Expert: Jana Connell RVT, CVT - 5/28/2009

Question
We live in the Chicago area of IL. Harley currently weighs 61 lbs (dropped from 65 lbs in January 2009) is a male and is neutered.  We feed Harley 1 1/2 cups of Natures Choice Venison and Rice food twice per day (morning around 6:00 am and evening around 4:00 pm).  His water consumption appears to be normal.  Harley is given Heartgard plus and Frontline plus the first of every month.

We got Harley from a rescue in January 2009 and he has suffered from diarrhea off and on since we rescued him and I recently learned that the foster home told the rescue center that they had the same issue.  Over the last several days, Harley has developed pudding-like diarrhea with occasional mucus inside and he has been vomiting a couple of times at night.

Here is what we have done:

Early January 2009:  Took him in for an overall exam, including fecal test. Everything came back normal.

Feb. 2009:  Diarrhea returned (no mucus).  He was at a "dog camp" and the staff noticed that Harley had diarrhea with what appeared to be blood in the stool.  Took Harley back to the vet.  Once again, no parasites found and the vet said he seems to be healthy,  but vet said could have had them and now passed through his system...no obvious issues.  Fortiflora was prescribed for 10 days.  This took care of his diarrhea.

March 2009:  The diarrhea returned (no mucus) along with him be a little lethargic.  Took Harley back to vet along with a stool sample to check for parasites.  No parasites found,  Gave him 30 days worth of Fortiflora and 10 days of Metronidazole (500 mg) to be given twice per day.  He was fine.

May 24 2009 to current:  Once again, Harley has pudding-like diarrhea this time with a little mucus.  Additionally, he has been thrown up in the middle of the night on 5/26 and twice on 5/27 around 10:30 pm and once around 3:00 am on 5/27.  I called the vet again on 5/26 early am and the tech advised us to not give Harley anything to eat for 12 hours, which we did, and to give him about 1/2 cup of food mixed wit about 1 cup of cooked white rice a few times per day which we did.  Again, he does not appear to be dehydrated (drinks normally....not too little and not excessive), but he was trying to "cool down" by going under our walk out deck, digging up the stones and laying on the cool dirt and he was a bit more lethargic on 5/25 and 5/26.  On 5/27 the lethargic behavior disappeared, but still has diarrhea and vomiting.

Finally my question:  Harley is a great, wonderful dog and we want him to get better.  Should I take Harley to a different vet?  If so, Is there a "specialty" vet I should be seeking out?

Thank you in advance for your reply.
Cindy  

Answer
There are many issues that Harley could be facing here. He has been treated for the parasite problem so we will skip that. The Metronidazole would have kicked any giardia but not coccidia, however that would have shown up on a fecal exam.

So we need to dig deeper.First it could be the food. While it's true that he is on a novel protein diet, he might have issues with the venison or the fact that this food is not consistently formulated.

Another issue here is the mucous that he had. That is a sign of a malabsorption problem.
The pudding like diarrhea is also a sign of this.

What this dog needs is an intestinal biopsy and a trial on a food that is totally hypoallergenic, such as Z/D.

I would do the food trials first, and then the biopsy. He could have protein losing enteropathy, or PLE.

Here are some articles about this problem:
First, Chronic Diarrhea:

Overview

Diarrhea is defined as the rapid movement of fecal matter through the intestine resulting in poor absorption of water, nutrients and electrolytes. With diarrhea the stools (bowel movements) become loose or runny. Chronic diarrhea refers to diarrhea that persists for three or more weeks. Occasionally the fecal material may contain fresh blood or mucus.

Chronic diarrhea is an important sign of intestinal disease in the dog. Persistent diarrhea can lead to weight loss from poor digestion and loss of important nutrients. Chronic diarrhea can lead to loss of body condition, development of a poor hair coat, and may also affect appetite and activity levels.

General Causes

Most causes of chronic diarrhea induce local irritation or structural abnormalities of the intestinal mucosa (lining). There are numerous diseases and disorders that can lead to chronic diarrhea. These include:

# Infectious agents such as bacterial infections, protozoal agents, fungal infections, and intestinal parasites
# Certain drugs and toxins
# Inflammatory bowel disease, e.g. enteritis (inflammation of the small bowel) and colitis (inflammation of the large bowel)
# Dietary intolerance or food allergy
# Gastrointestinal cancer
# Partial obstruction (blockage) of the intestinal tract
# Other systemic illnesses, such as liver disease, pancreatic diseases, kidney disease, etc.
# Small intestinal bacterial overgrowth (SIBO)
# Lymphangiectasia, and other disorders of malabsorption (inability to absorb food stuffs or cause proteins and other materials to be lost in the feces)
# Disorders of maldigestion (inability to digest food stuffs in the intestine)
# Short bowel syndrome
# Irritable bowel syndrome (spastic colon)

What to Watch For

# Passage of loose, watery stools that persist for more than three weeks
# A change in color of the stool
# Blood in the stool
# Mucus in the stool
# Straining to defecate
# Increased number of stools
# Decreased appetite
# Weight loss
# Poor hair coat
# Lethargy

Overview


Diagnosis

Veterinary care includes diagnostic tests to help determine the underlying cause of the diarrhea and to guide subsequent treatment recommendations. Some of the following tests may be necessary to diagnose the cause of chronic diarrhea:

# A complete medical history and physical examination

# Multiple fecal studies (flotation, smear and cytology, zinc sulfate test) to search for intestinal parasites, protozoal parasites, and bacteria

# A complete blood count (CBC)

# A biochemical profile

# A urinalysis to help evaluate the kidneys and level of hydration

# Abdominal radiographs (X-rays)

# Thoracic (chest) radiographs, particularly in geriatric patients and animals who are suspected to have cancer

# Bacterial fecal cultures

# Tests for absorption and digestion problems, such as serum trypsin-like immunoreactivity (TLI), serum folate and cobalamin levels

# Serologic tests for certain fungal diseases

Depending upon the clinical signs and the results of the above tests, your veterinarian may recommend further testing. These tests are chosen on a case-by-case basis:

# Abdominal ultrasonography

# An upper gastrointestinal (GI) barium series to help diagnose foreign bodies, partial obstructions, masses, thickening or displacement of bowel, etc.

# Barium enema if colonic disease is suspected

# Endoscopic examination and biopsy of the stomach, small intestine, and/or colon

# Serum bile acids for suspected liver disease

# A blood lead level test

# Exploratory abdominal surgery (laparotomy) if other diagnostic tests are inconclusive, or if a disease is suspected that requires corrective surgery

Treatment

Symptomatic or empirical treatment may be tried in some cases of chronic diarrhea, especially if initial diagnostic tests are inconclusive and the animal is feeling well and relatively stable. Empiric treatment does not replace the need to define the exact cause of the chronic diarrhea, it at all possible. Empirical treatment may include one or more of the following:

# Deworming for whipworms, which may not show up on routine fecal tests

# Short course of antibiotics for clostridial bacteria

# Changing the diet to a high-fiber diet if large bowel diarrhea is present or to a hypoallergenic diet if small bowel diarrhea is present

Supportive therapy for ill, malnourished and unstable patients may involve hospitalization with intravenous fluids, supplemental nutrition and vitamins, intestinal protectants and adsorbents, etc.

Specific therapy of most cases of chronic diarrhea depends upon reaching a definitive diagnosis as to the cause, and then instituting therapy for that cause. Such therapy varies widely and can involve medications, dietary changes and surgery.

Home Care

It is important to monitor your pet closely if he/she has chronic diarrhea. Pay particular attention to stool volume and character, the frequency of defecation, and any straining to defecate. Note the presence of any blood or mucus in the stool. Also monitor the dog's body weight, appetite and activity level. Administer all prescribed medications exactly as ordered by your veterinarian. Notify your veterinarian if you have any problems medicating your pet.

Information In-depth

Chronic diarrhea in a pet can be frustrating to care for and to resolve. When chronic diarrhea is associated with vomiting, lack of water intake, fever, depression, or other symptoms, it often indicates that your pet has a potentially serious underlying disease. Such signs should prompt an immediate visit to your veterinarian.

Causes

There are numerous diseases and disorders that can lead to chronic diarrhea., and they include:

# Infectious diseases can cause chronic diarrhea in any age and breed of dog, and include a variety of agents, such as the following:

Intestinal parasites, such as whipworms, roundworms, hookworms, and tapeworms

Bacteria, including Salmonella, Clostridium, Campylobacter, Yersinia

Fungal agents, such as histoplasmosis, aspergillosis, phycomycosis, candidiasis

Protozoal parasites, such as giardiasis and coccidiosis

Infection with blue-green algae, namely protothecosis

# Inflammatory bowel disease is a microscopic infiltration of the intestinal wall with inflammatory cells. The cause is unknown, although it is suspected to have an immune basis. It may affect the small intestines, large intestines, or both. Vomiting and weight loss are common but do not always accompany the diarrhea.
       
# Dietary intolerance or allergy is most often attributed to a particular protein in the diet, but can be associated with gluten, lactose, high fat content, and certain food additives. It can develop slowly, over weeks or months and cause chronic diarrhea.

# Drugs and toxins are more often associated with acute diarrhea; however chronic diarrhea may occur following the administration of certain antibiotics, nonsteroidal anti-inflammatory drugs, certain supplements, etc.

# Gastrointestinal cancer can cause chronic diarrhea by either destroying part of the intestinal walls or by causing a partial blockage of the intestine. The most common tumors seen are lymphosarcoma and adenocarcinoma.

# Partial obstruction or blockage may develop with cancer, ingestion of foreign bodies, intussusception (telescoping of the bowel into itself), cecal inversion, or stricture of the intestines.

# Metabolic disorders including kidney and liver disease, diabetes mellitus, and hypoadrenocorticism, are often associated with systemic signs of illness (e.g. vomiting, weight loss, chronic diarrhea, etc.).

# Pancreatic disease, especially exocrine pancreatic insufficiency (EPI) gives rise to chronic diarrhea because there is inadequate production of digestive enzymes.

# Small intestinal bacterial overgrowth (SIBO) is characterized by an overgrowth of normal intestinal flora (bacteria) usually secondary to other gastrointestinal diseases, but occasionally from chronic administration of antibiotics and other medications.

# Many diseases can cause malabsorption of food stuffs or poor digestion of food stuffs in the intestines, and subsequently chronic diarrhea. Malabsorption/maldigestion problems include lymphangiectasia (abnormality of lymph vessels of the intestines), inactivation or lack of digestive enzymes, inadequate supply of bile salts, severe inflammation of the lining of the intestines, inability to absorb sugars or proteins across the intestinal wall, etc.

# Short bowel syndrome is created after a large portion of the intestinal tract is removed surgically. The remaining bowel is too short to provide an adequate surface for digesting and absorbing nutrients.

# Irritable bowel syndrome (spastic colon) is a chronic, intermittent dysfunction of the lower bowel for reasons not entirely understood. This condition may be aggravated by stress.

An endoscope - a flexible tube - can be used to examine the stomach, intestines and colon. The patient is anesthetized for this procedure. An endoscope - a flexible tube - can be used to examine the stomach, intestines and colon. The patient is anesthetized for this procedure.
A biopsy sample of tissue can be obtained through the endoscope. A biopsy sample of tissue can be obtained through the endoscope.

Veterinary Care In-depth

Veterinary care includes diagnostic tests and subsequent treatment recommendations. Some, if not all, of the following tests may be necessary to diagnose the cause of chronic diarrhea:

# Complete medical history and physical examination are helpful in instituting an appropriate diagnostic plan.

# Multiple fecal studies (flotation, smear and cytology, zinc sulfate test) to search for intestinal parasites, protozoal parasites, and bacteria should be performed on all patients with chronic diarrhea.

# A complete blood count (CBC) evaluates the animal for infection, inflammation and anemia.

# A biochemical profile assesses kidney, liver, and pancreas function, as well as electrolyte status, protein levels, blood sugar, etc.

# A urinalysis helps to evaluate kidney function and the level of hydration of the animal.

# Abdominal radiographs (X-rays) assess the abdominal organs and may detect the presence of a foreign body, obstruction, or tumor.

# Thoracic (chest) radiographs are recommended in geriatric patients and animals who may have cancer, to detect metastasis (spread of cancer) to the lungs.

# Bacterial fecal cultures may be recommended in some cases.

# Serologic tests may be performed for fungal diseases that cause chronic diarrhea.

# Serum trypsin-like immunoreactivity (TLI) , serum folate, and cobalamin are blood tests that help assess digestion and absorption within the small intestines.

Depending upon the clinical signs and the results of the above tests, your veterinarian may recommend further testing. These tests are chosen on a case-by-case basis:

# Abdominal ultrasonography helps to evaluate the size, shape and consistency of the abdominal organs. It may detect thickening of the intestines, masses, partial obstructions and other organ abnormalities. Abnormal organs, lymph nodes and masses may be sampled with a needle or biopsy instrument with the guidance of ultrasound. This test may require referral of your animal to a veterinary specialist in internal medicine or radiology.

# An upper gastrointestinal (GI) barium series helps assess the passage of food stuffs through the upper intestine. A barium enema helps assess the lining of the lower bowel. The two tests may detect motility disorders, thickening of the bowel, twisting or displacement of the bowel, obstructions, strictures and masses of the intestines. They may also be helpful to detect foreign bodies that are not seen on plain radiographs.

# Endoscopic examination and biopsy are often required for diagnosing the cause of chronic diarrhea. Endoscopy involves passage of a flexible viewing scope into the stomach and small intestines. Colonoscopy involves passage of either a flexible or rigid scope into the rectum and colon. Small biopsies, as well as samples for cytology and culture are obtained through the scope

# A blood lead level may be performed on any dog with chronic intestinal signs, especially if their environment is suggestive of exposure to lead, if there is material showing up on plain x-rays that resembles lead in the intestines, or if certain characteristic changes of lead poisoning are seen on the complete blood count.

# Serum bile acid tests may be performed in animals with evidence of liver disease.

# Exploratory abdominal surgery (laparotomy) is often considered if other diagnostic tests are inconclusive, or if a disease is suspected that requires corrective surgery. It is sometimes needed to reach a conclusive diagnosis.

Veterinary Care In-depth


Treatment In-depth

Symptomatic Treatment

Symptomatic or empirical treatment may be tried in some cases of chronic diarrhea, especially if initial diagnostic tests are inconclusive and the animal is feeling well and relatively stable. Empirical treatment does not replace the need to define the exact cause of the chronic diarrhea, it at all possible. Empirical treatment may include one or more of the following:

# Deworming for whipworms, which may not show up on routine fecal tests

# Short course of antibiotics for suspected clostridial bacteria

# Changing the diet to a high-fiber diet if large bowel diarrhea is present or to a hypoallergenic diet if small bowel diarrhea is present

Supportive Therapy

# Supportive therapy for ill, malnourished and unstable patients may involve hospitalization with intravenous fluids, and supplemental nutrition and vitamins.

# Plasma transfusions and infusion of other dense fluids may be required for animals with low protein levels.

# Intestinal protectants, adsorbents, and antacids may be administered while results of diagnostic tests are pending, etc.

# Motility modifiers (medications that effect the movement of food through the intestinal tract) may be tried in some cases.

Specific Treatments

Specific therapy of most cases of chronic diarrhea depends upon reaching a definitive diagnosis as to the cause, and then instituting therapy for that cause. Such therapy varies widely and can involve medications, dietary changes and surgery:

# Deworming agents are required for intestinal parasites.

# Products used for protozoal parasites include sulfa drugs for coccidiosis and metronidazole for giardiasis.

# Antibiotics are administered for bacterial infections, small intestinal bacterial overgrowth, and some forms of colitis.

# Antifungal drugs (e.g. ketoconazole, itraconazole) are given for fungal infections and may be tried for protothecosis.

# Corticosteroids and dietary manipulation may be necessary for inflammatory bowel disease, lymphangiectasia, and other immune-mediated inflammatory disorders.

# Dietary manipulation is helpful in cases of dietary intolerance, food allergy, colitis, short bowel syndrome, and irritable bowel syndrome.

# Chemotherapy, radiation therapy or surgery may be helpful in certain cases of cancer.

# Surgical exploratory is indicated to correct causes of chronic obstruction, intussusception, cecal inversion, remove foreign bodies, etc.

# Intravenous fluid therapy and specific treatments for any liver and kidney disorders may be indicated.

# Pancreatic enzyme replacement therapy is necessary in documented cases of exocrine pancreatic insufficiency.

# Motility modifiers (medications that effect he movement of food through the intestinal tract) may be helpful in cases of irritable bowel syndrome.

# Supplementation with cobalamin, folate and other vitamins is often required in the malabsorption/maldigestion diseases.

# If lead poisoning is diagnosed antidotes may be started either orally or by injection.

Home Care

Keep in mind that the resolution of chronic diarrhea is usually gradual with treatment. In a few cases, despite a correct diagnosis and proper therapy, diarrhea may not completely resolve or may worsen, especially in patients with cancer.

It is important to monitor your pet closely if he has chronic diarrhea. Pay particular attention to stool volume and character, the frequency of defecation, and any straining to defecate. Note the presence of any blood or mucus in the stool. Also monitor the dog's body weight, appetite and activity level.

Administer all prescribed medications exactly as ordered by your veterinarian. Notify your veterinarian if you have any problems medicating your pet.

Repeated follow-up examinations, fecal tests and blood tests may be needed to bring the chronic diarrhea under control and prevent it from returning.


-------------------------------------

And then
Protein losing enteropathy (PLE):

Overview

Protein losing enteropathy (PLE) is a nonspecific term referring to conditions associated with excessive loss of plasma proteins into the gastrointestinal tract. There are numerous causes including:

Disorders of lymphatic system

# Intestinal lymphangiectasia, or blockage of the lymphatics of the gastrointestinal tract
# Cancer
# Congestive heart failure
# Granuloma (a non-cancerous mass of tissue) of the small intestines or the tissue that attaches abdominal organs to the body wall

Diseases associated with increased mucosal permeability, which is the passage of fluid through tissue

# Lymphoplasmacytic enteritis, a type of inflammatory bowel disorder
# Intestinal cancer
# Intussusception, which is telescoping of one part of the bowel into an adjoining segment
# Chronic intestinal foreign body
# Ulcerative gastroenteritis
# Histoplasmosis (fungal infection)
# Intestinal parasitism
# Immune-mediated diseases
# Hemorrhagic gastroenteritis (HGE) is a disorder with no known cause. It has a predilection for small breed dogs, and it is not recognized in cats. HGE is characterized by the sudden onset of profuse bloody diarrhea and occasional vomiting

PLE is seen in both dogs and cats. PLE can be seen in any age animal and equally in both genders. Although PLE affects all breeds, dogs with familial predisposition to lymphangiectasia (the most common cause of PLE) include soft-coated Wheaten terriers, basenjis, Lundehunds and Yorkshire terriers.

Although some patients may be asymptomatic (have no clinical signs), some may have life threatening manifestations of PLE.

What to Watch For

# Diarrhea
# Anorexia
# Lethargy
# Weight loss
# Ascities (fluid in the abdominal cavity)
# Edema (abnormal fluid accumulation in any part of the body)
# Respiratory difficulty secondary to fluid in the chest cavity

Diagnosis

# Complete blood cell count (CBC)
# Biochemical profile
# Urinalysis
# Fecal examinations
# Chest and abdominal X-rays
# Abdominal ultrasound
# Gastroduodenoscopy

Treatment

Treatment of patients with PLE should be directed at the underlying cause. Most of these individuals can be treated as outpatients.

# Dietary management is often recommended and varies depending on the underlying cause.

# MCT oil is a source of calories that is well tolerated by patients with PLE that may be indicated in patients who are severely emaciated.

# Fluid therapy may be necessary in some patients with severe vomiting and diarrhea, and is directed toward correction of dehydration and acid-base derangements, replacement of electrolyte deficits and to provide for ongoing losses.

# Diuretics that help remove excess fluid from the body may be indicated in some patients with PLE.

# Oncotic agents help maintain normal fluid distribution in the body.

# Antibiotic therapy, anti-inflammatory drugs, and/or antifungal agents may be indicated depending on the underlying cause of PLE.

Home Care and Prevention

Administer all medication and dietary recommendations as directed by your veterinarian. Follow up as directed.

If your pet's condition is not improving and is getting worse, seek veterinary attention at once. There is no preventative care for protein losing enteropathy.

Information In-depth

The term protein losing enteropathy (PLE) refers to a variety of intestinal diseases that are associated with hypoproteinemia (low protein levels) caused by an excessive loss of protein into the gut. It is important to note that the initial step in the diagnosis is to exclude non-intestinal causes of hypoproteinemia, specifically related to the liver or kidneys.

Many different disease processes can cause or are associated with PLE. The clinical signs seen are quite varied, ranging from mild non-specific intermittent signs, to profound weight loss, emaciation, and in some cases, life-threatening respiratory difficulty secondary to fluid accumulation in the chest cavity. Many disorders must be considered initially.

Liver Disease

Severe hepatic disease must be ruled out as a contributing cause of hypoproteinemia. These include:

# Hepatitis (inflammation of the liver)
# Cancer
# Cirrhosis

Kidney Disease

Protein losing kidney disorders need to be considered in hypoproteinemic patients. These include:

# Glomerulonephritis, an type of kidney inflammation involving the glomeruli, which are a mass of capillaries

# Amyloidosis, the deposition or collection of a type of protein in organs and tissues that compromises their normal function

Lymphatic Diseases

Disorders of the lymphatic system need to be considered. These include:

# Intestinal lymphangiectasia – blockage of the lymphatics of the gastrointestinal tract – is one of the most common causes of PLE.

# Cancer of any sort must be ruled out. Lymphosarcoma is a malignant cancer that is the most common cancer causing PLE. It most often takes the form of a microscopic infiltration into the bowel, although it may form mass lesions.

# Granuloma, a non-cancerous mass of tissue, of the small intestines or tissue that attaches abdominal organs to the body wall may be associated with profound protein loss.

# Congestive heart failure may be associated with hypoproteinemia. Constrictive pericarditis is a condition where the tissue covering the heart cannot expand for a variety of reasons.

Gastrointestinal Diseases

Diseases associated with increased permeability of mucosa commonly cause PLE. These include:

# Lymphoplasmacytic enteritis is a form of inflammatory bowel disease characterized by the infiltration of cells into the intestinal wall, causing a disruption of normal intestinal function and protein loss.

# Intestinal cancer of any kind may cause or contribute to protein loss in the gut.

# An intussusception, especially chronic, will often be associated with protein loss. This is a telescoping of part of the bowel into an immediately adjacent segment of bowel, and is most often associated with the presence of inflammation, foreign bodies, parasites or tumors.

# Chronic foreign bodies of the intestinal tract are often associated with a number of gastrointestinal signs including diarrhea, vomiting and weight loss, and occasionally hypoproteinemia.

# Ulcerative gastroenteritis is an inflammation of the lining of the gastrointestinal tract and is often associated with hypoproteinemia. It may be secondary to inflammation, drug administration, cancer or foreign bodies.

# Small intestinal bacterial overgrowth (SIBO) is characterized by an overgrowth of normal intestinal bacteria usually secondary to various gastrointestinal diseases, but occasionally as a primary entity.

# Histoplasmosis is a fungal infection that affects many systems, including the gastrointestinal tract. It has been associated with profound hypoproteinemia.

# Intestinal parasitism has been associated with PLE, especially in young puppies that are anemic as well.

# Roundworms, hookworms, whipworms, coccidia and giardia.

# Hemorrhagic gastroenteritis (HGE) is a dramatic, potentially fatal disorder with no known cause. It has a predilection for small breed dogs, and it is not recognized in cats. HGE is characterized by the sudden onset of profuse bloody diarrhea and occasional vomiting.

# Immune-mediated intestinal diseases may cause PLE.

# Food allergies and gluten-induced diseases of the intestines, which are a sensitivity to a component of wheat and other grains.

Miscellaneous

# Blood loss for any reason will decrease the protein level.

# Inadequate protein intake will contribute to hypoproteinemia.

Veterinary Care In-depth

Diagnosis In-depth

Certain diagnostic tests must be performed to make a definitive diagnosis of the underlying disorder and to exclude other disease processes that may cause similar symptoms. A complete history, description of clinical signs, and thorough physical examination are all an important part of obtaining a diagnosis. In addition, the following tests are recommended to confirm a diagnosis:

# A complete blood count (CBC) may be within normal limits but may reveal anemia (low red blood cell count), and in cases of lymphangiectasia, a decreased lymphocyte (type of white blood cell) count.

# A biochemical profile can help evaluate the kidney, liver, protein, and electrolyte status. Hypoproteinemia is the hallmark of this group of diseases. Hypocalcemia (low calcium) is often seen secondary to low protein levels. Additionally, in cases of lymphangiectasia, hypocholesterolemia (decreased cholesterol) is common.

# A urinalysis is most often within normal limits, and is helpful in ruling out protein loss associated with kidney disease. If there is any suspicion of kidney related protein loss, a urine protein:creatinine ratio should be evaluated. It is a simple test that can be performed on the urine.

# Fecal examinations should be performed to rule out parasitism. Chest and abdominal X-rays, although often within normal limits, may be of benefit in ruling out other disorders.

# Abdominal ultrasound may be indicated if the previous diagnostics have been inconclusive. It helps to evaluate the size, shape and integrity of the abdominal organs, and is especially helpful in evaluating for an intussusception or pancreatitis. It is a non-invasive procedure, although it may require a referral facility.

# An upper gastrointestinal (GI) barium series may be considered to help rule out foreign bodies that can be seen on X-ray and other causes of intestinal blockage. It also helps evaluate for intestinal ulcers, and can assess intestinal wall thickness. A safe dye is given to the pet by mouth and is watched as it travels through the GI tract. It is non-invasive and most often able to be performed by your veterinarian, although sometimes it may necessitate a referral facility.

# Gastroduodenoscopy is often indicated. This test allows direct visualization of the stomach and the duodenum by means of an endoscope that is passed through the mouth and esophagus into the stomach. With this procedure, biopsies can be obtained without an abdominal incision and submitted for microscopic evaluation. General anesthesia is necessary, but endoscopy is considered a relatively low risk procedure. It most often necessitates the expertise of a specialist and specialized instrumentation.

Your veterinarian may require additional tests to insure optimal medical care. These are selected on a case by case basis:

# Serum folate and cobalamin are blood tests, which generally increase and decrease respectively, in those cases with small intestinal bacterial overgrowth (SIBO).

# Cytologic examination of feces and the rectal tissue may reveal histoplasmosis.

# Cardiac ultrasound may be performed in those patients where heart disease is felt to play a part in the hypoproteinemia.

# Laparotomy, which is an incision into the abdominal, allows surgical biopsies of intestines, lymph nodes, and other organs to be obtained. Laparotomy is not recommended unless all prior procedures are inconclusive, and/or the patient is not responding well to appropriate therapy. There are moderate risks associated with doing surgery on hypoproteinemic animals, and should be performed only if absolutely necessary.

Therapy In-depth

Appropriate therapy for protein losing enteropathy is largely dependent on the underlying cause, and varies according to the type and severity of clinical illness. Depending on the severity of clinical signs and/or stage of disease, hospitalization may or may not be recommended. Patients who have severe vomiting and/or diarrhea, dehydration, or hypoproteinemia and associated inappropriate fluid accumulation are hospitalized for aggressive treatment and stabilization. Stable patients can be treated as outpatients as long as they are monitored closely for response to therapy. With appropriate therapy, many patients do quite well. It is important that all recommendations by your veterinarian are followed very closely, and any questions or concerns that arise during treatment are addressed immediately.

# Dietary management is often recommended and varies on the underlying cause. For lymphangiectasia, low fat diets are recommended. For gluten-induced enteropathy, diets with no gluten (wheat, grains) are recommended. For immune-mediated inflammatory bowel disease, easily digestible and/or non-allergenic diets are recommended. For lymphoplasmacytic enteritis, easily digestible and/or non-allergenic diets are recommended.

# MCT oil is a source of calories that is well tolerated by patients with PLE (specifically, lymphangiectasia) that may be indicated in patients who are severely emaciated.

# Fluid therapy may be necessary in some patients with severe vomiting and/or diarrhea, and is directed toward correction of dehydration and acid-base derangements, replacement of electrolyte deficits, and to provide for ongoing losses.

# Diuretics to help remove excess fluid from the body may be indicated in some patients with PLE.

# Oncotic agents (plasma, dextran, hetastarch) are products that help maintain normal fluid distribution in the body.

# Antibiotic therapy, anti-inflammatory drugs, and/or antifungal agents may be indicated depending on the underlying cause.

Follow-up

Optimal treatment for your pet requires a combination of home and professional veterinary care. Follow-up can be critical, especially if your pet does not rapidly improve. Administer all prescribed medication as directed. Alert your veterinarian if you are experiencing problems treating your pet.

Observe your pet's general activity level, body weight, appetite and evidence of return of clinical signs such as the accumulation of fluid in the chest (pleural effusion), accumulation of fluid in the abdomen (ascities), and accumulation of fluid under the skin (edema). Follow serum protein level as directed by your veterinarian.

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So that is what I suggest Cindy.It's been long enough that he has been treated for the usual things that cause diarrhea. So start with the food trials and then progress to the more expensive and invasive ones.

I hope you find the answer soon and with less expense. Please let me know how it goes with Harley.