UCD Veterinary Hospital



3200400-456565Tel: (01) 716 6000/2 Mon – Fri 09.00 - 17.00 hrsOOH Tel: (01) 716 6001 Mon – Fri 17.00 – 09.00 hrs Saturday and Sunday all dayThis is strictly for EMERGENCIESFax: (01) 716 6005Email: vethospital@ucd.ieWeb: ucd.ie/vthweb00Tel: (01) 716 6000/2 Mon – Fri 09.00 - 17.00 hrsOOH Tel: (01) 716 6001 Mon – Fri 17.00 – 09.00 hrs Saturday and Sunday all dayThis is strictly for EMERGENCIESFax: (01) 716 6005Email: vethospital@ucd.ieWeb: ucd.ie/vthweb457200-456565UCD Veterinary HospitalUniversity College DublinBelfield, Dublin 4, IrelandOspidéal Tréidliachta UCDAn Coláiste Ollscoile Baile ?tha Cliath,Belfield, Baile ?tha Cliath 4, EireTel: (01) 716 6000/2 Fax: (01) 716 6005 Email: uvh@ucd.ie00UCD Veterinary HospitalUniversity College DublinBelfield, Dublin 4, IrelandOspidéal Tréidliachta UCDAn Coláiste Ollscoile Baile ?tha Cliath,Belfield, Baile ?tha Cliath 4, EireTel: (01) 716 6000/2 Fax: (01) 716 6005 Email: uvh@ucd.ie-374650-28702000 UCDVH SMALL ANIMAL MEDICINE SERVICEDISCHARGE ADVICEProblem List prior to referral: A diagnosis of inflammatory bowel disease (IBD) made based on gut biopsies obtained at Nutgrove Veterinary Hospital on July 20th, 2016. The summary of the diagnosis was as follows; Mild to moderate lymphoplasmocytic gastritisHelicobacter in the stomach (significance unclear)Mild to moderate lymphoplasmocytic and eosinophilic enteritis Clinical signs of IBD had been present since May 2016 and included;Melena – on and off since MayBorborygmi (noisy gut sounds & wind) – on and off more recently3.Anaemia had been present also for some time, presumably secondary to blood loss via the gut 4.A blood transfusion had been supplied 3-4 weeks ago to address anaemia. Please note any future blood transfusion will require a test known as a cross match to be performed before it can be administered safely. 5.Over the last month episodes of panting had been noted. Those episodes appeared to be more common in the 10 days prior to referral. 6.Puppy has a longstanding history of arthritis, for which he receives a daily joint supplement. Reason for referral: Puppy was referred for a review the control of IBD, anaemia and to help determine the cause of recent panting. Outcome: Anaemia was still present. It was non-regenerative (meaning the bone marrow is nolonger replacing lost red blood cells). This is likely secondary to iron deficiency, caused by chronic blood loss via the gutPresumptive mild to moderate lymphoplasmocytic gastritis, with Helicobacter and mild to moderate lymphoplasmocytic and eosinophilic enteritis, based on endoscopic biopsies performed at Nutgrove 1 month agoA clear respiratory cause for panting was not identified. The lung fields and windpipe were largely normal on radiographs. Please note, a full respiratory investigation has not taken place at this time, for reasons outlined belowHistory:Puppy’s history began with melena/black faeces (4 month ago). Strangely vomiting, diarrhoea or weight loss were not reported. The cause of melena was investigated at your referring veterinarian’s clinic with an ACTH stimulation test, ruling Addison’s disease out and a failure to respond to symptomatic treatment. Puppy was also treated for potential lungworm with a weekly dose of Milbemax for 4 consecutive weeks. The upper GI scope performed at Nutgrove led to the aforementioned diagnosis. After gut biopsies were obtained prednisolone, tramadol and omeprazole were started. Around the same time, severe anaemia was noted, necessitating a blood transfusion. In the last 10 days you noted episodes of severe panting. Panting, is not reported all the time, there are defined episodes. The episodes last between 30 minutes and 2 hours. At the time Puppy is usually awake, stays lying down, pants continuously, is conscious and aware and these episodes are frequently at night. On at least one occasion, Puppy passed a significant amount of wind afterward one of these events. Notably an upper airway whistle is not noted, nor does Puppy adopt a stance that an animal usually would when they are struggling to breath. Physical examination:-Puppy was bright, alter and responsive. -The body weight was 27.2 kgs and the BCS was 3/5. -His heart rate was 84 bpm, with strong femoral pulses, but the gums were pale.-Tracheal and lung sounds were normal-Abdominal palpation was unremarkable-Rectal examination was also unremarkable, the prostate was not palpable and there was no evidence of melena at that time. Diagnostics performed and results:General bloods demonstrated moderate anaemia (PCV 28 %). Anaemia was non-regenerative and showed features that could be suggestive of iron deficiency. Biochemistry is still pending. Urinalysis (free catch) showed dilute urine (SG 1.014), but was otherwise unremarkable. The urine is most likely dilute secondary to increased drinking associated with steroid administration. Folate and cobalamin are vitamins absorbed by the gut. These were measured to ensure they were being absorbed adequately in the gut. Both folate and cobalamin were within their normal reference intervals. As a cobalamin inection (B12) was administered last week by your referring veterinarian, it may be prudent to recheck the cobalamin concentration in 4-6 weeks time, to ensure that the normal value obtained yesterday is not being masked by recent B12 administration. If B12 is low in the future than a protocol for supplementation should be implemented. Abdominal ultrasound (Final Report) was performed to assess for any changes that may be the cause of GI signs. The liver was mildly enlarged and patchy, while other differentials exist, it is highly likely that the changes noted are secondary to recent steroid administration.Chest and neck radiographs (final report) were taken to ensure there was no lung pathology that could explain the recent sporadic episodes of panting. There were no abnormalities on the chest radiographs that could explain these episodes. Some mineralize opacities were noted within the lungs, these most likely represent harmless mineral accumulations known as pulmonary metaplasia. Medications To Go Home With:Gut protectants: -Losec 30 mg twice daily by mouth. This is a dose increase from once to twice daily therapy for the coming 4 weeks. Treatment for IBDPrednisolone: 55mg once daily by mouth. This equates to 11 x 5 mg tablets once daily in the evening. This is a dose (the dose has been doubled) increase. Cyclosporine. A prescription was provided to collect a liquid formulation of cyclosporine. That formulation will have a strength of 100 mg/ml, meaning 1.5 mls of that liquid should be administered with food, once daily. This drug was advised as prednisolone may be contributing to the panting and may be cause weakness of the hind limbs. Our hope is that if this drug controls Puppy’s gut condition, that steroids can eventually be withdrawn. Buscopan 10 mg: Give 1.5 tablets twice daily with food. Again an external script was provided. This drug may relax smooth muscle and lessen wind.Royal Canin Hypoallergenic diet was prescribed. This food must be fed as the sole food source for a 28 kg dog, ideally for a minimum of 4 weeks, but possibly life long. To address iron deficiency -Ferrous sulphate 325mg/dog: Give 1 tablet once daily in the morning with food. For pain relief-Tramadol 50mg tablets: Give 1 & ? tablets twice daily with food. This is a dose decrease (dose halved). It was decreased because of concerns that it may lead to constipation or worsen wind. It may be possible for Puppy to be managed entirely without this drug. Discussion:At this point in time it is considered unlikely that the episodes of panting are being caused by respiratory pathology. As the gut related signs are not yet fully controlled, it is possible that the sporadic episodes of panting are secondary to gas build up or discomfort caused by IBD. Panting may also be complicated by administration of steroids and the fact that Puppy is anaemic. To try gain better control of presumed IBD we have recommended the following; -Starting a hydrolysed diet (such as Hills z/d or RCW hypoallergenic)-Increasing the dose of prednisolone to 55 mg per day-The addition of cyclosporine (150 mg once per day by mouth). Cyclosporin is being used, as it is not clear that Puppy was responding to steroids, albeit the dose was lower but also because Puppy has arthritis and panting and steroids tend to cause muscle mass loss, leading to hind limb weakness and panting. To address the anaemia we have recommended the following; -Starting iron supplementation-Consider, repeating worming with fenbendazole 50mg/kg per day for 3 days-We are also advising monthly monitoring of haematology at UCD Veterinary Laboratory. For now, based on the clinical examination and chest and neck radiographs, we are assuming that panting is related to pain associated with IBD, anaemia, steroids or a combination of all three. Pain associated with IBD is not usually responsive to commonly prescribed pain medications and is typically best managed by gaining optimal control of the gut disease. As a result it may be possible to fully withdraw tramadol from the treatment regime. There are of course other possibilities and if panting does not stop after better control of IBD and anaemia has been achieved, we may need to investigate the respiratory signs further. We hope that after 6-8 weeks on cyclosporine that the dose of steroid can be dropped by 1/3 and this can be repeated every 2 weeks, until steroid are at a low dose and are gradually withdrawn over several days. There after Puppy will be managed on cyclosporine and diet. Are eventual aim is that after a period of 2-3 months stability, that cyclosporine may be withdrawn and Puppy might be managed on diet alone, although please note that some dogs will relapse when the drugs are withdrawn. As Puppy does not have many of the common clinical signs associated with IBD, such as weight loss, vomiting or diarrhoea, progress or response to therapy may be harder to monitor. It is important that a diary is kept outlining Puppy’s willingness to eat, the colour and consistency of his faeces, episodes of wind or abdominal noise, body weight and evidence on blood panels that point towards resolving or worsening anaemia. Next visit: A revisit slot should be arranged for your referring veterinarian’s clinic in 1 month’s time. The following tests should be performed on that day; Weight checkFull clinical examinationReview of current medicationsFull CBC (to UCD Veterinary Lab marked for my attention)Assessment of vitamin B12 (cobalamin) concentrationCurrently the only results outstanding are is the biochemistry. These results should be available by Friday. I have advised your referring veterinarian to stay in close contact with me (Barbara.gallagher@ucd.ie), in particular after Puppy’s monthly visits.. Thank you for bringing Puppy to UCD. He is a total softie and was a pleasure to work with. Please do not hesitate to contact us if you have any remaining questions. CLINICIAN: Barbara Gallagher STUDENTS: Eamonn and John ................
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