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Anorexia In A Dog

by jk176 - February 19, 2021 View Case Report

Hugo is a 10 year, 9 month old MN Maltese with now almost complete anorexia. He has a decreased appetite since 12/20. He has occasional soft stools. Now his energy is quite low - it is always good in the clinic.
PE - BAR, mm pink, crt wnl, moderate calculus on few teeth, lavender tongue, 1/6 murmur, normal rhythm, lungs clear, abdomen tense, ambulatory x 4, previous history or urethrostomy due to a obstruction from a calculus, emaciated
pulse- thin/toned/wiry

blood test results: 12/21/20 - lymphs 4620(690-4500), mono 1232 (0-840), eos 4466 (0-1200), glucose 68 (70-138)
u/a - usg 1.020, ph 7.0, amporphous phosphates 21-50, calcium oxalate dihydrate 21-50)
cobalamin 185 (251-908)

abdominal ultrasound - thickened stomach wall, normal layering
thoracic radiographs - unremarkable

endoscopy/biopsies - gastric mucosa - hyperemic, prominent rugal folds, especially in the pyloric antrum, no ulcers, submucosal growth - about 2 cm diameter along luminal margin of greater curvature
biopsy - mild to moderate lymphoplasmacytic gastritis with moderate to abdundant number of spiral bacteria and variable mucosal edema and congestions - attempts were made to biopsy the area of the growth - but it is not certain if it was reflected in the biopsy
surgrical biopsy was offered and declined

duodenal mucosa - mildly inflamed with a cobblestone appearance
biopsy - mild to moderate lymphoplasmacytic and mildly eosinophilic duodenitis

Hugo has been on prednisone 1.8 mg PO BID, famotidine 2.5 mg PO SID and sq B12 injections weekly. Appetite stimulants had no effect.

He has shown no improvement.
He is wasting away. His owner declined feeding tube placement.

I started him on Kan Six Gentle pets 0.15 ml PO BID on 1/28/21. So far he has no response to this.

I was thinking of trying him on Xiao Yao San or do you recommend something else. I also wondered about trying to treatment for helicobacter, but 1) I know this is controversial and the internist that did the testing felt they were incidental and 2) I am concerned about giving him multiple oral antibiotics when he is not eating.

Do you think we should discontinue the prednisone?

by naturevet

February 19, 2021

Hi there,

Certainly there seems ample reason to believe the stomach issues are behind the anorexia, given the results of the work up. 'Lymphocytic-plasmacytic' should probably more often be taken as a sign of 'unresolved inflammation' rather than 'immune-mediated disease'. Tissues with unresolved inflammation show these same cell types in abundance. In addition, you have the monocyte elevation to tell you the dog is suffering from chronic inflammation (apparently in the stomach). High eosinophils are often associated with poor integrity of the GI mucosa, and may be stemming from the duodenal and gastric pathology as well.

To get rid of chronic inflammation, the tissue must receive an increase in perfusion, through a process known as 'active resolution'. Most of our anti-inflammatories do the opposite. They take blood away from tissues and are the pharmaceutical equivalent of ice packs. Their utility in reducing the severity of acute inflammation makes them exactly the wrong thing to manage chronic inflammation. In this context, use of pred in this dog is problematic.

Helicobacter acts as a marker of reduced gastric wall perfusion, since if it is normal, there is nowhere for the bacteria to hide from the immune system, and it promptly disappears. In other words, Helicobacter behaves as an opportunist. Ample gastric wall perfusion not only leads to elimination of the bacterium through immune system activity, but also increased gastric acidity, since the gastric mucosa now has enough of a blood supply to function properly. When gastric acid is insufficient, the bacteria thrives.
Long story short, then, your drugs are working against you. Famotidine makes it easier for the bacteria to survive by reducing acidity. Meanwhile, prednisone is suppressing the immune response against the bacteria. I understand the rationale why pred was used - to stimulate appetite and suppress an apparently immune-mediated disease. Given that the problem, however, is likely an under-perfused gastric wall, it is directly aggravating the problem with its 'ice pack' effects. This is why, if over-used, pred can lead to ulceration - because of a profound impairment in blood flow leading to a breakdown of stomach wall integrity.

Beginning a weaning process off pred is a good start, but how do you improve gastric wall blood flow to vanquish Helicobacter and resolve GI inflammation? I would suggest Yi Guan Jian. I liked your idea of Xiao Yao San, but YGJ is even more focused on the stomach and duodenum. Once the dog improves, or if it develops Damp symptoms, then XYS may ultimately be a better choice. You will probably see an improvement in the leukon at the same time as the appetite improves, if my guess is correct. As for LJZT, it was a sensible thing to try, but doesn't really tackle gastric wall issues.

Hopefully this helps you out. Please let us know how it goes!

Steve

Yi Guan Jian

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