HISTORY / CLINICAL SIGNS: 4 month Hx of progressive weight loss, inappetance, chronic vomiting, occasional diarrhea (large volume of soft stool). UTD on vaccines. Receives flea/HW preventive monthly. Diet: commercial wet and dry kibble.
PHYSICAL EXAM FINDINGS: BCS 4/9. BAR. mm pink/moist. CRT <2sec. Generalized skin seborrhea (no evidence of dermatitis). Grade 2/6 apical heart murmur. Bronchovesicular sounds normal. Abdomen non-painful. Mild generalized hepatomegaly. Bowel loops slightly distended/ fluid-filled. Moderate brown waxy discharge AU. Moderate periodontal disease.
What is on your differential diagnosis list? What diagnostic tests would you order? Any other questions?
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DIAGNOSTIC TESTS & RESULTS: (worked up systematically over several weeks)
- Bloodwork (initial): Eosinophils 1.12 (0-1X10^9/L). TP 8.3 (5.4-8.2g/dL). ALT 282 (20-100U/L). ALP 71 (10-90U/L). TBil 0.7 (0.1-0.6mg/dL). K 3.5 (3.7-5.8mmol/L). Otherwise, within reference range.
- T4: normal
- fPLI: negative
- FeLV/FIV/HW SNAP Test: negative
- Urinalysis: unremarkable
- Fecal float: NOPS
- Abdominal ultrasound: Multiple small hypoechoic liver nodules. Hypoechoic nodule (1.5cm) off the SI (most likely a mesenteric lymph node). SI wall layers unremarkable (no significant thickening or loss of layers). Stomach unremarkable.
- Ear cytology: moderate yeast AU
TOP 3 DIFFERENTIALS: Inflammatory Bowel Disease (IBD). Intestinal Lymphoma. Primary Liver Disease (Cholangiohepatitis, Hepatic Neoplasia, etc.).
Based on this patientโs signalment, clinical signs, physical exam findings, and test results, what is your diagnosis, recommended treatment, and prognostic outlook?
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PRESUMPTIVE DIAGNOSIS: Inflammatory Bowel Disease (IBD)
Inflammatory bowel disease is a syndrome of inflammation of the GI tract, primarily the small intestines and/or stomach. The cause is not always known and may be autoimmune in some cases, though infection and food allergy can trigger irritation in others. IBD can look similar to intestinal lymphoma, with the patient exhibiting similar signs of weight loss, poor appetite, & GI upset. A full-thickness intestinal biopsy is the gold standard to differentiate the two. However, in this case, the SI wall layers appeared normal on u/s, more suggestive of early/mild IBD than lymphoma (though IBD can certainly also cause thickening of the SI wall). Therefore, abdominal exploratory surgery or endoscopy with intestinal biopsy and intra-abdominal LN aspirate were declined, so IBD is a presumptive diagnosis of exclusion. The fact that the patient improved so well on the Tx described below is another indication that this disease is IBD.
TREATMENT: Denamarin โข (SAMe + silybin) X 1 mo. Amoxicillin X 2 wk. Prednisolone (anti-inflammatory dose) – ongoing. Royal Caninยฎ Hydrolyzed Protein diet – ongoing. The ears were also cleaned & treated with a topical antifungal. (Note: Chronic ear infections are common in patients with food allergies, which is thought to be the culprit behind this patientโs IBD.)
PROGNOSIS: This patient has improved very well over the past 2 years with ongoing medical therapy, eating well and gaining weight while only experiencing a rare vomit/diarrhea episode if he eats something he shouldnโt. Bloodwork results steadily improved until all values were within normal limits. Due to the chronic use of prednisolone, the patient is regularly rechecked to ensure that diabetes mellitus or iatrogenic hyperadrenocorticism does not occur. Since this patient improved while on the current treatments, the presumptive diagnosis of IBD is all the more likely.
Any other questions, comments, or suggestions?
Unless otherwise stated, these clinical cases are real-life cases that I have managed as a veterinarian in general small animal veterinary practice or else assisted with as a student in vet school. These cases are a great real-world learning tool for vet students and other veterinary professionals. They shall be used for learning purposes and collaboration of knowledge only. These cases are not intended to diagnose or treat any disease by pet owners. – Maranda Elswick, DVM
