Jan. 31, 2024

#112: The Condition-Formerly-Known-As-HGE: Updates And Myth-Busting. With Prof. Caroline Mansfield

#112: The Condition-Formerly-Known-As-HGE: Updates And Myth-Busting. With Prof. Caroline Mansfield
Apple Podcasts podcast player icon Spotify podcast player icon RSS Feed podcast player icon
Apple Podcasts podcast player icon Spotify podcast player icon RSS Feed podcast player icon
Season 1

Whether you're still calling it HGE, or you're getting used to saying AHDS, it's likely that haemorrhagic diarrhoea is one of the more serious and most common GI conditions that you treat in companion animal veterinary practice. But are you treating it the right way? And how can you even be sure that your severe GI case 'just' has the HGE/AHD syndrome, and not some other serious disease?

If you've ever asked yourself these, or any other questions about this condition, then this conversation with Prof Caroline Mansfield will answer your questions and get you up to speed with everything you need to know in 2024 about haemorrhagic diarrhoea. (Spoiler alert - they DON'T need antibiotics!)

Prof Caroline Mansfield is a board Certified Specialist in Companion Animal Internal Medicine whose research is focussed on enteropathies in dogs, the endocrine and exocrine pancreas, and the interaction between the gut microbiome and metabolic health and disease in dogs and cats. She’s had an illustrious career that includes her previous role as the Head of  Small Animal Medicine at the University of Melbourne and Director of Clinical Research. She’s the current editor of the Australian Veterinary Practitioner Journal, and has published over 80 peer-reviewed papers plus multiple textbook chapters and conference presentations. 

 

This episode is a condensed version or our full episode on the topic from our clinical podcast series, where we've tried to capture some of the key takeaways that we feel every practitioner should be aware of. For the full episode, the show notes, access to a library of more than 450 other clinical continuing education podcasts, two fresh episodes per week, and access to our members-only community spaces, join our Vet Vault Nerds at vvn.supercast.com.

I wanted to give you a quick rundown of something different that we're doing this year.You may or may not be aware that we host an entirely different set of podcasts called the Vetvault Clinical, where I interview specialists and ask them all of the questions that I've accumulated over MY20RD career about their topic of expertise.
All of the stuff that I used to or still get stuck on, updates on what's new, or sometimes just a revision of important things that I've long since forgotten.Now, you won't find these podcasts if you search for them on your podcast player.That is because access to them is through a paid subscription.
So they'll only show up on your podcast layer once you sign up for them at vvn.supercast.com.But what we're gonna start to do is to share more of that content on here on the open Free access.Vet vault the.Plan is to create an almost separate stream of podcasts on here so that you can come here for some clinical continuing education in addition to the inspiration and motivation and all of the other stuff that hopefully helps you to create a vet career that.
Works for you.There's two reasons for this change in strategy.First off, so much of the stuff that I learned from our guests is so good and so important that I feel like it's wrong not to share.It as widely as I.Can.It's the sort of stuff that can really impact the patients under your care, but also your ability to feel competent and confident in your job.
And I'm aware that not everyone is in a position to pay for full access, so we're doing a bit of sharing.The second reason is because I want you to get hooked on a clinical podcast when you see how good they are so that you will join our community of vet fault nerds by becoming a paid subscriber.That's how I get to grow the business component of the vet fault which allows me to make.
More useful content for you.We're starting the clinical feed with this excellent conversation about hemorrhagic diarrhea syndrome, which used to be called HDE but has been renamed AHDS Acute Hemorrhagic Diarrhea Syndrome.I love this one.Because it's such a common disease with so many things that we used.
To do and used.To believe that has been proven to be just not true.Quick warning, some of what we discussed might cause some arguments in your clinic when it makes you totally re evaluate how you diagnose and manage these cases.But I don't think you can argue too much with our guest, Professor Caroline Mansfield.
Prof Mansfield is a Board certified Specialist in Companion Animal Internal Medicine whose research is focused on interopathies in dogs, the endocrine and exocrine pancreas, and the interaction between the gut, microbiome and metabolic health and disease in dogs and cats.
She has had an illustrious career that has included, amongst many other things, a role as the head of small animal medicine at the.University of.Melbourne and Director of Clinical Research.She's the current editor of the Australian Veterinary Practitioner Journal and has published over 80 peer reviewed papers, plus multiple textbook chapters and conference presentations.
Basically, she probably knows more about GI diseases than your colleagues.Or even your boss.This episode is an edit of the full episode where I try to capture some of the key takeaways that I think every practitioner should be aware of.For the full episode and the show notes, plus all the other stuff that I mentioned above, sign up at vvn.supercast.com, OK Professor Caroline Mansfield and some HGE myth busting.
Professor Caroline Mansfield, thank you so, so much for joining us on the Vet Vault.You're very welcome.I've been so excited for this one for a while.It's such a common thing and there's still so many misconceptions and there's still so many things that I don't quite understand.And whether there's more stuff on it, I don't know, but we'll see.
But let's call it the hemorrhagic diarrhoea case, which used to be HGE hemorrhagic gastroenteritis but has a new name.What's the new name again?Acute Hemorrhagic Diarrhoea syndrome or AHDS.AHDSI cannot get it into my name.You know, every time we talk about it on the podcast, I default the I can't call it one thing for 20 years and then suddenly I have to change my name again.
Yeah, why the name change?There's been quite a few studies that have started to look at this syndrome, and one of the most recent studies.They looked at both postmortem and endoscopically, and they found quite a few necrotic and neutrophilic lesions, but only within the small and large intestines, so the stomach was virtually unaffected.
And so I guess if you go back to HGE, the GB kind of becomes obsolete.OK.So it's it's not a gastritis of any sort.Absolutely.And the colon is affected as well, which is why the fresh blood component is so prevalent in the presentation.
And I guess HGE kind of misses that as well.OK.Acute hemorrhagic diarrhea syndrome.So we we're leaving the gastritis part out of it.So it doesn't really play a role.But but they do.Am I wrong in saying they do often still come in with the occasional vomit?
Sometimes it'll be the first thing that you see is they'll have a puke.Yeah, So often that's proceeded with vomiting.Like, not usually that frequently, like it doesn't persist.Probably about, you know, a third of them will have some vomiting as a component.But, you know, dogs vomit with intestinal disease too.
So yeah.So don't confuse the vomiting component of that as a primary gastric problem.It's still lower down where the issue is and the the vomit is still the response to it.Can we?Start by putting some.Boundaries around the syndrome as to what defines a case of acute hemorrhagic diarrhea syndrome because there's heaps of reasons why you're going to have diarrhea even with blood in it.
So what makes you?Yes, I can call you that.Yeah.So I guess the the first thing is that it's it's an acute onset, acute to pericute onset of quite bloody diarrhea that maybe as we spoke about maybe proceeded with an onset of vomiting episodes, like 2 to 3 vomiting episodes.
There's a common misconception that the dogs always have a increased PCV.It's not quite necessarily the case, but that they're pretty much always hypovolemic.What they don't have is a low PCV.So typically their PCV is going to be, you know, at least above 35 before they're rehydrated and and above 25 once they've been rehydrated.
And the blood component of the diarrhoea is usually quite prominent.And so if we have other causes of of bloody diarrhoea, for example due to coagulopathies, and the animals are usually anemic because they're losing blood, but with these animals they're quite hemoconcentrated and so the PCV is in the middle to the upper range.
OK, I'm glad you clarified that because I had.I don't think I ever learned officially that the PCV had to be high.But then I have heard that opinion from people saying, well, that's not an HD HDS case because PCV's normal normal ish.And I was like, OK, well, it's OK, So it's semantics, right?
Yeah, normal is fine.You just don't want it to be low.And that is, again, because they should not be anemic because it's so cute they're kind of happy for limits.That's why low means if you run a PCV you should go what you go looking for something else.Yeah, absolutely.Yeah.
So they're simple enough.They walk through the door.You're middle-aged dog.You can smell them the moment they come in, right?If you if you come and shift in this one in hospital, you walk in and go.Now we've got a so usually you've got a strong suspicion by the time you do your well.That's often the the acutely vomiting dog that comes in and you're direct and you go, aha, there's my problem.
I I know what you're gonna become.You might not be at the end, but it's coming.And that's about for me.One of the hardest things to do then in especially in an emergency clinic but in in GP as well is to go OK, I think I know what you are but how am I going to confirm or rule out what do I need to go and rule out because I and especially in emergency one of our biggest fears is I don't want to miss something so making decisions about diagnostics in that first consult is always a tricky 1.
So you mentioned the younger dog.So I personally, when I see a a puppy or no no unvaccinated dog, they don't want to do poverty test at least.So that's the one thing I rule want to rule out.Beyond that though, what what do you do if you're the consultant you see this, How much?What do you check for?
How much do I do?Yeah, so I'll, I'll check pretty closely for abdominal pain.So they shouldn't be painful or certainly they shouldn't be like a really like focused pain.And quite often they're they're tachycardic because they're hypovolemic.
But if they've got an inappropriate heart rate like inappropriately slow heart rate, you know, then maybe I'd be more worried about something like Addison's make sure that there's no particular or ecchymoses which you'd be concerned about a a Coagulopathy and and make sure that I have a fever or a heart.
You know, my heart murmurs.If most of them have got heart Murmans, right.Because they're little little dogs, middle-aged dogs.But, you know, make sure that they don't have a diastolic or a funky heart murmur that that you're worried about.But also make sure that they don't have a really, really severe fever.If they don't have any of those, and even if they do, I think I'll just do a standard CBC and biochem including electrolytes.
And if that's all kind of normal, like you've got a, you know, if you've got a stress leucogram and your blood glucose isn't low, then you don't really have anything overwhelmingly.When you don't have overwhelming pain then you you should just treat and see how they go for the 1st 12 to 24 hours.
Can I double click on a couple of those for a second?Fever.So your your standard run-of-the-mill HDS shouldn't have a fever.It's not a bacterial disease.They're not overtly pyrectic.Yeah.So again, you often see them at 3939 something and I go, yeah, inflammation.
I'm sure if my gut's really upset, but if I'm pushing 40 then you start thinking OK well I've got a double check and something else isn't happening.Yeah, yeah.And if it's painful on top of that, then you're worried maybe there's a pancreatitis or there's a perforation or there's something a bit more funky going on in the abdomen than that.
Yeah, it's.Interesting that you say non painful or not massively painful.You're right, cuz they don't.Often, I almost assume, and I think especially as emergency clinicians, that well, if you're shedding your whole gut lighting, you're gonna be quite painful.But you're right, they're not super painful.
So if you feel them and they really go really growny, that's when you'll think maybe I should scan you, make sure there's nothing stuck or interception or something.Yeah, I don't think they like the rectal temperature taken, but I think abdominal palpation, they're not particularly painful.So you would always do for any of those ideally you'd recommend as CBC Biochem electrolytes as a minimum work up if the owners are happy with that.
Yeah.And and that is and I'm aware of this and I've only become really aware of it in the last couple of years.So what you mentioned today with the liquor Gram and we've discussed it before when we talked about Edison's on this podcast.But again, I just want to underline it for anybody who missed that, that your dog, a normal dog that has a hemorrhagic diarrhea, should really have an inflammatory leucogram, right?
You should see some neutrophils up and the immune system's a little bit upset.Yeah, at least.Or if it's not inflammatory, at least a stress leucogram.So the eosinophils should be low, yeah?OK, stress leucogram and the absence of a stress leucogram.So basically a completely boring normal white blood cell count should make you think maybe Edison's because I don't have cortisol to stimulate because that's what causes that stress.
Glycogram is the cortisol from stress, right?Correct.Yep.Absolutely.And glucose as well is that we're looking at glucose for the same reason, because again, if you're a little bit sicky, a little bit stressed, your glucose should be upper end.Yep, that and also for sepsis.So if your glucose is is low and I guess it depends on how how you measure your glucose.
So just be a little bit careful with that.If you send your glucose off and it's not in a fluoride oxalate tube, but if you're measuring it in house or you know it is in a fluoride oxide like tube and it's low, then the glucose, glucose is usually contained pretty well.
Like the body's pretty good at maintaining it above, you know, 3.5.And so if it's low, you know there's some bacterial focus that's chewing it up or there's no cortisone in the body.So you'd be thinking that there's something else going on.Your red flag number, you said 3.5, so if you start seeing it under 3.5 you kind of start thinking.
No, probably if it's under if it's under 3 for me.Under 3, All right.And then you said if.You have those.So you do your bloods and they have a bit of a stress dichrogram.Everything else is normal or as expected, if not necessarily normal.
Then you'd pause.There and start.Treating what about something I see a lot is testing for parasites.So intestinal worms or jihadi or those sort of things.Are they on your radar at all?Are they potentially?
Could they be the thing that upsets the Clostridium?Or could you theoretically get a dog with one of those diseases, especially middle-aged dog?Is it something you worry about?Well, that's a whole other podcast.I think it's that's very apart from Parvo, no, very unlikely to be causing anything acute if it's if it's really acute or par acute, no.
So I know Parvo's on that panel and in a bit no not high on my list and then I I worry once we start training yeah.So no, I I could go for a very long winded conversation and circle back to no.To No.OK, so parasite testing.
Intestinal parasite testing is not on your day one diagnostics or something that looks and smells like an HD.And even, and to be honest, even like with chronic diarrhea, which I when I do test for it, if I get a positive, I usually want to figure out what the underlying intestinal or immune suppression is.
Or, because they're usually not the primary pathogens, it's usually telling you there's something else wrong in an adult dog.Is this for your nepatodes, Angiotia or or what are we talking about when you say that?Definitely Giardia, but yeah, it usually indicates to me that there's an underlying problem because an immunocompetent adult dog with normal intestinal function should be able to deal with like giardias.
Most Giardias strain should not be pathogenic.But like I said, that's a whole other podcast.Yeah, yeah.We won't go down the drive at all completely, but I do just want to check because again we've when I qualified, we looked for Giardia with wet prep, which I know is quite insensitive and now we've got the machines, what do you call them, the AI things that go scanning for Giardia much better than I can.
Plus we've got the little snap test and then I'll sometimes get positives in cases where I didn't really expect it.Like yeah, you you're not a puppy from a kennel and that's now this SNAP test says you're Giardia positive.So I treat you as it's significant.
How sensitive are those?Or Canada carry a Giardia or two but not actually have signs of it?Basically, do I put you on a causometridol or not?No you don't.OK, short answer, I like it.
So most Giardia that we're testing for you can't differentiate between pathogenic and non pathogenic or zoonotic and non zoonotic strains.So most of the Giardia that if we type them are probably not pathogenic and are probably not zenotic.
There's only about five, 5% in A recent serological study or recent serovar sorry, study that was performed in the US, for example, of positive Giardia that was actually potentially pathogenic or zenotic.And so if they don't have diarrhoea and you get a positive Giardia, definitely don't treat because if you give it metronitis, oh, you're going to completely muck up their microbiome.
If they do have diarrhoea, I would be looking for other causes 1st and try and rectify or correct those causes before you start treating more, you know, blaming Giardia.I've seen many cases where there's been a positive Giardia one and there's been multiple treatments with metronidazole and it's actually the disbiases caused by the metronidazole.
It ends up being more of a problem for the dog in the long run.OK, that's big.I'm trying to think over the course of my career how many times I've chase jihadi as a diagnosis.Again, not in my early career that you didn't see it often and when you saw it, it would be a puppy from a sicky little puppy from a breeder and or from kennels and it would have thousands of jihadi and you teach them and they go great.
Yes.And that's a, that's a.That's a different scenario, right?And then in recent years, again with this increased and I feel like the the, the sad things for vets, almost many people listen to this and go damn it because it's so nice when you have this annoying diarrhea case and you hit your positive GID test, you're like, yes, I've got something to treat.
I can give you drugs and I can kill these things.But no, don't jump in with the treatment straight away.Yeah, that's right.One more diagnostic test.That I'd love to check.Caroline that I've seen done for these cases is clotting times.I can never say PTPTTI.
Feel like I was taught that intestinal bleeding is not something that really happens, especially not in isolation.Is that right?Like is it?Worth.Is it a test?Worth running my rat baits or my dog with clotting?Problem is it going to come in with hemorrhagic diarrhea?It's pretty unlikely that it's going to be just solely intestinal disease, but it goes back to our definition of that problem.
So if our PCV is above 35, it's unlikely to be primary Coagulopathy.So I probably wouldn't at that point and or if it's above 25 after you've rehydrated it, but if it's below that, then yeah, that might be an indication to look for a Coagulopathy.
It would be.I think it would be unlikely and GI bleeding is more likely to be due to platelet dysfunction or low platelet numbers rather than PTA PTT.Right.So we've done our tests.We're all looking good.We're not doing clotting times.
We're not checking for jihadi anymore.Now we've got to treat it.So we have a running diagnosis and we're gonna Chuck it on fluids.So we're managing, we won't do a fluid talk here, but actually maybe we should for the specific condition, do you have a, do we just manage it based on clinically percentage dehydration or is like a standard thing?
I think back at uni they told us while they they're often more dehydrated on a cellular basis than they look clinically, so we fairly aggressive fluids.What are your thoughts on on how do you manage these guys fluid wise?Yeah.So the the current recommendation is that they should receive at least one shock bolus and potentially you know even up to three shock boluses before they're put onto more of a maintenance fluid rate.
And I guess the aim of those shock boluses are to try and get their heart rate down probably, you know, down to less than 140 in a small breed dog, less than 100 and in a large breed dog probably, probably actually want it less than 120 in a small green dog.But I think that sometimes that's a bit unrealistic to get down to.
But but yeah, you want to give them the shock boluses initially because you're right, they are.They have a bigger fluid overall total body deficit that you can appreciate often on a clinical exam.So the the shock boluses is that if they present with the early signs of hypovolemic shock.
So tachycardic, Maybe shady pulses?Or do you do it as a yeah if?They're not.If they're not tachycardic, you know, and their PCV total solids are OK, then probably you don't need it quite as much.OK.You know you probably could be a little bit more conservative, but for the for the ones that are unwell then at usually at least one one shock bolus would be beneficial.
I do feel like these guys again often by the time they come in, they have lost quite a bit of volume and we underestimate it because your hand you sort of go well, it's just diarrhea, just diarrhea because it's a lot of fluid loss fairly quickly.So fluids, do you have a preference or is it just anything and and again we can?
Get very nerdy with all these.You see guys about what should be saline on that, but there's nothing that specifically is ideal for these guys.Bag of heart pins do the job fine.Yeah, because you're giving at such a high rate, absolutely crystallites to start with.I guess it's only if you know if they've got low albumin because of blood loss or they have some other issues like heart disease or something that's going to make things a little bit more complicated and if you need to use colloids or something else.
But but I mean, for the vast majority of dogs, crystalloids are going to be fine.I'm gonna interrupt Prof Caroline for a second to tell you a little bit more about our subscriber clinical podcasts.Why would you want to become a subscriber if we're sharing stuff for free?First, because we have a bank, a vault if you will, of around 450 episodes to date in small animal medicine, surgery, and emergency and critical care, with two new episodes.
Released each week.So the stuff that you'll hear on here is a drop in the ocean.Secondly, subscribers get access.To our beautifully crafted.Very popular show notes so that you can refer back to the stuff that you've learned on the podcast when you see that case that makes you think.I think I listened to a podcast on this, but I can't quite remember what they said.
Our notes have grown into a searchable library for quick reference and it's become my personal first line reference when I'm on the clinic floor.Third thing members get exclusive access to spaces on the Vet Vault network where you can ask questions and have discussions about the stuff that we're learning about and you get to help to guide what content gets produced next.
And lastly, ads.These public podcasts will usually have some sort of advertising attached to them like this message, whereas the subscriber feed will never have any ads.So if you like what you hear on this episode and you want to check out a full feed of clinical content, go and try it out for free for two weeks at vvn.supercast.com.
So we said before that no metadol for the jihadi that you may or may not found.Don't even go looking for the jihadi, the antibiotics question.I've heard it from these smart people that these guys do not need antibiotics as a rule unless they are feverish or, you know, unless they look like they're in trouble.
But people don't want to believe that.I had this discussion with somebody the other day who listens to our podcast and said I told my boss that these patients don't need Metrogel and the boss said no, they definitely do.They definitely do.Exactly.Can you just tell us where we are with antibiotics and these dogs?
Well, this is actually one condition where it's actually being shown in two prospective studies run in two different countries that there is absolutely no difference in outcome if they receive antibiotics or not.OK.So they do not need antibiotics.
And metronidazole is not a benign treatment.And there's also no benefit that's been observed in giving FMTS as an alternative or giving amoxicillin clavulanate.So it's not just metronidazole, it's all antibiotics.So the first thing is there's no, you know, when we talk about things, we want to say, A, is there a benefit and B, if there's, you know, a potential for there to be a benefit or it's a question about whether there's a benefit, do what is what we give potentially harmful.
So we know that there's no benefit Categorically.These dogs don't get better quicker.There's no difference in survival time except for that small percentage that may have bacterial translocation and end up with, you know, septicemia.Those dogs are a completely different subset and categorically need it.
But we know that otherwise there's no benefit.But is there potentially harm?And yeah, there is.It's been shown that dogs with Ahds, they're microbiome, if they're not treated with antibiotics, reverts to normal very, very quickly.
They're back super quick.Metronidazole may alter their ability to get back and get back as quickly.And then on top of that, we've also got our antimicrobial stewardship, the big one health global picture as well as the individual dog picture.So I don't think that there is an indication to treat these dogs with antibiotics at all.
OK.So the what used to be taught and the counter arguments that I'll hear when I discuss this with people is a you mentioned bacterial translocation.So the people who say well I I was taught that as soon as you damage the gut lining to that extent there's going to be bacteria or there's the risk of bacterial translocation and then you're going to dug go from I'm dehydrated to I'm going to go really sick.
So I'm going to put it on antibiotics to prevent that.That's one argument.I'm just to be clear, I'm over that, I'm over right for that.But what do you say in response to that when people talk, still talk about.Bacterial translocation.Yeah.So probably what we think of bacterial translocation is probably in the early stages.
It's probably not the bacteria themselves.It's probably the metabolites and toxins of the bacteria that make them sick.And then as disease progresses, then the gut gets leakier and leakier and then you can actually find bacteria within the circulation.So it's in that you're sort of intervening time.
And the best way to stop the disease is to actually to make the gut healthier, right?Like, it's not to kill the bacteria, it's to make the gut healthier.So the best way to make the gut healthy is to make the perfusion of the gut better, which is with fluids and to make the animal feel better and get it to eat so it has topical nutrition.
And so that the the gut replicates and has a better barrier and antibiotics as a preventative.I think we should be not really using that anymore.Like that's that's something that it doesn't serve us very well going into the future.I think.I think he lies early, like in the first sort of 12 to 24 hours, maybe even first day or two using something like neuropotent, you know, plus or minus Sundance trying to control vomiting and nausea is probably appropriate and that can encourage them to eat as well.
And to be honest, that's all I think you need, fluids and antiemetics.The other thing that intuitively feels like it's makes sense is your some sort of an acid reduction treatment.So whether it is PPI, so proton pump inhibitors or your H2 block is in that.
But is that out?Because we said, well, the gut that stomach's not involved and those don't work behind the stomach.Yeah, yeah.Is that right or where are we with that?Absolutely.So you're right, there's no stomach lesions and the pump only pumps are are in the stomach.So, and we don't, And Melina's not really a feature.
So no, no need for the acid reduction medication.It's no indication and and don't get me started on that.Oh, I want to get you started.I.Don't.Yeah, no, no, no, no.And omeprazole can make animals feel sick.You can contribute to vomiting and diarrhea and also dysplasis.
So yeah, that's like a that's another podcast.Really Well, I've.Heard of the dysbiosis?Because you're changing the acidity, which again the bugs in the gut, they love their environment.I didn't know about the feeling sick, So that in itself connects, because how often did we use to use it for the non, specifically slightly illy nauseous dog?
Yeah.So, so there'll probably be about two or three papers coming out in the veterinary literature over the next six months that actually show that.And there was a study that my resident did at Melbourne Uni as well.So we actually gave it omeprazole at at half a meek per kig and a meek per kig daily to healthy dogs.And we were going to look at metabolomics and metagenomics of the feces as part of that study and look at daily changes.
But we actually ended up having to stop the study because of the number of dogs that had complications.So we had over 50% of dogs that developed diarrhea, vomiting or anorexia on that dose.So these are healthy dogs.Wow.And we get similar reports.There are similar reports in other trials.
And so I guess when you think about when we use omeprazole clinically, we often use it with dogs with GI disease.And so they've kind of already got vomiting or diarrhea or anorexia.And we maybe we use the omeprazole and go, yeah, I know they've still got gut disease and we just keep going with the omeprazole, right.
But maybe the omeprazole's contributing a little bit to that and making it worse.So we really only should be using it if we've got a really clear and strong indication that it's necessary.Wow, OK.It's a bombshell.You mentioned we talked about pain earlier and the fact that they're not not as painful as pancreatitis or something.
The other thing that they often are on is the opioids.So there's an assumption that if you're pooping out your gut lining, you're probably gonna be uncomfortable and you could do with a little fentanyl or methadone or something like that.Is that reasonable still because I still for this, but the same reason I always go, well, you're quite sore, but I do know that lots of dogs will feel a bit queasy on the opioids and our goal is we want to get to eat.
So where did you have an opinion on on that either way?Yeah.So I'm not a huge fan of fentanyl for GI disease.I mean, it's a really effective analgesia, but it's also really effective against slamming the gut motility.And so it's not conducive to eating.
So with these guys, because pain usually isn't a big feature, usually something like buprenorphine, which is only like a partial mute agonist is probably going to be OK.And if you're having to reach for something heavier than that because you think that they're really painful, that would kind of bring us back to where we were talking about before.
And and you know, just make sure in your head that you're happy with your diagnosis.You know, if you're having to really titrate up the pain relief, then maybe there is something else going on.So I'm listening to this and I'm going, so how we treated them almost 20 years ago when I go back in rural Wales when I worked there, very basically fluids and sometimes, jeez, it was actually perfect except that we used to give them IV Metronite.
Metronite is all back in the day, but we discount that part of it.We actually treated them perfectly because again, I feel like it's escalated.We've gone, OK, well, let's get fancier, Let's bring in all these other drugs.That's given the IVPPIS and all of these and it's actually potentially doing harm.
So back it off a little bit.Yeah.Yep.So beyond that, anything else?I mean, there's nursing care, obviously expectations for the standard ones to make sure that you're on the right track.They, in my experience, 24 hours they should be looking not fine but substantially better.
And where do you sort of draw the line where you go you're taking longer than I thought.I'm gonna start digging.Two to three days.OK, That much like 2.To three days They should be better by one by one to two days, but at two to three days they should be interested in eating.Their fecal score can take a while to improve, to go back to normal, but you should be starting to think about being able to send them home in two to three days.
And if you're not, then there's something going on.OK.And then to wrap up, Caroline, you mentioned the buy home, so we haven't given them antibiotics because they haven't been sick enough for that and we should have avoided the Pvis.So you said they should bounce back straight away.
So in terms of anything else to go home with or anything like that like Probiotic or anything like that, now just food, get food in.You.Yeah.Like there's no indication that it's necessary at all.And the one study that looked at fecal microbial transplantation didn't show a benefit in having the microbiome go back any quicker to a sham treatment.
So at this point, there's no indication that a probiotic is considered to be beneficial.Yeah, it has.They haven't been studied specifically, but at this stage there'd be no indication.OK.That was magic.That was really, really good.Thank you.That clarified quite a few things.
Again, such a common thing and still a lot of uncertainty.So I really appreciate you most of your time on what sounds to be a crazy busy day.Thank you so much for joining us.

Prof. Caroline Mansfield