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3. small anim. Proct. Vol. 8, 1967, pp. 131 to 136. Pergamon Press Ltd. Printed in Great Britain.

A Clinical Approach to Diarrhoea* G. S. G. GRUNSELL Departmnt of Veterinary Medicine, University of Brirtot, Landord House, Bristol

Abstract-An attempt will be made to examine the symptom of diarrhoea in the context of broad clinical syndromes. Overlapping and omission are inevitable in this approach. The object will be to consider some of the commoner conditions in which the character and content of the stool is ab- normal, laying rather more emphasis on conditions which present problems in diagnosis.

D I A R R H O E A AS A N I N T E R C U R R E N T SYMPTOM IN THE conditions for consideration under this heading, diarrhoea is recognized as occurring as an important if not necessarily constant symptom. The epitheliotropic character of the distemper virus results not infrequently in involvement of the gastro- intestinal system. Thus in a survey of 50 dogs suffering from the disease, diarrhoea was a prominent symptom in 37 cases (Lauder, et al., 1954). The faeces are lighter in colour and sometimes contain blood flecks. These changes often occur early in the course of the disease and can in some cases be intractable to treatment. I n an experi- mental study in which fully susceptible puppies were exposed to virus, diarrhoea was a very prominent symptom (Gillespie et al., 1956).

\\'ilson and Lewis (1963), Staples (1955) and others, have drawn attention to the distemper-like syndrome which can be produced in lead-poisoning in dogs, with diarrhoea occurring as a symptom in a high proportion of cases. The similarity of the two conditions is enhanced by the higher incidence in dogs less than one year of age. The difficulty of differentiation has given rise to the postulate of a lead-distemper synergism (Hartley, 1956).

Tosoplasmosis is another infection which may be confused with, and may coexist Ivith, distemper. The diarrhoea occurring in this condition is reported to resist anti- biotic therapy (Holzworth, 1965). The fact that many cases of toxoplasmosis develop acute honcho-pneumonia may be of some assistance in differentiating from dis- temper but in a number of cases, it may be necessary for more positive diagnosis, to resort to the diagnostic methods for toxoplasmosis described by Heeley (1963). The variable manifestations of the disease in the cat have been described by Wilkinson (1963) but in the acute form, where the toxoplasm invades the liver, one of the symptoms of hepatic failure may be diarrhoea. With the more chronic form there is a

'#To be presented a t the 10th B.S.A.V.A. Congress, 1967.

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greater tendency for focalization and the production of granulomata of the intestine with resulting anaemia, weight loss and diarrhoea.

Mansi (1962) has stressed the importance of E. coli of the “0” group 042 in the production of gastro-enteritis in young dogs. He recognized three clinical states based on age, with dogs over 9 months of age developing a chronic intermittent diarrhoea which was resistant to treatment for periods of up to 12 months in some cases.

Diarrhoea, appearing as an intercurrent symptom in the adult dog and cat is more generally seen associated with the infections showing a more chronic course, as for example in nocardiosis (Pearson and Cox, 1963) and in toxaemic states. In renal failure the immediate pathogenesis of the vomiting and diarrhoea are not completely understood but are thought to be in some way related to the non-inflammatory mucosal infarction which follows the arteriolar necrosis in the wall of the tract. These lesions and the associated symptoms are likelier to occur in the more slowly develop- ing uraemic states (Jubb and Kennedy, 1963). A further example of diarrhoea related to toxaemia is afforded by some cases of pyometra in the bitch and in which the symptom may be remarkably resistant to treatment. Diarrhoea may be an inter- mittent symptom associated with lesians remote from the digestive tract. Thus in the cat, Wilkinson (1 966) describes two such conditions-toxic hepatitis and chronic hepatic congestion - associated with congestive heart failure.

DIARRHOEA AS THE MAIN PRESENTING SYMPTOM As in most of the conditions to be described diarrhoea is the only symptom in

evidence, it is important to acknowledge the normal individual variation in stool consistency. Next it must be recognized that when dogs of nervous temperament are exposed to certain environmental stimuli, intermittent diarrhoea can occur as a psychosomatic manifestation. On the other hand it may be possible to associate intermittent diarrhoea with the ingestion of certain foods. For example, Povar (1947) reported haemorrhagic enterocolitis in dogs which, he was able to demonstrate, occurred as an allergic response to cooked horse flesh or to kibble. Examples of other allergenic foods are wheat, corn meal and salmon.

Scott (1966) draws attention to the digestive disturbances which can arise in both kittens and adult cats fed on Lactose, which, it is claimed, encourages the prolifer- ation of certain organisms in the bowel flora. These bacteria ferment the Lactose with gas formation and resultant diarrhoea, which can become chronic. She points out the potential danger of the high Lactose content of whey, which may be incor- porated in the diet partly because it is rich in. riboflavin. A similar condition occurring in some cats, notably Siamese, is mentioned by Wilkinson (1966), in which diarrhoea is associated with a deficiency of sugar-splitting enzymes, which shows up on a milk diet. The resulting inflammatory reaction in the bowel, he postulates, may potentiate organisms of the coliform and Proteus groups.

This raises the whole question of the role of bacteria in enteritis in the dog and cat. A form of enteritis which is manifestly transmissable is well recognized as occurr- ing in dogs which are in immediate contact in kennels, and intermediate contact in urban areas ; the most spectacular form being the haemorrhagic enteritis encounter- ed in greyhound kennels (Kirk, 1947). Among the organisms assumed to be of primary pathogenic importance are haemolytic streptococci and staphylococci;

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various serotypes of E. coli; and in the more chronic forms of enteritis, Proteus spp. and Salmonella spp. Where the organisms isolated are normal bowel commensals, the decision on significance is proportionately more difficult. The value of the results of bacteriological examination in isolated cases of enteritis is very questionable, especially as sampling is so rarely pre-treatment.

The importance of helminth parasitism and of coccidial infection in relation to diarrhoea is almost exclusively in the very young animal, and is seen perhaps most conclusively in the so called pet shop-puppy syndrome (Howarth, 1965). As a cause of chronic diarrhoea in the adult, both helminths and coccidia are of minimal significance. The exception to this rule is in the case of Trkhuris uulpis found in the caecum of the dog, and which, when present in sufficient numbers, may be the cause of chronic diarrhoea with melaena (Lapage, 1956). The condition may be resistant to treatment. Among the recommended therapeutic agents are sodium fluoride, diphenylamine and n-butyl chloride.

Some of the remaining conditions which may be included under this general heading are:

intussusception-colitis recognized by the resulting alteration in defaecation pattern, and with which various protozoan helminth and bacterial infections have been associated ; a form of chronic persistent colitis described by Builder et al. (1950) as an eruptive lesion of the colonic mucosa spreading from the rectum; epithelial tumours of the rectum which are characterized by tenesmus and the passage of fresh blood in the faeces.

It is convenient to refer briefly to therapy for the group of conditions considered in the foregoing section. In the more acute conditions the importance of resting the digestive tract for 12-24 hr must be stressed and fluid therapy is sometimes indicated. In selecting the agent for oral use the question of whethcr absorption is or is not required will be decisive. Thus, for example, chloramphenicol, the tetracyclines and sulphadimidine are rapidly absorbed whereas streptomycin, furazolidone, sulpha- guanidine and neomycin are poorly absorbed. Identification of the pathogenic agent may also dictate the choice of drug, as may also sensitivity testing.

From time to time in cases of chronic intractable diarrhoea, the question of serious disturbance of bowel flora fcdlowing prolonged antibiotic therapy arises. Good evidence for ihis in fact occurring is lacking. In the case of prolonged neo- mycin therapy it has been found that it state of “complete sterility may be attained”, but it was shown that the state is of short duration and little consequence (Schwien- berg, et al. 1952). Nevertheless the value of the exhibition of the B complex vitamins following antibiotic therapy is well recognized.

Among the agents in use in combination with antibiotic treatment are kaolin, bismuth preparations, attapulgite, pectin and the anticholinergic drugs. This latter group may be of value in chronic ulcerative colitis by controlling spasm and reducing hyperirritability, but it has been found in man that full dosage and long continued administration is required (Goodman and Gilman, 1956). Synthetic substitutes are available for the belladonna alkaloid, and banthine adiphenine hydrochloride and methantheline bromide have been recommended for use in the dog (Kirk, 1965). Their superiority to atropine however is in some doubt.

(i)

(ii)

(iii)

134 G . S. C. C R U N S E L L

CONDITIONS SHOWING ABNORMAL FAECES A N D ASSOCIATED CACHEXIA

The most commonly recognised condition in this group is pancreatic disease in the form of exocrine deficiency. There is some evidence to suggest from pancreatic lesions found post-mortem (Jubb and Kennedy, 1963), and from clinical observation (Neilson and Pocock, 1953), that the more chronic forms of pancreatic insufficiency may follow a succession of acute bouts ofpancreatis some of which may be subclinical. In its mildest form deficiency of enzyme has been demonstrated in young dogs showing no more than unformed stools and slightly subnormal nutrition. In its more advanced form as seen in dogs under two years of age the condition may be associated with pancreatic atrophy or agenesis (Wilkinson, 1963). The more acute form of pancreatitis is sudden in onset and characterized by anterior abdominal pain, vomiting and blood stained diarrhoea (Wilkinson, 1963). The condition is most common in dogs between 7 and 9 yr old and although the aetiology is by no means understood it seem possible that the condition may arise from some interference with the production of the enzymes which are elaborated in the duodenal mucosa, and which are responsible for the stimulation of pancreatic enzymes.

The most commonly encountered form of exocrine insufficiency is characterized by copious pale, offensive stools, polyphagia, and marked loss of body weight. Confirmation of diagnosis is commonly by macroscopic examination of the stool and macroscopic examination of faeces for the presence of undigested meat fibres, starch granules and fat globules coupled with trypsin estimation as described by Davies (1957). This latter test has been found unreliable (Wolff etal., 1957; Vernon, 1962), and a vitamin A absorption test preferred. This test is based on the principle that oleum percomorphum can only be absorbed from the intestine in the presence of trypsin. Treatment is usually along the lines recommended by Wilkinson (1 962) ; namely the institution of a low fat diet, the incorporation of a wetting agent such as ox bile and the administration of a pancreatic enzyme preparation. Wilkinson (1962) also suggests measures to restore the pH of duodenal contents to normal. The exhibition of fat soluble vitamins parenterally would seem justifiable. In a proportion of cases there is a remission of symptoms under treatment but relapses occur, as for example, in the case reported by Neilson and Pocock (1953). However a number of cases completely fail to respond to treatment and it has been suggested that mal- absorption may occur more commonly than is generally accepted (Wilkinson, 1962). This state of malabsorption may coexist with pancreatic insufficiency (Miller, 1960) or occur as a separate entity (Kaneko et al., 1965; Bernon, 1962).

Three cases are reported by Kaneko et al. (1965) in which absorption failure was demonstrated for both carbohydrates and fats using glucose and I's1-labelled fat. These cases were in adult dogs and the symptoms included progressive weight loss with vomiting and diarrhoea. Increased gut motility was reported in two of the cases but the faeces did not contain blood mucus or fat. Only one case showed a macro- cytic anaemia and even in this case no megaloblasts were seen in the bone marrow. Based largely on the characteristic changes in the villi and crypts of the mucosa of the small intestine, Kaneko et ul. (1965), Vernon (1962), and others, have pointed out the similarity of this condition in the dog to idopathic sprue in man. Using the indirect fluorescent antibody technique sera from human cases with idiopathic

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steatorrhoea on a normal diet was found to give a reaction with the cytoplasm of jejunal epitheIia1 cells. This reaction was absent or much reduced on a gluten-free diet. This, it is suggested, shows that intestinal epithelium may absorb antigenic derivatives of gluten (Malik et al., 1964). I t is of interest that Kaneko and his co- workers, from their experiences with the malabsorption syndrome in dogs, suggest the omission of gluten from the diet as a useful line of approach in these cases. Incidentally, it is perhaps of importance to note that the symptoms of the nialabsorp- tion syndrome closely resemble those seen in the early stages of Lymphosarcoma of the digestive tract.

Although some reference was made in the previous section to colitis, the chronic nature of the condition now to be described and the possibility of confusing it with one or more of the conditions mentioned in this section, appear to justify its inclusion in the present context. This is a form of granulomatous colitis in dogs with histological features resembling Whipple's Disease in man and which has been described by van Kruiningen, et al. (1965). Although the condition has been seen in other breeds it appears to be commoner in Boxers. Young dogs are most susceptible and the clinical picture is of chronic diarrhoea with defaecation at more frequent than normal intervals. The faeces are described as glistening, soft, tan coloured and offensive, sometimes containing blood. The condition is afebrile throughout its course, towards the end of which there is weight loss and dehydration. More than one dog in a kennel population may be affected. Because of the similarity to Whipple's Disease in man, a similar line of treatment is recommended by the authors. This consists of a course of treatment lasting not less than ten weeks and takes the form of alternating chloramphenicol and salicylazosulfapyridine therapy. It is claimed that even where the condition has been in existence for as long as nine months cases respond to this treatment.

As was stated at the outset, no attempt has been made to include all the con- ditions which might be considered under the general title of this contribution, the aim being rather to afford a basis for further discussion.

REFERENCES BUILDER, P. L., FREAK, M. andJosI-ru.4, J. 0. :1950) Vet. Rec. 63, 794. DAMES, M. E. (1957) Vet. Rec. 69, 1071. GILLESPIE, J. H., BAKER, J. A. and POPPENSEIK, G . (1956) Ann. N.Y. Acad. Sci. 62, 206. GOODMAN, L. S. and GILMAN, A. (1956) T h Pharmacological Basis of Therapeutics. MacMillan, Nelv

HARTLSY, W. J. (1956) 3V.z. vet. J. 4, 147. HEELEY, D. M. (1 963) 3. small anim. Pract. 4,435. HoLzwoxTEr, J. (1965) Toxoplasmosis. In Veterinary Therapy, Smdl Animal Practice. (Ed. KIRK, R . W.)

HOWARTH, W. (1965) Diarrhoea. In Veterinag' Therapy, Small Animal Practice. (Ed. by KIRK, R. W.)

JUBB, K. V. F. and KENNEDY, P. C. (1963) Pathology ofDomestic Animals, vol. 2. Academic Press, New

KANEKO, J. J., MOULTON, J. E., BRODEY, J. S. and PERRYMAN, V. D. (1965) 3. Am. vet. med. Ass. 146,

KIRK, H. (1947) Index of Dingnosisfor Canine and Feline Surgeon. Bailliere, Tindall & Cox, London.

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KIRK, R. W. (1965) Veterinary Therapy, Small Animal Practice. Saunden, Philadelphia. KRUXNINGEN, H. J. van., MONTALX, R. J., STRANDBERG, J. D. and KIRK, R. W. (1965) Path. Val. 2,

LAPAOE, G. (1956) Ve’ctniMry Parm’tologv. Oliver & Boyd, Edinburgh. LAIJDER, 1. M., MARTIN, W. D., GORDON, E. B., LANSON, D. D. and CAMPBELL, R. S. F. (1954)

MANSI, W. (1962) Advances in Small Animal Practice, Vol. 3, p. 29. ~IALIK, G. B., WATSON, W. C., MURRAY, D. and CRUICKSHANK, B. (1964) Lancet 1, 1127. MILLER, R. M. (1960) M o h Veterinary Practice 41,34. NEILSEN, S . W. and POCOCK, E. F. (1953) Corn11 Vet. 44,567. PEARSON, H. and Cox, G. (1963) Advances in Small Animal Practice 4,79. Pergamon Press, Oxford. POVAR, R. (1947) J . Am. vet. mcd. Ass. 111,61. SCHWENBERG, F. B., JACOB, S. and RUTENBERG, A. (1952) P ~ o G . SOG. exp. Biol. Med. 79, 335. SCOTT, P. P. (1966) in Diseases ofrhc cat (Ed. WILKINSON, G. T.). Pcrgamon Press, Oxford. STAPLES, E. L. J. (1955) N.Z. vet. 3.3,39. VERNON, D. F. (1962)J. Am. vet. mcd. Ass. 140,1062. WILKINSON, J- S. (1962) Aahues in Smnll A n i d Practice, 4, 3 1. Pergamon Press, Oxford. WILKINSON, G. T. (1963) Vet. Rec. 75, 1198. WILKINSON, G. T. (1966) Diseuses of the cat. Pergamon Press, Oxford. WILSON, M. R. and LEWIS, G. (1963) Vet. Rcc. 75,787. WOLFT, A., DONOVAN, E. F. and NEILSEN, S. W. (1957) J . Am. vet. mcd. Ass. 131, 104.

521.

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RCswnC-Un essai sera effectut d‘examiner les symptBmes de la diarrhtc dans lc contexte de luges syndromes cliniques. Des rtpttitions et des omissions sont intvitables dans cette approache. L’objct sera la considtration des conditions les plus communes sous lesquelles les caracteristiques et le contenu des selles est anormal, soulignant particulitrement les conditions que prcscntent des probltmes de diagnose.

Zusammcnfassapg-Es wird ein Versucht gemacht werden, die Symptomc von Diarrhoe im Rahmen grober, klinischer Syndrome zu untenuchen. Bei diesem Vorgehen ist cin etwaiges Ober- greifen und Obersehen unvermeidlich. Der Zwcck des Versuches ist, cinige der haufigeren ZusGnde, bei welchen die Beschaffenheit und der Inhalt des Stuhls abnormal ist, zu berucksichtigen, wobei etwas mehr Gewicht aufjene Umstandc gelegt werden wird, welche Probleme bei der Diagnose hervorrufen.