Sibo Advice Needed Please

[Guest Stripeyfan]

Kelly finished his latest course of ABs (oxytetracycline) on Thurs, about 11am. By Friday night (after firming up nicely from an episode of soft stools a few days earlier) he had blowout D (although he was and is fine in himself) and we had to put him straight back on them - we had some on standby as this is the third time this has happened, and we didn't want to wait all weekend to be able to get him more tablets and have him go downhill in the meantime.

 

Our vet already suspects he has SIBO secondary to his parasite damage/suspected IBD, and yet again going back on the ABs seems to have it under control, but we have to take him in Weds as she's concerned that yet again he's relapsed. The reason I'm so worried is that previously, she's been very keen for us to get him scoped (the full open surgery type of scope), and I'm scared she'll start pressuring us again. We don't want to do this because of the risks and because he has improved so much with treatment, and especially because the vet herself has told us that it might not change anything, definitely won't cure him and may not even tell them why he's having issues.

 

But what alternative treatment options should I ask about? We have only tried one AB - two 3-week courses and one 5-week. Do I need to ask about trying a different one? Or trying it for much longer? Again, from reading articles about SIBO, it seems sometimes dogs with SIBO need long-term AB therapy, usually at doses below what's considered the 'standard' dose... but what is 'long term' - months? A year?

 

I would hate to think we weren't doing the best thing for our boy, but at the same time I am really not happy about the idea of putting him through surgery. Please help! Thanks.

[greyhead]

Oh my gosh, I'm so sorry. Let me dash off some fast thoughts right away and then I'll sign off and try to dig up articles that might help you. (I gave one really good one to my vet; it used to be on the Internet, now I can't find it, so I'll see if she kept the hard copy.)

 

And, yes, you DO have to educate your vet. I had to ask three times to have Spencer's poop tested for germs, as opposed to worms, before it got done. And even then I had to tell them to make Clostridium perfringens one that they'd tell the lab to test for. So not only do you have to educate, you have to insist, however nicely or not. Your dog, your money, and the vet loses nothing by humoring you.

 

So don't scope, at least not yet. (We've managed to never do it.) Get a poop sample in and have it tested, by means of a Culture and Sensitivity, for bacteria. It will take a week or more for results. First they have to see what germs grow in the culture and then they have to see to which antibiotics it is susceptible. (For Spencer it showed three antibiotics effective on his two strains of C. perfringens, and it took ALL THREE to cure it. Each of the a/b's was effective up to a point, but we could always tell -- by smell and consistency -- that we weren't quite done when the each a/b course was supposed to be over.) If memory serves, the three a/b's in order given were Simplicef, clindamycin, and metronidazole. And I believe we had to double back then for a second course of clindamycin. He has been on metronidazole, which is also useful for IBD, for a year and a half now, though we've been able to cut the dosage in half. He also wound up needing tylosin (Tylan) permanently too, though that hadn't worked at all when we first tried it (because it didn't address C. perfringens at all).

 

Scoping will not solve this problem, nor will throwing the usual a/b's at it, hoping that they work. IMO, scoping will just weaken Kelly further because of the anesthesia experience. Possibly, the sheer mechanics of sticking an object into the intestines will not do them any favor either. And as you point out and the vet even recognizes, scoping to identify inflammatory cells won't necessarily help with the IBD and won't do anything whatsoever to help with SIBO.

 

I'm so sorry you and Kelly are going through this. Forgive me if I sound opinionated. The strength it takes to stand up for what you know in these situations is considerable. I'm just trying to support your strength with our experience. Bottom line with the vet: The vet doesn't freakin' matter. Your only allegiance is to Kelly. I know you know this.

 

I'm off to look up articles now. Please, anybody else who can find them too, please do. Sweetdogs? MZH? tbhounds? Lindsay?

[Guest SusanP]

No words of wisdom, just hugs. You were there for me through Wizard's illness, and I'm so sorry to see that your pup has hit a rough patch. Sending healing thoughts from Iowa, USA.

[greyhead]

In dogs with histories like Kelly's and Spencer's (i.e., hookworm), it probably makes sense that the hookworm damage sets them up to be more susceptible to SIBO, which, uncured, sets them up for IBD. So it doesn't make sense to me to ignore the possibility of SIBO and try to just treat the IBD. IBD is an inflammatory disease, and unchecked bacteria are certainly inflammatory! That's the gist of my thinking on the whole matter. Here are the articles I was able to dig up quickly, which isn't to say they're the be-all and end-all on the subject.

 

About SIBO in general:

http://www.vin.com/p...VA2002&PID=2580 This is buy an english vet named Batt. His credentials are given at the bottom. Perhaps this would persuade your vet.

http://www.upei.ca/~...0overgrowth.htm I'm guessing this old (1998) Canadian article characterizes the way your vet is treating Kelly. Though I think it's out-dated, it might be good for you to read what your vet is thinking. It states that IBD could lead to SIBO, which, as I stated above, I think is backwards in general. But this may explain one reason your vet is so keen to scope. (It cites Batt as a source, but his 2002 article above is, obviously, more recent and up to date.)

 

About C. perfringens SIBO in particular:

http://www.veterinar...?P=A&A=2239&S=1

 

http://www.vin.com/V...000/PR00425.htm This article from 2001 says that fecal testing for C. perfringens is "meaningless." Well, it worked for us. (And I'll happily explain why it's not meaningless if you like.) But the rest of the article is worth reading anyway.

 

http://www.oaklandvh...D=162&Private=0 Ok, this article has this sentence, which refutes the fecal-testing-is-meaningless hypothesis. "Spore colony counts from a fecal sample greater than a certain number are associated with clostridial infection; lesser counts are often found in normal dogs without signs of clinical disease."

 

I just want to add that scoping may not do him lots of harm. It surely doesn't pack the wallop of a surgical biopsy of the intestines! It's just that it doesn't make sense to do something invasive like that before exhausing the non-invasive tests like a culture-and-sensitivity on the poop!

 

Hope this helps. I used to be an academic type, and apparently I'll never entirely grow out of it.

 

Hugs to you and scritches to Kelly,

Mary

 

Edited to fix massive typo. And to note that I'd initially missed the fact that your "scoping" is the full surgical biopsy, not just endoscopy.

Edited June 15, 2010 by greyhead

[Guest Stripeyfan]

Thankyou, thankyou, thankyou, both of you. And thankyou for the articles, Greyhead. I guess I could be over-worrying about this, and maybe the vet won't suggest surgery, but I want to make sure we're prepared to fight Kelly's corner for him.

 

FWIW, I DON'T think biopsy/scoping is wrong for all dogs with problems like this. If Kelly had not responded to the meds, put all the weight he lost back on and then some and gradually turned back into the cheeky, playful boy we first brought home (from a dog who was all ribs and hips and barely even had the energy for walks), then I'd want the vet to do everything possible to find out what was wrong, including surgery. But - touch wood - he HAS responded. And I think he has enough to deal with right now without adding to his problems by putting him through a procedure that very likely will make absolutely NO difference to him at-all, except to give him more pain and the need for even more medication, and possibly put his life at risk.

 

The truly frustrating/confusing thing is that the vet has said, in passing, that he might need ABs for a long time, and at the time she said it she didn't seem to think it was a worry. Only every time he has to go back on them, she isn't happy about it. Neither are we, I guess - we'd much rather he was healthy, for his sake, and I know there are side effects and possible future health problems to worry about with both the ABs and the pred, but the diarrhea would finish him off for certain if it got out of control - seeing him how he is now, compared to in March, I think he was closer to losing his fight with this than we realised.

 

I forgot to put in my OP that he has had a folate/cobalamin test and the results were abnormal, which is what led to the diagnosis of small intestinal problems in the first place - and from reading through some of the articles, that's a classic sign of SIBO. So to me it does seem very likely we're dealing with this as well as the probable IBD. He is also on 10mg pred/day (down from 30mg/day back in March), which we've only tried to reduce further once, by cutting it in half. It didn't work so I have asked if we can reduce it in smaller increments next time - something else we'll discuss again on Weds I guess.

 

Any more opinions or advice would be very gratefully received...

[EllenEveBaz]

No advice, just rooting for you and Kelly. We're glad he has you in his corner.

[greyhead]

Just found a really good comprehensive article on IBD. If a person could only read one article, this should be the one. Especially note that everything else (like SIBO) should be ruled out before testing for IBD, and that radiography, such as by ultrasound, should precede biopsy as it reveals the particular area of the GI tract that's problematic. And it's by an English doctor, Stripeyfan! It's from 2006 and billed as a "State of the Art" lecture by WSAVA.

 

http://www.ivis.org/...erman1.pdf?LA=1

 

Hope Kelly's vet visit has gone well. Please let us know!

Edited June 16, 2010 by greyhead

[Guest Stripeyfan]

Thankyou so much for that article, Greyhead, and also for your PM. I have only skimmed the article as my head is buzzing, but will read it through properly tomorrow after some sleep!

 

UPDATE: The vet visit went well - she only mentioned the surgery in passing and did not put any more pressure on us to do it. I am very relieved!! She palpated Kelly's abdomen and felt his lymph glands, and couldn't find anything out of the ordinary. He is also up to 34.5 kilos - and that's after a 24-hr fast, then 2 days of not much food at the weekend after he had bad D again, and up from the last vet visit when she said she'd be happy for his weight to stay at what it was then. So good news there, I hope.

 

However she is still very concerned that we don't seem to be able to get him off his meds - she says she's never seen a case like it (trust Kelly to be unique! ). So the plan now is to add enzymes to his food for a week (although his pancreas is normal, they can help with dogs who have IBD-type problems as they mean the gut doesn't have to work as hard to digest food), then, while he's still on those, try to drop the AB dose to 1 tablet 3 times a day as opposed to 2 tablets 3 times a day. Then we have to try to reduce the steroid dose by 25%. She said to 'play around' with the doses and find out what worked, in what combination. Also, if he started to get loose again when we were reducing his meds, try starving or cutting back food for a day first before putting the doses back up, in case that firmed him up. Doing that worries me a bit to be honest, but I think (hope!) we have enough experience with his problem now to use our judgement on how he's doing, so we'll see...

 

The vet also thinks it's unlikely now that he does have SIBO any more (although not impossible) - she thinks the ABs are having some other beneficial effect, so we are sticking with the same one for now (oxytetracyline).

 

One thing about the enzymes... 1 capsule is sufficient to digest 100g of food, and he can have up to 5 capsules a day. I just weighed out his daily ration - he has chicken and rice, he cannot eat anything else (and believe me, we've tried!), and he is having 2400g of food per day (over 4 feeds). I know, it's a LOT, but he loses weight on less. So will the enzymes actually help, seeing as they're only going to be 'digesting' about a quarter of each meal?? I guess we're gonna give them a try (why not) but any thoughts from fellow GTers on this would be appreciated!

Edited June 16, 2010 by Stripeyfan