LBAH Informational Articles

Hip Dysplasia

Hip dysplasia is a congenital disease that affects mostly large breed dogs. It is a laxity in the socked of the hip joint where the head of the femur fits into the pelvis. It causes weakness and lameness to the rear quarters, and eventually leads to painful arthritis. This arthritis goes by several names; degenerative joint disease, arthrosis, osteoarthritis.

This disease is so prevalent, and so debilitating, that a special veterinary organization called The Orthopedic Foundation for Animals (OFA) was organized to minimize the problem in the breeding pool of dogs. It occurs rarely in cats, primarily the Maine coon, and usually in females.


Cause

Many factors work together to cause this disease, which is a combination of a dog genetically inclined to get this disease interacting with environmental factors that bring about the symptoms. These environmental factors excess calcium in the diet of puppy food for large breed dogs, along with obesity, high protein and calorie diets, and a lack of or too much exercise. The breeding of dogs that already have hip dysplasia is one of the primary reasons the disease is still present. A dog that has hip dysplasia in one socket is prone to having a problem with the ligaments of the knee in the other leg (anterior cruciate rupture).

Pathophysiology

During the degenerative process the cartilage that lines the hip joint, called hyaline cartilage, is damaged. The damage results from the abnormal forces on the cartilage from the deformed hip socket. Small fractures can occur in the cartilage also. Eventually an enzyme is released that degrades the joint further and decrease the synthesis of an important joint protectant called proteoglycans. The cartilage becomes thinner and stiffer, further compromising its ability to handle the stresses of daily movement and weight bearing.As the problem progresses more enzymes are released, which now affect the precursors to proteoglycans, molecules called glycosaminoglycans and hyaluronate. Lubrication is negligible, inflammation occurs, and the joint fluid can no longer nourish the hyaline cartilage. This viscious cycle continues until pain occurs. The body attempts to reduce this pain by stabilizing the hip joint. New bone is deposited at the joint, both inside and out, along with some of the ligaments and muscle attachments to the area. This causes thickening and a decrease in the range of motion. This is the actual arthritis noted on a radiograph, which will not go away, and will continue to progress.

 

Breed Predispositions

Many dogs can develop hip dysplasia. Dogs that were commonly affected years ago, like German Shepherds and Labrador Retrievers, still get the disease but not as commonly as before.

According to the OFA some of the breeds with the highest prevalence are:

Bulldog Pug Otterhund Clumber Spaniel
Neapolitan Mastiff St. Bernard Boykin Spaniel Sussex Spaniel
American Bulldog Newfoundland American Staffordshire Terrier Bloodhound
Bullmastiff Chesapeake Bay Retriever Golden Retriever Gordon Setter
Rottweiler Chow Chow Old English Sheepdog Kuvasz
Norweigan Elkhound Giant Schnauzer German Shepherd Bernese Mountain Dog
English Setter Black and Tan Coonhound Shih Tzu Staffordshire Terrier
Welsh Corgi Beagle Briard Brittany
Bouvier des flandres Welsh Springer Spaniel Curly Coated Retriever Polish Lowland Sheepdog
Portugese Water Dog English Springer Spaniel Pudel Pointer Irish Water Spaniel

Diagnosis

Hip Dysplasia is diagnosed based on a history of weakness or lameness to the rear legs, especially after exercise or when first getting up after resting. Some young dogs will bunny hop when running, and might lie down on their stomachs with their legs stretched behind them. It is possible to palpate joint laxity on some dogs that are anesthetized (we call this the Ortolani sign). Sometimes we will feel grinding, called crepitus, in the hip joint as we move the leg around the socket.

Radiography is the definitive way this disease is diagnosed. It is not perfect though, since a dog can be hip dysplasia free on the radiograph (phenotype), but can be genetically predisposed to the disease (genotype). These dogs have the potential to be carriers of the disease, yet show no symptoms themselves.

Many variables affect the degree of lameness. They include age of onset, caloric intake, degree of exercise, and weather. To further add to the complication, pets with terrible looking hips on radiographs might act as if nothing is wrong, while others with barely discernible changes on their radiographs might be severely lame.

These are the x-rays of a dog with a normal pelvis. The diagram below explains why these hips are normal. View both of them at the same time if possible.

On the right side of this normal pelvis we have outlined 2 important anatomical features. The “U” shaped appearance of the neck (outlined in white), and the full rounded appearance of the head (outlined in black), are normal. They indicate a full socket with a tight fit and no signs of secondary changes due to instability of the ball and socket joint.

Here is a larger view of normal hips with digital radiography you can click on to see more detail

Normal-hipsweb

This dog has moderate changes that indicate it has hip dysplasia on the right side. The socket is not as rounded as it could be, and the head of the femur is slightly flattened. also, the neck of the femur does not have the U shaped indentation that is normal. You can see this better on the closeup views below.

 

The arrow points to the thickening in the femoral neck in the abnormal right socket. You can also visualize the slightly flattened appearance of the head of the femur and the fact that it does not fit into the socket as tight as the normal hip marked left.

This is a case of severe hip dysplasia. The arrows point to the thickened femoral neck on each side along with the secondary arthritis occurring on the left side. Notice how flat the sockets are and the lack of rounded appearance of the femoral head. This dog is probably in pain and has a difficult time walking in the rear quarters.

If left untreated the disease continues to progress, eventually causing a crippling lameness and severe pain. Correcting this problem at an early age might have prevented this.

These digital radiographs show even more detail on a dog with moderate hip dysplasia radiographically. The arrows point to boney projections from the pelvis. This is painful secondary arthritis forming due to the instability of the hip socket.

BadHipsarrowsweb

This is a another digital radiograph of even more advanced secondary arthritis in a dog with severe hip dysplasia

SevereHipDysplasia

Dogs are not the only species that gets hip dysplasia. It can also occur in cats (Maine Coons are commonly affected), although not as common as in dogs.

The white arrows outline the large amount of stool in the colon of the above cat with feline hip dysplasia. It is painful for this cat to squat to have a bowel movement, as a result it gets severely constipated.

Other diseases that cause lameness or soreness in the rear legs can mimic hip dysplasia. These include rupture of the cranial cruciate ligament in the knee, panosteitis, and degenerative disease of the spinal cord affecting the nerves to the rear legs.

Medical Treatment

Medical therapy might help in some cases. It depends on the size of your dog, what its function will be in your household, age, and severity of the problem. You might need to try several treatments until you find the one what works. Many of these treatments need to be used in combination with other medical therapies. Please keep in mind that large breed dogs are stoic. Do to their propensity to please you, these dogs can see fine on the outside but are painful on the inside. Watching for subtle signs is important.

Medical therapy will not cure the problem, and in most cases painful arthritis will set in. Early surgical intervention is usually the best course of action. It is not uncommon to radiograph your dog’s pelvis when it is already under anesthesia for a spay (OVH or ovariohysterectomy) or neuter.

Environmental

Keeping your dog’s weight under control and providing controlled exercise are very beneficial. Going for short walks will give you an idea of your dog’s limits. Proper exercise will maintain muscle tone and keep the joints moving and more fluid. Provide a warm environment and a well padded bedding area are also of benefit. Additional warmth helps chronically infected joints. Hot water bottles are helpful. We don’t recommend electric heating pads because of serious burn potential.

Swimming in a pool if your dog is comfortable with it can be beneficial. Hydrotherapy in a tub supervised by a veterinary certified in rehabilitative medicine is also helpful.

Non-Drug

Acupuncture, Laser Therapy, and VNA are excellent treatment choices in many cases because they are effective without the use of drugs. Our  Alternative Medicine page has detailed information.

Gentle passive range of motion exercises might help. Use of the food J/D (joint diet) is also recommended. There is also a version of J/D called Metabolic and Mobility that decreases weight in obese dogs while also providing treatment for the arthritis. It contains extra amounts of omega-3 fatty acids which might help reduce joint inflammation. One of these foods should initially be tried on all dogs with hip dysplasia.

Drugs

Many drugs have been used to control the pain associated with the secondary arthritis that occurs with hip dysplasia. Some of these drugs are extremely effective, and can provide a dog with a high degree of relief from pain. They only mask symptoms though and do not cure the problem.

Buffered aspirin and ascriptin (aspirin with maalox) are readily available over the counter remedies. Tylenol should not be used in dogs because of its potential for side effects. Tylenol is NEVER used in cats because it can cause a serious disease called methemoglobinemia.

NSAID’s (Non Steroidal Anti-inflammatory Drugs) are highly effective prescription medications. The work by inhibiting the release of prostaglandins, leading to less inflammation in the joints. They should be given prior to any bout of exercise. Some dogs will vomit or have diarrhea on these medications. Giving the medication on a full stomach and using GI protectants like Pepcid AC can minimize this problem. Their  use in labradors should be carefully monitored for signs of liver problems. Any dog that is on these drugs long term should have a blood panel taken to monitor internal organ function, especially kidney and liver.

Nutraceuticals are popular arthritis treatments, primarily because they are thought of as more natural than drugs. Humanoids use them commonly. They provide the raw material that enhance they synthesis of glycosaminoglycan and hyaluronate. Controlled studies are lacking to determine their true effectiveness. Oral versions take at least one month to become effective. A great advantage is their lack of side effects. Oral versions include Cosequin, Synovicare, Glycoflex, arthramine, and MaxFlex. Injectable versions include adequan, a drug that has been used in veterinary medicine, especially in horses, for many years. Injectable versions achieve a more rapid response than oral medications.

We can’t predict which medications will work best in an individual case. Trying different ones, even using some of them in combination, can let you determine which is the best approach in your dog.

 

Surgical Treatment

Most cases of hip dysplasia, especially in younger dogs, are treated surgically. One of the surgical specialists we consult with will make the determination of which procedure is the most appropriate. Three main types of surgery are performed.

This area contains graphic pictures of actual surgical procedures performed at the hospital. It may not be suitable for some children (and some adults also!).

1. Femoral Head Ostectomy (FHO) or Excision Arthroplasty

In this procedure the head (or ball) of the femur is removed. The remaining part of the femur forms a false joint with the muscles, ligaments, and tendons in the area. Even though this false joint is not as good as a real joint, there is a significant reduction in pain. almost any sized dog can have this procedure even though it is much more effective in smaller dogs. Obese dogs and those with significant loss of muscle do not do as well. Compared to the other types of surgery this one is much more basic, yet many pets that have this surgery return to almost normal function.

This are the hips of Mickey, a very active australian Shepherd. He has hip dysplasia on both sides. FHO surgery will be performed on his right hip.

After the skin incision is made the muscles are separated to give visualization of the femoral head. It is gently rotated and brought up as far as possible.

A special air powered drill is used to cut the neck of the femur at just the right angle.

The angle in the cut of the femoral neck is apparent. also present on the head of this femur is a piece of the round ligament, one of the structures that anchors the head of the femur into the socket.

An opening remains where the head of the femur used to reside. The remaining bone will form a false joint, and return this pet to almost 100% function.

The muscles that were separated and cut are now carefully sutured. These muscles are necessary for normal movement of the false joint that will soon form.

This is what remains after the surgery. Mickey healed rapidly after the surgery and is running around as fast as before, according to his worried mom.

 

2. Triple Pelvic Osteotomy (TPO)

This surgery is used in large breed dogs no older than 10 months of age. Candidates for this surgery can only have mild hip dysplasia and no signs of secondary arthritis. During the procedure the pelvis is cut and rotated slightly so that the head of the femur has a tighter fit into the socket. Since the pelvis is being cut it needs to be stabilized with bone plates.

The pelvis is cut in 3 locations. The locations of these cuts allows the proper rotation of the hips.

This is the final result after a TPO surgery. These two plates are angled to provide the proper pelvic rotation.

Click on this radiograph for a larger view of a TPO surgery

tpo

3. Total Hip Replacement (THR)

In this procedure the neck and head of the femur are replaced with stainless steel or titanium implants. This is a highly specialized procedure performed only by select veterinarians. It is used in young dogs that have achieved most of their skeletal growth and in adult dogs that weigh at least 40 pounds. It can be used in dogs that already have secondary arthritis, unlike the TPO. It has a high success rate but has to be performed carefully because if post operative complications occur they can be disastrous.

This is the end result of the surgery. These implants now make up the ball and socket joint, and will remain fully functional for many years.

An additional treatment modality that has yielded great success in treating hip dysplasia is called VNA. It is a non-invasive and non-painful way to stimulate the nervous system to help the hip dysplasia syndrome.

Prevention

This is achieved by neutering pets that have the disease. Dogs can be screened for this problem by taking radiographs of their hips at 2 years of age. If they are certified free of hip dysplasia by the Orthopedic Foundation of america (OFA), there is much less of a chance they will sire offspring with the problem. It is best to purchase large breed dogs only if their parents are OFA certified to be hip dysplasia free.

No guarantee can be given when breeding hip dysplasia free dogs radiographically that their offspring will not deveop the disease. A dog can be hip dysplasia free on a radiograph, yet still carry the genetic predisposition to this disease that will be transmitted to its offspring.

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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)

Icterus, also known as jaundice, is a yellow discoloration

icterusgums

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 -SpleenRad Splenectomy-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. 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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Hypertension (High Blood Pressure)

Many cats are living longer lives, and unfortunately, are acquiring diseases that were not commonly seen in the recent past. Hypertension (high blood pressure) is one of these diseases. The increase in blood pressure affects many organs, particularly the liver, eyes, kidneys, and heart. Hypertension hastens the progress of these diseases and substantially predisposes your cat to blindness.We have only recently been measuring blood pressures in dogs and cats, so our database is not as complete as in humanoids. We are at the beginning stages of understanding if an elevated blood pressure is the result of a disease, a cause of a disease, or has no bearing on a disease.

High blood pressure can be primary, where the cause is unknown. In most animals though, it is secondary to some other disease.

We have a short Quicktime video on the use of our doppler blood pressure monitor. It will take a few minutes to download-you need Quicktime from www.apple.com to view it.

The are two main factors that determine blood pressure.

Cardiac output

It is the amount of blood pumped by the heart in a specific period of time. The determinants of cardiac ouptut are the heart rate (measured in beats per minute) and the stroke volume (the amount of blood in ml ejected with each beat of the heart).

Vascular resistance

This is how constricted or dilated the artery is as the blood is flowing through it. A dilated artery has a larger diameter, so less blood pressure needs to be generated by the heart for blood to flow through this dilated vessel. Arteries constantly constrict and dilate, all depending on the needs of the body overall and the specific organ they are supplying blood to. For example, the arteries to your muscles dilate when you exercise. This allows the muscles to receive extra nutrients and oxygen. When you are done exercising they start constricting and blood is diverted to other areas of the body where it might now be needed. Maybe now you are eating a meal and the digestive system needs the added blood flow.

As it turns out, is is cardiac output X vascular resistance that determines the blood pressure. If you get scared, adrenaline secretion will increase the heart rate and your blood pressure will rise due to the increased cardiac output. If you become dehydrated, the stroke volume might decrease due to a lack of fluid, and your blood pressure will decrease due to a decreased cardiac output. Older pets tend to have arteries that are not as elastic as when they were younger, the animal world version of arteriosclerosis. These blood vessels stay constricted more than dilated. This increases the vascular resistance, resulting in increased blood pressure.

Normal regulation of the blood pressure involves a complicated set of metabolic processes. Many body systems are involved, including the nervous system, the renal system, the cardiovascular system, and the endocrine system. It is a highly refined system that can make minute changes in rapid response to changing physiologic needs.

In a nut shell, the kidneys secrete a hormone called renin. This can be in response to a decreased blood flow to the kidneys, stimulation of the nervous system, secretion of hormones like adrenaline (epinephrine), or low sodium levels. Renin will activate the conversion of angoitensin I to angiotensin II in the lungs. Angiotensin II will constrict the blood vessels (increased vascular resistance) and stimulate the secretion of aldosterone. Aldosterone will increase water retention by its effects on sodium. Constriction of blood vessels (increased vascular resistance) and increased water retention (increased stroke volume) lead to an increased blood pressure. Pretty easy huh?

Pathophysiology

Abnormally high blood pressure causes blood vessel damage, particularly in the eye, kidney, heart and brain. These damaged blood vessels will bleed, cause clots, fluid buildup, and tissue death. The mechanism for this is complex.

Hypertension also places excessive strain on the cardiac (heart) muscle. The heart has to pump against more pressure (vascular resistance), causing further deterioration. As it progresses the heart enlarges and a murmur might be heard with the stethoscope.

Symptoms

There are no specific set of symptoms of high blood pressure. That’s why its called the silent killer in people. What might appear are the symptoms of the disease that is causing the high blood pressure in the first place.

The primary symptom in cats some owners notice is a sudden onset of blindness, as evidenced by dilated pupils and bumping into objects. Cats that were apparently fine just a day or two earlier are now completely blind. Prior to the onset of blindness an owner might notice other symptoms. These might include weight loss, excess drinking and urinating, vomiting, change in appetite (up or down) and fast heart rate. Monitoring some of these parameters ahead of time is possible to look for subtle signs of diseases. This is explained in our In Home Exam section and our Wellness section. 

Ollie is exhibiting all the classic signs of blindness. Both pupils are dilated and stay that way, even when a light is shined on them. In addition, his left eye shows signs of potential hemorrhage.

Cause

Feline hypertension is almost always secondary to other problems, namely hyperthyroidism and kidney failure. The majority of cats with these two diseases will eventually develop hypertension. Any cat that has been diagnosed with one or both of these diseases should be monitored for hypertension every 3-6 months.

Kidney Failure

Every beat of the heart sends a significant amount of blood to the kidneys. As cats age the kidneys do not function properly, and through complex mechanisms mentioned in the physiology section, the blood pressure will elevate.

Hyperthyroidism

The increased level of thyroid hormone (thyroxine) in the blood stream causes the heart to increase its output of blood, leading to a racing heart and an increase in blood pressure.

Diagnosis

As in people, hypertension is a silent disease. You don’t feel ill, and there are no obvious symptoms until it is too late. Fortunately, we have sophisticated medical equipment that will help us make this diagnosis.

Signalment

Found in cats and dogs. There is no breed predilection, but tends to occur more in males and older animals.

History

Older cats that have racing and pounding heart rates, along with blindness, give an indication of hypertension. Hypertension is suspected in cats that have been diagnosed with kidney or heart disease in addition to hyperthyroidism.

Physical Exam

In most cases there are no obvious physical abnormalities. Blood samples that are easily obtained, or pulsate in the syringe when obtained, are another indirect indication of hypertension. The pupils might be dilated, the thryoid gland might be enlarged, the kidneys might feel abnormal, and there could be blood in the urine (hematuria) or nose bleed (epistaxis).

An examination of the retina by an specialist will sometimes give an indication of hypertension. There might be areas of hemorrhage or even detachment of the retina. Every blind cat should be seen by an ophthalmologist to check for hypertension, along with other causes of blindness like FeLVFIP, fungal infections, and Toxoplasmosis.

Diagnostic Tests

An important tool in the diagnosis of hypertension is a blood pressure monitor. Cat arteries are very small, and the usual method to detect hypertension in people is not accurate in cats. A special blood pressure unit called a Doppler can be used. Its basis in principle is the Doppler effect (obviously). The Doppler effect is the change in frequency of a sound wave as it comes towards you then moves away from you. The best analogy of the Doppler effect is the sound a speeding race car makes as it comes towards you, then passes away from you. In the case of a Doppler blood pressure unit, it is the movement of red blood cells through the artery that is being measured. During the frequency change that occurs during this red blood cell flow the reflected sound wave goes from the ultrasonic to the audible range.

Taking a blood pressure reading on a cat is more difficult than in a person. Their arteries are very small, and of course, cats are covered with hair. Also, cats are easily stressed, which can lead to a false reading. We will routinely take several readings, discard the lowest and highest, and average the rest. Sometimes we find a cat with consistent readings each time, so not as many readings are needed. A cat with a systolic pressure over 170-180 mm Hg is considered hypertensive. In dogs we consider over 180 mm Hg to be high. Sight hounds, overweight, and older animals tend to have higher numbers. These are not hard and fast numbers, just a guideline for each individual case. In many cases of high readings we repeat the blood pressure readings later to check for consistency in the readings.

We prefer owners stay with their cat in one of our quiet exams rooms. After clipping the fur on the bottom of the rear foot (we also use the front foot and tail) we set up our equipment. We take our first pressure reading when everything is calm and all equipment is set up. Our new doppler unit has the added advantage of having head phones so that the sound of the beating artery is not disturbing to your cat.

This is an overall view of our equipment. The transducer is under our nurse’s hand at the bottom, the blue pressure-wrap is lightly around the ankle, and the pressure gauge is on the top.

This is the hi-tech part of the unit. It is a doppler transducer that allows us to detect the faint arterial blood flow to the foot

We usually inflate the pressure to over 200 or until the artery sound can no longer be heard. The pressure is slowly released until the artery sound can be heard again- this is the systolic pressure. Measurement of the diastolic pressure is not accurate by this method.

The use of the head phones is a big aid in maintaining a stress free environment. When we have obtained an adequate number of readings we can take the headphones off and allow you to listen to the artery sound with the external speaker.

Low blood pressure can be of significance in animals. Usually this is encountered during anesthesia. Our Doppler unit allows us to monitor the blood pressure during anesthesia and make corrections as needed. We also encounter low blood pressure during shock, trauma, bleeding, and from certain medications.

 

Treatment

Underlying treatment of the disease that is causing the hypertension is sometimes all that is needed to prevent hypertension. Use of K/D food, with its decreased salt (sodium chloride) might be beneficial, but this is unproven. If hypertension still persists after treating the primary problem then we sometimes will use specific medication to lower the blood pressure:

Heart Drugs

ACE inhibitors like Enalapril or Lotensin (prevent conversion of angiotensin to angiotensin II, thus decreasing stroke volume and vascular resistance)

Beta-adrenergic blockers like Propranalol or atenolol (decrease the heart rate)

Calcium channel blockers like Norvasc (decrease vascular resistance)

Diuretics

Lasix or aldactone (decrease the stroke volume)

Vasodilators

Hydralazine (decrease vascular resistance)
Blind cats need to be placed on a drug called Norvasc to rapidly lower the blood pressure. There is a chance of regaining sight with the use of this drug, especially if utilized as soon as blindness is noted. Cats that are on this drug should have their kidney tests monitored 2 weeks after starting Norvasc, then every 3 months.

The best treatment for hypertension and its associated blindness is prevention. Any cat over 8 years of age, or diagnosed with kidney disease, diabetes mellitus or hyperthyroidism, should be monitored periodically for hypertension. This will allow diagnosis of the problem before it causes blindness.

Monitoring

All pets with hypertension should have their blood pressure checked every 3 months. In addition, blood panels, thyroid tests, urinalysis, and eye exams should be performed every 3-6 months.

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Lick Granuloma

A very frustrating skin disease found mostly in dogs is called acral lick dermatitis (ALD), commonly know as a lick granuloma. Dogs with this disease lick incessantly, causing chronic skin lesions of the limbs.

Many aspects of ALD are similar to allergic dermatitis in general. This page will give you an opportunity to link to the aspects of the allergic dermatitis page that also apply to ALD.

Pathophysiology

Constant licking leads to hair loss and irritation of the skin. As the problem progresses the skin becomes ulcerated and infected. As the ulceration progresses nerves become inflamed and the area becomes pruritic (itchy), so much so that the dog can not stop licking. A vicious cycle develops and the condition becomes chronic.

It is theorized that some dogs get into such a licking habit, and actually derive pleasure from it, that once the initiating cause is eliminated they still continue to lick.

Cause

This is a disease that has many factors involved with the cause. Some of these work in combination, adding to the complexity of the problem. In some breeds, notably Doberman Pinschers and Great Danes, the cause might not be found. The most common causes include:

Allergic Dermatitis

This is considered the primary cause of the problem. We have a detailed page on allergies to learn more about this complex problem. Food allergy is a component of this also.

Arthritis

Joints in the area of the lesion can be painful, causing excessive licking of the skin over the area. Since the licking does not cure the problem, it continues, eventually causing significant skin lesions.

Neuropathies

Inflammation of the nerves under the skin in the area of the lesion can cause significant discomfort, again leading to excess licking.

Neoplasia

Skin cancer can cause chronic lesions that are uncomfortable and lead to chronic licking.

Fungal Infections

Deep seated fungal infections, including blastomycoses and Ringworm can initiate the problem.

Ectoparasites

External parasites like scabies and demodex are also potential causes.

Psychogenic

This is a catch-all term for psychological causes that are thought to be involved. They include boredom and stress factors. Similarities have been made between this and obsessive-compulsive disorders in people. When you see a dog licking incessantly at his legs you can see why this comparison is made.

Symptoms

The most consistent symptom in pets with ALD is excessive licking of the extremities, especially the front and rear legs. Lameness could occur due to infected skin or even arthritis. If the skin infection is serious enough there might be a lack of appetite (anorexia) or lethargy.

Diagnosis

The correct diagnosis for ALD does not come easy, so a thorough approach is needed. In every disease we encounter we follow the tenet’s of the diagnostic process to ensure that we make an accurate diagnosis, and that we do not overlook some of the diseases that are also encountered in pets as they age.

  1. Signalment

    Several breeds are prone to ALD:

  2. History

    ALD usually starts appearing when dogs reach at least 5 years of age, especially the above breeds. When it first appears it might coincide with allergy symptoms that are seasonal in nature.

  3. Physical Exam

    This is a picture of the classic finding in a dog with ALD.

    If the skin infection is severe enough there might be swelling (cellulitis) due to the infection. Also, the lymph node that drains the affected area might be enlarged and there might even be a fever.

  4. Diagnostic Tests

    Diagnostic tests are important since many skin conditions look the same, even though they have different causes and are treated differently. In some situations other skin diseases can occur simultaneously with ALD.

    • Skin Scraping

      It is important to do a skin scraping in many cases of ALD because the symptoms and lesions commonly mimic those of ectoparasites like demodexor scabies.

    • Fungal Culture

      Ringworm lesions can look similar to ALD lesions. In Ringworm there is usually not as much licking.

    • Radiography

      If we suspect the licking is from a painful joint we can sometimes make this diagnosis from an x-ray.

    • Skin Biopsy

      This test is used to help differentiate skin tumors or deep fungal infections as the initial cause of ALD.

    • Fine Needle aspiration

      As an alternative to an actual skin biopsy we can do a simpler test called a fine needle aspirate. In this test we use a syringe with a tiny needle to take a sample of the affected area. This sample is put on a microscope slide for analysis by one of our pathologists.

      It does not require general or local anesthesia and can be performed during an office call. Only a small amount of tissue is sent to the lab for analysis, so it is not always possible to make a complete diagnosis this way.

    • Bacterial Culture

      This test will give us an indication of the type of bacteria involved. Staphylococcus and Enterobacter are the more common pathogens. Since the top of the lesion is contaminated with many bacteria, some of which are not part of the problem, a culture is performed on biopsy samples that are taken in a sterile manner.

    • Allergy Test

      Allergies can be a major component of ALD. Please refer to our allergic dermatitis page due learn about allergy testing.

Treatment

ALD tends to be a chronic disease that leads to significant frustration. The wide variety of treatments that are used to treat ALD are an indication of the complexity of this disease and the fact that many different causes, some working in tandem, are involved.

Flea Control

We can not emphasize the importance of proper flea control in any pet that has a skin condition since we live in a flea endemic area year round. Even pets that are 100% indoors are possible flea victims.

The products available today are a significant improvement over flea control products in the recent past. They are economical, safe, effective, and very convenient. The two main products we recommend are Trifexis for dogs© and Revolution for cats©. We have detailed brochures on each to explain how they work, please ask one of our receptionists. In addition to treating fleas they prevent heartworms and treat parasites.

Anti-inflammatories

Cortisone is used initially to minimize swelling and licking. It is not used as the primary means to control ALD in the long term since a skin infection is almost always present and cortisone decreases the immune system’s ability to fight this infection. Cortisone is used much more often in treating allergic dermatitis. There is a section there on its proper use.

As an option to using cortisone to minimize the licking we suggest the use of elizabethan collars. A good option that is tolerated well by larger dogs is a small plastic bucket with a hole cut out of the bottom that is placed over the head.

Antibiotics

Oral antibiotics are the most important treatment we have for ALD. In some cases we need to use them for 4-6 months due to the chronic nature of the problem. It is important to continue them for at least 3 weeks after the skin looks healed. In some pets we put them on intermittent antibiotic therapy for the rest of their lives- this is called pulse therapy.

Antibiotics that work best include:

  • Cephalexin
  • Primor
  • Baytril
  • Clavamox

Laser Therapy

We have had success using our laser machine in the treatment of this problem. It usually takes at least 3 treatments, and in some cases can be a significant help in minimizing the licking.

This Labrador has an ALD lesion on top of its rear foot area. It is been prepped or laser treatment.

The laser is being used at a light setting with an intermittent pulse.

The appearance of the lesion immediately post laser treatment.

Pain Medication

Initially it is useful to put your pet on pain medication until the antibiotics and other treatments start working. NSAID’s like Rimadyl can because because they decrease inflammation and also pain. Tramadol can also be used initially.

Antifungals

If a deep seated fungal infection is diagnosed we will use oral fungal medication for an extended period.

Allergy Shots

This can be a good way to minimize itching without using cortisone. The less we use cortisone to minimize itching the faster the problem will resolve. These are injections give on a long term basis, usually once per month once the allergy is improving.

Food allergy

We recommend feeding hypoallergenic diets to any pet that has a skin condition caused by an allergy.

Food Supplements

Some allergic dogs and cats scratch less when supplemented with essential fatty acids. The main ones we use are Derm Caps and EFa-Z.

Surgery

This is not a rewarding way to treat ALD since the problem commonly recurs after the surgery.

Topical Medications

It is a natural tendency to want to use topical medication only on a skin problem. If used in combination with long term oral antibiotics this topical medication can be beneficial. They are not effective when used alone.

Behavioral Modification Medications

Some dogs are compulsive lickers without any obvious cause. Some veterinarians believe that the incessant licking in ALD is similar to the exaggerated grooming habits of people with obsessive-compulsive disorders.

These medications are helpful, but do have the potential to cause side effects, especially when used with other medications. One of our doctors will let you know if they apply in your situation.

Veterinary Neuronal Adjustment

An additional treatment modality used to treat ALD is VNA. It is a non-invasive and non-painful way to stimulate the nervous system to stop the sensation that is causing the problem.

Prognosis

ALD has a guarded prognosis. An early and accurate diagnosis (when one is apparent) offers the best option by instituting proper medication before the problem becomes so chronic that treatment is only marginally effective.

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Rabies

Rabies is a viral disease of warm blooded animals (you won’t see Rabies in birds and reptiles) that occurs world wide, with significant human health significance due to its fatal nature. Various outbreaks have occurred in the United States in the last decade. Adequate vaccination of dogs and cats is the primary line of defense in preventing outbreaks. The Centers for Disease Control and Prevention, along with the veterinary community, produce reports detailing the incidence of rabies in specific areas of the country. Thousands of animal rabies cases are reported every year, with the actual number of cases being much higher. The majority of rabies cases in animals in the U.S. occur along the East coast, with pockets of rabies in various other states.

Approximately 500 cases of human rabies are reported yearly, with the actual number again being probably much higher. Discrepancies in diagnosis and reporting make actual numbers hard to come by. Several countries are free of rabies, and institute extreme quarantine measures to prevent spread.

We have never seen a case of rabies in our hospital, a testimony to the effectiveness of the rabies vaccine.

Cause

Rabies is caused by an RNA virus belonging to the order Mononegavirales. All warm-blooded animals, including humans, are susceptible. Raccoons, skunks, bats and foxes, account for 90% of the cases in the U.S., with raccoons making up the majority, followed by skunks, bats, and foxes. Forty years ago it was the domestic animals that accounted for the majority of the cases. More cats get rabies than dogs.

Transmission

When a wild animal is bitten by a rabid animal the virus enters the bloodstream, eventually spreading to the spinal cord and brain. It remains there for up to 3 months, during which time the affected animal has no symptoms of rabies. When the virus passes to the salivary glands the animal shows symptoms, and will usually die within 7 days. It is during this time that it can infect another wild animal, a human, or a dog or cat.

The main animals that infect humans are dogs, cats, cattle and horses, because they are exposed to these animals much more than wildlife. In addition to bite wounds, the virus can rarely be transmitted through the mucous membranes, as an aerosol, and through cornea transplants.

Symptoms

Clinical signs of rabies are quite variable, with a change in behavior being one of them more consistent findings. This behavior change can be as subtle as apprehension, or as extreme as biting in a normally friendly dog. Dogs might chew at the site they were bitten when they became infected, and can even maim themselves.

As the disease progresses dogs may show increased irritability, viciousness, excitability, and eating unusual objects (pica) like wood. These dogs may hide in dark or quiet places, and will bite when provoked. Central nervous system signs like seizures will exhibit, and there may be paralysis prior to death.

A phase of the disease causes paralysis of the muscles in the throat. This leads to excessive drooling and choking sounds due to an inability to swallow, and is the sign most people think of when describing rabies. It is also common for people to think their dog has something stuck in its throat, and cause themselves to be exposed to virus laden saliva when attempting to removed the suspected foreign body.

Diagnosis

The disease is suspected in dogs that show neurological signs consistent with rabies, and may or may not have been bitten by another animal. Since these signs are so variable rabies needs to be considered in any dog showing behavioral changes. Blood samples are not helpful in the diagnosis. The only way to confirm a diagnosis of rabies in animals is to have the brain examined. A test called Fluorescent Antibody (FA) is performed on the brain cells of a dead animal.

In humans tests for the virus are performed on saliva, serum, spinal fluid and skin biopsies. In some cases the test checks for antibodies to the rabies virus, in other cases it looks for the virus itself.

Treatment

Animals that have rabies are not treated because they can shed the virus in their saliva for extended periods.

Prevention

The vaccination of dogs by a licensed veterinarian is the most effective means to control rabies. Every state has specific laws regarding vaccines. They are usually given to dogs at 4-6 months of age, repeated one year later, then every 3 years. In order to get a dog license, a certificate of vaccination by a veterinarian licensed in that state must be presented. Rabies vaccine is given to animals only under the supervision of a veterinarian licensed in that state. Cats are also given rabies vaccines.

In humans a pre-exposure vaccine is given to high risk groups, usually veterinarians, animal handlers, and laboratory workers. By giving this vaccine prior to any exposure to rabies, a person that eventually gets exposed to the rabies virus will need less post-exposure treatment, and will partially protect people that were exposed to rabies without realizing it. approximately 18,000 people per year received this pre-exposure vaccine, while 40,000 people per year receive the vaccine after they have been exposed.

Public Health Significance

Rabies has extreme human health significance due to the fatal nature of this disease. Symptoms include fever, headache, anxiety, confusion, hypersalivation, paralysis, and ultimately even death. In the early 1900’s more than 100 people died annually from rabies in the U.S. That number is down to 1-2 per year, because of vaccination of domestic animals and post exposure treatment. Most people in the U.S. die from rabies because they were not aware they were exposed to the virus, and never sought treatment. Post exposure treatment in humans has to be instituted before any symptoms appear for it to be effective in preventing death.

Most humans are infected by a dog bite, therefore aggressive wound cleansing can be of help. Tens of thousand of people are given rabies shots after being bitten, this therapy has proven to be highly effective. High risk groups (people that work extensively with sick animals like veterinary hospital personnel) can receive vaccines prior to exposure. animals that have bitten people must be quarantined for 5-10 days, depending on local laws, to observe for any signs of disease. Animals that have bitten someone are not euthanized unless they have successfully passed their quarantine period or their brain is scheduled for an examination.

The Centers for Disease Control and Prevention has an extensive section on rabies if you would like more information.

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Ringworm

An occasional cause of skin conditions in pets is caused by Ringworm. The scientific name for this disease is Dermatophytosis. It is caused by a fungus not a worm, and the lesion is not always in the shape of a ring. Since fungi are everywhere in our environment, it is difficult to determine which pets will develop the problem. The fungus that causes Ringworm can be cultured from the hair coats of normal dogs and cats. These pets might be carriers of the disease to other pets along with people. We tend to see the problem more in young animals.

People will sometimes pick up a case of Ringworm from their pet, but just because a pet has Ringworm does not necessarily mean that the people that interact with that pet will develop the problem. A dog or cat can transmit Ringworm to a person without showing any symptoms at all.

Cause

There are 3 specific fungi of significance in this disease.

  • Microsporum canis

The source of this species of Ringworm is almost always a cat.

  • Microsporum gypseum

This species of Ringworm is usually from dogs and cats that dig into contaminated soil.

  • Trichophyton mentagrophytes

This species infects dogs and cats when they are exposed to rodents or the burrows they live in.

In cats, almost all cases of Ringworm are caused by Microsporum canis. In dogs the majority of cases are caused by Microsporum canis. Which of these 3 main dermatophytes causes the Ringworm in dogs depends on geographic location.

Symptoms

The skin lesions that appear with Ringworm are variable, and do not necessarily form a ring. There will be hair loss, usually in small patches at first. as time goes on the patches may disappear or appear at other locations on the skin. There might be scratching due to itchiness. If the hair loss occurs on the face or feet there is a chance it is due to digging habits or exposure to rodents.

This patch is typical of the lesion seen in Ringworm. A diagnosis of this disease can not be made based just on the appearance of this lesion because other skin conditions (Demodex for example) can show similar lesions.

Diagnosis

There are several different ways to diagnose Ringworm. All require some type of test because it is impossible to make the diagnosis just by looking at the skin. This concept holds true for all skin conditions; making a diagnosis of a skin disease requires all of the aspects of the diagnostic process.

If a person in a household has been positively identified with Ringworm by their physician it is possible they obtained it from their pet, even if their pet has no symptoms of the disease. This is especially important in multiple cat households. We will culture these pets using the culture technique we describe below, but in this case, we might run a new toothbrush over the hair coat to obtain a sample for culture.

One of the simplest ways to diagnose Ringworm is with the Woods lamp, which is an ultraviolet lamp, also know as a black light. 50% of the Microsporum canis species will fluoresce when the Woods lamp is placed near the area of hair loss.

The lamp emits a purple/blue glow from the tube, and when there is fluorescence on the skin, it has a greenish appearance. Other material on the skin (dander, medication, etc.) can also fluoresce, so interpretation is important.

Since only 50% of a certain species of Ringworm fluoresces under the glow of the Woods lamp, a culture is used to verify the diagnosis:

The first step in the culture process is to gently remove hair follicles in the area of the lesion

These hairs are cultured in a special media that inhibits bacterial growth and enhances fungal growth. This culture can be sent to our outside lab or done in house. Since a fungus is a slow growing organism it can take up to several weeks to determine if there is growth or not.

The positive culture on the right, from our in house lab, demonstrates two findings that are needed for a positive diagnosis. The first is the cottonish fungal growth, and the second is the reddish color of the culture media. This color change must occur at the same time the fungal growth appears.

The culture media prior to the start of the test. Positive fungal growth after 10 days of incubation at room temperature.

Treatment

Topical shampoo therapy is used in almost every case, especially in longer haired pets. It is common to clip some or all of the hair in some pets to make it more effective. These baths will also remove infected hairs that can be the source of an infection to people or other animals.

Specific anti fungal cremes are also used when a pet is infected in an area that already has sparse hair growth, or there are small, discrete lesions.

Oral anti fungal medications are also used in select cases. They have the potential to cause side effects, so their use is confined to specific situations.

In some pets the disease may resolve by itself.

Prevention

Since fungi are everywhere it is almost impossible to prevent exposure. Pets that chase rodents, especially into burrows, might be at an increased risk.

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Allergic Dermatitis

Allergies are a common cause of skin conditions in dogs and cats. This type of allergy goes by several names: the most common are atopy, allergic skin disease, or allergic inhalant dermatitis.

The main difference between us and pets is that allergies in pets tend to cause skin conditions, as opposed to runny eyes, runny noses, and sneezing we encounter in people. Along with other skin conditions besides allergies,  symptoms typically include scratching and itching. Medically this is called pruritus.

Allergies can be hard to control and are chronic in nature. This causes significant frustration for pet owners and discomfort for pets. A correct diagnosis along with proper therapy instituted early in the course of the disease will minimize this frustration. Many pets stores and groomers will give advice on a “food” to feed to cure your pet’s skin condition. It is irresponsible for them to be giving any advice of this nature due to the numerous causes of skin conditions, let alone the complexity of this disease, and also the fact they have not examined your pet and do not have any important physical information about your pet. We have a short page on Nutrition Advice that addresses this issue of people giving medical advice when they have no business doing so.

This page summarizes and generalizes the complex problem know as allergic skin disease. It is detailed, and will take a few minutes of your undivided attention to help in understanding this problem.

In the beginning of this page we will give you the background of their causes and how we diagnosis them. We will take about treatment towards the end.


Pathophysiology of Allergies

When the immune system encounters an allergen that has the potential to cause disease (ex. parvo virus) it produces antibodies called IgG (immunoglobulin G, previously known as gammaglobulin) and IgM (immunoglobulin M). For the first 7-14 days of infection the virus spreads throughout the body because not enough antibodies are produced to stop them. Within 7-14 days enough antibodies are made to neutralize the virus, and the pet eventually recovers from the disease, all other things being equal.

As time goes on, the now sensitized immune system is ready to produce large amounts of antibodies rapidly the next time it encounters this virus. The rapid antibody response neutralizes the virus immediately, instead of taking the 7-14 days that occurs the first time it encountered the virus. This is called the anamnestic response, and is why a pet that recovers from parvo virus does not get the disease again.

A different scenario presents itself when the immune system encounters an allergen that is not necessarily pathogenic (ex.- a pollen particle). A different part of the immune system kicks into high gear when these non pathogenic allergens invade the body.

When a pollen particle enters the body for the first time (through the skin or respiratory passage) it stimulates the body to produce antibodies also, this time they are called IgE (immunoglobulin E). This IgE antibody attaches to the allergen in order to neutralize it, just like IgG would do to a parvo virus. This process, called sensitization, occurs in the first season a pet encounters a specific allergen in its area. Without this sensitization there is no allergy. This type of allergy is the most common type, and is called atopy or atopic dermatitis.

The next time a pet encounters these pollen particles (usually the next allergy season), the immune system produces large amounts of IgE antibodies rapidly because it has been sensitized to them from the previous season. Again, this is similar to what happens when the immune system makes IgG and IgM antibodies against parvo virus.

IgE, with attached allergens, circulates throughout the bloodstream to a type of cell called the mast cell. Mast cells contain many chemicals that can cause inflammation, the most important of which, in relation to allergies, is called histamine. When an IgE antibody (even IgG can be involved) with an attached allergen encounters a mast cell under the skin, it alters the membrane of the cell, and histamine leaks into the surrounding tissue. Histamine causes inflammation, noted as redness (erythema) and itching (pruritus) on the skin surface. The reaction that is seen on the skin surface is called a wheal or a hive. This causes your pet to lick, scratch, or bite at this area which now itches.

It is the mast cell, that releases histamine when it encounters an IgE antibody with a pollen particle attached, that is a major component of allergies. This is what occurs in atopy and is suspected to occur in food allergy. In flea allergies, it is an allergic reaction to the flea saliva that causes the immune system reaction.

Other immune mediators are impliacated in atopy. They include cytokines, neuropeptides, peptides, proteases, and leukotrienes. They can affect nerve fibers to the skin, causing itchiness.

As if that is not enough, there are other immune mediators called Interleukin 31 (IL-31) that are involved. It’s an understatement to say that the immune system is very complicated. Add the ever present skin bacteria to this equation and it is easy to see how this can become a frustrating problem.

Food allergies have a slightly different pathophysiolgy then atopy in some cases. In food allergies, the offending allergen (usually a protein) is absorbed through the lining of the small intestines and proceeds right into the bloodstream.  This causes a different immune system reaction. If the intestines are inflamed from some other disease process, for example IBD (inflammatory bowel disease) in cats, the normal barrier lining the intestines is compromised and more allergens can enter the bloodstream.


Types

There are 3 main types of allergies in relation to skin conditions. It is possible for a pet to have a combination of all 3 allergy types:

    1. Flea Allergy Dermatitis (FAD)This is a very common cause of skin allergies, even if you do not see a flea on your pet. When a flea bites a dog or cat it is looking for a meal of blood in which to nourish itself. In order to suck this blood it inserts an anticoagulant into its saliva to prevent the blood from clotting while it sucks it through its small proboscis. It is the allergens in this saliva that cause an allergic reaction to occur.With the advent of new treatments that are convenient and very effective, this problem, while still important, has diminished in importance. The products we recommend are oral Nexgard, Comfortis or Trifexis in dogs and topical Revolution in cats. In addition to excellent flea control these products also prevent heartworms and internal parasites like Roundworms. Revolution in cats even controls mites. Our staff has detailed information to give you on these products along with others to help you make the right decision for your circumstances.Since we live in a flea infested area we recommend using these monthly flea products year round. They have the added advantage of worming your pet every month for Roundworms, Hookworms, and Whipworms.Fleas are a common cause of skin allergies in cats.
    2. Atopy or Allergic Inhaled Dermatitis
      Another common cause of skin allergy is atopy. It is a genetically determined predisposition to produce IgE antibodies when exposed to an allergen. Re-exposure to this same allergen in the future causes allergic skin disease (you learned the mechanism above). Depending on the study, it is estimated that between 3% and 15% of dogs have atopy.Common allergens that cause this reaction are ragweed, pollen, house dust, house dust mites, mold, animal dander, feathers inside the house. Outside its grasses, trees, and shrubs. The allergens can be inhaled, pass through the pads of the feet, and even possibly ingested. Since these compounds are in abundance everywhere, it is apparent that preventing exposure in the first place is difficult.If fleas are not a factor, atopy accounts for up to 90% of the allergies that cause allergic dermatitis.  A certain number of pets with atopy also have a food allergy concurrently, which compounds the diagnosis and treatment.
    3. Food Allergy

The least common cause of skin allergies is food allergy, although pets stores and groomers are under the impression that this is the sole and most important cause of skin allergy, which is why they give amateur advice on what to feed. They are in the business of selling food, which is why they only see food as a solution to atopy, when it is the least common cause.  Our page on Nutrition Advice has much more information on this topic.

It is important to distinguish food intolerance from an actual food allergy. They are not the same, but many people giving amateur advice on this problem do not understand the difference.

In the vast majority of cases, food allergies are caused by an allergic reaction to proteins in food. The size of the protein particle is important. They have a molecular weight of between 18 and 70 kilidaltons (kD). In laymens terms, they are very, very tiny.

Heredity is a major predisposing factor in people, and probably so in animals.

Some of the more common food allergens in dogs and cats are:

horse meat eggs
beef fish
pork corn
lamb soy
chicken wheat
dairy products rawhide chews and dog biscuits/treats

In dogs, beef, dairy products, and wheat tend to cause most of the problems, with chicken, lamb, and soy following. In cats, beef, dairy products, and fish account for most of the food allergies. Premium dogs foods can contain these products, so just because you are feeding a higher quality or more expensive food doesn’t mean that food will not cause a food allergy.

Many pet stores are there to sell food, so they will tell you a certain type or brand of food will cure your pets skin (and other) conditions. The employees of these stores have no business giving their advice unless they are licensed nutritionists for animals, or are licensed veterinarians,  and have discussed with you the following points that are so important in making a diagnosis of any disease, including allergic dermatitis:

      • Your pet’s predisposition to certain diseases, including allergies
      • Your lifestyle and your pet’s lifestyle
      • The specific history of your pet’s skin condition- time of year, where they are itching, etc.
      • Results of a thorough physical exam checking all organs besides skin
      • Routine blood panel to assess the status of your pets internal organs along with protein levels, blood glucose, electrolytes, red blood cells, and white blood cells.
      • Diagnostic tests to eliminate internal (hormonal etc.) and external (mites for example) causes of skin conditions.
      • The efficacy of prior treatments
      • The effects a change in diet will have on other organs besides the skin

Most of the symptoms of food allergy involve inflammation and scratching of skin or ears, but might also include vomiting or diarrhea. These gastrointestinal symptoms tend to occur more in cats.

In those pets that truly have food allergy, a high percentage also have atopy at the same time. Cats might have more food allergies than dogs, although fleas are a common cause of skin allergy in cats.

Symptoms

The most consistent symptom in pets with allergic skin disease is excessive itching. The medical term for this is pruritus. High strung dogs might itch more than placid dogs. Chewing, biting, or licking, or rubbing the skin can all be manifestations of pruritus.

Dogs can chew so incessantly that they wear down their incisor teeth to the gumline

 

In dogs some of the more common areas for pruritus to occur are the face, feet, and armpit areas. As the problem progresses the whole body might be involved. Some pets will scratch excessively but not show any problems with their skin.

If your pet has an allergy to fleas you might find tiny blood spots where it has layed down. These are the result of flea dirt that has fallen off your pet and become wet. Since flea dirt is made up mostly of blood that the flea has sucked out of your pet and has passed through its digestive tract, they appear as small blood spots on the floor or table tops when wet.

Other symptoms can include:

The slight redness (erythema) to the face of this dog.

 

The dark, stained areas on this poodle’s foot are due to excessive licking. The color change is due to the chronic saliva on the hair, and the changes it causes on the hair coat.

 

This dog’s skin is oily from chronic rubbing. This loss of hair is called alopecia.

 

This Golden Retriever has significant redness (erythema) on its ear flaps. Chronic ear inflammation or infections can be a sign of atopy or a food allergy.

 

The above pictures were all caused by atopy. They could have been caused by other diseases though, so you cannot make a diagnosis of a skin condition just by looking at them.

Cats get skin allergies also, although not as frequent as in dogs. They might exhibit the same or different symptoms. Different symptoms include tiny bumps throughout the body, ulcers on the lips, excoriation of the neck, and even patches of missing hair (alopecia) without any skin lesions. Ear problems related to allergies are rare in cats compared to dogs. Cats get a problem called psychogenic alopecia that can be similar in appearance to atopy.

It can be difficult to tell pruritus from normal feline grooming. Vomiting hair balls, hair in feces, and hair in your cat’s mouth when you brush its teeth (you are doing this aren’t you?) are all clues.

This cat has an allergy that caused it to irritate the skin above its eye by rubbing its face

 

This is a severe version of an ulcer on the lips. It is called the Eosinophilic Granuloma Complex.

Diagnosis

Since the symptoms of allergic skin disease mimic those of other skin diseases, a thorough approach is needed to differentiate them. In every disease we encounter we follow the tenets of the “diagnostic process” to ensure that we make an accurate diagnosis, and that we do not overlook some of the diseases that are also encountered in conjunction with skin diseases.

It is too easy to jump to the conclusion as to what is causing your pet’s pruritus. Here is a list of  possible causes of scratching and itching in pets in random order:

  • Atopy
  • Drug reaction
  • Flea allergy dermatitis
  • Food allergy
  • Lice
  • Autoimmune disease
  • Pyoderma
  • Contact Dermatitis
  • Viral infection
  • Fungal infection (Malassezia)
  • Mites
  • Seborrhea
    1. Signalment
      Typically, atopy occurs in mature dogs between 1- 3 years of age, although it can occur earlier (Shar pei’s can get it as early as 3 months). The condition rarely starts in dogs over 6 years of age.Most dogs get their first exposure to an allergen and develop sensitization in their first exposure to a pollen season. Symptoms usually occur during their second season of exposure to the pollen allergen when the immune system has its exaggerated response to the allergen and produces high levels of IgE. Dogs that are highly allergic can show signs of atopy during their first season of exposure to pollen allergens. It depends on how long the pollen season lasts and how rapidly their body produces the IgE antibodies.Several canine breeds are prone to getting atopy. They include, but are not limited to:

      Terriers Beagle
      Retrievers Setters
      Lhasa apso Miniature schnauzer
      Shih Tzu Pug
      Cocker spaniel Boxer
      Dalmatian Shar Pei

  1. History
    Atopy, in it’s initial stage, tends to be a season problem. This can be a help in differentiating it from food allergy, which would be a non-seasonal problem. Atopy tends to be a progressive disease with worse symptoms each allergy season. Many dogs will be more affected during a specific season. As time goes on dogs can have allergies year round. It is not a contagious disease, so other dogs, cats, and people in the same household do not usually have symptoms (unless of course it is another dog that is highly prone to allergies).The progeny of atopic dogs are more prone to developing atopy than other dogs. Careful breeding therefore can help minimize the occurrence of this problem.Pets that have been treated with cortisone in the past, and did not improve, give us a clue that something else besides an allergic disease is involved.Food allergies in dogs and cats can start at any time in a pet’s life, even those on the same diet for a long period of time. Non-seasonal allergies bring food allergies to mind, along with vomiting or diarrhea, although these are not consistent findings. The skin lesions in food allergy are indistinguishable from atopy, but have a propensity to show only inflammation of the ears. Feeding dog and cat foods that contain ingredients that pets are routinely allergic to might also clue us in to a food allergy. This includes the premium foods and those that contain lamb.Flea allergies are suspected whenever we are presented with a pet that has a skin condition, especially towards the back end,  and is not on routine flea control. This is true even for pets that never go outside. Other pets in the household that are itching might also indicate fleas in the environment. Flea allergies routinely cause hair loss at the lower back area (called the dorsal-lumbar area), which is not typical of atopy and food allergy.
  2. Physical Exam
    The physical exam of a dog with a skin condition is the same as any other sick pet. We examine the whole body for clues as to the cause of the skin condition. The distribution of the skin lesions gives us a clue as to the cause, but is not consistent in all skin conditions.Some of the more common exam findings are:

    Pyoderma

    This dog has licked so much it has maimed itself, and now has pyoderma, which is a skin infection, typically a Staph. infection


    Conjunctivitis

    This is an inflammation of the eyes. The green discharge in the corner of the eye is from fluorescein stain that was checking for a scratch on the cornea.


    Lichenification and hyperpigmentation

    Chronic licking and scratching can cause thickening and dark pigmentation of the skin. The white arrow points to mild hair loss, hyperpigmentation, and lichenification in a Yorkie.


    Acute Moist Dermatitis

    Commonly know as a hot spot, it is an area of skin that has been maimed from intense pruritus. Pyoderma is also present, and the skin is very painful. Hot spots occur rapidly and can encompass a large section of skin in a short time. Affected areas usually include the rump and the side of the face. Other common causes of hot spots include anal gland problems, ectoparasites like mange, grooming, and deep skin infections. Golden and Labrador retrievers, St. Bernards, Collies, and German shepherds are more prone than other breeds.

    The serum that is exuded from the inflamed skin matts the hair and causes the problem to progress under the hair coat without anyone realizing how serious it is. These pets can be so painful that we need to sedate them prior to clipping the hair and cleaning the wound.


    Hot spots can progress and cause serious skin conditions. What looks like a minor skin wound with matted hair can actually be a serious and painful infection once the hair is removed.


    Otitis externa

    This is an infection of the outer ear canal. Sometimes this is the only symptom of allergy, especially food allergies. This ear is so severely infected that it is difficult to ascertain the normal anatomy. The ear canal is completely occluded, necessitating surgery to correct it. This dog is painful.


    Pododermatitis

    Infection of the feet can occur from chronic licking.


    Acral Lick Dermatitis

    These are commonly known as lick granulomas. There are many causes, allergies being a primary one. Other causes include arthritis, skin tumors, inflamed nerves, fungal infections, ectoparasites, and psychological factors like boredom and stress. Once the licking starts the problem is difficult to control. In some cases we have found that the use of the laser has been a significant help. The most effective treatment is the use of antibiotics for many months.

    This small lick granuloma is on the front leg of a Golden Retriever


    Fleas or flea dirt

    Flea dirt is literally droppings from the flea after is has bitten a pet and the blood has passed through the flea’s digestive tract. It looks like pepper, and is easily visualized on a pet with a white hair coat.

    This is an example of lots of flea dirt.

    Flea eggs are small white particles, similar in size to flea dirt, that fleas lay in a pet’s hair coat. They eventually drop off and contaminate the environment. A pet can have fleas, yet show no evidence of fleas, flea dirt, or flea eggs.

    Flea allergy dermatitis typically does not cause hair loss around the face, eyes, and ears like in atopy, although this is not a hard and fast rule.


  3. Diagnostic Tests
    Diagnostic tests are important even if we strongly suspect an allergy. In some situations other skin diseases can occur simultaneously with the allergy. It is impossible to make a diagnosis in any skin condition just by looking at it. This is because there are many diseases that affect the skin, yet the skin has only a limited number of ways to exhibit signs of disease.For food allergies we want to completely remove the offending protein and see if the problem (skin disease or GI signs) completely resolves. At that point we again feed the offending protein and see if the problem recurs. This is called a trial elimination diet, and is the only way to confirm a diagnosis of food allergy.The diagnosis of food allergy is not complete until we cause the allergy again by feeding the original food. This is because there are many allergens in the environment that can cause pruritus after the food allergy is controlled. Also, it is easy to assume the food allergy is under control when your pet is on medication simultaneously.

    Skin Scraping

    It is important to do a skin scraping in many cases of allergy because the lesions of atopy commonly mimic those of other diseases. Ectoparasites like demodex or scabies can cause skin lesions and itching.

    Fungal Tests

    Ringworm can mimic allergy symptoms. Lesions from Ringworm tend not to be as pruritic as allergies.

    Malassezia, another fungus, is commonly associated as a secondary problem when the skin is infected. Even though it is a normal part of an animals hair coat, it will add to the itching if other conditions are present. Common areas for Malassezia include the ears, lips, muzzle, between the toes, and the anal area. Indications that Malassezia is present include pruritus, erythema, and greasy skin with an offensive odor. These symptoms can occur with other diseases besides Malassezia.

    Malassezia is diagnosed by the above symptoms and by looking for the organism under the microscope after swabbing the skin and placing the discharge on a microscope slide. Many pets respond to shampooing with specific antifungal shampoos twice weekly. These topicals will only work when the underlying allergy and its associated skin infection are under control. In some cases we use oral antifungal medications to control the problem.

    Thyroid Test

    Hypothyroidism can cause skin conditions, although dogs with only hypothyroidism are not terribly pruritic.

    Fecal Exam

    Hypersensitivity to internal parasites can cause symptoms similar to atopy. This is not a common situation.

    Skin Biopsy

    In some cases it is difficult to make a diagnosis. When we are presented with this situation we will biopsy several small pieces of infected skin and have them analyzed by a veterinarian that specializes in tissue analysis of the skin.

    Here is a typical report from one of them. All of the big words mean that in this skin biopsy an allergy is most likely, but autoimmune disease cannot be ruled out for sure.


Allergy Testing

Allergy tests are performed in cases where we already have a diagnosis of allergy. The main purpose of allergy testing is to find exactly what your pet is allergic to, and also to set up a protocol for allergy injections. If giving allergy shots is not contemplated then this test is of less value, although it will let us know what allergens we want to avoid. Trying to avoid these allergens though is the hard part because they are in our houses and almost everywhere outside.

There are two main types of allergy tests that are performed. Neither one is perfect, and they can have false positives and false negatives. They are not accurate in diagnosis a food allergy.

Intradermal (skin) Test

Most of us are familiar with the first one. In this test, called the allergy skin test or intradermal test, small amounts of materials that routinely cause allergies in dogs are injected under the skin. The reaction, if any, is graded, and a determination is made as to whether or not a pet is allergic to that specific allergen.

This test is very subjective, and therefore prone to errors in interpretation, and therefore requires significant experience. Many different techniques are used.

Your pet must be off of oral cortisone medication for at least 1 month before testing. If injectable cortisone is given, the waiting time is longer. Your pet must not be on any tranquilizers at the time of testing and must be off of any antihistamine medication for 10 days.

Pets usually are given a sedative to calm them and to minimize the release of cortisone due to stress, which will affect the outcome. The hair on the side is clipped where there is no current dermatitis occurring. A tiny amount of histamine is injected first. If there is no reaction to histamine, the full test is postponed. A small amount of sterile saline is also injected as a control.

The areas where the allergen is injected are marked


Numerous allergens are injected into the skin and a reaction is noted at 15 minutes and again at 30 minutes. The reaction we are looking for is called a wheal. A positive test to a specific allergen occurs when the reaction is in between the saline and histamine tests in size.

In some cases the wheal is obvious, in others it is subtle, which is part of the interpretation process.


RAST (in vitro test)

The second type of test that is performed is called the RAST test. RAST stands for radioallergosorbent test. Another in vitro test is called the ELISA (enzyme linked immunosorbant assay) test. RAST tests for the levels of allergen specific IgE. In this test a blood sample is taken and submitted to a special lab for analysis.

The RAST test has advantages over the intradermal test. There is no clipping, sedating, and there is no potential to have an adverse reaction to an allergen injected into the skin. There is less of a chance that prior drug therapy (cortisone) will influence the outcome, and it can be used in patients that have dermatitis.

The primary disadvantage is the fact that false positives are more common when compared to the intradermal test.


The RAST test is very thorough and checks for many different allergens in the home, outside, and in your pet’s food. Here is an example of one of their reports:

Here are 4 of the dozen household allergens they tested. This dog is borderline for orris root and human epithelial cells, and positive for jute/sissal and tobacco smoke.


These are a few of the food allergens tested in this sample. There was no allergy to venison, eggs, or milk, but this dog was allergic to soybean. This give us a rough idea of what food your pet might be allergic to, and can only be confirmed with the trial elimination diet.


This is a tiny sample of the numerous allergens found in the environment tested for on the same dog as above.


Allergy tests can be unreliable at diagnosing food allergy. A better way to diagnose food allergies is using a technique called the elimination trial. By taking away a food that is suspected of causing the food allergy you can determine if the problem resolves. This might take up to several months to know for sure. To verify the diagnosis you need to feed the suspected food again to see if the skin condition returns. Commercial diets that contain rice, venison, fish, and potato are commonly used for the elimination trial. There is a food manufactured by Hills called Z/D that has been a big help in diagnosing and treating food allergies.


Routine Blood Panels

On occasion a specific type of white blood cell, called an eosinophil, is elevated in allergic conditions. Other conditions, notably worms, can also cause this elevation in eosinophils.

A routine blood panel can also give an indication of internal or hormonal problems that might show up as a skin condition. The most important of these are hypothyroidism and Cushing’s Disease.

This blood panel shows an elevated alkaline phosphatase level. This could be an indication of a hormonal problem called Cushing’s Disease.


Treatment

In the early years of atopy the pruritus is more easily controlled. As the problem progresses treatment is not as rewarding. Chronic changes to the skin can occur, especially lichenification and hyperpigmentation.

Treatment is aimed at all the factors that contribute to pruritus. For example, a pet that is normally not atopic might become so if exposed to fleas, or if it gets a pyoderma, or is allergic to a protein in its diet. This concept is called summation of effects, and might push the pet over what is called the pruritic threshold. By minimizing one of these components you might keep your pet under the pruritic threshold and minimize its skin or GI symptoms.

Food Allergy

Hypoallergenic means foods that your pet has never eaten, which technically, it cannot be allergic to. We recommend using these foods in some cases when we feel the pruritic threshold has been reached and any decrease in allergen load will put your put under this threshold. It might take up to 2 months to know if the food is working. You cannot feed any other foods or treats during this trial period, so plan on rewarding your pet with something else besides food.

There are 3 different diets to help:

    • Homemade
    • Commercial Novel Protein
    • Commercial Hydrolyzed Protein

Homemade diets can be beneficial, and have the advantage of controlling the protein and carbohydrates sources. It is important to pick a protein source your pet has never been exposed to. To be sure of this we sometimes need to resort to diets that contain some unusual ingredients.

Homemade diets have the substantial drawback of time, expense, guesswork, and being nutritionally incomplete. Some pets do not accept the food, and some of them develop diarrhea. For these reasons most pet owners do not use this treatment method.

Commercial Novel Protein Diets are a popular treatment for food allergies. Novel protein means your pet has never eaten this protein in the past.  For them to work, just like homemade diets, the protein source has to be a food your pet has never been exposed to, which can be difficult to determine. Traditionally they have contained fish, lamb, potato, or venison. Many pets react to several different proteins compounded the problem. Compared to homemade diets commercial diets have the advantage of being nutritionally complete and convenient. It is becoming more and more difficult to find a food that conatins a protein that is truly novel.

In many cases these foods work well to eliminate or decrease the food allergy. It takes up to 8 weeks to know if they are working, and your pet needs to be fed only these foods and nothing else, and be off all medications to decrease scratching. You might have to try different foods to find one that works for your pet. Unfortunately, its possible for some pets to eventually develop and allergy to one of the novel proteins in the food you are feeding.

Commercial Hydrolyzed Protein diets are the best option in most cases. The advent of these diets for food allergies has been a big step in eliminating the problem. Instead of trying to find a novel protein, these foods have literally decreased the size of the protein particle that gets absorbed in the intestines into the bloodstream. This reduced size is now too small to cause a food allergy, no matter what the protein source initially. These foods are nutritionally complete, convenient, and the ones we tend to recommend in most cases of food allergy. The brand we use most is Hill’s z/d. Hill’s was the first manufacturer to identify this solution and z/d is still the gold standard. This food is  unconditionally guaranteed and you will get your money back if you are not satisfied.

It is important that you do not have your pet on cortisone or antihistamines while trying to determine if your pet has a food allergy, since they will decrease the scratching and lead to an erroneous conclusion on the effect of the food. This causes a dilemma for those pets that have significant scratching, since they need immediate relief. In these cases we recommend using medication initially and starting your pet on a hypo-allergenic diet at the same time. If the itching is decreased after 1-2 months you can start weaning your pet off the medication to determine if the scratching is still diminished while on the hypo-allergenic diet also. In some cases we find the use of this food will allow us to use less medication to control the scratching.

Compliance is important, so make sure that everyone that even remotely feeds your pet knows about the diet change. If you give your pet food with medication, or treats, make sure it is not the original food that might have caused some allergy. Some pets need time to make the transition to a new food so be patient. Never let a cat go more than a few days without eating due to potential problem with the liver. Mix their new food in with their original food and make the transition over 7 days.

Avoidance

Obviously, if it is exposure to an allergen that causes the problem in the first place, then logic will dictate that we eliminate this exposure. In reality though, these allergens are everywhere. Minimizing exposure can be beneficial since it will decrease the allergen load, and hopefully keep your pet under the pruritic threshold.

Pets that are allergic to kapok, wool, cotton, feathers, animal dander, newspaper, and tobacco smoke all might benefit from limiting exposure. Limiting the number of houseplants could be helpful, and use synthetic material for your pets bedding. Pets allergic to house dust mites might do better kept out of bedrooms or placed outside more often.

Being outside though might expose them to more pollens. Grass is a common allergen causing skin allergy, so if possible, try to minimize exposure.  Keep the grass cut short, and keep pets out of the yard when cutting the grass. Rinse your pet’s feet and face off thoroughly after being exposed to grass can be beneficial in some cases.

Mold allergies might be helped by dusting and cleaning more thoroughly, especially house plants and bathroom carpets. Even think about replacing your carpets with wooden flooring. Keep your pet away from damp areas like basements (in California that’s easy since we don’t have many) and use humidifiers and air conditioners in humid weather. Rinse their filters frequently and clean with chlorine bleach. To truly filter most of the dust, mites, pollens, bacteria, and molds in your house you need to use a HEPA (high efficiency particulate air) filter. Upright vacuum cleaners return most of the dust back into the air, so use canister or cylindric type machines.

Routine and thorough washing, cleaning, and vacuuming of your household will keep mold, house dust, and house dust mites to a minimum. Keep your pet out of the house when doing thorough cleaning and vacuuming to minimize allergens that are stirred up by the cleaning. Put flea powder or a flea collar in the vacuum bag. Put plastic over bedding that might harbor house dust. Keep pets indoors at dusk and early morning during heavy pollen seasons.

Flea Control

Since we live in a flea endemic area year round, we cannot emphasize the importance of proper flea control in any pet that has a skin condition. Even pets that are 100% indoors are possible flea victims. This is especially important in cats, both indoor and outdoor cats.

The products available today are a significant improvement over flea control products in the recent past. They are economical, safe, effective, and very convenient. The product we recommend for dogs is Trifexis©. It prevents fleas, heart worms, and internal parasites, and is given orally instead of a topical gel.

The flea control product of choice for cats is called Revolution©. In addition to treating fleas, it treats heartwormear mites, and internal parasites (depending on the species).

Both of these products are used monthly. In some situations one of our doctors will have you use it more often. We also have detailed brochures on these products.

There are many  flea products that also can be used. Some are oral, some are topical, some are long lasting collars. Here are some of our recommendations:

Topical- Canine

Advantage Multi

Frontline Tritak

Vectra

         Oral- Canine

Comfortis

Nexgard

Sentinel

Trifexis

      Collar- Canine

Serestro

      Topical- Feline

Advantage II

Revolution

Vectra

       Oral- Feline

Comfortis

       Collar- Feline

Serestro

Medical Therapy

Every pet reacts differently to the medication used in atopy, so we might need to try different ones, at the lowest dose possible, to find the medication, or medications, that work best. Since treatment tends to be long term, so our goal is always to substatntially minimize the itching whilel using as little medication as possible. We use a multmodal approach, utilizing topicals, antibiotics, nutrition, and anti-inflammatories, to give the best possible outcome.

Cortisone

One of the mainstays of therapy for treating atopy is cortisone, commonly know as steroids. These steroids fit in the class of drugs called corticosteroids, which are not the same thing as anabolic steroids used by bodybuilders. Cortisone use is usually reserved for flare-ups, since long term use has the potential for causing side effects. Long term use of high doses of cortisone can lead to hair loss, thinning of the skin, liver problems, stomach problems, and muscle weakness. The overuse of cortisone can also cause iatrogenic Cushing’s disease.

Cortisone is a potent drug used in human and veterinary medicine literally thousands of times each day. Without this drug we would not be able to treat a large number of diseases. Cortisone has been abused by some people, leading to a bad name for this drug in some people’s minds. When used judiciously, and under a doctor’s supervision, it is one of the most important drugs we have. It is our first line of defense when a pet is scratching so severely it is maiming itself.

Cats are more resistant to the side effects of cortisone than dogs. Some cats are difficult to pill, so it is not uncommon to use an injectable version of cortisone that lasts for several  weeks to months. Older cats need to be checked for underlying problems like sugar diabetes and heart disease before instituting cortisone therapy. Cortisone will raise the blood sugar level, making it more difficult to control the problem. It can also cause the body to retain more sodium. This is only a problem in a cat that is in congestive heart failure.

Cortisone is usually given on an every other day basis and eventually decrease the dose even further as your pet improves. This minimizes side effects yet still gives an adequate amount of the drug to minimize scratching. In many cases we give an injection first to give your pet immediate relief from the scratching. We routinely use cortisone for 1-2 weeks to help get the scratching problem under control. Since cats are more tolerant to cortisone, and can be difficult to pill, it is not unusual to use the injectable version of cortisone in them.

While on cortisone you will notice that your pet drinks and urinates more than usual. It might also have an increased appetite and might show some behavioral changes. These symptoms will go away, in the meantime make sure your pet has access to fresh water at all times and can go outside to use the bathroom frequently.

Antihistamines

Antihistamines can be effective in treatment in some cases. They counteract the release of histamine (that’s why they are called antihistamines) from the mast cell, which as you know is the source of the itching. They are the mainstay of our long term medical treatment for skin allergies. Occasional side effects include drowsiness and dry mouth, both of which tend to resolve. In general, they are safe to use on a long term basis.

We will initiate an antihistamine trial to determine which one, if any, is most effective for your pet. We do a trial for up to 2 weeks to determine if one is effective or not. It is helpful not to have your pet on cortisone at the same time we are trying a new antihistamine, since we will not know if a decrease in pruritus is due the cortisone or the antihistamine. If we find one antihistamine that works well we stay with it on a long term basis. Eventually this might change, and if there is a significant flare up we will use cortisone to control the problem for several weeks. In the long run, even if antihistamine use has only minimal effects on decreasing pruritus, its use can help us decrease the use of cortisone.

Some of the common antihistamines we use are:

  • Benadryl A
  • Atarax
  • Tavist
  • Chlorphenaramine
  • Amitryptiline

Medications used to treat allergic dermatitis are used on a long term basis. We will refill medications as needed, and require a complete physical exam every 6 months to verify we are still treating the correct problem and to check for potential side effects to medication. A blood sample will be recommended periodically to verify the health of internal organs that might be affected by long term medication.

There is a combination antihistamine and cortisone called Temaril-P that has been use for decades. The two drugs in combination haven proven to be highly effective, and since each of these drugs is at a low dose side effects are rare.

Cortisone/Antihistamine Combination

A popular remedy we use commonly and successfully is called Temaril-P. The cortisone and antihistamine are in a low dose (trimeparizine -5 mg, prednisolone-2 mg), but when combined in the same medication have the effect of a larger dose. We get the best of both worlds in this case because the low amount of medication means less chance for side effects when used long term. This drug is also effective for pets that are coughing and vomiting.

Antibiotics

Some dogs scratch so severely they cause a secondary bacterial infection of the skin called pyoderma. The bacteria that commonly causes this is called Staphylococcus intermedius or pseudointermedius.This secondary bacterial infection intensifies the itching. These dogs need treatment with antibiotics for several weeks to several months. In addition, they need to be bathed with shampoo that will help the skin infection. Long term use of antihistamines are not effective if a skin infection (pyoderma) is allowed to persist.

If a hot spot is present it will be gently clipped and cleansed. Pets with hot spots must be put on antibiotics and usually short term cortisone to prevent the problem from progressing. Hot spots are very painful, and oftentimes require sedation if the wound is to be clipped and cleansed properly.

Antibiotics that work best for pyoderma include:

  • Cephalexin
  • Baytril
  • Clavamox

There is a new version of injectible antibiotic called Convenia that lasts for 2 weeks. This is especially useful in cats due to the difficulty in giving them a pill.

Antifungals

Secondary fungal infections can occur, especially when the feet are licked constantly. The most common one is called Malassezia. It is treated with topical antifungals in most cases.

Cyclosporines

An effective long term treatment for atopy relies on cyclosporines, the medication that prevents organ transplant rejections. It is called Atopica© 

 Your dog must weigh at least 4 pounds for it to be used. Its main advantage is the fact it works without any side effects on a long term basis that can be encountered in drugs like cortisone.

It has recently been approved for us in cats in a liquid form

Atopica is highly effective, and we recommend it as one of our important long-term treatments for atopy. It does not contain cortisone so we do not have the side effects associated with cortisone.

Initially it is given once daily for 30 days, and should be given one hour prior or two hours after a meal. If a response is achieved we will decrease the dose slowly, with the ultimate goal of giving it 3X per week. It becomes cost effective at this twice per week dosing, and it is warranted to try this medication if your pet is on chronic cortisone use or you want an effective treatment without cortisone.

Apoquel

There is a relatively new medication available that shows great promise in treating atopy. It’s our fallback medication when the other treatments do not work. We give it for a 10 day trial the first time. Some dogs stop their itching and stay this way for quite a while. Other dogs need to be on Apoquel long term.

It is a member of a class of drugs called Janus Kinase (JAK) inhibitors. It is an immune mediating drug that suppressed cytokine function. Cytokines are implicated in the cause of itchiness (pruritus).

A very small amount of dogs had diarrhea, vomiting, and excess drinking, which went away eventually.

It should  not be used in dogs with history of cancer (neoplasia), demodectic mange, or that have severe immunoseppresion. Its simultaneous use with cortisone (prednisone) has not been evaluated.

Allergy Shots

If an allergy test is performed on your pet we will know what it is allergic to, and allergy shots can be custom designed for your pets specific allergy. Giving allergy shots is called hyposensitization or immunotherapy. Theoretically, hyposensitization stimulates the production of IgG, which subsequently attaches to the allergen, preventing IgE from attaching to this same allergen. If there is no IgE attached to the allergen, then the mast cells do not release histamine.

Even if you do not give the allergy shots, knowing what your pet is allergic to can be beneficial in some cases, assuming you can remove the offending allergen (see previous section on avoidance). We tend to rely on allergy shots when avoidance methods and medication are unsatisfactory in minimizing pruritus.The company that performs the RAST test also supplies us with the allergens to give the allergy shots.

Giving allergy shots can be a significant way to minimize your pets scratching, although just like in people, no guarantee can be given to the outcome. Estimates vary, but in general, you can expect some improvement 60% of the time. In some cases we will still keep your pet on an antihistamine or cortisone, or Atopica©, but at a reduced dose. A decision to undertake this treatment modality takes a commitment to a lifetime of giving these injections in most cases.

Giving the injection is very easy since it is a small amount with a tiny needle. We will teach you how to give them, and if need be, will give them for you. Initially, the injections are given every few days for several months. It takes at least several months to know if the injections are working, and up to a year for full effectiveness. Eventually, they are only given from once every few weeks to only a few times per year. Each pet’s response is different.

Allergens are made specifically for each pet. This dog is allergic to many things, so three vials are needed to treat its problem.


Room Purifier

If your pet is kept in a confined area, the use of a room purifier that filters out pollen particles can be of help.

Food Supplements

Some allergic dogs and cats scratch less when supplemented with essential fatty acids.  Essential fatty acids tend to work best when combined with an antihistamine. The main ones we use are Derm Caps and EFA-Z. As with other therapeutic options, essential fatty acids will not work when the skin has pyoderma. It will take at least several weeks of supplementation to see any improvement. In some cases the need for inflammatory medication will be reduced when a pet is put on essential fatty acids supplementation.


Bathing

Bathing in cool water several times per week is beneficial. Do not use hot water because it can intensify the itching. Proper bathing will help remove allergens and eliminate dry skin, both factors that affect the pruritic threshold. Bathing your pet too often will dry its skin out and increase its itchiness.

We have many different shampoos that will help you- please ask one of our receptionists to show you. We have had best results with oatmeal shampoos and rinses, along with antihistamine shampoos and rinses. Use a mild shampoo once weekly to keep the hair coat clean without drying it out. For hot spots we use Oxydex shampoo. If we suspect a secondary fungal infection caused by Malassezia we will use an antifungal shampoo called chlorhexidine.

This is an allergic reaction to shampoo in the arm pit area of a 8 month old female pit bull named Pumpernickel. This illustrates the principal that many things can cause an allergic reaction, even treatments for allergies.


Topical Medications

There is a strong tendency on the part of pet owners to use topical medications for allergic skin disease. They are used, and are helpful, but should not be relied upon as the primary source of treatment. Topical medications we use usually have an antibiotic, an antihistamine, or cortisone as ingredients. We tend to use topical agents most often when presented with pets with hot spots. In these cases we use antibacterial creme in addition to antibiotics that are given orally.


Prognosis

Allergic Dermatitis is a chronic disease that is not cured, only controlled. It can be the cause of significant frustration, and will wax and wane in some cases. Understanding this disease will help you formulate a long term plan that suits your needs and minimize the chance of side effects when medications are used on a long term basis.

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Spay Canine

One of the most common surgical procedures we perform on dogs is a spay, known medically as an ovariohysterectomy (removal of the ovaries and uterus). It is performed for several medical reasons:

  • It prevents dogs from going into heat.
  • It prevents dogs from getting pregnant.
  • It significantly helps prevent dogs from get breast cancer later in life.
  • It prevents dogs from getting uterine infections later in life. An infected uterus is called a pyometra, and is a serious disease. After you view the pictures of a routine surgery you will be given an chance to see a picture of the uterus of a dog that has a pyometra.

In addition to these medical reasons, it prevents unwanted pregnancies, a significant problem in our society. Millions of dogs are euthanized every year because they are strays.

We usually spay a dog when it is around 6 months of age. This timetable is variable, the important point is to perform the surgery before it goes into heat. The ongoing old wives tale that states dogs should go into heat before spaying is incorrect. Most dogs go into heat twice each year.

On the day of surgery we need your pet 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 cat 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. 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.

This 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, because surgery is not an area to cut corners. All of our spays receive a physical exam prior to surgery. Only if they pass this exam will we draw a small amount of blood for an in-hospital pre-anesthetic test. When everything is to our satisfaction we will administer a sedative. This will calm the pet down and make the administration of the actual anesthetic, along with post operative recovery, much smoother. Once a pet is anesthetized, prepared for surgery, and had its monitoring equipment hooked up and reading accurately, the surgery can begin.

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

_D2A8630

 

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

Rabbit-femurfx-9

 

 

Surgery

 

Every major surgery we perform begins with proper patient preparation. This will help prevent infection, which could be a serious complication in this surgery because during a spay we have an opening into the abdomen.

Our nurse is using a special cleaning agent and scrubbing the skin 3x in a circular motion

This is the final look of the skin in a pet that is ready for surgery. In the very center of the screen is the umbilicus (belly button), an important landmark for the surgery.

The surgeon makes an incision near the umbilicus and extends it 3-5 inches in the direction of the tail (the tail is at the left in this picture). We try to make our incisions as small as possible to minimize anesthetic time, decrease post operative discomfort, and minimize the healing time.

 

The tissue just underneath the skin is called the subcutaneous layer. It consists mostly of fat and small blood vessels, and is the next layer we cut into after the skin. If these small blood vessels don’t clot within a few minutes they are clamped with instruments, and if necessary, they are cauterized.

 

The final layer we need to cut before we are actually into the abdomen is called the linea alba. It is an area of muscle in the center of the abdomen that is covered by a tough layer of tissue. This is the most important layer resutured at the end of the surgery because it is the only layer strong enough to hold the abdominal muscles together to prevent a hernia. In this picture the linea is being held up with a forceps and a scalpel blade (held upside down) is being used to make the incision.

 

A scissors is commonly used to extend the linea incision and facilitate the removal of the uterus. Care has to be taken not to puncture internal organs like the bladder.

 

Buried within the abdominal organs and abdominal fat is the uterus. A special instrument called a spay hook is sometimes utilized to gently pull one of the uterine horns through the abdominal incision. In this picture our surgeon is using his finger to bring the uterus out of the incision.

 

The uterine horn is traced into the body cavity until the ovary is found. It has to be gently teased from its location near the kidneys in order to be able to pull it out through the abdominal incision. In older dogs this part of the procedure is much more difficult. The ovary (arrow) is usually covered with fat.

 

The blood supply to the ovary is extensive so a special technique is utilized to prevent hemorrhage. This technique involves the use of 3 clamps. In this picture the first clamp is being applied to the left of the ovary (arrow). Besides making it easier to place a suture on the tissue, this clamp stops the flow of blood from within the abdomen to the ovary.

 

A second clamp is applied just above the first. The third and final clamp is applied to the right of the ovary (arrow). All of the tissue to the right of the second clamp is removed during the surgery.

 

The tissue is cut with a scissors between the second and third clamp

 

The third clamp (with ovary) is pulled away leaving the first two clamps to prevent any hemorrhage.

 

Two sutures are securely placed under the first two clamps. When the surgeon is certain there is no risk of bleeding the clamps are released and the sutured tissue is allowed to fall back into the abdomen. In this picture one of the two clamps has been removed and the second suture is being placed. This whole process is repeated for the other ovary that female dogs have in their abdomen.

 

Both ovaries with their attached clamps have been removed from the abdominal cavity. They have been pulled towards the right enabling the surgeon to gently pull the cervix out of the abdominal cavity also.

 

In this picture the two ovaries are off the screen to the far right. Two clamps are placed at the cervix and the remaining body of the uterus with its two attached ovaries is cut away.

 

The uterus is sutured in the same manner at the ovaries, with two secure stitches placed under the clamps. Once our surgeon is certain the cervix sutures are secure the cervix is placed back into the abdominal cavity.

 

The linea alba is now securely resutured. Stainless steel sutures are sometimes used because they are very strong, cause minimal tissue reaction, and show up vividly on an x-ray of the abdomen .

 

The subcutaneous layer is now closed with a type of suture that dissolves over several months.

 

The last layer sutured is the skin. Sometimes we put the sutures on the outside, which means they have to be removed in 7-10 days. In this example we put the sutures in just under the skin, so no removal is needed. They will dissolve on their own in a few months just like the sutures in the subcutaneous tissue.

 

It is at this point that we will give a pain injection, which might make this dog groggy for the evening. When you pick up a pet after a spay operation you will be given detailed post operative instructions.

 


Infected Uterus

 

This is a picture of a uterus in a female dog that has an infected uterus, called a pyometra. The uterus is completely filled with pus, and this dog is very ill. If surgery is not performed to remove this uterus it could rupture and even cause death. The uterine tissue is very fragile and can easily rupture during the surgery, so great care is taken to prevent any release of pus into the abdominal cavity.

 

An occasional pyometra can be tremendous in size. Great care has to be taken to minimize this uterus from rupturing during the surgery.

 

A diagnosis of pyometra is made based on several findings. There is a history of being in heat a few months prior, along with lethargy, lack of appetite, and sometimes even vomiting. Most dogs will be drinking and urinating excessively because of the toxic effects of the infection on the kidneys. A blood sample will somtimes show a very elevated white blood cell count, and an x-ray of the abdomen might show an enlarged uterus.

This x-ray shows an enlarged uterus in the abdomen. The uterus (U) is the area just to the left of the bladder (B). You can see it as several areas that are circular or elongate. A normal uterus does not usually show up on an x-ray.

 

Postoperative Care

 

Most dogs go home late in the afternoon on the day we perform the surgery. They might be groggy from the pain injection which is advantageous because they will remain calm and allow the healing process to start immediately. By the following morning the grogginess will have worn off.

When you first get home do not be in a big rush to feed. After 1 hour at home offer a small amount of food and water. If the appetite is good, offer more several hours later. Do not over do the feeding the first night because anesthesia can make them nauseous.

Keep contact with children and other pets to a minimum the first night, and restric activity for several days to allow the incision to heal. Do not let your dog go outside until healing is complete.

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Guinea Pig X-Rays

This little guy is laying on his back, with the front legs towards the top. The big dark spot the arrow is pointing to is air in the intestines, and is normal. Did you notice he is missing one of his front legs? It was amputated years earlier.


 

This is the same pig from the side view. Can you tell he has only one front leg from this view?

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Guinea Pig Eye Surgery

This cute little one had a problem with his eye. Here he is starting his anesthesia before surgery.

GPig-EyeSx-2

All of our small patients are kept on a special warm water blanket to prevent hypothermia

Surgery-GPigWaterBlanket1

The problem is a congenital hair irritating the cornea

GPig-EyeSx-5

GPig-EyeSx-6

Our patient is prepped and draped for surgery. You can see how this hair is attached under the eyelid.

GPig-EyeSx-9

This is meticulous surgery so Dr. R needs magnification (he looks like an alien creature)!

GPig-EyeSx-3

We use the laser for many reasons. It gently removes the hair, and it does this without any bleeding or inflammation. This is important in this very sensitive area. In the years before we had the laser we used a small scalpel blade. Even though it was a small blade it still caused bleeding and inflammation post operatively.

GPig-EyeSx-11

No more hair, and more importantly to our surgeon, no bleeding or swelling

GPig-EyeSx-13

Lisa keeps a close tab postoperatively to make sure our small patients wake up without any problems

Surgery-GPigWaterBlanket

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