Nutritional Assessment in a Dog with Chronic Enteropathy

Linda Toresson, DVM, Evidensia Specialist Animal Hospital, Helsingborg, Sweden

Gregg K. Takashima, DVM, WSAVA Global Nutrition Committee Series Editor

Kara M. Burns, MS, MEd, LVT, VTS (Nutrition), Olathe, Kansas

April 2018|Nutrition|Peer Reviewed

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Nutritional Assessment in a Dog with Chronic Enteropathy

THE CASE

A 4.5-year-old intact female shar-pei was presented for chronic recurrent diarrhea, which was either watery or mucoid, of more than a year’s duration. Vomiting and hyporexia developed the month before presentation and was associated with mild weight loss. The dog was the only pet in the household and was up-to-date on vaccinations and flea/tick preventives; heartworm prevention was unnecessary, as there is no heartworm disease in Sweden or northern Europe, where this dog lives.

Physical Examination

The patient had to be sedated for physical examination due to temperament. BCS was 4/9, with a muscle condition score showing mild muscle atrophy and a dull hair coat. Despite chronic diarrhea, no signs of dehydration were observed. All other vital parameters were within normal limits. Rectal palpation was painful despite sedation.

Dietary History

Several therapeutic diets labeled intestinal, including a high-fiber diet, had been tried throughout the last year without clinical improvement. The protein sources of those diets included chicken, egg, and turkey, and the owners sometimes gave treats such as cold cuts and table scraps. Water intake remained the same throughout the year. Metronidazole had been prescribed on several occasions; diarrhea would cease with metronidazole but would recur each time after discontinuation of therapy.

Diagnostic Results

Diagnostics included screening for intestinal parasites, CBC, serum chemistry profile, urinalysis, and a GI panel, including trypsin-like immunoreactivity, cobalamin, and folate. No intestinal parasites were detected. Subnormal serum concentrations of folate, cobalamin, and cholesterol were detected (Table). CBC and serum chemistry profile were otherwise unremarkable.

Endoscopy of the stomach and small and large intestine were performed. Histopathology of biopsies of the small and large intestine revealed a moderate lymphocytic-plasmacytic enteritis, with a moderate degree of villous atrophy, and moderate lymphocytic-plasmacytic colitis.

TABLE

SUBNORMAL SERUM CHEMISTRY RESULTS

Test Reference Interval Baseline 9 Weeks After Baseline 5 Months After Baseline
Cobalamin 251-908 ng/L (185 - 670 pmol/L) 231 ng/L (170 pmol/L) 705 ng/L (520 pmol/L) 250 ng/L (184 pmol/L)
Folate 7.7-24.4 µg/L (17.4 - 55.3 nmol/L) 3.5 µg/L (7.9 nmol/L) 35 µg/L (79.3 nmol/L) 25 µg/L (56.6 nmol/L)
Cholesterol 158-282 mg/dL (4.09 - 7.30 mmol/L) 124 mg/dL (3.21 mmol/L) 189 mg/dL (4.90 mmol/L) N/A

DIAGNOSIS:

CHRONIC ENTEROPATHY

Treatment & Follow-Up

The dog’s diet was changed to a commercial lamb and rice novel single-source protein diet, and folate supplementation (5 mg PO q24h) was initiated. Treatment with prednisolone was initiated (initial dose, 1.5 mg/kg q24h) and slowly tapered over 6 months (maintenance dose, 0.2 mg/kg q48h). Several attempts to further taper the dose were made but would cause diarrhea to relapse. Four weekly cobalamin injections (800 µg) were administered according to Texas A&M University Gastrointestinal Laboratory recommendations (see Suggested Reading). 

At follow-up 4 weeks after the last cobalamin injection, the dog’s stool had normalized, vomiting had stopped, and appetite returned. Serum cobalamin concentration, cholesterol, and folate had normalized (Table). Folate and cobalamin supplementation was stopped and prednisolone was further tapered to 0.5 mg/kg q48h.

At follow-up 3 months later, the dog had experienced 2 recurrences of diarrhea, and serum cobalamin concentrations had decreased to subnormal levels. A new parenteral cobalamin maintenance supplementation protocol was recommended; however, the owners were not interested in a new series of injections but were instead interested in oral cobalamin supplementation. 

Oral cobalamin supplementation has been proven to be effective in humans with cobalamin deficiency,1-5 and recent studies have confirmed its efficacy in dogs and cats with chronic enteropathy and hypocobalaminemia.6-9 It offers an alternative to parenteral supplementation and may suit some owners better, as oral administration may be an easier and more cost-effective alternative to monthly injections, particularly for patients requiring long-term maintenance supplementation. Because oral supplementation in dogs with hypocobalaminemia had not been studied at the time of this case, the potential for failure of this therapy was carefully discussed with the owners before supplementation (1 mg PO q24h) was initiated. 

At follow-up 2 months later, serum cobalamin concentration was higher than after the first series of injections and the dog was clinically stable. The dog has been on successful oral cobalamin maintenance therapy for 8 years.

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Changing the diet to a novel protein is most likely to be successful in patients with chronic enteropathy if:

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Which of the following statements regarding cobalamin is true?

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What is the most likely mechanism behind the cobalamin deficiency in this patient?

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In which breeds has congenital cobalamin malabsorption been reported?

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A middle-aged intact female cocker spaniel with a history of lethargy and reduced appetite of 2 months’ duration has a subnormal serum cobalamin concentration. The dog has been fed a homemade diet due to hyporexia for 6 weeks. How should the cobalamin deficiency be interpreted?

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Diet in Disease is a series developed by the WSAVA, the Academy of Veterinary Nutrition Technicians, and Clinician’s Brief.

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