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Buddy

Buddy is an 8 year old Boston Bull terrier who presented to us 2 years ago having difficulty controlling his newly diagnosed diabetes.  We adjusted his insulin needs and managed to get good diabetic control within a few weeks time.  Since then Buddy had been doing great with the exception of developing cataracts in both eyes due to his diabetes (the high blood sugar resulting from the diabetes, gets into the eyeball and seeps into the lens, which then causes water to be attracted into the lens causing the lens to become opaque).  Recently, Buddy underwent successful cataract removal surgery at the local veterinary ophthalmologist and his sight was regained. 

Over the past 2 months, Buddy has had a loss of appetite and developed chronic diarrhea.  Our first thought, when facing a diabetic with inappetence, was that the diabetes was out of control.  We ran a comprehensive blood panel to check for any problems in his major organ systems, infection, electrolyte disturbances etc and found no clue to his current problems.  We ran a fructosamine assay which tells us how well his blood sugar has been regulated over the past two weeks and found the diabetes to be under control.  Not finding any major problems, we opted to try conservative management with a bland diet, and anti diarrheal drugs.  After 3 weeks,  4 different drugs and no success, we decided to look more deeply into Buddy's problem.   First we took abdominal radiographs (x-rays) looking for signs of intestinal foreign bodies, gall stones, bladder stones, or gross evidence of cancer.  All we noted on the radiographs were thickened intestines, which is a rather non specific finding.  Next, we performed abdominal ultrasound, which allows us to get a cross sectional view of the organ systems as if you were slicing into a roast beef.  Abdominal ultrasound is very sensitive at finding small tumors, which might not be seen on radiographs.  After scanning the belly, we did not find any solid tumors in any organs.  However, as we examined the small intestines, we found that they were swollen to about twice the normal size.  Moreover, the swelling was not due to fluid inside the intestines, but due to swelling of the actual walls of the intestines.  This type of swelling is generally caused by either diffuse cancer, most often, Lymphsarcoma, or by Inflammatory bowel disease. Unfortunately,  you cannot differentiate the two using ultrasound alone. 

We attempted to stick a needle, guided by ultrasound, into the intestine and obtain a diagnostic sample, which could tell us what was wrong.  Unfortunately, the samples were non diagnostic. 

At this point, we recommended an exploratory surgery to obtain biopsies of the intestines, which would  give us the answers we needed.  We considered performing endoscopy, but endoscopes can only travel a few inches into the small intestines, and may have missed lesions further down the GI tract. 

Buddy was prepped for surgery and we opened his belly.  After visualizing the entire abdomen, we concluded that the ultrasound exam was correct in that there was no evidence of solid tumors in any organ.   The intestines were much thicker than normal and did not have the supple feel of normal intestines.  We took biopsies of the stomach, all three parts of the intestines (duodenum, jejunum and ileum) as well as the liver and pancreas.  Buddy was closed up and recovered uneventfully.  He was kept in the hospital for a few days until he regained some appetite and discharged.  A few days later, the biopsies returned indicating that Buddy had inflammatory bowel disease (IBD).  This was a great relief to us and Buddy's owners as the prospect of intestinal cancer was very disheartening.  IBD is a syndrome  in which the immune system in the intestinal tract gets over stimulated.  The result is inflammation within the walls of the intestines, which inhibits their normal function.  As a result, food is not digested properly, which then leads to diarrhea.  In humans, this disease can cause nausea and loss of appetite in addition to the diarrhea and we find similar symptoms in dogs and cats. 

Treatment for this disease is based on using drugs to suppress the immune system, thereby reducing the inflammation and hopefully resolving the symptoms.  In addition, we rely on special diets, which are “hypo-allergenic” to hopefully reduce the stimulation of the immune system in the first place.  The first drug of choice in most IBD cases is some form of corticosteroid, such as cortisone, prednisone, or, more recently, Budesonide, which acts locally in the intestine and has less overall side effects.  Unfortunately for Buddy,  steroids antagonize insulin and make diabetic control more difficult. Therefore, we had to move to Azathiaprine, which is an immunosupressant agent used in this disease and in some forms of cancer therapy.  This drug can have serious side effects and requires regular blood monitoring, but when used properly, it can be very effective.  Along with the Azathiaprine, we started Buddy on Hill's Z/D ultra food, which is a hypo allergenic diet. 

Buddy came in for his 2 week recheck this week and finally his appetite is returning, his stools are starting to form up and he is putting on weight.   His owners are thrilled and Buddy is a happy camper too  Our plan is to slowly taper the drugs off over 6 months and see if we can maintain Buddy with just the hypoallergenic diet. .

Ultrasound of intestines, arrow points to swollen walls.

Histopathology section of inflammatory bowel disease, the purple dots are inflammatory cells in a Grossly swollen wall section