Should We Get Endoscopy/biopsy For Diagnosis?

[greyhead]

Spencer's test results finally came back yesterday. Fecal was negative for parasites, though he has a long history of systematized hookworm. It took so long to diagnose them in the first place (2-1/2 years ago) that his intestines surely suffered.

 

But now the blood work indicates "a malabsorptive condition throughout the small intestine," because both the folate and cobalamin levels are low and out of range. The TLI test was normal, so there's "no evidence of EPI at this time." I'm quoting from the letter my vet wrote me to go along with the test report and article ("Cobalamin and Gastrointestinal Disease" from ACVIM 2002). He'll have to get subcutaneous shots of cobalamin for the rest of his life.

 

What is unknown is what caused this condition. (Btw, TBD testing was negative, though only for Prototek's 4 main kinds, and a 10-day use of Tylan improved his appetite but not his poops.) Her letter says the best diagnostic strategy is exploratory surgery with full tissue biopsies but that most owners find this a bit drastic. Yup, that would be me! She says that some kind of biopsy of the small intestine is indicated, at least endoscopy with multiple biopsies of stomach tissue and small intestine. She wants me to read through the material she gave me, think about it, and call her tomorrow.

 

She did mention, in person yesterday, that whether this turns out to be IBD or something else, the treatments are pretty much the same: metronidazole (I think she said) and a steroid. So we could just treat that way and see what happens. She adds that you can tweak the treatment nicely based on information provided by biopsies, though.

 

So what do you think: Is it worth it to go the endoscopy route, given the risk inherent in sedation/anesthesia? Spencer was 8 in December, and this 6 months of diarrhea/pudding poops have aged him, as do the hookworms. So he's an "old" 8. My instinct is to avoid invasive strategies whenever possible, but I don't know...

 

All advice, opinions, and experiences shared will be GREATLY appreciated. I've been going crazy with this for months, and Spencer and I could really use some help here.

 

ETA: Update in Post 32

Edited February 8, 2009 by greyhead

[Guest skinnydog]

If the diagnosis after the anesthetic isn't going to change treatment, I would avoid the anesthetic. I just went through the same question with Lucy, and did not do the scope/biopsies.

[ahicks51]

I'm at AlphaGraphics editing my book (ha!), so I'm a bit addled- could you tell me how Spencer has been fed over the past few years, and the general quality of his poop?

 

First instinct is (if the only parameters out of whack are the vitamins) to try an elimination diet- either for allergies or for starch- and see if things resolve. This is to say, in the absence of other symptoms, try getting rid of the wheat- or corn- or starch entirely- and give it a month. Raw feed if needs be.

 

Back to editing!

[RobinM]

After much research, debate, research, 2nd and 3rd opionions we are going this route tomorrow.

 

Beau has had soft serve or diarreah since before Thanksgiving. His eating became non existant for a few days and now he is eating, but not enough to sustain his 64 pound weight frame. Even when he is eating, he is not absorbing correctly. He is not gaining.

 

We have had 6 negative fecals, treated anyway for worms, multiple blood tests of various sorts. All were normal.

 

So, tomorrow he is having a sugical biopsy to get to the bottom of this.

 

The problem with treating with pred first, is that if it needs a surgical bx after using the pred, it won't be as accurate.

[greyhead]

I'm at AlphaGraphics editing my book (ha!), so I'm a bit addled- could you tell me how Spencer has been fed over the past few years, and the general quality of his poop?

 

First instinct is (if the only parameters out of whack are the vitamins) to try an elimination diet- either for allergies or for starch- and see if things resolve. This is to say, in the absence of other symptoms, try getting rid of the wheat- or corn- or starch entirely- and give it a month. Raw feed if needs be.

 

Back to editing!

Keep editing! I can wait a bit! But thanks for responding, and here's the info.

 

Spencer came to us in Oct of '05. After a month of soft poops plus stomach rumbling, we went through several slow food changes: Canidae, Natural Balance, Timber Wolf, things like that. The rumbling increased, he developed poor morning appetite, and he kept acting like he was being bitten and biting at his sides. After 10 months we got a positive fecal for hookworm. Problem solved.

 

I'd noticed he didn't do well on formulas with white rice or corn. So for over a year thereafter, he thrived on Iams Large Breed with brown rice/barley (plus whatever canned we were using). When P&G bought Iams and changed the formula, he started losing fur on his trunk in small circles, a year ago. (All tests were negative, so cause unknown. Vet thought it might be the food.) So we looked for new foods again and added Missing Link to anything we gave him. (The hair never grew back, but he never developed more patches.) The foods we tried then included Newman's Own, Spot's Stew, Canidae again, Natural Balance, probably a few more I've forgotten. He finally tolerated Wellness Core Low-Fat well, and that's where he has been until recently. That Wellness variety has no grains at all.

 

The pudding poops began shortly after a dental, last July. At first I thought it was from the post-operative antibiotics and maybe the chlorhexadene dental chews, but it persisted. Tried other foods again (same as above, pretty much), to no effect. Re-dosed with Panacur, to no effect. Tried dexamethazone for two weeks for possible TBD, no effect. Used beet pulp and probiotics for 2-3 weeks, but it didn't help. He refused to eat either pumpkin or sweet potato. After he had lost 6 lbs., I switched his kibble to Kirkland Chicken & Rice (despite the rice) about 3 weeks ago, and I switched the canned food from Newman's Own to Wellness. His appetite has normalized. Don't know if it was the food or the two rounds of antibiotics that is responsible.

 

In all of these foods I've tried to avoid corn and soy at all costs, and until just recently we avoided white rice. The rice may still not agree with him, but at least he's eating the food.

 

Given what we've already been avoiding, going to pure meat is about all that I can see that's left. I don't know how to approach this competently. The vet thinks we should hold the food constant now and see how he responds, first of all, to the cobalamin injection by Wednesday. So if I'm going to address food instead of using medicine, I'll have to justify it to her (and to my ignorant self). And I'll probably need help with that, though she is respectful and easy to talk to. Is feeding raw appropriate in a case like this?

 

Thanks for your help. Get back to me when you can. I can help you with editing, but only as to grammar!

 

 

 

 

 

After much research, debate, research, 2nd and 3rd opionions we are going this route tomorrow.

 

Beau has had soft serve or diarreah since before Thanksgiving. His eating became non existant for a few days and now he is eating, but not enough to sustain his 64 pound weight frame. Even when he is eating, he is not absorbing correctly. He is not gaining.

 

We have had 6 negative fecals, treated anyway for worms, multiple blood tests of various sorts. All were normal.

 

So, tomorrow he is having a sugical biopsy to get to the bottom of this.

 

The problem with treating with pred first, is that if it needs a surgical bx after using the pred, it won't be as accurate.

 

Sorry about Beau, Robin, and I've been reading your threads. Didn't know you were going the biopsy route. Good luck, and I'll stay tuned for your posts.

 

Thanks for the info about using pred. I totally didn't know about that!

[Batmom]

Some thoughts:

 

I would question your vet further on how useful she feels the info provided by a biopsy might be, and how likely that biopsy is to provide any useful info (sometimes they don't). If the treatment is basically the same no matter what is wrong, then it comes down to how badly do you want to know, and how much can you afford to pay for a procedure that might -- and might not -- tell you. (Keep in mind that if he had intestinal lymphoma, for example, you'd probably see some other signs.) My understanding is that intestinal biopsies often aren't as clear cut as a biopsy from a palpable lump, for example.

 

I might be inclined to try an allergy-type elimination diet along the lines Aaron suggests. Meat doesn't have to be raw. I have a dog who, for reasons other than poop quality, eats almost exclusively cooked meat with eggshell (or a purchased calcium supplement); she gets a multivitamin now, but it was awhile before I felt safe to add that, and she didn't deteriorate in the meantime. Raw might be easier; cooked is what works for my household.

 

Back to the issue of tests. I can't tell *you* whether to do the biopsy or not. If the dog were losing weight and condition rapidly, no matter what was fed, I personally would probably be inclined to do it. If the dog were not losing weight rapidly, I probably wouldn't; I'd try some dietary things and some meds and see if anything helped.

 

That said, tho ... when my Batman was diagnosed with a mass in his chest cavity, I did get a fine needle aspirate/biopsy. We knew before the FNA that it was growing rapidly. I had a human need to know more about what it was, and to determine whether there was anything I could do about it. There wasn't much chance it would tell me anything I could act on, and it didn't. But knowing that it would kill him, probably soon, was useful.

 

That's kind of morbid, isn't it? But what I mean to illustrate is, for you as a human being, it might -- or might not -- be useful to know that "my dog has thus and such condition." Even if that doesn't change what you and your vet would do.

 

Sending hugs and best luck in making your decision and in helping your pup be comfortable and happy.

[greyhead]

Thanks everyone. I still have to decide, but hearing how other people have made such decisions is really helpful.

 

Btw, AJ, I forgot to mention that the only other out-of-whack parameter is low platelets -- not dangerously low, but enough to suggest, along with other symptoms, that TBD testing/treating was appropriate.

 

I'm off to read a detailed PM from Robin. Has anyone gone the medication-without-biopsy route?

 

Thanks again!

[Batmom]

greycious_gal might have some thoughts for you, too -- I PMed her so hopefully she'll respond in not too long a time.

[greyhead]

OMG! DH just came back from walking the pups. He said Spencer's poop was mostly formed! And mostly brown! it was runny and yellower at the very end. Nonetheless, we haven't seen anything that good from him in six months!

 

Could yesterday's cobalamin injection have accomplished this? Is it possible that the malabsorption IS the problem, and there is nothing else (other than hookworm damage, for instance)?

[Guest SoulsMom]

Medication without biopsy here. Both vets on Soul's case leaned toward not doing the scope unless absolutely necessary. His bloodwork came back fine, and his ultrasound showed nothing abnormal, so we're keeping Flagyl on hand at all times and slowly trying to manage his condition and figure out his triggers. I was worried about GI lymphoma, so had the ultrasound done. The vet said they could see no area that would need to be biopsied.

(Soul has had two bouts of massive GI bleeding and he had to be hospitalized for one of them)

 

My vet (and I agree) feels the less invasive the better, unless the dog was in obvious, dangerous distress

Edited January 21, 2009 by SoulsMom

[tbhounds]

I would ask your Vet if the lining of the gut has been damaged (scarred) from the parasite burden he had. I don't think you really get true representative biopsy's via endoscope as they are only getting the samples from the surface of the gut--you really need to get full thickness biopsy's (and then have it sent out for a PCR) to get an accurate representative of the tissue--and that means surgery Tough decision--I had a endoscopy performed on my boy and the biopsy's were inconclusive--I opted not to do the full thickness biopsy's and treated him medically--lucky he responded (has IBD/PLE).

Although I must add the endoscopy was a breeze for him--had it done at U.Penn

Edited January 21, 2009 by tbhounds

[greyhead]

I would ask your Vet if the lining of the gut has been damaged (scarred) from the parasite burden he had. I don't think you really get true representative biopsy's via endoscope as they are only getting the samples from the surface of the gut--you really need to get full thickness biopsy's (and then have it sent out for a PCR) to get an accurate representative of the tissue--and that means surgery

 

Is there any way our vet can know if the gut has been scarred from the parasites beforehand? I mean, without the endoscopy or full-thickness biopsy?

 

[ahicks51]

re: scarring. If the scarring were bad enough, you might expect to see other problems, as Batmom has said: weight loss, either from inability to absorb protein ("leaky gut," protein losing enteropathy, whatever you want to call it), inability to absorb fat, inability to absorb nutrients.

 

Now, that last one is what you're seeing: you have B12 deficiency and folate (vitamin B9). These can be out of whack due to diet, but based on what you're feeding, that's not it. Default value: malabsorption. The question remains- why? Organic damage due to hookworms, or ulceration due to intestinal flora being completely out of whack? If you stayed off the grain train for several months and you're *still* seeing this, I'd lean towards physical damage (although I concede knowing next to nothing about hookworm damage).

 

I'm not finding the Wellness CORE low-fat stuff; any hints as to the exact brand?

http://www.wellnesspetfood.com/dog_wellness_dry_index.html

 

The dental thing may be very telling; it is not at all unusual for some types of (human) intestinal disorders to be set off by a dental; I know people with Crohn's who refuse to visit the dentist annually as it causes flares.

 

One thing I've seen mentioned: the B12 patch. I have no idea if it works, or which brands worked. It came across my desk a few days ago, and cannot find the original reference. Here is one brand; I have no further information.

 

http://www.b12patch.com/

 

On the hound, perhaps application somewhere in the groinular area might work. It is conceivable it could obviate the need for injections of B12. I don't think the firm stool was caused by B12; its primary effect is to help make correctly-formed red blood cells, although it also serves very important purposes in nervous tissues:

 

http://en.wikipedia.org/wiki/Vitamin_B12

 

Note the bit about how it is synthesized only by bacteria. Much of what an animal needs is probably formed in its own gut, and absorbed directly. Problems with production or absorption (such as through chronic D) may cause deficiency. Ditto with folate, also produced in the gut.

[greyhead]

I'm not finding the Wellness CORE low-fat stuff; any hints as to the exact brand?

[

 

Here's the link: http://www.wellnesspetfood.com/dog_wellness_grain_index.html

It was listed on your link on the far left as "grain free" options.

 

re: scarring. If the scarring were bad enough, you might expect to see other problems, as Batmom has said: weight loss, either from inability to absorb protein ("leaky gut," protein losing enteropathy, whatever you want to call it), inability to absorb fat, inability to absorb nutrients.

He has gone from 89 lbs to 82.7. Sounds big, I know, but he has bones sticking out from top to bottom. They didn't do a urine sample or anything that would show what he's doing with protein. I'm probably going to ask for more complete testing.

 

'scuse me while I bop back to your post to read the links and info. Thanks much!

Edited January 21, 2009 by greyhead

[Guest zoolaine]

Sunny - nongrey- was diagnosed with PLE last summer. He had an ultrasound done first and later the endoscopic biopsy. The biopsy itself was inconclusive from the tissue samples but the vet said that with the endoscope they could see that Sunny's intestines looked abnormal and bled easily. We ended up adding another medicine. To me it was worth the money - I think I paid $250. If I hadn't done it I'd be worried that it would have shown something and I could have gotten Sunny better treatment.

[Guest mandm]

I'd be thinking that the improvement could very well a result of the B12 injection. I have no experience with B12 injections, rather I give my greyhound oral B12, but I have heard that the injections can be very, very helpful. When my greyhound was diagnosed with both low folate & low cobablamin, the vet said the levels, especially the B12, had to come up. I know nothing about nutrition, but questioned why? So the dog's test results look better on paper? I didn't care anything about numbers or test results, only wanted to see my greyhound get well. I compared it to kids who do very well on standardized tests because they have been prepped for them, but that are dumber than rocks. I didn't want my greyhound to have great looking test results, but unable to hold weight. But my vet explained that, no, it is not just numbers, correct balance of B12/B9 will actually aid digestion & absorption. So I follwed her orders to bring up my greyhound's numbers, and it worked. We had a plan. First -- change his diet, one meat source only, low fat. Oral supplementation of large doses of B12 &I B9. Recheck folate/cabalamin in 1-2 month, and if no improvement, then do B12 injections. Well, his levels improved dramatically with diet change & oral supplements alone. I believe it was the diet change that did it & the oral supplements helped.

 

That was a little over 2 years ago. I never did scope because the diet change pretty much fixed him. He still eats his special diet, I don't think he can ever eat kibble again. But he is fine. Looks strong & healthy. Has a wonderful, shiny coat & lots of energy. He was a mess when I got him -- skinny & sick w/ constant diarrhea.

 

I'd try a serious diet change & if that doesn't work, then scope. If my plan hadn't worked, I would have scoped.

[Guest mandm]

Hookworms -- my greyhound had those too, and God knows what other kind of intestinal parasites. I treated & treated & treated. And I think I got them. But I suspect that they did a number on his gut -- caused some serious damage. Even though it's said that intestinal parasites don't cause permanent damage -- maybe they are talking about roundworm & tapeworm. I believe that hooks & whips CAN cause severe damage.

 

The good news is that after 2 years, my greyhound's gut seems to be getting better, stronger. It's never going to be a retriever gut, but it's slowly getting better.

[greyhead]

greycious_gal might have some thoughts for you, too -- I PMed her so hopefully she'll respond in not too long a time.

Thanks for this, Batmom, and for the considered reply you gave above. I haven't heard from greycious_gal yet, but she may yet appear.

 

Based on what you and everyone has pointed out, I'm leaning toward the diet-change approach. Would two weeks be enough time to see a result from, say, a steamed chicken/eggshell/vitamin diet? I figure we could spare that length of time before resorting to what right now feels like Plan B to me, which would be medicinal. The endoscopy doesn't sound promising enough of results, and the surgical biopsy seems too drastic for what's currently at stake or seems likely to be the root cause of the malabsorption. So I'll sit with those thoughts a while and see how they hold up!

 

 

 

Hookworms -- my greyhound had those too, and God knows what other kind of intestinal parasites. I treated & treated & treated. And I think I got them. But I suspect that they did a number on his gut -- caused some serious damage. Even though it's said that intestinal parasites don't cause permanent damage -- maybe they are talking about roundworm & tapeworm. I believe that hooks & whips CAN cause severe damage.

 

The good news is that after 2 years, my greyhound's gut seems to be getting better, stronger. It's never going to be a retriever gut, but it's slowly getting better.

 

Before we knew that it was hookworms causing his digestive problems three years ago, a holistically oriented vet gave him a product to restore the gut to health, but I can't remember what it was. Did you use anything like that or just let time and hookworm treatment take care of it?

[Guest mandm]

Before we knew that it was hookworms causing his digestive problems three years ago, a holistically oriented vet gave him a product to restore the gut to health, but I can't remember what it was. Did you use anything like that or just let time and hookworm treatment take care of it?

Nope, just time & proper diet. I never tried anything, even though well intentioned people would urge me to try things that they found helpful, I always resisted. With greyhounds so sensitive as ours, I think it is best to keep it as simple as possible. Once I removed the irritations -- the worms, the unnatural diet, the meds -- the gut started healing itself.

[ahicks51]

Based on what you and everyone has pointed out, I'm leaning toward the diet-change approach. Would two weeks be enough time to see a result from, say, a steamed chicken/eggshell/vitamin diet? I figure we could spare that length of time before resorting to what right now feels like Plan B to me, which would be medicinal. The endoscopy doesn't sound promising enough of results, and the surgical biopsy seems too drastic for what's currently at stake or seems likely to be the root cause of the malabsorption. So I'll sit with those thoughts a while and see how they hold up!

 

Try two weeks, maybe four if after two weeks it's inconclusive. If things get dramatically worse, look at another protein source- beef, fish, lamb, whatever.

[Guest SoulsMom]

When Soul had his first episode he went on the ID diet for a full month to let his gut settle. Then over a period of two weeks I slowly transistioned him back to his regular food. I got to about half an half and stopped because he seemed gassy. I was transistioning back to all ID when he had his 2nd bout. So, now he's on all ID for a month again, doing well, and then we'll start slllooowly trying different foods again to try and figure it out. I'm also keeping a journal of EVERYTHING that goes in his mouth each day, and even what the weather conditions are and what his day has been like in case it's stress causing the GI bleeding . . . .

[Guest greycious_gal]

Sent a message.

 

We did use elimination in the diet selection as far as we could. Diane has a pretty methodical way of going about this, and I recommend talking with her. We did add a multi-vitamin, acidophilus, the metronidazole at times, etc. We had to find what was intolerable to our pupper. No chicken or beef. But, corn seems to be fine.

 

Anyway, feel free to shoot questions at me. We've been there, done that, and still hang in the neighborhood, if you know what I mean.

Edited January 21, 2009 by greycious_gal

[tbhounds]

I believe the supplement you may be referring to would be L-Glutamine (500mg/day)

[Guest Spencers_Greyt]

How is Spencer doing now? Did you end up going the endoscopy route? I know it's been a long and painful route with Spencer so just wanted to know how he's doing.

[Guest gr8greys]

Here is something that happened to us.

Oct 08 we adopted a Chi pup from a shelter. They said he had a residual cough from Bordatella (kennel cough). His cough got worse and my vet put him on antibiotics thinking that he had an upper resp. infection. Still coughing after 2 weeks of meds, and getting worse, they gave him another round. Again, getting worse, they did an xray, found nothing and put him on an "almighty" antibiotic which would kill off anything lingering in his tiny body. Nothing helped so they sent him to a specialist. They decided an endoscopy would be favorable to see if something was caught up in his soft palate that their xray couldn't pick up. I was very hesitant at first because he'd been through so much already at such a young age but I was at a loss and he was now getting distressed with the coughing. So we did it the week prior to Christmas and whilst he was under they decided to take cultures and a biopsy. When I picked him up that afternoon, they said that everything looked clear and they couldn't see any irritation but I'd have to wait for the lab results.

End result: He had a very resistant type of kennel cough which only a certain antibiotic would treat. Apparently he had a VERY heavy growth of it.

So, had we not done the endoscopy/cultures then we'd now be at an allergist (they had said perhaps he had allergies) and we'd be no closer to getting a diagnosis. For us, it was the best thing we did.

Irene