LBAH Informational Articles

Kidney (Renal) Cancer

Its not that often that we see a primary kidney cancer in a young pet. Unfortunately, it does occur. This page will show you how we diagnosed and treated it on a one year old Basenji.

This page emphasizes how fast things change, and a pet that is perfectly healthy on a physical exam and blood panel, can change for the worse.

Click on any photo to enlarge it. Graphic photo of a kidney with cancer on this page.

Normal Physical Exam

As part of our routine pre-operative spay exam a blood panel is run. It came back normal. Note the circle over BUN and Creatinine. They are tests of the kidneys, and they are normal.

Kidney-Tumor12 copy

Surgery and healing progresses as expected for a young dog. Over the next several months there was no indication of a problem.

Abnormal Physical Exam

History

Three months later this young dog was presented with signs of decreased appetite and not feeling herself.

Physical Exam

  • Body Temp- 101.6 degrees F
  • Mucous membranes- pink
  • Respiratory rate- 40 breaths per minute
  • Heart rate- 150 beats per minute
  • Haircoat- normal
  • Musculoskeletal system (bones and muscles)- normal
  • Mout- normal
  • Eyes- normal
  • Abdomen- normal
  • Lymph nodes- normal
  • Ears- normal
  • Heart- normal
  • Urogenital- normal
  • Weight- 22#, no change from 3 months prior

Interpretation- Even though this exam is essentially normal, a lack of appetite in a young dog is of concern. Also, no weight gain over the last 3 months is cause for concern in a young animal, and confirms the owners observation of lack of appetite.

Diagnostic Tests

  • Blood Panel

    It is obvious there is a serious problem with the kidney tests compared to 3 months prior. In addition, other tests are elevated, all leaning towards a serious kidney problem.

    Kidney-Tumor6

  • Ultrasound

    This is the abdominal ultrasound report. Read it carefully to see how detailed it is and note the abnormalities.

    The abnormalities are marked in the pictures to follow.

    Kidney-Tumor1

    Left kidney

    Kidney-Tumor2

    Right kidney

    Kidney-Tumor3

    Liver

    Kidney-Tumor4
    Kidney-Tumor5

    Small intestine

    Kidney-Tumor13

  • Cytology

    A fine need aspirate (FNA) was obtained during the ultrasound. This is a non-invasive way to obtain a sample as compared to a highly invasive (and more expensive) exploratory surgery. The skill of our ultrasound doctors gives us confidence in the accuracy of the FNA, although there is on guarantee it will give us an accurate cause to the enlarged kidneys.

    The sample is sent to a pathologist for microscopic analysis. It came back a malignant cancer called lymphosarcoma (LSA), also known as lymphoma.

    Kidney-Tumor9

  • Necropsy

Necropsy photo of a cat with kidney cancer. This is how lymphoma looks in a cat, not the dog above. The cancer is at the arrow, from the 7 PM to 2 AM position on the left.

cancerouskidney

Treatment

This is a serious problem that needs to be treated by a veterinary oncologist.

We send all of our cancer cases to the Veterinary Cancer Group

Kidney-Tumor14

This is the treatment protocol initiated 4 months ago

Kidney-Tumor11

Four months later this dog is doing well, with the kidney tests dramatically improved:

BUN- 35

Creatinine- 1.8

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Hemangiosarcoma

Spleen Disease (Hemangiosarcoma, Hematoma)

It is not uncommon for us to encounter problems with the spleen. Sometimes it just enlarges without any major problems, sometimes it twists on itself, sometimes it causes internal bleeding, and oftentimes it becomes cancerous. This page will emphasize cancer of the spleen, called hemangiosarcoma.

In breeds that have a high incidence of splenic tumor we recommend yearly exams starting at 5 years of age,  with radiographs and ultrasounds to catch this problem early before complications and spread, since the prognosis is poor in most cancerous spleens because they have already spread by the time of diagnosis.

Unfortunately, some pets, especially large breed dogs, will not show any symptoms until the spleen is huge. This occurred with a Labrador Retriever that was presented to us with the owner telling us “he just wasn’t doing right”.  He was eating good, was not vomiting, had no diarrhea, and was not coughing. This owner was astute and brought him in for an exam just in case.

A thorough exam and blood panel revealed no problems, so a radiograph was taken. This radiograph revealed a large abdominal mass. This could have been coming from the liver, spleen, intestines, kidneys, pancreas, or mesenteric lymph nodes. An ultrasound revealed it was from the spleen. The next day we removed an 8 pound rupturing spleen! You can see pictures of the surgery to remove this large mass in the surgery section later in this page.

Graphic surgical photos are on this page

Nomenclature

We will use some medical terms regarding the spleen:

  • Extra medullary hematopoeisis – The making of red blood cells outside of the bone marrow
  • Reticuloendothelial system – in regards to the spleen, it is the system that recycles red blood cells
  • Anemia – a low amount of red blood cells or hemoglobin
  • Thrombocytopenia – a decrease in thrombocytes, which are an important part of the clotting factors when there is bleeding.
  • Hemoabdomen – free blood in the abdomen
  • Splenomegaly – enlargement of the spleen as a result of any cause
  • Splenectomy – removal of the spleen
  • Hypersplenism- an enlarged spleen that is normal and not causing any problem

Spleen Anatomy

The spleen is an elongated and relatively flat organ that resides in the abdomen of mammals along the outer edge of the stomach. It has a tremendous blood supply that is closely attached to the blood supply supporting the stomach. It is the largest filter of blood in the body.

It has an outer capsule composed of smooth muscle and elastic fibers. The internal part of the spleen (called the parenchyma) has white pulp and red pulp. The white pulp is lymphatic tissue and the red pulp is part of the venous blood system. In between these pulps is elastic tissue that can fill up as needed.

A normal spleen in a cat

A normal spleen in a  small dog

A normal spleen in a medium sized dog

A swollen spleen in a medium sized dog

The blood supply to the spleen is closely adjoined to the stomach. You can see the dark vertical blood vessels in this photo as they enter fat between the stomach and a very enlarged and dark spleen in a semi-circle at the far right.

Physiology

The spleen has many functions. The four primary ones are:

  • Storage of cells
  • Production of red blood cells
  • Filtration of the bloodstream
  • Production of cells for the immune system

Iron that has been recycled from old red blood cells is stored in the spleen where it awaits transport to the bone marrow.

Fortunately, the body can get by without a spleen in most cases, so if there is a serious problem, and all other factors are equal, we will remove it. We tend to remove only spleens that are cancerous, rupturing, or have a torsion.

Diseases

Splenomegaly

Splenomegaly is a generalized term that simply means enlargement of the spleen. In some species, like ferrets, an enlarged spleen can be normal, and is called hypersplenism. A spleen can be enlarged diffusely or it might  have nodules in certain areas.

There are many causes for an enlarged spleen. The most common and important are listed in more detail below. Some of the more uncommon ones are due to infectious agents (erlichiosis, babesia, hemobartonella), FIP, medications, and immune mediated diseases.

This spleen has splenomegaly in addition to numerous nodules

Splenic Torsion

In this problem the spleen twists on itself, compromising the blood supply. When the spleen twists the blood keeps on pumping into it by the arterial system, but this same blood is not able to leave through the venous system, and the spleen becomes grossly engorged.

It can occur on its own, after excessive exercise, or due to trauma. It can occur in conjunction with Gastric Dilatation Volvulus (GDV), also known as bloat. We tend to see this torsion, along with GDV, in large and deep chested breeds.

If the torsion is chronic, there might be no symptoms at all, or there might be:

    • poor appetite (anorexia)
    • weight loss
    • discolored urine
    • vomiting- might be intermittent
    • weakness
    • weight loss.
    • collapse
    • death

Examination of a pet with splenic torsion might reveal:

    • pale mucous membranes (gums)
    • rapid heart rate (tachycardia)
    • painful abdomen
    • a large mass in the abdomen upon palpation
    • fever
    • dehydration
    • jaundice (icterus)

A blood panel might reveal:

    • anemia
    • low platelets (thrombocytopenia)
    • elevated white blood cells (leukocytosis),
    • elevated liver enzyme tests,
    • hemoglobin in the urine (hemoglobinuria)

This disease is diagnosed by imaging tests when the above symptoms are present. A radiograph might reveal a mass in the abdomen with the spleen abnormally located. Ultrasound can confirm the problem and give us an idea of its severity.

A splenic torsion is considered an emergency, so the treatment of choice is surgical removal after a pet has been stabilized by treating for shock. On the deep chested breeds we might even tack the stomach to the abdomen to help prevent potential GDV in the future.

Splenic Cancer

Some splenic masses that are cancerous are classified as benign, meaning they do not generally spread (metastasize), and only take up extra space within the abdomen. Even though they do not spread, sometimes this extra space they take up can interfere with other organs.

Some benign cancerous masses include lipoma (fatty tumors), hemagioma (associated with vasculature), and plasmacytosis (infiltration of plasma cells throughout the splenic nodule or tissue in general). Unfortunately, when a spleen has cancer it commonly is the malignant version and not this benign version.

The most common malignant tumor in the spleen is the hemangiosarcoma (HSA). It is also called malignant hemangioendothelioma). The cause is not known. It can spread to many different organs, making it highly malignant:

    • heart
    • lungs
    • muscle
    • skin
    • bones
    • abdomen
    • diaphragm
    • brain
    • kidney

HSA can also cause complications, such as disruption of the coagulation cascade which causes a mixture of abnormal clot formation as well as inability to control internal bleeding (known as disseminated intravascular coagulation, DIC).

Symptoms of HSA vary, and range from mild to severe. In extreme cases sudden blood loss can lead to sudden death.

These large nodules on this spleen are a malignant cancer called hemangiosarcoma

Another common type of malignant splenic cancer is lymphosarcoma, a type of cancer that can have a primary tumor in any other organ (i.e. lung, gastrointestinal tract, liver). Lymphosarcoma is one of the more common tumor types observed in the spleen of cats. Sometimes the tumor within the spleen is not even the primary tumor, but rather a single nodule or multiple nodules due to metastasis from a distant primary tumor.

Hematoma

Hematomas are one of the most common causes of an enlarged spleen in dogs, representing over 50% of splenomegaly cases. This type of splenic mass is basically an accumulation of pooled blood within the splenic tissue; many stop growing and are then resorbed after a period of time, but others grow exponentially and eventually rupture. A ruptured hematoma originating from the spleen is an emergency, and often the pet experiences an acute collapsing episode followed by a significant loss of blood into the abdomen (hemoabdomen). You can see the surgery of a dog with an 8 pound hematoma later in this page

Other causes

Congestions of the spleen can occur from iatrogenic causes, which are those associated with administration of certain drugs (i.e. anesthetic agents or tranquilizers). Congestion can also occur due to increased blood pressure within the vasculature of the liver (known as portal hypertension), which can occur secondary to congestive heat failure among others.  The spleen can over-react to particular conditions, resulting in a disease process known as hyperplastic, or reactive, splenomegaly. A spleen can become reactive when there is excessive stimulation of the immune system from conditions such as immune-mediated disease, bacterial infections, tick-borne diseases, and many more.

This spleen has a laceration

Diagnosis

Signalment

Dogs, cats, and ferrets can get splenic diseases, although it is much more of a problem in dogs. Splenomegaly itself can occur in most any age due to the numerous causes of the condition. For instance, if the cause of splenic enlargement is infectious, then the pet may be quite young. However, if the enlargement is cancerous, the pet tends to be middle aged (average 10 years in dogs). Due to the wide range of causes, there is no known gender predilection (males tend to be affected equally as often as females). Certain disease processes tend to be over-represented by specific breeds:

Splenic torsion tends to occur in large breed, deep-chested dogs:

Splenic tumors like HSA tend to occur in several breeds. It can be some common in some breeds that we  recommend physical exams, blood work, abdominal radiographs, and especially abdominal ultrasounds, yearly in these dogs as they reach 5 years of age:

    • German Shepherds
    • Golden Retrievers
    • Portugese Water Dogs
    • Boxers
    • English setters
    • English pointers
    • Great Danes
    • Skye Terriers
    • Bernese Mountain Dogs

History

In many cases, a patient with splenic disease has very little or no specific clinical signs. Observations made by owners at home might include non-specific indicators of illness:

    • lethargy
    • inappetence
    • weight loss
    • diarrhea
    • vomiting
    • collapse
    • discolored urine
    • abdominal distention

Physical Exam

Upon palpation of the abdomen, significant abnormalities of the spleen can usually be detected, especially when a large mass is present within the cranial aspect of the abdomen (toward the chest). However, a mass or enlarged organ in the cranial abdomen cannot always be differentiated from a mass or enlargement of the liver. In some cases, decreased pallor (pale gums) can be a sign of anemia or shock, which in combination with an abdominal mass can indicate a ruptured splenic mass or torsion. We confirm this with an ultrasound before surgery.

If the gums are pale, certain diseases of the spleen may lead to free blood in the abdomen, which can sometimes but not always be detected by palpation of a fluid wave. Other generalized signs might include weakness, fever, dehydration, poor pulses, increased heart rate (tachycardia), increased bleeding at site of blood draw (due to coagulopathy), and/or increased size of peripheral lymph nodes.

Diagnostic Tests

Some diagnostic tests which provide significant information include radiographs, blood work, ultrasonography, evaluation of the cells (cytology) through a fine-needle aspirate sample, and surgical exploration.

Radiography

The arrow points to what a spleen looks like on a radiograph. It is enlarged, although a lobe of the liver can easily overlap the spleen and make the spleen look enlarged. So in this case, technically its called hepatosplenomegaly.

Here is a dog with an enlarged spleen. Can you see it?

Splenectomy -SpleenRadSplenectomy -SpleenRadSplenectomy-LateralRad

The red circle delineates the enlarged spleen.

L.I. – Large Intestine

Pr- Prostate

Splenectomy -SpleenRadSplenectomy-SpleenRadCircle

Blood Panel

Blood work (clinical chemistry and complete blood counts) is a crucial component for detection of compromised organ function. Splenic involvement might reveal anemia (decreased red blood cells), thrombocytopenia (decreased platelets for clotting), leukopenia (decreased white blood cells) and reticulocytosis (increased immature red blood cells to indicate that the body is trying to compensate for the loss of mature red blood cells).

This is a blood panel that might be seen with splenic disease, although many other diseases can also cause this type of blood panel. The primary problem in this blood panel is anemia.

Fluid Analysis

If abdominal fluid is present we can remove it and analyze it. This is called abdominocentesis. There is no guarantee this will make a diagnosis since many cancers, including HSA, might not be found in this fluid.

Ultrasonography

Ultrasonography has revolutionized diagnosis in animals, and prevented many unnecessary exploratory surgeries (called celiotomies or laparotomies), while at the same time alerted us to the fact that we need to do immediate surgery. Keep in mind, our patients do not talk to us, and  an enlarging tumor in the abdomen in one of us humanoids would be uncomfortable, and cause us to seek medical care long before we see a dog or cat with a tumor growing in the abdomen.

Ultrasonography of the abdomen is an important modality for diagnosis of splenic disease because of its sensitivity to changes of organ size, shape, location, and even texture. An ultrasonographic examination in combination with radiographs provides a comprehensive understanding of which organs are involved and often helps to narrow the possibilities down to a select few differentials.

We use ultrasound to confirm our suspicions of a splenic tumor based on the breed, history, exam findings, and blood panels and radiographs. Ultrasound confirms the diagnosis, lets us know if the spleen is already rupturing, tells us the size of the spleen, and if there are any other internal organ problems. A critical component of the ultrasonographic exam in HSA is echocardiography (evaluation of the heart). A key site of metastasis associated with hemangiosarcoma is the right atrium. HSA that has spread to the right atrium of the heart is a serious sign, and the prognosis is not good. This is important information if we are thinking of surgical removal of the spleen.

The lines demarcate the margins of this spleen

Do you see the spleen in this picture without the demarcation?

A typical ultrasound report on a dog with a cancerous spleen

This ultrasound of the heart (echocardiogram) shows spread of the tumor to the right atrium, which is a poor prognosis

RV- Right ventricle

RA- Right atrium

Cytology

Aspiration of the cells in an organ for cytological exam by a pathologist is an important part of most abdominal ultrasounds. It helps prevent an exploratory surgery, and can lead to a diagnosis in many cases. Cytologic evaluation of splenic problems is not always indicated and can sometimes be contraindicated depending on certain disease processes. Certain cancers of the spleen as well as hematomas may result in significant blood loss if stuck with a needle due their fragile nature. Even though the ultrasound guides the biopsy location, if the disease process only involves a small portion of the splenic tissue, or is sporadically located throughout, then a small needle-sized sample may not obtain the affected tissue at all.

ECG (Electrocardiogram)

This tests the electrical activity of the heart. I some HSA’s there will be an arrhythmia

Definitive Diagnosis

Histopathology is the analysis of the spleen after it is removed. This gives us our final diagnosis.

Histopathology

Treatment

Surgery is a common treatment for splenic disease. This is called a splenectomy. If there is trauma or a problem in only a small part of the spleen, we might do a partial splenectomy since we always want to preserve as much function of the spleen as possible. This partial splenectomy is not common.

We do the surgery to remove the tumor, and if malignant add chemotherapy to help prevent spread after we do the surgery. Prior to surgery we do an ultrasound of the heart as already mentioned, and also take chest radiographs to check for spread of a tumor. We also perform a clotting panel since blood loss is common in this surgery and we do not want post operative bleeding.

Unfortunately, survival time for dogs and cats with surgery alonge HSA is only 1-3 months, with most dogs dying due to spread of the HSA to other organs, causing these organs to malfunction. This emphasizes the need for an early diagnosis in the breeds prone to this cancer.

Dogs that have surgery to remove the spleen, and that are also treated with chemotherapy, might survive up to 9 months. This depends on whether the tumor has spread, and again emphasizes the need for an early diagnosis. Dogs and cats have less side effects than people on chemotherapy, and their quality of life is high if this therapy is instituted immediately after surgery.

Dogs that are diagnosed at a young age, have had the HSA rupture prior to surgery, have evidence of spread to other organs when the splenectomy is performed, or have a more aggressive grade of tumor, do not tend to live 9 months after surgery.

The primary chemotherapy drug for HSA is Adriamycin (doxorubicin). It will slow the disease process, but it will not cure your pet of this disease. The doctors at the Veterinary Cancer Group in Tustin institute this therapy.

If a pet is anemic, or we anticipate significant blood loss during surgery, we will give a blood transfusion prior to surgery or during the procedure. Post operatively if a pet is not doing well we will give a blood transfusion also.

After doing a cross match to ensure compatibility we obtain whole blood for the transfusion

Splenectomy

A splenectomy is performed to treat and sometimes cure this problem. It is sometimes done as an emergency procedure if the spleen has ruptured and there is significant internal bleeding.

Pre-anesthetic preparation is important in every surgery we perform, no matter how routine, because surgery is not an area to cut corners.  Once a pet is anesthetized, prepared for surgery, and had its monitoring equipment hooked up and reading accurately, the surgery can begin.

This is a sterile abdominal surgery, and our surgeons scrubs with a special antiseptic soap prior to gowning and gloving

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While our patient is being anesthetized our surgeon is already in our surgical suite setting up instruments. Our surgeon is ready to start before our patient is at a proper plane of anesthesia. Once the anesthetist gives the green light the surgery starts immediately. We want our surgeon waiting for his patient, not the other way around.  All of this is to minimize anesthetic time.

OVH-rabbit-3

OVH-rabbit-2

We keep a close tab on important physiologic parameters for all of our surgeries. Monitors like this give us an early warning of an impending problem.

This machine monitors:

Temperature

Heart Rate

Heart rhythm

Oxygen saturation

Carbon dioxide level

Respiratory rate

Surgery-Monitor

In addition to our monitoring equipment our anesthetist stays “hands on” in monitoring important physiologic parameters. Our anesthetist is using a special stethoscope (esophageal), that is passed down the esophagus and lays right over the heart. This gives us a clear sound of the heart and how it is beating.

Rabbit-femurfx-9

To minimize anesthetic time we routinely have 2 doctors working as a team performing the splenectomy.  They work together as a well orchestrated team.Our patient is under anesthesia and our surgeons are completing the draping process while our anesthetist is adjusting the surgical lights.

By working together early in the surgery we minimize anesthetic time.

For a pet that might already be anemic it is important to minimize blood loss during surgery. Special care is taken on entering the abdomen to minimize loss. There is minimal bleeding at this point as our surgeon gently dissects the sub Q (subcutaneous) tissue just under the skin.

As the surgery progresses we sometimes encounter significant bleeding from blood vessels in the sub Q fat and from muscles that are cut. All of them are clamped or cauterized before proceeding further. For a pet that might already be anemic this added blood loss is important to control, and it is stopped immediately.

When all bleeders are under control (called hemostasis) we enter the abdomen. We make our incision at a specific spot in the abdominal muscles called the linea alba. It is at this spot that there are minimal blood vessels. The linea also has strong tendinous attachments to the muscle, so when we sew it back together these tendons attachments have more holding ability than the abdominal muscles alone. This will prevent a hernia.

Our first view of the spleen once we have entered the abdomen. It is the round and reddish structure at the top of the abdominal opening and just to the left of our surgeon’s finger.

A spleen that is not healthy is friable and can easily rupture when handled. Our surgeon has to gently coax it out to prevent  this from happening.

Once it is finally exteriorized the problem is obvious. At this point we do not know if it is cancerous or not. We do know it is in the process of rupturing and glad we are getting it out now.

Now that we have it ready for removal we have to ligate its blood supply. As you remember from your surgical anatomy above the blood vessels to the spleen are closely related stomach. It is important to ligate the blood supply very close to the spleen so as not to compromise the blood supply to the stomach, leading to serious consequences.

This blood supply can be surrounded by fat. We have to isolate segments before we ligate.

In the center of this picture you can see one blood vessel that is already ligated. On the right our surgeon is in the process of ligating another blood vessel.

We have completed 3 ligations at this point, with many more to go.

Our surgeons work simultaneously, each starting at a different end of the spleen, so they can complete this tedious part of the surgery sooner. Its all about secure ligation of these blood vessels and minimal anesthetic time.

As part of the natural healing process there is a tissue in the abdomen called omentum. It is like a net, and surrounds an organ that might be diseased. For example, a ruptured intestine that is leaking intestinal fluid (extremely irritating to the abdomen and will cause a peritonitis), will have this net surround the intestine to wall off the leak.

In the case of this rupturing spleen the omentum covered the spleen to help prevent further blood loss. These are clots on the omentum from that. At this point in time during the surgery we cannot determine for sure if these are clots or spread of tumor. The report from the pathologist will tell us for sure. It turns out that this time they are clots.

When the spleen is completely removed we complete our exploratory surgery by checking the other internal organs, especially the liver. Once this check is complete we suture the muscle layer (the linea alba) closed. Again, we work as a team, with each surgeon (they are both lefties) suturing the linea until they meet in the center.

Once we have finished suturing our patient, who is already on a pain patch (Duragesic or Fentanyl patch- which is removed in 3 days), is given an additional pain injection and carefully monitored post-operatively. As part of the monitoring we perform a simple blood panel to make sure there was no problem with blood loss during surgery. If the blood loss is significant we will give a blood transfusion with the blood we have already set aside specifically for this patient.

Post operatively we take radiographs of the chest and perform and ultrasound every 2 months for cases of HSA looking for distant and local metastasis.

Occasionally we come across a spleen that is so large it is hard to believe it can get this big. The following spleen was over 8 pounds, removed for a 65 pound labrador named Jake.  Dr. P and Dr. R had to do this one together. Removing it was like delivering a baby!

The size was obvious as soon as we entered the abdomen. At this point in time we were not sure if it was a boy or a girl! Dr. P is coaxing it out of the abdomen at the beginning of the surgery, being very careful not to rupture it.

We had to be very gentle  because it was quite delicate(friable) and already rupturing

Ligating the blood vessels to the spleen was more difficult than usual because of the size, scar tissue, and omental tissue that covered the rupturing spleen

It turns out that this was a hematoma and the dog did fine for several more years. Lucky this spleen did not rupture before the surgery.  Most likely, with a hematoma this large, death would have ensued rapidly.

Ancillary Treatment

After surgery we will consult with the oncologists at the Veterinary Cancer Group for further treatment

Post Surgical Treatment

Prognosis

A successful outcome from surgery depends on what disease process is present and how long it has been present.

Splenic Hematoma – good

Splenic Torsion – good

Hemangiosarcoma – guarded to poor.

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Lymph Node Diseases

The lymph nodes are part of the lymphatic system. They have several important functions and are good indicators of disease. During a physical exam the external ones can be palpated to determine if they are enlarged. The medical term for this is lymphadenopathy.

Causes

Lymph nodes can enlarge due to several reasons:

  • Inflammation

    A reaction to a foreign body might cause this.

  • Infection

    Bacterial, viral, or fungal infections can cause them to enlarge. This enlargement might be a sign that they are performing their job as expected. When the infection subsides the lymph node should return to normal size.

  • Cancer

    The most common cancer that causes this problem is called lymphoma (also know as lymphosarcoma)

Examination

Internal Lymph Nodes

Numerous lymph nodes exist within the thoracic and abdominal cavities. They can not be palpated easily, and their enlargement does not show up on routine blood samples. They might be seen on radiographs or ultrasound if they are significantly enlarged. They can be found when performing an exploratory surgery.

This radiograph of the chest shows the heart and lungs clearly. The lower arrow points to the location of the sternal lymph node. It is not visible in this dog because it is normal. The top arrow points to a round, white structure. It is a tumor nodule that has spread from cancer elsewhere in body.

This radiograph of the abdomen shows the liver and stomach clearly. The lower arrow points to the general location of the mesenteric lymph node. The top arrow points to the location of the sublumbar lymph node. Neither one is visible.

The scalpel blade is pointing to the mesenteric lymph node. This node is found at the center of the small intestine loops. This one is enlarged because this cat has kidney cancer, which has spread to the mesenteric node.

Here is another enlarged mesenteric lymph node from a cat with intestinal cancer called lymphosarcoma.

External Lymph Nodes

Mammals have numerous external lymph nodes (also called peripheral lymph nodes) that can be palpated during a physical examination. This is of great advantage because we can easily feel if they are enlarged without having to rely on diagnostic tests. Reptiles and birds do not have external lymph nodes.

Five external lymph nodes are routinely palpated during a physical exam. All of them are paired, which is another advantage because we can compare one to another and notice subtle changes in size:

  1. Submandibular

    They are located in the neck area near the angle of the jaw. They lay right next to the salivary glands, so it is important to palpate the correct structure.

  2. Prescapular

    Located just in front of the shoulders. Follow the arm up to the point of the shoulder to find them.

  3. Axillary

    Found on each side of the chest in the armpit area. They tend to be small, and are more forward then most people realize.

  4. Inguinal

    Found on the abdomen towards the inside of each rear leg. There is significant fat in this area, so they might be difficult to find, even if enlarged. Also, there is mammary tissue in the area that can easily feel like an enlarged lymph node if the mammary tissue has an infection or cancer.

  5. Popliteal

    Found on each rear leg on the opposite side of the knee. They are relatively superficial and easy to feel.

We will gladly teach you how to palpate these lymph nodes whenever you bring your pet in for a physical  exam. These are internal organs so they are always palpated in a gentle manner. You might want to palpate them on a weekly basis at home. If you think they are enlarged bring your pet in for an exam so we can determine if there is a problem.

Diagnosis

Fine Needle aspiration

This test is a relatively simple way to obtain a significant amount of information from an enlarged lymph node. In this test we use a small needle (similar to the one we use to give vaccines) and gently insert it into the enlarged lymph node. We aspirate some of the lymph node material and put it on a microscope slide.

This ferret has a very large right submandibular lymph node. Do you see the needle on the left side of the picture that we are using to obtain the aspirate sample?

The aspirated material is put on a microscope slide for analysis by a pathologist. They will put special stains on the material and carefully scrutinize it under the microscope.

This is a typical report obtained when the pathologist reads the sample on the microscope slide. It is from a labrador with 2 enlarged lymph nodes.

The fine needle aspirate test is not infallible at finding a problem. When the needle is inserted it is put in only by feel. It is possible for the lymph node to have a problem area that the needle missed. Also, we are giving the pathologist only a very small sample to read. It can be difficult to determine the health of the whole lymph node when only a small sample is taken.

Due to these limitations the pathologist sometimes can not say for certain what caused the lymph node to enlarge. If it comes back inconclusive then we might keep the lymph node under close observation. If there are other changes in the rest of the physical exam, or laboratory data indicates there might be a significant problem, we will remove the whole lymph node and submit it for analysis.

If the fine needle aspirate report comes back that cancer is suspected we will remove the lymph node, no matter what the other laboratory tests indicate.

Biopsy

The most accurate way to determine if a lymph node is seriously diseased is to remove the whole node and submit it for analysis. It gives us significantly more information than the fine needle aspirate. It requires anesthesia and an small incision in the skin. We routinely use our laser for skin incisions for its great ability to minimize bleeding, swelling, and post-operative pain.

This picture shows a popliteal lymph node in Dr. P’s hands. He is getting ready to make an incision in the skin over the lymph node with the laser.

This is the inflamed popliteal lymph node as it appears under the skin. It will be completely removed.

Here it is after complete removal. It is the size of a large pea.

The report on this dog gave us a diagnosis of valley fever, which is a fungal infection. You don’t have to read through all of the medical mumbo jumbo to get to the valley fever diagnosis at the end. In the last paragraph you can see that special stains were needed to make the final diagnosis. These special stains are not easily performed on a fine needle aspirate.

This report of cancer came back on a Labrador Retriever. This is the same dog that had the fine needle aspirate report above.

This cat has an enlarged popliteal lymph node. We used the laser in this case also.

We use the laser to make an incision in the skin because of the lasers ability to minimize bleeding.

The inflamed lymph node is easily visualized. Note the lack of blood in the surgery site.

The anatomy of this lymph node is not normal, an indication that it is diseased.

Because of the unique qualities of the laser we are able to perform this surgery with a very small incision.

Treatment

Inflamed lymph nodes are treated with an anti-inflammatory like cortisone. Pets with bacterial or fungal infections are treated with antibiotics or anti-fungal medications. There is no specific treatment for a lymph node that is enlarged due to a viral infection. If cancer is the cause of the enlargement it will be treated with surgery, chemotherapy, radiation, or a combination of all of these.

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Neuter-Canine

One of the most common surgical procedures we perform is a dog neuter, know medically as an orchectomy. It is performed for several reasons:

  • It minimizes roaming
  • It minimizes aggressive behavior
  • It prevents male dogs from impregnating females.
  • It prevents most prostate problems.

At the Long Beach Animal Hospital use of the laster is mandatory for all neuters. In this page we will first show you the surgery using the laser, then the traditional way this surgery is performed without the laser. The advantages of using the laser will be obvious.

Sometimes people get a jaded mindset when it comes to routine surgeries like neuters, that are performed by the thousands, especially at low cost spay and neuter clinics. It is a major surgery, and we treat it as such at the Long Beach Animal Hospital, which you will learn about in this page.

Several days prior to any surgery please bring in your pet for a preanesthetic exam and blood panel to confirm your pet is ready for anesthesia. At that time one of our doctors will go over any questions you have.

On the day of surgery we need your dog in the hospital between 7:30 AM and 8 AM. Please take away all food and water when you go to bed the evening before surgery, and do not give your dog anything to eat or drink the morning of surgery.

Our surgeon will call you after the surgery is complete and your dog is awake. It can go home in the late afternoon the day of surgery unless instructed otherwise. Please call our office at 4 PM for pickup time, you will be given written post operative instructions then. We are open in the evening if you need to pick up later.

The following page contains graphic pictures of an actual surgical procedure performed at the hospital. 

Anesthesia

Pre-anesthetic preparation is important in every surgery we perform, no matter how routine. Surgery is not an area to cut corners. All of our neuters receive a physical exam prior to surgery.

The pre-surgery physical exam is performed by the surgeon

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If we haven’t already taken a blood panel prior to surgery we can take one the day of surgery and have a report within 30 minutes

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Once a pet is anesthetized, prepared for surgery, and had its monitoring equipment hooked up and reading accurately, the surgery can begin.

We keep a close tab on important physiologic parameters for all of our surgeries. Monitors like this give us an early warning of an impending problem. Our patients are carefully monitored to detect any abnormalities before they become a problem.

This machine monitors:

Temperature

Heart Rate

Heart rhythm

Oxygen saturation

Carbon dioxide level

Respiratory rate

Surgery-Monitor

In addition to our monitoring equipment our anesthetist stays “hands on” in monitoring important physiologic parameters. We use a special stethoscope (called an esophageal stethoscope) that is passed down the esophagus and gives us a clear sound of the heart

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Once our surgeon has scrubbed up and is in a sterile gown, gloves, and mask, the surgery begins

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While our patient is being anesthetized our surgeon is already in our surgical suite setting up instruments. Our surgeon is ready to start before our patient is at a proper plane of anesthesia. Once the anesthetist gives the green light the surgery starts immediately. We want our surgeon ready and waiting for his patient, not the other way around.  All of this is to minimize anesthetic time.

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Surgery

This page shows the surgical procedures for:

  • A normal testicle using the laser
  • A short video of a bloodless laser neuter at our hospital
  • A testicle that has not completely descended into the scrotum and is in the inguinal canal using the scalpel blade
  • A testicle that is still in the abdomen using the scalpe blade
  • The use of neuticles

Laser Surgery

Using the laser has many advantages over using a scalpel blade. These include negligible bleeding during the procedure and post operative pain. Click on any of these pictures below for a larger version.

Once our patient is draped the procedure an begin

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The initial skin incision in the scrotum

Notice the lack of bleeding from the skin as we enlarge the incision for room to remove the testicle. The white structure in the center is the testicle covered with protective tissue.

Once the incision is large enough the testicle bulges through with the aid of our surgeon.

The testicle is covered with a tissue called tunic. This tissue is gently opened with the laser to reveal the actual testicle.

All of the pertinent structures associated with the testicle are apparent in this picture. The white horizontal line below the surgeon’s thumb is the epididymus. The dark structure to the right of this is the panpiniform plexus. This plexus contains arteries and veins to cool the testicle, supply it with nutrients, and allow testosterone to go into the bloodstream.

Our surgeon is using a clamp to remove the excessive tissue of the tunic before ligating the vessels.

We always put two sutures on the blood vessels for safety’s sake and piece of mind for us.

We use the laser to cut the tissue. The testicle is to the right, and will be completely removed once the laser finishes the cut. The body is too the left, and once our surgeon makes sure there is no bleeding, this blood vessel is allowed to retract back into the body cavity.

The appearance of the blood-free initial incision just prior to suturing the skin

The final appearance of the sutured skin. There will be dramatically less postoperative swelling and pain with the use of this laser compared to the traditional way without the laser.

In addition to using the carbon dioxide laser to perform the surgery, we use the companion laser to aid the healing process at the incision before our patient is fully awake.  When combined with the actual medication for pain we administer our patient wakes up with minimal to no pain and the healing process progresses faster.

After the skin is sutured we use our companion laser. This aids the healing process and decreases post operative swelling so your pet is more comfortable.

Companion Laser in use after an OVH

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Click on the video to see it in action

Most dogs recover from this surgery in a few days, even those that have incisions in their abdomen. It is important to keep these dogs quiet for a few days postoperatively to allow the incision sites to heal. In most neuters we put in sutures that are just under the skin and dissolve on their own, so there is no need to return for suture removal.

Our Laser Page has detailed information on the use of the laser for various surgeries. Click on the movie below to see the neuter performed by laser.

Canine Laser Neuter

Cryptorchid surgery

The dog being neutered in this picture has only one testicle in the scrotum, called a cryptorchid or retained testicle. This happens in only a small percentage of the animals we neuter. The other testicle can be in the abdomen or in the inguinal canal (inner thigh region).

In this dog’s case it is in the inguinal canal, as evidenced by the bulge (arrow). It is important to remove the retained testicle because it can become cancerous later in life.

First we will remove the normal testicle, in this case the laser was not used because it was not available then. The procedure begins with an incision in the skin. We prefer to make our incision in front of the scrotum and not actually on the scrotum. This tends to minimize post operative licking and aids the healing process.

The testicle is gently squeezed forward and the incision over the testicle is made just big enough to gently squeeze it out. Smaller incisions heal faster, require less anesthetic time and there is less chance for complications.

The testicle bulges out of the incision cover by its internal layers called tunics. These tunics are carefully incised to expose the testicle and all its associated structures. In the picture on the right you can see 3 main testicular structures now that the covering is off. The vertically running dark blood vessels on the left are called the pampiniform plexus. They are a group of blood vessels that supply nutrients to the testicle, keep the testicle at an optimum temperature for viable spermatozoa, and distribute testosteron from the testicle into the general bloodstream. The structure just to the right of the pampiniform plexus, and partially surrounding the testicle, is the epididymus, the storage area of spermatozoa already produced by the testicle. The round structure to the right is the testicle itself.

The blood supply to the testicle is brought out and two sutures are placed around it. After the testicle is cut the sutured tissue is placed back through the incision.

Two layers of sutures are used to close the incision. The first is called the subcutaneous layer, because it is the layer of tissue under the skin. Sealing this layer gives an added margin of safety, especially if the dog licks the area excessively.

The skin layer is frequently closed in a suture pattern called subcuticular. This layer is the underside of the skin. This technique gives a cosmetic appearance and makes it difficult for a dog to chew its stitches out.

Since our patient in this case has one of his testicles in the inguinal area, the surgery is not finished yet. The skin incision and exposure of the other testicle is similar to the normal testicle removal. In this region though, there is significant fat under the skin.

The actual structures of the testicle and its blood supply are exposed, ligated with two sutures, and placed back into the inguinal area.

The same 2 layer closure is used in the inguinal area also. First the subcutaneous tissue, then the skin.

Here is a final view of our patient and his two incisions. As he wakes up from anesthesia he will be given an injection for pain.


When the retained testicle is not in the inguinal area it is located in the abdomen. This testicle can also become cancerous so it is important to remove it.

This patient only has one testicle in the scrotum. The other is in the abdomen.

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In this case we have to make an incision along the penis and literally find this testicle in the abdomen. In this picture the testicle has been brought out through the 3 inch incision in the abdomen.

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The post operative appearance showing both incision sites

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You can easily see the difference in size between the atrophied testicle in the abdomen (left) and the normal testicle in the scrotum. The testicle in the abdomen was removed at a young age so it never had a chance to become cancerous.

This is the appearance of a different dog that had a cancerous testicle, called a seminoma. It was not removed until later in life, so it had a chance to enlarge tremendously.

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This is the final look of the incision sites for this dog with the testicle in its abdomen. The head is towards the right and it is laying on its back. At the far left  is the skin incision from the removal of the normal testicle in the scrotum. At the right-bottom  is the incision from the testicle in the abdomen.

Both incisions are treated with our companion laser just after surgery

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Neuticles

An interesting variation on this neuter surgery is the placement of solid silicone implants in place of testicles. This gives a natural look after neuter surgery that is desirable to some people. We highly frown upon having this done, have only performed it once, and don’t plan on repeating it.

This is the appearance of a normal dog scrotum prior to neuter surgery. Use it as a basis of comparison at the end of this section to see what the scrotum looks like when we have implanted neuticles in place of the testicles.

In this surgery the testicle is removed and the neuticle is placed in the sack that holds the testicle, called the tunic.

This is the sterile neuticle on the surgery tray ready for placement. Neuticles come in various sizes and shapes to be custom fitted to each individual.

The neuticle is gently implanted in place of the testicle. A proper fit is imperative, so it is important to order the proper size ahead of time.

When we are sure of a proper fit we carefully suture the tunic with a suture material that will eventually dissolve.

This is the final appearance after the placement of the neuticle.

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Parvo Virus

Disease associated with the canine parvovirus started appearing around 1978. It is postulated that this virus is a mutation of the feline distemper virus. Since so few dogs had developed natural antibodies in the late 1970’s, a large number of dogs died from this disease. In some cases, the virus affected the heart, and caused death within a few hours.

We can still remember people coming into our clinic in droves to get their dogs vaccinated. There was no parvo vaccine for dogs then, since we did not even know what parvo was. The vaccine we gave initially was the cat feline distemper vaccine since there was no dog parvo vaccine available at the time. Our universities and drug companies immediately responded to the challenge, and identified the virus and manufactured a highly effective vaccine.

Decades later most dogs have encountered the parvovirus, either naturally (maternally) or through vaccines. These natural antibodies pass on to puppies (called maternal antibodies) when they nurse in the first few days of life. Maternal antibodies initially give a pup protection from parvovirus, along with many other viruses and bacteria. They last for a variable period of time, and start diminishing by around 2 months of age, yet can stay around until 5 months.

It is at this time that a pup starts becoming vulnerable to the parvovirus, so we begin vaccines then. We never know exactly when these maternal antibodies diminish, which is why we give the parvo vaccine in a series. If we start the series much before 2 months of age we are wasting it because the maternal antibodies will negate the effects of the vaccine. In essence, we are trying to give the vaccine just as the maternal antibodies are diminished and just before the pup becomes susceptible to an exposure to the parvovirus.

There are reports of people and cats getting this disease, but in our locale this is almost non-existent. Pigs can get their own version of parvovirus, but it does not affect dogs or act in a similar manner.

This disease is still prevalent, as evidenced by the number of e-mails we receive regarding this topic. Many of these dogs would not suffer this problem if they were properly vaccinated. Preventing this disease is dramatically more effective (not to mention less expensive) than treating it.

There are several graphic pictures at the end this page of the intestines of a dog that has complications from parvo.

Cause

The disease is caused by a highly contagious virus that is transmitted mostly by dogs orally contacting infected feces. Being a virus, they contain only DNA or RNA, and are not capable of reproducing unless they invade a cell. Once inside the cell they take over and force the cell to produce so many new virus particles that the cell eventually bursts, releasing these new virus particles into the bloodstream and tissues so they can invade other cells. The only thing that can stop this is the immune system.

Viruses are the smallest of know living organisms, and can only be seen with special microscopes called scanning electron microscopes, that cost millions of dollars (ours is on order). The parvovirus is extremely small (the Latin word for small is parvo)- just 1 thimble full of stool can contain millions of virus particles. It is easy to see why contamination occurs so readily. Incubation period varies from 5-10 days. As in many viral diseases of the intestinal tract, some dogs can pick up the disease and shed the virus without significant symptoms in themselves. These carrier dogs have what is called a subacute infection.

This is an electron microscope view of a cluster of parvo virus particles. It is courtesy of Dr. Cornelia Büchen-Osmond Biosphere 2 Center. “Universal Virus database of the International Committee on Taxonomy of Viruses, ICTVdB.

The scale at the bottom shows the length of 100 nanometers (nm). A nanometer is 1 billionth of a meter, so it is obvious these particles are real small

The virus has 3 basic strains:

  1. CVP2 which was the first one found in 1978
  2. CVP2a came on the scene in the early 80’s
  3. The strain most prevalent today is CVP2b

Eventually a new strain will appear because the virus will adapt to the immune system of dogs.

The parvovirus can linger in the environment for many months, allowing it to affect other dogs. It can withstand common household disinfectants (except bleach) and can withstand freezing winter temperatures. It can be spread on the hair and feet of dogs, in addition to shoes, clothes, and eating utensils.

We tend to see parvo in dogs that have other diseases, especially intestinal parasites (worms). This might be because these dogs have immune systems that are weakened, making them more susceptible to a viral infection. Also, the parvo virus capitalizes on the fact that the lining of the intestines of these dogs with intestinal parasites are damaged and susceptible to the parvovirus.

Pathophysiology

Parvovirus has a predilection for rapidly dividing cells (similar to cancer). The rapidly dividing cells in a dog are the intestines, bone marrow, and the immune system. When the virus infects these areas the lining of the intestine literally dies, the bone marrow cannot make red or white blood cells in adequate quantity, and the immune system can become impaired.

Initially the virus replicates in the tonsils (which are lymph nodes) after oral ingestion. The virus rapidly multiplies and enters the bloodstream within a few days. From here it spreads to those parts of the body that contain rapidly dividing cells as mentioned above.

The main cause of death in parvo infected dogs is septicemia. Poisons from bacteria that are attacking the susceptible lining of the intestines release toxins into the bloodstream. These toxins add to the complications of a puppy that is dehydrated from vomiting, diarrhea and not eating, is hypoglycemic from not eating, and has electrolyte imbalances from vomiting and not eating. The bodies immune system becomes overwhelmed and death ensues if treatment is not instituted early and aggressive enough. Even if toxins are not released by bacteria, the dehydration and electrolyte imbalance that occurs can lead to shock and eventual death.

In actuality, whether a pup recovers from the virus depends on a race between parvovirus particles causing septicemia and dehydration, and the immune system’s ability to neutralize the virus. Fortunately, for most pups that get medical care early enough, the good guys win the race.

Symptoms

The majority of dogs presented with parvovirus show signs of fever, lethargy, vomiting, diarrhea, and lack of appetite. In severe cases the diarrhea is very watery and frequently bloody, with a telltale odor. They are very ill, with significant abdominal pain. The virus is so strong that it literally causes the lining of the intestines to slough. It is painful to eat, and with the severe diarrhea and vomiting that is present, they rapidly become dehydrated. The also have a disruption in their electrolytes (sodium, potassium, chlorine) that adds to the weakness.

There is a complication that can occur from all the intestinal activity regarding vomiting and diarrhea. It is called an intussusception, which is literally a telescoping of the intestine into itself. This will cause the intestine to die, resulting in death of the pup. Treatment is surgical, unfortunately, these pups are in no shape for surgery. Luckily we do not encounter this very often, if at all. Graphic pictures of intussusception to follow.

In the peracute form of this disease the virus attacks the heart and causes rapid death. Fortunately, it is rare to encounter this nowadays.

Diagnosis

The diagnosis of canine parvovirus is frequently made by age of pet (usually under 6 months of age), symptoms exhibited, and physical exam. Other diseases can mimic the signs of parvovirus, so x-rays and routine blood samples are sometimes run to help eliminate them as a cause. A CBC (complete blood count) might show a reduced white blood cell level, an indication that a virus is present in the body. A blood sample can be run looking for Parvo antibodies, but the results are open to interpretation as to whether the dog has an active infection or not.

 

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An accurate, simple to perform, and inexpensive test has been developed to test the feces for the virus. It can be performed by our in hospital lab within 15 minutes.

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If only one vertical bar appears the test is negative

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When two vertical bars appear the test is positive

Recent vaccinations can interfere with the interpretation of this test. No test is perfect though, and like many diagnostic tests for diseases, there can be false positives and false negatives.

Treatment

Dogs with parvovirus need immediate veterinary care because they are usually very sick. They should not be treated at home if they are significantly ill. This care involves large amounts of intravenous fluids, added electrolytes, antibiotics, and special medications to minimize vomiting. It is common for them to be hospitalized for anywhere from 3-7 days.

We monitor red blood cell counts and protein levels to identify those dogs that are not responding to routine treatment. If the protein level becomes low we institute therapy with additional fluids (called colloids) to combat the problem. Dogs that continue to decline in spite of therapy may also need a blood transfusion because they can become anemic and deplete their protein. We will also treat the internal parasites (worms) that can be an integral part of this disease.

Special precautions are taken when we treat parvo dogs. They are put in a special area so that we can monitor them closely. They are also isolated so that other dogs in the hospital are not exposed to the virus.

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 Staff members that treat them wear disposable gloves and gowns, and clean their shoes in a special chlorine foot bath to prevent hospital contamination of the virus.

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We do all of our work in our isolation room, including placing an intravenous (IV) catheter and treatments

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Intravenous fluids, given with a special fluid machine that gives out the exact quantity of fluid needed as determined by a doctor, is crucial in the treatment

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Parvo patients are very ill and need special treatment and nursing care if they are to pull through it.

We do not feed them until they have gone 12-24 hours without vomiting. We need to get them eating soon so the lining of the intestines can function properly and so they don’t go into a negative nitrogen balance.

We will send your dog home if it is eating and not vomiting for 24 hours. We expect it to have a persistent soft stool or diarrhea for several days after returning home. You might even send home supplemental fluids for several days.

Fortunately, most dogs recover with our intensive therapy, although there still is an occasional dog that does not. This may be due to a weak immune system that cannot produce adequate antibodies, or a particularly strong (virulent) strain of the virus that we encounter occasionally. Dobermans and Rottweilers seem to be especially sensitive to this virus, and have the most difficult time recovering from an infection.

Some dogs strain so much from the diarrhea that they develop an intestinal blockage called an intussusception. This is where the intestines telescope into each other, and requires surgery to correct. It is fatal if not corrected. An intussusception is diagnosed with a radiograph and confirmed with ultrasound.

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The advent of digital radiography has dramatically improved our ability to diagnose problems like this

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This is what the intussusception looks like internally

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A different dog with intussusception

Once your dog is well on its way to recovery we will send it home with supplemental fluids, antibiotics to be given orally, along with a special bland food made for recovering patients with gastrointestinal disease . It is called I/D (Intestinal Diet). Even though the pup might be ravenous, feed the food in small amounts frequently.

Your dog should be rechecked within a week to make sure it is putting on weight and thriving. At that point we will continue (or in some cases begin) its routine vaccination series. Since the pup is potentially contagious to other dogs, it is well advised to keep it away from other animals for at least 30 days since it can still spread the virus.

Pups that have recovered from parvo do not get the disease later in life. They can completely recover and lead a normal life.

Prevention

As with all infectious diseases, minimizing exposure from infected animals is the most effective means of prevention. Since infected dogs shed large amounts of virus in their stool, contamination is always a possibility. The virus is quite resistant in the environment, especially in public areas that are not disinfected. This is a good reason to keep your pup away from these areas until it is older, worm free, and had its full series of dog vaccines.

Since this disease occurs mostly in puppies, worms (internal parasites) and poor nutrition add susceptibility. Puppies should be wormed frequently until they are 3 months old.

Any dog you already have in the household before you exposed it to a parvo dog you recently brought in (whether it died or recovered from the parvo) should be current on its vaccines and should have minimal exposure, if possible, to the contaminated areas. It is rare for an adult dog that is current on its parvo vaccine (yearly boosters) to get parvo.

If you had a dog die of parvo we recommend thorough cleaning with diluted bleach (1:30 with water, or 4 ounces of Clorox in a gallon of water) and waiting 1-2 months before introducing a new dog to the area. Spray the yard as best as possible with a hose and keep new dogs away from the area for 1-2 months. Do not put bleach on your dog to rid it of parvo.

Vaccines are highly effective. Dogs should be vaccinated at 8, 12, and 16 weeks of age. Ideally, we should vaccinate pups every 2 weeks starting at 6 weeks of age and lasting until 5 months of age, especially in the more susceptible diseases. Puppies should not be exposed to other dogs or their feces until at least one vaccine is given. Puppies need to socialize at the critical 6-16 weeks of age mark, and if you do not expose them to other dogs early in life you might have a serious behavior problem later as an adult. So use precaution until your pup’s vaccine series is complete.

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Addison’s Disease (hypoadrenocorticism)

This disease of the adrenal glands of dogs (it’s very rare in cats) involves inadequate hormone levels of cortisol (cortisone) and electrolytes (sodium and potassium). This unusual disease can show a vast array of different symptoms, and sometimes these symptoms mimic other diseases.

There is even a version of this disease called “atypical”, which adds to the complexity. Because there can be such a variety of symptoms, Addison’s disease is sometimes known as the great pretender or great imitator.

Addison’s is named after a physician in 1849’s who discovered this disease. President John Kennedy suffered from the human version of this disease.

Addison’s disease is the opposite of another problem with the adrenal glands called Cushing’s Disease (hyperadrenocorticism). In Addison’s there is not enough cortisol, in Cushing’s, there is too much cortisol.

We have an interesting page on adrenal disease in ferrets, which causes different symptoms than in dogs and cats.

Click on photos and some of them will enlarge.

Nomenclature

Several medical terms and abbreviations relate directly to Addison’s:

glucocorticoids – Cortisol tachypnea-increased respiratory rate
exogenous cortisone– supplemental cortisone by mouth or injection bradycardia-abnormaly slow heart rate
catabolic steroid– cortisol and its equivalent polyuria– excess urinating
anabolic steroid– opposite of catabolic, testosterone is the most common one polydipsia– excess drinking
hyperkalemia- high potassium (K) level in the bloodstream PU/PD– polyuria and polydipsia
tachycardia -abnormally fast heart rate mineralcorticoid-hormone that affects sodium and potassium
hypoglycemia– low blood glucose (sugar) level iatrogenic– caused by something a person does as opposed to happening naturally.
hyponatremia- low sodium (Na) in the bloodstream ACTH– adrenocorticotrophic hormone
atrophy-an  organ that is smaller than it should be adrenomegaly– enlarged adrenal gland
anemia– low red blood cells microcardia- small heart
cortisol– Cortisone made by the adrenal glands  azotemia– elevated BUN and creatinine

Adrenal Gland Anatomy

The adrenal glands are paired organs that lay right in front of the kidneys on each side. They are quite small, and measure only a few millimeters in length. This small size is not an indication of their importance though. Even though they are small, the cortisol (cortisone) they secrete, along with their other functions, have great significance to normal physiology.

The arrows point to the paired adrenal glands in front of each kidney. The extensive blood supply to the kidneys and adrenal glands is apparent. In the diagram they are easy to see. They are not so easy to see during ultrasound or exploratory surgery because normally they are small and buried in fat. They do not show up on an X-ray unless they are calcified or much larger than normal.

This is a picture of an enlarged adrenal gland (arrow) that is buried in fat near the kidney (K). It is from a ferret that has an adrenal gland tumor, so the adrenal gland is inflamed and easily visualized. This is not necessarily the case in dogs and cats that have adrenal gland tumors.

The internal architecture of the adrenal gland is made up of several distinct zones.

Cortex

The cortex (outer shell) of the adrenal gland is made up of 3 anatomical parts:

Zona Glomerulosa

This is the outer layer of the adrenal gland. This section secretes the mineralcorticoid aldosterone. Aldosterone is vital to proper sodium and potassium regulation. Aldosterone has a role in maintaining  blood pressure.

Zona Fasciculata

This is the next layer as you go inward, and produces the glucocorticoid cortisol. The cells in this area are the ones that cause Cushing’s when they secrete cortisol in excess.

Zona Reticularis

As we continue inward we come across this section that secretes the sex hormones known as androgens (male sex hormones), estrogen (female sex hormones), and sex steroids. These are usually secreted in such small amounts as to be of no major significance in healthy animals. The gonads in dog and cats secrete most of the sex hormones.

Medulla

This consists of the very center of the adrenal gland. It secretes hormones called catecholamines. The two important ones are epinephrine (adrenaline) and norepinephrine.

Physiology

The tiny adrenal glands have a profound influence on many internal organs. The hormones they secrete work in unison with other hormones and internal organs, particularly the liver, and have an enormous effect on physiology. These hormones interact with many other hormones that have the opposite effect, usually in some type of feedback mechanism that is monitored by the brain. This interaction is complex, so only a summary of adrenal hormone physiology is presented.

The adrenal glands secrete several important hormones, most of which are synthesized from cholesterol. We will explain 3 of them; cortisol, aldosterone, and epinephrine:

Cortisol

Cortisol maintains a normal blood glucose level, facilitates metabolism of fat, and supports the vascular and nervous systems. It affects the skeletal muscles, the red blood cell production system, the immune system, and the kidneys. Obviously, it is a very important hormone, and necessary for life.

It is considered a “catabolic steroid”. This means it takes amino acids from the skeletal muscles and, and with help from the liver, converts them to glycogen, the storage form of glucose. These functions are the exact opposite of “anabolic steroids”, the drugs that weight lifters take to increase muscle mass. The end result of this is an increase in the level of glucose in the bloodstream. The hormone called insulin has the opposite effect on blood glucose, adding to the complexity of this system. You can learn more about insulin by going to our diabetes mellitus page.

The level of cortisol in the bloodstream continually fluctuates as physiologic needs vary. Surgery, infection, stress, fever, and hypoglycemia (low blood sugar) will cause cortisol to increase. This continual fluctuation adds to the difficulty of diagnosing any disease involving cortisol (Addison’s and Cushing’s), because the amount of cortisol in the bloodstream is so variable.  A test taken at one moment in time might have different results if taken later.

To control the level of cortisol the hypothalamus and pituitary gland in the brain secrete chemicals into the bloodstream called releasing factors. In the case of the adrenal glands , the hypothalamus secretes a hormone called corticotropin releasing hormone (CRH). This hormone goes to the pituitary gland and stimulates it to release a hormone called adrenocorticotrophic hormone (ACTH). It is the amount of ACTH circulating in the blood stream that tells the adrenal glands (specifically, the cells at the zona fasciculata) how much cortisol to secrete. There is a negative feedback loop that allows the hypothalamus and pituitary gland to refine precisely how much cortisol circulates in the bloodstream. The more cortisol secreted by the adrenal glands, the less CRH and ACTH secreted. This allows the body to precisely refine the level of cortisol, and to change the level rapidly due to changing physiologic needs.

This negative feedback mechanism is a highly profound adaptation to evolutionary pressures, and is the basis for our survival as a species. Without this, life as we know it, would not exist for us and many species on this planet.

Numerous organ systems are affected by cortisol:

  • Musculoskeletal
  • Cardiovascular
  • Skin
  • Renal
  • Gastrointestinal
  • Immune

Mineralcorticoids

Aldosterone is the principal mineralcorticoid secreted by the adrenal glands. This hormone is secreted as a response from the kidneys when fluid volume in the bloodstream is decreasing. It involves other hormones called renin and angiotensin. The end result is an increase in sodium in the bloodstream, with a corresponding increase in blood volume and blood pressure. This increase in blood volume and pressure is because  sodium  pulls fluid from the intestinal tract, and the area around each cell called the extracellular fluid, into the bloodstream.

This hormone also interacts with and affects potassium levels. To further complicate the picture, ACTH also has an affect here, just like it does with cortisol.

Epinephrine (Adrenaline)

This compound, technically called a neurotransmitter, also has hormone-like properties. It is a very powerful chemical that affects all organ systems. It acts very rapidly, with effects remaining only for a short period of time. It is the primary reason the body has the ability to respond to an emergency. This physiologic mechanism is also known as the “flight or fight” response.

Upon stimulation of the central nervous system (ex.-fear or pain), the adrenal medulla is stimulated to secrete epinephrine into the bloodstream. We are all familiar with what happens next. The pupils dilate, the heart rate and blood pressure increase, and the palms get sweaty. Internally, the body is increasing the blood glucose level, the breathing passages are opened up, more red blood cells are secreted into the circulation, blood is shunted away from the skin and other internal organs, and blood flow is increased to the brain and skeletal muscles. All of this has the effect of bringing the brain and skeletal muscles extra glucose and oxygen, and accounts for the extra boost of awareness and energy we all feel at this time. For such a small set of organs it is apparent that the paired adrenal glands have a very important role in normal health.

Pathophysiology

When the disease affects the part of the adrenals that secrete cortisol (the zona fasiculata) a vast array of different symptoms can occur. This is because of the profound effects cortisol has on almost all body systems.

When the disease affects the part of the adrenals that secrete aldosterone (the zona glomerulosa), then electrolytes like sodium (Na) and Potassium (K) are affected.

The overwhelming majority of the adrenal cortex must be affected before it secretes inadequate amounts of cortisol and aldosterone and before any symptoms are noted.

There are 3 forms of this disease:

Primary Hypoadrenocorticism

 This classic form of the disease is due to a lack of both mineralcorticoids and glucocorticoids. The zona fasiculata and the zona glomerulosa are both involved. This means the problem is at the adrenal gland itself.

Causes:

Immune system destruction of the adrenal gland due to autoantibodies is the most common cause

Medication to treat Cushing’s disease (mitotane or trilostane)

Infection

Coagulation disease

Cancer

Loss of blood supply to the adrenal gland (an infarction)

Secondary Hypoadrenocorticism 

This more unusual form of the disease occurs when the zona fasiculata only is involved. This means the problem is at the pituitary and not at the adrenal gland, therefore only cortisol production is compromised and the electrolytes sodium and potassium are not affected.

Causes:

Abruptly stopping oral or injection cortisone that has been administered for a period of time (exogenous cortisone)

Congenital defects of the pituitary gland

Cancer or trauma to the hypothalamus

Atypical

This includes all of the dogs classified as secondary, so only cortisol is involved. In these dogs electrolytes are normal,  just like in secondary hypoadrenocorticism. What makes this atypical is that fact that many dogs might change to primary during the course of the disease. Only then will the electrolytes  be involved.  This can make treatment difficult, because a pet that is being treated successfully for secondary might need to be treated for primary at some point. This emphasizes the need for close monitoring with blood panels and exams at least every 6 months.

Diagnosis

Signalment

Usually found in female dogs that are middle aged or less. It is more commonly found in dogs that are not spayed (ovariohysterectomy). Atypical Addison’s tends to occur more in the older dog. Certain breeds get this disease more often than others:

  • Great Danes
  • Standard Poodles
  • Bearded collies
  • Portugese water dogs
  • Rottweilers
  • Wheaten Terriers
  • West Highland White Terriers (Westies)

History

Symptoms are quite variable, and can come and go over months.  As a result, it is easy to miss this disease or get it confused with other diseases that have the same symptoms. Symptoms might be mild or life threatening, and can be found in many other diseases.

In some cases a pet has been ill in the past, and treated with fluids with a successful outcome, and now the problem has returned. A blood panel in this cause might show a kidney problem due to dehydration, which is why the fluids helped. If this is a recurring problem Addison’s should be tested for.

Typical symptoms might include:

  • lethargy
  • inappetence
  • weight loss
  • diarrhea or dark stools
  • vomiting
  • shaking
  • dehydration
  • shock
  • collapse
  • drinking and urinating more than usual (PU/PD)
  • abdominal pain
  • seizures if severely low blood sugar is present

Physical Exam

Just like the symptoms above, the physical exam of a dog with this disease can be quite variable. Typical exam findings we might encounter include:

  • depression
  • pale gums
  • tacky gums
  • panting
  • hair loss
  • weak pulse
  • increased heart rate (tachycardia) if shock
  • decreased heart rate (bradycardia) if potassium is high
  • increased respiratory rate (tachypnea)
  • low body temperature
  • painful abdomen upon palpation

Diagnostic Tests

Radiography

X-rays might be helpful in diagnosis, although they are not the primary way this disease is diagnosed. On a radiograph we might find a small heart and liver due to dehydration and shock. On rare occasions megaesophagus might be present. Neither of these are diagnostic of Addison’s by themselves since numerous other diseases can cause these symptoms.

This heart is small, typical of dehydration due to Addison’s, along with other diseases. Compare it to the normal sized heart below.

Addisons-microcardia2

rad2

The adrenal glands do not show up on an abdominal radiograph unless they are calcified or extremely enlarged, which would be more indicative of Cushing’s and not Addison’s.

Electrocardiogram (ECG)

If the potassium is high enough (hyperkalemia) the heart rate might be slow (bradycardia) and there might be changes in the electrocardiogram. There are other causes of hyperkalemia, so this is not diagnostic for Addison’s, it is a clue that Addison’s might be present.

Below is a normal ECG strip for 4 beats of the heart. Below the strip is an enlargement of one beat.

If hyperkalemia is significant, changes to the ECG might include:

  • slow heart rate (the 4 beats below might only be 2-3 beats)
  • absent P waves
  • widening (prolonged) QRS complex
  • Shorter (decreased amplitude) R wave

EKG

Ultrasonography

Ultrasonography would usually show small adrenal glands, although a dog can have Addison’s and have normal adrenal glands on ultrasound. The adrenal glands in Addison’s are tiny and can be difficult to find in some cases.

This is a normal right adrenal gland enlarged for easier viewing. It is marked by the + signs.

OLYMPUS DIGITAL CAMERA

This is a small left adrenal gland like we might find in Addison’s. It is the whitish area in the center towards the top with the dark area in the center. It takes an experienced ultrasonographer to find a small adrenal gland.

Tuffy3

Blood Panel

Blood work ( chemistry and complete blood count) is a crucial component for detection of this disease. Common abnormalities might include one or more of these findings:

  • anemia (low red blood cells)
  • increased eosinophils and lymphocytes
  • low blood sugar (hypoglycemia)
  • azotemia (high BUN and creatinine)
  • hypercalemia (high calcium)
  • hyperkalemia (high potassium)
  • hyponatremia (low sodium)
  • hypochloremia (low chloride)
  • increased liver enzymes (ALT)
  • increased alkaline phosphotase (ALP)
  • hypoalbuminemia (low albumin)
  • hypercholesterolemia (high cholesterol)
  • low ratio of sodium (Na) to potassium (K). If the ratio is less than 27:1, and the history and symptoms are consistent with this disease, then a high index of suspicion is appropriate.

Cortisol decreases the blood flow (also called GFR-glomerular filtration rate) to the kidneys. This will result in an decrease in the amount of water and waste products filtered by the kidneys. On the blood panel this might show up as kidney disease, when in reality it is Addison’s. Our kidney disease page has more details.

Each of the following blood panels was taken from a dog with Addison’s. They are all different, a testimony to how variable this disease can appear on a blood panel. When coupled with the wide variety of symptoms, that can wax and wane, a diagnosis of this disease is not black and white.

 In this first blood panel, the only abnormal finding of significance is the low RBC, HGB, and HCT. This means the pet has anemia.

Notice how these tests are mostly normal, although this dog has Addison’s

In this dog with Addison’s, the chloride, sodium, and glucose  are low. Na/K ratio is OK.

BuddyHansonBlood

This dog with Addison’s has numerous abnormalities, this time including a low Na/K ratio

Tuffy2

Special Tests

Cortisol level

In this test a baseline cortisol level is run by taking a blood sample.  If the baseline cortisol is over 2 mcg/dl (micrograms per deciliter) then the dog does not have Addison’s. There is no need to go any further since Addison’s is not involved at this point. If the baseline cortisol is less than 2 mcg/dl then we will do the ACTH stimulation test.

ACTH Stimulation test

Diagnosis is confirmed with an ACTH (adrenocorticotrophic hormone) stimulation test. This test is also used to help diagnosis the opposite problem of Addison’s disease, which is called Cushing’s disease.

ACTHgel

Once the baseline blood cortisol is obtained we give an injection of a specific amount of ACTH. One hour later we take another blood sample to check if the cortisol level has changed. We get the reports from the lab usually the next day.

If the baseline cortisol is less than 2 mcg/dl, and it does not increase on the blood sample taken one hour later after we have injected ACTH, then the disease is confirmed.

Addison's-4

Akita’s and Shiba inu’s sometimes have elevated potassium levels on blood tests. This can be very confusing when a patient has symptoms that suggest Addison’s disease. The ACTH Stimulation test will let us know if they have Addison’s.

An occasional dog will be presented with symptoms consistent with Addison’s, including abnormal sodium and potassium levels. These dogs might have Whipworms and not Addison’s. Again, the ACTH Stimulation test will let us know if they are Addisonian. We have a page on internal parasites that includes Whipworms.

Treatment

Acute Phase

In the acute phase, dogs are presented collapsed and in a state of shock and hypothermia. They need shock doses of intravenous fluids and injectable cortisone (dexamethasone) along with warmth. If the hyperkalemia is causing bradycardia, the IV fluids usually suffice.  If not, insulin needs to be administered. If hypoglycemia is present, dextrose is added to the IV fluids.

Chronic Phase- Most dogs are presented in this phase

For low cortisol we use prednisone orally at a relatively low but consistent dose. Any pet with chronic Addison’s needs to have this dose increased when there is a stress like fireworks, going to the groomer or veterinarian, or anything in general that causes extra stress.

We will test the blood every 6 months at the least to make sure there are no serious side effects to this use of cortisone. For the majority of dogs there are no side effects, and the drug is mandatory for treatment of this disease. The symptoms of the disease, and their potentially life threatening nature, far outweigh side effects when used under our supervision.

Prednisone

For an imbalance in electrolytes we use one of two drugs, although the injectable version is much more convenient and very effective:

  1. Percorten-V (DOCP)Percorten-V works extremely well for most dogs and allows them to lead a normal quality of life. This injectable medication is given every 25 days for the majority of dogs. We will test the electrolyte levels with a blood panel early in the course of treatment to monitor Na and K levels and adjust the timetable accordingly. We will then test the blood at least every 6 months.

    Percorten

    Harmony is drawing up Buddy’s Percorten

    Addisons-HarmonyInjection1

    Buddy comes in every 25 days on the dot, and after his pinprick injection (we use a 25 gauge needle so it is jut a pinprick) he is good to go for another 25 days.

    Addisons-HarmonyInjection2

  2. Florinef It does have some cortisone properties, and in some cases a dog does not need prednisone when on this drug. This does not apply to stressful situations, and additional medication in the form of prednisone tablets is always needed.This oral medication has fallen out of favor as a treatment because it has to be given daily and some dogs develop a resistance wherein the dose has to be increased.Florinel

Prognosis

This is a hormone disease, which means it is part of a highly tuned and refined mechanism that is in constant state of change. Vigilant monitoring is of essence for a successful outcome. We have numerous dogs at our hospital currently being treated successfully with prednisone and Percorten-V over many years. These dogs are leading a normal life, and you would have no idea they have a serious hormone disease when you see their owners bring them into our hospital or take them for a walk.

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Arthritis

 

One of the most insidious diseases we encounter in animals is arthritis. It was not long ago that we all-too-often euthanized animals that seemed “old” based on their symptoms of poor appetite, decreased activity, and lethargy. In reality they were not “old”, they had arthritis, and acted like they were old because they were painful. Today we can treat their arthritis and give them a new lease on life and lead a great quality of life for many more years.

All animals get arthritis, we most commonly see it in dogs and cats. This page will emphasize it in dogs.

Many of our pets are stoic, and can have a disease process brewing on the inside yet show no external symptoms. As the disease progresses, eventually the symptoms appear and we are presented with a very ill pet that seemingly became sick overnight. The reality is that the problem was present for a period of time, and it went unnoticed until your pet went rapidly downhill, when the bodies mechanisms for compensating and coping with the disease have become overwhelmed and the pet is in critical condition. At this point the disease process is so well entrenched that the prognosis for recovery is poor.

This concept applies to arthritis in dogs and cats.With our new digital radiography that gives us much more detail, we are diagnosing it earlier. Coupled with substantially improved treatments, we can successfully treat these arthritic and painful animals, and give them a vastly improved quality of life for many more years.

What’s even better is the fact that some of these new treatments do not involve the use of drugs. We have a multi-system approach to arthritis due to its chronic and debilitating nature and the fact we strive for treatment modalities that involve minimal use of long term drugs.

Here is a summary of how we approach this important problem. We will talk about these treatments in more detail later in this page:

  1. If your pet is overweight, a common problem, modifying diet and feeding habits to bring it back to its fighting weight can minimize the symptoms of arthritis. This common sense and inexpensive and drug free option seems to escape many people.

    Hills-MetabolicMobility

    Hill’s makes a prescription diet called Metabolic + Mobility that addresses obesity and arthritis at the same time. It is the food of choice for overweight dogs that that are also arthritic.

  2. Arthritis tends to be a disease of the aging. Older pets have different nutritional needs that need to be addressed. These needs cannot be addressed by going to a pet store and listening to the advice of some amateur nutritionist behind the counter trying to sell you the latest gimmick in dog food marketing. It comes after you discuss your pets individual lifestyle needs with your veterinarian, and your pet is given a thorough physical exam, and your veterinarian has blood panel and radiographic tests on your pet. Only then will the full picture of your pets needs be understood and a custom treatment protocol established.
  3. Chondroprotective agents called neutraceuticals can help in some cases.  These are the chondroitin sulfate- glucosamine products available everywhere, including Trader Joe’s at the checkout stand. They are not a panacea, and its important to take a critical look to see if they are working in your pet’s case. Sometimes the placebo effect seems to be transmitted in our minds and we do not have an objective standard to determine if these medications truly help. Fortunately they do not hurt, so we can achieve or first goal of “do no harm” as veterinarians.
  4. NSAID’s  (non-steroidal anti-inflammatory drugs) are a tremendous advancement in the treatment of arthritis. Non-steroidal means they do not contain cortisone, which was one of the primary drugs used to treat arthritis in the recent past. The NSAID’s are better at treating arthritis when used judiciously to maximize their good effects while minimizing their potential for side effects. Every pet reacts differently, so if one NSAID does not seem to work we will try another.
  5. Veterinary Neuronal Adjustment (VNA or VOM) is a tremendous treatment modality that uses the bodies natural healing processes without the use of any drugs. It involves stimulating the autonomic nervous system (specifically the sympathetic branches) and provides substantial pain relief. We have been using VNA at the Long Beach Animal Hospital for more than a decade.
  6. Therapy Laser brings an additional and highly effective treatment modality that again does not involve the use of drugs. This laser penetrates the hair and skin and goes right to the problem area to decrease inflammatory mediators. We recently updated our equipment to include a new therapy laser called MLS that treats using two different wavelengths.
  7. Acupuncture can also be used to augment all of the above therapies.
  8. Stem cell therapy is starting to be used utilizing your dogs own fat cells. It is still in the early stages, and treatment is not long lasting. As this area of treatment evolves and becomes more practical we will utilize it.
  9. Exercising your pet in the cooler part of the day, without excess trauma like jumping for long periods of time, will keep your pet flexible, the joins warm and lubricated, and keep its weight under control. If your pet is not afraid of water letting it swim in a shallow area is a great way to enhance mobility.

We will use the words arthritis and osteoarthritis (OA) interchangeable because they are the same thing in regards to the pain your pet is feeling and how it is treated.

Please be realistic about the fantastic claims that abound on the Internet for cheap treatments that will help your pets arthritis. These treatments have show to be nothing more than effective marketing. This disease is complicated and serious, and needs more than some supplement you purchase online.

What is Arthritis?

Dogs are prone to many different types of bone problems. This page will focus on the arthritis that tends to occur in dogs, especially as they age. Arthritis literally means inflammation of the joint, but the term is used more generally to describe several different processes. These include degenerative joint disease (DJD), infectious joint disease, immune mediated joint disease, and crystal-induced joint diseases. Many people use the term arthritis synonymous with osteoarthritis (OA), a complex, slowly progressive, and degenerative arthritis that is characterized by the gradual development of joint pain, stiffness, and a decreased range of motion.This is the type of arthritis common in older pets, and is increasing as pets live longer.

As we learn more about the subtleties of feline medicine we realize that many cats get significant arthritis especially in their lower back. This problem, also know as feline hypersethesia syndrome, causes tremendous discomfort and decreases the quality of life for many cats.

Anatomy

A normal joint is lined with hyaline cartilage, which is the covering over the end of the bone. It provides an almost frictionless surface for the bones to articulate, and also acts as a shock absorber. Hyaline cartilage is comprised of chondrocytes, proteoglycans, and collagen.

A normal joint is encased in a fibrous structure called the joint capsule. The joint capsule helps stabilize the joint and keeps the cartilage bathed in synovial fluid. Ligaments, which attach bone to bone, also provide joint stability.

This picture is from an actual surgery on the knee of a dog with a ruptured cranial cruciate ligament. The head is on the right, the foot is on the left, so the joint appears horizontal.

Arthritis-StifleJointArrow

The ridge of bone running horizontally at the bottom (arrow) is arthritis. The normal smooth cartilage above it is the normal groove of the knee (stifle) joint. The patella runs along this groove. 

Cause

The cause of this complex and multi factorial disease can be primary or secondary. Primary OA results from normal stresses acting on abnormal cartilage. Secondary OA is more common, and results from abnormal stresses acting on normal cartilage, such as an unstable joint caused by canine hip dysplasia, fragmented coronoid process, ununited anconeal process, patellar luxation, or a ruptured cruciate ligament. Some of the factors that can cause OA include excessive exercise, obesity, poor nutrition, trauma, immune reactions, and genetic predispositions.

The radiograph on the top is from a normal shoulder joint. The one on the bottom has an abnormal flap of cartilage at the arrow. This is know as osteochondritis dissecans, and is a primary OA. Without this radiograph we never would have know this limping pet had this problem.

shoulder arthritis

This normal shoulder joint shows no problems
osteochondritis

The white arrow points to a flap of cartilage that has eroded off

Damage to cartilage might occur as one event, or be the culmination of many small events over years. As swelling occurs, and the joint capsule becomes stretched, pain occurs. Your pet will use the joint less because of this pain, leading to muscle atrophy and the inability of the surrounding tendons and muscles to support the joint. As the muscular support of the joint weakens the joint capsule, ligaments, and cartilage become further stressed and stretched, leading to even further pain.

At this point the body releases chemicals called inflammatory mediators, (the therapy laser works on these mediators) which further damage the cartilage and add to even more swelling. It is obvious that this rapidly becomes a vicious cycle leading to debilitating pain. When OA progresses to the point that you notice your pet in discomfort or pain, the damage to the joint might be irreversible.

Symptoms

Symptoms are related to joint pain and stiffness. Most owners notice a pet losing its ability to perform normally, such as a reluctance to jump or climb stairs, or even limping. Stiffness after rest that diminishes rapidly as your pet starts moving and warms up is a hallmark sign of OA. Other symptoms of arthritis include lethargy and poor appetite, which are the result of pain.

Dogs that will not go on extended walks, or dogs that pant excessively during a walk could also indicate OA. Symptoms can be worsened by obesity, too much exercise, and by cold or damp conditions.

It is important to understand the initial symptoms might be subtle. Your pet will be experiencing pain or discomfort, yet it might not show any external signs.

Diagnosis

Signalment

OA is commonly diagnosed in older dogs and cats. Some breeds are prone to getting it because of the conformation of their joints.

Dogs like Dachshunds have abnormally shaped long bones that might predispose them to OA. This is the wrist, forearm, and elbow of a Doxie. The medical terms are carpal, radius, ulna, and olecranon.

History

Most dogs show a reluctance to run or move about. Some will be reluctant to go up or down stairs, or might even be limping. As the disease progresses these dogs might be in overt pain and lose their appetite. Some of these symptoms occur in other diseases, notably hip dysplasia and intervertebral disk disease. The are treated in similar ways in some cases, in different  ways in other cases, so a proper diagnosis is imperative.

Physical Exam

In some pets there are no abnormalities detected during a physical exam. Pain or discomfort might be found by palpating a joint or pushing on the mid or lower back. We might feel grinding of joints (crepitus), a swollen joint, abnormal bone formation and roughened bones, or inflammation at the joint. Dogs with longer standing OA might show atrophy of muscles. There might also be subtle signs during the neurologic part of the exam.

Some pets are so distracted during an exam (this happens to us people commonly) that they do not exhibit signs of pain when touched in painful places. This is why we need some basic diagnostic tests.

Diagnostic Tests

Radiography is an important diagnostic test to perform on a dog or cat suspected of having OA. Even though a radiograph can be normal in a pet that has OA, it is a substantial help in verifying the diagnosis and determining the degree of involvement. There are many diseases that can mimic the symptoms of OA, so a radiograph should be taken on every suspected OA  to eliminate these other causes.

This is a normal knee joint radiographically

This one has arthritis. The arrows point to all of the rough edges that are indicative of OA. Compare these rough edges to the smooth edges on the radiograph above. Also, the bone has a stronger whitish appearance, another indication of OA.

This dog was originally suspected of having arthritis based on a history of soreness in the hip area. It would be a mistake to treat this dog with an arthritis supplement and let the undiagnosed problem progress.

Radiographs revealed the true diagnosis was not the assumed arthritis, as can be seen at the arrow at the far left of the radiograph. The white circular area in the bone has the potential to be several different diseases, some of them serious like cancer.  A bone biopsy is need to know for sure.

A close-up view gives you a better idea of this dog’s problem

This form of OA is called spondylosis, which is arthritis of the vertebrae in the spine.
It is very common as pets age and causes substantial discomfort, nerve weakness, and even urinary and bowel incontinence.

You can learn more about the bones of the spine by going to our intervertebral disk page.

This dog was sore around its rear quarters when petted by the owner. This could easily be arthritis, but as you probably already figured out, something else was amiss. The owners of the dog assumed it was arthritis.

Did you figure out what is going on? Those circular white objects towards the top right of the radiograph are 3 pennies in the rectum! Seems like a safe place to store your money!

A very important differential when diagnosing OA on a radiograph is a bone tumor. This one is on the femur (thigh bone). This dog had symptoms of muscle atrophy and limping on this leg. If a radiograph had not been taken these symptoms could have easily been mistaken for arthritis. At this stage of the disease amputation is usually the only way to temporarily stop the tumor from spreading.

This is a serious form of cancer, and usually requires amputation 

The other important differential on radiograph like this is a bone infection called osteomyelitis. The fuzzy or roughened edges at the arrows is the infection.

The incorporation of digital radiography into our practice gives us substantially more detail on a radiograph. This is easily seen in the Ferret spine radiograph.

Treatment

Treatment of OA initially includes correction of any underlying primary diseases such as surgical correction of a torn ligament or arthroscopy to remove a cartilage flap. Once any primary disease has been addressed, the goal of treatment is to slow the progression of OA and to keep your pet comfortable. It’s important to realize that there is no cure for OA.

Nutrition

Most pets with OA will require some adjustment in their lifestyle. Weight management is most important, since obese pets put unnecessary strain on joints, leading to a more rapid progression of the disease. Depending on the degree of obesity your veterinarian might put your overweight pet on Hill’s Metabolic Diet. This is a new weight control product with lasting effects and is our first recommendation. We might also use Hill’s W/D (weight diet) or Hill’s R/D (reducing diet).

If your pet is not overweight  we will utilize a food called Hill’s J/D (joint diet). It has added chondroitin sulfate and glucosamine in addition to essential fatty acids and carnitine. These foods are complete and balanced nutrition and can be fed for the rest of your pets life. There is a version for dogs and one for cats. Like all Hill’s foods it highly recommend in almost every case of arthritis unless your pet has some other disease that precludes their use. All Hill’s Prescriptions Diets our doctors recommend are unconditionally guaranteed. We have a detailed page on Nutrition Advice to help clear the air on all the hype that exists on the Internet to get you to put your money into this multi billion dollar a year business.

Excessive exercise that leads to pain or discomfort should be avoided, but moderate exercise is recommended. Swimming is an excellent exercise for pets that have OA and aren’t fearful of water. Most pets do best with several short, exercise periods per day rather than fewer extended periods. Each patient will have their own unique program of weight management and exercise, and we can help you individualize one for you and your pet.

Chondroprotective Agents

These products typically contain precursors of cartilage and joint fluid synthesis. We like to use these medications first since there are negligible side effects and they might be an aid in preventing further deterioration of the cartilage. Hill’s J/D contains adequate amounts of these ingredients. Please remember that if a little is good a lot is not necessarily better because you disrupt the nutrient balance that is so important in nutrition.

These products have a positive effect on cartilage matrix synthesis and  an inhibitory effect on the enzymes that break cartilage down. They might require up to 6 weeks of use before OA symptoms are diminished. Unfortunately they do not work in every case.

Adequan

Adequan (polysulfated glycosaminoglycan) is an injectable chondroprotective agent. Adequan incorporates into joint cartilage and inhibits several enzymes that break down cartilage. No studies have been done in animals other than horses and dogs, but it appears to be safe and effective in other species including cats, rabbits, ferrets, and birds. We use it first because of its ability to rapidly help a painful pet.

The intramuscular injections are initially given twice weekly (every 3-4 days) for a month, then given monthly as needed. Adequan seems to be most effective when given in the early stages of OA, but is beneficial in all stages of the disease. Side effects of adequan are much less common than with NSAID’s.

Dasuquin

Unlike the injectable adequan, Dasuquin and other oral joint supplements are considered nutraceuticals, or nutritional supplements, and do not require FDA approval. Cosequin contains glucosamine and chondroitin sulfate, agents proven to be effective at supporting and protecting joint cartilage.

In addition, Dasuquin contains ASU (avocado/soybean unsaponifiables) that makes the glucosamine and chondroitin sulfate more effective.

There is a Dasuquin made for cats also

NSAID’S

The non-steroidal anti-inflammatories (NSAID’S) are the most commonly used drugs in treating OA in dogs. We also use them in cats, but for a shorter duration.

NSAID’S work by inhibiting an enzyme in the inflammatory pathway, thereby providing analgesia (pain relief), antipyrexia (decreased fever) and reduced tissue swelling. The enzyme that is inhibited is  cyclooxygenase (abbreviated COX). This enzyme causes an inflammatory reaction in the joint fluid that surrounds the joint.

NSAID’s are highly effective and tend to be the drug of choice when we put your pet on actual arthritis medication. They are so effective we even use them for routine post operative pain control in dogs and cats.

A common NSAID is Rimadyl

 

Before we start your pet on NSAID’S we perform an examination and run a baseline blood sample. Every 6 months we will examine your pet and recheck the blood to look for any potential side effects. This will make sure kidney and liver function is adequate.

Using NSAID’S alone is not recommended since the signs of arthritis are masked, leading to a more active dog and a quicker progression of arthritis. NSAID’S, in combination with weight loss and chondroprotective agents, provide cartilage building blocks in addition to pain relief, and may slow the progression of OA.

All NSAID’S carry a small risk of side effects, so careful observation of your pet while on one of these medications is important. If they occur, the most common side effects are vomiting and diarrhea. There might also be kidney and liver problems, and even bleeding. These side effects can be minimized by using the lowest dosage and frequency possible, giving the medication on a full stomach, and giving Pepcid AC  prior.  The best way to minimize the potential for side effects, yet still get the most out of NSAID’s, is to use the lowest effective dose of the NSAID of choice, and combine it with  VNA and Companion Laser as additional treatments. You will learn more about these treatments below.

We do not routinely use NSAID’s in cats due to their potential to cause kidney damage. These cats do best with weight loss if they are overweight, J/D diet if they are not overweight, Dasuquin, VNA, and Companion Laser. A new NSAID for cats is called Onsior. It is approved for treatment of pain and inflammation for 3 days, so we use it routinely in our post operative cat patients.

VNA (also called VOM in the past)

An additional treatment modality that has yielded great success  for well over the last 20 years is called VNA. It has been a game changer for us in the treatment of arthritis in a wide variety of animals.

It is a non-invasive and non-painful way to stimulate the autonomic nervous system to help correct the problem. Through the use of VNA we can decrease the use of the above medications in almost all cases. By decreasing the use of these medications, we help your pet live a longer and healthier life, while decreasing you medication costs over the life of your pet. Click here to learn more about VNA.

This dog is getting VNA therapy for its arthritic spine

id=”Feline-Hyperesthesia”>Feline Hyperesthesia Syndrome

Cats respond very well to VNA treatment. They get what is called the “Feline Hyperesthesia Syndrome. In this syndrome, their lower backs are extremely sensitive, so much so that they start licking compulsively when scratched there, can bite an owner due to pain, and even go into a seizure.

Look how sensitive this cat is when scratched at its rear quarters

As we perform VNA the cat relaxes completely because the sensitivity is diminished

Companion Laser Therapy

In the last few years we have added a new and natural way to treat arthritis using the Therapy Laser. This modality has been used to treat people for over 30 years and has recently been approved by the FDA for use in animals. This treatment modality has been a huge boon to our geriatric pets with painful arthritis, especially when used with low dose NSAID’s and VNA.

To learn more about it please click here or on the picture below.

Acupuncture

This can also be used at any time to augment the treatment already being utilized. To learn more about how we use acupuncture follow this link.

Tramadol

This highly effective pain medication is used when the arthritis is progressing and the above treatments are not as effective as they used to be.

Gabapentin

This seizure medication is another useful adjunct as the arthritis progresses.

Stem Cell Therapy-  Adipose Derived Stem Cells ( Ad-SCT )

This promising yet unproven treatment utilizes stem cells from your own dog’s fat cells to alleviate arthritis symptoms. This means there is no chance of rejection, a major advantage of this technique.

Your dog has to be anesthetized for a short time in order to harvest the fat cells. Collection sites can be in many areas depending on your dogs conformation and fat reserves. Once the fat cells are harvested they are shipped overnight to the company that isolates the stem cells with a specialized technique. They are returned usually within 48 hours. We sedate your pet again and inject the stem cells into the affected area.

We will keep you posted as this promising therapy is given better scrutiny to make sure it has no deleterious effects in the long run and actually helps.

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Liver Disease

This page has a detailed description of this disease in dogs and cats (canine and feline). We will discuss proper animal care along with natural remedies including food and homeopathic treatments. Our pets cannot talk to us, so it is important that you understand this disease as much as possible.

The largest organ in the body is the liver, an indication of its importance in health. It is involved with almost all of the biochemical pathways that allow growth, fight disease, supply nutrients, provide energy, and aid reproduction. Liver cells, which are called hepatocytes, go through thousands of complex biochemical reactions every second in order to perform these myriad functions.

Since the liver is involved with almost all biochemical processes it is no wonder that there are many different diseases that will affect it. This page will cover some of the more important ones we see in animals. The beginning of this page will discuss liver anatomy and physiology, eventually leading to detailed explanations of the more common liver diseases we encounter. This complex organ does not lend itself to easy classification or understanding. Many of the functions of the liver overlap with other organs, and some of the liver’s functions involve complicated biochemical pathways. If this page is too complex for your needs you can go right to our summary page on liver disease.

Even though it makes for good reading, you can skip the anatomy and physiology section and go right to the section on specific diseases if that is all that interests you:

We have a very short Quicktime movie of a liver ultrasound that shows a stone in the gall bladder. Make sure you have Quicktime on your computer to view it. You can get it at www.apple.com


Terminology

It is helpful to be exposed to several medical terms that will be used later in this page:

hepatic- having to do with the liver icterus (jaundice) – yellow discoloration of skin or mucous membranes
hepatocyte- individual liver cell hypertrophy- increased size of an organ
hypoalbuminemia – low albumin polyuria- excess urinating
hypoproteinemia- low protein polydypsia- excess drinking
polyphagia- excess appetite PU/PD- polyuria and polydypsia
ascites- fluid buildup in the abdominal cavity gluconeogenesis- the manufacture of glucose
hypertension- increased blood pressure iatrogenic- caused by something a person does as opposed to happening naturally.
euglycemia- normal blood glucose (sugar) level homeostasis- normal physiology
hepatomegaly- enlarged liver septicemia- excess accumulation of bacteria and toxins in the bloodstream
hepatitis- a general term for inflammation of the liver parenchyma- the internal anatomy of an organ
encephalopathy- chemicals, like ammonia, that depress the brain laparotomy- exploratory surgery of the abdomen
anorexia- poor appetite H.E.- hepatic encephalopathy
metastatic- a tumor that has spread from elsewhere in the body microhepatica- abnormally small liver
cholestasis – excess bile accumulation in the liver

Next you will learn about Liver Anatomy

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Bladder Stones

Stones in the urinary tract are common in dogs and cats. Even though dogs and cats do get kidney stones, it is bladder stones that cause more problems. The medical terms for bladder stones are urolithiasis or cystic calculi. We will use stone, calculi, and urolith synonymously in this page. The two most common calculi are calcium oxalate and struvite.

Stones can also occur in the kidneys, where they are called nephroliths. This page will limit its discussion to stones in the bladder.

Towards the end of the page we have a video on a surgery where we remove bladder stones with the laser.

Cause

There are several factor, usually working in combination, that lead to urolith formation:

  • Mineral Crystals

    Urine that is saturated with excess amount of certain minerals is prone to form bladder stones. These minerals commonly include magnesium, phosphorous, calcium, and ammonia. Most stones consist of an organic matrix of protein surrounded by crystalline minerals.

    Diet can have a major impact here, and is one of the primary methods we use to treat and prevent uroliths.

  • Urine pH

    pH is an indicator of acidity by measuring the hydrogen ion concentration. A pH of 7 is neutral. Below 7 is acidic, above 7 is alkaline. As a general rule, dog and cats tend to have an acidic urine. Some uroliths have a propensity to form in acidic urine, while others tend to form in alkaline urine. Urine pH needs to be measure immediately upon voiding from the bladder for it to be accurate.

  • Bacteria

    Some uroliths form due to the presence of bacteria in the urine, so control of these bacteria is important. Bacteria are diagnosed by culturing the urine during a sterile urinalysis, or by culturing the inside of a stone after surgical removal. Normal urine is sterile, so any bacteria cultured from the urine is abnormal. When bacteria are cultured a pet has a urinary tract infection (UTI) and needs antibiotics. Common bacteria in UTI’s include E. coli, Staph. spp., and Proteus.

    If any bacteria are cultured in the urine our laboratory will test numerous antibiotics to determine which are the best ones to eliminate the bacteria. This is called sensitivity testing. We also do a test called MIC (Minimum Inhibitory Concentration) to let us know the best antibiotic to use and the best dose of that antibiotic.

  • Diseases

    Liver shunts are an abnormality of blood flow to the liver. Blood that would normally flow through the liver now bypasses the liver. One of the many consequences of this disease, called Portosystemic shunts (PSS), is the formation of ammonium urate bladder stones.

  • Medications

    Medications can predispose pets to forming bladder stones. Sometimes they do this by increasing the calcium level in the urine. Medications that increase or decrease the pH of the urine can also set the stage for stone formation. Some medications can actually cause formation of stones when used for long periods of time. The following list includes some of these medications:

    • Lasix
    • Cortisone
    • Ascorbic Acid (Vitamin C)
    • Sulfa medications
    • Tetracycline’s

Predisposing causes of bladder stones include pets that are not drinking enough or are not allowed to urinate frequently. Bacteria and stone forming chemicals stagnate in the urinary bladder and increase the chance of a stone forming. Mechanical flushing of the bladder, in the form of normal and frequent urination, will prevent this.

Always make sure your pet has access to fresh water, changed several times per day, and the ability to urinate frequently. As a matter of fact, if you feed dry food you should be giving more than one cup of water per cup of dry food. An easy way to get around this important requirement for water is not to feed dry food at all. Your pet’s urine should be clear, with no odor or color, and your pet should urinate every few hours. Sometimes these common sense suggestions are so obvious that we tend to forget about their importance.

Typical symptoms of bladder stones:

  • Straining to urinate (stranguria)
  • Blood in the urine (hematuria)
  • Urinating small amounts frequently (pollakiuria)
  • Often times there are no symptoms at all, and the problem is discovered on routine abdominal palpation or radiography.

There might also be excess urination (polyuria), pain in the rear quarters, reluctance to jump or play, or even lethargy and a poor appetite. Some pets can have bladder stones without any apparent symptoms at all!

The bladder stones can pass out of the bladder and lodge in the urethra, especially in male dogs due to the smaller diameter of their urethra. In some cases they can block the flow of urine, which is a medical emergency. This can cause problems with the kidneys, leading to the buildup of toxic waste products. Common areas for these urethral obstructions are the ischial arch near the pelvis and further down the urethra at the os penis. Both of these areas have small diameter urethras that do not expand to allow passage of a stone. You will learn more about this later.


Diagnostic Tests

  • Urinalysis

    A urinalysis is crucial in making a correct diagnosis. The pH of the urine, and the presence of bacteria or crystals all provide valuable information.

    Abnormalities that can be found in the urine in a pet with a urolith include:

    • Blood
    • Increased white blood cells
    • Increased protein
    • Crystals
    • Bacteria
    • Low or high pH

    The presence of crystals (crystalluria) is a sign that a urolith is possible, and usually warrants further investigation. At this point we might take radiographs, do an ultrasound, do a urine culture, or recheck it in the next few weeks or months.

    This is an example of a normal cat urinalysis. The pH is acidic, there are no white blood cells (WBC’s), red blood cells (RBC’s), crystals, or bacteria.

  • Urine Culture

    Bacteria are implicated in many cases of urolithiasis. Culturing the urine will let us know what bacteria, if any, are involved, and which antibiotic(s) will be effective. In addition to serving as a nidus for urolithiasis, these bacteria can ascend from the bladder into the kidneys, causing a pyelonephritis.

    This is a culture & sensitivity report we received from our lab. We sent them a sample of urine directly from the bladder, and asked them to let us know if there are bacteria in the normally sterile urine. The organism they cultured is E. coli, a common bacteria in both animals and humanoids. This bacteria is pathogenic in the bladder, and is causing a urinary tract infection. The lab tests numerous antibiotics and determines which antibiotic(s) E. coli is sensitive to.

As you can see from this culture, E. coli is resistant (R) to numerous antibiotics


After we have determined that bacteria are part of the problem our lab provides us with information on how effective antibiotics will be at the level of the bladder.

Radiography

One of the best methods to make a diagnosis of uroliths is radiography. Many stones are radiopaque, which means they show up vividly on an x-ray. Radiopaque stones include struvite and calcium oxalate. Some stones are radioulucent, and depending on size and number, do not show up on a regular x-ray. These stones are diagnosed by injecting air, dye, or a combination of both, into the bladder to outline any suspected stone. Ultrasound is a great way to detect these stones. Radiolucent stones include ammonium urate.

 

This is the side view of a dog with a very large radiopaque stone in its urinary bladder

 

This is a picture of the stone that was in the x-ray above

 

Other stones aren’t always this smooth. Even though this stone is small, the roughened edges were probably painful in this dogs bladder.

This dog has stones in the bladder and in the urethra as marked by the two arrows on the right. The arrow on the left is showing an enlarged liver lobe.

Click on any of these photos to make them larger

Did you notice the stones in the kidney also?

Radiographic appearance right after surgery to remove the stones in the urinary bladder

Ultrasound

Ultrasound is a very precise method to diagnose stones in the urinary bladder. It is particularly helpful for radiolucent stones and anatomical defects of the bladder wall.

OLYMPUS DIGITAL CAMERA

In this picture the bladder stone is demarcated by the two crosses.

This cat had blood in the urine and a urinary tract infection. There were no calculi in the bladder. Unfortunately there was a malignant cancer in the bladder called a transitional cell carcinoma. Surgery was performed to removed the cancerous portion of the bladder. What we originally thought was a urinary tract infection, with possible cystic calculi, turned out to be a more serious problem. This ultrasound finding, and subsequent treatment, emphasizes the importance of thorough diagnostics.

Bagel Freer Nichole bladder surgery TCC? Linda Larsen

Without the ultrasound we would have not found this tumor soon enough to treat.

 


Composition

We send our stones to the Minnesota Urolith Center at the Univ of Minnesota. They have more experience than any other place in the world regarding animal bladder stones.

minnurolith4

Bladder stones are compliclated, and made of many layers and compounds

minnurolith2

They give us a detailed report on the stone

minnurolith3

This is the protocol for a calcium oxalate stone to prevent recurrence

There are many different types of bladder stones. Some of the most common ones include:

    • Struvite

      This urolith is diagnosed in almost half the cases of bladder stones. It is also called MAP (Magnesium-ammonium-Phosphate), or triple phosphate. Struvite uroliths come in many different shapes and sizes, are radiodense, and form in an alkaline urine.

      It is the predominant stone type in female dogs of all breeds except Dalmatians. This is because of the high association of struvite crystals with urinary tract infections, which are more common in female dogs. If a female dog gets a bladder stone, 80% of the time it is struvite because of this association. Dogs under a year of age, no matter what  sex, get struvite as the most common bladder stone for this same reason. Miniature Schnauzers are the most commonly affected breed, along with bichon frise, cocker spaniels, and miniature poodles.

      Canine  urine is commonly supersaturated with struvite crystals due to the high protein and mineral content of current diets. This excess of these crystals in the urine, stored in the urinary bladder, combines with bacteria to set the stage from the formation of bladder stones (uroliths). Bacteria that are commonly implicated include Staphlycoccus, Enterococcus, and Mycoplasma.  These bacteria increase the amount of organic debris available for crystallization.

      These bacteria also produce urease as a by product of their metabolism. They  split the urea in urine into ammonia and carbon dioxide. As this ammonia is broken down it changes the pH of the urine from its usual acid (pH less than 7) to alkaline (PH > than 7). High urine ammonia concentrations in the urinary bladder can damage the glycosaminoglycans that help prevent the bacteria from adhering to the bladder mucosa (interior lining of the bladder). When we treat for this disease we address these issues.

      What does all of this mean?

Excess struvite crystals in the urine  set the stage for the formation of the urolith.

Urinary Tract Infection (UTI)- some bacteria produce a byproduct called urease. Urease will increase the pH of the urine and promote ammonium in the urine.

The formation of an alkaline (pH greater that 7.0) urine from the diet, or from urease producing bacteria, will cause the struvite crystals to precipitate out of solution and begin the formation of a urolith.

Urine that stays in the bladder longer than usual gives the struvite crystals further opportunity to precipitate out of solution and form a urolith.

    • Cats commonly form struvite bladder stones in the absence of a urinary tract infection. This is probably because cat urine is more concentrated (higher specific gravity) than dogs, so the urine is more saturated (we call this supersaturation) with magnesium, ammonium, and phosphate. This is especially true when the urine pH is highly alkaline, which can occur with the use of some drugs, in certain diets, and when the tubules of the kidney are diseases. If there is a bacteria involved it is usually Staphlycoccus.

Calcium Oxalate

This is the second most prevalent type of urolith after struvite, making up around 30-50% of the uroliths we diagnose, especially in male dogs of all species, except Dalmatians. They come in two versions; the monohydrate and the dihydrate. Sometimes the two are found together, sometimes they are found with other uroliths like calcium phosphate, struvite, or ammonia irate. They show up well on a radiograph. They form in an acidic or neutral urine (pH is 7 or just slightly less). Recurrence is common, so diligence on your part is needed to prevent recurrence.
Feeding an older pet with Kidney problems a food like Hills Prescription Diet K/D may slow or prevent further growth.
If this stone is small and not causing any apparent problem it can be monitored. Some pets will have high calcium (hypercalcemia) in the bloodstream.

Several predisposing factors work together to increase the chance of this urolith forming:

Increased calcium in the bloodstream (hypercalcemia)

Increased calcium in the urine (hypercalciuria) with no hypercalcemia

Concurrent Cushing’s disease

Use of cortisone for skin allergies or Addison’s (hypoadrenocorticism) disease.

Feline
These tend to occur in neutered middle aged cats and older cats, especially Burmese, Himalayan, and Persian breeds. One of the predisposing conditions might be an increased calcium level in the bloodstream. These uroliths tend to form in an acidic urine.
Canine

This is a problem most commonly in older male dogs. It is suspected that there is a correlation with hormone changes that occur as a pet ages. Several breeds are prone:

Miniature Schnauzer

Lhasa apso

Yorkshire terrier

Bichon Frise

Shih Tzu

Miniature poodle

Urate and Ammonium Urate

This is a common urolith found in Dalmatians around middle age, with males affected much more often than females. This is because they metabolize protein differently in the liver, with the end result being uric acid buildup in the urine. In addition to their high prevalence in Dalmatians, they are found in Bulldogs and Yorkshire terriers.
There does not seem to be a connection with a urinary tract infection, and they tend to form in an acidic urine.
Urate stones are radiolucent. If they get large or covered with other minerals they might become radiopaque. Urate calculi tend to be small and occur as several stones. These stones usually form in the bladder, and when passed through the urethra, can become lodged.

Ammonium urate uroliths are sometimes formed in pets with PSS (liver disease) due to improper metabolism of ammonia to urea. This will cause excess uric acid levels in the bloodstream. The kidneys filter out this excess uric acid in the production of urine, thus increasing the level of uric acid in the bladder. The excess ammonia that is in the bloodstream from the liver problem also builds up in the urine in the bladder. These two compounds combine to form the ammonium urate bladder stone.
Dogs with ammonium urate bladder stones might have ammonium urate crystals in their urine and a low specific gravity (dilute urine). These stones might not be seen on a radiograph because they are radiolucent. This same radiograph might also show a small liver, an indication of PSS. This small liver is due to the diverted blood flow to the liver. Dogs with PSS will commonly have abnormalities in the blood sample to give us further clues.

Compound Uroliths

Most bladder stones are caused predominantly by one type of mineral. The more common ones have been described above. In a small percent of cases, the bladder stone is caused by a combination of minerals in similar quantities. These stones are called mixed uroliths. Some bladder stones consist of a core mineral surrounded by a lesser amount of a different mineral in a different layer. These are called compound uroliths. Why some minerals form mixed uroliths and others form compound uroliths is not understood.
Compound uroliths form when the factors that predispose to one type of stone formation have now changed to factors that favor a different type of stone formation. If a struvite stone is treated with antibiotics and urinary acidifiers the problem tends to resolve. The change in urine pH might promote excess calcium in the urine, resulting in a shell of calcium oxalate formation around the core struvite stone. The opposite can occur also- a struvite stone can form over a calcium oxalate stone.
In general, these stones are removed surgically and an effort is made to medically prevent the mineral that is at the core of the stone.

Miscellaneous Uroliths

There are other uroliths that occur, although they are relatively uncommon. They include cystine, silica, calcium phosphate, and miscellaneous minerals.


Treatment

Struvite

Most cases of struvite are treated surgically. The procedure is explained below.

Struvite bladder stones can also be be treated medically with a food called Hills S/D. The mechanism involves creating a urine that is undersaturated with the crystals that caused the struvite urolith to form in the first place. This undersaturation literally cause the urolith to dissolve in the urine, and then get urinated out. It is a slow and gradual process, although most pets get relief from straining and blood in the urine soon after starting this diet.

S/D has several modifications in its ingredients to set up this undersaturated urine. Its reduced in protein, so there is less ammonia buildup in the bladder from bacteria. Magnesium and phosphorous are restricted also. With less contents of the minerals that form the struvite urolith (magnesium, ammonia, and phosphorous- MAP) the urolith starts dissolving.

S/D also has an increased amount of salt (sodium chloride). This promotes drinking and urination and literally helps flush the struvite crystals out of the bladder. It also changes the pH to a more acidic state, which further makes the struvite stone dissolve.

The rate of dissolution is proportional to the surface area of the stone expose to this now undersaturated urine and the control of the urinary tract infection in dogs.  Feline struvite stones tend to dissolve faster than canine because bacteria are not implicated.

S/D must be the only food fed for it to work. We can monitor whether or not an owner is doing this by looking at the pH of the urine along with the specific gravity of the urine. also, the BUN (blood urea nitrogen) of a pet on S/D should be lower than normal.

We have clues from other diagnostic tests to help decide if a urolith found in the urinary bladder on a radiograph is truly struvite. The urinalysis gives us an idea of the composition of the urolith by looking at the crystals in the sediment. The pH of the urine will be alkaline. Also, the presence of bacteria on a culture in a breed that is prone to struvite uroliths is also a strong indication.

If bacteria are found on a urine culture in dogs then antibiotics must be used simultaneously while a pet is on S/D. It must be the correct antibiotic, so the importance of the urine culture is obvious. Both S/D and antibiotics are used for one month after the stone is no longer visible on a radiograph. If there is a persistent urinary tract infection we might use a urease inhibitor called acetohydroxamic acid. Urinary acidifiers are usually not used.

If the urolith is still present after 2 months of S/D and antibiotics, then surgery should be performed. Most pets need to be fed S/D for 4-6 months for complete resolution. It should be fed for an addition 30 days after there is no longer any stone based on a radiograph.

S/D is restricted in protein, so it is not a complete diet for long term use in dogs. It also should not be used pregnant dogs, lactating dogs, ground dogs, and after surgery due to this protein restriction. While on S/D your dog’s blood should be monitored to ensure there are no side effects of the restricted protein.

Due to the high salt (sodium chloride) it should not be used in dogs with congestive heart failure and hypertension.

S/D diet tends to work faster in cats because bacteria are not usually involved. S/D should also be fed for 30 days after there is no more evidence of a stone in the bladder when radiographed. Feline S/D is not protein restricted, so it can be used for the rest of your cat’s life.

Calcium Oxalate

The only treatment for these uroliths is surgical removal. This is the easy part, its preventing their recurrence that is difficult. The protocol in how to do this was shown earlier.

Urate

If there is no PSS these uroliths can sometimes be handled medically also. A food called Hills U/D should be used. It is low in purines and has restricted protein. A medication called allopurinol is given which helps minimize the amount of uric acid produced in the urine. Potassium citrate is also used to make the urine less acidic, although this might occur with the use of U/D alone. Adding salt to the diet or mixing water with the food will also promote urination of the urate crystals. Recurrence is common, so this diet needs to be used for the life of your pet, especially in Dalmatians. We will talk more about this later in the prevention section.

Surgical Treatment

Many bladder stones are treated surgically.

We usually use the laser to make an incision in the bladder. Here is a link to how we do surgery at our hospital.

Many of these bladders are thickened from chronic irritation, which means they have an extensive blood supply. You will see that in the following photos. When you watch the laser surgery on one of these thickened bladders notice the blood supply and how little bleeding there is.

Surgery-Monitor

We keep a close tab on important physiologic parameters for all of our surgeries. Monitors like this give us an early warning of an impending problem

_D2A8630

Once our surgeon has scrubbed up and is  in sterile gown, gloves, and mask, the surgery begins

The surgical removal of a stone in the urinary bladder is called a cystotomy. It involves making an incision into the abdomen, exteriorizing the urinary bladder, removing the stone(s), and resuturing the bladder. When we make the incision into the bladder the laser is used in almost all cases because of dramatically less bleeding during the surgery and dramatically less inflammation after we remove the stone and suture the bladder.  For those of us that have had surgery we know the importance of minimizing post operative pain. Your pet will be happy we used the laser!

Laser-cystotomy

The initial incision of this thickened bladder with the laser. Notice the lack of bleeding, even though this is the second time these stones have been removed. Click on this link to see a short movie of this incision

 

Laser-cystotomystone

The actual calcium oxalate stone (there were 5 of them overall) removed from this bladder

A movie of this stone removal

 

The bladder is not the only location for stones to occur. This dog has 2 in its urethra at the tips of the black arrows.

 

A close-up view give better visualization. This is an example of stones that are lodged at the ischial arch, described previously in the symptoms section.

We passed a urinary catheter under anesthesia and started flushing the stones towards the bladder. Once they are in the bladder they can be removed via cystotomy.

In this view you can see how the stones have moved slightly from the flushing. It took 8 more flushings to move them all the way into the bladder.

This is a picture of the bladder during the actual flushing. The bladder has an incision in it because this dog also had a calculi in its bladder, which has already been removed. It takes significant force to move the stones from the urethra back into the bladder.

You can see the saline solution flowing out of the bladder towards the left (arrow)

How we suture the bladder after the stones are removed

These are the three stones that were removed- one was in the bladder and two were in the urethra

 

This is the stone analysis of the above uroliths verifying that they are calcium oxalate stones

The center of the stone was cultured. The culture yielded an organism called nonhemolytic coagulase negative Staph. This is the same bacteria that can be found on your skin.

This bacteria is sensitive (S) to 5 of the antibiotics on the list.

There is another common area for stones to lodge in the urethra of male dogs. Towards the end of the urethra male dogs have a boney structure that surrounds the urethra. This structure is called the os penis. In this area the urethra cannot expand to let a stone pass, hence stones commonly lodge here. This can prevent urination, with potentially serious consequences for the kidneys.

The white line outlines the urethra as it passes from the bladder, goes over the ischial arch and through the os penis. The arrow points to the beginning of the os penis, the area where a stone would lodge.

buddy1

The arrow points to a stone at the os penis

buddy2

It was flushed back into the bladder with a catheter. Here it is part way back.

buddy3

After a few more flushings it was pushed back into the urinary bladder, along with the other stones that are already in the bladder. It was removed doing a routine cystotomy.

buddy5

After the large stones we removed the smaller ones, which are hard to visualize in the bladder, are flushed out. This radiograph after surgery shows there are no more stones in the bladder.

buddy7

This is the stone that was originally stuck behind the os penis, and flushed back into the bladder. It is only a few millimeters in size, but with its rough appearance, is probably not very comfortable to say the least.

There are several sequelae to these stones in the urethra. If the urinary bladder has been distended long enough it loses its ability to contract and urinate properly. Nerve damage in the spinal cord can also cause this. The end result is an animal where the urine builds up in the bladder until the point it passively overflows and they dribble.  These animals are predisposed to chronic infections, not to mention the pain and discomfort of a distended urinary bladder.

This radiograph shows a dog with a seriously distended urinary bladder (UB). Its the large white area in the middle of the radiograph. The dark area to the left and slightly overlapping the front of the urinary bladder is the stomach (S) filled with food.

Prevention

Medical dissolution or surgical removal of the bladder stone is the first step in the process. The next, and just as important step, is the prevention of the stone’s recurrence. Some of these stones will require a diet change only, while others might require long term medication. Some breeds are predisposed to forming stones in spite of what we do to prevent them. Our doctors will set up a specific protocol for your pet based on the breed and type of stone removed.

Long term follow up is important. Your pet will have to return periodically to recheck a urinalysis, culture the urine for bacteria, and x-ray the bladder. Many stones recur because owners forget the importance of long term prevention.

At all times make sure your pet has access to fresh water and the ability to go to the bathroom. This treatment alone will go a long way to prevent recurrence. Giving your pet food that has more moisture will increase the flow of water through the urinary system and minimize crystal formation in the bladder. As a general rule, we do not recommend adding salt (sodium chloride) to the food to get your pet to drink more water because it might promote calcium formation in the urine, thus setting the stage for a stone to form. Your doctor will let you know if this applies in your case.

Struvite

Pets that have struvite urolithiasis, whether treated surgically or medically, have a chance of recurrence if not monitored carefully. If the urine is alkaline on a urinalysis it should be cultured to check for bacteria. Antibiotics are indicated if the culture is positive. If the pH stays alkaline in spite of antibiotic therapy, then Hills C/D should be used. It will help maintain an acidic urine, and has some mild restrictions in protein and minerals. As a general rule, we recommend C/D for all pets that have had struvite crystals. It can be used on a long term basis, and is helpful in preventing FLUTD in cats. S/D can also be used long term in cats.

If your dog gets recurring urinary tract infections, thus predisposing it to a struvite bladder stone, it is important to examine it for abnormal anatomy of the vulva, for obesity, and problems with the urethral sphincter.

Calcium Oxalate

Recurrence rates with this urolith are high, so a long term plan and commitment to sticking with it are important.

Baseline data consisting or radiographs, urinalysis, urine culture, and blood panel needs to be obtained. Particular attention is paid to the blood calcium level.

A diet with reduced quantities of protein, calcium, and sodium, that also does not make an acidic urine, is the ideal diet to feed. Too much of a reduction in these nutrients can be detrimental, so no supplements should be added. The primary diet in the cat that accomplishes this ideal is Hills Prescription Diet K/D. In dogs, K/D, W/D, and U/D are used. The use of U/D might preclude the use of potassium citrate as long as there are not calcium oxalate crystals in the urine and the pH is alkaline. There is a C/D that treats calcium oxalate uroliths in cats.

Certain foods that are high in oxalates or calcium, or foods that increase calcium levels, must be avoided. They include high protein foods, spinach, rhubarb, parsley, milk products, and table salt.

When we diagnose a calcium oxalate stone we will check the calcium level in the bloodstream to make sure it is not abnormally high. This normal calcium level was from the dog above that had the surgery to remove the calcium oxalate stones from its bladder and urethra.

Vitamin C and D, along with drugs that make the urine more acidic, should not be added to the diet. Cortisone also should be used cautiously because it increases the calcium level in the urine.

Potassium citrate will inhibit calcium oxalate crystal formation and keep the pH of the urine in the ideal range. We will use this if U/D does not keep the urine alkaline.

After surgery your pet should return in 2 weeks for a urinalysis. If there are calcium oxalate crystals in the urine we will add potassium citrate as per above. If there are no crystals we will not need to do a recheck for 3 months. At this 3 month recheck of the urine we will also re-radiograph the bladder and check a blood panel noting the calcium level.

Two weeks after surgery this is the urine sample of the dog with the above stones. This is what we want to see- no crystals, no bacteria, and an alkaline pH.

If calcium oxalate crystals persist in the urine 2 weeks after adding potassium citrate, we will add Vitamin B6 to the diet. If the B6 does not eliminate the crystals, we will use a drug called hydrochlorothiazide. Use of this drug requires close monitoring of the potassium level and the calcium level in the bloodstream.

A urinalysis should be performed every 3-6 months to look for crystals in the urine and monitor the pH. A urine culture should also be performed at this time to decide if antibiotics are needed.

Ammonium Urate and Urate – Medical care for Dalmatians after surgery includes:

  1. Increasing water consumption so the specific gravity of the urine is near 1.018. adding water to dry food, feeding more canned food, and adding encapsulated light salt (KCl) all will help.
  2. Feeding a diet low in purines. Diets low in purines include the Hills Prescription Diets K/D or U/D dry and U/D canned.
  3. Increasing the pH of the urine to 7.0-7.5. The above diets might accomplish this pH. If not, adding oral potassium citrate to the diet will help.
  4. Controlling urinary tract infections, if any, by performing urine culture and sensitivity tests every 3-6 months, and using antibiotics on a long term basis if needed.
  5. Adding allopurinol to the diet to prevent the conversion of purine to uric acid.This therapy needs to be followed diligently for the life of your Dalmatian.

Medical care for cats and non-Dalmatian dogs after surgery is similar. Most of these uroliths are caused by a PSS, thus surgery to correct the liver problem will help prevent the recurrence of these stones in the bladder. In some PSS’s the liver problem cannot be completely resolved, adding to the risk of formation of these bladder stones in the future. Long term therapy is similar to Dalmatians:

  1. Increasing water consumption so the specific gravity of the urine is near 1.018 for dogs and 1.025 for cats. adding water to dry food, feeding more canned food, and adding encapsulated light salt (KCl) all will help.
  2. Feeding a diet low in purines for dogs. Diets low in purines include the Hills Prescription Diets K/D or U/D dry and U/D canned. For cats feed diets that do not acidify the urine, which unfortunately, many do to prevent FLUTD.
  3. Increasing the pH of the urine to 7.0-7.5. The above diets might accomplish this pH. If not, adding oral potassium citrate to the diet will help.
  4. Controlling urinary tract infections by performing urine culture and sensitivity tests every 3-6 months, and using antibiotics on a long term basis if needed.

Compound Uroliths

Since these stones have a combination of minerals they present a dilemma in their prevention. In general, it is recommended that an effort is made to prevent the mineral that forms the core of the stone.

The majority of compound stones are struvite core with a calcium phosphate outer core.

An additonal treatment modality, used especially after we remove the urolithiasis is VNA. It is a non-invasive and non-painful way to stimulate the nervous system to increase blood flow to the kidneys. This will increase urine output, making it more difficult for the stone to start all over again. It is a highly effective way to help prevent the problem from recurring.


Dietary Information

Pet food manufacturers have dramatically increased their sophistication in treating bladder problems in dogs and cats. It is because of these advances that we are able to treat and prevent many of these uroliths medically. Unfortunately, a change in food to treat struvite uroliths predisposes a pet to calcium oxalate uroliths, and vice versa. One of the ways we have gotten around this is to produce a food in cats, called C/D multicare, that prevents both. There is even a C/D stress diet for cats in multiple cat households, or those prone to stress.

In order to remedy this situation it is important to make a correct diagnosis so that the proper type of food can be used. To ensure that you are not setting up an environment for a different urolith to form in the future, the urine should be monitored every 3 months.

Another remedy is to use combined diets that have been formulated to take care of both of these calculi simultaneously. This might help if compound uroliths are present.

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Sarcoptic Mange (Scabies)

Sarcoptic mange (cats get a version called notoedric mange ), commonly know as scabies, is caused by an external parasite called Sarcoptes scabei  that burrows deep into the skin. It commonly occurs in dogs, not so commonly in cats, unless is it notoedric mange), also occurs in foxes, ferrets, rabbits, sheep, goats, cattle, pigs and guinea pigs. 

It is contagious to other pets and occurs in many different animals. It causes intense itchiness, especially affecting the ear margins, elbows, and face. People can pick up this disease from their pet and show symptoms of itching, but it goes away by itself in many cases and usually  does not require treatment in most cases (always check with your doctor).

It is important to note that the diagnosis of this skin condition, like most skin conditions, can not be made just by looking at a pet. Diagnostic tests are mandatory to arrive at a correct diagnosis and achieve a satisfactory outcome to therapy. Stating that an animal looks “mangey” is not the same thing as making a positive diagnosis of mange. Pets that have Ringworm , Demodex. and allergies can look like they have Sarcoptic mange.

 Life Cycle

This ectoparasite spends it life cycle of 14-21 days entirely on the host it has infected.  Overcrowded conditions increase risk for transmission. 

History

The following history for an itching pet with sarcoptes usually involves:

  • Severe itching that is non-seasonal
  • Recently adopted or boarded pet
  • Multiple pets in the house
  • Humans in the same house that are itching with red lesions on their skin.

 Symptoms

In dogs most of the symptoms involve intense itching at the ear margins, elbows, hocks and abdomen. Less common areas of itching can include the face and feet. This itching will inflame the skin and cause scabs with a secondary bacterial infection (pyoderma) occurring due to the trauma. Some pets will shake their ears excessively and cause an aural hematoma (swollen ear). These symptoms can mimic those of other skin conditions, so the rules of the diagnostic process should be carefully adhered to.

Other symptoms that might be present sometimes include:

  • Lethargy and depression
  • Lack of appetite
  • Weight loss

Cat mange (notoedres cati)

In cats, sarcoptic mange is caused by a mite called notoedres cati, a microscopic ectoparasite that burrows in to the skin. It is not as itchy, and occurs more often on the face, ears, paws, and tail.

This is a highly magnified view of notoedres cati as it appears under the microscope

This cat has scabies, but you can’t say that for sure just by looking at it.

The top of his head shows how irritating the problem is, especially at the ears.

Diagnosis

The primary way to diagnose sarcoptic mange is to do a skin scraping where the patches of alopecia occur. Finding these mites, their eggs, or their feces,  under the microscope can be very difficult in this disease. a pet that has the symptoms of Sarcoptic mange and is negative on skin scrapings for the parasite can still have the disease. In these cases we commonly treat for the disease anyway, because the treatment is highly effective.

In rare cases we will do a skin biopsy, which is a great way to rule out other diseases that have similar symptoms.

Other diseases in dogs that mimic scabies include:

  • Folliculitis
  • Malassezia (fungus)
  • Allergies
  • Contact dermatitis
  • Cancer
  • Pemphigus (immune system disease)

Diseases in cats that mimic scabies include:

  • Demodectic mange
  • Otodectic mange
  • Cheyletellia
  • Herpes dermatitis
  • Allergies

Treatment

The usual treatment for Sarcoptic mange is a drug called Ivermectin. It is an injection given weekly for up to 6 weeks. Most pets decrease their scratching rapidly after the first injection. Some dogs, particularly Collies, Shetland Sheepdogs, and Old English Sheepdogs do not tolerate the medication well. In these pets we use a dip called Lyme Sulfur that is also very effective. The disadvantage to the dip is the odor it causes and the staining of white coated animals. All pets in a household should be treated regardless of whether they are showing symptoms or not. Pets that have secondary skin infections from the trauma might also be put on antibiotics. Other common treatments include Revolution (selamectin) topical. 

Other pets in the same household are commonly treated if they are in close contact. Treating the environment is usually not needed if all pets in the house are treated.

Some pets itch more in the first few days of treatment due to dying mites. These pets can be put on cortisone in a reducing dose to get over this phase.

This dog has scabies

This is a picture from the dog above 7 days after its first Ivermectin injection

Prevention

Good nutrition and plenty of play and exercise are always important to maintain the proper balance to fight off disease. All pets in a household that has a pet diagnosed with this disease should also be treated.

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