"><b>Dogs with Acute Diarrhea<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><b>Kelley, et al.<\/b> In one study, 31 young adult dogs with acute, uncomplicated, nonspecific diarrhea were enrolled in an unblinded, randomized prospective study, receiving either <em>Bifidobacterium animalis<\/em> strain AHC7 (Prostora, iams.com) or placebo for 2 weeks.<sup>17<\/sup> Mean time to diarrhea resolution was significantly less for the probiotic group (3.9 \u00b1 2.3 vs 6.6 \u00b1 2.7 days). <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Hersted, et al.<\/b> In a double-blinded, placebo-controlled study, 36 dogs with acute diarrhea or acute gastroenteritis were randomized to receive a probiotic cocktail (2 <em>Lactobacilli<\/em> species and 2 <em>Bacillus<\/em> species) or placebo.<\/span><span class=\"s2\"><sup>18<\/sup><\/span><span class=\"s1\"> Duration of abnormal stools was shorter for dogs receiving probiotics (1.3 vs 2.2 days). There was no difference in duration of vomiting between groups. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">These study results suggest that probiotic therapy is a rational approach for shortening the duration of diarrhea, improving patient comfort in dogs assessed to have acute, self-limiting diarrhea. Similar studies in cats have yet to be published.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Prevention of Diarrhea<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Probiotics likely have a role in diarrhea prevention, such as for pets in stressful conditions. Cats and dogs housed in an animal shelter were studied to determine whether feeding <em>Enterococcus faecium<\/em> SF-68 (FortiFlora, nestlepurina.com) would decrease episodes of diarrhea and improve fecal scores.<\/span><span class=\"s2\"><sup>19<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Animals in one room were supplemented daily with FortiFlora while controls received a placebo. The percentage of cats with diarrhea &gt; 2 days was significantly lower in the probiotic group (7.7% vs 20.7%), suggesting that probiotics may lessen how long cats have diarrhea. Diarrhea prevalence rates were low for all dogs so statistical differences were not detected.<\/span><\/p>\n<\/div>\n<h3 class=\"p1\"><span class=\"s1\"><b>References<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">CPE = Clostridium perfringens enterotoxin; ELISA = enzyme-linked immunosorbent assay; GI = gastrointestinal; HGE = hemorrhagic gastroenteritis; IBD = inflammatory bowel disease; PCR = polymerase chain reaction<\/span><\/p>\n<p class=\"p5\"><span class=\"author-bio\"><strong><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/P.-Jane-Armstrong.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-full wp-image-9234\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/P.-Jane-Armstrong.png\" alt=\"P. Jane Armstrong\" width=\"100\" height=\"133\" \/><\/a>P. Jane Armstrong<\/strong>, DVM, MS, MBA, Diplomate ACVIM (Small Animal Internal Medicine), is a professor in the Department of Veterinary Clinical Sciences at University of Minnesota College of Veterinary Medicine. She is also a member of the World Small Animal Veterinary Association (WSAVA) Liver Standardization Group. Her clinical and research interests include gastrointestinal disease, feline medicine, integrative medicine, clinical nutrition, and canine genetics. Dr. Armstrong is a past president of the American College of Veterinary Internal Medicine (Small Animal) and Comparative Gastroenterology Society and an Editorial Advisory Board member for <em>Today&#8217;s Veterinary Practice<\/em>. She received her DVM from Ontario Veterinary College, University of Guelph; then completed an internship at University of Illinois and residency and Master&#8217;s degree at Michigan State University.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>P.<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":5758,"footnotes":""},"categories":[374],"tags":[13],"class_list":["post-1310","post","type-post","status-publish","format-standard","hentry","category-may-june-2013","tag-peer-reviewed","column-features","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 v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>GI Intervention: Approach to Diagnosis &amp; Therapy of the Patient With Acute Diarrhea | Today&#039;s Veterinary Practice<\/title>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"GI Intervention: Approach to Diagnosis &amp; Therapy of the Patient With Acute Diarrhea\" \/>\n<meta property=\"og:description\" content=\"P.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/\" \/>\n<meta property=\"og:site_name\" content=\"Today&#039;s Veterinary Practice\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/todaysveterinarypractice\" \/>\n<meta property=\"article:published_time\" content=\"2013-05-01T16:20:36+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2022-02-17T19:08:54+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"20 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/\"},\"author\":{\"name\":\"\",\"@id\":\"\"},\"headline\":\"GI Intervention: Approach to Diagnosis &amp; Therapy of the Patient With Acute Diarrhea\",\"datePublished\":\"2013-05-01T16:20:36+00:00\",\"dateModified\":\"2022-02-17T19:08:54+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/\"},\"wordCount\":4087,\"commentCount\":1,\"publisher\":{\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/todaysveterinarypractice.com\\\/wp-content\\\/uploads\\\/sites\\\/4\\\/2011\\\/07\\\/pdf_button.png\",\"keywords\":[\"Peer Reviewed\"],\"articleSection\":[\"May\\\/June 2013\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/#respond\"]}]},{\"@type\":[\"WebPage\",\"MedicalWebPage\"],\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/\",\"url\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/\",\"name\":\"GI Intervention: Approach to Diagnosis &amp; Therapy of the Patient With Acute Diarrhea | Today&#039;s Veterinary Practice\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/#primaryimage\"},\"image\":{\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/todaysveterinarypractice.com\\\/wp-content\\\/uploads\\\/sites\\\/4\\\/2011\\\/07\\\/pdf_button.png\",\"datePublished\":\"2013-05-01T16:20:36+00:00\",\"dateModified\":\"2022-02-17T19:08:54+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/\"]}]},{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/#primaryimage\",\"url\":\"https:\\\/\\\/todaysveterinarypractice.com\\\/wp-content\\\/uploads\\\/sites\\\/4\\\/2011\\\/07\\\/pdf_button.png\",\"contentUrl\":\"https:\\\/\\\/todaysveterinarypractice.com\\\/wp-content\\\/uploads\\\/sites\\\/4\\\/2011\\\/07\\\/pdf_button.png\"},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/gastroenterology\\\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"GI Intervention: Approach to Diagnosis &amp; Therapy of the Patient With Acute Diarrhea\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/#website\",\"url\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/\",\"name\":\"Today's Veterinary Practice\",\"description\":\"Peer-Reviewed Veterinary Journal\",\"publisher\":{\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":\"Organization\",\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/#organization\",\"name\":\"Today's Veterinary Practice\",\"url\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/#\\\/schema\\\/logo\\\/image\\\/\",\"url\":\"https:\\\/\\\/todaysveterinarypractice.com\\\/wp-content\\\/uploads\\\/sites\\\/4\\\/2022\\\/01\\\/tvp-logo.png\",\"contentUrl\":\"https:\\\/\\\/todaysveterinarypractice.com\\\/wp-content\\\/uploads\\\/sites\\\/4\\\/2022\\\/01\\\/tvp-logo.png\",\"width\":179,\"height\":89,\"caption\":\"Today's Veterinary Practice\"},\"image\":{\"@id\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/#\\\/schema\\\/logo\\\/image\\\/\"},\"sameAs\":[\"https:\\\/\\\/www.facebook.com\\\/todaysveterinarypractice\",\"https:\\\/\\\/www.youtube.com\\\/thenavc\"],\"email\":\"info@navc.com\"},{\"@type\":\"Person\",\"@id\":\"\",\"url\":\"https:\\\/\\\/navc.sitepreview.app\\\/todaysveterinarypractice.com\\\/author\\\/\"}]}<\/script>\n<!-- \/ Yoast SEO Premium plugin. -->","yoast_head_json":{"title":"GI Intervention: Approach to Diagnosis &amp; Therapy of the Patient With Acute Diarrhea | Today&#039;s Veterinary Practice","robots":{"index":"noindex","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"og_locale":"en_US","og_type":"article","og_title":"GI Intervention: Approach to Diagnosis &amp; Therapy of the Patient With Acute Diarrhea","og_description":"P.","og_url":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/","og_site_name":"Today&#039;s Veterinary Practice","article_publisher":"https:\/\/www.facebook.com\/todaysveterinarypractice","article_published_time":"2013-05-01T16:20:36+00:00","article_modified_time":"2022-02-17T19:08:54+00:00","og_image":[{"url":"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png","type":"","width":"","height":""}],"twitter_card":"summary_large_image","twitter_misc":{"Written by":"","Est. reading time":"20 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"Article","@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/#article","isPartOf":{"@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/"},"author":{"name":"","@id":""},"headline":"GI Intervention: Approach to Diagnosis &amp; Therapy of the Patient With Acute Diarrhea","datePublished":"2013-05-01T16:20:36+00:00","dateModified":"2022-02-17T19:08:54+00:00","mainEntityOfPage":{"@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/"},"wordCount":4087,"commentCount":1,"publisher":{"@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/#organization"},"image":{"@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/#primaryimage"},"thumbnailUrl":"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png","keywords":["Peer Reviewed"],"articleSection":["May\/June 2013"],"inLanguage":"en-US","potentialAction":[{"@type":"CommentAction","name":"Comment","target":["https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/#respond"]}]},{"@type":["WebPage","MedicalWebPage"],"@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/","url":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/","name":"GI Intervention: Approach to Diagnosis &amp; Therapy of the Patient With Acute Diarrhea | Today&#039;s Veterinary Practice","isPartOf":{"@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/#website"},"primaryImageOfPage":{"@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/#primaryimage"},"image":{"@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/#primaryimage"},"thumbnailUrl":"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png","datePublished":"2013-05-01T16:20:36+00:00","dateModified":"2022-02-17T19:08:54+00:00","breadcrumb":{"@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/"]}]},{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/#primaryimage","url":"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png","contentUrl":"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png"},{"@type":"BreadcrumbList","@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-and-therapy-of-the-patient-with-acute-diarrhea\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/"},{"@type":"ListItem","position":2,"name":"GI Intervention: Approach to Diagnosis &amp; Therapy of the Patient With Acute Diarrhea"}]},{"@type":"WebSite","@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/#website","url":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/","name":"Today's Veterinary Practice","description":"Peer-Reviewed Veterinary Journal","publisher":{"@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/#organization"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"},{"@type":"Organization","@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/#organization","name":"Today's Veterinary Practice","url":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/","logo":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/#\/schema\/logo\/image\/","url":"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2022\/01\/tvp-logo.png","contentUrl":"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2022\/01\/tvp-logo.png","width":179,"height":89,"caption":"Today's Veterinary Practice"},"image":{"@id":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/#\/schema\/logo\/image\/"},"sameAs":["https:\/\/www.facebook.com\/todaysveterinarypractice","https:\/\/www.youtube.com\/thenavc"],"email":"info@navc.com"},{"@type":"Person","@id":"","url":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/author\/"}]}},"_links":{"self":[{"href":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-json\/wp\/v2\/posts\/1310","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-json\/wp\/v2\/comments?post=1310"}],"version-history":[{"count":1,"href":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-json\/wp\/v2\/posts\/1310\/revisions"}],"predecessor-version":[{"id":28258,"href":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-json\/wp\/v2\/posts\/1310\/revisions\/28258"}],"wp:attachment":[{"href":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-json\/wp\/v2\/media?parent=1310"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-json\/wp\/v2\/categories?post=1310"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-json\/wp\/v2\/tags?post=1310"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}