Case study: Gary, Part I
Gary is an 8-year-old neutered male Yorkshire Terrier whose owners took him to his regular veterinarian when they noticed he was intermittently vomiting and having diarrhea. Gary’s veterinarian found that he had hypoproteinemia, or low protein levels in the blood, and abdominal effusion, fluid in the abdomen. His veterinarian referred him to Veterinary Referral Hospital of Hickory, where Gary was admitted through the emergency service.
Gary came through Veterinary Referral Hospital of Hickory’s emergency service, where an emergency veterinarian performed a physical exam and ran bloodwork. Gary had good body condition, but his fur was dull and dry, and he had some abdominal distension. He weighed in at 10.9 pounds.
His bloodwork showed that his albumin and globulins – simple proteins – were low, he had a low calcium level, and his white cell count was slightly elevated. Gary’s bloodwork also showed a low blood pH and low magnesium level. The emergency veterinarian then ran a cPL – a check for pancreatic problems – and the test gave a normal result.
The emergency doctor started Gary on IV fluids right away, administering a combination of:
- Sodium chloride solution with added dextrose and potassium (because his acid-base balance was off, due to the vomiting)
- Hetastarch (a colloid to keep fluid in the blood vessels)
- Cerenia and protonix (gastrointestinal drugs to stop the vomiting)
His final diagnosis on this day was hypoproteinemia due to GI loss. The emergency veterinarian requested that Gary be transferred to Dr. Scott Helms.
Dr. Helms sees Gary for the first time, performs a comprehensive exam, and continues to monitor his bloodwork. His exam revealed a distended abdomen and a grade III medial patellar luxation on the left kneecap (the kneecap is overly mobile atop the knee)
The fluid therapy is working and Gary’s bloodwork starts to normalize. Blood protein levels are up. His lab work on this day identified a panhypoproteinemia (low protein level of all measured proteins), hypocholesterolemia (abnormally low cholesterol), a low total calcium, and mild leukocytosis (a higher than expected number of white cells in the blood).
Dr. Helms continues Gary’s fluid therapy, including calcium gluconate and magnesium sulfate to resolve the low calcium and magnesium blood levels. He continues to monitor Gary’s bloodwork to look for response to the fluid therapy.
At this time, the main concern for Gary is his low protein levels. Low protein can be an effect of various conditions. One is emaciation – an underfed dog will have low protein because he is not getting adequate nutrients. However, Gary’s weight and body condition do not suggest he isn’t adequately fed. The next concern is kidney function; in Gary’s case, there was no indication of kidney disease. As such, Dr. Helms began looking for the next cause: a GI issue, which is consistent with Gary’s vomiting and diarrhea.
Dr. Helms performed an ultrasound on Gary, which showed some free fluid in the abdomen and mesenteric thickening. The mesentery, a net of fibers, tissue, and fat, is attached to the stomach, small intestine, pancreas, spleen, and other abdominal organs. Gary’s kidneys, bladder, adrenal glands, and spleen appeared normal. Gary’s liver was enlarged and gall bladder distended, however, there was no evidence of obstruction. Dr. Helms identified diffuse thickening of the wall of the small intestine, but there was no visible evidence of cancer.
Gary is quiet, alert, and responsive. He has had no vomiting or diarrhea but was still on medication to prevent both. His abdomen remained distended.
With the ultrasound not definitive, Dr. Helms performed an endoscopy of Gary’s GI tract to take biopsies. Endoscopy is less invasive than exploratory surgery to gather samples. At this point, considerations for Gary’s underlying condition include:
- Inflammatory bowel disease
- Liver disease
The endoscopy showed a normal esophagus, but the stomach had increased granularity (was not smooth) and there were abnormalities in the duodenum, the section of the small intestine next to the stomach. Biopsy samples were taken of the stomach and duodenum.
Over the next four days, Dr. Helms monitors Gary, taking bloodwork each day to look for improvement. His low levels rise and stabilize. Gary’s biopsy results come back, enabling Dr. Helms to give Gary a definitive diagnosis of lymphoplasmacytic enteritis causing his panhypoproteinemia.
Lymphoplasmacytic enteritis is a form of inflammatory bowel disease (IBD) in which inflammatory cells infiltrate the lining of the stomach and intestine as the result of an abnormal immune response. The exact cause is not known. It has been speculated that genetics, food allergies, intestinal parasites, and intestinal bacteria each has the potential to cause IBD.
Gary responded to supportive care and improved significantly during his time at Veterinary Referral Hospital of Hickory, and his albumin rose, but was still low. Dr. Helms recommended a hypoallergenic diet for Gary, plus prednisone, a steroid used to treat inflammation, and metronidazole, an antibacterial and antiprotozoal drug. He also prescribed omeprazole, which treats various GI issues, and cerenia, which treats nausea and vomiting.
Dr. Helms prescribes Hill’s Prescription Diet z/d with instructions that Gary should eat about 1.66-2 cans per day, eating 2-5 times per day.
Dr. Helms schedules Gary for a recheck in one week.
Check out our next post for the rest of Gary’s story!