April newsletter

This was supposed to be the April issue of our new newsletter, but then life (e.g. EC-SAVA, playing wedding photographer nr Warmbaths and the spay campaign in Missionvale) happened. As you’ve probably NOT been checking your in-box daily wondering what on earth happened to it, I’m Case study

Date change to PE CPD Talk
Page 4
Signalment: 10 yo MN Minature Schnauzer
Presenting complaint: Joint pain (esp hips
and also RF) for some time. This had been getting worse recently and he was given 2.5 mg pred daily for the last 10 days. For the last few weeks - months he was less active and more clingy. Today, he was unable to get up and his abdomen appeared distended. Use of antihistamines
Appetite appeared unchanged / slightly de- Clinical examination: T 38.4, P 168, RR pant, wt 9.8 kg, bcs 5/5
Amanda’s hot tips
Colour pale side of normal. Tartar 3+ and halitosis. Gingival resorption but not much inflammation. ln NAD. Thoracic auscultation NAD, ab- update for Section 21
dominal palpation: solid. Rectal NAD. Orthopaedic examination: hair applications
discoloured R carpus as licking ++ and lame RF 3/5 rapidly improving with exercise. Decreased ROM RF carpus more than L. Thickened toes Drug labels
RF. Definitely much better outside on grass and definitely better once on his feet - consistent with DJD. Nn exam: no deficits in myotactic reflexes or conscious proprioception, hopping. No R armpit pain Minimum database:
• Haematology: no significant changes
• Biochem (K9 senior wellness): sample slightly lipaemic even after
heparin. Changes consistent with steroid use (cholesterol, ALP)
Urine analysis: SG 1.026, pH 6, protein 1+, sediment NAD (1+ debris)
Question 1: What’s on your master problem list?
Question 2: What would you do next?
Qustion 3: How would you reach a diagnosis?
Question 4: Is there anything else you’d do before collecting biopsies?

King Edward Veterinary Referral Hospital, Newsletter April 2010 Answer 1: Even after an MDB there is very little to work with here. He is diffusely unwell with possible
abdominal distension. The multifocal DJD, obesity and dental disease are likely to be concurrent conditions rather than the primary problem. Lipaemia is likely to be breed associated. The concurrent problems need to be taken into account with management / treatment choices, but are unlikely to lead to a diagnosis. The col-lapse could be a consequence of his DJD alone. Pain from the DJD could be exacerbated by another source eg abdominal pain but there is no corroborating evidence at the moment. Urine is not perfectly concentrated but this could reasonably be a steroid side effect.
A nswer 2: Abdominal radiography / ultrasound to investigate the abdominal distension.
U ltrasound is a lot more sensitive than radiography.
Ultrasound abnormalities:
- liver: multiple small (2-4 mm) hypoechoic nodules in otherwise normal liver DD nodular hyperplasia,
mets. Present on scan 6 months ago and have not changed.
- stomach: focal area of gastric wall in fundus shows increased wall thickness (from 0.42 cm to 2.28
cm) with an irregular inner margin and complete loss of wall layering.
Remainder of GIT of NAD.
Blue: outline of spleen Green: stomach wall with more normal layering to the right and severe thickening with loss of layering to the left There is gas trapped under the thickened portion of the stomach resulting in dirty shadowing. Normal stomach wall Blue: right limb of pancreas Green: duodenum. Often this is significantly thicker than the rest of the small intestine in dogs, which helps you find it. Follow it from the pylorus or find the thick, straight bit of SI in the right upper quadrant Pink: colon wall is usually < 2 mm thick (vs duo-denum < 5.1 mm in dogs less than 20 kg) Blue: right limb of pancreas next to duodenum – a good land mark The marked thickening and loss of layering in the stomach wall is consistent with focal inflammation or infiltration, with neoplasia more likely owing to the severity of the change King Edward Veterinary Referral Hospital, Newsletter April 2010
Answer 3: You have 3 options. They are not mutually exclusive
Ultrasound guided FNA
Endoscopic biopsies
Surgical biopsies
Less invasive, quicker post Most invasive op recovery May need sedation but GA Can visually inspect whole Have to rely on palpation rarely necessary Can rapidly biopsy many Sample sites limited by noma, less for spindle cells Non-diagnostic sal lesions – may miss looks or feels abnormal proximal jejunum in most along small intestine dogs Can inspect oesophagus cannot and r/o oesophagitis at the same time
Answer 4: Radiograph the lungs (better images once he is anaesthetised). If there is convincing
evidence of pulmonary metastasis, some owners may not want to pursue further investigation.
It is unusual to perform upper GI endoscopy on animals that do NOT vomit / have diarrhoea. If
either of those signs is present, a full faecal analysis including a Giardia screen should precede
biopsies.
Results
endoscopy:
- oesophagus NAD
- Stomach: well marginated mass - mildly erythematous, soft, with fine spiderweb over the
convoluted surface. Remainder of stomach NAD but easy to biopsy incl around pylorus. Biop-
sies collected from normal stomach, adjacent to mass and mass itself. Mass easy to sample,
billowy but did not bleed much after sample collection
Histopathology:
Prominent lymphoplasmacytic gastritis (LPG) and mucosal gland ectasia that is generalised ie
not limited to the mass. Secondary gastric rugal hypertrophy. Prominent oedema in some sec-
tions probably explains the mass effect. These findings are consistent with lymphoplas-
macytic gastritis.
King Edward Veterinary Referral Hospital, Newsletter April 2010 Diagnosis: suspected severe lymphoplasmacytic gastritis

Comment: LPG can progress to lymphoma or can represent the superficial change associated with
a deeper lying lymphoma in the gastric wall. It bothered me that the patient had no obvious
change in appetite and was not vomiting - changes I would typically associate with LPG. Surgical
biopsies would be necessary to reliably differentiate the two. These were discussed with the owner
but declined.
The dog responded well to steroid therapy (1 mg/kg bid). His owners have started tapering the
dose (slowly, every 2-3 weeks).
Usually a dog with idiopathic gastritis would be placed onto a novel protein diet eg hill's z/d. In this
case, we had to balance the urgent need to control his weight and his joint pain with the possible
benefit that a novel protein feed would provide. We thus stuck with the hill's j/d reduced calorie
diet.
Change of date for next CPD talk in Port Elizabeth We decided to move the next Port Elizabeth CPD talk from the 9th to the 8th June because the 9th is the start of the school holidays and we thought some of you would want to head off into the blue and distant yonder. I’ve also decided to change the topic to pancreatitic disease – canine and feline, acute and chronic. This is because Sharon Centre is doing a whole day on liver disease at the SAVA congress. She has been doing research on liver disease for ever and will be able to talk on stuff that hasn’t even hit the literature yet. I can always update people that didn’t make it to congress later in the year. Free Lasix syrup
Mount Croix
Animal Clinic
has 50 Cyclohexal
100mg capsules to sell
bottle of Lasix oral sus-
pension after her pet
King Edward Veterinary Referral Hospital, Newsletter April 2010 Antihistamines – which drug when?

Histamine receptors:
H1 – in skin, smooth muscle and glands of airways and GIT
H2 – most important cause of HCL secretion in the stomach and peripheral vasodilation
Histamine release
Allergies / anaphylaxis (mainly H1 but also H2 receptors – eg the tachycardia is H2 recep- Mast cell tumours (see H1 and H2 mediated paraneoplastic effects) Drugs: e.g. (opiates – most pronounced in morphine), Saffan (cremphor L carrier). Stimu- lation of H1 causes GI hypersecretion and hyperperistalsis. Indications for H1 blockers
Allergies – H1 blockers lower the dose of prednisone needed to control signs. Efficacy var-
ies between drugs and between individuals. Try different ones for a week while keep-ing all other treatments the same. (Aterax v expensive!) (Anaphyllaxis – effect of H1 blockers too weak. Use adrenalin +/- rapid acting cortisol eg Solu-cortef) Tablet size
0.2-0.4 mg/kg i/v or i/m tid 0.2-0.4 mg/kg i/v or i/m
General side effects of H1 blockers: sedation, dry mouth, rarely paradoxical excitement
Additional uses of specific H1 blockers:
Motion sickness / vomiting associated with vestibular disease. The following are particu-
larly effective. Their effect appears at least partially Independent of H1 inhibition –they also seem to work directly on vestibular nerves. Cyclizine (Valoid): 4 mg/kg tid (both species) or 25-100mg total bid in dogs only. In
people, cyclizine is used to treat post op nausea, particularly related to GA agents / opiates. Diphenhydramine (not practical in SA because only available in combination flu
Appetite stimulant because of concurrent serotonin blocking effect – cyproheptadine: 0.1-
0.5 mg/kg po 2-3x daily in dogs and cats Pre-med before chemotherapy: H1 blockers are administered before doxorubicin treat-
ment to decrease the chance of allergic reactions / anaphylaxis. H1 blockers are more effective when administered before the allergy/anaphylaxis is triggered. King Edward Veterinary Referral Hospital, Newsletter April 2010 Indications for H2 blockers
Gastric / oesophageal ulceration – H2 blockers. Cimetidine effect weak and many drug interac-
tions. Use ranitidine and consider adding omeprazoel initially (esp with oesophagitis) GI prokinetic – some of the H2 blockers (see below). Can use ranitidine to treat idiopathic
Prokinetic
affect metabolism of many other drugs - Absorption decreased by food - Protracted dosing at 10 mg/kg immu-nosuppressive that Side effects rare, do not induce above. Hypotension and cardiac arrhythmias whole GIT 0.5 – 1 More potent - Poor oral absorption -No inhibition of P450s- not metabolised The last 2 do not appear to be available in South Africa at this stage. Omeprazole (Losec) is signifi-cantly more effective at increasing gastric pH than H2 blockers. Amanda’s hot tips
******* ******* ******* Update for Section 21 applications ******* ******* ******* We have recently found out that the payment of R200.00 needs to be paid with each application, therefore every time you re-order, you will need to pay again Drug Labels
To stay legal you need to show the following on your drug labels: 1. Prescription reference number *** new *** King Edward Veterinary Referral Hospital, Newsletter April 2010

Source: http://www.kingedwardvet.co.za/images/articles/newsletters/April%20Newsletter.pdf