CASE #8
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 "Puppet" at presentation to OSU |
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Puppet was presented to OSU for evaluation of one month duration of vomiting, diarrhea, and weight loss. The vomiting occurs anywhere from 10 minutes to 6 hours after eating. It is usually bile-stained fluid but if he has eaten recently, it contains food. The diarrhea has been watery and brown. Once or twice they have seen bright red blood in the stool. He usually has 2 to 3 bowel movements a day.
His appetite has been decreased. He is currently being fed Prescription Diet i/d, which the owners say he doesn’t like. He has been treated by the RDVM with Ampicillin and Tribrissen® (SMZ-TMP) with no improvement. Blood work performed one week PTA at OSU revealed hypoalbuminemia and mild anemia.
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diarrhea| Diagnostic Evaluation: | ||
| CBC: | see results | |
| Biochemical profile: | see results | |
| Amylase: | 810 iu/L (normal = 350 - 1950) | |
| Lipase: | 482 iu/L (normal = 260 - 1700) | |
| UA: | see results | |
| Fasting serum
bile acids (SBA): |
7 umol/L (Normal = <20 umol/L) | |
| Post-prandial SBA: | 9 umol/L (Normal = <20 umol/L) | |
| Fecal flotation: | negative | |
Thoracic radiographs were unremarkable.
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 Abdominal radiographs revealed decreased abdominal contrast, some gas accumulation in the stomach and small intestine. No evidence of foreign body or obstruction. Possible thickening of the stomach and small bowel were noted. |
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| Abdominal ultrasound revealed severe thickening of the small intestine with wall thickness greater than 9 mm and severe mesenteric lymphadenopathy. |
FNA of lymph node = majority of cells are small well-differentiated lymphocytes. An occasional medium lymphocyte, mast cell, and neutrophil were seen. Assessment: reactive lymph node.
FNA stomach wall = majority of cells are lymphocytes. Small to medium in size with slightly clumped chromatic and rare nucleoli. The lymphocytes do not appear as undifferentiated as expected for lymphoma. Therefore, cannot exclude gastritis.
FNA intestinal wall = inconclusive
An upper and lower GI endoscopy were performed the following day.
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| The stomach had thickened rugal folds with a few small hemorrhages. | An irregular nodular pattern was seen on the gastric incisura. | |
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| The duodenal mucosa appeared thickened with increased granularity. | The colonic mucosa also appeared thickened. |
Endoscopic biopsies were performed.
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Histopathology
of endoscopic biopsies obtained from the stomach, duodenum, ileum,
and colon were similar and revealed a diffuse infiltrate of monotonous
lymphocytes consistent with lymphoma. |
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Questions:
1. Would you characterize Puppet’s diarrhea as small or large bowel (or a combination)? Be able to explain your answer.
2. Do you think Puppet is vomiting or regurgitating? Why?
3. List
three major pathophysiologic mechanisms for hypoalbuminemia.
Which of the three do you think is most likely
for Puppet? Why?
4. Why doesn’t Puppet have ascites and edema 2º to his hypoalbuminemia?
5. If you
were unsure whether 1+ protein in the urine was a “significant” amount, what
test could you do to
help make that determination?
6. Is there a test that can document protein loss in the feces? What is it called?
7. What is the most likely mechanism for hypocalcemia? Is Puppet likely to show signs of hypocalcemia? Explain your answer.
8. What is your explanation for Puppet’s anemia?
9. Based
on the clinical, laboratory, and ultrasonographic findings, list your top
3 differential diagnoses for Puppet’s
vomiting and diarrhea. Can you definitely
differentiate these disorders by their GROSS appearance at endoscopy?
10. What areas of the GI tract are examined in an “Upper” and “Lower” GI endoscopy?
11. What is your final diagnosis?
12. What chemotherapy is available for treatment of GI lymphoma in dogs? What is the prognosis?
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