Small Animal Medicine Midterm 1

Why would you see PU/PD in hepatic disease? Stranguria?

• decreased urea formation results in decreased ability to concentrate the urine causing more water to be lost in the urine

• Stranguria occurs due to urate stones in the bladder

What are the leakage enzymes and when do you see them increased? Cholestatic liver enzymes?

• ALT, AST due to irritation or death to hepatocytes

• ALP, GGT due to inflammation in bile duct, obstruction or cholestasis.

What are 4 products that may be lowered in hepatic disease/failure?

GUAC

glucose, urea, albumin, cholesterol

For animals with hepatic disease, what might you see in a urinalysis? (2)

• low USG

• urate crystals

What are two liver function tests that can be done? Explain.

• pre and post prandial bile acids which can be increased if there is bile duct obstruction or rupture. Not needed if bilirubin is known to be high.

• PT/PTT where significant hemorrhage is possible when >1.5x normal

What imaging means is best for visualizing the liver? How about CT?

ultrasound

finds nodules and anomalous vessels well in larger dogs.

What are three options for biopsies in liver?

• US guided tru-cut biopsy with a 14-16g needle on at least two lobes

• laparscopic biopsy

• take sample during an exploratory surgery

What are 6 medications that can be used as therapeutic options in dogs with liver disease?

1. antibiotics based off liver/bile culture

2. immunosuppressants if immune mediated (prednisolone, cyclosporin or mycophenolate)

3. ursodial (synethic bile acid to promote watery bile formation when cholestasis)

4. milk thistle/silymarin (free radical scavenger)

5. S-adenosyl methionine (SAMe) which is a building block for glutathione which scavenges free radicals

6. meds for hepatic encephalopathy like lactulose

How does ursodial work?

• synthetic bile acis which promotes more watery bile and less inflammation. Useful for cholestatic patients. But go straight to surgery if there is a bile duct obstruction.

How does milk thistle/silymarin work?

• free radical scavenger used for acetominophen and amanita mushroom toxicity

How does S-adenosyl methionine (SAMe) work?

Building block for glutathione which is used to scavenge free radicals and metabolize toxins

How does lactulose help with hepatic encephalopathy? What else can help?

• promotes beneficial bacteria and speeds food through the gut to acidify stool and trap ammonia

• protein restricted diet

What are three metabolic liver diseases?

• vacuolar hepatopathy (steroid hepatopathy)

• non-specific reactive hepatitis

• hepatic lipidosis

____________________: high circulating glucocorticoids due to hyperadrenocorticism or prednisone therapy. Hepatocytes become enlarged with lipid and glycogen (will see high alk phos). Diagnosis via clinical history and biopsy. Treat by correcting the underlying disease. Most have the signs of Cushing’s.

Vacuolar Hepatopathy (steroid hepatopathy)

_____________________: due to sepsis/endotoxemia. Common to see increased ALT and Alk Phos and bilirubin. Tends to resolve when sepsis is treated. Can happen with inflammation anywhere (even periodontal dx) and the liver tries to filter the mediators.

Non-specific reactive hepatitis:

___________: seen in obese cats who suddenly go anorexic. Fat is mobilized too rapidly and hepatocytes become filled with lipid and can’t function. Diagnosed by elevated liver enzymes and bilirubin; liver biopsy. Treatment via feeding tube and correct concurrent underlying disease (if identified). 

Hepatic Lipidosis

How would you immediately treat hepatic lipidosis in a cat?

feeding tube

try to correct underlying disease or caused if identified

How would you diagnose a portosystemic shunt (2)? How would you treat it is extra-hepatic? Intrahepatic?

• elevated bile acids, CT angiogram or portogram

• surgical ligation

• coil embolization

__________________: formerly called microvascular dysplasia. Hepatic vasculature is abnormal on a micro level (like 100s of tiny shunts). 

• Diagnose via elevated bile acids with no shunt seen on CT. No evidence of inflammation or neoplasia on biopsy. 

• Treat by controlling hepatic encephalopathy if present. Good long term prognosis. 

Portal Vein Hypoplasia

What is one antibiotic that can cause hepatotoxicities?

TMS

What species is lepto seen in? What organs can it affect? How would you diagnose? Treatment?

• dogs

• liver, kidneys, or both

• serum lepto titres or urine lepto pcr

• ampicillin or doxycycline and supportive care

How do most bacterial cholangiohepatitis infections occur? How would you diagnose?

• GI bacteria entering liver via bile duct or blood

• liver biopsy and culture

What causes infectious canine hepatitis? What about an infectious cause in cats?

• canine adenovirus type 1

• FIP

What are three chronic hepatic diseases?

• immune mediated cholangiohepatitis (treat with immunosuppressants

• copper storage disease

• hepatic neoplasia

What gene is responsible for copper storage disease in terriers? Labs? How would you treat it?

• COMMD-1 gene

• ATP-7A/B

• chelating agents

What is the most common primary hepatic neoplasia?

• hepatocellular carcinoma

Gallbladder mucoceles occur when there is abnormal formation of mucous. Why do we worry? How would you diagnose?

• pressure necrosis of wall can occur and rupture

• US with distinct appearance

Describe the five steps tof the pathogenesis of pancreatitis?

1. Tripsinogen to trypsin in acinar cell or duct causing auto digestion. Inflammatory cells invade local area.

2. edema, necrosis and hemorrhage 

3. local inflammation

4. adjacent fat necrosis

5. systemic enzyme release

What are 3 risk factors for pancreatitis? What breed is it seen most in?

• high fat meals

• lipid disorders

• endocrine disorders (Cushings, DM, etc)

• Schanuzers

Typical signalment for pancreatitis?

• >7y overweight spayed females most of the time with Shaunzers and terriers having high prevalence

An overweight dog comes in with boughts of acute vomiting, anorexia and diarrhea. They are in a hunched or prayer position. What condition are you suspecting?

pancreatitis

Why might you have jaundice with pancreatitis?

• extra hepatic bile duct obstruction due to inflammation surrounding it

What will the CBC show for a dog with acute pancreatitis?

• neutrophilic leukocytosis, left shift, toxic change and low TP

What are 6 changes seen in the biochemistry of dogs with pancreatitis?

• increased ALP, cholesterol, bilirubin, glucose

• decreased albumin and calcium

What test would you use to diagnose pancreatitis? Explain it.

• cPLI wich tests pancreas specific lipase where 200-400ug/L is the grey zone. Some dogs have mild increases when there is another disease occurring.

What are the 4 therapeutic steps you’d do for dogs with pancreatitis?

• rehydration

• analgesia (opioids)

• anti-emetics

• nutrition ASAP

What are 3 anti-emetics to use?

• maropitant (serenia)

• ondanestron ($$)

• metoclopramide (helpful for ileus but not used as much now)

What are 3 more common complications of pancreatitis?

• DM (transient— permanent possible but less likely)

• bile duct obstruction

• arrhythmias

What are 5 less common complications of pancreatitis?

• hypercoagulation

• permanent DM

• EPI

• pancreatic abscesses

• sepsis

True or false:

pancreatitis in cats is most often idiopathic

true

What are 3 signs of pancreatitis in cats?

• lethargy

• anorexia

• hypothermia

True or false:

A low fat diet is recommended for cats with pancreatitis

false— not needed

How would you test for pancreatitis in felines? What other measure may you see abnormal? Imaging?

• feline pancreatic lipase test

• low cobalamin

• US may show a mottled pancreas, nodular, hypoechoic with hyperechoic mesentery

Common tumour in pancreas?

• pancreatic adenocarcinoma

What does aldosterone do?

• increases reabsorption of sodium and secretes potassium in kidney

What are 4 general functions of glucocorticoids?

• protects the GIT from acid

• maintains glucose concentration

• maintains vascular reactivity

• counteracts effects of stress

True or false:

Addison’s disease is always bilateral failure of adrenal glands.

true

What percentage of adrenal reserve must be gone before clinical signs will appear in Addison’s?

85-90%

What kind of hypoadrenocorticism is most common?

• primary which is immune mediated destruction resulting in the inability to produce GC and mineralcorticoids like aldosterone

What is seen in atypical Addison’s?

• adequate mineralcorticoids made so Na and K are normal but GC

____________________ : results from abrupt cessation of chronic GC therapy (chronic pred). They had atrophied glands and then can’t produce. Also from misuse or OD of mitotane or trilostane to treat Cushing’s. 

iatrogenic hypoadrenocorticism

How would you describe the CS of Addison’s?

• anorexia, vomiting, diarrhea, PU/PD. Decreased appetite

Is there alopecia in dogs with Addison’s?

NO

What would you expect to see on the bloodwork and urinalysis for a dog with Addison’s?

• anemia with LACK of stress leukogram (normal or elevated lymphocytes)

• hyperkalemia and hyponatremia

• USG <1.030 in most

Describe the two methods to diagnose Addison’s?

• ACTH stim test where cortisol is measured before and after ACTH is given. Normal animals should have an increase in cortisol.

• Baseline cortisol test: if over 55 then not addisons. If questionable then do an ACTH stim test

Do you suspect a dog has Addison’s if the baseline cortisol is 65nmol/L?

NO— because over 55nmol/L

What are 3 treatment goals for Addison’s?

• correct hypovolemic shock (IV)

• correct electrolyte imbalances (IV)

• provide rapid GC (dex)

How would you deal with an Addison’s dog in shock?

• shock dose is 90ml/kg and you can give ¼ shock boluses over 15min increments until out of shock

• use 0.9% saline (as this does not have potassium)

• can also consider insulin or IV glucose if there are arrhythmias

For classic Addison patients, what are 2 mineralcorticoids you can give?

• fludrocortisone acetate

• desoxycorticosterone pivilate

Can the tympanic membrane regenerate?

Yes, in 14-35d

What is the stria mallearis? How does it differ between cats and dogs?

the manubrium of the malleus

C shaped in dogs and perpendicular in cats

How does the anatomy of the bulla differ between cats and dogs and why do we care?

small ridge between dorsal flaccida and ventral tensa in the dog but more separation in the cat. This makes it hard to access both sections in the cat and they may need surgery

What are 3 examples of primary causes of otitis?

• ear parasites

• neoplasia

• aural polyps

What would you suspect if your cat had pruritic ears with coffee grounds appearance?

• ear mites

Two neoplasia ddx for ears?

• adenocarcinoma or cerminous gland tumour

What species are aural polyps most common in? How would you treat? Success?

• cats

• removal via grasping, snare loop, cautery or bulla osteotomy

• often will return

What kind of factors for otitis increase risk but don’t cause disease on own? Give 2 examples?

• predisposing factors

• anatomy, moisture

What kind of factors prevent resolution and increase risk of recurrence? What are two examples for otitis?

• perpetuating

• inappropriate treatment, otitis media

What are secondary causes of otitis?

• bacteria or yeast

What are three common pathogens for otitis?

• Staph pseudointermedius

• Pseudomonas aeruginosa

• Malassezia pachycermatis

What are the 7 steps to approach otitis?

1. history to help with the primary cause

2. physical and dermatological exam

3. ear cytology

4. otoscopic exam

5. clean and treat external ear canal

6. work up and address underlying cause

7. address otitis media

What are the two types of otitis and how do they differ?

• erythroceruminous otitis: waxy and seborrheic

• suppurative: erythema, ulceration, neutrophils. Often Pseudomonas

Should you sample both ears for cytology if only one has clinical signs?

yes

You notice a cobblestone appearance when doing an otoscopic exam. What are you seeing? Treatment?

• glandular hyperplasia

• GC

How does Triz-EDTA work?

increases the permeability of the cell walls so antibiotics can penetrate better

What is the endpoint for treatment for otitis?

• cytological and clinical cure

What are two drugs that get inactivated in purulent material? What drug can cause cochleotoxicity if the round or oval windows are damaged and should not be used if there are neuro signs?

• neomycin and gentamicin

• gentamicin

Should you use topical or systemic treatment for otitis media?

• systemic

What procedure is it when you incise the tympanum at the 6 o’clock position and flush and drain?

myringotomy

What are the 6 steps in evaluating a pruritic animal?

1. history

2. physical and derm exam

3. minimal database: cytology***, skin scrapings, flea combing, etc

4. parasiticidal therapeutic trial

5. dietary restrictions

6. environmental allergy tests and therapy

What is the most common causative agent of bacterial pyodermas?

Staph. pseudointermedius

What type of pyoderma is intertrigo? Describe it? How would you manage it?

• surface

• dermatitis in the folds of loose skin. Usually breed related

• GC, topical abx, address inflammatoion, surgical correction in some cases

What is the most common type of folliculitis? Can yoxu distinguish it from dermatophytosis?

• bacterial

• no

Two breeds that often have deep furunculosis?

• golden retreivers

• Newfies

When do you use systemic abx for pyodermas?

When deep. Use topical for surface and superficial pyodermas

For pyodermas, what happens if the bacteria is not a cocci?

If you see rods, be cautious and think of where the sample was taken and if there was fecal contamination of contamination from outdoors on feet. Culture and if the there is a big lesion then think infection. Use a culture if you must do systemic (pseudomonas, etc). Don’t forget topical. 

True or false:

bacterial resistance does not increase virulence

true

True or false:

Malassezia is not normal flora

False

How does Malassezia dermatitis present? Treatment?

• pruritus, greasy with brown colour, alopecia, lichenification, hyperpigmentation.

• 2x weekly baths, topical miconazole or chlorhex.

What is the term for dark brown discharge in nails? Seen in what disease?

paronychia

malassezia dermatitis

Species of fleas? What causes flea allergy dermatitis? Treatment?

• Ctenocephalides felis

• antigen in saliva causes type I and IV rxn

• treat fleas and then allergies with GC

Are demodex normal flora? Where are they found? Contagious in dogs? Cats?

• yes in haired areas

• live in hair follicles, tend to be in localized refions in face, lip, commisures, etcs

• no

• yes if D. Gatoi

When do we often see canine demodicosis?

• in purebred juveniles like dobermans or Boxers that have endoparasitism or malnutrition

• adults when immunosuppressive drugs are used

How would you treat demodicosis in cats?

• it is contagious so treat all animals in house. Do 2% lime sulfur weekly dips and advantage multi off label

What kind of skin scraping is done to diagnose demodicosis? When do you stop treatment? How do you treat it if generalized?

• deep skin scarping then do trichogram

• 2 negative scrapings 4w apart

• amitraz dip every 10d

NOTE: can try isoxalines which inhibit GABA chloride channels (caution with neuro issues)

_______________: caused by Sarcoptes scabies var. Canis. Which is a superficial burrowing mite. Contagious to owners causing a papular rash on forearms and abdomen. Contagious to other dogs and cats. 

• typical lesions include the golden crust, papule, alopecia, erythema, scaling, severe pruritic (acute), margins of the pinae, hock and elbow. Can be generalized. 

Sarcoptic Mange

If you suspect sarcoptic mange but get a negative skin scraping, what should you do?

parasiticidal therapeutic trial

Proper name for intolerances and allergies are _____________________. Immune mediated reactions are food __________ but non immune-mediated responses are _____________.

cutaneous adverse food reactions (CAFR).

allergies

intolerances

What are the top 5 canine allergies? Cats?

• beef, dairy, chicken, wheat, lamb

• beef, fish, chicken, wheat, corn, dairy, lamb (basically the same but add fish and corn)

True or false:

Cutaneous adverse food allergies are indistinguishable from atopic dermatitis (environmental allergens)

true but food allergies commonly have some GIT signs too