The Frustrations of IBD
Its cause is unknown, its diagnosis difficult
by Lexiann Snider
Copyright 2003 Belvoir Publications Inc. Posted with permission, Your Dog. For subscription and other information, call (800) 424-7887 or visit this website.
Debilitating, costly, frustrating, heartbreaking – those are the terms owners of dogs with inflammatory bowel disease (IBD) use to describe the condition. Veterinary texts define IBD as a group of disorders resulting in chronic stimulation of inflammation in the gastrointestinal tract. The inflammation causes frequent, recurring episodes of vomiting and/or diarrhea. But diagnosing and treating the condition can be difficult.
What’s unknown about IBD is probably greater than what’s known, including its cause. Some researchers believe it’s an autoimmune response where the body either overreacts to a foreign antigen — a substance that provokes an immune response — or reacts inappropriately to a normal antigen, such as a food protein.
Possible precipitators of the inflammatory response can be a bacterial, viral or protozoal infection, parasitic infestation, hypersensitivity or intolerance to dietary ingredients, digestive enzyme deficiencies or intestinal wall defects.
“No one really knows what the most frequent or likely triggers are,” said Mary Labato, DVM, Dip. ACVIM, clinical associate professor at Tufts University School of Veterinary Medicine. “There is no single, overwhelming type or cause.”
Because IBD can affect different portions of the GI tract, symptoms vary greatly from pet to pet, making it even more difficult to identify. Besides diarrhea or vomiting, other signs may include gurgling stomach, belching or gas, loss of appetite, desperation to get outside or soiling in the house, pain with bowel movements, weight loss and mucous, or blood in the stool.
Most cases of vomiting and diarrhea have a benign cause. They start suddenly and resolve quickly. “Acute gastro-enteritis is self-limiting,” Dr. Labato said, “but IBD is chronic. It comes and goes, and it keeps recurring.”
Search for Answers
Ame’s problems began when Michelle Barton, a rescue volunteer from Edmonton, Alberta, Canada, brought her home at 9 months. “First I noticed large amounts of stool that soon became mucous covered,” Barton said about her German Shepherd. “This was followed by vomiting of undigested food and her not wanting to eat. Her stools progressed to a pudding-like consistency, then explosive diarrhea and at its worst to blood-only diarrhea.”
Barton continually consulted the veterinarian who put Ame though many tests, including a biopsy, to reach a conclusive diagnosis. The Shepherd was treated for severe whip- and round-worm infestation and appeared to improve for a while.
Within weeks she went downhill. Ame lost about 20 percent of her normal weight. She stopped eating and drinking, and was hospitalized, with the expectation she would die.
“She was non-responsive,” Barton said. “She laid in her kennel and had terrible, bloody diarrhea. The vet gave her IV fluids and wrapped her in heated blankets. She could not fight anymore,” Barton said. “I asked to take her home.”
Today, thanks to Barton’s efforts and veterinary care, Ame hasn’t had a flare-up in nearly two years.
To reach a diagnosis, veterinarians do blood work to rule out other problems, such as pancreatitis, Addison’s and kidney disease or malignancy. They examine fecal samples for worms or infections, such as giardia. They also may take X-rays and use ultrasound to check for obstructions or other abnormalities. Although some dogs like Ame have parasites or infections, often test results are normal except for minor thickening of the intestinal walls, an occasional elevation in liver enzymes or mild anemia.
A diagnostic test for IBD is a positive biopsy, obtained through an endoscopy of the stomach or a colonoscopy of the lower GI tract. But results still may be unclear.
“Even among pathologists, there’s a great deal of difference in scoring the amount of white blood cells found in the intestinal lining to say, ‘This is IBD,’” Dr. Labato said. “One may read test findings as abnormal, or another one will describe the inflammation as mild or a slight increase but normal.”
If a biopsy report comes back positive for inflammation, it’s not necessarily IBD, said Matthew Krecic, DVM, a researcher in gastrointestinal disease and speaker on IBD at the 2002 American College of Veterinary Internal Medicine Forum. “Lots of things, such as infection, cause inflammation, which can be treated.
“If it’s true IBD, you treat it a little differently,” said Dr. Krecic with Alabama Veterinary Specialists, a referral-only practice in Birmingham. “Food sensitivity may respond with diet alone, but you may have to manage IBD with other medications, also.”
Because of the ambiguity of biopsy results, veterinarians may try dietary changes and drugs to see if symptoms improve before doing the biopsy.
The first line of defense in the treatment of possible IBD is an elimination diet. If food sensitivity is a contributing factor, it’s likely the ingredient has been in the diet for many months. All foods used in the past or being currently fed, including treats, are eliminated.
Then a “novel protein,” a source never eaten previously and one that is easy to digest, is substituted. Rabbit, duck, venison and kangaroo are common sources. Fats are moderately restricted because they lengthen the time it takes to digest food, increasing the likelihood of nausea. Special products that meet these requirements are available from a variety of commercial manufacturers and veterinarians offering prescription IBD diets.
Veterinarians may suggest a bland diet while getting vomiting or diarrhea under control. Dr. Labato recommends a mixture of cottage cheese and rice for her patients. Other options are boiled hamburger and rice or chicken and rice – along with short-term use of Kaopectate or Pepto-Bismol, anti-diarrheal liquids.
Because it can take two- to six weeks for improvement, dogs who are showing worse symptoms or who have lost too much weight will likely take other medications simultaneously. A staggering variety of drugs can be used to treat IBD.
“Which drugs are best depends on the severity of signs, how recurrent they are and the animal’s overall condition,” Dr. Labato said. “I’m inclined to use Flagyl (an anti-protozoal anti-biotic also known as metronidazole) and steroids (corticosteroids, cortisone, prednisone, Prednisolone, etc.), or a combination of drugs based on the symptomology.”
Additional categories of drugs that may help include: compounds containing a sulfa anti-biotic, anti-inflammatory and mild immunosuppressants (sulfasalzine, mesalamine); other antibiotics such as Tylan or tetracycline; other immunosuppressants to suppress an over-reactive immune system (azathioprine, chlorambucil); anti-spasmodics or anti-hypermotility agents that relieve abdominal cramping or slow the digestive tract; or prescription-strength acid inhibitors like Pepcid, Prilosec or Prevacid
“A pet’s signs may be exacerbated by rapid changes in diets or medications,” Dr. Labato said. “If you have a lot of changes at once, they may go right back to episodes of vomiting or diarrhea. You need to go slowly so you can see what’s working.”
Veterinarians may change the diet, prescribe drugs, watch for a few weeks, then assess the changes. If no improvement is shown, they will suggest a different food or drug. But when a dog becomes emaciated or debilitated, the time for wait-and-see trials are over.
“This may be when a referral is made,” Dr. Labato said.
It took six months, a general practice veterinarian and two veterinary specialists to diagnose Frankie, a Clumber Spaniel, owned by Kristin Caruso of Denver, Colo.
“Frankie’s symptoms began at age 4 months with consistently loose stools that progressed to diarrhea,” Caruso said. “He frequently refused his meals, vomiting what he did eat. A vet visit resulted in a switch to a prescription diet and Tylan to treat a possible clostridium (bacterial) infection.”
Improvement was brief. In a few weeks, Frankie became lethargic, vomited large quantities of food and had explosive diarrhea. Although a young dog, he failed to gain weight. Caruso consulted a veterinary specialist in internal medicine who ran a series of tests, including blood, urine, fecal, bile acid, ultrasound and endoscopy, which confirmed a diagnosis of IBD.
The Spaniel was placed on prednisone, Reglan (a drug that decreases acid reflux into the esophagus, helping to reduce nausea) and Flagyl, and put on a new prescription diet. For the next two years, Frankie had to be kept on steroids and given different diets as he continued to have flare-ups.
The treatment goals in IBD are to eliminate an identifiable cause, reduce diarrhea and vomiting, decrease bowel inflammation and stabilize the dog’s weight. After gaining control over acute episodes, long-term management may come down to diet.
“An animal may be doing fine then accidentally get a crumb that isn’t part of their [prescribed] diet,” Dr. Labato said. “Sometimes it just takes one or two bites to trigger a flare-up.” Despite periods of remission, she warns clients that IBD is progressive.
Although some dogs may need maintenance drugs, veterinarians prefer to prescribe a minimum dosage, then taper the amount until the animal is off the drug, especially steroids.
“We don’t like to keep animals on these drugs for life,” Dr. Krecic said. “If we can control diet, maybe we can reduce the drugs. Pets can never go back to their old diet because they can relapse. We look to control the symptoms and severity since this is a lifelong illness that you are never done treating.”
The health of her dog became Caruso’s daily priority. “When he was sick, I’d hug him and massage his belly,” she said. “When he was in pain, I’d sleep with him, waking every hour to check his condition. I thought I might lose him.”
Her vigilance paid off. “He has been off prednisone for several months, and Frankie’s IBD is now under control. I stuck with the plan and his diet, and he’s doing great.”
Perseverance worked for Barton, too. Before releasing Ame from the hospital, the veterinarian administered a steroid injection. Armed with daily doses of prednisone, Pepcid and Flagyl, Barton took Ame home, where she ate for the first time since becoming so ill. Two weeks later, Barton changed the dog’s diet one last time.
“At first it was hard cleaning the constant messes in and around the house,” Barton said. “However, Ame was my responsibility no matter what. With that attitude, we made it through the ups and downs of the disease. It took two years of medication and a strict diet, but she made an incredible recover.”
Finding the right food is a matter of trial and error, one change at a time, at the veterinarian’s direction. “No one diet is suitable for all patients,” Dr. Krecic said. In addition to special foods, IBD dogs do well when owners add fiber in the form of cooked potatoes, sweet potatoes or pumpkin to their meals.
Although management of IBD symptoms can be elusive, it’s critical to control them to prevent complications, such as liver damage, ulcers, anal sac infections and malnutrition. “Be diligent in finding a diagnosis,” Caruso advised. “Develop a relationship with your veterinary team and understand what you need to do.”
“When Frankie’s health began to improve, I showed him and finished his AKC [American Kennel Club] Champion title. It was meaningful because he’d been through so much with his health,” Caruso said. “We’ve begun tracking and he loves it. I’m a firm believer that an IBD dog can enjoy and participate in life as much as any other dog.”
Regardless of its challenges, both owners and veterinarians say, the condition can be managed, and IBD dogs can lead quality lives. It simply takes patience.
Lexiann Snider, who lives in Ohio, is an eight-time recipient of the Maxwell Award for excellence in dog writing, presented by the Dog Writers Association of America.
Breeds Likely To Develop IBD
Researchers don’t always agree on the breeds prone to developing inflammatory bowel disease, but these seem to be diagnosed with the condition more than others:
Basenji, Boxer, Cocker Spaniel, Dalmatian, German Shepherd, Irish Setter, Lundehund, Shar-Pei, Rottweiler, Soft-coated Wheaton Terrier and Yorkshire Terrier.
The types of IBD they develop are sometimes considered variants of the more common form of the condition, with different types of inflammatory cells attacking different gastrointestinal tissue. Treatment is nearly identical but depends on the type of cells affected, location of the inflammation and the dog’s symptoms.
Although a dog can have IBD at any age and show subtle signs when young, the average age at diagnosis is about 6 years. The disease affects males and females equally.
$18,000 Later, A Boxer Still Struggles With the Disease and Its Complications
At the tender age of 2, Kia, a Boxer belonging to Gerry Langgut, was frequently gassy and had episodes of diarrhea, vomiting and lack of appetite. When she was 5, the dog also developed gastro-esophageal reflux (GER), immediately followed by uncontrollable salivation.
Langgut of Oak Park, Ill., consulted several veterinarians. Some dismissed the problem as the dog having eaten something unusual. A few told Langgut her dog needed only more fiber. One veterinarian suspected inflammatory bowel disease and changed Kia’s diet, supplementing with probiotics, substances that promote the growth of natural bacteria in the intestinal tract that aid in digestion, and Pepto-Bismol.
But Kia showed no improvement. She was referred for allergy testing and was determined to be hypersensitive to several protein sources, including beef, lamb, venison, milk and fish. Once again her diet was changed. Although she ate voraciously, Kia lost 12 pounds.
A veterinary internal medicine specialist performed a biopsy and confirmed she had IBD. “It took six years to receive a diagnosis,” Langgut said. “I don’t know what caused it, but I was told it could be linked to food allergies.”
The veterinarian started Kia on large doses of prednisone and Flagyl, which brought an immediate cessation of symptoms. The dog also took phenylpropanolamine (a sympathetic nerve stimulant used to increase muscle tone and help prevent GER), azathioprine (an immunosuppressant), Sucralfate (an anti-ulcer medicine) and Pepcid (an anti-acid).
“Kia is very stoic, so it’s hard to tell if she’s in pain,” Langgut said. “There have been times when she wouldn’t eat for a couple days, or she would flinch when she had a bowel movement. With the salivation, she was in distress and couldn’t lie down for hours at a time, drooling so much she soaked carpets and herself. It’s difficult to tell how much discomfort she has because of the medication’s side effects.”
Attempts were made to wean Kia off prednisone, but she always relapsed. As a result of long-term steroid usage, she developed Cushing’s disease, causing her to be lethargic, lose hair and muscle tone, and become hypothyroid. Additionally, Kia has had changes in skin color, reduced alertness, joint stiffness and started defecating in the house.
Her veterinarian prescribed Thyroxine, a synthetic form of thyroid to replace Kia’s inadequate level of the hormone. Although it’s too early to tell, Langgut is hopeful it will improve her dog’s condition. “I vacillate between feeling overwhelmed and helpless, and feeling envious of owners whose dogs are healthy and energetic. Mostly I feel very sad.
“Kia doesn’t do things most dogs do, and she spends the majority of her time sleeping. Her quality of life is certainly compromised,” Langgut said of her now 8-year-old dog. “But she still loves spending time with us, follows us around the house and eagerly greets us. She is an extraordinarily wonderful dog who’s a part of our family.”
Langgut spends much of her time caring for Kia. She buys special food and prepares all her meals from boiled buffalo meat and potatoes. She regularly cleans up messes on the rug. Kia takes 18 different drugs and nutritional supplements twice daily. She’s been hospitalized on occasion and has had surgeries to repair problems related to IBD complications. In all, Langgut has spent about $18,000 on medical bills and food.
“Would I do it over again?” Langgut asked. “Part of me thinks not; I wouldn’t want another dog to go through what she has. But having experienced the joy that she’s brought, I would do it all again in a flash.”