Acute Critical Care Gastroenteritis
World Small Animal Veterinary Association World Congress Proceedings, 2007
Dave Miller, BVSc, MMeDVet [Med]
Ridgemall Specialist Referral Centre, Johannesburg, South Africa

Introduction

Acute diarrhoea is second only to pruritic dogs in numbers of sick dogs presented to veterinarians. There is however a large difference in the pathophysiology and the consequences of a "run of the mill acute diarrhoea" and an Acute Critical Care Gastroenteritis

Acute Small Intestinal Diarrhoea

Caused by diet change, over eating, ingestion of a preformed toxin, garbage disease, dietary indiscretion and infectious triggers. Abrupt onset and has a short clinical course that ranges from transient and self-limiting to fulminating.

Typical treatment of acute diarrhoea

Usually needs only supportive and symptomatic therapy, since most animals that die from [non critical care] diarrhoea do so not as a result of the inciting cause but from the loss of electrolytes and water, with subsequent dehydration, acidosis and shock.

The Mucosal lining of the SI

The intestinal epithelial cells carry out a multitude of functions:

 Villus crypts function primarily to secrete fluid into the bowel.

 After division in the crypts, the cells migrate up the villus reaching the tip in 3-5 days. During migration, the cells mature and change their primary function from secretion to surface digestion and absorption.

 Villus tip carries out the final stages of protein and carbohydrate digestion together with absorption of nutrients, salts and water. The villus tip gives an increase of absorptive surface area of over 30 times.

Rapid cell turnover is the major reason why most acute diseases of the small intestine are self-limiting. Normal mucosal integrity and function are usually restored in 2-3 days, provided the inciting cause is eliminated and the initial insult is not sufficiently severe to damage the crypts.

Non-specific, symptomatic treatment of acute diarrhoea

Treatment may not always be indicated as many animals improve spontaneously in a day or two without treatment.

All cases require a minimum date base consisting of a history, clinical exam, faecal float, urinalysis and a blood smear examination.

General treatment measures include:

 Dietary restriction (12-18 hours - but no longer in puppies), maintenance of fluid and electrolyte levels and acid-base homeostasis.
Small, bland meals frequently [when resume feeding], then gradually convert to regular commercial food once the diarrhoea resolves.

 Deworming - empirical deforming in all cases

 Antibacterials:
Antibiotics have long been part of standard treatment of acute diarrhoea; yet there is little evidence for bacterial infection as a major cause of diarrhoea in small animals. Antimicrobial agents can cause rapid changes in normal intestinal flora which are protective of the host, inhibiting colonisation by resistant organisms. The disruption of bacterial flora exposes the host to more pathogenic processes and may prolong the return of normal intestinal function.

Antibiotics are only indicated when extensive damage to the intestinal mucosal barrier occurs. Haemorrhagic Diarrhoea, fever and sever toxic left shift are examples where antibiotics are indicated.

Severe Acute Diarrhoea [e.g. critical care cases]

Parvo virus colonises fast dividing cell lines and through it's replication process's, destroys them. The typical parvo puppy thus loses the bone marrow and the lining of the GIT. So you are left with an immuno-compromised dog with probable septicaemia!!

Therapeutic Goal(s):

 Rehydration

 Treat /Prevent sepsis

 Correct potassium and glucose levels

 Normalise blood pressure

 Stop vomiting

 Pain control

 Enteral nutrition

Our Current Treatment Protocol for Canine Parvo Virus

Acute general Treatment
At Admission

Place IV catheter, administer IV penicillin/cephalosporin [repeat TID], plus quinolones in small breed puppies.
Test - Ht / TSP/glucose
Replacement fluid with 20 meq. KCL(1 vial) + 20 ml 50% dextrose

1st 2 hours

Work out the sum of re-hydration + Maintenance for 1st 12 hours
Give ¼ to ½ of amount over first 2 hours to correct intra-vascular volume and blood pressure (warm fluids to body temp).
Colloids can be used at 5-20ml/kg over 1-4 hours if in severe shock or if albumin low.

After 1st 2 h

Give rest of fluid over next 10 hours.
Test Ht + TSP + K + Glucose
Warm patient on heating pad at this point [NB - not before as may dilate peripheral vasculature]
[Spike drip with more glucose if needed. [50ml 50% =2.5% / 100ml 50% = 5%]
Plasma can be administered as an immunotherapy and for oncotic pressure. Indicated if plasma albumin <15.
Blood transfusion or Oxyglobin is indicated if puppy worsening with Ht <15-20.

Approx. 2-3 hrs

Metoclopramide IV or IM or as a constant rate infusion (CRI) to treat ileus and/or vomiting.
Pain control - Buprenorphine [TID/QID]
Start Cimetidine/Ranitidine IV for GI ulceration and reflux oesophagitis
Ulsanic 1ml/3kg TID if dogs vomiting a lot (for reflux oesophagitis)
Amikacin IV if blood pressure improved or quinolones if concerned re nephrotoxicity
(Test blood pressure or check for urine in bladder and CRT<2 sec's)

Approx. 4 - 5 hrs.

Start to feed (aim for at least 1/3 of requirements over next 24 hours).
Feed through vomiting
Work out requirements with formula - [(bwx30) +70] x illness factor (1.25 - 1.5)
See below for added control of vomiting and diet.

Approx. 12 hrs.

Re-assess hydration [weight patient daily]: continue rehydration or change to 1 ½ to 2x maintenance fluid rate.

 

IV - intravenous, IM - intra-muscular TID - 8 Hourly, Ht - Haematocrit, TSP - Total serum protein, KCL - Potassium chloride, K -Potassium, CRT - capillary refill time.

Monitoring

The following should be monitored at admission, after 2 hours of fluids and then on a daily basis [or 2-3x/day] in patients that are still ill:

 Body weight

 Blood glucose

 Haematocrit and TSP (Microhaematocrit tube and refractometer)

 Serum potassium - check around time of admission and up to 2-3x daily after that - even if you are not suspicious of hypokalaemia.

Use paediatric sampling tubes or take very small quantities of blood.

Fluid Therapy

Rehydration - Body mass x 10 x % dehydration = volume in ml.

Ongoing losses - Estimated at 10 - 20 ml/kg/24 Hrs if still vomiting/diarrhoea

Potassium supplementation

Serum Potassium mEq/l of patient

Supplementation potassium (per 1000ml)
replacement fluid
(mmol KCL = meq K+)

3.5 - 5.5 (N)

20 mEq K (1 vial KCL 15 % = 20mmol)

3.0 - 3.4

30 mEq K

2.5 - 2.9

40 mEq K

2.0 - 2.4

60 mEq K

Chronic Treatment

Repeat blood, plasma, colloid or Oxyglobin transfusions as often as needed.

To control vomiting [ensure no intussusception]

 Step 1 - CRI metoclopramide

 Step 2 - Add Ondansetron 2-3 x/day

 Step 3 - Add Prochlorpemazine suppositories

Diet/Nutrition

The previous "NIL PER OS" is not followed anymore

 Start to feed once rehydration is underway (+/- 4-12 hours after admission?)
(We try to never starve a puppy for longer than 12 hours)

 Aim for a minimum of 1/3 of nutritional requirements over next 24 hours

 If vomiting a lot, miss out 1-2 hours, cut back on quantity but do not starve!

 Feed high protein, high calorie foods

 It is the authors opinion that small volume is far more important that ultra low fat content

Deworming

 Fenbendazole [PO] course for 3-5 days [even if vomiting].

 Ivermectin [S/C]

Drug Interactions

 Flunixin meglumine is nephrotoxic and should be avoided in shocked patients

 Quinolones used for 5-8 days should be safe and not cause cartilage problems

 Ivermectin deworming not advised in debilitated patients

Recommended Reading

1.  Mohr AJ et al: Effect of early enteral nutrition on intestinal permeability, intestinal protein loss, and outcome in dogs with severe parvoviral enteritis, Journal of Veterinary internal medicine 2003;17:791-798.

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Dave Miller, BVSc, MMeDVet [Med]
Ridgemall Specialist Referral Centre
Johannesburg, South Africa


MAIN : Gastroenterology : Acute Critical Care Gastroenteritis
Powered By VIN

Friendly Reminder to Our Colleagues: Use of VIN content is limited to personal reference by VIN members. No portion of any VIN content may be copied or distributed without the expressed written permission of VIN.

Clinicians are reminded that you are ultimately responsible for the care of your patients. Any content that concerns treatment of your cases should be deemed recommendations by colleagues for you to consider in your case management decisions. Dosages should be confirmed prior to dispensing medications unfamiliar to you. To better understand the origins and logic behind these policies, and to discuss them with your colleagues, click here.

Images posted by VIN community members and displayed via VIN should not be considered of diagnostic quality and the ultimate interpretation of the images lies with the attending clinician. Suggestions, discussions and interpretation related to posted images are only that -- suggestions and recommendations which may be based upon less than diagnostic quality information.

CONTACT US

777 W. Covell Blvd., Davis, CA 95616

vingram@vin.com

PHONE

  • Toll Free: 800-700-4636
  • From UK: 01-45-222-6154
  • From anywhere: (1)-530-756-4881
  • From Australia: 02-6145-2357
SAID=27