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FOR THE SUNSHINE STATE’S VETERINARY COMMUNITY FROM BLUEPEARL VETERINARY PARTNERS
FALL 2015
When is Feline
Hyperthyroidism and Kidney
Failure a Concern?
IT IS WELL DOCUMENTED that increases in renal blood flow and
glomerular filtration rate secondary to hyperthyroidism can mask
renal insufficiency. Inversely, correction of the hyperthyroid condition
thereby normalizing the hypermetabolic state may allow a concurrent
kidney insufficiency to become apparent. Even though the hyperthyroid
treatment is not the cause, azotemia may become evident.
The good news is that,
despite the development of
posttreatment azotemia, most
cats will do fine. In one study,
the median survival time in cats
treated for hyperthyroidism that
developed azotemia was similar to
treated cats that did not develop
azotemia (>500 days).
It is the correction of the
Technetium scans
hyperthyroid state and not the type
confirming increased
of treatment that unmasks the
radioactive uptake by the
azotemia. Therefore, it is possible to
thyroid glands
get a preview of the cat’s true kidney
function, prior to curing the condition with radioactive iodine, by
performing what has been termed a methimazole trial. To perform
a trial, administer methimazole with the goal of dropping thyroid
hormone levels into the normal range. Once thyroid levels have
normalized, then blood tests performed two to four weeks later would
be expected to demonstrate the BUN and creatinine values that you
would see after radioactive iodine therapy.
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When should a methimazole trial be performed?
There is no straightforward answer to this question. Most cats
with hyperthyroidism don’t need a methimazole trial. After all,
you still have to treat the hyperthyroid condition. Nevertheless,
we will consider performing a methimazole trial in cats greater
than 15 years of age and in those cats with any suspicion for
concurrent kidney disease based on the patient’s history, exam
findings, and lab test results (significantly elevated BUN value
and isosthenuria).
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What is the best treatment for hyperthyroidism?
Overwhelming opinion is that radioactive iodine therapy is the
best treatment. Curing the condition by this method does not
risk damage to the parathyroid glands, which may occur during
surgical removal of the thyroid glands. On the other hand, poor
client compliance and inadequate methimazole dosing can allow
the hyperthyroid condition to slowly damage the heart and even
the kidneys when medical management is pursued.
The risk for side effects from the methimazole and the
additive expense of the medication and subsequent thyroid
monitoring are additional reasons to consider curing the condition
with a single dose of radioactive iodine. In a recent JAVMA study,
hyperthyroid cats treated with radioactive iodine were shown
to live longer than those treated with methimazole despite the
iodine-treated population actually being older in age.
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WHEN THEY CAN’T
EAT ANOTHER BITE
Do You Hate Stormy Mondays?
YOU WOULD NEVER RECOGNIZE it by its name, astraphobia, which is derived from the
EVERY HOLIDAY I OVEREAT. My belly gets a little distended, and I feel over full. I
recognize my mistake and swear not to eat as much next year. But what if the
food you ate at the holiday meal kept on increasing in volume as it sat in your
stomach? That could be a problem.
So it is with dogs who get into a bag of dry food. Every dog will eat until they
are full; that’s not the problem. It has been reported that the normal canine stomach
can accommodate 7-8% of the dog’s body weight in food. The problem starts when
the dry food starts to absorb fluid from the stomach, or the dog drinks. The dry food
swells as it absorbs the fluid overdistending the stomach. This condition is known
as food bloat.
Signs of food bloat are usually acute in onset. Patients frequently present
similar to those with GDV. Dogs
demonstrate abdominal discomfort
and anxiety. Attempts at vomiting
are frequently non-productive,
and pressure on the diaphragm
from the gastric distention can
cause increased respiratory
effort. Occasionally, the stomach
is distended enough to interfere
Food bloat is diagnosed with radiographs. The
food-filled stomach, unlike a GDV, is normally
with blood return by the vena cava
positioned.
causing signs of poor cardiac
output.
Treatment recommendations for
patients with food bloat vary:
1. Some clinicians attempt to
induce vomiting; however,
this is frequently ineffective.
Overdistention of the stomach
interferes with its ability to
contract and expel its contents.
GDV
We don’t recommended emesis.
2. The administration of IV fluids
is recommended. Dogs risk dehydration as the dry stomach contents draw in
fluid. Furthermore, the stomach contents need to be moist enough to be broken
down and passed through the pyloris. Those dogs demonstrating compromise in
perfusion from dehydration, or reduced cardiac return from the excessive gastric
dilation, could also benefit from fluid therapy.
3. Providing frequent walks has been suggested as it appears to help stimulate
gastric emptying.
4. Administering pro-motility medications such as metoclopramide may also be
helpful.
5. Analgesics are indicated in painful dogs. It has been suggested that NSAIDs
be avoided so as not to further irritate the stomach.
6. Finally, the resolution of food bloat takes time. Most dogs improve within 12
hours of presentation.
7. Surgery is not recommended to treat food bloat unless the stomach is torsed.
How about lavaging the food out of the stomach?
Lavage is typically not necessary and would likely prove difficult to perform
because of the density and dryness of the stomach contents. The risk of inducing
aspiration pneumonia in many cases outweighs any potential benefit you might
gain. Lavage might be considered if the stomach is distended to the point where
perfusion is compromised.
NOTE: The occurrence of food bloat has not been associated with an increased
risk of developing GDV.
Greek word for lightning. However, if your dog has this fear, it will drive you crazy.
Technically, it is the fear of thunder and lightning, but to those of us who deal with
these patients, we recognize it as the fear of thunderstorms.
Astraphobia is more common than you think, affecting up to 30% of dogs. For
some dogs it’s the loud noise that frightens them. These dogs would be expected to
demonstrate similar signs after hearing gunshots and fireworks. Other dogs appear
to start demonstrating signs even before the rain starts falling possibly due to a drop
in barometric pressure. It is suspected that the pressure drop is sensed by the inner
ear. Other triggers for astraphobia remain less apparent but could include increased
static electricity in the air or even the smell of ozone resulting from the lightning.
Affected dogs demonstrate mild to severe signs of anxiety and fear. Panting,
pacing, trembling, drooling, whining, hiding, or climbing onto the owner are most
commonly described. Occasionally dogs will become destructive as they try to escape
from the storm. Cortisol levels have been documented to rise in affected pets due to
the stress.
So what’s an owner to do?
It is important for pet owners not to show anxiety or behavior changes, which the
pet may key in on. It is also important that owners not overly coddle their pet during
these periods to the point of reinforcing or rewarding the behavior.
Determining the most effective
treatment for each particular pet
requires trial and error.
1.Owners can try to create a more
comforting environment during storms
by identifying a safe place for the pet
to hide or even turning on white noise
to mask the storm sounds. They might
also try to distract the pet by playing
a game.
2.Garments that snuggly fit around
the trunk of dogs have been used to
calm anxious pets. Few studies exist
supporting the effectiveness of these
garments; however, many pet owners
swear by them. How these garments
calm the dogs remains undetermined.
3.Various synthetic pheromone products on the market may help to calm the pet.
4.Occasionally, excessively anxious dogs will benefit from medications to reduce their
anxiety. Alprazolam, clomipramine, fluoxetine, and diazepam have been prescribed
for this purpose. Tranquilization with acepromazine is less commonly used due to
its systemic side effects, such as inducing hypotension.
Finally, dogs with severe thunderstorm phobia are best evaluated by an animal
behaviorist who can work directly with the pet and owner to countercondition and
desensitize the pet. Counterconditioning involves training the dog to associate storms
with something enjoyable. Desensitization is the process of getting the pet used to
the storm conditions typically by introducing mimicked storm sounds at low levels
and increasing them over time.
It’s not just dogs
In people, astraphobia has been reported to be the third most common phobia in the
U.S. Astraphobia has also been identified in cats though much less frequently.
Can you prevent your pet from developing astraphobia?
This is unknown. There may be a genetic basis to the response. Interestingly, studies
suggest that dogs living with other dogs are less likely to demonstrate anxiety during
thunderstorms.
DOGS WITH SEVERE THUNDERSTORM PHOBIA ARE
BEST EVALUATED BY AN ANIMAL BEHAVIORIST WHO
CAN WORK DIRECTLY WITH THE PET AND OWNER
Medical Director:
Erick Mears DVM, DACVIM
Editor:
Amy Johnson CVT
AVIAN/EXOTICS
Peter Helmer DVM, DABVP-Avian
CARDIOLOGY
Alan Spier DVM, DACVIM
CRITICAL CARE
John Gicking DVM, DACVECC
Lauren Harris DVM
Brittany Jaeger DVM
Danielle Pollio DVM
Miryam Reems DVM, DACVECC
DERMATOLOGY
Robert Schick DVM, DACVD
Nadine Znajda DVM
DIAGNOSTIC IMAGING
Wendy Gwin DVM, DACVR
Valerie Sadler DVM, DACVR
EMERGENCY MEDICINE
Katherine Brammer DVM
Lee Burstiner DVM, DABVP
Dee Ann Dugger DVM
Kelley Eckert DVM
David Hoch DVM
Kevin Kelley DVM
Sonja Olson DVM
Allison Shreve DVM
Taylor Tungsten DVM
Steven Tutela DVM
Jessica Weeks DVM
Marie Yakubik DVM
Gastrointestinal Ulcers in Fido?
GASTROINTESTINAL (GI) ULCERATIONS ARE DEFECTS in the mucosal barrier that
Diagnosis
extend into the deeper layers of the gastrointestinal tract. The gastric mucosal
barrier is a complex defense mechanism protecting the normal mucosa from
erosions and ulcers. GI ulcers may occur in the stomach and in the duodenum.
They may be superficial or deep and range from simple epithelial erosion to full
thickness bleeding or perforating lesions. The GI ulcer may occur independently
or due to a disease process. There is no predilection for a particular age group
or breed, and signs can be extremely variable from patient to patient. Some
patients may have no clinical signs, while others may be in immediate need of
intensive support and hospitalization, including blood transfusions.
A presumptive diagnosis of GI ulceration can sometimes be made on the basis of history
and clinical findings such as the previously mentioned aspirin administration or known
foreign body ingestion. A full diagnostic workup is recommended, regardless of the cause.
A complete blood cell count (CBC), biochemical profile and urinalysis should be
performed in all cases. A CBC will evaluate for the presence of infections, inflammation and
anemia, associated with gastrointestinal ulceration. A biochemical profile evaluates organ
function, which is important to establish if there may be an underlying metabolic disorder.
Screening abdominal radiographs are commonly normal; yet, they may support
the diagnosis of an ulcer secondary to a tumor or foreign body. Abdominal radiographs
will also help with diagnosis of a GI perforation. An abdominal ultrasound may
note thickness in the GI wall; however, GI ulceration is commonly not evident with
ultrasonography. The abdominal ultrasound evaluates the abdominal organs and helps
determine if tumors are present that may be associated with ulcers.
A contrast upper GI study with barium may identify ulcers. It is a safe test; results
are not always conclusive. Gastrointestinal endoscopy is the gold standard in diagnosing
GI issues. It may facilitate the removal of foreign bodies, evaluate for ulcers and sample
tissue for the presence of inflammation or cancer, which may cause the ulcer. It does
require general anesthesia in our veterinary patients; however, it is a fairly quick and
safe procedure.
Other tests may be recommended on a case-by-case basis. These may include
a liver function test for certain liver disorders or an ACTH stimulation test to rule out
hypoadrenocorticism (Addison’s disease).
Causes
There are many potential causes of GI ulceration ranging from medication to
tumors. Some cases of ulceration are clear-cut. A prime example would be in a
case of dog being treated with nonsteroidal anti-inflammatory drugs (NSAID)
and a corticosteroid simultaneously. Others, and perhaps the majority, are more
difficult to determine.
Some of the more common causes of GI ulceration in our pets include
• Ingestion of certain medications (NSAIDs and corticosteroid)
• Systemic disorders such as renal failure, hepatic disease and
hypoadrenocorticism (Addison’s disease)
• Stress, pain and/or major medical illness/surgery
• Dietary indiscretion or the ingestion of foreign objects
• Pancreatitis (inflammation of the pancreas)
• Microscopic disease of the GI tract including inflammatory bowel
disease
• Primary GI neoplasia (lymphoma, adenocarcinoma, leiomyoma, and
leiomyosarcoma)
• Mast cell tumors and gastrinomas
Symptoms - What to Watch For
There are a number of symptoms that patients with
gastrointestinal ulceration may exhibit. The most common
include any/all of the following:
••
••
••
••
••
••
••
••
Vomiting (with or without digested blood)
Hematemesis
Melena
Abdominal pain
Decreased appetite
Anemia
Weakness
Anorexia
Treatment
Management of gastrointestinal ulcers centers on treatment of the primary cause and
blocking excessive stomach acid production. Rarely, in severe cases control of bleeding
and blood transfusions may be indicated.
Withholding food initially is recommended to avoid stimulation of gastric acid and
pepsin secretion. Gradual reintroduction of small amounts of bland food should then be
instituted, similar to treatment of pets with acute gastritis.
Drugs may help decrease acid production by the stomach and expedite the
resolution of GI ulcers. Examples include H2 blockers (famotidine, cimetidine) and proton
pump inhibitors (omeprazole, pantoprazole). The proton pump inhibitors offer a more
complete inhibition of gastric acid secretion.
Cytoprotective agents include antacids and sucralfate which help protect the healthy
denuded musosa and promote gastric mucosa epithelialization. Antiemetic drugs, fluid
therapy and/or antibiotics are considered in treatment of some patients on a case-by-case
basis. Pain medication should be considered in pets with ulcer disease. Ulcers can cause
intense abdominal discomfort, and affected patients may benefit greatly.
Endoscopy may be indicated to remove foreign objects, diagnose tumors causing
ulcers, or biopsy associated tissue with the ulcer. Surgery is less commonly performed to
treat gastric ulceration.
You Are What You Eat
DIET IS AN OFTEN OVERLOOKED component of treating dogs and cats with a variety of disorders. In our culture, pet owners
are looking for the easy cure. And in our attempt to please our clients we get into the habit of prescribing the pill that
will fix every illness. But is this really the best medicine? Maybe we should be taking a page from the human field where
a significant number of illnesses are managed with recommendations for dietary changes, increased activity and stress
reduction. Sure, it’s hard to get pet owners to change the way they are treating their pets. But it’s not enough to treat
arthritis with just anti-inflammatory medications or a metabolic disease with anti-nausea medications. The appropriate
dietary changes could reduce a pet’s need for medications.
Hill’s Pet Nutrition, a BluePearl Partner in Education, continues to research the roles diet plays in treating our pets’
diseases. They have recently introduced a number of new diets to treat patients afflicted with multiple conditions such as
arthritis in overweight dogs and urinary tract issues in overweight cats as well as to reduce canine GI inflammation that
may be related to stress or food sensitivities.
Give your Hill’s representative a call today to find out what diets you should be adding to your treatment arsenal. And
make certain to ask about their free trial bag and sample program for those clients who are reluctant to switch a pet’s
diet without trying the food first.
INTERNAL MEDICINE
Jennifer Goodman DVM
Anthony Ishak DVM, DACVIM
Melinda Larson DVM
Brian Luria DVM, DACVIM
Erick Mears DVM, DACVIM
Cathy Meeks DVM, DACVIM
Melanie Otte DVM, DACVIM
Neil Shaw DVM, DACVIM
NEUROLOGY
Michael Kimura DVM, DACVIM
ONCOLOGY
Jen Coyle DVM, DACVIM
Curtis Kane DVM
OPHTHALMOLOGY
T. Miller Michau DVM, DACVO
Jessica Stine DVM
Anja Welihozkiy DVM, DACVO
Jennifer Welser DVM, DACVO
One of Hill’s new metabolic diets
REHABILITATION
Jennifer Brown DVM,
DACVS-LA, DACVSMR, CCRT
SURGERY
Helga Bleyaert DVM, DACVS
Sylvia Lee DVM
Nick Rappa DVM
Michael Reems DVM, DACVS
Nicole Salas DVM, DACVS-SA
Andrea Smith DVM, DACVS-SA
Elbow Dysplasia
The problem
Elbow dysplasia includes the following conditions: fragmented
medial coronoid process (FCP), osteochondritis dissecans (OCD),
elbow incongruity, ununited anconeal process (UAP) and ununited
medial epicondyle. FCP is a small piece of bone on the inner side
of the joint, which has broken off the ulna. This fragment of bone
irritates the lining of the joint and grinds off the cartilage of the
adjacent humerus (similar to a pebble in your shoe that is irritating
your foot). UAP is a condition in which the anconeal process fails
to fuse with the main ulna bone during the growth phase. Normally
this bony process fuses to the ulna bone by 20 weeks of age. OCD is
a condition in which a piece of cartilage becomes partially or fully
detached from the surface of the humerus bone. Elbow incongruity is
a poorly fitting joint, which results in excessive wear of the cartilage
within the joint. The ununited medial epicondyle is a piece of bone,
which has separated from the medial side of the humerus bone. This
is the site where a group of forelimb muscles attaches. If this region
fails to develop into bone within the normal timing of development,
the muscles may pull this part off the humerus, resulting in a loose
piece of bone that rubs on the inner side of the elbow and on the
ulnar nerve.
Fig. 1
Clinical signs
Clinical signs include acute or chronic forelimb lameness that
worsens after exercise. Large and giant breed dogs are commonly
affected, with both elbows involved in 35% of affected dogs. Signs
often become apparent at 5-12 months of age.
Fig. 2
Diagnostics
Physical examination findings may reveal varying degrees
of lameness and pain with manipulation of the elbow joint,
(specifically with medial palpation, flexion and supination).
Craniocaudal, 90° lateral and flexed lateral radiographs of the
elbow joint are recommended to evaluate UAP, ununited medial
epicondyle and sometimes OCD, as well as to document changes
consistent with arthritis. CT scan and arthroscopic surgery of the
elbow joint are usually the best diagnostic tools used to diagnose
FCP, OCD and incongruity of the elbow joint.
Fig. 3
CONTINUED BELOW
Companion
3000 Busch Lake Blvd
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Elbow Dysplasia
CONTINUED FROM ABOVE
Treatment
Arthroscopic surgery is the recommended treatment for elbow conditions.
The joint is examined with a very thin telescope to confirm the diagnosis.
If an OCD cartilage flap is present, it is removed from the joint. The OCD
bed is trimmed at the edges, and small holes are made in the OCD bed so
that healing will occur faster. The area of the medial coronoid is examined
with the arthroscope. If fragmented, it is removed with a combination of an
arthroscopic shaver and small instruments. If an UAP is present, the bony
fragment is removed via a 2 cm incision made on the side of the joint. If
an ununited medial epicondyle is determined to be the problem, the joint
is examined with the arthroscope, as some of epicondyle will be removed
through a separate 3 cm incision. Elbow incongruity is not treated surgically
if it is mild. If this problem is significant, the ulna bone is cut just below the
elbow joint to improve congruity.
Prognosis
Arthroscopic elbow surgery is currently one of the best methods available to
both diagnose and treat elbow conditions. Although all dogs that have elbow
dysplasia develop arthritis, surgical intervention with arthroscopy can help
decrease pain within the joint. Stem cell therapy may also be of benefit and
can be coordinated with our surgery service. Continued medical management
including weight control, fatty acid supplementation, nutraceuticals,
intermittent use of NSAIDs and physical rehabilitation may be indicated to
manage arthritis long term.
BluePearl Veterinary Partners is a leader in minimally invasive
procedures. A member of the surgery team is on-call 24/7 to provide
consultations to our emergency doctors and to perform emergency surgeries
when on call. Our specialists are available for questions and consultations
on surgical conditions Monday through Saturday.
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